Seniors entering nursing homes need drug review

An article by Dr. Paula Rochon, a geriatrician and senior scientist at Baycrest Geriatric Health Care System, appeared in The Globe and Mail newspaper addressing the issue of seniors entering nursing homes who are on many medications and the risk for side effects and further health complications.

My mother recently moved into a nursing home. I am concerned that she is on too many drugs and at risk of side effects and further health complications. What can I do?

Your concern about the number of drugs your mother is on and whether any are unnecessary is a very important issue. In 1997, my research team and I published a study in the British Medical Journal (BMJ) that identified a problematic prescribing situation that we described as the “prescribing cascade.”

For example, in some people, taking high-dose NSAID therapy (nonsteroidal anti-inflammatory drugs) to treat arthritic pain can cause an increase in blood pressure, which may then require treatment with anti-hypertensive drugs. However, because the hypertension is caused by the NSAIDs, it may not be appropriate to use anti-hypertensive therapy. Instead it may be better to either change the dose of the NSAIDs or discontinue them altogether and find an alternative treatment for the arthritic pain. Otherwise, the person may be unnecessarily exposed to the risk of adverse effects from the anti-hypertensive drugs.

People who have illnesses that last a long time (chronic illness), and who are on many medications, are at a higher risk for experiencing a prescribing cascade. Often, adverse drug effects can be mistaken for signs of the natural aging process, especially if the symptoms look like an illness that is common in the elderly.

Because adverse drug effects may often look like a new medical condition, it is important to rule that out first before adding further medications. Some of the common ways that adverse drug effects present in the elderly in nursing homes are confusion, oversedation, or falls that result in injury.

As your Mom’s advocate, you play an important role in helping with the medication challenge. To begin with, collect all her drugs and bring them to her assigned nursing- home doctor for a thorough review upon her admission. This includes all prescription drugs and over-the-counter medications, vitamins and herbal medications, as well as anything she may only take on occasion.

The doctor, along with the pharmacist, will assess everything being taken by your mother and determine if any medication needs to be removed, added, or the dose adjusted. This is an opportune time to determine if your mother is taking certain medications which might be interacting with each other and causing any of her health complaints. They will also check if there are particular drug side effects that may be causing some of the adverse symptoms she is experiencing.

It’s not uncommon for nursing-home residents to be sent to the hospital for various treatments and then transferred back. These moves can sometimes result in confusion or errors in medication routine. In hospitals, it’s not unusual for a patient to be put on medication for constipation while on certain pain medications, or given a sleeping pill if the individual has difficulty sleeping in the hospital environment. These medications may need to be discontinued once the person is discharged from hospital back to the nursing home.

To reduce the risk of medication issues during these transfers, doctors now employ a strategy known as “medication reconciliation”. Working with the doctor issuing the transfer, the pharmacist makes a precise list of every medication the patient is taking, including the drug names, dosages, how often it should be taken and how it should be taken. The patient takes this list when seeing other doctors or specialists in the health-care system. The hospital’s list of your mother’s medications should be reviewed and compared with her medication regimen in the nursing home and see if anything needs adjusting.

Finally, it is important to be aware of a class of drugs called anti-psychotics, which are sometimes prescribed in the nursing home to come agitative and difficult behaviours related to dementia. These sedative drugs should be used only after other approaches have failed, because they are associated with side effects such as falls. It is important to talk to your mother’s nursing-home doctor before she is put on an anti-psychotic, to ensure that it is necessary and that non-pharmacological options have been explored first.

Good communication between you and your mother’s doctor, as well as between her doctor and any other doctors in the health-care system who might prescribe medication to her, will help ensure she is on the most appropriate and safe medication regimen.

Dr. Paula Rochon is a geriatrician and senior scientist with Baycrest Geriatric Health Care System in Toronto