Chapter 7.5Identify Medications Considered Inappropriate for the Elderly INTRODUCTION – Medication toxic effects and drug-related problems can have profound medical and safety consequences for elderly adults. A group of physicians conducted a national survey of geriatric experts to identify medications to be avoided or used with caution in the elderly. The result of this survey was published in 1991 and is known as the Beers Criteria (or Beers List). This list was updated in 2003 and much of it was adopted in nursing home regulations.

A. Beer’s Criteria (the Beers List). 1 A. Beer’s Criteria (the Beers List) 1. The Beer’s List - a list of medications that are generally considered inappropriate when given to elderly people because these medications may pose more risk than benefit. 2. For a wide variety of reasons, the medications listed tend to cause side effects in the elderly due to the physiologic changes of aging. 3. The list is the result of recommendations by geriatric experts. 4. Published in 1991 and updated in 2003. 5. Much of the updated list has been adopted into nursing home regulations. 6. Review the list (briefly) with students. 7. Recommend that a copy of the list be placed with the facility’s drug reference source.

Web Resource: Potentially Inappropriate Medications for the Elderly According to the Revised Beers Criteria ________________________________________ The list of drugs below is a summary of information from the following report in Archives of Internal Medicine: Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med. 2003;163:2716-2724. [ Link ] Click on the name of each medication or medication class for detailed information from MEDLINEplus, a service of the US National Library of Medicine.

7.6 Identify Reasons For Clients’ Refusal to Take Medications and Respond Appropriately. INTRODUCTION: Clients refuse to take medications for many reasons. Each client has different ideas and feelings about health, illness and healing. An individual may not understand the seriousness of an illness or may misunderstand the reason for which a drug is prescribed. Whatever the reason, when a client refuses medication, the Medication Aide must listen attentively to fully understand the reason for the refusal. This objective explores some common reasons for refusing medications and strategies for managing medication refusals.

A. When the client refuses medication. 1 A. When the client refuses medication. 1. The client always has the right to refuse medications. 2. Clients refuse to take medications for many reasons. Some of the reasons are: a. The effects and/or side effects are unpleasant or unwanted. b. The medication tastes bad. c. The client has difficulty swallowing. d. Religious, cultural, or ethnic beliefs. e. Depression or loss of will to live. f. Delusional belief that staff is intending to harm (“poison”) him/her.

B. Types of refusal 1. Active refusal is when a person directly refuses to take the medication. 2. Passive refusal is less direct and requires closer observation. Examples are: a. The client takes the medication but later spits the medication out; he may or may not attempt to hide the medication. b. The client takes the medication when offered but then intentionally vomits within ½ hour of taking the medication. C. Questions to ask to try to determine the reason for refusal: 1. Is the client experiencing unpleasant effects from the medication? 2. Does the client have difficulty swallowing? 3. Is the client afraid for some reason? 4. Is the client refusing other medical treatment?

D. Strategies for dealing with client’s refusal: D. Strategies for dealing with client’s refusal: 1 If the client refuses and gives no reason, wait for 15 minutes and then offer the medication again. If the client refuses again, try again in another 15minutes before considering a final refusal. This is particularly important with clients who have a diagnosis of dementia. 2. Notify the HCP or supervisor when a client refuses medication. 3. Document refusal. 4. Observe the client and report any effects which may result from refusal. 5. Consider changing the dosage form if there is swallowing difficulty. 6. Consider changing the time of administration if taking the drug interferes with an activity or with sleep. (Example: diuretics may limit a clients ability to participate in an outing because of the need to go to the bathroom frequently.) 7. If there is a suspicion of passive refusal such as ‘cheeking’ medication or vomiting after administration, follow the recommendations for action on the client’s Individualized Service Plan. 8. If the refusals continue, explore other options with the HCP.

7.7 Identify Issues Related to Over-The-Counter Medications and Herbal Preparations and Non-Medical Substances. INTRODUCTION: Herbal medication use is increasing in popularity. These medications are easily purchased in a variety of settings such as health food stores, discounts stores, pharmacies and the internet. These preparations are not regulated by the FDA and do not have to meet federal or state standards for approval. As with over-the-counter medications, these medications may interact with others the client is taking and may cause side effects, allergic reactions, or other problems. Medication Aides must report the clients use of these preparations to the HCP.

A. Use of over-the-counter medications. 1 A. Use of over-the-counter medications 1. Most commonly used OTC medications: a. Pain relievers b. Laxatives c. Cold treatment d. Benadryl® (diphenhydramine) for sleep 2. These drugs are often not reported to the HCP. This can result in: a. Increasing or decreasing the effect of prescription drugs. b. Damage to vital organs such as the kidneys, liver, and stomach. 3. Must have a HCP order even though they may be purchased without prescription. 4. Must be recorded on the MAR and documented in the same manner as prescription drugs. 5. OTC errors must be reported in the same manner as prescription medications. 6. OTC medications must be stored in the same manner as prescription medications.

B. Use of herbal medications. 1 B. Use of herbal medications 1. These preparations are becoming increasingly popular. 2. Not regulated by the FDA & do not have to meet federal or state standards. 3. As with OTC, these drugs are often not reported to the HCP. This can result in: a. Increasing or decreasing the effect of prescription drugs. b. Damage to vital organs such as the kidneys, liver, and stomach. 4. Use of the preparations should be reported to the HCP. 5. Must have a HCP order if they are administered by Medication Aides. 6. Must be recorded on the MAR and documented in the same manner as prescription drugs. 7. Examples of herbal medications: melatonin ginkgo biloba glucosamine L-tryptophan St. Johns Wort

C. Use of non-medical substances. 1 C. Use of non-medical substances 1. Legal substances such as alcohol, nicotine, and caffeine affect the way the body works. 2. The use of any illegal drugs, such as marijuana, should be reported to the HCP. 3. These drugs may interact with both OTC and prescription medications and may cause side effects, allergic reactions, and other problems. 4. Some non-medical substances / drug interactions can be life- threatening.