Patient Safety Tip of the Week
April 4, 2017 Deprescribing in
Long-Term Care
AHRQ has just added to their collection of patient safety
primers a new one on patient safety in long-term care (AHRQ 2017). It separates
long-term care into long-term acute care hospitals, inpatient rehabilitation
hospitals, and skilled nursing facilities (SNF’s). Almost 40% of Medicare
patients are discharged to some form of long-term care facility following
hospital discharge. The term “post-acute care” generally refers to care in a
setting where care following an acute hospital discharge is rendered. Such
patients represent an increasing proportion of the overall SNF population. One
study found that 22% of Medicare SNF patients had an adverse event, about half
of which were preventable. A similar study (Levinson 2016)
found that 29% of Medicare patients admitted to a post-acute rehabilitation
facility (rehab units in acute care hospitals were excluded) experienced either
an adverse event or temporary harm event (see our September 2016 What's New
in the Patient Safety World column “Adverse
Events in Rehab Facilities”).
Almost half (46%) of these were deemed to be likely preventable. These event
rates are really quite similar to rates the OIG has found for Medicare patients
in acute hospitals (27%) and simply demonstrate that all the factors which
contribute to adverse events in hospitals are not unique to acute care
hospitals but also occur in almost all healthcare settings.
The new AHRQ primer points out that common hazards in older
patients in these settings include medication errors, healthcare-associated
infections, delirium, falls, and pressure ulcers. Timely in this regard are some
new studies on medication issues in long-term care settings.
A recent systematic review of medication errors found that
medication errors occurred in 16-27% of SNF residents in studies looking at all
types of medication errors (Ferrah 2017).
And 13-31% of SNF residents had medication errors in those studies looking at
transfer-related medication errors. And 75% of SNF residents received at least
one potentially inappropriate medication (PIM). However, the authors also found
that serious outcomes were relatively infrequent and death related to
medication errors was rare in this setting, though they speculated that serious
outcomes might be underreported.
It should not be surprising that medication errors and
adverse drug events (ADE’s) are near the top of the list of adverse events in
long-term care. The AHRQ primer notes that many of the safety tools we use in
acute hospitals (eg. barcoding, CPOE) are not as widely implemented in
long-term care. In addition, patients in long-term care often have multiple
comorbidities and are on numerous medications. So two interventions in
long-term care are critical in reducing ADE’s: medication reconciliation and
deprescribing. We’ve done numerous columns on deprescribing (see the list at
the end of today’s column). Liu and Campbell recently offered some tips on
deprescribing in long-term care (Liu
2016).
The Liu article includes an excellent tip sheet for
deprescribing in the nursing home. It builds upon the excellent 5-step protocol
to aid the deprescribing process described by Scott and colleagues (Scott
2015) that we discussed in our July
2015 What's New in the Patient Safety World column “Tools
for Deprescribing”. But it adds a few considerations that focus on patients
in long-term care. The Liu tip sheet emphasizes that deprescribing should be
considered any time the patient’s medication list is reviewed, which should
include any time there is a change in a patient’s condition or a new symptom,
before prescribing any new medication, and at every visit. It then recommends
the following steps before discontinuation or tapering of any medication:
- Review all medications (for indication, dose, continued need,
possible drug interactions, possible side effects, and risk:benefit ratio)
- Identify potential medication to discontinue
-Look for “prescribing cascades”
-Always consider that any new symptom might be a side effect or adverse effect of an existing medication
-Use Beers List and the STOPP Tool to identify potentially inappropriate medications (see list of our prior columns below regarding these)
-Review the American Geriatrics Society list of things to avoid in the Choosing Wisely® Campaign - Determine the goals of care, life expectancy, disease trajectory,
and length of time to benefit of preventive medications
- Choose one medication at a time
- Consider consulting with a specialist
- Discuss with the patient, family, responsible party, facility staff
Once you’ve
identified a medication to discontinue, begin taper process and monitor and
reassess:
- Write the order for initial dose reduction or discontinuation
- Educate nursing home staff for what to monitor
- Identify specific targets for monitoring (eg. blood pressure,
weight, etc.)
- Communicate with patient or family and request they call if they
identify any potential adverse effects
And then they add another
important point that we have harped upon in many columns (most recently in our March
2017 What's New in the Patient Safety World column “Yes!
Another Voice for Medication e-Discontinuation!”): document all about discontinuation of
the medication! That includes documenting the reason for
discontinuation, the plan for monitoring and follow-up, the patient/family communication,
other communications, and outcomes).
A couple points
deserve special comment. Particularly important is consideration on how the
intended benefit of any medication relates to the overall goals of care, life
expectancy, and disease trajectory (and length of time to benefit of preventive
medications). The article also has tables with symptoms that are common side
effects of various medications and common examples of the prescribing
cascade. For example, a patient might develop urinary retention while
taking amitriptyline. But if it is not recognized as a side effect of the
amitriptyline the patient may be started on tamulosin. The article also has a
nice list of medications that are commonly associated with discontinuation
syndromes. The article also has a nice discussion about some of the
barriers to deprescribing that may come from patients, families, collaborative
partners, and nursing staff.
We think you’ll use
this tip sheet often if you care for patients in long-term care. Quite frankly,
all the recommendations apply equally well to elderly patients in almost any
setting.
And, of course, one
of the items on the American
Geriatrics Society list of things to avoid in the Choosing Wisely® Campaign is “Don’t use antipsychotics as
the first choice to treat behavioral and psychological symptoms of dementia.”
Antipsychotics have often been used in long-term care not just in
patients with delirium but also in patients with dementia and agitation or
aggressive behavioral issues. We’ve often discussed the efforts to reduce use
of antipsychotics in long-term care patients (see our February 3, 2015 Patient
Safety Tip of the Week “CMS
Hopes to Reduce Antipsychotics in Dementia”).
Use of antipsychotics in patients with dementia has long
under fire because of limited efficacy and occurrence of serious adverse
effects, such as an increase in stroke and mortality (Corbett 2014). They may also
cause sedation, extrapyramidal signs, and some may produce orthostatic
hypotension. The latter may all contribute to falls and fractures, as reported
recently in patients 65 years and older who were started on an atypical
antipsychotic medication as an outpatient (Fraser
2015). That study found that antipsychotic use increased the risk of
serious falls by 52% and the risk or nonvertebral osteoporotic fracture by 50%
compared to a matched control group, regardless of the specific agent used.
Despite guidelines and warnings against their use,
antipsychotics continue to be used often in nursing homes and long-term care
settings. In 2012 CMS challenged LTC and SNF facilities to reduce use of
antipsychotics by 15% and between the
end of 2011 and the end of 2013, the national prevalence of antipsychotic use
in long-stay nursing home residents was reduced by 15.1 percent. CMS developed
its National Partnership to Improve Dementia Care in Nursing Homes, a
public-private coalition of CMS and several other partners, with a national
goal of reducing the use of antipsychotic medications in long-stay nursing home
residents by a further 25 percent by the end of 2015, and 30 percent by the end
of 2016 (CMS
2014). In a commentary on those goals Leonard Gellman, MD pointed
out that most antipsychotic medications are not actually prescribed by the
nursing homes (Frieden
2014). Rather they are often started when the patient is in a hospital and
continued upon discharge or they may have been started by the patient’s primary
care physician. Once they have been started, facilities and patients’ families
are reluctant to discontinue or reduce them. Since the start of the CMS
National Partnership, there has been a decrease of 27 percent in the prevalence
of antipsychotic medication use in long-stay nursing home residents, to a
national prevalence of 17.4 percent in Fiscal Year (FY) 2015 Quarter 3 (CMS
2016a).
Our February 3, 2015 Patient Safety Tip of the Week “CMS
Hopes to Reduce Antipsychotics in Dementia” further described several
interventions and programs that had successfully reduced the use of
antipsychotic drugs in long-term care settings. The updated CMS web page for
the National Partnership also provides access to numerous resources (CMS
2016b).
One underappreciated consideration regarding medications in
the long-term care population is the association between frailty and impaired renal function. The percentage of patients
with frailty in this population is very high and, because of sarcopenia in the
frail, measuring renal function with creatinine and eGFR is problematic.
Therefore, Ballew and colleagues (Ballew 2017)
looked at cystatin C in addition to creatinine and urine albumin in community-dwelling
men and women 66 years or older. Of almost 5000 subjects, 7% were determined to
be frail. Among frail subjects, prevalence of
eGFR < 60 calculated using creatinine and cystatin C were
45% and 77%, respectively. After adjustment, frailty showed a moderate
association with eGFRcr but a strong association with eGFRcys and
albumin-creatinine ratio. Moreover, hyperpolypharmacy (defined as
taking ≥10 classes of medications) was more common in frail
individuals (54% vs 38% of nonfrail), including classes requiring kidney
clearance (eg, digoxin) and associated with falls and subsequent complications
(eg, hypnotic/sedatives and anticoagulants). While this was not a long-term
care population, we don’t doubt that the same findings would apply to the
long-term care population since the prevalence of frailty there is so high.
These results suggest we need to be assessing renal function in this population
using cystatin C to make more rational judgments about usage and dosing of
certain drugs in this population.
Transitions from acute care to long-term care or other
post-acute care setting are particularly vulnerable to error. Medication
reconciliation at the time of hospital discharge provides a good opportunity to
identify medications that might be appropriate for discontinuation or dose
reduction (see our May 2015 What’s New
in the Patient Safety World column “Hospitalization:
Missed Opportunity to Deprescribe”). One group of clinicians implemented
a brown bag medication reconciliation process in the hospital setting to
decrease medication discrepancies by encouraging evaluation of medication
adherence, side effects, and monitoring at posthospitalization follow-up (Becker
2015). After implementation, a 7% decrease in reportable errors was noted.
And several times we have mentioned a specific type of error
that may occur in patients discharged back to an SNF. The classic example is methotrexate. Methotrexate for most
non-oncologic indications is dosed on a weekly basis. But sometimes patients
returning from a hospital or ER or specialty clinic erroneously get started on
daily methotrexate at the SNF, often with dire consequences. In our July 2011 What's New in the Patient
Safety World column “More
Problems With Methotrexate” we noted that the patient in a long-term care facility may be especially vulnerable.
In such cases, the original order for methotrexate is usually written by a
specialist. The patient is then followed in the LTC facility typically by a
primary care physician who may be less knowledgeable about the particular use
of methotrexate for that condition. Also, the LTC patient may not be seen by a
physician for periods as long as a month. And many LTC patients have cognitive
impairments that might prevent them from understanding issues about their
medications. So if a medication reconciliation error has occurred and a patient
intended for once weekly dosing is now on daily dosing, the opportunity for
toxicity is greatly increased. So LTC facilities should take steps to ensure
that any of their residents taking methotrexate get the same level of supervision
and protections that non-LTC patients would get. Those SNF’s with CPOE should
always use weekly dosing as the default and require hard stop overrides for any
attempt to order daily methotrexate.
And, of course, the classic example of medications that are
no longer needed are proton pump
inhibitors that were begun during an ICU admission but never discontinued.
If the patient gets sent back to the long-term care facility on PPI’s they are
likely to be continued indefinitely, even though they are no longer necessary,
unless someone does a careful review of the medication list with deprescribing
in mind.
Lastly, one anecdote we love to tell. The fall rate at one
SNF fell dramatically one month. So we asked “how did you do it?”. It turned
out that there had been a disruption in the relationship the SNF had with a
consulting psychiatrist. As a result, multiple patients did not have renewals
of their orders for a variety of antidepressants and antipsychotic agents. That
inadvertent cessation of these medications had led to a striking reduction in
falls!
Some of our past columns on deprescribing:
- March 4, 2014 “Evidence-Based
Prescribing and Deprescribing in the Elderly”
- September 30, 2014 “More
on Deprescribing”
- May 2015 “Hospitalization:
Missed Opportunity to Deprescribe”
- July 2015 “Tools
for Deprescribing”
Some of our past columns on patient safety issues in
long-term care settings:
- July 21, 2009 “Medication
Errors in Long-Term Care”
- January 18, 2011 “More
on Medication Errors in Long-Term Care”
- July 2011 “More
Problems with Methotrexate”
- March 20, 2012 “Adverse
Events Related to Psychotropic Medications”
- May 2012 “Safety
of Hypnotic Drugs”
- August 2012 “New
Joint Commission Tools for Improving Handoffs”
- February 3, 2015 “CMS
Hopes to Reduce Antipsychotics in Dementia”
- July 28, 2015 “Not
All Falls Are the Same”
- February 2016 “Avoiding
Methotrexate Errors”
- February 16, 2016 “Fall
Prevention Failing”
- September 2016 “Adverse
Events in Rehab Facilities”
Some of our past columns on Beers’ List and Inappropriate
Prescribing in the Elderly:
- January 15, 2008 “Managing
Dangerous Medications in the Elderly
- June 2008 “Potentially
Inappropriate Medication Use in Elderly Hospitalized Patients”
- October 19, 2010 “Optimizing
Medications in the Elderly”
- September 22, 2009 “Psychotropic
Drugs and Falls in the SNF”
- September 2010 “Beers
List and CPOE”
- June 21, 2011 “STOPP
Using Beers’ List?”
- December 2011 “Beers’
Criteria Update in the Works”
- May 7, 2013 “Drug
Errors in the Home”
- November 12, 2013 “More
on Inappropriate Meds in the Elderly”
- January 28, 2014 “Is
Polypharmacy Always Bad?”
- March 4, 2014 “Evidence-Based
Prescribing and Deprescribing in the Elderly”
- September 30, 2014 “More
on Deprescribing”
- February 10, 2015 “The
Anticholinergic Burden and Dementia”
- May 2015 “Hospitalization:
Missed Opportunity to Deprescribe”
- July 2015 “Tools
for Deprescribing”
- November 2015 “Medications
Most Likely to Harm the Elderly Are…”
- August 2, 2016 “Drugs
in the Elderly: The Goldilocks Story”
Our prior columns related to methotrexate issues:
- July 2010 “Methotrexate
Overdose Due to Prescribing Error”
- July 2011 “More
Problems With Methotrexate”
- February 2016 “Avoiding
Methotrexate Errors”
- June 21, 2016 “Methotrexate
Errors in Australia”
References:
AHRQ PSNet. Patient Safety Primer. Safety in Long-term Care.
AHRQ 2017
https://psnet.ahrq.gov/primers/primer/39
Levinson DR (Office of the Inspector General. Adverse Events
in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries.
July 2016
https://oig.hhs.gov/oei/reports/oei-06-14-00110.asp
PDF
https://oig.hhs.gov/oei/reports/oei-06-14-00110.pdf
Ferrah N, Lovell JJ, Ibrahim JE. Systematic Review of the
Prevalence of Medication Errors Resulting in Hospitalization and Death of
Nursing Home Residents. J Am Geriatr Soc 2017; 65(2): 433-442
http://onlinelibrary.wiley.com/doi/10.1111/jgs.14683/full
Liu LM, Campbell IG. Tips for Deprescribing in the Nursing
Home. Annals of Long-Term Care 2016; 24(9): October 17, 2016
http://www.managedhealthcareconnect.com/article/tips-deprescribing-nursing-home
Scott IA, Hilmer SN, Reeve E, et al. Reducing Inappropriate
Polypharmacy. The Process of Deprescribing. JAMA Intern Med 2015; 175(5):
827-834
http://archinte.jamanetwork.com/article.aspx?articleid=2204035
Choosing Wisely® Campaign. American Geriatrics Society list.
http://www.choosingwisely.org/clinician-lists/#parentSociety=American_Geriatrics_Society
Corbett A, Burns A, Ballard C. Don’t use antipsychotics
routinely to treat agitation and aggression in people with dementia. BMJ 2014;
349 doi: http://dx.doi.org/10.1136/bmj.g6420 (Published 03 November 2014)
http://www.bmj.com/content/349/bmj.g6420
Fraser L-A, Liu K, Naylor KL, et al. Falls and Fractures
With Atypical Antipsychotic Medication Use: A Population-Based Cohort Study.
Research Letter. JAMA Intern Med
2015; Published online January 12, 2015
http://archinte.jamanetwork.com/article.aspx?articleid=2089230
CMS. National Partnership to Improve Dementia Care exceeds
goal to reduce use of antipsychotic medications in nursing homes: CMS announces
new goal. CMS Press Release September 19, 2014
CMS. Update Report on the National Partnership to Improve
Dementia Care in Nursing Homes. June 3, 2016
CMS. National Partnership to Improve Dementia Care in
Nursing Homes. Last updated 12/1/2016
Frieden J. Antipsychotics for Dementia: CMS Says Use Less.
Medpagetoday 2014; September 22, 2014
http://www.medpagetoday.com/Geriatrics/Dementia/47781
Ballew SH, Chen Y, Daya NR, et al. Frailty, Kidney Function,
and Polypharmacy. The Atherosclerosis Risk in Communities (ARIC) Study. Am J
Kidney Dis 2017; 69(2): 228-236
http://www.ajkd.org/article/S0272-6386(16)30525-X/fulltext
Becker D.Implementation of a Bag Medication Reconciliation
Initiative to Decrease Posthospitalization Medication Discrepancies. Journal of
Nursing Care Quality 2015; 30(3): 220-225
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