The importance of eliminating UNNECESSARY medications.
Once put on certain medications in nursing homes patients often stay on them indefinitely. Examples are drugs like cholinesterase inhibitors that are designed to slow down the progression of Alzheimer’s disease. While effective for a limited time, once started, patients may stay on these for years, sometimes up until death, with no benefit and wasted money.
Comprehensive medication reviews are rarely done, but can actually be quick and effective. Doing this twice a year at minimum, could save thousands of dollars and prevent side effects including costly falls, sedation and other issues leading to further impairment in cognition and function. Many nursing homes employ pharmacy consultants to monitor these medications but a prescriber who knows the patients will have a better understanding of the patient’s actual needs. Long-term care administrators and public health agencies would certainly support the effort as the cost savings could be significant. Nurses and families would support saving time and money, and would also appreciate the fact that it can lead to better care. Benefits for nurses include improved compliance and efficiency with less medication for patients to swallow, fewer pills for nurses to pass out, less count time and fewer medications sitting in carts leading to a decreased risk in drug diversion.
Psychiatry should review all medications twice yearly to see any medications can be eliminated. In long-term care settings the team of psychiatric consultants, the attending MD and Nurse Practitioners often add psychiatric medication over time which can lead to polypharmacy. In outpatient psychiatric settings, patients should be taught to list all medications, including herbal remedies and then have their psychiatric provider review them twice yearly to ensure medications are still needed.
What to look for:
Unused or infrequently used PRN (as needed) medications; for example: If the patients have not used the PRN benzodiazepine in the past two months it should be discontinued. Keeping it increases cost and risk diversion.
Medications with little efficacy where risk may outweigh the benefit; for example, Aricept (donepezil) which may have a benefit, for a short period of time but has side effects like syncope or anorexia. If it is still being used frequently an MMSEs (Mini-mental status exam) should be completed to justify its continued use.
Add on medications for side effects; examples might include adding Mirtazapine (Remeron) to a cholinesterase inhibitor-induced anorexia. Or Cogentin (Benztropine) for Parkinsonism induced by antipsychotic medication. Elimination of the cholinesterase inhibitor might eliminate the need for Mirtazapine while reducing the anti-psychotic might reduce the need for Cogentin.
Meds with no indication; example: A patient with no known history or diagnosis of a seizure or mood disorder who is admitted on Lamictal (Lamotrizine) with no indication for use should perhaps be tapered.
Duplicate medications at suboptimal doses; for example, a patient is on Olanzapine (Zyprexa) 10 mg and Risperdal (Risperidone) 0.5 concurrently. Why not eliminate the Risperdal and if patient decompensates, increase the Olanzapine so that he is on one medication instead of two? Patients are often on two antidepressants at low doses. Why not stick with one and taper it up to a dose where maximum benefit on one can be seen or ruled out before adding a second?
Medical medications causing psychiatric symptoms; for example, many medical medications can cause psychiatric symptoms and many classes of medication cause depression. Medications with anticholinergic properties cause confusion. (1) Identifying the medications and either reducing them or switching them may reduce the need for an added psychiatric medication. If a person has both medical and psychiatric symptoms, a single drug may occasionally help both issues and a beta blocker may aid both hypertension and anxiety.
Psychiatric medications causing psychiatric symptoms; for example, a patient on a benzodiazepine might have behavioral issues due to disinhibition or a patient with hypomania is being induced by being on two separate antidepressants. Reducing or eliminating these medications may actually prevent having to add another to address their behavioral issues or symptoms.
In summary biannual, medication reduction reviews in long-term care should be a standard in long-term care settings as they can be quite beneficial in reducing costs, time and most importantly improving patient care.
Ellison, J. MD MPH IS it something I’m taking” Bright focus foundation taken from the www at https://www.brightfocus.org/alzheimers/article/it-somethingim-taking-medications-can-mimic-dementia July 7.2108