Medication Review

This article is written based on Swedish conditions. Hopefully it can inspire interested people from other countries.

Medication reviews should occur at least once a year for those who take many medications. Nurses and doctors need to jointly plan so that all residents receive their annual medication review. The region often has requirements on how medication reviews should be carried out. The nurse can contribute to the quality of the review by preparing with a review using, for example, Phase-20 or Phase Proxy.

Foto: Mostphotos

At a nursing home, there was a dedicated doctor and equally dedicated nurse who systematically went through medication use. The average consumption decreased from just over ten medications per resident to just under five. Many of the residents had a much better life. Two residents were able to move back to their own homes again.
Similar stories have appeared in the media. It has happened that all medications have been discontinued for a person who was essentially dying, and that the person revives after a short period of rehabilitation returned to a more normal life.

Side Effects

All medications can cause side effects, and some affect the elderly particularly hard. Many are well known and can easily be prevented. When the mucous membranes and kidneys deteriorate, the absorption and excretion are not as efficient. The regulation of blood pressure and reduced levels of neurotransmitters that transmit signals in the nervous system are other factors that affect the action of drugs. For the elderly, for example, Tramadol® and Propavan® should be avoided.

As the proportion of body fat increases, fat-soluble drugs have a larger volume to distribute in. Thus, they can remain in the body longer with a risk of accumulating and causing side effects. Psychotropic drugs are often fat-soluble.
The National Board of Health and Welfare recommends that simple drug reviews are conducted together with the patient, possibly with relatives and healthcare staff. During a simple drug review, current drug treatment is checked and assessed, any action is taken, and the drug list is documented and updated.

Chief Physician Eva Oskarsson, Sundsvall Hospital / Region Västernorrland, and Licensed Pharmacist, AT-doctor Emelie Sörqvist Fagerberg write in an article in Internet Medicine that older people are increasingly taking medications. This means that healthcare always must consider that new symptoms may be side effects from drug treatment. Studies show that 10% of acute hospital admissions are wholly or partially drug-related.

Older people have less margin and thereby worse biological protection to compensate, for example, blood pressure changes. The body's composition changes so that the proportion of body fat increases and body water decreases. Fat-soluble drugs have a larger volume to distribute in, which leads to the drugs remaining longer in the body.

Malnutrition and dehydration also contribute to increased risks for drug side effects. At the same time, the kidneys and liver function worse, which can mean that drugs cannot be excreted from the body as quickly. Altogether, this can cause the body to become poisoned.
The aging brain is also more sensitive, especially to drugs that affect the central nervous system. This can lead to both dizziness and confusion. The risk is particularly high in people with dementia.

Many psychotropic and blood pressure-lowering drugs, as well as drugs that treat Parkinson's disease, can contribute to dizziness, falls, and fainting. Drug review is, therefore, a significant part of fall prevention work.

Cognitive impairment can also be drug-induced. In addition to psychotropic drugs and drugs for the treatment of Parkinson's disease, many drugs for incontinence problems also contribute. However, there are often drug choices that reduce the risk of side effects in the elderly as presented on the "Wise List".
Pain can have different expressions. Mismanaged pain can resemble side effects. To treat pain, one must start with a pain analysis. There are different methods to investigate pain. When it comes to people with dementia, the Abbey Pain Scale can be used. Occupational therapists and physiotherapists can often supplement the treatment and contribute positive side effects for the resident.

Fatigue is also a symptom that can have different underlying causes. In addition to under- or malnutrition, depression, heart failure, or urinary tract infection can be underlying causes.

Preparation for Drug Review

The nurse and doctor jointly plan for all residents to have their annual drug review. Often the region has requirements for how drug reviews should be conducted. The nurse can contribute to the quality of the review by preparing with a review such as Phase-20 or Phase Proxy to identify symptoms in the elderly that may be related to drug treatment, such as side effects or unwanted side effects when certain drugs react together (interaction).

An in-depth drug review is conducted if the resident has many drugs or suffers from side effects. Then a deeper analysis of medical history and status, tests, lifestyle habits, lifestyle, and indication for treatment is carried out. The National Board of Health and Welfare has issued recommendations "Good drug therapy in the elderly". It includes a special list of drugs that should not be prescribed to the elderly.

The purpose of the drug review is to map out which drugs the patient is prescribed, how the patient takes the drugs, create a current drug list, evaluate the treatment, and assess whether it is appropriate and safe. Necessary measures to solve or prevent drug-related problems must be taken. Each drug must have a current indication stating why the resident should take them. The benefits of the treatment should outweigh the risks. Some regions provide a pharmacist who can contribute valuable knowledge in the drug review.

Interaction means that the interaction between drugs can give unexpected negative effects. For example, the effect of one drug is greatly enhanced. Over-the-counter drugs can give unwanted effects. As a patient, you must, therefore, tell the doctor about drugs like Alvedon, Treo, Ipren, and herbal medicines. Interactions can lead to states of confusion. It has happened that people perceived as demented have regained their memory and functioned well when drugs were discontinued.

Alcohol interacts with some drugs, which can cause unexpected and unwanted effects. Always read the package leaflet before using a drug. Much has been done to reduce the risk of serious interactions. Among other things, journal systems and the prescription tool Pascal often warn of the most serious ones.

Interactions are described in FASS but then only apply to pairwise combinations. What happens in the body when a person takes a number of medicines in different combinations is not clarified. Drug treatments for physical diseases have increased, and we must constantly weigh the benefits against the risks by continuously evaluating all drug treatment. When treating the elderly, it is recommended to start with low doses when introducing new drugs.

Medication Story

A man ate Haldol when he moved in. Haldol is an older neuroleptic that is not used so much today. When the nurse investigated why the man took his Haldol, it turned out that he had been eating it since 1964. It had been introduced when the man was admitted for depression. The dose was too low to really have any antipsychotic effect. The nurse and doctor agreed to discontinue the drug. After a while, the man's walking ability improved. The dry mouth decreased, and the man generally seemed more alert.

Older people have often been prescribed drugs by different doctors at different times. To get a picture of what was the basis for the drug being initiated originally, a drug story is valuable.

Drug review is a way to map a patient's total prescribed and used drugs to ensure safe prescriptions. The review includes analysis, reconsideration, and follow-up of the patient's entire drug use. The purpose is to find drug-related problems (LRP). It increases the quality
and safety in drug treatment, especially in fragile elderly who are a vulnerable group. There are two types of drug reviews, simple and in-depth.

Many people have over the years met different doctors who have introduced drugs. It is not certain that the introductions and assessments linked to the introduction are available in the same journal. If clear documentation of why a drug was introduced is missing, doctors are forced to guess how their colleagues thought earlier and why.

For a patient who has received many drugs introduced over a long time and from different doctors, a pharmacist can go through the journals and compile a drug story. It is then easier to get an overview of the drugs and why they were introduced. It can form a basis for trying to discontinue drugs, especially in a situation where one suspects that disease symptoms are side effects.

When the drug story is clear, it is good if the doctor can go through it together with the resident and relatives. This way, additional information may come up. At the same time, the resident is reminded of why the drugs were introduced.

Läs mer om Phase20 och Phase Proxy

Reflection - Drug Review
Care Staff:
• What do you do if you experience that a resident has side effects from a drug?
• How can you work in the group to limit the need for, for example, anxiety-reducing drugs or sleeping pills?
• Do you get information if someone gets new drugs or stops with something?

Manager, Nurse, Occupational Therapist, and Physiotherapist:
• Do all residents meet your doctor and go through the drug treatment?
• Do you check if the use of sleep and anxiety-reducing drugs is increasing or decreasing?
• Do the nursing assistants receive training on side effects and how to report these?
• Does your doctor write drug stories where it is clearly stated when medicines were introduced and why the treatment started?

Resident and Relatives:
• Does the doctor have time to talk to you during drug reviews?
• Do you know why drugs were introduced once upon a time?

Erland Olsson
Specialist Nurse
Better care every day

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