Last week, MedAware hosted a one-hour webinar with geriatricians, Dr. Mike Cantor and Dr. Mark Yurkofsky. Throughout the session, they spoke of the challenges of polypharmacy in the long-term care setting, what contributes to it, and how to improve patient safety and the quality of care by deprescribing. Several questions were addressed, including:

• Why has polypharmacy become such a challenge in long-term care?
• How do you balance the potential benefit relative to the risk of stopping a medication? 
• How has COVID-19 impacted polypharmacy?
• What can facility leadership do to help with polypharmacy?
• What kind of technological tools are available today that can be used to better manage polypharmacy and help with the deprescribing process?

This article provides a sneak peek into two of these answers, specifically addressing the role of leadership and technology in polypharmacy.

What can facility leadership do to help with polypharmacy?

Dr. Yurkofsky: Addressing polypharmacy is really a team effort. Nursing is critical to giving the appropriate medications and doses as prescribed. It’s important to communicate with patients and their family members who can provide additional information about medications being taken, and for nursing to understand why those medications were prescribed. Nursing assistants are also key players since they’re often the first to notice if a patient is having a new symptom. Encouraging them to communicate with the care team about what they’re observing is an early warning system that something might be going on. Within the facility structure, having quality improvement processes in place that can identify if there’s an adverse event or medication error and look for root causes is important to addressing this systemic issue.

Dr. Cantor: To add to that, leadership is critical to creating expectations among the team. For example, when those nursing assistants are noticing symptoms, they need to be empowered to react and investigate. Leadership sets the context and creates a culture that not only gives permission for staff to spend time thinking about medications and how they may be contributing to a patient’s symptoms, but they also need to create an accountability framework for reviewing medication errors and usage of medications. 

Dr. Yurkofsky: In our facility, we have a “good catch” award given when a staff member identifies a polypharmacy issue that places a patient at risk. This recognition is another way leadership can emphasize and recognize the efforts of staff, by having a culture of system improvement and quality improvement.

What kind of technological tools are available today that can be used to better manage polypharmacy and help with the deprescribing process?

Dr. Yurkofsky: Tools come at different levels. Just having a resource at your fingertips where you can look up medications and interactions is helpful. Then there are more structured tools like the Beers Criteria, which lists medications that are higher risk in older patient populations. There are also EMR embedded alerts that will light up when certain medications are prescribed. The challenge with these is that the potential side effects for any given medication are huge. Many of the automatic alerts are overly sensitive and repetitive.

Dr. Cantor: I agree, there’s a lot of alert fatigue. If a patient is taking two blood thinners that have been prescribed by their cardiologist after a heart attack, we know that’s the right thing for them to be taking. But the EMR will alert us that they’re on two blood thinners. That’s not helpful at all, and situations like this happen all the time. What’s interesting is that there are new technologies coming out that can look at the totality of the patient and the medication – not just drug-drug interactions that look at how medications affect each other. In long-term care, particularly, you need to look at the patient holistically – their kidney function, weight, etc. to know whether a medication may have a higher risk of an adverse event. In the near future, I think we’ll have more insight and more opportunities to personalize the risk profile for each patient.

Dr. Yurkofsky: It’s really a multi-pronged approach. We need these technologies. We need them to be more sophisticated. But we also need to do the detective work, to understand the medications, and to perform a complete assessment. It all needs to happen together. There’s no single solution that’s going to solve the problem of polypharmacy, and that’s really what makes it so challenging.

Hear more of this conversation in the on-demand webinar, Protecting the Vulnerable: Addressing the Dangers of Polypharmacy in Long-Term Care.