Week 3- Part 1: Introduction And Problem Statement Paper
Week 3- Part 1: Introduction And Problem Statement Paper
Introduction and Problem Statement: An Effective Plan to Reduce Polypharmacy in a Long-term Care Facility
Older adults face multiple health problems exacerbated by the aging process that results in psychosocial and physiological changes. Health concerns, including altered cognitive function, physical frailty, and a high prevalence of chronic conditions, such as cardiovascular diseases (CVDs) and diabetes pose burdensome and significant problems to global healthcare systems. According to Christopher et al. (2022), the projected population of people aged 60 and above will be 22% by 2050. The steady increase in the aging population increases the healthcare burden and contributes to a high demand for patient-centered, evidence-based care. Appropriate medication use is a priority area when caring for older adults grappling with multiple healthcare concerns. In this case, medication processes, including prescribing, ordering, dispensing, administering, and monitoring are central to the achievement of the desired care outcomes (Christopher et al., 2022). Although appropriate medication use may translate to improve care outcomes, older people are susceptible to drug response variations, altered body pharmacokinetics and pharmacodynamics, and an increased likelihood of drug contradictions and adverse effects. Polypharmacy is one of the leading causes of inappropriate medication use and associated adverse effects in older adults with a high prevalence of co-morbidities. This paper elaborates on polypharmacy as a clinical problem and reviews evidence-based elements of an effective plan for reducing polypharmacy in a long-term care facility.
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Problem Statement
Polypharmacy is a profound public health problem, considering its association with adverse medication outcomes and other far-reaching health ramifications. Varghese, Ishida & Haseer Koya (2022) define polypharmacy as “using five or more medications based on a review of current data.” In a long-term care facility, healthcare professionals provide care to older adults at risk of multi-morbidity (coexistence of two or more chronic conditions). For instance, a high prevalence of chronic conditions renders older adults dependent on medical interventions, including medication administration.
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In the United States, people aged 65 years and older account for about 14% of the population. However, they are responsible for over one-third of outpatient spending on medication prescriptions in the country (Varghese, Ishida & Haseer Koya, 2022). More essentially, they are likely to require more than ten medications during hospital admissions and more than five medications at discharge; hence, polypharmacy (Dahal & Bista, 2023). Although the current medication prescription guidelines may recommend the use of more than one medication in the prevention and treatment of underlying health conditions, polypharmacy poses significant patient health and safety challenges.
Polypharmacy and Negative Health Outcomes
Exposure to an excessive number of drugs (inappropriate polypharmacy) is the leading cause of negative health outcomes in older adults with multi-morbidity. According to Delara et al. (2022), polypharmacy can result in an increased risk of death, altered drug interactions, non-adherence to the administered medications, and prolonged hospitalization. In the United States, the health burden associated with inappropriate polypharmacy is approximately $50 billion (Delara et al., 2022). Physical and physiological changes associated with aging expose older adults to the multiple adverse effects of the administered medications. Dahal & Bista (2023) identify altered drug metabolism and clearance are primary risk factors for negative outcomes of inappropriate polypharmacy. Further, older adults are an at-risk population for visual impairment and cognitive declines that affect medication adherence and compliance with pharmacologic guidelines.
Besides an increased risk of premature death, altered drug interactions, prolonged hospitalization, and non-maleficence to medications, inappropriate polypharmacy is a risk factor for multiple side effects of drugs. Varghese, Ishida & Haseer Koya (2022) argue that consistent intake of ‘too many’ medications can lead to decreased alertness, constipation, sleeplessness, tiredness, confusion, depression, loss of appetite, and diarrhea. Other overlooked side effects of drugs emanating from polypharmacy include incontinence and a lack of interest in social activities (Varghese, Ishida & Haseer Koya, 2022). In sharp contrast, healthcare professionals may end up administering more medications to manage these side effects, instead of adequately investigating the potential incidences of inappropriate polypharmacy. This concern may exacerbate drug side effects and contribute to more adverse health outcomes.
Polypharmacy and an Increased Risk of Falls
Polypharmacy is a risk factor for patient falls and fall-related injuries. Zaninotto et al. (2020) define falls as “an anticipated incident in which a person comes to rest on the ground or a lower level” (p. 2). In long-term care facilities, patient falls are highly prevalent and burdensome, considering their association with life-threatening injuries, fractures, and increased care costs. According to Zaninotto et al. (2020), one-third of people aged 65 and over experience at least one incident of fall annually, while injuries occur in about 20% of these incidences. Although patient falls are multifactorial healthcare concerns, side effects of medications are among the profound risk factors. Co-prescription of medications (inappropriate polypharmacy) of high-risk medications like anticholinergic medications, sedatives (anxiolytics), narcotics, and cardiovascular medications can lead to far-reaching side effects, including confusion, respiratory failure, dependency, memory loss, blurry vision, and hallucinations (Dahal & Bista, 2023). These side effects contribute to an increased risk of patient fall.
Polypharmacy and Medication Errors
Medication errors are often failures in drug therapies that result in adverse effects to patients, including increased mortality rate, lengthy hospitalization, and high care costs. According to Rasool et al. (2020), polypharmacy among older adults is a factor for medication errors since it involves drug duplication, co-prescription, and over-prescription. Further, altered drug-drug, drug-disease interactions, and adverse drug effects can lead to inappropriate prescribing, poor adherence to medications, overdose, and inappropriate drug selection (Ye et al., 2022). In other instances, healthcare professionals overlook drug side effects emanating from polypharmacy and end up prescribing more medications to treat and manage drug side effects. The association between polypharmacy and medication errors represents inappropriate medication use and can significantly lead to poor health outcomes, including poor quality of life and premature mortality.
Based on the adverse outcomes associated with polypharmacy, healthcare professionals should understand the causes of inappropriate polypharmacy, and comprehend changes in drug pharmacokinetics and pharmacodynamics exacerbated by the aging processes. Also, Varghese, Ishida & Haseer Koya (2022) indicate the need for multidisciplinary collaboration among healthcare professionals in preventing medication duplication, determining the thresholds for discontinuing all unnecessary medications, and involving patients, family members, and community pharmacists in medication prescription and monitoring.
An Effective Plan for Reducing Polypharmacy in a Long-term Care Facility
The current scholarly literature provides evidence-based recommendations for preventing polypharmacy and alleviating its associated adverse effects. According to Dahal & Bista (2023), judicious prescribing methods and steps for deprescribing medications that pose significant health threats are the initial approaches for preventing polypharmacy. Secondly, care providers should engage patients, family members, and home-based caregivers in establishing collective goals of care plans, alongside conducting comprehensive risk assessments. Dahal & Bista (2023) recommend various models as profound tools for preventing polypharmacy. These models include NO TEARS, Hyperpharmacotherapy Assessment Tool (HAT), Beers Criteria, Screening Tool of Older Person’s potentially inappropriate Prescriptions (STOPP), Medication Appropriateness Index (MAI), and Anticholinergic Drug Scale.
The NO TEARS model is a seven-component model that aids and guides efficient medication review to prevent adverse effects and document the physiological decline associated with aging that may affect individual compliance with pharmacologic interventions. According to Dahal & Bista (2023), the seven components of the NO TEARS tool include Need/Indication, Open questions, Tests and monitoring, Evidence-based guidelines, Adverse Events, Risk Reduction, and Simplification. When implementing this model, healthcare professionals review medications’ indications and duration, including intended treatment durations, appropriate dosing, and the review of alternative non-pharmacologic interventions.
Further, healthcare professionals ask patients open-ended questions regarding their understanding of medications, assess the patients’ conditions consistent with clinical findings and labs, review medication appropriateness based on the current evidence-based guidelines, document any adverse drug reaction, and simplify medical treatment with medication reconciliation and proper transition of care planning (Dahal & Bista, 2023). Consequently, this model is effective in reducing the potential side effects of medications, the identification of issues affecting patient compliance with pharmacologic interventions, and the alignment of treatment options with evidence-based guidelines.
Like the NO TEARS tool, the HAT model and other recommended frameworks for preventing polypharmacy emphasize various goals. These goals include monitoring the number of prescribed medications, decreasing inappropriate drug use, optimizing the dosing regimen, avoidance of high-risk medications, comprehensive screening of drug interactions, prevention of duplicate therapies, and effective assessment of drug side effects, including effects on cognition, functional activity, falls, mortality, and hospital readmission (Dahal & Bista, 2023). Other considerations for preventing polypharmacy are patient education, maintenance of accurate medication records, including lists and medical history, linking medication prescriptions with diagnoses, proper communication hand-offs, post-discharge follow-up, and effective medication reconciliation during t transition of care (Varghese, Ishida & Haseer Koya, 2022). These evidence-based strategies require interdisciplinary collaboration, coordinated practices, and teamwork.
Conclusion
Polypharmacy is a significant public health problem, considering its potential adverse effects. Often, older adults grapple with multi-morbidity, which refers to the coexistence of two or more chronic conditions. These co-morbidities increase the risk of co-prescription and prescription duplication, leading to polypharmacy. Besides multi-morbidity, older adults are susceptible to physical, cognitive, and physiological changes that contribute to poor compliance with pharmacologic interventions, altered drug interactions, and adverse effects of prescribed medications. If left unaddressed, polypharmacy can lead to multiple adverse ramifications, including overlooked side effects like delirium, vomiting, diarrhea, sleeplessness, and tiredness. Also, it can lead to an increased risk of patient falls and medication errors that inflict a massive burden on patients and healthcare systems. An effective plan for addressing polypharmacy should include extensive strategies for assessing drug interactions, identifying drug side effects, discontinuing high-risk medications, and educating patients on appropriate drug interactions and treatment goals. Various evidence-based tools accommodate these approaches and provide frameworks for preventing polypharmacy. Examples of these tools are the Beers Criteria, NO TEARS model, Hyperpharmacotherapy Assessment Tool (HAT), Medication Appropriateness Index (MAI), the Screening Tool for Older Person’s potentially inappropriate Prescriptions (STOPP), and Anticholinergic Drug Scale.
References
Christopher, C., KC, B., Shrestha, S., Blebil, A. Q., Alex, D., Mohamed Ibrahim, M. I., & Ismail, N. (2022). Medication use problems among older adults at a primary care: A narrative of literature review. AGING MEDICINE, 5(2), 126–137. https://doi.org/10.1002/agm2.12203
Dahal, R., & Bista, S. (2023). Strategies to reduce polypharmacy in the elderly. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK574550/
Delara, M., Murray, L., Jafari, B., Bahji, A., Goodarzi, Z., Kirkham, J., Chowdhury, Z., & Seitz, D. P. (2022). Prevalence and factors associated with polypharmacy: A systematic review and meta-analysis. BMC Geriatrics, 22(1), 601. https://doi.org/10.1186/s12877-022-03279-x
Rasool, M. F., Rehman, A. ur, Imran, I., Abbas, S., Shah, S., Abbas, G., Khan, I., Shakeel, S., Ahmad Hassali, M. A., & Hayat, K. (2020). Risk factors associated with medication errors among patients suffering from chronic disorders. Frontiers in Public Health, 8(1). https://doi.org/10.3389/fpubh.2020.531038
Varghese, D., Ishida, C., & Haseer Koya, H. (2020). Polypharmacy. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532953/
Ye, L., Yang-Huang, J., Franse, C. B., Rukavina, T., Vasiljev, V., Mattace-Raso, F., Verma, A., Borrás, T. A., Rentoumis, T., & Raat, H. (2022). Factors associated with polypharmacy and the high risk of medication-related problems among older community-dwelling adults in European countries: A longitudinal study. BMC Geriatrics, 22(1). https://doi.org/10.1186/s12877-022-03536-z
Zaninotto, P., Huang, Y. T., Di Gessa, G., Abell, J., Lassale, C., & Steptoe, A. (2020). Polypharmacy is a risk factor for hospital admission due to a fall: Evidence from the English longitudinal study of ageing. BMC Public Health, 20(1). https://doi.org/10.1186/s12889-020-09920-x
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Assignment Prompt
The purpose of assignments Part 1 – Part 3 is to gradually guide the student in developing the signature assignment. The idea is for the student to take a stepwise approach to completing the signature assignment. The signature assignment will be broken up into three steps: STEP 1 – Introduction and Overview of the Problem; STEP 2 – Project Purpose Statement, Background & Significance and PICOt Formatted Clinical Project Question; and STEP 3 – Literature Review and Critical Appraisal of the Literature. The three steps, when completed, will be combined in the final Signature Assignment formal paper in Week 8.
This week’s assignment is STEP 1 – Introduction and Problem Statement.
First, the student will select a clinical question from the Approved List of PICOt/Clinical Questions or seek approval for a question from the course professor only for Nurse Educator and Health Care Leadership MSN majors who wish to tailor their research question to their specialized major. The student will select an approved topic from the list (or with faculty approval as previously stated) and will customize the question to meet his or her interest.
Next, the student will use the outline below and submit via a Word doc to the assignment link.
- Provide a title that conveys or describes the assignment.
- Introduction – Provide an introduction to your topic or project. The introduction gives the reader an accurate, concrete understanding what the project will cover and what can be gained from implementation of this project.
- Overview of the Problem – Provide a synopsis of the problem and some indication of why the problem is worth exploring or what contribution the proposed project is apt to make to practice.
- References – Cite references using APA 6th ed. Manual.
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Approved Clinical Questions For PICOt Development List
Implementing a clinical practice protocol/guideline for the management of [hypertension or disease] in [the homeless or population/clinic type]
Developing a clinical protocol to prevent [community acquired pneumonia or disease] in [vulnerable populations] in primary care
Identifying barriers to [diabetic treatment or disease or health promotion] adherence in a community primary care clinic
An educational program to improve [influenza and/or pneumococcal or type] vaccination rates among [population]
Evaluation of an intervention protocol to improve adult vaccination rates among [older adults or population]
Primary care providers’ adherence to treatment guidelines for the management of [Type II diabetes or disease] in a [rural or type] clinic
The implementation of a clinical protocol to identify and manage [COPD or disease] in [the working poor or vulnerable population or setting]
Evaluation on implementing [smoking cessation or disease prevention/health promotion] primary clinic in long-term care
Improvement of screening rates for [sexually transmitted diseases or disease prevention targets] in a primary care clinic
Implementing a peer review process in a primary care clinic or setting
The effectiveness of implementing the [Geriatric Depression Scale or standardized assessment instrument] for the treatment and management of [depression or disease] in primary care
Evaluating the use of computer reminder systems for providers to improve treatment guideline adherence in [community care or setting]
Screening for mild cognitive impairment in a primary care setting
Primary care provider practice patterns for the treatment and management of [pain or disease] in [older adults or population]
Effectiveness of obesity management strategies in [working adults or population] with [cardiac risk factors or disease] in primary care
The impact of the Adult-Gerontology Primary Care Nurse Practitioner’s role in a healthcare home model
Identification of perceived barriers to care of [women or population] seeking treatment for [depression or disease] in primary care
Culturally sensitive care for [Asian Americans or population] seeking treatment for chronic [hypertension or disease] management in primary care
Barriers and facilitators to implementing a culturally sensitive clinical protocol in [Hispanic men or population] with [prostate cancer or disease]
Evaluation of [cost or type] outcomes of a primary care model that includes a psychiatric-mental health care nurse practitioner overlay service
Development of a [cardiac or disease/type] risk profile to identify high risk [women or population] in primary care
Effective [ADHD/Other] Screening of Children in the Primary Care Setting
Reducing BMI of Overweight and Obese [Children or population]: Evidence-Based Approach
Expedited Partner Therapy: An Option in the Treatment of [Genital Chlamydial Infection or other STI]
Effectiveness of the Use of Insulin [pens/pump]: An Analysis of the [Hispanic adult or population] Patient’s Satisfaction and Outcomes
An Effective Plan to Reduce Polypharmacy in a [State Prison or Long-term Care Facility]
The Role of Reminder Cards and Telephone Follow -Up on Office Visits on Adherence of Patient with [T2DM or other chronic disease]
Effects on A1C among Insulin Managed Diabetic Patients following an Electronic, Patient-Centered, Feedback System: An Evidence-Based Practice
The Effect of Language in the Delivery of Care in [Home Health or other community setting]
The Effect of Culture and Eating Habits on [Childhood or population] Obesity in [United States or state]
The Effectiveness of [Basic Daily Monitoring or other intervention] for [Elderly or population] with Heart Failure to Reduce Hospital Readmission
Adherence to Diet and Exercise to Reduce Hyperlipidemia in [Adults or population]
Evidence-Based Practice in Management of Acute Otitis Media: Topical versus Systemic Treatments
[Walking 3x/week or Other exercise activity] for 45-minutes Reduce Blood Sugar levels in [African- Americans or population] with Type II Diabetes
Implement a [Brisk Physical Activity or other activity} to Improve BS Levels in [Women with GDM or population]?
Asthma Treatment in Pediatric Patients: Spacer versus Conventional Inhaler
Concurrent use of Probiotics during Antibiotic Therapy Reduce the Incidence of Developing Antibiotic-associated Diarrhea
The Role of Nurse Practitioner in the [Breast Cancer Risk Assessment or other Assessment] on [Hispanic Women or populations]
Brain Exercise Reduce the Cognitive Decline in Patients with [Cognitive Decline or population]
Measuring the Effectiveness of 5-2-1-0 every day to Reduce Obesity in [Children or population]
Spiritual Care: The Missing Link in Health Care Among Patients with [Advanced Cancer in Palliative Care or population]
Effectiveness of Nurse Practitioner’s Home Visits in Improving Patient Adherence in the Management of [Hypertension or population]
Nurse Practitioner’s Focus Patient Education to Prevent Complications of [Pre-eclampsia or population]
Providing Education to [Reduce Hb1Ac or Other measure] in Adherence with Current [Diabetes or other chronic disease] Guidelines
Utilization of Nurse Practitioners in the [Emergency Department or other Community Settings] on Patient Satisfaction, Provider to Patient time, and Length of Stay
Use of NP-led Triage Orders in Emergency Department for Early Patient’s Discharge
Screening of Patients with Drug-Seeking Behaviors in [Emergency Department or other Community Setting]
Developing an Education-based Approach to Increase Awareness on [Prostate Cancer or other] Screening
Reducing [HPV or other preventable disease] Incidences with Vaccination among the [Latino Population ages 11-26 in the United States or population]
Evaluate the Effectiveness Of Post-Discharge Follow-Up Among [Congestive Heart Failure or high-risk population] Patients on Reduction of Hospital Readmission, Improve Quality Of Life, Medication Reconciliation, Self-Care Skills and Coordination of Care During Transition to Home [Other]
Primary Care Provider Practice Patterns for the Identification, Treatment, and Management of [early onset sepsis disease or other disease] in [pediatric or populations]
Evaluation on Implementing and Follow-up with Health Screening Guidelines [Colonoscopy or other Screening] in a Primary Clinic or other Community Setting
Primary Care Provider Practice Patterns for the Treatment and Management Follow-up after UC or ED visit in [older adults or population]
Barriers and facilitators to implementing a culturally sensitive clinical protocol in [refugee men or population] with [depression or other chronic disease]
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