Reducing Adverse Drug Events in Old Age

Geriatric Nursing and Drug Interaction 

Adverse drug Reaction,Assessment Strategies,Assessment f drug interaction,drug interaction,over the counter drug,high Risk Medicine,Nursing interventions and strategies.

Drug Events in Old Age

    One in seven Medicare beneficiaries experienced an adverse event while hospitalized in 2008. Of those, 31% of the adverse events were related to medications (Levinson, 2010). 

    Nearly 1.9 million adverse drug events (ADE) occur each year in older adults enrolled in Medicare and 180,000 of those are life threatening or fatal (Gurwitz et al., 2003). ADEs are common in older adults yet are potentially preventable (Safran et al., 2005).

    Persons older than the age of 65 years' experience medication-related events for seven major reasons: 

(a) alteration in pharmacokinetics (ie, reduced ability to metabolize and excrete medications) and pharmacodynamics (Mangoni & Jackson, 2004; Rochon, 2010)

(b) polypharmacy (Gallagher, Barry, & O'Mahony, 2007; Hajjar & Kotchen, 2003)

(c) incorrect doses of medications (more than or less than therapeutic dosage, Doucene, McDonough. Klepser, & McCarthy, 2005, Hanlon, Schmader, Ruby, & Weinberger, 2001; Sloane, Zimmerman, Brown, Ives, & Walsh, 2002 )

(d) using medication for treatment of symptoms that are not disease dependent or specific (ie, self-medication or prescribing cascades: Neafey & Shellman, 2001: Rochon & Gurwitz, 1997)

(e) iatrogenic causes such as ADEs and inappropriate prescribing (Fick et al., 2003, Pirmohamed et al., 2004; Rothberg et al., 2008)

(f) problems with medication adherence (Steinman & Hanlon, 2010)

(g) medication errors (Agency for Healthcare Research and Quality (AHRQ), 2001: Doucette et al., 2005). 

    Intrinsic factors such as advanced age, frailty, and polypharmacy place older adults at greater risk for adverse outcomes. 

    Older adults are the largest consumers of medications with 82% taking at least one medication, 29% -39% taking five or more drugs, and up to 90% taking over-the-counter (OTC) drugs (Hanlon. 

    Fillenbaum, Ruby, Gray, & Bohannon, 2001: Kohn, Corrigan, & Donaldson, 2000). Older adults often combine OTC medications with prescription medications yet do not report their OTC use to health care providers. 

    Likewise, providers often do not inquire about OTCs or herbal remedies. Underreporting may lead to unrecognized adverse drug-disease or drug-drug interactions (Astin, Pelletier, Marie, & Haskell, 2000; Rochon, 2010). 

    These factors make it paramount that nurses identify older adults at risk for adverse events.

Adverse Drug Events

    An ADE is an adverse outcome that occurs during normal use of medicine, inappropriate use, inappropriate or suboptimum prescribing, poor adherence or self-medication, or harm caused by a medication error. 

    It is estimated that 35% of older persons experience ADEs, almost half of which are preventable (Safran et al., 2005). Older adults are also at significant risk for further ADEs while in the hospital and after discharge. 

    Acute drug toxicity represents 2.5% of emergency department (ED) visits for unintentional injuries. of which 42% resulted in a hospital admission (Budnitz et al., 2006; Hanlon et al., 2006). 

    Significant morbidity and mortality are associated with ADEs, with the cost estimated to be approximately $75-$85 billion annually (Budnitz et al., 2006; Fick et al., 2003: Hanlon et al., 2001). 

    ADEs are also associated with preventable adverse outcomes such as depression, constipation, falls, immobility, confusion, hip fractures, rehospitalization. anorexia, and death (Aspden, Wolcott, Bootman, & Cronenwett, 2007).

 Latrogenic Causes of Adverse Drug Events

    Older adults' susceptibility to ADEs is well documented in the literature on iatrogenic events and medication errors (Gurwitz et al., 2003; Hohl et al., 2005). The term iatrogenic, as it relates to ADEs, means any undesirable condition in a patient occurring as the result of treatment by a health care professional, specifically pertaining to an ill-ness or injury resulting from a medication/drug or treatment. 

    An iatrogenic medication event is one that is preventable, such as the wrong dose of a given medication resulting in an adverse outcome. Adverse drug reactions (ADRs), inappropriate prescribing of high-risk medication to older adults, and medication errors are also considered iatrogenic ADEs. 

    In a systematic review, the most common preventable ADEs included antiplatelet medications, diuretics, and anticoagulants. Prescribing problems, adherence problems, and monitoring problems have been associated with preventable admissions as well (Howard et al., 2007; Steinman & Hanlon, 2010). 

    Frail older adults with multiple medical problems, memory issues, and multiple prescribed and nonprescribed medications are at highest risk for ADEs (Rochon, 2010).

Adverse Drug Reactions

An ADR, a type of ADE, is any toxic or unintended response to a medication (Committee of Experts [COE] on Safe Medication Practices, 2005). The prevalence rate of hospital admissions caused by ADRs has been reported between 5% and 35% (Gurwitz et al., 2003: Kohn et al., 2000). 

    A recent systematic review reported 10.7% prevalence rate of hospital admissions caused by ADRs in older adults; however, a confounding factor in the accuracy is the different methods and studies employed to gather the data (Kongkaew, Noyce, & Ashcroft, 2008). 

    Among a community-dwelling population of older adults, 38% of ADRs were considered serious, life threatening, or fatal and 27% were considered preventable (Gurwitz et al., 2005). 

    Pirmohamed et al. (2004) reported that 70% of ADRs were either possibly avoidable or definitely avoidable in a study of 18,820 older adults,

    Twenty-nine percent of ADEs require evaluation by a physician, evaluation in the emergency room, or hospitalization for clinical management (Hohl et al., 2005; Petrone & Katz, 2005). 

    A meta-analysis revealed that ADRs accounted for 6.7% of hospital admissions and in-hospital ADRs; when extrapolated, they would be the fourth-sixth leading cause of in-hospital mortality for all causes of death, which does not include ADRs related to errors, nonadherence, overdose, or therapeutic failures (Lazarou, Pomeranz, & Corey, 1998; Steinman & Hanlon, 2010). 

    Drug-drug and drug-disease interactions are the most common ADRs (Hansten, Horn, & Hazlet, 2001: Juurlink. Mamdani, Kopp, Laupacis, & Redelmeier, 2003; Zhan et al., 2005). 

    Drug-drug interactions occur when one therapeutic agent either alters the concentration (ic. pharmacokinetic interactions) or the biological effect of another agent-pharmacodynamic interactions (Leucuta & Vlase, 2006). 

    Gray and Gardner (2009) reported that polypharmacy and multiple prescribers tend to be key factors in these adverse reactions. Older adults with multiple chronic medical problems requiring multiple medications are at high risk for these interactions (Rochon, 2010).

Medication Errors

    The Institute of Medicine (IOM) reported in 1999 that almost 7,000 hospital deaths were associated with medication errors (Kohn et al., 2000). Medication errors occur frequently, yet many hospitals still lack automated physician order entry systems that are reported to decrease the number of medication errors (National Coordinating Council for Medication Errors Reporting and Prevention [NCC MERP), 2001).

    A medication error is defined by the COE on Management of Safety and Quality in Health Care (COE, 2005) as any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional , patient, or consumer. 

    Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication, product labeling, packaging, and nomenclature; compounding, dispensing, and distributing; administration, education, and use. 

    A large percentage of errors are caused by administration of the wrong medication or the correct medication with the wrong dose or at the wrong time interval between dosing (Rochon, 2010). 

    There are many reasons medication errors occur; however, it is beyond the scope of this chapter. Information regarding the immense literature on medication errors is provided in the Resources section of this chapter.  

Adhesion

    Medication adherence (or compliance) with a medication regimen is generally defined as “the extent to which a person's medication-taking behavior corresponds with agreed recommendations of a health care provider” (Sabaté, 2003, pp. 3). 

    Seventy percent of patients who begin taking a prescribed drug discontinue it within 1 year, with the greatest drop-off rate at 6 months (Osterberg & Blaschke, 2005). 

    A national survey of 17,685 Medicare beneficiaries older than age 65 years found that 52% do not take medications as prescribed (Safran et al., 2005). 

    Nonadherence was primarily associated with a belief that the drug made them feel worse or was not helping (25%), or cost of the medicine, resulting in a decision to skip or take a smaller dose (26%). 

    Prescription drug coverage significantly impacted adherence, with 37% nonadherence among those with our coverage compared with 22% nonadherence beneficiaries with coverage. Patients are often reluctant to admit nonadherence; however, pill counts and refill history can aid in determining this issue (Osterberg & Blaschke, 2005; Steinman & Hanlon, 2010).

    Acute care nurses are ideally positioned to identify and aid in preventing ADEs in hospitalized older adults and in transitions to other levels of care. 

    Areas in which nurses must be familiar are iatrogenic causes of ADEs such as ADRs, inappropriate medications, identifying system issues to reduce medicine errors, and risk of nonadherence in older adults. 

    Education of patient and families, recognizing inappropriate medications, and reinforcing the need for drug monitoring are areas where nurses can make a difference in aging persons (Fick et al., 2003; Rochon, 2010). 

    Nurses must take a proactive role in ensuring patient safety through interdisciplinary collaboration with patient and family, doctors, advance practice nurses, and pharmacists to prevent adverse medication outcomes.

Assessment Tools

    Assessment tools are used to evaluate an older adult's ability to self-administer medications (ie., functional capacity assessment); assessment of the medication list for potential inappropriate medications, drug-drug or drug-disease interactions; and assessment of renal function in collaboration with interdisciplinary team members. 

    Commonly used tools include the following:2002 Criteria for Potentially Inappropriate Medication Use in Older Adults: Independent of Diagnoses or Condition (Fick et al., 2003). 

    Used to assess medication list for medications that should generally be avoided in older adults. (See http://www.consultgerirn.org/resources, “Try This” series, issue number 16.1.) 2002 Criteria for Potentially Inappropriate Medication Use in Older Adults: Considering Diagnoses or Condition (Fick et al., 2003; see “ Try This” series, issue number 16.2). 

    Used to assess for the presence of medications that may interact adversely with a disease or condition a person has. Drug-Drug Interactions. List of medications known to interact with other medications. 

    This may be performed by a computer or personal digital assistant (PDA) program, such as Facts and Comparisons PDA program to identify drug-drug and drug-disease interactions or “Physician Order Entry (POE)” programs.

    Cockroft-Gault Formula (Table 17.2). Useful for estimating creatinine clearance based on age, weight, and serum creatinine levels (Terrell, Heard, & Miller, 2006). Functional Capacity (activity of daily living (ADL), independent activity of daily living (ADL). Mini-Cog/Mini-Mental State Exam (MMSE). 

Assessment Strategies

Changes With Aging

    Aging changes in pharmacokinetics and pharmacodynamics are important to consider when assessing medications in older adults (Mangoni & Jackson, 2004; Rochon, 2010). Pharmacokinetics is best defined as the time course of absorption, distribution across compartments, metabolism, and excretion of drugs in the body. 

    As the body ages, the metabolism and excretion of many drugs declines and physiological changes require dosage adjustment for some drugs (Cusak & Vestal, 2000). Pharmacodynamics is defined as the response of the body to the drug that is affected by receptor binding, post receptor effects, and chemical interactions (Cusak & Vestal, 2000). 

    Pharmacodynamic problems occur when two drugs act at the same or interrelated receptor sites, resulting in additive, synergistic, or antagonistic effects. Many interactions of drugs are multifactorial, with sequence of events that are both pharmacokinetic and pharmacodynamic (Spina & Scordo, 2002). 

    The following are changes that may occur with aging:Changes in drug absorption (ie, increased gastric pH and decreased gastrointestinal [GI] motility in an absorptive surface) once thought to be caused mainly by aging changes are now thought to be caused by underlying disease states (Mangoni & Jackson, 2004). 

    There may, however, be a change of absorption rate in persons taking many medications, for example, fluoroquinolones taken with iron may impair absorption (Semla & Rochon, 2004).

Complete Medication History

Date Performed

Patient Name

Medication allergies and type of reaction (eg, hives)

Prescription medications

    Specifically ask about eye drops, topical creams, B injections, or other injections (at home or at medical office, how often). Recently discontinued medications and why. Medication reconciliation performed and verified Discrepancies found and reason(s) Over-the-counter drugs How often do you exceed the recommended dose on package? Do you read the labels? Why or why not? Do you ask a pharmacist or your provider about interactions with your prescriptions? Ask specifically what patient is taking in the following classes:

Pain relievers

    What have you tried, what works, and what does not? What pain do you take it for? How often?

    Allergy medications When do you take them? Year round? What season? Or When symptoms develop?

    Sinus congestion/cold or cough medications (combined products with more than one ingredient?)

    Heart burn medications, how often?

    Diarrhea or constipation treatments, how often?

    Sleeping medications, ask specifically diphenhydramine (Benadryl) Eye drops-how often what do you take them for?

Herbal remedies (orally or as a tea) or Chinese medicine

- ginkgo biloba

-ginseng-glucosamine

- St. John's wort

- echinacea

Nutritional supplements

 Ask how often?

Ask specifically about:

Calcium with vitamin D, vitamin E, C, or B's

Megavitamins

Protein supplements such as Ensure, Boost, or protein bars

vitamin drinks

Medications that have been stopped and why? (Did you discontinue or provider?) Alcohol

Ask about type/amount per day

    Smoking (what and how much; eg, cigarette packs per day, how many years) Past or annual immunizations, date last received Pneumonia vaccine Flu vaccine

    Regular lab tests-performed to evaluate medication levels or side effects (eg potassium level, digoxin level, INR, liver toxicity, renal function). Inquire about those not drawn that should be based on the aforementioned medical list.

    Use of memory aids-reminders to take medications (eg, pill dispenser box) Assess adherence: Consider using DRUGS tool (Edelberg et al., 1999; Hutchison et al., 2006).

    Drug distribution changes associated with aging decreased include cardiac out- put, reduced total body water, decreased serum albumin (which is more likely to be related to malnutrition or acute illness than aging), and increased body fat. 

    Reduced total body water creates a potential for higher serum drug levels because of a low volume of distribution and occurs with water-soluble drugs (hydrophilic) such as alcohol or lithium. 

    Decreased serum albumin results in higher unbound drug levels with protein-bound drugs such as warfarin, phenytoin, digoxin, and theophylline. Lipophilic drugs (eg, long-acting benzodiaz-epines [BZDs) are stored in the body fat of older persons and slowly leech out, resulting in increased half-life and resulting in the drug staying around longer (Gallagher et al., 2007).

    A significant change in drug metabolism is a reduction in the cytochrome p-450 system, which affects metabolism of many drugs cleared by this enzyme system (Cusak & Vestal, 2000; Mangoni & Jackson, 2004; Tune, 2001). 

    Many classes of drugs are cleared by the cytochrome p-450 enzyme system including cardiovascular drugs, analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs). antibiotics, diuretics, psychoactive drugs, and others (Mangoni & Jackson, 2004). 

    Drugs such as beta-blockers that have a first pass effect in the liver may be effective in lower doses in older adults (Gallagher et al., 2007). For a list of drugs cleared by this enzyme system see The Merck Manual of Geriatrics at http://www.merckmanuals.com/mm geriatrics. 

    Metabolism may be affected by disease states common in older individuals (eg, thyroid disease, congestive heart failure [CHF), and cancer) or drug induced metabolic changes (Cusak & Vestal, 2000). Several drugs are cleared by multistage hepatic metabolism, which is more likely to be prolonged in older persons (Mangoni & Jackson, 2004). 

    Some drugs undergo hepatic metabolism then renal clearance. Such drugs (diazepam) have enormously longer half-lives in the older adult because both systems are impaired.

    Elimination or clearance of medications from the body may be slowed because of decline in glomerular filtration rate, renal tubular secretion, and renal blood flow that naturally decreases with age (Semla & Rochon, 2004). 

    Decrease in clearance prolongs drug half-life and leads to increase plasma concentrations (Gallagher et al., 2007). A decrease in glomerular filtration is usually not accompanied by an increase in serum creatinine because of decreasing lean muscle mass with age and subsequent decline in creatinine production. 

    Lack of dosage adjustment for renal insufficiency is a common reason for ADEs (Rochon, 2010). Therefore, serum creatinine is not an accurate measure of renal function in the older adult. 

    Instead, assessment of renal function using the Cockroft-Gault formula (Table 17.2) should be calculated prior to initiation of renal clearing medications (Mangoni & Jackson, 2004; Semla & Rochon, 2004).

Beers Criteria

    In 1999, the Centers for Medicare and Medicaid Services (CMS) incorporated the Beers criteria into regulatory guidelines in long-term care (Lapane, Hughes, & Quilliam, 2007). Long-term care facilities can be cited if any of the drugs on the list are prescribed. 

    The Joint Commission (TIC) also adopted the criteria as a potential sentinel event (2007) in hospitals. The Beers criteria address two key areas: 

(a) medications or medication classes that should generally be avoided in persons aged 65 years and older

(b) medications that should be avoided in older persons with specific medical conditions

    A severity rating of high or low is given to each medication based on its potential negative impact on older adults. 

    The most recent Beer's criteria, updated in 2003 by Fick et al., identifies 48 medications or classes that should generally be avoided in persons older than 65 years, as well as 20 specific medications that should not be used in the presence of specific conditions. 

    Inappropriate medications on the Beers list that resulted in ED visit for ADEs included insulin, warfarin, and digoxin (Fu, Liu, & Christensen, 2004); these drugs are commonly reported as high risk in other studies (see High-Risk Medications section). See “Try This series, issue numbers 16.1 and 16.2 at http://www.consultgerirn.org for Beer's criteria.

    Medications on the Beers inappropriate list have been shown to be associated with poor health outcomes. Fick and colleagues (2003) reported that ambulatory older adults prescribed with medications from the Beers list were more likely to be hospitalized or evaluated in an emergency room than those not taking such medications. 

    Other studies report a positive association between potentially inappropriate drug prescribing and ADRs in first-visit older adult outpatients (Chang et al., 2005; Fu et al., 2004). 

    Although the Beers criteria for inappropriate medications are an excellent guideline for assessing potential inappropriate medications, they need to be used in conjunction with patient-centered care (Swagerty, Brickley, American Medical Directors Association [AMDA), & American Society of Consultant Pharmacists [ASCP ], 2005). 

    A joint position statement by the AMDA and ASCP points out that the Beers criteria are based on consensus data (eg, lower level of evidence) rather than on higher levels of evidence such as systematic reviews or randomized controlled trials. 

    Jano and Aparasu (2007) found that use of inappropriate medications (Beers list) was associated with an increase in ADRs and increased costs across settings; however, they suggest the predictive ability of the criteria needs to improve.

Assessment for Potential Adverse Drug Reactions

    ADRs commonly occur because of the number of medications taken (polypharmacy) by older persons and their concomitant medical conditions. The severity of adverse reactions increases because of changes in pharmacokinetics and pharmacodynamics in older adults. 

    Assessment for older adults' risk of ADRs and potential drug-disease and drug-drug interactions must be considered before initiating medications in the older adult.

    Potential medication-related and patient-related risk factors for ADRs in older people were examined and reported by Hajjar and Kotchen (2003). A consensus panel of four geriatric pharmacists and geriatric physician experts reviewed a list of evidence-based risk factors compiled by two experts from the literature to ascertain older adult risk factors for ADRs.

    The most preventable ADRs in the outpatient setting reported by Gurwitz and colleagues (2003) are cardiovascular medications followed by diuretics, nonopioids analgesics, hypoglycemics, and anticoagulants. 

    In 2005, the largest number of preventable ADRs occurred at the prescribing or monitoring stages and includes wrong drug choices or dosages, inadequate patient education, or clinically important drug-drug interactions (Gurwitz et al., 2005). 

    Monitoring for errors include inadequate evaluation of drug levels and failure to respond to signs, symptoms, or abnormal lab levels indicative of toxicity. 

    Nurses can help to prevent ADRs in the acute care setting by monitor in gor recommending lab values, determining appropriateness of drugs and doses when orders are written, and monitoring for signs and symptoms of toxicity. 

    It is important for nurses to understand that ADRs may be difficult to recognize as they often present as atypical symptoms such as confusion, falls, lethargy, constipation, and depression (Hanlon et al., 1997).

Drug Drug Interactions

    Concurrent use of more than one drug simultaneously, particularly those with similar properties, can result in serious toxicities in older adults resulting in synergistic, additive, or antagonistic effects. 

    For example, concurrent use of any two of the following drugs: antiparkinsonian drugs, tricyclic antidepressants (eg, amitriptyline), antipsychotics (eg, Haldol), antiarrhythmics (eg, disopyramide), and OTC antihistamines (eg, diphenhydramine, chlorpheniramine) may cause or dry mouth, gum disease, blurred vision, constipation, urinary retention, and/or cognitive deficits (Cusak & Vestal, 2000) . ); however, studies indicate that drug-drug interactions are a common cause of predictable ADEs (Hansten et al., 2001). 

    Drug-drug interactions have resulted in serious adverse events among several classes of medications. For example, hypoglycemia resulted in around 900 patients out of 179,000 older patients treated with glyburide along with cotrimoxazole, and 12 patients died. 

    Digoxin toxicity was experienced by more than 1,000 out of 230,000 patients admitted and 33 died while hospitalized (Juurlink et al., 2003). Those with digoxin toxicity were 13 times more likely to have received clarithromycin 1 week prior to hospitalization; suggesting avoidance of concomitant use of digoxin and clarithromycin may have prevented the toxicity. 

    In the same study, concomitant prescribing of angiotensin-converting enzyme (ACE) inhibitors and potassium-sparing diuretics 1 week before admission were observed in 622,285 older persons with ADRs. The researchers estimated that 7.8% of hospitalizations for hyperkalemia could have been prevented if addition of potassium-sparing diuretics had been avoided (Juurlink et al., 2003). 

    In a retrospective review of the National Hospital Ambulatory Medical Care Survey, Zhan and colleagues (2005) reported that older adults with two or more prescriptions had at least one inappropriate drug-drug combination present, and 6.6% of patients on warfarin were prescribed a drug with a potentially harmful interaction.  

Interactions With Over-The-Counter and Herbal Remedies

    Drug interactions between prescription medications and herbal remedies or OTC medications are often not reviewed during medication reconciliation, hospital admission, or office visits, yet 40% of all OTCs are consumed by older adults (Astin et al., 2000; Kohn et al., 2000). 

    In a survey of 1,001 older adults, up to 75% reported using OTCs that increased as age increased. Twenty-three percent reported use of two or more OTCs for chronic conditions in the past month: OTC use has increased over the last decade as well as polypharmacy (Hanlon et al., 2001; Radimer et al., 2004; Sloane et al. , 2002).

    Community-dwelling older adults in the United States approximately consume 1.8 OTC medications per day (Hanlon et al., 2001). Herbal or dietary supplement use such as ginseng, ginkgo biloba extract, and glucosamine is on the rise among older adults, increasing from 14% in 1998 to 26% in 2002 (Kaufman, Kelly. 

    Rosenberg, Anderson, & Mitchell, 2002; Kelly et al., 2005). In a study examining community-dwelling older adults' use of prescription, OTC, and dietary supplements, 68% of older adults used prescription medications concurrently with OTCs, dietary supplements, or both (Qato et al., 2008). 

    More than 50% of older adults used five or more prescriptions, OTC, or dietary supplements, concurrently. The prevalence rate of 5 or more prescription medications increased steadily with age, and 1 in 8 older adults regularly used five or more dietary supplements. 

    This substantially increases the risk of drug-drug interactions in older adults (Qato et al., 2008). The researchers also reported 46 potential drug-drug interactions with 11 classified as potentially of major severity, 28 classified as moderate severity, and 7 as minor severity. Overall, 1 in 25 older adults (2.2 million) were at risk for potential major drug-drug interactions. 

    Half of all potential major drug-drug interactions involved nonprescription medications (Qato et al., 2008). 

    The most commonly reported prescription or OTC medications, according to Qato et al. (2008), included single or multicomponent products that were cardiovascular drugs such as antihyperlipidemic, aspirin, hydrochlorothiazide, lisinopril, metoprolol, and others; dietary supplements were primarily multivitamins or minerals. 

    Alternative therapies included garlic, coenzyme Q, omega-3 fatty acids, and glucosamine-chondroitin. In a review of herbal products and potential interactions with cardiovascular (CV) diseases, Tachjian, Maria, and Jahangir (2010) described herbal remedies that produce adverse effects on the CV system. 

    These include St. John's wort, motherwort. ginseng, ginkgo biloba, garlic, grapefruit juice, hawthorn, saw palmetto, danshen, echinacea, tetrandrine, aconite, yohimbine, gynura, licorice, and black cohosh. Herbal agents that interfere with digoxin levels include Chan Su, danshen, Asian and Siberian ginseng, licorice, and uzara root. 

    Those that may adversely interact with warfarin include St. John's wort, ginseng, ginkgo biloba, and garlic. Motherwort and BZDs together have a synergistic sedative effect and can result in coma. Ginseng may have either a hypotensive or hypertensive effect. Several other interactions are presented in this review.

    St. John's wort was reported as being in the top selling herbs in the United States yet could potentially result in serious adverse reactions. Its effect on drug metabolism induces the cytochrome p-450 enzyme system where many prescription medications are metabolized. 

    OTC and herbal supplements are typically not reported to medical providers as most consumers do not consider them medication and many health care providers do not ask about herbal remedies and OTC drugs (Astin et al., 2000: Gardiner, Graham, Legedza, Eisenberg, & Phillips, 2006; Tachjian et al., 2010). 

    Other concerns are herbal products that lack scientific evidence of safety, lack regulatory oversight, and there is an abundance of public misinformation (Tachjian et al., 2010). The implications for unidentified drug-drug and drug-disease interactions are astounding.

Medication Adherence

    As individuals age, they may encounter difficulties that decrease their ability to adhere to medication regimens (eg, vision impairment, arthritis, economics). Medication adherence with older adults is complex and needs careful nursing assessment. 

    There are a number of ways to assess for potential adherence-related problems (Bergman-Evans, 2006; Edelberg et al., 1999) as well as to ascertain if a patient is adhering to recommended treatment (Rohay, Dunbar-Jacob, Sereika, Kwoh, & Burke, 1996). 

    Barriers to medication adherence include forgetting to take or limited organizational skills; belief that the drug is either not needed, is ineffective, or too many drugs are being taken; patient has difficulty taking such as opening bottles or swallowing; and cost (Steinman & Hanlon, 2010). 

    Several interventions are available in this systematic review but are beyond the scope of this chapter. An array of devices can assist in enhancing adherence behavior (Fulmer et al., 1999; Haynes et al., 2005; Steinman & Hanlon, 2010). See Resources section for further information.

Reconciliation of Medications

    Medication reconciliation (MR) confirms the patient's current medication regimen and compares this against the physician's admission, transfer, and discharge orders to identify and resolve discrepancies. 

    Discrepancies between physician-acquired prescription medication histories and comprehensive medication histories at the time of hospital admission were common, occurring in up to 67% of cases (Tam et al., 2005). 

    Around 22% of medication discrepancies could have resulted in patient harm during their hospitalization and59% of the discrepancies could have resulted in patient harm if the discrepancy continued after discharge (Sullivan, Gleason, Rooney, Groszek, & Barnard, 2005). 

    Poor communication of medical information at transition points of care (ar admission. transfer, and discharge) often results in medication errors, but appropriate strategies can reduce the likelihood of errors (Santell, 2006). 

    Adverse events were seen on transfer from hospital to a nursing home in 20% of patients, particularly those readmitted to the nursing home (Boockvar et al., 2004). TJC has recommended standards for communicating drug therapies to other levels of care and across the continuum (Nickerson, MacKinnon, Roberts, & Saulnier, 2005). 

    MR is often performed by pharmacists or nurses; however, MR can be performed by a nurse with pharmacist collaboration or computer-based programs (Doucette et al., 2005; Gleason et al., 2004; Nickerson et al., 2005). Accuracy of the list can mean the difference between patient safety and patient harm.

    The MR process includes comparison of medications on patient and family report or admission and transfer documents with medication orders at the time of admission, time of transfer to other units, or discharge to other levels of care. 

    Barriers for nurses performing MR reported in one study included lack of confidence in existing institutional safety systems, inconsistent practices (whether pharmacists are consulted or not), lack of communication between health professionals, and staffing concerns (MR is time consuming: Chevalier, Parker, MacKinnon, & Sketris, 2006). 

    The brown bag method can be used for corroborating medications (Nathan et al., 1999) with community dwelling older adults, when used in conjunction with a good medication or admission history.

    At discharge, the pharmacist has been involved in identifying problems with drug therapy and communicating with the community pharmacy, medical provider, or admitting staff at the transitional site of care (Hanlon et al., 2001; Nickerson et al., 2005). 

    A systematic review across many health care settings and at home found that interventions by clinical pharmacist showed a considerable reduction in drug-related problems as well as reduced morbidity, mortality, and health care costs (Hanlon, Lindblad, & Gray, 2004). 

    Many hospital pharmacies are now linked electronically to health care providers and/or local pharmacies. Finally, discharge education and counseling to patients including assessment of factors that might affect adherence has shown to reduce ADEs (Hanlon et al., 2001).

    Methodologies known to enhance understanding such as “teach back” especially low-literacy populations (Schillinger et al ., 2003). See Resources section for evidence based information on medication reconciliation.

High-Risk Medications

    Many studies have revealed common high-risk medications in older adults. Special attention should be paid to drugs that carry a high risk of serious adverse effects such as warfarin, hypoglycemic drugs, and digoxin that result in one-third of all emergency room visits for ADEs (Steinman & Hanlon, 2010). 

    Additionally, taking BZDs is an independent risk factor for falls; diphenhydramine (Benadryl) may lead to impaired cognition or urinary retention (in men); and antipsychotics may lead to falls, death, or pneumonia (Steinman & Hanlon, 2010). 

    Antipsychotics and other psychotropics are also associated with an increased risk for falls (Rochon et al., 2007). Nurses should become familiar with high-risk medications and medication classes prescribed for older adults in order to aid in preventing ADEs. 

    Many tools are available for the nurse to assess for high-risk medications, for potential drug-drug, drug-disease, or drug-herbal interactions. Common high-risk medications are discussed in the following sections.

Warfarin

    Warfarin has been identified throughout many research studies as among the highest risk medications taken by older persons (Gaddis, Holt, & Woods, 2002: Hanlon et al., 2006). 

    Warfarin leads to ED visits, preventable hospital readmission, and adverse events after discharge (Alexopoulou et al., 2008; Budnitz et al., 2006; Howard et al., 2007: Pirmohamed et al., 2004). 

    Together, polypharmacy and warfarin use consistently increases the risk of ADRs (Hanlon et al., 2006).

    Warfarin is highly bound (approximately 97%) to plasma protein, mainly albumin. The high degree of protein binding is one of several mechanisms whereby other drugs interact with warfarin (Olson et al., 2010). 

    Those with malnutrition and low albumin levels are at risk for unbound warfarin in the bloodstream and higher risk of bleeding. Warfarin is metabolized by hepatic cytochrome P450 isoenzymes predominately to inactive metabolites excreted in the bile; it is also excreted by the kidneys. 

    Warfarin metabolism may be changed in advanced age and in the presence of liver problems. Drug interactions are extensive and include 

(a) drugs that inhibit warfarin metabolism and prolong prothrombin time (eg. Cipro, phenytoin, amiodarone) 

(b) drugs that inhibit vitamin K activity (eg, cephalosporins and high-dose penicillins)

(c) additive effects with other anticoagulants such as aspirin, Lovenox, and others; and 

(d) drugs that reduce the effectiveness of warfarin such as phenytoin, barbiturates, cholestyramine. and others (Olson et al., 2010)

    Fifty-eight percent of older persons do not report use of herbal supplements. Commonly used herbal remedies (ginkgo biloba and garlic) interact with warfarin to augment its anticoagulant effect and may lead to serious bleeding problems (Astin et al.. 2000; Miller, 1998). 

    Many foods may interact with warfarin, specifically those with high vitamin K content such as chickpeas, spinach, and green tea (Miller, 1998). It is imperative to identify older adults on warfarin who fall or are at risk for falling as their risk of serious injury increases on warfarin. 

    The risk of harm versus the benefit must be weighed and the nurse should clarify the risk versus benefit with the primary prescriber (Steinman & Hanlon, 2010).

Anti-Hypertensive Agents

    Hypertension affects approximately two thirds of individuals older than age 65 years but only 27% of people have adequate control. Physiological changes of aging can alter the pharmacokinetics and pharmacodynamics of cardiovascular drugs in older persons, thus increasing the risk of ADEs (Nolan & Marcus, 2000). 

    The antihypertensives, as a class, tend to produce a variety of unintended effects including orthostatic hypotension (associated with diuretics and alpha-blockers), sedation and depression (associated with some beta-blockers), confusion (associated with alpha-blockers), impotence , and constipation (eg, verapamil). 

    Comprehensive and ongoing assessment for potential adverse effects (eg, routinely checking orthostatic blood pressure) is key to monitoring drug efficacy and safety while hospitalized. Nurses should monitor for symptoms such as dizziness and lightheadedness on standing. 

    The use of four or more medications should prompt the measurement of postural blood pressure (Tinetti & Kumar, 2010). Particular attention should be given to the possible discontinuation or dose reduction of medications known to increase orthostasis or fall risk.

    Dose for dose, water-soluble compounds are more potent in aging persons, whereas fat-soluble drugs (such as propranolol and carvedilol) can be expected to have an extended half-life because of their higher volume of distribution. 

    Because of changes in fat or lean body mass, older adults may require an increase in dosing intervals of fat-soluble beta-blockers. Additionally, because of age-related changes that decrease the integrity of the blood-brain barrier, it predisposes older adults to untoward events with alpha-agonists. 

    Bronstein and colleagues (2008) reported lipid soluble beta-blockers that have marked antidysrhythmic effects more lethal (eg. propranolol, oxprenolol). 

    The lethality significantly increases when given with calcium channel blockers, cyclic antidepressants, and/or psychotropics, even if the amount of beta-blocker is relatively small (Bronstein et al., 2008).

    Orthostatic hypotension is a serious problem that can affect older adults on continuous antihypertensive therapy. Sustained treatment makes them more susceptible to diuretic-induced dehydration and orthostatic changes. 

    Orthostasis may also be caused by concomitant illness (eg, infection). The known sequelae of orthostatic hypotension in older adults include falls that is a true trauma and a medical emergency in physically frail, anticoagulated, or functionally compromised older adults. 

    Orthostatic hypotension is an independent risk factor for recurrent falls in nursing home residents (Ooi. Hossain, & Lipsitz, 2000).

Psychoactive Drugs

    Mental health disorders are not part of normal aging. Nearly 20% of persons older than age 55 years experience mental disorders with the most common prevalence being anxiety, severe cognitive impairment, and mood disorders, respectively. 

    Mental disorders are underreported and suicide rates are highest among older adults compared to younger adults. Adults older than age 85 years have the highest suicide rates of all- more than twice the national rate.

    Sedative-hypnotic drugs significantly increase risk for adverse events in older adults and should generally be used sparingly and monitored very closely. BZDs, regardless of half-life, have been associated with cognitive impairment, hip fractures, and falls (Bloch et al., 2011: Hajjar et al., 2003). 

    In a prospective study of 9,093 patients, older adults who take BZDs are at greater risk for mobility problems and ADL disability, and short-acting BZDs did not appear to improve safety benefits over long-acting agents (Gray et al., 2006). 

    Higher plasma concentrations of sedatives and hypnotics are seen because of increased volume of distribution as well as increased sensitivity, including BZDs and opioids (Rochon, 2010). 

    The likelihood of falls with fractures is more than twice as high for the long-acting BZDs than short-acting agents. Likewise, Tamblyn, Abrahamowicz, du Berger, McLeod, and Bartlett (2005) reported that 17.7% of older persons given at least one prescription for BZDs at hospital discharge were treated for at least one injury on follow-up visit of which fractures were the most common. 

    In a study of intubated ICU patients, lorazepam was identified as an independent risk factor for development of delirium (Pandharipande et al., 2006). Oversedation, respiratory depression, confusion, and other alterations in cognitive capacity, as well as falls, are frequently associated with sedative-hypnotic drug use.

    Psychoactive medications include antidepressants (tricyclics, selective serotonin reuptake inhibitors (SSRIs]), anxiolytic agents (eg, diazepam, lorazepam), antipsychotics (also referred to as neuroleptics), mood-stabilizing compounds (lithium), and psychoactive stimulants. 

    Psychoactive compounds are prescribed to stabilize mood, agitated behaviors, and for therapeutic effects in clinical depression. Mood stabilizers and psychoactive stimulants are known to have a relatively narrow therapeutic window even in younger adults. 

    Lithium, in particular, requires very close monitoring of levels and signs of toxicity in older adults; it also interacts with many other drugs. Some unintended interactions may be prevented if age-related changes are considered and careful surveillance is part of routine care (Budnitz et al., 2006).

    The half-life of psychoactive drugs is prolonged in older adults and, in general, this class of drugs must be used with extreme caution to avoid inducing delirium, falls, and other traumatic events. 

    In a systematic review, medications strongly linked with falls included sedatives, hypnotics, BZDs, and antidepressants (Woolcott et al., 2009). A significant association between falls and psychotropic medications has also been reflected in two other meta-analyses (Bloch et al., 2011: Leipzig. 

    Cumming, & Tinetti, 1999). Drug classes determined to be a risk factor for falls included psychotropics, antidepressants, BZDs, hypnotics, neuroleptics, and tranquilizers. Risk seemed to be more significant for adults older than age 80 years in each of the classes. 

    Drug classes that had double the odds of traumatic falls included neuroleptics, antidepressants, and BZDs. An extensive list of specific drugs for each class is listed in the review by Bloch et al. (2011). 

    Although antianxiety agents such as BZDs and sedative-hypnotics are generally overprescribed for older adults, the antidepressants are generally considered to be under prescribed. 

    It is estimated that almost 15% of older persons living in the community , 5% in primary care, and 15%-25% in nursing homes have significant depressive symptoms (Spina & Scordo, 2002).

    The SSRIs, as a class of antidepressants, have strikingly different side effects than other antidepressants (eg, tricyclics). This class does not cause cardiotoxicity or orthostatic hypotension and does not have anticholinergic effects as do tricyclic antidepressants. 

    In general, these drugs tend to be a better choice of antidepressants in older adults. The most common side effects are GI related (nausea, anorexia) that may be ameliorated by starting with a low dose (half that for younger adults; eg, fluoxetine 5 mg) and slowly increasing (eg, to 10 mg) after 1 week. 

    A serious but uncommon sequela of SSRIs is serotonin syndrome. This syndrome may occur if more than one antidepressant is prescribed with an SSRI or if concurrent use of St. John's wort, a commonly self-administered OTC herbal remedy for depression.

    The antipsychotics are often used inappropriately as first-line treatment for persons older than age 65 years presenting with agitation and behavioral problems associated with dementia (Kindermann, Dolder, Bailey, Katz, & Jeste, 2002). 

    Evidence-based recommendations suggest the underlying cause of agitation should be determined (may be caused by delirium or pain) and nonpharmacological interventions attempted prior to administering antipsychotics such as Haldol (Zwicker & Fletcher, 2009).

    Most antipsychotics are not US Food and Drug Administration (FDA) approved for agitation (without a psychotic diagnosis) and data on their effectiveness suggest that the risk is greater than the benefit (Leipzeig et al., 1999; Woolcott et al., 2009).

     Antipsychotics must be used with extreme caution in this population, largely because of the potential for development of abnormal, and often irreversible, involuntary movements (extrapyramidal symptoms) associated with their administration and increased risk for falls. 

    The newer antipsychotics present a much lower risk of extrapyramidal movement disorders than conventional antipsychotics. Unlike conventional antipsychotics, the newer atypical ones (eg, clozapine, risperidone, olanzapine, and quetiapine) apparently provide several advantages with respect to both efficacy and safety. 

    A major study examining the effectiveness of antipsychotic use in Alzheimer's disease concluded that the adverse effects are greater than the advantages of these therapies (Schneider et al., 2006). 

    In 2004, the FDA issued a warning against off-label use of antipsychotics for dementia-related psychotic symptoms because of potential adverse effects. 

    Data from the CMS indicate that newer atypical antipsychotic medications, compared to older antipsychotics, do not appear to be associated with an increased risk of ventricular arrhythmias or cardiac arrest (Liperoti et al., 2005). 

    Psychotropic medications are associated with an increased risk for falls (Gurwitz et al., 2005). Drug-drug interactions with antipsychotics are common.

Anti-Cholinergics

    Medications with high anticholinergic properties must be used with great caution in older adults because of adverse effects such as inability to concentrate to frank delirium, agitation, hallucinations, blurred vision, slowed Gl motility, decreased secretions, urinary retention, tachycardia, impaired sweating, and constipation (Rochon, 2010; Spina & Scordo, 2002; Terrell et al., 2006; Tune, 2001). 

    Studies have reported that patients with dementia are at higher risk for delirium associated with anticholinergics; however, a recent study indicates that use of anticholinergic drugs is “independently and specifically” associated with a subsequent increase in delirium symptom severity in older medical inpatients (Han et al., 2001).

    Urinary retention, resulting from an anticholinergic, can be a lethal side effect in a male with benign prostatic hypertrophy (BPH) and a history of UTIs; urosepsis and death may result in men. 

    Catterson and colleagues (1997) discussed the vicious cycle of treatment and/or iatrogenesis that may occur with administration of anticholinergic drugs. An illustrative example is an older adult with dementia and BPH who is administered diphenhydramine (Benadryl) for sleep and who is also taking oxybutynin (Ditropan), both of which have anticholinergic properties. 

    The additive effects of the two medications may lead to urinary retention and agitation that may, in turn, lead to treatment of the agitation with antipsychotics (which also have anticholinergic effects) and exacerbate the problem and cascade of events further. Rochon (2010) referred to this as the “prescribing cascade” that leads to cascade iatrogenesis.

    Anticholinergic properties occur not only in antidepressant and antipsychotic medications, as previously mentioned, but are also properties of most OTC antihistamines and sleep aids, intestinal and bladder relaxants, corticosteroids, antihypertensives, antiarrhythmics and other cardiovascular drugs, and some antibiotics.

     See Tune (2001) or Kemper, Steiner, Hicks, Pierce, and Iwuagwu (2007) for a list of medications with anticholinergic effects. An anticholinergic risk scale (ARS) has been developed by Rudolph, Salow, Angelini, and McGlinchey (2008) to identify older adults at highest risk for adverse effects from anticholinergic drugs.

Cardiotonic

    Digoxin is useful in treating CHF because of systolic dysfunction in the older adult but is not the recommended treatment for CHF from underlying diastolic dysfunction in older adults. Digoxin toxicity occurs more frequently in older adults, presents atypically, and may result in death. 

    Juurlink and colleagues (2003) reported that about 2.3% of cases of digoxin toxicity could have been prevented in hospitalized older adults. Ahmed, Allman, and Delong (2002) reported that digoxin is often prescribed inappropriately in hospital patients. 

    Classic symptoms of digoxin toxicity (nausea, anorexia, visual disturbance) may occur; however, symptomatic cardiac disturbance and arrhythmias are more common in the older adult and are not often thought to be caused by digoxin toxicity. 

    Older adults may experience toxicity symptoms even with normal plasma levels of digoxin (Flaherty. Perry, Lynchard, & Morley, 2000). 

    Many older people will have some reduction in renal function with aging; therefore, monitoring for symptoms, especially atypical symptoms of digoxin toxicity, and monitoring renal function and potassium levels is important.

    Particular caution must be exercised when digoxin is prescribed with diuretics; this combination can cause hypokalemia and exacerbate renal impairment that can potentiate digoxin toxicity. 

    Because the therapeutic window for digoxin is narrow and because it is water-soluble (eg, the drug has a smaller volume of distribution and, thus, higher plasma concentration), correct and safe dosing of older adults is challenging. 

    The maximum recommended dose in older persons for treating systolic heart failure is 0.125 mg (Fick et al., 2003). Debilitated older adults who often have low serum albumin levels are at risk for higher plasma level and digoxin toxicity.

    Despite the recommendation that ACE inhibitors (ACEIS) should be prescribed for all patients with heart failure because of left ventricular or systolic dysfunction and who have normal renal function (Packer et al., 1999).

    Sloane and colleagues (2002) found that 62% of adults in assisted living residents (n=2,014) were not on an ACEL Monitoring of renal function and serum potassium should continue as the ACEI dose is titrated up. 

    Rarely do older patients on an ACE inhibitor need potassium supplementation, the combination of which can be lethal. Juurlink and colleagues (2003) reported that 523 out of 1,222,093 patients on ACEIs were hospitalized with hyperkalemia; of these patients, 21 died while hospitalized.

Hypoglycemic Agents

    Hypoglycemic agents carry a high risk of serious adverse effects in older adults. Control of blood glucose level is paramount to prevent microvascular and macrovascular complications of diabetes. 

    However, the use of general disease-specific evidence guidelines for diabetic control can lead to overmedication in older adults. Tight glycemic control in advance age or in older person with multiple comorbidities can result in greater harm than benefit (Greenfield et al., 2009; Steinman & Hanlon, 2010).

    The American Geriatrics Society (AGS) has issued guidelines for improving the care of older people with diabetes (Brown, Mangione, Saliba, Sarkisian, & California Healthcare Foundation (CHF)/American Geriatrics Society [AGS] Panel on Improving Care for Elders with Diabetes, 2003). 

    They suggest that the risks of intensive glycemic control, including hypoglycemia, polypharmacy, and drug-drug and drug-disease interactions, may significantly alter the risk-benefit equation. 

    For frail older adults, persons with limited life expectancy, and others in whom the risks of intensive glycemic control appear to outweigh the potential benefits, a less stringent target than the American Diabetes Association (ADA) recommendation of 7% or 8% in frail older adult is appropriate. 

    Oral agents with shorter half-life are also recommended and insulin is less often recommended because of vision changes and common arthritic conditions, unless it is provided in pre-filled syringes. Metformin is not recommended for those older than age 80 years because it may lead to metabolic acidosis. 

    Blood pressure and lipid control, however, are recommended to help reduce microvascular and macrovascular problems along with a daily low-dose of aspirin (Greenfield et al., 2009; Steinman & Hanlon, 2010).

Over-The-Counter Medications

     Self-medication with OTC medications, herbal remedies, and dietary supplements may lead to adverse drug-disease interactions and drug-drug interactions (Astin et al.. 2000: Rochon, 2010). 

    Neafsey and Shellman (2001) found that 86% of sample of 168 older adults attending a hypertension clinic reported at least two or more self-medication practices that could result in an adverse drug interaction. 

    In the United States, community-dwelling older adults take about as many OTC drugs as prescription drugs (Hanlon et al., 2001). Salicylates, such as aspirin, are a significant concern regarding ADRs in older persons. 

    In a study of 18,820 patients, 18% of all ADR hospital admissions were aspirin-related and low dose aspirin was involved most often (Pirmohamed et al., 2004). In combination with alcohol, because of its water solubility, age-related renal insufficiency can worsen and result in chronic salicylate intoxication. 

    Cold remedies that include alcohol are a significant source of drug potentiation in aging adults. Indeed, alcohol consumption is frequently omitted from history taking of older adults, even though it interacts with OTC and prescription medications in frank and subtle ways to produce unintended drug harm.

    The OTCs most commonly implicated in hospital admissions are low dose aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs, Pirmohamed et al., 2004). 

    The FDA has been evaluating OTC ingredients and labeling of OTCs; however, it is a long-range project and yet to be seen if the FDA will be more specific on safety issues that relate to older adults. 

    Astin and colleagues (2000) reported that 24% of seniors use herbal remedies (the most common being ginkgo biloba and garlic), and 58% did not report usage to their primary provider. 

    Ginkgo biloba and garlic interact with warfarin to augment its anticoagulant effect and may lead to bleeding (Miller, 1998); the potential adverse consequences are staggering.

Interventions And Care Strategies

    Medication assessment begins with a thorough drug history and assessment obtained from the older adult or a reliable informant. Medication history errors occur in up to 67% of patients at the time of admission to the hospital and increased up to 83% when nonprescription drugs were included (Tam et al., 2005). 

    This suggests a need for systematic approach to accurate medication histories at the time of admission. No studies provide a systematic approach to history taking, although specific aspects of the medication assessment include the following evidence-based activities.

    Obtain a complete medical history and validate that the medication history is true (Lau Florax, Porsius, & De Boer, 2000), ascertaining the numbers and types of medications typically consumed, as well as an estimate of how long it has been taken.

    Nathan and colleagues (1999) recommended that older adults bring all their medications and OTCs to provider or hospital or other health care setting in a brown bag in order to document medication types, instructions for self-administration, dates, and duration of the drug regimen. 

    This method fosters identification of multiple prescribers and dispensing pharmacies and can signal polypharmacy and/or possible substance abuse, particularly regarding analgesics. anxiolytics, and sedative hypnotics. 

    Focused questions by the clinician should address nicotine and alcohol use. as well as vitamins, herbal remedies, and OTC medications that are routinely used (Astin et al., 2000; Lau et al., 2000). 

    Ask detailed questions about OTC and “recreational” drugs, alcohol use, and herbal or other folk remedies. Provide a list of herbal remedies and folk medicines to choose from (Tachjian et al., 2010). Be specific about the actual amount and under what circumstances these substances are used. 

    Accurate information can help explain symptoms that otherwise may not make sense. Evaluate for duplicate medications or classes that occur because of unrecognized trade names versus generic names, and OTCs with the same active ingredients in them, especially acetaminophen (Astin et al., 2000).

    Perform MR to verify actual medication regimen at hospital admission and discharge and across the continuum of care (Gleason et al., 2004; Nickerson et al., 2005: Tangalos & Zarowitz, 2006).

    Patients are often reluctant to admit to nonadherence; however, pill counts and refill history can aid in determining this issue (Steinman & Hanlon, 2010). Employ a medication discrepancy tool to facilitate discrepancy across settings (University of Colorado Health Sciences Center, 2005).

    Monitor new symptoms and consider their likelihood of being caused by an ADR before adding new medications to treat the symptom (Petrone & Katz, 2005: Rochon, 2010) prior to requesting a new medication to treat symptoms, avoid the prescribing cascade.

    a trial of nonpharmacological interventions and treatments prior to requesting medication for new symptoms (eg, agitation). Nurses often make these recommendations when notifying primary provider for a new problem or symptom. 

    Continuously monitor for possible toxicity to those drugs with high prevalence rate of toxicity (see Beers criteria: Beers, 1997; Beers et al., 1992). PDA technology can help nurses assess high-risk medications such as facts and comparisons. 

    Consider medications as the underlying cause when falls occur. Particularly, consider recently added medications that are high risk for causing falls such as diuretics and psychotropics.

    Collaborate with the interdisciplinary team to effect change in reducing the numbers of ADEs and ADRs, many of which are preventable (Hanlon et al., 2001). 

    Although many studies describe and recommend an interdisciplinary approach as the best method for improving drug treatment outcomes, most do not delineate the specific role or function of the individual team members not do they measure outcomes of the team (Lam & Ruby, 2005; Williams et al., 2004). 

    Recommendations to consider for an interdisciplinary approach include a medication care team (nurse, pharmacist, primary physician/nurse practitioner, social worker) with specific functions assigned to review medications at admission and discharge utilizing evidence-based recommendations. 

    Discharge interventions may be performed by various team members including the following:

    Reminder systems may be instituted by pharmacists in collaboration with nurses as reported effective by Muir, Sanders, Wilkinson, and Schmader (2001). A visual intervention (medication grid) was delivered to physicians to see if it could reduce medication regimen complexity, and researchers report that the simple intervention had a significant impact on medication regimen complexity in older adults.

     Pharmacist may also review (preferably using a computer-based program) medication list at admission, when new medications are added and prior to discharge for potential drug-drug interactions, drug-disease interactions, and/or inappropriate medications for older adults.

  Age-specific alerts sustained the effectiveness of drug-specific alerts to reduce potentially inappropriate prescribing in older people and resulted in a considerably decreased burden of the alerts (Simon et al., 2006).

    Computerized physician order entry system has the potential to prevent an estimated 84% of dose, frequency, and route errors. Anywhere from 28% to 95% of ADEs can be prevented by reducing medication errors through computerized monitoring systems (AHRQ, 2001).

    Medication interaction alerts may reduce the frequency of prescribing of interacting medications (Feldman et al., 2006).

    Pharmacist may also function as the communicator of the hospital drug regimen to community pharmacy, primary care provider, and/or other levels of care.

    Social worker may review issues at home such as access to medications, costs, caregiver support, and barriers to discharge interventions. Nurses and other interdisciplinary members need to be proactive participants in reducing rehospitalization related to ADEs and implement discharge education and counseling to patients including the following:

    Devices to accommodate some impairments or barriers may be recommended. For example, tamperproof lids are often difficult for older adults to remove. particularly if there are arthritic changes. 

    A simple request to the pharmacist to provide a nonchild proof lid may improve the safe and effective use of prescribed medication. Consult with occupational therapy.

    Other health literacy (Curry et al., 2005). Query whether the older person understands what the drug is to be used for, how often it is to be taken, circumstances of ingestion (eg with food), and other aspects of drug self-administration that signal intelligent drug use; use teach-back method to verify understanding (Hutchison et al., 2006: Schillinger et al., 2003).

    Assess for ability to recognize generic versus brand name medication and their use (Curry et al., 2005). Ask the older adult to describe the circumstances in which the medication was not used or was used differently than prescribed. 

    If the older adult cannot describe medication use, consider removing the drug or provide written instruction for the home (Muir et al., 2001).

     Assess beliefs, concerns, and problems related to the medication regimen. Ask older adult if she or he believes that the drug is actually doing what it is intended to do. 

    If the medication is not useful, not creating symptom relief, or causing adverse effects, consider removing it or replacing it with a more acceptable substitute.

    Discuss the impact of medication expenses. Many medications particularly those that are new to the market can be prohibitively expensive, particularly for people on fixed incomes. Discuss influence of TV ads. 

    Ask the older adult what concerns they have about the costs and risks of administration (Curry et al., 2005). In addition, discuss Medicare Part D concerns or confusion. Where economic problems are identified, generic drugs and other avenues should be explored to manage the cost issue.

    Consider instrumental issues related to drug use, such as availability of family members or other social supports to facilitate medication adherence, and who monitors the need to change specific medications dictated by third-party reimbursement and medication coverage plans.

    Patients should be given the necessary information and the opportunity to exercise the degree of control they choose over health care decisions that affect them and the necessary information to effectuate this. 

    Patients who are informed and are involved in decision making are less likely to make decisions that may lead to ADRs, such as abruptly discontinuing a medication that should be tapered off slowly (NCC MERP, 2001).