Monthly Archives: December 2015

AMDA Conference March 17-20, 2016 in Orlando

Mark your calendars!  AMDA  – The Society for Post Acute and Long-Term Care Medicine, is holding its annual conference in Orlando, Florida from March 17-20, 2016.  As we have done for years, a stipend is available to Medical Directors who attend this conference and our Golden Living Physician Gala which will be held on site on Friday Night.  The conference is unique in its blend of clinical and administrative content, providing the best available resource on how to excel as a Medical Director.  The keynote speaker is Dr. John Abramson, lecturer in Health Care Policy at Harvard Medical School.  He will be speaking on the subject of how much we can trust evidence that underpins our evidence-based medicine.

At the Golden Living Gala, you’ll get a chance to meet with your fellow Medical Directors, see the awards presentation of the Golden Living Medical Director of the Year for each Region and hear from our corporate leaders.

The conference site will be the Gaylord Palms Resort & Convention Center.  Early registration helps to save on costs and assure lodging. Please join me in March!

Highlights From the 2015 Beers List Update

AGS photo Lowerred

History of Beers Criteria

In 1991, the late geriatrician Dr. Mark Beers published a landmark article in the field of geriatrics.  In it, he and a group of experts listed medications which could be considered potentially inappropriate medications in the frail elderly population. There actually were two lists, one which outlined potentially inappropriate medications (PIMs) and one in which medications were potentially inappropriate in patients with common chronic diseases. This article helped to alert doctors caring for the elderly that there were certain medications which were particularly harmful in older patients or in which had a very poor benefit to risk ratio.

Over the years, the “Beers List” as it came to be known, became accepted broadly as a guide to physicians. The list was updated several times, and its aim expanded to include all patients 65 and over. In 2011 the American Geriatrics Society (AGS) assumed the responsibility for updating and maintaining the Beers Criteria.  Updates by the AGAS have been was published in 2012 and 2015.

Not surprisingly, organizations and agencies, such as the National Committee for Quality Assurance (NCQA ) and CMS have relied on the Beers criteria to help them develop quality measures addressing medication related quality measures. CMS also incorporates Beers criteria into Medicaid Part D policy.

Now in November 2015, the latest update has been published. The methods used to choose the medications for the list are extensive and careful. A comprehensive literature review was performed by a multidisciplinary committee of 13 experts, who graded evidence and reached a consensus on each decision.

Some notable changes in the 2015 update include:

  • Identification of select medications which should have dosage adjustments in patients with renal insufficiency
  • Recommendation to avoid use of scheduled Proton Pump Inhibitors (PPIs) beyond a maximum of eight weeks
  • Clarification of what is meant by “avoid sliding-scale insulin”
  • Recommendation against use of newer non-benzodiazepine sleep medications
  • Opioids added to avoid list in patients with history of falls/injuries
  • Meclizine added to the avoid list regardless of indication
  • Addition of select drug-drug interactions

Medication list for which dosage adjustments or avoidance is recommended in renal impairment
There are over 20 medications on this list, and creatinine clearance thresholds at which action is required are listed. Among the medications listed are certain novel anticoagulants (NOACs), potassium sparing diuretics, and H2 blockers.

Patients with prolonged PPI use
Evidence continues to mount regarding the harms of the relatively common practice of prolonged scheduled Proton Pump Inhibitor usage.  Resultant changes in gastric pH make patients more prone to infections such as C. Difficile. Bone loss and fractures also have been associated with prolonged PPI usage.

Clarification regarding Sliding-Scale Insulin
The AGS authors clarified that their recommendation to avoid sliding-scale insulin refers to usage as sole insulin coverage in the absence of basal or long acting insulin. It does not refer to “correctional insulin” (i.e. titration of basal insulin or use of additional short- or rapid-acting insulin in conjunction with scheduled insulin).

Nonbenzodiazepine, benzodiazepine receptor agonist hypnotics
Continued evidence shows that drugs in the non-benzodiazepine sleep medications (eszopiclone, zaleplon, and zolpidem) have side effect profiles similar to the benzodiazepines and share a similarly unfavorable efficacy to risk ratio.  In 2012, the Beers list recommendation was to avoid usage over 90 days. Now they strongly recommend  to avoid them without regard to duration of use, just like they recommend against use of benzodiazepines.

Opioids
Opioids have been added to the list of medications which affect the CNS and should be avoided in patients with a history of falls or fractures. Keep in mind that NSAIDs remain on the list of drugs to avoid when possible, especially indomethacin due to its negative side effect profile.

Meclizine
This medication, frequently prescribed for patients with vertigo, was already on the warning list of medications with strong anticholinergic properties. In 2015, the medication is now on the list for meds to avoid regardless of diagnosis.

Antipsychotic medications
In addition to the previous recommendation against usage in behavioral problems of dementia, antipsychotics were recommended against as first line treatment of delirium, due to conflicting evidence of efficacy and risk of adverse effects (appropriate usage exceptions: schizophrenia; bipolar disorder; short term anti-emetic usage during chemotherapy).

AGS identified a few selected drug-drug interactions
Most were straightforward such as recommending against utilizing multiple medications which together would increase the anticholinergic burden. Others were less obvious, such as the warfarin -amiodarone combination which may cause an increased risk of bleeding.

What does this mean for the rounding SNF physician?

The Beers list is not intended to replace clinical judgment. Each patient has his or own unique set of medical issues and personal values, and this must always be taken into account by the physician. The Beers list should not dictate what medicines are prescribed for each individual patient.

It is important to know that because of the specific needs and different therapeutic goals for patients who are under palliative care or hospice care, the AGS Expert panel specifically excluded them from their analysis of these medications.

I recommend that you review the article carefully and see which medications you more frequently use or are frequently prescribed to patients who come under your care. Our patients are increasingly complex with multiple diagnoses, and often we “inherit” patients from the hospital who have some of these medications on the list.

In general, it is a good idea to consider an alternative medication if a patient is admitted with one  or more of these PIMs as part of their regimen. Your consultant pharmacist also can assist you in finding an appropriate alternative medication, corresponding dosage and give advice on the safest way to wean a patient of a medication if necessary.

If you decide to use a medication on this list, then it makes sense to clearly document why this decision was made, and to discuss it with the patient and family if appropriate. This will help protect you and your LivingCenter from a liability and regulatory standpoint and will assure that the patient is empowered to take part in the decision.

As Medical Director, you may be approached by your DNS or consultant pharmacist about an attending physician on your staff who may be using more potentially inappropriate medications than advisable. It will be up to you to discuss the cases clinically and figure out the best way to communicate any concerns to your physicians.

As we increase the number of younger, subacute patients, there will be more who have “Beers list” medications as part of their regimen upon admission.  While these patients may be younger and have better renal function, they still may have complex medical issues and opportunities for drug-drug or drug-disease interactions.

You can get the Beers list update for free at:
http://onlinelibrary.wiley.com/doi/10.1111/jgs.13702/pdf

References:

American Geriatrics Society 2015 Beers Criteria Update Expert Panel,  American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults  J Am Geriatric Soc 63:11 November 2015, pp. 2227-2246.