● Comprehensive medication reviews and associated clinical pharmacy interventions. ● Standardization of medication administration practices, with electronic health record alerts. ● Educational resources and training. Self-Assessment Quiz Question #5 A comprehensive medication review should include all the following EXCEPT: a. Match each drug to a valid indication. b. Review a medication profile for drug–drug interactions. c. Determine if the patient can comply with the medication regimen. d. Choose the patient or prescriber’s preferred pharmaceutical manufacturer. ● Naproxen 500 mg twice daily. ● Ferrous sulfate 325 mg twice daily. ● Pantoprazole 40 mg every morning (initiated as stress ulcer prophylaxis during her hospital stay three months ago). ● Oxybutynin XL 15 mg every morning. ● Tramadol 50 mg every 6 hours if needed for pain. ● Zolpidem 5 mg at bedtime if needed for sleep. Questions 1. Without disease progression or other compelling reasons to maintain or escalate treatment, what drug-related problems and subsequent interventions could be identified during medication reconciliation? 2. Which medications are likely to contribute to fall risks? 3. Are there any medications that no longer have a valid indication for use?
Additionally, several specific medications—digoxin and epinephrine—were highlighted based on dosing and route of administration concerns. The medications and therapeutic classes identified in this alert largely overlap with high-risk medications in acute care settings; however, the complicating factors of the patients and resources in this care setting likely confer an added risk of harm. Numerous interventions to improve medication safety for elderly patients in long- term care settings exist. Sluggett and colleagues offered 21 comprehensive strategies to monitor and enhance the use of high-risk medications in long-term care facility residents, which apply to medication management best practices regardless of the medication risk level (Sluggett et al., 2020). Suggested strategies included: ● Risk assessment tools (e.g., STOPP/START, AGS Beers criteria). ● Deprescribing guidelines and protocols. Case study – Part II GA, an 82-year-old female, presents to her primary care provider for a scheduled follow-up visit. She was hospitalized three months earlier after sustaining a hip fracture from a supervised fall in the assisted living facility where she has resided for the past two years. Her current medical problems included hypertension, osteoporosis, hyperlipidemia, diabetes mellitus type 2, overactive bladder with intermittent incontinence, osteoarthritis, anemia, sleep dysregulation, and residual lower extremity pain from her hip fracture. Additionally, caregivers and family members report that GA has reported new signs of forgetfulness and repetitive questioning. The patient reports using the following medications: ● Lisinopril 5 mg every morning. ● Calcium carbonate 600 mg with vitamin D every morning ● Simvastatin 10 mg every evening. ● Glipizide sustained release 10 mg every evening with dinner
Discussion for all questions: Drug-Related Problems
Potential Modifications to the Current Regimen
Drug interaction between calcium supplement and ferrous sulfate. Sulfonylurea use in an elderly patient, compounded by evening administration, may increase the risk of nocturnal/morning hypoglycemia with serious sequelae. Anticholinergic medication (oxybutynin) in elderly patients may increase fall risk. Naproxen use in older people may increase risk of renal dysfunction and/or gastrointestinal bleeding.
Separate the administration of calcium supplements from other medications by at least two hours. Consider replacing sulfonylurea with metformin; if sulfonylurea remains, change to morning administration and monitor blood glucose trends.
Discontinue oxybutynin.
Change naproxen to acetaminophen around the clock (not to exceed 3,000 mg/day). Discontinue zolpidem, tapering off if used regularly; consider nonpharmacologic sleep hygiene interventions for insomnia; add melatonin if necessary. Discontinue tramadol; consider prn NSAID for breakthrough pain. Discontinue pantoprazole via slow taper over four weeks; if ongoing gastric acid suppression is warranted, consider famotidine
Tramadol and zolpidem use may increase fall risk.
Tramadol accumulation and toxicity (including seizures) may occur with age-related renal impairment. Pantoprazole is no longer indicated for stress ulcer prophylaxis; prolonged use is associated with C. dificile diarrhea, hypomagnesemia, bone loss, aspiration pneumonia Self-Assessment Quiz Question #5 Which of the following is generally associated with the least risk for use in elderly patients? a. Acetaminophen. b. Lansoprazole.
c. Tramadol. d. Zolpidem.
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Book Code: RPTTX2024
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