• Assessment Tools
  • Use appropriate assessment tools as indicated for each individual's needs and specific setting:
    • Beers Criteria: 2002 Criteria for Potentially Inappropriate Medication Use in Older Adults: Independent (see Table 12.1 in the original guideline document). 2002 Criteria for Potentially Inappropriate Medication Use in Older Adults: Considering Diagnoses or Condition (see Table 12.2 in the original guideline document) (Fick et al., 2003 [Level VI]).
    • Common Drug–Drug Interactions (see Table 12.3 in the original guideline document). List of some commonly known interactions.
    • Cockroft-Gault Formula: to estimate renal function (see Figure 12.1 in the original guideline document).
    • Functional Capacity (activities of daily living [ADL], instrumental ADL [IADL], Mini-Cog, or Mini-mental State Examination [MMSE]). (See the NGC summaries of the Hartford Institute for Geriatric Nursing guidelines Assessment of Function and Assessing Cognitive Function.)
    • Brown Bag Method (Nathan et al., 1999 [Level IV]). Method used to assess all medications an older adult has at home, including prescriptions from all providers, over-the-counter (OTC) medications, and herbal remedies (all medications are to be brought in a "brown bag"). Should be used in conjunction with a complete medication history (see Table 12.4 in original guideline document).
    • Drugs Regimen Unassisted Grading Scale (DRUGS) Tool. Assessment of self-administration ability (Edelberg, Shallenberger, & Wei, 1999; Hutchinson et al., 2006 [both level IV]). Typically used at time of transfer to other levels of care.
• Assessment Strategies
  • Comprehensive medication assessment should be performed at admission, discharge, and intervals in between (Petrone & Katz, 2005 [Level IV]; Shekelle et al., 2001). Obtain a detailed medication history and confirm its accuracy (Lau et al., 2000 [Level IV]; Tam et al., 2005 [Level I]), detailing the type and amount of prescriptions, OTCs, vitamins, supplements, and herbal remedies (Hanlon et al., 2001 [Level V]; Kaufman et al., 2002 [Level IV]), alcohol and illicit drugs, using appropriate assessment tool (e.g., Brown Bag method) (Nathan et al., 1999 [Level IV]).
  • Assess renal function using Cockroft-Gault formula for assessing renal function prior to administering renal-clearing drugs (see Figure 12.1 in the original guideline document).
  • Reconciliation of medications ordered at admission and at discharge in consultation with a pharmacist (Gleason et al., 2004 [Level IV]; Santell, 2006 [Level VI]), geriatric expert, or computer-based program (Joanna Briggs Institute, 2006 [Level I]; Feldman et al., 2006 [Level IV]).
  • Review medication list using Beers criteria for potentially inappropriate medications, particularly those with high severity and for potential drug–drug and drug–disease interactions (see Tables 12.1 and 12.2 in the original guideline document) (Fick et al., 2003 [Level VI]; Zhan et al., 2005 [Level IV]).
  • At discharge from hospital, use appropriate tools to assess individual's ability to self-administer medications:
    • Assess functional capacity: ADLs, IADLs, Mini-Cog. (See the NGC summaries of the Hartford Institute for Geriatric Nursing guidelines Assessment of Function and Assessing Cognitive Function.)
    • Assess individuals (at admission or initial encounter and at discharge) who administer their own medicines with DRUGS tool to identify potential areas of self-administration difficulty (see Resources section of topic at www.ConsultGeriRN.org) (Edelberg, Shallenberger, & Wei, 1999; Edelberg et al., 2000; Hutchinson et al., 2006 [all Level IV]).

Interventions and Nursing Care Strategies

• Reduce adverse drug events (ADEs) (during and post hospitalization)
  • Patient empowerment. Patients should be given the necessary information and the opportunity to exercise the degree of control they choose over health care decisions that affect them. If patients are involved in decision making, they are less likely to make decisions that may lead to adverse drug reactions (ADRs) (National Coordinating Council for Medication Errors Reporting and Prevention [NCC MERP], 2001 [Level VI]), such as abruptly discontinuing a medication that should be tapered off.
  • Comprehensive Medication Assessment on admission as indicated in assessment (see Table 12.4 in the original guideline document).
  • Collaborate with the interdisciplinary team to effect change in reducing the numbers of ADEs and ADRs, many of which are preventable (Hanlon et al., 2001 [Level V]).
  • Prescribing Principles. Monitoring for appropriate prescribing and alerting the prescriber to potential problem areas helps reduce medication-related problems. Prescribing a medication is multifaceted: deciding that a drug is truly indicated; choosing the best drug; determining appropriate dose for the individual; monitoring for toxicity and effectiveness; and seeking consultation when necessary (Rochon, 2006 [Level V]). These principles support recommendations to:
    • Reduce the dose. "Start Low and Go Slow," or give the lowest possible dose when starting a medication and slow upward titration to obtain clinical benefit; many ADEs are dose-related (Petrone & Katz, 2005 [Level IV]; Rochon, 2006 [Level V]). Primary provider should be notified if the dosage ordered is higher than the recommended starting dose (e.g., digoxin maximum dose <0.125 mg for treatment of congestive heart failure [CHF]) (Fick et al., 2003 [Level VI]).
    • Discontinue unnecessary therapy. Prescribers are often reluctant to stop medications, especially if they did not initiate the treatment. This practice increases the risk for an adverse event (Rochon, 2006 [Level V]).
    • Attempt a trial of nonpharmacological interventions/treatments prior to requesting medication for new symptoms (Rochon, 2006 [Level V]).
    • Recommend safer drugs. Avoid drugs that are likely to be associated with adverse outcomes (review Try this: Beers Criteria in resources section at www.consultgeriRN.org) (Petrone & Katz, 2005 [Level IV]).
    • Assess renal function using Cockroft-Gault formula (for renally cleared drugs) to determine accurate dosage prior to prescribing such as many routinely prescribed intravenous (IV) antibiotics. Dosage recommendations are available based on this formula in Physician's Desk Reference (PDR) and other common prescribing resources.
    • Optimize drug regimen. When prescribing medications, the focus should be on risk versus benefit where the expected health benefit (e.g., relief of agitation in dementia with psychosis) exceeds the expected negative consequences (e.g., morbidity and mortality from falls that result in hip fracture) (Leipzig, Cumming, & Tinetti, 1999 [Level I]; Ooi, Hossain, & Lipsitz, 2000 [Level II]).
    • Initiation of new medication. Assess for potential drug–disease and drug–drug interactions and correct dosages, the most common causes of ADRs, before starting new drugs (Doucet et al., 2002 [Level V]; NCC MERP, 2001 [Level VI]; Petrone & Katz, 2005 [Level IV]).
    • Avoid the prescribing cascade. Avoid the prescribing cascade by first considering a new symptom as being a consequence of a current medication prior to adding a new medication (Rochon, 2006 [Level V]; Rochon & Gurwitz, 1997 [Level V]).
    • Avoid inappropriate medications in older persons. Review criteria for potentially inappropriate medications (see Table 12.1 in the original guideline document) or drug–disease interactions (see Table 12.2 in the original guideline document) and potential drug–drug interactions (see Table 12.3 in the original guideline document) (Fick et al., 2006 [Level VI]).
• Specific interventions for prevention of iatrogenic adverse drug reactions (in hospital and after discharge)
  • Consider any new symptom as a possible ADE before requesting/administering new medication for the symptom, avoiding the prescribing cascade (Gurwitz et al., 2003 [Level IV]).
  • Monitor medication orders for wrong drug choices (high-risk inappropriate medications, drug–disease and drug–drug interactions), wrong dosages, or administration errors (Doucette et al. 2005 [Level V]; Gurwitz et al., 2003 [Level IV]; Hanlon et al., 1997 [Level IV]). Consider use of technological handheld devices such as personal digital assistant (PDA) for quick access to Beers criteria, drug–drug or drug–disease interactions, and geriatric assessment tools (see www.ConsultGeriRN.org).
  • Improve prescribing practices by documenting indication for initiation of new drug therapy, maintaining a current medication list, documenting response to therapy, as well as the need for ongoing treatment (Knight & Avorn, 2001 [Level VI]; Merle et al., 2005 [Level VI]) and evaluating co-morbidities (Merle et al., 2005 [Level VI]).
  • Institutional implementation of computer-assisted technology for medication order entry: has the potential to prevent an estimated 84% of dose, frequency, and route errors; and from 28% to 95% of ADEs can be prevented by reducing medication errors through computerized monitoring systems (Agency for Healthcare Research and Quality [AHRQ], 2001 [Level I]). Identifying and reporting of ADRs can also be performed using computer-assisted National Surveillance system. Institutions must facilitate a culture of safety to reduce ADRs/ADEs.
• Interventions at discharge
  • Reconciliation of medications at discharge (Gleason et al., 2004 [Level IV]; Nickerson et al., 2005 [Level II]; Joint commission on Accreditation of health care Organizations [JCAHO], 2006, 2007 [Level VI]) helps to reduce ADR/ADEs and therefore rehospitalization.
  • Assess abilities and limitations and health literacy in self-administration of medications using appropriate tools at discharge (Curry et al., 2005 [Level VI]) and recognize that self-administration and nonadherence can induce ADRs (Merle et al., 2005 [Level VI]).
  • Assess for adherence issues that may develop after discharge, which can help to reduce ADEs (Nickerson et al., 2005 [Level II]) and rehospitalization (Bergman-Evans, 2006; Edelberg, Shallenberger, & Wei, 1999 [Level IV]; Fulmer et al., 2000). Recommend devices that can assist in enhancing adherence behavior (Fulmer et al., 1999) and interventions to address cost and other adherence issues.
  • Patient/Caregiver Education. Provide patient and caregiver education using relevant nursing content and principles (Curry et al., 2005 [Level VI]) including assessment of factors that might affect adherence. Nurses are the primary source for providing education to patients at discharge; therefore, their role is key to preventing medication-related consequences after hospitalization, including rehospitalization. Discharge education and counseling includes:
    • Education tailored to the age group and needs of the individual (Bergman-Evans, 2006)
    • Educate the patient/caregiver about benefits and risks (Shekelle et al., 2001) and potential medication side effects (Rochon, 2006 [Level V]).
    • Teach safe medication management (Curry et al., 2005 [Level VI]).
    • Consider an interactive computer program (Personal Education Program [PEP]) designed for the learning styles and psychomotor skills of older adults to teach about potential drug interactions that can result from self-medication with OTC agents and alcohol (Neafsey et al., 2002 [Level II]).

Follow-Up Monitoring

• Health care providers will:
  • Provide consistent and appropriate care and follow-up in presence of a medication-related problem.
  • Evaluate with physical exam and laboratory tests (as appropriate) on regular basis to ensure that the older adult is responding to therapy as expected (Edelberg et al., 2000 [Level IV]).
• Institutions will:
  • Provide ongoing assessment of staff competence in assessing and intervening for prevention of ADEs.
  • Embed reduction of ADEs in the culture of safety

Definitions:

Levels of Evidence

Level I: Systematic reviews (integrative/meta-analyses/clinical practice guidelines based on systematic reviews)

Level II: Single experimental study (randomized controlled trials [RCTs])

Level III: Quasi-experimental studies

Level IV: Non-experimental studies

Level V: Care report/program evaluation/narrative literature reviews

Level VI: Opinions of respected authorities/Consensus panels

Reprinted with permission from Springer Publishing Company: Capezuti, E., Zwicker, D., Mezey, M. & Fulmer, T. (Eds). (2008) Evidence Based Geriatric Nursing Protocols for Best Practice, (3^rd ed). New York: Springer Publishing Company.

References open in a new window

Electronic copies: Available from the Hartford Institute for Geriatric Nursing Website.

Copies of the book Geriatric Nursing Protocols for Best Practice, 3rd edition: Available from Springer Publishing Company, 536 Broadway, New York, NY 10012; Phone: (212) 431-4370; Fax: (212) 941-7842; Web: www.springerpub.com.

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