This is part 2 of a 2-part series on drugs whose side effects send seniors to the emergency room. Part 1 can be found here
The 3 classes of drugs implicated in seniors’ ER visits are found scattered on the BEERS list, but there are many drugs within these classes on the market today, and “it’s difficult to point out which particular drugs are causing the problems,” Shehab says. “Simply putting these drugs on the list is not an answer.”
Watanabe says Shehab’s research team has done a good job of showing it’s not just the drugs on the BEERS list that we need to be concerned about: There are others we need to worry about outside of it.
“I think we need to do a much better job of educating prescribers — and also patients — so patients are engaged and empowered to ask about medication, and be part of the decision making,” he says.
He points out how today there is a new kind of anticoagulant — and one that is not monitored, like Xarelto. Once patients are put on it, then it’s up to them to report any reactions.
“There’s a risk of being over anti-coagulated, so they could have more bleeding events. There’s less maintenance, but there’s still a risk, because we don’t know how the patients will respond,” Watanabe points out. With the monitored blood thinners, there are periodic blood tests, and diet restrictions, hence more maintenance.
Shehab says it’s difficult to ascertain if it’s these novel anticoagulants that have led to an increase in ER visits, but they do result in some of them. Those on Xarelto and not Coumadin (warfarin), considered the gold standard of blood thinners, can ask for regular monitoring, particularly during the first few months.
“The risk of bleeding is something we as clinicians always consider when prescribing someone a blood thinner,” notes Schuchman.
Multidisciplinary, Coordinated Care with Doctors and Pharmacists
One way to prevent drug interactions and adverse reactions in seniors is to involve pharmacists and prescribers in the decision making, a multidisciplinary approach that Watanabe is involved in with a clinic where he consults.
This approach can avert adverse reactions. Some of the methods include sending a home health care worker to follow up with seniors, which might prevent ER visits and re-hospitalizations. Shehab agrees: “Diabetes patients,” for example, “who can be counseled by a nurse educator on which insulin to take, and how to regulate their diet — those patients can have better control of their diabetes.”
Watanabe’s research group also evaluates prescribing practices, and found that misdiagnosis or overdiagnosis occurs when a senior might complain about not sleeping, and gets put on a sedative like Ambien.
“If they already have a long medication list, we need to do a careful review of that list before adding a sleeping aid, and look to see what is causing the sleep issues,” he says.
“We are not where we need to be and there could be more improvements in prescriptions, such as more cautious prescribing practices.”
At the program of all-inclusive care (PACE) clinic in San Ysidro, California, if a senior is put on an anticoagulant or diabetes drug, they’re only given a 2-week prescription. Then they come in for a review, and only once they’ve stabilized are they put on it for the long term.
But there are way more senior patients in proportion to the providers available, so adequate follow-up is a challenge, Watanabe says. However, he points out that if everyone involved agrees on what the high risk medications are, and a risk assessment system is put in place, it can be managed.
It’s also easier to prescribe a new medicine than to de-prescribe an old one, which would involve going back to review prescriptions senior patients may have been on for years, a practice for which doctors don’t always have time, Schuchman points out.
Shehab summed up by observing that, “We are not where we need to be and there could be more improvements in prescriptions, such as more cautious prescribing practices. Do we need to revisit guidelines for these drugs? Are patients adhering to monitoring criteria? These are questions we need to address.”