Principles of Prescribing

With patients seeing multiple providers across different clinical settings, it is essential that the medication list remain updated. In one prospective observational study, 74% of patients were taking at least one medication of which their primary physician was unaware (Bikowski et al., 2001).

At least once yearly, ask your older patients to bring in all their medications, including OTC medications. Use a checklist to review each medication (Table 4-13). With each medication, first and foremost, review the indication. Educating the patient about the indication can decrease ADEs and increase adherence (Garcia, 2006). Is the medication effective? Medications are often started for good clinical reasons but never revisited as to their efficacy. Are there side effects? Medications should be discontinued if there are intolerable side effects, and always consider an ADE as a cause of any new patient symptom. Avoid the "prescribing cascade," in which medications are started to treat an ADE. Does the medication require any laboratory monitoring? This may include direct drug levels (e.g., digoxin) or monitoring for side effects (e.g., electrolytes in patient taking hydrochlorothiazide).

Is the patient taking the medication? Medication nonad-herence is a common and complex issue with both physician and patient factors. Depending on the definition, "nonad-herence" ranges from 14% to 70% (DeSmet et al., 2007). Adherence is associated with the number of medications, cost, frequency of dosing, and patient's knowledge of the condition. It is important to obtain the patient's perspective and concerns about medications in a nonjudgmental manner (Erice Group, 2009). Methods to increase adherence have focused on educational interventions and external cognitive aids. For short-term therapies, written information, counseling about the medication's indication and potential side effects, and personal phone calls increased adherence. The same effect was not seen for patients taking long-term medications (Haynes et al., 2008; McDonald et al., 2002).

Finally, the checklist should include asking if the medication is still needed. Has the patient's condition changed to where you can stop unnecessary drugs, such as preventive medications in a hospice patient?

Continuity of pharmacists is as important as continuity of physicians in decreasing medication errors. Encourage patients to use one pharmacy, and inform the pharmacist of any medication changes. Seeking input from the pharmacist can reduce inappropriate prescribing (Garcia, 2006). With inpatient settings, pharmacists obtain more accurate medication histories from patients, reducing the rate and severity of ADEs (Carter et al., 2006; Reeder and Mutnick, 2008). Simplify the medication regimen by using once-daily dosing and generic drugs, if possible. Discontinue medications that have no indication or benefit (Carlson, 1996). When initiating medications, start one at a time at the lowest dose possible (Table 4-14).

The decision to prescribe a drug depends on many factors besides age, including the patient's functional status, comor-bidities, other medications, and personal preferences and values. Physicians must be extremely vigilant in prescribing, especially for the frail elderly patient, carefully weighing the risks and benefits of any new medication. Periodic review of patients' medication list is essential to monitor for adverse effects, potentially inappropriate drugs, drug-drug interactions, and drug-disease interactions.

KEY TREATMENT

Current methods of improving medication adherence for chronic health problems are not predictably effective (Haynes et al., 2008; McDonald et al., 2002) (SOR: B).

Certain drugs should be avoided or limited in the elderly patient (Fick et al., 2003/04) (SOR: C).

Obtain local pharmacists' recommendations to reduce inappropriate prescribing and adverse drug events (Garcia, 2006) (SOR: B). Reviewing a medication list regularly can reduce polypharmacy and inappropriate prescribing (SOR: B).

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