With more states enacting legislation that permits direct access to physical therapy, the role of the therapist as a primary point of patient contact increases. As such, physical therapists need to have a better understanding of pharmacology and the mechanism of action and side effects of different medications.
The older adult population has a well documented history of polypharmacy, with some medications being used “off label” by physicians. These drugs may have negative side effects that interfere with rehabilitation. There are many medication-related problems associated with older adults due to inadequate or inappropriate drug prescription.1,2 The prevalence of inappropriate medication prescribing ranges from 14 percent in community-dwelling older adults to more than 40 percent in residents in long-term care facilities.3
The World Health Organization defines an adverse drug reaction (ADR) as “a reaction that is noxious and unintended and that occurs at doses normally used in humans for prophylaxis diagnosis, or therapy.”4 With a reported prevalence between 5 percent and 35 percent, ADRs are common in community-dwelling older adults and pose a major risk to individuals’ quality of life.5
The Side Effects
There are many negative consequences associated with ADRs. ADRs are responsible for an increased need for greater health care services, physicians’ visits, hospitalization and emergency room visits. ADRs are associated with polypharmacy, a previous history of ADR, multiple chronic medical issues, and a past medical history of dementia.5
Prescribers can minimize ADRs in patients by recommending medications as intended by the manufacturer and tracking patients’ current medications to note any drug-to-drug interactions.
A national initiative, one of the goals of the Healthy People 2000 campaign was to improve the overall health of Americans by recommending regular review of medications used by older adults.6 Drug utilization reviews are one means to achieve this goal. However, explicit criteria to complete these reviews were necessary. In 1991, gerontologist Mark Beers, DPM, enlisted a consensus panel to identify medications or classes of medications considered inappropriate in a nursing home population.
Since its inception, the criteria have been used in other health care settings, including acute care, rehabilitation, home care and in outpatient clinics. In 1997, the criteria was revised and recommended for all adults over age 65.
The latest revision in 2003 updated the medications included on the list. There are currently two categories on the list; one category lists medications that are potentially inappropriate independent of patients’ medical history, and a separate medication list details inappropriate medications when used with older adults with specific diagnoses.
The Beers criteria provides a standard by which medications used among older adults can be analyzed on a national level and can assist physicians and pharmacists improve pharmacotherapeutic regimens. In addition, the list is built into the Centers for Medicare and Medicaid Services guidelines to assess compliance with medication-related regulation.
Knowing the Limits
There are several limitations to the Beers criteria. Variations in the definition of inappropriate medications for older adults may differ between physicians, and there is a concern that the list should not be universally applied to older adults without regard to the individual’s response to a medication (e.g., diazepam).
Also, the criteria do not address drug-to-drug interactions, the under-utilization of drugs, or the duplication of medication treatments.7 In addition, the list does not address appropriate medication dosages or timeframes for patient use. Furthermore, the criteria do not have a recognizable order according to physiological systems and extensive, long-term research regarding the use of the criteria is lacking.8Some medications should not be prescribed to adults with specific medical conditions, which are omitted in the Beers criteria; for instance, the use of non-steroidal anti-inflammatory drugs should not be used with patients who suffer from chronic renal failure.
Other medication screening tools exist that may also reduce inappropriate prescribing in the older adult population. The Improved Prescribing in the Elderly Tool, developed in Canada, contains different categories of drug-disease interactions and lists contraindicated medications. Other guidelines developed in Europe include the Screening Tool of Older Persons’ Prescriptions list and Screening Tool to Alert Doctors to Right Treatment list.
However, these tools and guidelines have been seldom tested outside their area of origin and therefore, within the United States, the Beers criteria is currently the gold standard.9
Since 2005, The Joint Commission has included medication reconciliation as part of its National Patient Safety Goals. For participating hospitals, rehabilitation centers, home care agencies and outpatient services, the goal is to improve patient safety with regard to medications by interviewing patients to ascertain their medication regimen, accurately record these drugs, educate patients, and remind patients to bring their updated medication list to their physician.10 Many health care providers can participate in accomplishing this important goal.
Implications for PT
While pharmacists bear great responsibility in regulating medications, it’s beneficial for inpatient and outpatient providers to review medications as well. Pharmacists conduct drug utilization reviews for high-risk drugs, interview patients to determine other medications (e.g., prescriptions, OTCs, herbal remedies), and notify prescribers of polypharmacy. However, older adults may not accurately report the medications they are taking to their pharmacists.
Failure to report drugs may be related to a simple oversight or memory impairment. In addition, some individuals may not report herbal remedies because they do not consider them to be traditional medications.
A physical therapist is qualified to act as another safeguard. According to the Guide to Physical Therapist Practice, physical therapists should review patients’ current medications and medications taken in the past when conducting an initial evaluation.11
It’s important for physical therapists to realize that it’s not uncommon for patients to receive at least one inappropriate medication in their drug regimen, and that patients who receive a greater number of medications are more likely to receive inappropriate medications as per the literature.2
State boards have clarified the role of physical therapists in reviewing drug regimens in different therapy settings. It is the responsibility of therapists to review their state practice acts regarding medication review and appropriate follow-up. While physical therapists cannot make medication changes, many states allow for medication review and provide guidelines for communication with prescribers.
The APTA recommends that therapists engaging in direct access in the outpatient sector take continuing education courses on pharmacology and rehabilitation to maintain clinical competency in that area. The organization also offers online courses in pharmacology on their website.
In general, physical therapists may review a patient’s medications, educate on side effects, and remind patients to provide their physicians with an updated list of medications upon office visits.
In addition to patients’ physical benefits, there are great financial implications when using medications correctly. It has been estimated that $1.33 in health care resources are used for medication-related morbidity and mortality for every dollar spent on medications in long-term care facilities.12 There is also an increase in medication use related to the treatment of side effects of some medications. Clearly, better collaboration between physicians, pharmacists and other health care providers could both minimize these expenditures and also decrease the billions of dollars spent on the medications themselves.
Future research should emphasize the economic impact of inappropriate medication prescribing, the potential negative outcomes associated with agents on the Beers list, medication effects on the frail elderly, current prescribing trends, and the impact of ADRs on older adults.2
In addition, with the pharmacologic options of medications evolving over the past several years, the Beers criteria will soon need to be updated. Clinicians who use the criteria should bear this in mind.
It should be noted that research has demonstrated that polypharmacy can be minimized without adverse health outcomes. Physical therapists can use the Beers criteria to help them identify medications that may have negative side effects in the older adult population. When appropriate, physical therapists should communicate with physicians regarding concerns of polypharmacy, in order to provide optimal quality care and act in patients’ best interest.
References available at www.advanceweb.com/pt.
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