November 1999

Information Bulletin 99-27
NH-36

Your Right To Prescribe

And The New CMS Focus On Medications With A High Potential For Adverse Drug Reactions In The Elderly

A GUIDE FOR PHYSICIANS FROM
COLLEEN COOPER, M.D.
MEDICAL ADVISOR
MINNESOTA DEPARTMENT OF HEALTH

You may be hearing that the federal Health Care Financing Administration (HCFA) has published new survey procedures that severely limit your ability to prescribe certain medications for your nursing home patients. The purpose of this memo it so let you know that the intent of the HCFA guidelines is to heighten awareness of medications which have the potential to cause significant side effects in the elderly. NOT TO RESTRICT YOUR ABILITY TO PRESCRIBE. If you believe that a medication with a high potential for an adverse drug reaction is the most appropriate treatment for a patient, we encourage you to work with the consulting pharmacists and the nursing home staff to provide information regarding the necessity (benefit vs. risk) of the identified medication for the individual. HCFA has not prohibited the medications listed below, but is asking that special attention be paid to their use.

Nursing Home residents receive an average of 7-8 medications/day. Adverse Drug Reactions (ADRs) are well recognized sources of morbidity in the elderly. In response to published medical literature (Beers, AIM, Vol.157, July, 1997) regarding ADRs, HCFA expanded the focus of the nursing home survey process to include a review of medications that carry high potential for adverse drug reactions in the elderly. The intent is to minimize ADRs and associated complications of ADRs. As physicians caring for nursing home residents, you are asked to review three elements of care: their patients' medication regimens - with special attention to the list of medications that have been identified as carrying a high potential for ADRs in the elderly, the conditions that put individuals at increased risk for ADRs with certain medications and symptoms that could be attributed to an ADR.

The MD Role

Physicians practicing high quality geriatrics consistent with currently accepted standards of medical care routinely consider medication side effects, interactions, risk/benefits when treating patients. The regulatory focus on medication use in the elderly recognizes the complicated process of selecting medications and asks physicians to be explicit about medication choices, goals and mechanisms for monitoring.

Physicians can help the nursing home by documenting the considerations and rationale behind the choice of treatment, particularly when there is a significant risk of side effects. Physicians should clearly indicate the benefits of the chosen treatment, the assessment upon which the clinical decision is made and plans for monitoring.

 
Medications with High Potential for SEVERE ADRs:
Talwin Aldomet LA Benzodiazepines
Diabinese Elavil GI antispasmotics
Sinequan Barbiturates Meprobamate
Demerol Norpace Ticlid
  Lanoxin  
 

Medication/Diagnoses combinations with High Potential for SEVERE ADRs

  • Hypnotics/sedatives in COPD

  • NSAID's in GI disease

  • Reglan with seizures

  • Antiplatelet meds with blood clotting disorders

  • Drugs with anticholinergic effects in BPH

  • Some antidepressants in arrhythmia

 
Medications with High Potential for LESS SEVERE ADRs:
Butazolidin Benadryl for sleep Persantine
Tigan Muscle relaxants Antihistamines
Indocin Ergot Mesyloids
(Hydergine, cyclospasmol)
Reserpine

 

Medication/Diagnoses combinations with High Potential for LESS SEVERE ADRs:

  • Corticosteroids in Diabetes

  • Aspirin or Potassium Supplements in GI Disease

  • Antipsychotics with Seizures

  • Narcotics with BPH

  • Meds with anticholinergic effects in constipation

  • Various meds in the presence of Insomnia

The Surveyors' Role:

Surveyors will review:

  • Meds taken within the past 7 days (with emphasis on listed drugs.) Other drugs may be reviewed especially if there appears to be an ADR.

  • Residents over 65 and who have resided in the facility for over 7 days.

Sources of information include:

  • Resident's record, observations, staff, physicians, pharmacist, residents, family interviews.

  • Pharmacy drug regimen review.

What They are looking for:

  • Indications, effectiveness, duplicative therapy

  • Evidence of monitoring for potential ADRs including a system for identifying: side effects, decline in functional status and risk/benefit analysis.

Updated Tuesday, December 10, 2013 at 11:01AM