F 329 Unnecessary Medications:

Geriatric PrinciplesMeets Regulations

F 329 Unnecessary Medications:

Geriatric PrinciplesMeets Regulations

Charles Crecelius MD PhD FACP CMD

F-tag 329 Unnecessary Medications

F-tag 329 Unnecessary Medications

• Updated, consolidated

• Incorporates newest geriatric principles

• Written by CMS with advise of leading geriatricians, pharmacists, nurses

• Associated pharmacy tags– F428 Medication Regiment Review

• Sets guidance for all – physicians, pharmacists, homes, surveyors

F 329 Unnecessary Meds Intent F 329 Unnecessary Meds Intent

• Meds clinically required to treat a condition• Non-pharmacologic measures used• Medication promotes highest well-being• Avoid actual or potential negative outcome• Negative outcome promptly found / treated

Doesn’t empower surveyor to practice medicine - should investigate the basis for decisions and interventions

Key DefinitionsKey Definitions

• Adverse consequences & ADR

• Behavior interventions

• Distressed behavior

• Gradual dose reduction

• Monitoring

• Non-pharmacologic intervention

• Psychopharmacological medication

Basic Pharmacologic PrinciplesBasic Pharmacologic Principles

• Promote non-pharmacologic interventions• Indication for use• Select based on individual risk / benefit• Appropriate dose / duration• Avoid duplicative therapy• Monitor efficacy & side effects• Prevention, identification, and response to

adverse consequences• GDR (gradual dose reduction)

Non-pharmacologic InterventionsNon-pharmacologic Interventions• Require:

– assessing and understanding causes for need of medication

– reduction/elimination of impediments, triggers and causes:

• Examples– Modification of environment– Modification/elimination of psychological

stressors• Accommodation of previous lifelong

activities or roles• Modification of staff/resident interactions• Behavioral Interventions

Individual Risk & BenefitIndividual Risk & Benefit

• Distinct / unique review of needs & goals • Informed choice

– Condition, options, risk / benefit, outcomes– Effects refusing treatment – Regular review

• Can’t refuse physician directed treatment to treat imminent danger

• Advance directives don’t preclude other treatment (no code is not no care)

Monitoring CriteriaMonitoring Criteria

• Identify essential information– who collects, how recorded

• Determine frequency of monitoring– Condition, risk ADR

• Define communication and analysis– Interdisciplinary team, goal

• Re-evaluate & update plan– Change meds/conditions/diet

When to Evaluate Medication for Benefit / Adverse Consequences When to Evaluate Medication for Benefit / Adverse Consequences

• Admit / readmit

• Clinically significant change in status

• New symptom / problem

• Worsening existing problem

• Unexpected decline function / cognition

• Non specific symptom without cause

• New med, review of med, med irregularity

• MMRR

Special ConsiderationsSpecial Considerations

• New Admits– Justify each med, consider ADR

• New med order as an emergency– Address underlying cause– Re-evaluate after acute phase over

• Psychiatric disorder or distressed behavior– Appropriate diagnosis, seek cause

• Multiple prescribers

GDR GDR

• All Medication Potential Candidates

– When condition stable or improved, causes target symptoms resolved, non-pharmacologic tx success

– Opportunities• MMR• Quarterly MDS Review• Practitioner review

• Psychopharmacologic medication– Review & document risk/benefit q 3 months

GDRGDR• Antipsychotics / non-anxiolytic/sedatives

– 1st year – 2 separate quarters, at least 1 month between

– Annually thereafter – Unless clinically contraindicated

• Sedatives / Hypnotics– If used more than 3 times a week– Attempt taper at least quarterly, 3 out of 4

quarters– Unless clinically contraindicated

Medications of Particular Relevance to Long-Term Care

Medications of Particular Relevance to Long-Term Care

• Broad list of medications with potential concerns in the elderly & long term care

• Replaces revised “Beer’s list”• Lists medication class, then specific names• Ask to consider various factors

Indication Dosage / durationMonitoring Adverse consequencesDocumentation

• Documentation proportional to degree risk/benefit

Surveyor Investigative ProtocolUnnecessary Medications

Surveyor Investigative ProtocolUnnecessary Medications

Non-compliance• Inadequate indication for use• Inadequate monitoring• Excessive dose• Excessive duration• Adverse consequences• Antipsychotic

– Absence of specific condition– Without behavior intervention & GDR

Deficiency Categorization ExamplesDeficiency Categorization Examples

• Level 4 Immediate Jeopardy– INR > 9 with failure to assess / act– Failure to monitor INR without care plan, staff

knowledge potential problems– Failure to monitor or dose reduce for antipsychotic

in presence of side effect– Failure to do non-contraindicated GDR with

resulting tardive dyskinesia while on prolonged antipsychotics

– Failure to recognize, assess or respond to meds that caused a GI bleed

Deficiency Categorization ExamplesDeficiency Categorization Examples

• Level 3 Actual Harm that is not Immediate Jeopardy– INR 4-9 with failure to act with bleeding– Failure to evaluate seizure as a result of other

meds, adding potentially unneeded AED– Failure to perform GDR resulting in continued

antipsychotic use with decline, adverse effect

Deficiency Categorization ExamplesDeficiency Categorization Examples

• Level 2 No actual harm with potential for more than minimal harm– INR 3.5-9 with failure to act and no bleeding– Failure to monitor INR, prior stable INR, no

bleeding– Failure to identify med as cause of rash– Failure to monitor potential med adverse

effect (e.g. no TSH & on thyroid Rx)

Deficiency Categorization ExamplesDeficiency Categorization Examples

• Level 1 No actual harm with potential for minimal harm– Failure to provide appropriate care & services

to avoid unnecessary meds / minimize adverse outcomes place residents at risk for more than minimal harm

– No level 1 severity

The Medical Director & F329 Reducing Medication Related Problems

The Medical Director & F329 Reducing Medication Related Problems

Individualize approach depending on problematic areas facility

• Education of Staff & Attendings

• Improve systems which impact medication management

• Monitor performance & provide feedback

Educational Efforts for StaffEducational Efforts for Staff

• Non-pharmacological Interventions

• Top offending medications

• GDR Requirements

• Monitoring tools / requirements

• Targeting frail / declining residents• Common ADR (serotonin syndrome, EPS,

TD, NMS anticholinergic side-effect)

Educational Efforts for StaffEducational Efforts for Staff

Signs, Symptoms & Conditions Possibly Associated w/ Medications

• Anorexia, unplanned weight loss or gain• Behavioral changes, unusual behavior patterns• Bleeding / bruising, spontaneous / unexplained• Bowel dysfunction • Dehydration, fluid/electrolyte imbalance• Depression, mood disturbance• Dysphagia, swallowing difficulty

• Falls, dizziness, impaired coordination

Educational Efforts for StaffEducational Efforts for Staff Signs, Symptoms & Conditions Possibly

Associated w/ Medications• Gastrointestinal bleeding• Headaches, muscle pain, general nonspecific

aching or pain• Mental status changes, (new, worsening, delirium) • Rash, pruritus• Respiratory difficulty or changes• Sedation (excess), insomnia, disturbed sleep• Seizure activity• Urinary retention or incontinence

System ImprovementsUtilization Monitoring Tools

System ImprovementsUtilization Monitoring Tools

• Physiological, cognitive functional– Vital signs– Labs, EKGs, blood sugars, Hgb A1C– RAI, FAST, IADL, PSMS– MMSE, CAM, AIMS, FAST

• Mood/Affect (MDS / QI)– GDS, Cornell DDS, Mania Rating Scale

• Behavior (MDS / QI)– Behave AD, CMAI, NPI-NH

System ImprovementsProtime / INR MonitoringSystem Improvements

Protime / INR Monitoring

• System-wide use coumadin flow sheets– Pulled when labs drawn– Sent to physician for fax adjustment or read to

physician if called– Contains default orders for common situations

• Set standard protime draw days

• CMT “signs off” new order

• Recap orders require check last protime

Auditing Medication ManagementAuditing Medication ManagementMonitor Indication with Consulting

Pharmacist• Do target symptoms / causes warrant

therapy• Could non-Rx interventions be relevant• Is a particular medication pertinent to

managing symptoms or condition• Is risk worth benefit• If prn are circumstances for use clearly

delineated

Auditing Medication ManagementAuditing Medication Management

Review GDR & Psychopharmacologics

• Triggered with new order; tickler system for old orders

• Special form of MRR using pharmacist & medical director

• Placed in front of order section

• Lists requirements of F329, offers tapering suggestions

• Results audited, presented to attendings

Always consider medicationas a possible problem,

and not just as the solution

Any symptom in an elderly patient should be considered a drug side effect until proved otherwise (Gurwitz)

A medication is a poison with a desirable side-effect (Osler)

F329 Unnecessary Medications

Medications of Particular Interest in Long Term care

F329 Unnecessary Medications

Medications of Particular Interest in Long Term care

Appendix

Medication Issues of Particular Relevance to Long-Term Care

Medication Issues of Particular Relevance to Long-Term Care

• Analgesics– Acetaminophen– NSAIDs (Traditional, COX-2)– Opioids (esp. meperidine)– Pentazocine– Propoxyphene (and combinations)

• Antibiotics (all)– Vancomycin / aminoglycosides– Nitrofuration– Fluoroquinolones

Medication Issues of Particular Relevance to Long-Term Care

Medication Issues of Particular Relevance to Long-Term Care

• Anticoagulants– Warfarin

• Anticonvulsants– All– Seizure or mood stabalizer

• Antidepressants– All (class listings)– MAO inhibitors– Tricyclics

Medication Issues of Particular Relevance to Long-Term Care

Medication Issues of Particular Relevance to Long-Term Care

• Anti-diabetic Medication– Metformin– Glitazones– Chlorpropamide & glyburide

• Antifungals– Imidazoles

• Anti-manic medications– Lithium

Medication Issues of Particular Relevance to Long-Term Care

Medication Issues of Particular Relevance to Long-Term Care

• Anti-Parkinson medication (all) • Antipsychotics

– Conventionals– Atypicals

• Anxiolytics– Short-acting benzodiazepines– Long-acting benzodiazepines– Buspirone– Diphenhydramine / hydroxyzine– Meprobamate

Medication Issues of Particular Relevance to Long-Term Care

Medication Issues of Particular Relevance to Long-Term Care

• Cardiovascular medications– Antiarrhythmics (amiodarone,

disopyramide)– Antihypertensives - All– Methyldopa– Digoxin– Diuretics– Nitrates

Medication Issues of Particular Relevance to Long-Term Care

Medication Issues of Particular Relevance to Long-Term Care

• Cholesterol lowering medicines– Statins– cholestyramine

• Cognitive enhancers

• Cold, cough and allergy medication– All

– H1 blockers

– Oral decongestants

Medication Issues of Particular Relevance to Long-Term Care

Medication Issues of Particular Relevance to Long-Term Care

• Gastrointestinal medications– GI antispasmotics– Phenothiazines, trimethobenzamide– Metoclopramide– Proton pump inhibitors

• Glucocorticoids• Hematinics

– Erythropoiesis stimulants– Iron

Medication Issues of Particular Relevance to Long-Term Care

Medication Issues of Particular Relevance to Long-Term Care

• Laxatives• Muscle relaxants• Orexigenics (appetite stimulants)• Osteoporosis medications

(biphosphonates) • Platelet inhibitors

– Salicylates– Ticlopidine– Clopidogrel

Medication Issues of Particular Relevance to Long-Term Care

Medication Issues of Particular Relevance to Long-Term Care

• Respiratory medication – Theophylline– Inhalants

• Sedative / hypnotics– All– Barbituates

• Thyroid medication• OAB medication All

Medications with Significant Anticholinergic Properties

Medications with Significant Anticholinergic Properties

• Antihistamines• Respiratory (ipratropium)• GI drugs• Tricyclic antideressants• Trazedone• Muscle relaxants• Urinary antispasmodics• Antiparkinson• Antipsychotics