The Big Picture for PACE Pharmacy—The Use of Multiple CNS-acting Medications in Older Adults

When it comes to the medication needs of those in the PACE environment, there are unique challenges to consider. A new study has determined that the number of older Americans who take three or more medications that affect their brains has more than doubled in just a decade. The sharpest rise occurred in seniors living in rural areas, where the rate of doctor visits by seniors taking combinations of such medications—opioids, antidepressants, sedative-hypnotics, and antipsychotics—more than tripled. This “polypharmacy” of medications that act on the central nervous system is concerning because of the special risks to older adults that come with combining multiple medications with overlapping effects. Falls—and the injuries that can result from them—are the chief concern, along with problems with driving, memory, and thinking.

A Look at the Impact on PACE Providers, Including PACE Pharmacy

Combining opioid painkillers with other medications such as benzodiazepines is of particular concern, recently receiving the strongest possible warning from the FDA due to an increased risk of death from combined use. Polypharmacy significantly increased for seniors with a pain diagnosis, occurring in the context of the overall growth in opioid prescribing, which has reached epidemic proportion. But visits without pain, insomnia, or other mental health diagnoses accounted for nearly half of CNS polypharmacy visits and grew significantly from 2004 to 2013. Ensuring that prescribing is evidence-based is one of the key challenges to achieving appropriate polypharmacy, particularly in the geriatric population, including PACE. It is well known that evidence to support prescribing decisions in the geriatric population is lacking because of the under-representation of this population in clinical trials. Additionally, prescribing guidelines typically focus on single disease states and often fail to provide guidance on how to prioritize treatment recommendations when compared to those with comorbidities. [Tweet “This type of #polypharmacy is having a particular impact on seniors, including #PACE participants”]

The PACE Pharmacy Provider’s Role in Combatting the Issue

Recent developments have sought to address some of these issues. For example, an expert panel from the American Geriatrics Society has developed a set of guiding principles on the management of older patients with comorbidities. Prescribing assessment tools can play an important role in identifying and addressing potentially inappropriate prescribing. However, there are limitations associated with their clinical application in ensuring appropriate polypharmacy. For example, they do not provide guidance as to how treatment decisions should be prioritized—and in many cases, predictive validity has not been established. Deprescribing has become one of the important aspects of combatting polypharmacy, and is described as “a systematic process of identifying and discontinuing medications in instances in which existing or potential harms outweigh existing or potential benefits within the context of an individual’s care goals, current level of functioning, life expectancy, values, and preferences.” Though the main goal is to eliminate potentially harmful adverse drug events through the use of evidence-based stoppage of multiple medications, barriers exist that can impede the process of helping the PACE participant. Some of these barriers include: resistance from participants or family members, fear of losing participant-provider relationship, concern from clinicians to discontinue medications started by another provider, time expenditure, fear of medication withdrawal side effects, and lack of resources, such as a clinical pharmacist or database availability. Prescribers and PACE pharmacy providers must collaborate in collecting as much information as possible to answer the following questions:
  • Why and when was a therapy initiated?
  • Was the diagnosis substantiated?
  • Was the medication prescribed to counter adverse effects of another medication?
  • Is the medication continuing to benefit the PACE participant?
  • Are there alternative and equally effective nonpharmacological therapies available?
Polypharmacy and deprescribing are the responsibility of the providers and pharmacists that interact with PACE participants on a regular basis. Some mental health conditions seen among PACE participants require taking a medication indefinitely. Ultimately, how long a person takes a psychotropic medication depends on his or her individual illness, responses to treatment, and personal situations. Some key factors must be taken into account when prescribing/deprescribing medications, especially considering their poor safety profile in the senior population. Fall risk is a major concern among the geriatric population, especially when taking medications that affect mental processes and behavior. In 2015, Medicare costs alone for falls totaled over $31 billion, landing fall injuries on the top 20 most expensive medical conditions. The use of non-pharmacological techniques is essential when attempting to discontinue a medication that may increase the risk of fall and injury to PACE participants in the home environment. A structured approach integrated with clinical judgement is required along with the full engagement of the participant, family, and caretakers. PACE participants have unique and specialized needs when it comes to medication usage. The Grane Rx PACE pharmacy team understands those challenges and works with PACE centers to overcome them. Partner with us today by calling (412) 449-0504.]]>

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