Article contributed by AAPACN Business Partner PharMerica
When asked why they chose their profession, nurses often say they feel a personal calling or have a desire to serve others. Administering medications doesn’t even make the list, yet senior and long-term care nurses spend much of their time doing just that. Fortunately, a focus on deprescribing, or medication optimization, is taking more nurses back to what made them choose this career.
The Challenge
Nearly half of all adults aged 65 and older have prescriptions for five or more medications, which is defined as polypharmacy. Add over-the-counter meds, vitamins, and supplements, and the number is even higher. Polypharmacy puts individuals at risk of adverse events, medication interactions, and problems such as falls or cognition issues that can lead to emergency room visits and hospitalizations. It also increases the time nursing teams spend on medication administration and heightens the risk of errors, such as missed dosages. A growing focus on deprescribing, or medication optimization, is a natural evolution and is making a real difference.
The Opportunities
DONs and their nursing teams can take the lead on deprescribing efforts by:
- Ensuring team members, including CNAs, know what potential side effects or medication-related issues to watch for and how to document and report them.
- Identifying residents taking five or more medications and working with the physician and pharmacist to review drug regimens, looking for opportunities to reduce doses, eliminate duplicate or unnecessary medications, or transition to safer alternatives.
- Working with the pharmacist on monthly medication reviews, as well as reviews targeting residents taking specific high-risk medications or those who have experienced problems such as falls, cognitive decline, or weight loss.
- Employing the American Geriatrics Society Beers Criteria® to help identify potentially inappropriate medications in older adults that can be targeted for review and potential deprescribing.
- Advising family members against providing vitamins, herbal products, or other over-the-counter medications for their loved one without first consulting the physician or pharmacist.
- Considering the benefits of nonpharmacologic interventions for issues such behavioral changes, problems sleeping, and anxiety.
Team Takes the Field with Nurses in the Lead
As one study found, deprescribing is a team endeavor that requires the involvement of stakeholders, including dietary and housekeeping staff and family members, but with nurses taking the lead. These efforts benefit from a champion in the facility who takes the lead and communicates consistently with all the various players. The authors stated, “We purposely began by connecting with front-line health care providers and middle managers responsible for medication management in LTC homes, representatives of residents and families, and then engaged other sector stakeholders. Through this process, our team identified which individuals from each organization were best suited to serve as champions.”
Deprescribing is a multifaceted issue for nursing staff. There are numerous challenges associated with polypharmacy beyond the number of medications a resident is taking and the potential side effects of these drugs. It also involves issues such as residents who have trouble swallowing, resident/family financial limitations, discomfort and inconvenience of having to take numerous pills at various times (thus potentially disrupting/limiting sleep, meals, or activities), resident refusal to take medications, or special monitoring requirements required for some medications. All of these issues can complicate medication administration and cause undue burdens for both residents and staff.
DONs and their nurses play a key role by supporting appropriate dose reductions, medication discontinuation, and transitions to safer alternatives. They often know residents best and are positioned to monitor for and communicate red flags, concerns, and condition changes to the prescriber. Additionally, they can work with the pharmacist to educate and train staff on the dangers of polypharmacy and how they can best support medication optimization.
Getting Started
“It is important to try to instill a culture of medication optimization among nursing staff,” said Arif Nazir, MD, CMD, medical director for the Program of All-Inclusive Care for the Elderly (PACE) at Kinship Health. Part of this means always looking for opportunities to deprescribe. Elsewhere, order sets, groups of bundled standard orders that may contain medications, can increase efficiency but can also contribute to polypharmacy. “Cookie cutter care” without an individualized approach to treatment, including medications, “doesn’t get us to quality care,” said Nazir.
To address these concerns, more organizations and practitioners are focusing on deprescribing. DONs and other team leaders are increasingly taking charge on such efforts, which involve pharmacist-led medication reviews, conversations with prescribers, and resident and family education. There is much to learn by studying these efforts and identifying best practices and opportunities to improve the health and quality of life for residents while reducing costs and administration burdens.
“Polypharmacy is really about us making sure we are very comfortable with every medication that every patient in our care is taking,” Nazir stressed. “If an individual needs more medications, they should get the medications they need.” The focus, he suggested, should be less on fewer medications and more on the right medications. This will lead to appropriate deprescribing and, ideally, free nurses to spend more time doing the work they love.
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