© Geriatric Times. All rights reserved.
The Reality of Drug Regimen Reviews
by Gary Snodgrass, Pharm.D.
| Geriatric Times |
 |
September/October 2000 |
|
Vol. I |
|
Issue 3 |
Not long ago, I was reading an article on Resident Assessment Protocol (RAP)
Utilization Guidelines (Consultant Pharmacist 2000;15[3]) by Nancy
Losben, R.Ph. The guidelines contain 18 categories or potential problems that
can diminish a long-term care facility resident's quality of life. These
potential problem areas or conditions include delirium, cognitive loss, visual
function deficits, communication deficits and a host of other conditions for
which pharmacists need to rule out medication as the etiology. Losben does a
good job explaining the purpose for which the RAP Utilization Guidelines were
designed:
- Ensure that a full range of causal factors is considered;
- Help describe the nature of a condition;
- Identify complications and risk factors;
- Reveal the need for further investigation; and
- Formulate individualized care plan goals and approaches.
As I continued to read the article, I struggled to maintain a mental diagram
of how the 18 RAP categories-interrelated with the Health Care Financing
Administration's (HCFA) 24 quality indicators-meshed with HCFA domains, F-tags,
interpretive guidelines and the Minimum Data Set (MDS) 2.0.
Just then the phone rang, my mental picture scrambled and my brain read:
"Unusable signal." This is the message from my satellite dish when I am trying
to change a TV channel after a teenager has played with all four remote
controls.
This experience reminded me that, at my age, I am beginning to have
difficulty tackling complex issues with the same organization and clarity
presented in the article. As a corollary to this, my consulting practice often
diverges from the clear decision-tree analysis the Omnibus Budget
Reconciliation Act (OBRA) advocates. Therefore, in this issue I will present a
case study of a resident referred to me for drug regimen review. The goal is to
share with you some of the challenges I think most consultants face in melding
what we should do with what reality allows us to do.
One of my clients is a 99-bed skilled nursing facility (SNF) in Northern
California. It has an active Medicare wing and several private-pay residents.
About 70% of the other patients fall under MediCal. Like similar facilities, it
has weathered the storm of reimbursement pressures, unrealistic expectations
from residents' families, aggressive surveyors and less-than-timely physician
visits. By any measure of quality of care, however, this client is the best SNF
within the geographic area. It is important to frame the following case study
within that context. Overall, this is a very good facility, and it is chosen by
most of the community leaders within the area when they are seeking long-term
care for their loved ones.
"GS" (not his real initials) is a 91-year-old white male, admitted to the
SNF from an acute care hospital four years ago. His discharge diagnoses from
acute care included: left hemispheric cerebrovascular accident (CVA) with left
hemiplegia; Wernicke's aphasia; possible right homonymous hemianopsia versus
right neglect; oral motor apraxia and cognitive defects; atrial fibrillation;
osteoarthritis; history of prostatic cancer (treated with Lupron and
flutamide); possible congestive heart failure (previously used Dyazide); and
impaired mobility. He had a past history of CVA with transient right-sided
weakness, for which he did not seek medical attention, one year prior to the
acute care admission. Prior to admission he lived at home with his wife, who is
very attentive and visits him at the SNF daily.
The resident was admitted to the SNF on Coumadin (warfarin) 4 mg qd,
Procardia (nefedipine) XL 30 mg qd, Colace 100 mg bid, Propine (dipiverine
hydrochloride) 0.1% ophth. soln. 1 gtt ou qd, Tylenol (acetaminophen) prn, MOM
and Dulcolax supps. prn. He began working with an occupational therapist to
assist with upper extremity strengthening and coordination, neuromuscular
re-education, and assessment and training in basic activities of daily living.
A speech therapist worked with him on speech, language, swallowing and
cognition. Recreational therapists began to work on community mobility and
community re-entry.
When I first saw GS in December 1998, he was lethargic but could communicate
partially by grunting. He was accepting about 70% of his diet and weighed 186
pounds (up from his admission weight of 170 lbs), but he still had dysphagia.
He had been placed on a mechanical soft diet, with close supervision at
meals.
The physician progress note read, "Unfortunately, there is little to do
except continue supportive care. Will have PT & OT re-eval in light of new
CVA. Will use Haldol (haloperidol) for extreme agitation." The list of
admission diagnoses had been amended to include: CVA (onset 11/98), increased
agitation and cortical blindness. The nursing staff reported multiple behavior
tallies of thrashing about in bed, severe yelling, inability to calm self and
angry outbursts. He had an order for "May use pelvic restraint in wheelchair
for safety" and another for "R. leg elevated & secured to W/C leg rest to
keep flaccid leg from injury."
From a medication standpoint, he continued with ophthalmic medications,
various prn orders for laxative cascade, Ascriptin 1 qd, Tylenol ES 1000 mg
bid, acetaminophen 650 mg po q4hrs prn general pain, Vicodin (hydrocodone) 1
q4hrs prn moderate general pain. He also had orders for haloperidol 5 mg po
q4hrs prn extreme agitation, along with an order for haloperidol 5 mg IM if po
refused.
At this point, his compliance was poor, with medication refusals making it
difficult to assess the efficacy of any particular medication.
He had no acute cardiac or gastrointestinal distress, but the nursing staff
was concerned that he would yell constantly for about an hour in the early
morning. They would medicate him with haloperidol and hydrocodone prns, but
then his wife would become upset that he was lethargic when she came in to feed
him lunch. I discussed with the staff the need to minimize lethargy by limiting
administration of haloperidol to combative behavior and danger to self/others.
Since he appeared to c/o right arm pain, we set a goal of trying to rule out
pain as the cause of his behavioral outbursts.
By avoiding haloperidol prns and documenting better his response to prn
analgesics, perhaps we could disentangle his drug regimen. I was also hoping to
adjust the hydrocodone dose or find an optional analgesic (e.g., trial of
nonsteroidal anti-inflammatory drugs or Celebrex [celecoxib]/Vioxx[rofecoxib])
to limit the total daily dose of acetaminophen. In addition to clinical
concerns, I also expressed the need for better documentation of medical
necessity for the antipsychotics. GS's physician was less than interested in
OBRA compliance.
On my next visit to the facility, I found that GS's wife had lectured the
physician on the evils of haloperidol. Therefore, Haloperidol was discontinued,
and Ativan (lorazepam) 0.5 mg po q12hrs routinely was started for anxiety
manifested by angry outbursts. In addition, lorazepam 1 mg IM q8hrs prn loud
yelling was ordered. The nursing staff had been unable to establish any pattern
of analgesic response, but GS continued to grimace, yell most of the morning
and receive hydrocodone prns two to three times daily. Compliance with oral
meds had worsened, and GS alternated between screaming and lethargy. Most of
the hydrocodone prns and lorazepam IM prns were given before noon, so his wife
was less than pleased with the staff for making it difficult for her to feed GS
at lunch.
I met with the wife to discuss the significant differences in GS's behavior
in the morning versus the afternoon, and I explained the pattern of alternating
agitation and sedation with multiple prns. I again negotiated with the nursing
staff, giving options for increased doses of routine meds versus prns, a
possible trial of low-dose Risperdal (risperidone) if we could get better
compliance and the need to enlist the wife as an ally. I reviewed non-drug
behavioral interventions, pain versus dementia and the necessity of detailed
documentation.
On a subsequent visit, I could see we were going backward. Compliance with
routine meds was almost zero. Nursing was able to get him to accept more prns,
and lorazepam 1 mg po q8hrs prn had been added to routine lorazepam po and
Ativan IM prns. The resident had become more combative and had struck out at
several members of the staff and other residents.
I voiced my opinion that GS was declining and was becoming an inappropriate
placement and, unfortunately, the next step might be transfer to a secured
facility or dementia unit. The staff had become fearful of GS, his wife felt
helpless and GS had little if any "quality-of-life." It took me almost two more
months to convince the physician to try low-dose haloperidol decanoate. Brusque
progress notes were traded, we had some heated discussions, more education with
the wife (no other family was available), and impromptu inservice programs on
regulatory noncompliance and legal liability were held with the
administrator.
We started haloperidol decanoate 12.5 mg IM q4weeks and obtained some
positive response. Nursing staff was able to track a pattern of the medication
wearing off in about 10 days. We increased the frequency of haloperidol
decanoate to q2weeks, and the staff experienced the same pattern. GS still had
some yelling episodes, but no combativeness. He was occasionally sedated, but
had an easier time with meals. (He still received lorazepam prns, but not
frequently.) The physician, however, did not grant me any newfound credibility
for my recommendation. Therefore, my further recommendations for trying
optional analgesics went unheeded. This is from the "leave-well-enough-alone"
school of pharmacology.
Finally I was pleased we had done some good for GS. At least he could eat
his lunch, was mobile in his wheelchair and was 100% compliant with po meds. I
had visions of being able to taper the haloperidol decanoate and starting a
very low dose of one of the newer atypical antipsychotics, as the literature
suggests we should. As long as I was being this optimistic, maybe we could even
revisit his hydrocodone prn/high-dose acetaminophen regimen for
osteoarthritis.
I wish that had been the end of the case study. On my next visit, however, I
received a dose of "political" pharmacology. Mrs. GS apparently had the
administrator on the carpet because the nursing staff had "given him two
shots." Obviously the administrator wanted me to confirm or disprove the
medication error. I met with both Mrs. GS and the administrator to hear their
concerns and to reassure them.
After interviewing the staff and reviewing the chart, I found that his wife
wanted to take GS home over the holiday. Concerned about potential sedation,
she had talked a nurse into holding the haloperidol decanoate. Three days later
he decompensated and became very combative. He was returned to the SNF, and the
nursing staff gave him lorazepam 1 mg IM prn. The haloperidol decanoate was
also given, although three days late. This is what his wife had misinterpreted
as an error of haloperidol double-dosing. I again met with Mrs. GS and the
administrator and explained what had happened. The wife said she understood and
that she was not upset.
My progress note read, "Met with Mrs. GS and administrator to review her
concern about lethargy and 'they gave him two shots.' It turns out that she
requested holding the haloperidol on 4/22, which was delayed until 4/25. This
extended his 10-day cycle, as per his previous pattern he became combative, and
he received lorazepam 1 mg IM x 1 on 4/26, before the haloperidol decanoate
injection could take effect. The lorazepam resulted in increased sedation, and
difficulty in accepting meals. Options for the future include: re-enforcing
with family the importance of being consistent with the haloperidol decanoate
cycle, and considering d/c of early morning lorazepam 0.5 mg po, and changing
lorazepam 1 mg prn to hs only." In addition to my written note, I asked the
nursing staff to contact the physician by phone and update me.
Following-up a few days later, I had to write the following note: "Drug
Consult follow-up: Apparently, above recommendations not shared with t
he physician. Staff reported some drooling on 5/6 and the physician ordered
Haldol decanoate d/c'd. Wife now reports alternating episodes of morning
yelling and sedation. Observed today at 12:45 and he is sedated, probably
secondary to Ativan prn severe yelling for 90 minutes this morning.
If the above trial off Haldol is not effective, consider re-instituting
Haldol decanoate at a dose of 25 mg q14days, or Risperdal 0.5 mg q hs if still
po med compliant."
In conclusion-and in my defense-I have oversimplified this case, and I have
left out a lot of detail and descriptions of attempted interventions. With the
mixture of anger, frustration and disappointment, and the nagging feeling of
maybe I could have done something else, it is difficult to bare failure in a
column. It is small solace that we did GS some good temporarily. Mostly I hope
this case sparks some ideas for improved consulting effectiveness. Best
wishes.
P.S. I will be back to that facility next week to try again.
Dr. Snodgrass is an independent consultant and president of
Triad Management Group. His firm assists health care managers in pharmacy
systems analysis, vendor evaluation, medication utilization and quality
assurance in long-term care, residential care and psychiatric
facilities.