#PTonICE Daily Show – Wednesday, October 11th, 2023 – Medication issue: now what?

In today’s episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Alex Germano as she discusses the topic of medication management in older adults. She talks about the importance of screening for inappropriate medications and what to do when such medications are found. Medication management is a crucial component of falls prevention programs, as many older adults are on medications that may not be suitable for them. Alex emphasizes the need for clinicians to assess medications as part of their overall approach to fall prevention.

Take a listen to learn how to better serve this population of patients & athletes.

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Good morning, everyone. Welcome to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. My name is Alex Germano, a member of the older adult division. Today, what we’re going to be talking about is a question that came up at our course this weekend in Falls Church, Virginia. It was about how to handle inappropriate medication, how to screen for it, and what to do after you learn that your patient’s taking a quote unquote inappropriate med for an older adult. The older adult division is really finishing off 2023 strong. We have eight more course offerings this year alone. This weekend in particular we’re going to have Christina out in Fountain Valley, California. We’re in New Jersey next weekend and Annapolis, Maryland the first weekend of November. Additionally, you can catch us in New York, Westmont, Illinois, Chandler, North Carolina, Spring, Texas, and Portland, Maine, before 2023 closes out. So we hope to see you out there. I wanted to expand on this topic a bit more.


It’s all about medication management and how we encourage clinicians to look at medications and what do we do when we find an inappropriate medication. I feel really passionate about this topic and we really do As a component of our falls prevention programs, we need to be looking at meds, screening them, because a lot of our older adults are on a lot of medication that they should not be on. So, as part of the World Guidelines for Fall Prevention in Older Adults, medications are deemed as a domain that we need to assess. If you work in more acute settings, so maybe like acute care, skilled nursing facilities, home health, you likely have to do some sort of medication screening. You’re asking about meds, they’re in a system, the system or the EMR that you use actually may flag inappropriate medications already. I’ve heard that in the home health world that some of the it’s more of the medication interactions that are being flagged versus like type of medication that we should be weary of. But if you’re in outpatient settings, you may ask about medication intake on eval. but you might just write that down and then that’s it. Even my, um, uh, EMR that I use and I’m working in an outpatient on wheel setting is just, you put in the meds and that’s it. There’s no followup. The system doesn’t help me in any way. It’s kind of on, on, it’s my responsibility rather to perform some type of medication reconciliation, look at the meds, make sure they’re on the appropriate ones. Okay. Now, if we have older adults on our caseload, we can’t just ask about medications. We really need to double check some of these meds because they can have a huge impact on our patient’s physical function, their lives. And it’s absolutely part of our scope of practice because these medications can impact our patient’s balance, their fatigue, their overall physical function and exercise tolerance. So it’s definitely worth it to get familiar with some of these classes of medications. Older adults, it’s important to know one, why is this a problem?


Older adults handle medications differently. There’s a few changes that occur with age. We have an increase in body fat and a decrease in our total body water, and this could change the half-life of certain drugs. The clearance of the drugs through the hepatic system or the renal system, so liver or kidneys, also changes as a result of age, and then if you have a disease process on top of it, that will affect medication clearance. Okay, so drugs aren’t being, are not leaving our patients’ bodies as well, so we often see higher levels of drugs circulating systemically, which could cause negative side effects. Now, it’s not really our role to decide if my patient’s hepatic function or renal function is appropriate for a certain medication. And, you know, that’s not our job. We are trusting the medical providers out there prescribing medications and, you know, deciding what our patient needs and at what dosage. But I argue as people and I’m sorry, as medical providers who spend a lot more time with patients, we have a unique opportunity to visualize the impact of medications that affect our patients functionally. We have the ability to see our patients for many hours after they start using a medication, whereas doctors may not see them until months away. They might not be asking about the new medication until months after. They might not have a follow-up for a while. I mean, the current state of our medical system is that many people aren’t even seeing their doctors for months and months in between. So if the patient isn’t tolerating the medication or if we find that the medication isn’t working for their lifestyle, and I’ll explain that in a minute, we are the perfect provider to alert the other medical providers on the team about this situation. So first, how do we even know that a medication is inappropriate? What are we screening for? We will link and the Instagram post of the American Geriatric Society beers criteria. Okay. They have a 2023 edition that is available to be viewed. Usually we were seeing that the free one was like a few years back, but now the 2023 version is free and open access. We recommend becoming familiar with these classes of medications so that if they appear on your patient’s medication list, you know that you are going to have kind of a red flag in your mind that you’re going to want to monitor for any symptoms and really define if this medication is appropriate for the patient. This document organizes medications considered to be inappropriate for older adults or those with certain diseases. They organize medications that should be used with caution, any other potential drug interactions, or medications that need to be adjusted based on renal function. Again, not entirely our scope, but we will be aware because if we see symptoms in our patient, we’re going to want to report that. It also gives you a rationale for use with each medication class. That’s very helpful when you go to talk with the prescribing physician because it’s important to give a rationale or to cite this criteria in order to kind of get them listening and get them to really take you seriously when you go to report a medication issue.


Now it’s not only important to screen the type of medication, but it’s very important to screen how your patient takes their medication. This seems really the, I always say it seems dumb. It’s really not dumb. It’s very important, but you really wouldn’t know how many issues there are with medication intake unless you were watching your patient take a lot of meds, which lucky for me, when I work in people’s homes, I see a lot of things. Okay. Do, does your patient just use the pill bottle to pour out into their hand every morning to take their meds? Do they use a pill container? Do they use pill packs, which are those things that you can, um, order where all of their medication comes in like a nifty pack. They just rip it open and take it. It’s great to ask your patient or their caregiver the current way that they take medications. And to ask if there’s any barriers to that medication intake, again, I have a ton of privilege being in people’s homes, seeing the way they take meds, and you’d be surprised how many people have barriers to taking medication. It could be cognitive, where they have to take medication three times a day, and they are used to only taking it once a day, or once at the end of the day. All right, hopefully we’re back. I lost you for a second. And if your patient has to take medications more than once a day, that is going to increase the risk that something goes wrong. And if your patient happens to nap through med time, they miss a dose in the middle of the day, they don’t have anyone there to remind them of that, that can also cause many problems. Some of our patients have difficulty with dexterity and their ability to pour medicines out from the pill container and into their hand and getting all of those small pills from their hand to their mouth. That’s why you might find medication or pills kind of all over. Sorry, I’m going to ditch Instagram at this time. That’s why you might find medications kind of all over the floor when you get to their house. They’re having trouble getting small pills from their hand to their mouth. There’s also many people that struggle maintaining, managing their meds and getting their pill containers to be filled appropriately. This is all great to screen for because these are all problems, physical therapy, but more so occupational therapy can help with. Occupational therapists are who I’ve personally leaned on to help with some of these dexterity problems, equipment problems, cognition issues, just because their scope of practice is a lot bigger and they are really experts at med management. So say now you have identified a problem medication. For example, my patient was given Xanax, which is a common benzodiazepine for daily management of high blood pressure. That is a super strange recommendation immediately caused a red flag in my mind because I know benzodiazepines are not supposed to be used for the beers criteria, but I connected the patient’s past medical history with problems with this med. This patient has vestibular implications. has peripheral neuropathy and clinical levels of frailty so he’s already quite weak and very unsteady so adding on a medication that increases false risk could be really dangerous now what i didn’t do was i i didn’t immediately call the doctor and complain about this prescription i let them i let the patient see if I let the patient trial the Xanax. He really was interested in doing so because the doctor said so, but I remained on high alert, monitoring for symptoms. They thought that because he had a lot of anxiety that the medication or Xanax would decrease his anxiety and drop his blood pressure. We didn’t see a big change in blood pressure on subsequent visits. And he started to tell me really how woozy he felt in the morning and how he felt more very, very tired throughout the day after taking the medication. This is exactly when it’s time for us to step in. Some of our patients may be on contraindicated meds and they may also feel fine and have no symptoms. They’ve taken them for years. They don’t have a problem. If they’re on a contraindicated med, however, it’s just important we try to see if they have any concerning symptoms or just continuously ask or check in about them. So do they have fatigue or dizziness? At this point, we want to communicate with the prescribing physician regarding our concerns. I have sent letters with my patients to their doctor’s appointments because sometimes it’s hard to connect with the doctor. But I very often just call in to the nursing line to discuss the medication use. I let them know what I’m seeing in terms of symptoms and some of how the medication may be interacting between my patient’s lifestyle. and the symptoms they have and their physical function. And then I kind of align that all with the recommendation based on the beer’s criteria. I always cite it, like I said before, because it can just give you more power in this space. I have never, this is again, very personal, but I’ve never been met with a doctor that was not interested in exploring a different medication choice, or just at least talking through the symptoms and at least coming to a consensus of why the medication is appropriate for now. Many times the doctor is very willing to change or remove the medication. I think it’s all about our approach here and not coming off a little too hot. We just have to come off with curiosity and just asking about, you know, just relaying symptoms, relaying data, relaying a rationale. And oftentimes I’m met with a really good response from the doctors. Now, it would also be wise to make some community connections with a local pharmacist or somebody who can help your patient with general medication questions, dosing questions, or if they’re interested in getting a medication reconciliation. You may have to do some work to discover what pharmacists in the area offer. There may be virtual services available for certain patient populations. I’m thinking like the VA, for example, has some resources. There may also be private pharmacists helping with this. But again, this is very specific to your community. I would probably try to connect with that like small local pharmacy. Those folks are going to be great at having the time and the willingness to dive into medication reconciliations with your patients. So really, in summary, let’s start leaning into our role as advocates for our patients’ medication intake. If anything new gets added, or if your patient’s been on medication for decades, it’s part of our role to screen for symptoms of these meds, especially if they’re on that inappropriate list for older adults. We can check on how our patient is able to take meds, see any barriers to taking medication. Remember, less doses per day is better for this population. Make sure we have people to communicate these problems with, that we get comfortable being advocates with physicians, that we get comfortable making connections with pharmacists in the area, so that we have a place to refer our patients if necessary. Getting patients off certain medications or getting them changed to a better medication well tolerated by older adults can truly have impacts on their life and function far more than any resistance training that we can give them. Deadlifts are definitely life changing, but if you can get off a scary medication that’s making you feel dizzy and unsteady, then that can be far more powerful. So think about leaning into that space and we look forward to hearing how it goes. See you next Wednesday.


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