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The Memorial Sloan Kettering Cancer Center GERIATRIC PLAN©: Review of Medications

An Ambulatory Nurses' Guide to Assist Older Adults Through Cancer Treatment

Review of Medications

Related Issues:

Medication adherence, polypharmacy, medication misuse, medication reconciliation, ADEs (adverse drug events), PIMs (potentially inappropriate medications)

Why Review of Medication is Important:

  • Nearly one-third of community dwelling adults aged 65 and older take more than five prescription medications, and almost 20% take 10 or more; 42% take at least one over-the-counter drug, and 49% take at least one nutritional supplement (Qato et al., 2008)
  • The prevalence rates of polypharmacy and potentially inappropriate medications (PIMs) in older adults with newly diagnosed cancer have been found to be as high as 80% and 41%, respectively (Prithviraj et al., 2012)
  • People older than 65 are at greater risk for developing ADEs for the following reasons:
  • Age-related physiologic changes that result in altered pharmacokinetics  and pharmacodynamics
  • Incorrect doses of medications (over or under a therapeutic dosage)
  • Multiple medications (i.e., polypharmacy)  that are often prescribed by multiple providers
  • Problems with medication  adherence (Boparai & Korc-Grodzicki, 2011)
  • Polypharmacy has been an important subject in the geriatric literature, and its prevalence ranges from 13% to 92% (Maggiore, Gross & Hurria, 2010; Lees & Chan, 2011)
  • Polypharmacy has been associated with significantly increased risks for drug interactions, inappropriate prescribing, the development of geriatric syndromes, decreased functional status, and increased health care costs; patients with cancer are particularly at risk for the effects of polypharmacy (Puts et al., 2010)
  • The US National Comprehensive Cancer Network Guidelines for Senior Adult Oncology 2015 state that a review of medications (prescription and over-the-counter medications, vitamins and supplements) and a review for duplication and appropriate use should be performed at every visit to evaluate for PIM use (NCCN, 2015)
  • The issue of medication adherences is becoming increasingly important in oncology as more cancer therapies are delivered orally (Korc-Grodzicki, Boparai & Lichtman, 2014)

Normal Age-Related Changes:

Pharmacokinetics (absorption, distribution, metabolism, excretion)

GI Absorption:

  • Decreased (gastric emptying rate, intestinal motility, intestinal blood flow, intestinal surface area, gastric acid output) & increased gastric pH → Delayed onset or peak of medication

IM Absorption:

  • Decreased (muscle mass & peripheral circulation) & Increased connective tissue → Decreased IM absorption

Transdermal Absorption:

  • Decreased (skin hydration, surface lipids, peripheral circulation) & increased keratinization → Decreased absorption

Distribution:

  • Decreased (muscle mass, body water, cardiac output) & increased % body fat → Increased distribution of lipid soluble medications and decreased distribution of water-soluble medications
  • Decreased albumin levels → decreased distribution of acidic drugs which require albumin as a binding site

Metabolism:

  • Decreased liver mass and hepatic blood flow → reduced first pass metabolism → increased concentration of (benzodiazepines, tricyclic antidepressants, B-blockers, narcotic analgesics)
  • Average renal function of an 80-year-old is about 50% of that of a 20-year-old
  • Decreased clearance of renally-metabolized drugs: must decrease dosing

Pharmacodynamics

  • Changes in number and sensitivity of receptors due to aging can affect older patients' sensitivity to some drugs

Older adults are at increased risk if they have any of the following:

Conditions

  • Any physiologic or psychological condition requiring prescribed or over-the-counter medication and or herbal therapies
  • Any physiologic or psychological condition that interferes with a person's ability to self­-administer medications

Medication-Related Risk Factors

  • Total number of medications currently taking
  • Interaction of herbal or vitamin therapies with prescribed medications: 
  • SAMe → may increase homocysteine levels
  • Gingko → may increase anticoagulant effects of ASA, warfarin, NSAIDS and ticlopidine
  • Calcium → interferes  with levothyroxine absorption
  • Use of high risk medications:
  • Chronic and/or high dose NSAIDS → renal impairment, Gl bleeding
  • TCA's, antihistamines, anti-Parkinson drugs → anticholinergic  side effects
  • Anticoagulants → bleeding risk
  • Antihypertensives → risk for hypotension  → falls
  • Psychoactive medications
  • Cardiotonics (digoxin)
  • Use of medications with known side effects:
  • Narcotics → constipation, sedation, potential for confusion
  • Steroids → hyperglycemia, osteoporosis with long-term use
  • Use of medications requiring decreased dosing due to altered renal function:
  • Allopurinol
  • ​Digoxin
  • NSAIDs
  • Ciprofloxacin
  • H2 antagonists (ranitidine, famotidine)
  • Venlafaxine
  • ​Morphine
  • Use of medications that can interact with diet:
  • Warfarin  and Vitamin K-containing foods
  • Phenytoin and Vitamin D metabolism
  • Methotrexate and folate metabolism

Behavioral Risk Factors

  • Dementia
  • Substance use/abuse

Chemotherapy-related Risk Factors

  • See Chemotherapy Index

Surgery

  • Changes in medication and/or dosing in the perioperative period

Assessment:

1. Screening Questions

  • How many medications do you currently take? Are you taking any over-the counter or herbal medications?
  • Do you know what your medications are for?
  • How often do you miss taking a dose of your medication?
  • Are you currently experiencing any negative side effects that you feel your medication is causing? (i.e. dizziness, confusion, frequent  urination, dry mouth, constipation, falls)

2. Observations

  • Number of medications (polypharmacy)
  • Medication reconciliation
  • Screen for high risk medication
  • Screen for medications requiring decreased dosing due to altered renal function
  • Evaluate for medication side effects
  • Screen for patient's ability to self-administer medications (especially self-administered oral chemotherapy)

3. Screening Tests and Measurements

  • STOPP Criteria (Screening Tool of Older Person’s Prescriptions) (Gallagher et al., 2008)
  • Validated screening tool for detecting inappropriate prescriptions in older adults
  • START Criteria (Screening Tool to Alert Doctors to the Right Treatment) (Gallagher et al. 2008)
  • Tool to identify drug therapy likely to be beneficial to the patient
  • Brown Bag method (Nathan et al.,1999)
  • Assess what medications/vitamins/supplements patients are actually taking
  • Beer's List (American Geriatric Society, 2012)
  • Screen for high risk/ potentially inappropriate medications
  • Calculate creatinine clearance (Cockroft-Gault Formula)
  • ADL's IADLs, Mini-Cog
  • Screen for patient's ability to self-administer medications

4. Standard Physical Evaluation

Review of Medications

Nursing Intervention:

  • Complete medication history and validate currently used medications at every visit/encounter
  • Patients taking > 5 medications should be evaluated by geriatric pharmacist or a geriatric specialist for possible simplification of medications
  • Review medication list using Beers criteria and evaluate for medication side effects
  • Assess patients who self-administer medications at every change in plan of care to identify potential areas of med error due to self administration
  • Discuss trial of non-pharmacologic interventions prior to starting new medications for new symptoms
  • Review lab results with LIP: K, INR, digoxin, liver toxicity, renal function, blood counts
  • Dose modification if altered CrCI (Allopurinol, digoxin, NSAIDs, Cipro, H2 antagonists [ranitidine, famotidine], venlafaxine, morphine)
  • Consider medication side effect for any new onset fall
  • Collaborate with all other healthcare providers
  • Evaluate effectiveness of interventions and modify as needed

References

American Geriatrics Society 2012 Beers Criteria Update Expert Panel. (2012). American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc, 60(4), 616-631.
Boparai, M.K. & Korc-Grodzicki, B. (2011). Prescribing for older adults. Mt Sinai J Med, 78(4)613-626.
Edelberg, H.K., Shallenberger, E., & Wei, J.Y. (1999). Medication management capacity in highly functioning community-living older adults: detection  of early deficits. Journal of the American Geriatrics Society, 47(5), 592-6.
Fick, D.M., Cooper,J.W., Wade, W.E., Waller, J.L., Maclean, J.R., & Beers, M.H. (2003). Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med,163(22), 2716-24.
Gallagher, P., Ryan, C., Byrne, S., Kennedy, J., & O'Mahony, D. (2008). STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation. Int J Clin Pharmacol Ther, 46(2), 72-83.
Korc-Grodzicki, B., Boparai, M. & Lichtman, S. (2014). Prescribing for older patients with cancer. Clinical Advances in Hematology and Oncology, 12(5), 309-318.
Lacasse, C. (2011). Polypharmacy and Symptom Management  in Older Adults. Clinical Journal of Oncology Nursing, 15(1)27-30.
Lees, J. & Chan, A. (2011). Polypharmacy in elderly patients with cancer: clinical implications and management. Lancet Oncol, 12(13), 1249-1257.
Maggiore, R.J., Gross, C.P., Hurria, A. Polypharmacy in older adults with cancer. (2010). Oncologist, 15(5), 507-522.
Nathan, A.,Goodyer, L., Lovejoy, A., & Rashid, A. (1999). 'Brown bag' medication reviews as a means of optimizing patients' use of medication  and of identifying potential clinical problems. Fam Pract.,16(3), 278-82.
National Comprehensive Cancer Network. US National Comprehensive Cancer Network Guidelines for Senior Adult Oncology 2015. Version 2.2015.
Prithviraj, G.K., Koroukian, S., Margevicius, S., Berger, N.A., Bagai, R., & Owusu, C.(2012). Patient Characteristics Associated with Polypharmacy and Inappropriate Prescribing of Medications among Older Adults with Cancer. J Geriatr Oncol, 3(3), 228-237.
Puts, M.T., Monette, J., Girre, V., et al. (2010). Potential medication problems in older newly diagnosed cancer patients in Canada during cancer treatment: a prospective pilot cohort study. Drugs Aging, 27(7), 559-572.
Qato, D.M., Alexander, G.C., Conti, R.M., Johnson, M., Schumm, P., & Lindau, S.T. (2008). Use of Prescription and Over-the-counter Medications and Dietary Supplements Among Older Adults in the United States. JAMA, 300(24), 2867-2878.
Zwicker, D., & Fulmer, T., (2012). Reducing Adverse Drug Events. In M. Boltz, E. Capezuti,T. Fulmer, & D. Zwicker (Eds.), Evidence-Based Geriatric Nursing Protocols for Best Practice. (324-362). New York: Springer.