Preventing and managing drug-related problems in long-term care by pnx67864


									Preventing and managing drug-related
                                                                                  continuing education lesson
                                                                                                              ce                                    1.5
problems in long-term care                                                                                                                        July 2006
■ Rosemarie Patodia, BScPhm, CGP

                                                                                                              or caregiver, there are a number of other poten-
 Learning objectives                                                                                          tial problems that may occur. These are gen-
  Upon successful completion of this lesson, you should be able to:                                           erally related to medical conditions and the
  1. assess some of the more common risks of drug-related problems in long-term care residents                medications prescribed, misinformation of
     with Alzheimer disease, Parkinson’s disease, chronic obstructive pulmonary disease, pain                 caregivers, medication incidents and lack of
     and heart failure                                                                                        monitoring.
  2. proactively identify potential problems with medication therapy for common conditions of                     Pharmacists have a critical role in both pre-
     elderly residents of long-term care facilities by performing a detailed medication review                scribing and resident outcomes in LTC. The
  3. make recommendations to optimize both specific medication therapies and outcomes for                     American Society of Consultant Pharmacists’
     long-term care residents with Alzheimer disease, Parkinson’s disease, chronic obstructive                Fleetwood Project was conducted to demonstrate
     pulmonary disease, pain and heart failure.                                                               the impact of consultant pharmacist services on
  To successfully complete the post-test for this lesson, you may need access to the                          resident outcomes and costs in LTC facilities.
  Compendium of Pharmaceuticals and Specialties (CPS).                                                        Phase I of this study showed that drug regimen
                                                                                                              reviews conducted by consultant pharmacists
                                                                                                              saved $3.6 billion (U.S.) per year and increased
      ccording to a 1999 Statistics Canada survey,      unique challenges but also have great opportu-        optimal therapeutic outcomes by 43%.7
A     76% of Canada’s seniors living at home
took at least one medication and 53% used two
                                                        nities to impact upon the health outcomes and
                                                        overall quality of life of these residents.
                                                                                                                  A study in London, Ont., demonstrated that
                                                                                                              pharmacist intervention (achieved by identify-
or more medications in the two days prior to the            Pharmacists in various clinical settings,         ing prescribing problems and writing a letter to
survey.1 Seniors comprised approximately 12%            including community and hospital practice, may        the physician and suggesting alternatives) was
of the Canadian population but received about           have the opportunity to care for patients receiving   well-received by physicians. Ninety-two per-
40% of all prescriptions.2,3                            LTC. This lesson will focus on key areas in which     cent of physicians involved indicated that they
     A small percentage—about 14%—of Cana-              pharmacists can work to prevent and manage            found the pharmacist’s letter “somewhat help-
dian seniors over the age of 75 reside in long-         drug-related problems in elderly LTC residents.       ful” or “very helpful” in improving prescribing,
term care (LTC) facilities, including nursing and                                                             and 37.9% of potentially inappropriate pre-
retirement homes, and chronic care facilities.4          Medication use in long-term care                     scriptions were modified by physicians.8
Although the number of seniors living in LTC            On average, a LTC resident will receive
facilities in Canada is relatively low, the number      approximately seven to eight medications per           Conditions commonly associated
of drug-related problems that occur is high in LTC      month.6 Although adherence is not a major              with drug-related problems
facilities.5 Pharmacists who provide pharmaceuti-       problem, since medication administration fol-         Admission to a LTC facility is usually asso-
cal care services to residents of LTC facilities face   lows a schedule and is usually done by a nurse        ciated with a difficulty managing indepen-

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continuing education lesson

 TABLE 1        Comparison of
                                                                                     Preventing and managing drug-related problems in long-term care

                                                    lar visits, medication reviews and monitoring,
                                                    can help manage these conditions while mini-
                                                                                                        cholinesterase inhibitors. It is important to
                                                                                                        note that no washout period is required when
                cholinesterase inhibitors13         mizing problems that can commonly occur.            switching between agents. Currently, there is
                                                                                                        no evidence to support the use of combination
 Medication      Dosing                             Alzheimer disease and other types                   cholinesterase therapy for patients with AD.
 donepezil       5–10 mg daily; more adverse        of dementia                                         Adherence is important with all of these ther-
                 effects at 10 mg dose              About one-half of people living with dementia       apies because benefits could be lost very
 rivastigmine    1.5 mg BID up to 6 mg              reside in LTC facilities.10 Medication therapy      quickly (i.e., in 6 weeks) if the medication is
                 BID                                can include agents to slow cognitive decline        stopped.14
 galantamine     4 mg BID up to 12 mg               (e.g., cholinesterase inhibitors), in addition to        Memantine is an N-methyl-D-aspartate
                 BID or 8–24mg ER                   those aimed at managing behavioural prob-           (NMDA) receptor antagonist that is indicated for
                 capsule once daily; avoid          lems associated with this dementia.                 the treatment of moderate to severe Alzheimer
                 in severe renal or hepatic              Pharmacists should be able to assess           or vascular dementia. This agent has been
                 impairment                         patient outcomes related to cholinesterase          studied alone or in combination with donepe-
                                                    inhibitor therapy, as well as provide recom-        zil.15 Memantine has been shown to improve
                                                    mendations with respect to dose and duration        cognitive, functional and global end points in
 TABLE 2        Medications with                    of therapy. Cholinesterase inhibitors, in gener-    moderate to severe Alzheimer dementia by
                anticholinergic effects*            al, have been shown to delay the onset of           reducing NMDA activity that occurs due to glu-
 • tricyclic antidepressants                        behavioural problems and delay nursing-home         tamate excess in AD. Further study is needed to
   (e.g., amitriptyline, imipramine)                placement, as well as improve cognition.11, 12      determine the impact of combining memantine
 • antispasmodics (e.g., hyoscine)                  Measurement of outcomes can be difficult to         with other cholinesterase inhibitors.16
 • benzodiazepines (e.g., diazepam,                 do, particularly if there is no baseline Folstein        Anticholinergic medications, or those with
   alprazolam)                                      Mini-Mental Status Examination (MMSE)               anticholinergic effects, can contribute to con-
 • oxybutynin                                       result on file. In a resident who is no longer      fusion and further impaired cognitive status in
 • antihistamines (e.g., diphenhydramine,
                                                    responding, there may be consistent declines        patients with AD.17 Pharmacists should review
 • antipsychotics (e.g., thioridazine)              in MMSE scores and increased behavioural            patient profiles to ensure that anticholinergic
 • MAOIs (e.g., phenelzine)                         disturbances, as well as increasing difficulty      load is minimized where possible (Table 2).
 • atropine                                         with global functioning and activities of daily          Behavioural disturbances are commonly
 • opioids (e.g., codeine, oxycodone)               living (ADLs).11,12 It is important to note that    associated with dementias. Pharmacists can
 * Adapted from reference 13; not a                 although there is no well-documented guide-         play an important role in helping to identify
 complete list.                                     line for duration of therapy with cholinesterase    behaviours that can respond to medication ther-
                                                    inhibitors, it has been suggested that the          apy and those that generally do not respond to
dently at home. There are a number of condi-        medication may be effective for up to five          medications. Agitation, depression, insomnia
tions that are commonly seen in LTC facilities      years.13 However, residents should remain on it     and hallucinations are manifestations that can
and each presents a unique opportunity for          for only six to 12 months if deterioration con-     be effectively treated with medications including
monitoring medication therapy and prevention        tinues.13 Nonetheless, many patients remain         anxiolytics, antidepressants, hypnotics and
of drug-related problems. Among these condi-        on these medications without further benefits       antipsychotics (newer agents with a lower inci-
tions are Alzheimer disease (AD), Parkinson’s       for several years. If a resident cannot tolerate    dence of extrapyramidal symptoms and anti-
disease (PD), stroke, chronic obstructive pul-      an optimal dose of one of the available agents,     cholinergic effects). Clinicians should not
monary disease (COPD), arthritis, and heart         it is feasible to switch to another one. Table 1    attempt to treat other types of behaviours—
failure (HF).9 Pharmacists, through their regu-     compares        dosing     of   the     available   including wandering, calling out and repetitive

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  This month                                        Reviewers                                           This lesson is published by Rogers Publishing
  Preventing and managing drug-related              All lessons are reviewed by a minimum of            Limited, One Mount Pleasant Rd., Toronto,
  problems in long-term care                        six pharmacists for accuracy, currency and          ON M4Y 2Y5. Editorial office: Tel: (416)
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  Author                                                                                                Tel: (416) 764-3879 Fax: (416) 764-3937
                                                    CE Co-ordinator                           
  Rosemarie Patodia, BScPhm, CGP, is a
                                                                                                            No part of this CE lesson may be repro-
  certified geriatric pharmacist with several       Brenda McBean Cochran, B.S.P., M.Sc.(Phm)
                                                                                                        duced, in whole or in part, without the writ-
  years’ experience working in long-term care       Pharmacist consultant, Bedford, N.S.
                                                                                                        ten permission of the publisher.
  facilities. In addition to speaking and writing
                                                                                                            The authors, expert reviewers and
  extensively on the topic to pharmacists,                    This lesson (CCCEP file # 406-0406)
                                                                                                        provider state that they have no real or
  nurses and the public, she teaches courses                  has been approved for 1.5 CEUs by
                                                                                                        potential conflict to disclose. This lesson is
  in geriatric pharmacotherapy to pharmacists.                the Canadian Council on Continuing
                                                                                                        supported by an unrestricted grant from
                                                    Education in Pharmacy. Approved for
                                                                                                        Genpharm Inc.
                                                    1.5 CEUs by l’Ordre des pharmaciens du
                                                    Québec. Accreditation of this program
                                                    will be recognized by CCCEP until
                                                    April 20, 2009.

2     Answer online at                                                                           Pharmacy Practice | July 2006
continuing education lesson

 FIGURE 1                                            TABLE 3
                                                                                     Preventing and managing drug-related problems in long-term care

                                                                     Motor fluctuations complicating Parkinson's disease20
 Antipsychotics and incidence of
 extrapyramidal symptoms*, 23                         Motor fluctuation        Management                           Rationale
                                                      on-off phenomenon        • add dopamine agonist           • increasing availability of dopa-
                                                      (sudden lack of          • modify distribution of dietary mine in the brain can minimize
        haloperidol       MORE EPS
                                                      symptom control, not     protein (can reduce absorption on-off fluctuations
                                                      associated with last     of levodopa)
          loxapine                                    medication dose)         • add entacapone
                                                      peak dose dyskinesia     • discontinue selegiline             • selegiline can aggravate peak
        risperidone                                   (abnormal involuntary    • switch from CR to regular          dose dyskinesia
      (higher doses)                                  movements; time to       levodopa                             • CR may be more likely to cause
                                                      peak varies, approxi-    • decrease levodopa dose             dyskinesias than regular levodopa
                                                      mately 1–2 hours)        • add or increase dopamine           • dopamine agonist and/or amanta-
                                                                               agonist                              dine can allow for a reduction in
                                                                               • add amantadine, if                 levodopa dose without contributing
        quetiapine       FEWER EPS                                             appropriate                          to dyskinesias
                                                      diphasic dyskinesia      • switch from CR to regular          • CR more likely to cause
 *Listed in descending order of likelihood            (at beginning and end    levodopa                             dyskinesias
 of causing extrapyramidal effects;                   of levodopa response     • increase dose of dopamine          • redistribute levodopa or increase
 EPS = extrapyramidal effects                         cycle)                   agonist                              dopaminergic therapy to smooth
                                                                               • spread out levodopa dosing         out resulting dopamine levels
                                                                               in several early day or midday
vocalizations—with medications.19 Other strate-                                doses
gies should not involve the use of medications to     wearing off effect       • add dopamine agonist               • increase dopaminergic effect
sedate the patient; instead, they should involve      (predictable decline     • increase frequency and/or          • CR will extend duration of action
an assessment of the potential reason for the         in effectiveness at      dose of levodopa                     • entacapone prolongs effect of
behaviour and subsequent plans to minimize it.        end of levodopa          • add or substitute CR levodopa      levodopa and increases bioavail-
                                                      dosing interval)         • add entacapone                     ability
                                                                               • decrease or redistribute           • dietary protein may decrease
Parkinson’s disease
                                                                               protein                              bioavailability of levodopa
Another condition that causes significant func-
tional impairment in later stages is PD. The          freezing (difficulty     • if at peak, increase dopa-         • increase dopaminergic therapy to
                                                      initiating gait)         minergic (i.e., levodopa and/or      increase effectiveness
hallmark symptoms of tremor, rigidity, akinesia
                                                                               dopamine agonist) therapy            • if during on time, will not be
and postural instability can impair an indi-                                   • if during off time*, see           affected by medication dosing
vidual’s ability to perform ADLs and lead to                                   wearing off effect
institutionalization as the disease progresses.                                • if during on time**, use
Medication management of PD can be chal-                                       sensory cues (e.g., moving
lenging, particularly when motor fluctuations                                  towards a target on the ground,
begin to develop after two to five years of levo-                              singing a marching song)
dopa therapy.20 Pharmacists should be aware           dystonia (cramping,      • if early morning, use CR           • extend the duration of action of
of strategies for managing these fluctuations to      muscle stiffness)        levodopa or dopamine agonist         dopaminergic therapy if in the
help optimize symptom control (Table 3).                                       at night; add entacapone             morning
                                                                               • if at peak of levodopa levels,     • high individual levodopa dose
    Drug-disease interactions can occur in
                                                                               decrease levodopa dose or add        can contribute to dystonia
patients with PD. Of note are medications that                                 dopamine agonist
can cause extrapyramidal symptoms (EPS)—
                                                      CR = controlled release; *off time is when the patient’s functioning is affected by PD
commonly, the antipsychotic medications.21
                                                      symptoms; **on time is when the patient is functioning well
Since dementia often develops concurrently in
patients with PD, pharmacists can play an           due to the greater risk of serious adverse effects     entacapone to levodopa therapy, it is important
important role in selecting medication ther-        in this population.20,24 Some of the older             to note that a dosage reduction of approxi-
apies if they are required for symptoms such as     dopamine agonists, such as pergolide and               mately 25% of the levodopa product may be
hallucinations and delusions. Figure 1 outlines     bromocriptine, are more likely to cause psychi-        required to reduce the risk of dyskinesias that
the relative risk of a resident experiencing        atric symptoms (e.g., hallucinations, paranoia)        can occur when entacapone is added.25
extrapyramidal effects with various antipsy-        which can worsen behavioural problems in
chotics. The agents with a lower risk of EPS        patients with dementia.20 Switching from regu-         Stroke
(newer, or atypical antipsychotics) should be       lar levodopa preparations to controlled release        Monitoring and followup of the patient post-
used in residents with PD.22                        (CR) formulations requires a dosage adjust-            stroke requires attention to the management of
    Medications with anticholinergic effects,       ment (30% more is required if switching from           stroke complications, as well as secondary pre-
such as amantadine and trihexiphenidyl,             regular to CR).20 Entacapone, a catechol-O-            vention of stroke.
although often useful for the management of         methyltransferase (COMT) inhibitor, is often               The functional impairment that can result
tremor in PD, are not recommended for               added to levodopa therapy to enhance avail-            from stroke is a common cause of institu-
patients who are older (over 50 years of age),      ability of dopamine in the brain. When adding          tionalization. Pharmacists should review medi-

Pharmacy Practice | July 2006                                                                            Answer online at          3
continuing education lesson

 TABLE 4         Secondary prevention
                                                                                   Preventing and managing drug-related problems in long-term care

                                                  tral nervous system [CNS] depressants) and
                                                  dysphagia (e.g., antipsychotics, anticholiner-
                                                                                                       tions. Medications that can cause respiratory
                                                                                                       depression, such as long-acting benzo-
                 of stroke26                      gics).                                               diazepines and propranolol, may aggravate
                                                      Secondary prevention of stroke should            symptoms of COPD and have been identified in
    Patient        Secondary prevention           include the use of antithrombotic agents, includ-    the Beers criteria as potentially inappropriate
    history        strategy
                                                  ing ASA, clopidogrel, warfarin or dipyridamole/      drug/diagnosis combinations in the elderly.27
 TIA or stroke, ASA 50–325 mg OD                  ASA.26 Ticlopidine is not recommended due to         Long-term use of long-acting benzodiazepines
 noncardio-     Alternatives: clopidogrel         the risk of neutropenia with no added benefits.27    should be avoided where possible, and alterna-
 embolic        75 mg OD, dipyridamole
                                                  An important role of the pharmacist is to ensure     tive strategies to managing insomnia or other
                200 mg/ASA 25 mg BID
                                                  appropriate monitoring and international normal-     indications should be sought.
 TIA or stroke     warfarin to INR 2–3 (or        ized ratio (INR—a standardized representation
 with atrial       ASA 50–325 mg OD if
                                                  of prothrombin time [PT] that replaces the mea-      Arthritis and chronic pain
 fibrillation      contraindicated)
                                                  surement of PT) levels for patients on warfarin in   Osteoarthritis is the most common type of arthri-
 TIA = transient ischemic attack                  LTC, as well as avoidance of drug interactions.      tis to affect people later in life.34 In the LTC set-
                                                  This is an important area of education for nurses    ting, pain due to arthritis and other conditions
                                                  and caregivers in LTC. Warfarin tends to be          (e.g., chronic, nonspecific musculoskeletal pain;
 TABLE 5      American Geriatrics                 underused in the elderly LTC facility population     cancer pain) is prevalent and often overlooked.
 Society anticoagulation guidelines for           due to perceived high risk of bleeding.28 It is      Pain can manifest as behavioural changes in
 the elderly patient30
                                                  important to note that cardiovascular benefits       patients with cognitive impairment or dementia,
 starting oral       • baseline INR               have not been shown to be achieved at INR            in the form of facial cues, increase or decrease
 anticoagulation     • determine if potential     levels below established therapeutic ranges (i.e.,   in movements, restlessness and vocalizations.35
                     drug interactions            INR 2–3).29 Table 5 presents monitoring guide-       Other types of manifestations of pain in cogni-
                     • start < 5 mg per day       lines from the American Geriatrics Society for       tively impaired patients are listed in Table 6.
 monitoring          • INR daily until stable     older patients on warfarin.                          Improving pain symptoms can help to improve
 therapy             (5–7 days)                                                                        day-to-day functioning, reduce disruptive beha-
                     • then 2–3 times weekly      Chronic obstructive pulmonary disease                viours in some residents, relieve caregiver bur-
                     for 1–2 weeks
                                                  Another condition commonly encountered in            den and maximize quality of life.
                     • then weekly for
                     1 month                      the elderly LTC resident is COPD, which often             Pharmacists can assist in optimizing pain
                     • then monthly               occurs as a result of a long history of smoking.     management in LTC facilities through the
                     thereafter                   Therapy is generally given via inhalation device     evaluation of medication therapies as well as
 more frequent       • medication changes         and this, in itself, is a common source of drug-     the implementation of pain assessment scales
 monitoring          • diet changes               related problems in LTC. Pharmacists are             and tools to assist nurses and caregivers in
                                                  required to ensure that nurses and caregivers,       evaluating pain control. Common pain scales
 managing high INR:
                                                  as well as the patient, if capable, are educated     used for patients who are not cognitively
 INR 3–5,            • hold one dose
                                                  in the proper technique for using dry-powder         impaired and are able to express themselves
 no bleeding         • resume therapy when
                                                  inhalers, and metered-dose inhalers (MDIs)           include visual analogue scales (i.e., rate your
                     INR in therapeutic
                     range                        with spacers. Some patients may have diffi-          pain on a scale of 1–10), faces scales (e.g.,
                                                  culty with the inspirational drive required to       Wong-Baker scale), and descriptive scales (i.e.,
 INR 5–9,            • hold 1–2 doses
                                                  use dry-powder inhalers. It has been recom-          rate your pain on a scale from no pain to the
 no bleeding         • resume when INR in
                     therapeutic range            mended that all elderly individuals who must         worst pain possible).37 For patients who con-
                     • consider vitamin K         use an MDI use a spacer with them.31                 tinue to experience pain while on medication
                     1–2.5 mg PO if at            Technique is most important with this device         therapies, pharmacists should determine the
                     increased bleeding risk      and is often overlooked in a busy facility, thus     effectiveness of the medication. For example, if
 INR > 9,            • hold warfarin              resulting in less than optimal outcomes for the      the medication provides relief but only for a
 no bleeding         • give vitamin K 3–5 mg      patient. Patients with arthritis, tremor or other    short time, the patient may benefit from a
                     PO                           conditions that impair their fine motor abilities    change in dosing interval, and may not require
                     • additional vitamin K       may have difficulty with inhaled dosage forms.       a change of medication.
                     if INR not reduced in
                                                      The use of nebulizers to manage patients              Ensuring that appropriate medication ther-
                     1–2 days
                                                  with COPD is questionable in many circum-            apies are used for specific types of pain is also
 bleeding at         • discontinue warfarin       stances. For the patient who has an acute exa-       an important role of the pharmacist. For ins-
 any INR             • give vitamin K 10 mg
                                                  cerbation, many trials (note that most trials are    tance, neuropathic pain may not respond well
                     IV infusion (may repeat
                     Q12H)                        in children) show that the delivery of medication    to traditional analgesics such as opioids but
                                                  through this route is no better than via a MDI       may be more effectively managed with anti-
 INR = international normalized ratio;
                                                  plus a spacer.32,33 Some patients find comfort in    convulsants (e.g., gabapentin, carbamazepine)
 IV = intravenous
                                                  the mist of the nebulizer, but increased costs       or antidepressants (e.g., nortriptyline, desip-
                                                  and sometimes less than optimal medication           ramine).38 The long-term use of analgesic and
cations that can exacerbate symptoms such as      delivery, make this option less favourable.          anti-inflammatory medications should be
incontinence (e.g., diuretics, lithium, seda-         Another potential problem in residents with      assessed regularly to ensure the patient has
tives), confusion (e.g., anticholinergics, cen-   COPD is the use of CNS depressant medica-            the best pain control possible with no or mini-

4      Answer online at                                                                          Pharmacy Practice | July 2006
continuing education lesson

 TABLE 6       Behaviours in cognitively            TABLE 7
                                                                                      Preventing and managing drug-related problems in long-term care

                                                                     Pharmacist medication review process52
 impaired individuals experiencing pain*
                                                      Process step          Example                               Pharmacist's action
  Category          Specific behaviours              Are all drugs          Ranitidine is not indicated for       Review effectiveness of pain manage-
 facial             frown, grimace, rapid            indicated?             cytoprotection with an NSAID.         ment strategy. If effective, recom-
 expressions        blinking                                                                                      mend discontinuing ranitidine and
                                                                                                                  starting a PPI medication for cytopro-
 vocalizations      moaning, calling out,                                                                         tection.
                    verbal abuse
                                                     Are there condi-       No antiplatelet agent for a           Recommend ASA, clopidogrel, ticlopi-
 body               fidgeting, pacing, gait          tions that should      patient with a history of             dine, dipyridamole/ASA or warfarin
 movements          changes                          be treated with        ischemic stroke.                      depending on the patient's history.
 changes in         social withdrawal,               medications that
 interactions       aggressive behaviour,            are not?
 with others        resisting care                   Are medications        The use of hydrochlorothiazide        Review monitoring parameters (blood
 change in          wandering, appetite              and dosages            (HCTZ) 100 mg daily (maxi-            pressure, electrolytes) and recommend
 activity levels    changes, sleep pattern           appropriate?           mum 25 mg recommended) for            decreased dose of HCTZ (taper down
                    changes                                                 hypertension.                         to 25 mg daily). HCTZ is not effective
                                                                                                                  and should not be used when creati-
 mental status      confusion, irritability
                                                                                                                  nine clearance is < 30mL/minute.
                                                     Is medication          Resident appears to be experi-        Review digoxin levels and electrolytes.
 * adapted from reference 36
                                                     safety optimized       encing digoxin toxicity at a          Review indication for digoxin. If
                                                     (i.e., are there       dose of 0.25 mg daily.                indicated, recommend reduced dose
mal adverse effects. Long-term use of long
                                                     drug interactions,                                           of 0.125 mg daily.
half-life, nonselective nonsteroidal anti-           adverse effects?)?
inflammatory drugs (NSAIDs) (e.g., naproxen,
                                                     Are the correct        INR measurements are consis-          Recommend increase in dose of war-
piroxicam) at full dosages is not recommended
                                                     monitoring             tently below 2 in a post-stroke       farin and monitoring q3–5 days until
due to the increased risk of bleeding in this        parameters being       patient on warfarin.                  therapeutic INR achieved (i.e., INR
population.27 All NSAIDs, whether COX-2              followed? Are the                                            2–3).
selective (e.g., celecoxib) or not, can worsen       results optimal?
poor renal function, so pharmacists should           Have any medi-         Resident has been receiving           If selegiline is providing benefit for the
ensure that renal function is monitored regu-        cation errors          selegiline at bedtime resulting       resident, recommend that it be given
larly (i.e., serum creatinine and estimated          occurred?              in insomnia.                          morning and noon to reduce impact
creatinine clearance). Opioid use can exacer-                                                                     on sleep.
bate constipation that may already be a prob-        Are there any cost/    Waiting for coverage of medica-       Depending on the circumstances,
lem for many elderly people due to reduced           coverage issues to     tion through provincial plan.         follow up with either prescriber or
activity levels and mobility. Those taking           be addressed?                                                pharmacy regarding coverage details.
chronic opioids for pain should be receiving         Have recommended No documentation of pneumo-                 If resident or caregiver is not certain
laxative therapy on a regular basis to prevent       vaccinations been coccal vaccination in a resident           if it was given, recommend that resi-
constipation. Senna is often the laxative of         given?            over 65 years of age.                      dent receive pneumococcal vaccination.
choice in this case. Patients with chronic pain      HCTZ = hydrochlorothiazide; INR = international normalized ratio; NSAID = nonsteroidal
should also be prescribed “as needed” imme-          anti-inflammatory drug; PPI = proton pump inhibitor
diate-acting pain medication to be used for
breakthrough pain.                                 American Heart Association (ACC/AHA) guide-              that residents initiated on ACE inhibitor ther-
    Misconceptions about the use of opioids        lines for chronic heart failure, HF patients in          apy are titrated slowly to a tolerable dose with
(e.g., fears about addiction and abuse, exces-     stage C or D (i.e., those with structural heart dis-     maximal benefits will help to avoid orthostatic
sive sedation) in this population are common,      ease with prior or current symptoms of HF, or            hypotension.37 If a resident is also taking
so pharmacists must be prepared to address         those with refractory HF) require drug therapy           spironolactone, pharmacists should ensure that
any factors that prevent appropriate use of        with diuretics, angiotensin converting enzyme            renal function and potassium levels are moni-
these medications for the management of            (ACE) inhibitors and beta-blockers, at the very          tored regularly.39 Recent concerns of increased
chronic pain where warranted.                      least. In addition to this, many residents may           morbidity and mortality associated with hyper-
                                                   also require spironolactone, an angiotensin              kalemia in elderly people have arisen in light of
Heart failure                                      receptor blocker (ARB), digoxin or a hydralazine/        increased use of spironolactone as a result of
HF can result from damage to the myocardium        nitrate combination. Many of them have other             RALES (a trial that demonstrated mortality
or from other causes. Due to the progressive       underlying conditions that are related to their          reduction when spironolactone was added to
nature of this condition, many residents of LTC    condition that require drug therapy (e.g., hyper-        heart failure therapy in later stages) data.40,41
facilities are in the later stages of HF by the    tension, smoking, dyslipidemia).39                           Digoxin is commonly used for HF in LTC
time of admission.                                     In light of the complex nature of the care of        facility residents.42 In most cases, this is rea-
    One of the greatest challenges with manage-    residents with HF, pharmacists need to stay              sonable to continue in light of data to support
ment of HF is the need for multiple medications.   apprised of current therapies and monitoring             a decrease in hospitalizations in HF patients
In the latest American College of Cardiology/      parameters. For specific medications, ensuring           on digoxin.43 However, the elderly resident

Pharmacy Practice | July 2006                                                                             Answer online at           5
continuing education lesson

tends to be more sensitive to the effects of
digoxin and it is thought that the administra-
                                                                                        Preventing and managing drug-related problems in long-term care

                                                     on drug interactions with the influenza vacci-
                                                     nation. Warfarin and theophylline have been
                                                                                                                The frequency of medication reviews is
                                                                                                            often dictated by provincial or facility require-
tion of digoxin in doses over 0.125 mg daily         known to potentially interact with the vaccine,        ments, or simply by the discretion of the physi-
can increase the risk of adverse effects due to      however, this is not a contraindication to the         cian or pharmacist in the LTC facility. Many
decreased renal clearance.27                         vaccine; closer monitoring of INR and theo-            pharmacists perform medication reviews quar-
    For a resident who has been receiving a          phylline levels may be required for concomi-           terly for LTC facility residents. It is not, how-
dose higher than 0.125 mg daily, it may be           tant use of the vaccine with these agents.49           ever, mandated that pharmacists perform
prudent to suggest a decrease in dose and fol-           The Public Health Agency of Canada                 medication reviews with a physician, so phar-
low up by monitoring the digoxin level.44,45         (PHAC) recommends that antivirals be used for          macists are often faced with the challenge of
Digoxin toxicity in the elderly can manifest         prophylaxis of patients in the control of              demonstrating their value in this process.
with nausea, headache, bradycardia and beha-         influenza outbreaks in LTC facilities. In an out-
vioural disturbances (in those with dementia)        break, both residents who are not ill and nurs-         References
and can occur at lower serum digoxin levels (as      ing staff who have not been vaccinated should                1. Health Canada. Canada’s seniors at a glance. www.phac-
low as 1.54 nmol/mL in one study).42 Drug            receive either oseltamivir or zanamivir. Recent
                                                                                                            (accessed December 15, 2005).
interactions can occur and, where alternative        testing in the current flu season has shown                  2. Anderson G, Lavis J. Prescription drug use in the
therapy can be used, should be recommended.          that most influenza virus isolates are resistant       elderly: expenditures and patterns of use under Ontario and
                                                                                                            British Columbia provincial drug benefit programs.
However, where it is not possible to use anoth-      to amantadine; consequently, PHAC has                  Queen’s/University of Ottawa Economic Projects, February 1994.
er medication, the resident should be moni-          recommended that it not be used for prophy-                  3. Angus Reid Group Inc. Medication use in Canadians
                                                                                                            aged 55 and older: opinions and attitudes. Canadian Coalition on
tored closely for any signs of digoxin toxicity.     laxis or treatment of influenza.50                     Medication Use and the Elderly, Ottawa, Ont., 1991.
Interacting drugs include amiodarone, quini-             For prophylaxis, oseltamivir is given as 75 mg           4. National Advisory Council on Aging. Expression
                                                                                                            18(4); Fall 2005.
dine, antifungals, calcium channel blockers,         once daily until the outbreak has been declared
                                                                                                            exp18-4_e.pdf (accessed December 16, 2005).
macrolide antibiotics, NSAIDs and diuretics.42       complete.46 If creatinine clearance is 10–30                 5. Gurwitz JH, Field TS, Judge J, et al. The incidence of
                                                     mL/min, the dosage should be reduced to 75 mg          adverse drug events in two large academic long-term care
                                                                                                            facilities. Am J Med 2005; 118(3):251-8.
Influenza outbreaks                                  every other day. Treatment with neuraminidase                6. Doshi JA, Shaffer T, Briesacher BA. National estimates of
A common concern in the LTC setting is the           inhibitors such as oseltamivir is used for residents   medication use in nursing homes: findings from the 1997
                                                                                                            medicare current beneficiary survey and the 1996 medical
risk of influenza outbreaks. The risk of spread      who have confirmed influenza and are at risk of        expenditure survey. J Am Geriatr Soc 2005;53(3):438-43.
of illness is high in these enclosed settings        complications.46 It is prudent to have preprinted            7. Bootman JL, Harrison DL, Cox E. The health care cost of
                                                                                                            drug-related morbidity and mortality in nursing facilities. Arch
and the residents have a high likelihood of          or prewritten orders available in the event of an      Intern Med 1997;157:2089-96.
becoming ill with influenza or developing com-       outbreak in order to avoid delays in receiving               8. Gill SS, Misiaszek BC, and Brymer C. Improving pre-
                                                                                                            scribing in the elderly: a study in the long term care setting. Can
plications such as pneumonia.                        medications, particularly since oseltamivir is
                                                                                                            J Clin Pharmacol 2001; Summer 82(2):78-83.
    An outbreak of influenza in a LTC facility       most effective for treatment if given within 72              9. Tomiak M, Berthelot JM, Guimond E, et al. Factors asso-
has been defined as three or more residents in       hours of the onset of symptoms.48                      ciated with nursing home entry for elders in Manitoba, Canada.
                                                                                                            J Gerontol A Biol Sci Med Sci 2000;55(5):M279-87.
a nursing unit with an influenza-like illness                                                                     10. Alzheimer Society of Canada. Statistics. www.alzheimer.
and an oral temperature of at least 37.7°C            The pharmacist’s role                                 ca/english/disease/stats-caregiving.htm (accessed December
                                                                                                            16, 2005).
(100°F) or a rectal temperature of at least          Some of the more common conditions that                      11. Takeda A, Loveman E, Clegg A, et al. A systematic
38.3°C (101°F) within a three-day period.46,47       require pharmacist intervention in long-term           review of the clinical effectiveness of donepezil, rivastigmine and
                                                                                                            galantamine on cognition, quality of life and adverse events in
Measures that have been recommended for              care facilities include AD, PD, COPD, stroke,
                                                                                                            Alzheimer’s disease. Int J Geriatr Psychiatry 2005;21(1):17-28.
management of influenza outbreaks in LTC             pain and HF. Pharmacists should regularly                    12. Thompson S, Lanctot KL, Herrmann N. The benefits
facilities include isolation of residents with       assess appropriateness of medication                   and risks associated with cholinesterase inhibitor therapy in
                                                                                                            Alzheimer’s disease. Expert Opin Drug Saf 2004;3(5):425-40.
influenza-like illness or influenza, offering vac-   therapies, outcomes and adverse effects for                  13. Johannsen P. Long-term cholinesterase inhibitor treat-
cines to unvaccinated residents or staff, rein-      long-term care residents.                              ment of Alzheimer’s disease. CNS Drugs 2004;18(12):757-68.
                                                                                                                  14. Holden M, Kelly C. Use of cholinesterase inhibitors in
forcement of frequent handwashing by staff               Medication review is an important compo-           dementia. Advances in Psychiatric Treatment 2002;8: 89-96.
and using chemoprophylaxis for influenza A           nent of the pharmacist’s role in providing phar-             15. Tariot PN, Farlow MR, Grossberg GT, et al. Memantine
                                                                                                            treatment in patients with moderate to severe Alzheimer disease
outbreaks.46,47 Pharmacists should note that         maceutical care for residents of LTC facilities.       already receiving donepezil: a randomized controlled trial. JAMA
facilities may restrict visitor access during an     This is often referred to as drug-regimen              2004;291:317-24.
                                                                                                                  16. Rossom R, Adityanjee and Dysken M. Efficacy and
influenza outbreak, and this could affect the        review, which is defined as a review of the
                                                                                                            tolerability of memantine in the treatment of dementia. Am J
ability to provide on-site consultation services     patient, medical conditions and drug therapy           Geriatr Pharmacother 2004;2:303-12.
for pharmacists servicing multiple facilities.       in order to determine whether to continue                    17. Lu CJ, Tune LE. Chronic exposure to anticholinergic
                                                                                                            medications adversely affects the course of Alzheimer disease.
    The role of the pharmacist in helping to         treatment.51 Table 7 outlines the specific acti-       Am J Geriatr Psychiatry 2003;11(4):458-61. ajgp.psychiatryon-
prevent and manage influenza outbreaks is            vities involved in a medication review by a   (accessed November 6, 2005).
                                                                                                                  18. Tune LE. Anticholinergic effects of medication in
multifocal. As a member of the multidiscipli-        pharmacist. The results of a review should be          elderly patients. J Clin Psychiatry 2001;62 suppl 21:11-4.
nary team, it is important that all pharmacists      documented in the resident’s medical chart.                  19. Herrmann N. Recommendations for the management
                                                                                                            of behavioral and psychological symptoms of dementia. Can J
working in LTC receive an annual influenza               The patient-focused goals of a medication
                                                                                                            Neurol Sci 2001;28(suppl 1):S96-S107.
vaccination unless otherwise contraindicated.        review are improvement in therapeutic out-                   20. Olanow CW, Watts RL, Koller WC. An algorithm (deci-
Also, education of residents and staff about         comes for the patient through optimizing control       sion tree) for the management of Parkinson’s disease (2001):
                                                                                                            treatment guidelines. Neurology 2001;56(11 Suppl 5):S1-S88.
influenza, vaccination, complications and            of chronic medical conditions, improvement in                21. Miller CH, Mohr F, Umbricht D, et al. The prevalence of
treatment is essential. Only 70–91% of LTC           quality of life and functioning, and reduction in      acute extrapyramidal signs and symptoms in patients treated
                                                                                                            with clozapine, risperidone, and conventional antipsychotics. J
facility residents receive flu shots.48              adverse effects, drug interactions, hospitaliza-       Clin Psychiatry 1998;59(2):69-75.
Pharmacists may be called upon to comment            tion, or need for enhanced care or transfer.52               22. Poewe W. Psychosis in Parkinson’s disease. Mov Disord

6     Answer online at                                                                                     Pharmacy Practice | July 2006
continuing education lesson

2003;suppl 6:S80-7.
     23. Tarsy D, Baldessarini RJ, Tarazi FI. Effects of newer
                                                                   (COPD). Qual Saf Health Care 2002;11:376-82.
                                                                                                                Preventing and managing drug-related problems in long-term care

                                                                         34. The Arthritis Society. Osteoarthritis.
                                                                                                                                                 43. The Digitalis Investigation Group. The effect of digoxin
                                                                                                                                           on mortality and morbidity in patients with heart failure. N Engl
antipsychotics on extrapyramidal function. CNS Drugs 2002;16(1):   types%20of%20arthritis/osteoarthritis/default.asp?s=1                   J Med 1997;336:525-33.
23-45.                                                             (accessed December 19, 2005).                                                 44. Adams KF Jr, Gheorghiade M, Uretsky BF, et al. Clinical
     24. Guttman M, Kish SJ, Furukawa Y. Current concepts in             35. Beckman Research Institute. Assessing pain in the             benefits of low serum digoxin concentrations in heart failure.
the diagnosis and management of Parkinson’s disease. CMAJ          cognitively impaired.           J Am Coll Cardiol 2002;39:946-53.
2003;168(3):293-301.                                               Pain%20in%20the%20Cognitively%20Impaired.pdf (accessed                        45. Miura T, Kojima R, Sugiura Y, et al. Effect of aging on
     25. Novartis Pharmaceuticals. Comtan monograph. www.          Nov 6, 2005).                                                           the incidence of digoxin toxicity. Ann Pharmacother (accessed April 4, 2006).           36. American Geriatrics Society Position Paper. The               2000;34:427-32.
     26. Albers GW, Amarenco P, Easton JD, et al.                  management of persistent pain in older persons. www.ameri-                    46. Health Canada. National Advisory Committee on
Antithrombotic and thrombolytic therapy for ischemic stroke.                   Influenza. Statement on influenza vaccination for the 2005-2006
The 7th ACCP conference on antithrombotic and thrombolytic         (accessed November 6, 2005).                                            season.
therapy. Chest 2004;126:483S-512S.                                       37. Fisher R, Ross MM, MacLean MJ, eds. A guide to end            asc-dcc-6/ (accessed December 14, 2005).
     27. Fick DM, Cooper JW, Wade WE, et al. Updating the          of life care: 2000. University of Toronto and University of Ottawa.           47. Drinka PJ, Gravenstein S. Management of influenza in
Beers criteria for potentially inappropriate medication use in (accessed April       the nursing home. Ann Long-Term Care Clin Care Aging 2000;8:
older adults. Arch Intern Med 2003;163:2716-24.                    4, 2006).                                                               23-30.
     28. Gurwitz JH, Monette J, Rochon PA., et al. Arch Intern           38. Richmeier S, Macres SM. Understanding neuropathic                   48. Bradley SF. Prevention of influenza in long-term-care
Med 1997;157(9):978-84. Atrial fibrillation and stroke preven-     pain.             facilities. Long-Term-Care Committee of the Society for
tion with warfarin in the long-term care setting.                  html (accessed April 4, 2006).                                          Healthcare Epidemiology of America. Infect Control Hosp
     29. Singer DE, Albers GW, Dalen JE, et al. Antithrombotic           39. Hunt SA, Abraham WT, Chin MH, et al. ACC/AHA 2005             Epidemiol 1999;20:629-37.
therapy in atrial fibrillation. Chest 2004;126:429S-456S.          guideline update for the diagnosis and management of chronic                  49. D’Arcy PF. Vaccine-drug interactions. Drug Intell Clin
     30. American Geriatrics Society. Oral anticoagulation for     heart failure in the adult: summary article. Circulation 2005;112:      Pharm 1984;18(9):697-700.
older adults (2002). Pocket guide. www/americangeriatrics/ord/     1825-52.                                                                      50. Public Health Agency of Canada. Influenza in Canada:
products/position papers/ANT_Coag_{pocketV61.pdf (accessed               40. Juurlink D, Mamdani M, Lee D, et al. Hyperkalemia in          2005-2006 season update. February 2006. www.phac-
November 6, 2005).                                                 the aftermath of the Randomized Aldactone Evaluation Study. N 
     31. Boulet LP, Becker A, Bérubé D, et al. Canadian Asthma     Engl J Med 2004;351(6):11-19.                                           (accessed April 4, 2006).
Consensus Report, 1999. Inhalation devices and propellants.              41. Pitt B, Zannad F, Remme WJ, et al for the Randomized                51. Zermansky AG, Petty D, Raynor DK, et al. Randomised
CMAJ 1999;161(90111).         Aldactone Evaluation Study Investigators. The effect of spirono-        controlled trial of clinical medication review by a pharmacist of
suppl_1/s44 (accessed December 20, 2005).                          lactone on morbidity and mortality in patients with severe heart        elderly patients receiving repeat prescriptions in general prac-
     32. Kisch GL, Paloucek FP. Metered-dose inhalers and neb-     failure. N Engl J Med 1999;341:709-17.                                  tice. BMJ 2001;323:1-5.
ulizers in the acute setting. Ann Pharmacother 1992;26(1):92-5.          42. Misiaszek B, Heckman GA, Merali F, et al. Digoxin pre-              52. Clark TR, Gruber J, Sey M. The early history and evolu-
     33. Wright J, Brocklebank D, Ram F. Inhaler devices for the   scribing for heart failure in elderly residents of long-term care       tion of DRR. Consult Pharm 2003;18(3):7-14.
treatment of asthma and chronic obstructive airways disease        facilities. Can J Cardiol 2005;21(3):281-6.

 1 Which of the following would increase the                       b) Does he have any pain? The pharmacist                                calcium carbonate 1250 mg BID, vitamin D 800
anticholinergic load in an elderly nursing-home                       should complete a pain questionnaire with PT                         IU daily and alendronate 70 mg once a week. In
resident with Alzheimer dementia?                                     to evaluate potential pain symptoms in light of                      the past week, she has been quieter and has indi-
a) doxepin            c) levodopa                                     his prescription for acetaminophen as needed.                        cated that she has greater pain (now a 7 on a
b) memantine          d) zanamivir                                 c) How well are his symptoms of PD controlled?                          scale of 1–10; previously it was a 5). What
                                                                      The pharmacist should evaluate a symptom                             should the pharmacist recommend?
 2 AJ is an 89-year-old female nursing-home                           log (if kept by a caregiver) and review all of the                   a) A more detailed pain assessment to deter-
resident with long-standing COPD and arthritis.                       possible solutions related to medication ther-                          mine if the pain is relieved at all with mor-
She has recently had a stroke and has been hav-                       apies if symptoms are not well-controlled.                              phine, since she has been experiencing a fair
ing difficulty taking her medications. Nursing                     d) all of the above                                                        amount of pain.
staff have reported that she is having choking                     e) a and c                                                              b) Switch her pain medication to gabapentin
episodes frequently. Which of the following                                                                                                   since she is probably experiencing neuro-
actions would be the highest priority in helping AJ                 4 JG is a 79-year-old male with HF—stage C, as                            pathic pain that may not respond to opioids.
manage this particular problem?                                    well as hypertension and dyslipidemia. He is cur-                       c) Add diclofenac 50 mg BID to augment the
a) ensuring that AJ is not taking medications that                 rently taking ramipril 5 mg daily, atenolol 25 mg                          current analgesic.
   can aggravate COPD, such as hypnotics, since                    daily, atorvastatin 40 mg daily, ASA 325 mg daily,                      d) none of the above
   this could be causing her choking episodes                      digoxin 0.25 mg daily and a multivitamin daily. JG
b) reviewing her medication list to determine                      has been experiencing increasing shortness of                           Upon performing a detailed medication review
   whether or not she is taking anything that can                  breath and swelling of his ankles over the past few                     for KJ, an 80-year-old female nursing-home resi-
   exacerbate dysphagia that can occur as a                        days. Which of the following is the highest priority                    dent, the pharmacist notes the following list of
   result of a stroke                                              drug-related issue for the pharmacist to address?                       medications and diagnoses: allopurinol 200 mg
c) recommending that she be prescribed war-                        a) JG should be taking lower dose ASA (i.e., 81                         OD, naproxen 500 mg BID, ranitidine 150 mg
   farin to prevent subsequent stroke                                 mg daily) to reduce his risk of bleeding.                            HS, metoprolol 25 mg OD, warfarin 2 mg OD
d) ensuring that she has had a pneumococcal                        b) JG’s digoxin level should be measured to rule                        and nitroglycerin spray 0.4 mg SL PRN; and a
   vaccination                                                        out toxicity as a cause of his symptoms.                             history of gout, hypertension, atrial fibrillation,
                                                                   c) JG should be receiving a diuretic to help con-                       angina and falls.
 3 PT is a 77-year-old male with PD and demen-                        trol his HF symptoms; recommend furosemide
tia. He is currently taking levodopa-carbidopa                        40 mg daily to start.                                                 6 Which of the following is an appropriate com-
100/25 five times per day, risperidone 1 mg daily,                 d) JG should be prescribed spironolactone in                            ment for the pharmacist’s review of KJ?
selegiline 5 mg BID, magnesium hydroxide 30 mL                        addition to his other therapies for heart failure.                   a) She should be taking ASA rather than war-
HS, and acetaminophen 325 mg QID PRN. He                                                                                                      farin due to her history of falls.
appears to be more agitated in the past few days.                   5 MC is an 82-year-old female with chronic                             b) Allopurinol should not be used long term for
Which of the following is/are the most appropriate                 back and hip pain who was admitted to the LTC                              the prevention of gout attacks.
question(s)/intervention(s) by the pharmacist?                     facility after a fall last year that led to a hip frac-                 c) There is no indication for ranitidine, thus it
a) When is PT taking selegiline? If taken at                       ture. Her mobility is very limited and she usually                         should be discontinued. Instead, a proton
    night, it could be disrupting his sleep and a                  sits in her chair all day. She is on long-acting                           pump inhibitor should be considered for pro-
    lack of sleep may be causing agitation.                        morphine sulphate 15 mg BID for pain as well as                            phylaxis of NSAID-induced ulcer.

Pharmacy Practice | July 2006                                                                                                            Answer online at                         7
continuing education lesson

                                                                                            Preventing and managing drug-related problems in long-term care

d) Warfarin should be increased to a therapeu-           b) Decrease the dose of warfarin to 2.5 mg daily.         signal the presence of pain.
   tic dose of at least 2.5 mg daily.                    c) Hold two doses of warfarin and re-evaluate          b) The long-term use of anticonvulsants for
                                                            the INR in one to two days.                            chronic neuropathic pain in the elderly is not
 7 Which lab test results for KJ should be               d) Administer 10 mg vitamin K to reverse the              recommended.
reviewed by the pharmacist and ordered if not               effect of warfarin on the INR.                      c) Short-term use of traditional NSAIDs with
available?                                                                                                         cytoprotection (i.e., proton-pump inhibitor or
a) MMSE            c) PT                                 12 Upon reviewing the medical chart of SV, an             misoprostol) should not be used for pain
b) INR             d) folic acid                         85-year-old female with AD, the pharmacist notes          management in this population.
                                                         the following information: SV has had increas-         d) Celecoxib should not be used in this popula-
 8 The pharmacist reads in KJ’s chart that her           ingly difficult behaviours manifested as shouting         tion due to the increased risk of cardiovascu-
renal function is declining (last estimated crea-        out and resisting care. Since she started receiv-         lar adverse effects with this medication.
tinine clearance was 40 mL/minute [normal is             ing risperidone 0.5 mg daily she has been
50–125 mL/minute]). What drug-related problem            calmer; however, her family has indicated that         17 Which of the following is a potential medica-
should be addressed?                                     she is not the same and somewhat “dopey.” What         tion-related problem encountered by residents
a) KJ is taking a medication for which there is no       should the pharmacist recommend?                       with PD?
    indication. Warfarin should be discontinued.         a) Investigate other potential causes of these         a) freezing with anticholinergic medications
b) KJ’s dose of warfarin is inappropriate based             behaviours (e.g., pain, constipation) which         b) paranoia with pergolide
    on her current renal function.                          may eliminate the need to medicate SV with          c) suboptimal dosing when switching from CR
c) KJ is taking a medication that may be wors-              risperidone.                                            levodopa to regular-acting levodopa due to
    ening her renal function. Naproxen should            b) Switch from risperidone to olanzapine 7.5 mg            decreased bioavailability of the regular levodopa
    be discontinued.                                        daily.                                              d) all of the above
d) none of the above                                     c) Increase the dose of risperidone to 1 mg daily
                                                            to better manage her behaviours.                    18 NF, an 80-year-old male resident of a LTC
 9 Which of the following is the most important          d) Discontinue risperidone.                            facility has had COPD for several years and is
way a pharmacist can help to prevent drug-                                                                      now having difficulty with exacerbations of this
related problems that can occur during an                13 Which medication-related problem has been           condition. He is taking ipratropium bromide 2
influenza outbreak in a facility?                        identified increasingly in the elderly population?     puffs QID, salbutamol 2 puffs BID PRN and theo-
a) vaccinating all residents and staff of the facility   a) bleeding with warfarin therapy                      phylline SR 200 mg daily. Which of the following
b) ensuring that oseltamivir is dosed appropri-          b) exacerbation of COPD due to inappropriate           should the pharmacist recommend?
    ately for prophylaxis                                   use of inhalers                                     a) NF should receive his inhalation medications
c) teaching all residents the technique for use          c) motor fluctuations with selegiline                     via nebulizer to ensure that he is getting
    of the zanamivir inhaler device                      d) hyperkalemia with spironolactone use to                maximal dosing.
d) ensuring that all residents have an order for            manage HF                                           b) NF should be using a spacer device, prefer-
    amantadine for prophylaxis of influenza                                                                        ably with mask, with his inhaled medications
                                                         14 Which of the following is true regarding               to ensure that he is getting adequate
10 LP is a 79-year-old man with PD. He has had PD        prophylaxis of influenza in a nursing-home out-           amounts of each dose of his medication.
for about seven years and has been taking levo-          break situation?                                       c) Theophylline should be discontinued as it
dopa-carbidopa CR 100/25 QID for the past three          a) Zanamivir should not be used to prevent                offers no additional benefit for residents like
years. He is also taking pramipexole 0.125 mg               influenza infection in nursing-home staff if an        NF with COPD.
daily, docusate sodium 100 mg daily and lactulose           outbreak has been identified.                       d) NF should receive a benzodiazepine at night
30 mL daily for constipation. Over the past few          b) Oseltamivir has been associated with more              to help control anxiety associated with his
weeks, he has been experiencing episodes during             resistance than amantadine when used for               exacerbations.
which he is unable to move or take a step forward           prophylaxis.
a couple of hours after taking his levodopa-car-         c) Oseltamivir requires no dosage reduction in         19 Upon review of AP’s chart, the pharmacist
bidopa. What should the pharmacist recommend?               residents with impaired renal function when         notes that the 87-year-old male has AD and has
a) Discontinue pramipexole as it can be causing             used for prophylaxis.                               been taking donepezil 10 mg daily for at least
    dyskinesia.                                          d) Amantadine should not be used for prophy-           five years. Which of the following is an appropri-
b) Add amantadine 100 mg daily to help control              laxis or treatment of influenza infection.          ate recommendation by the pharmacist?
    the symptoms.                                                                                               a) Discontinue donepezil as it is no longer effec-
c) Add selegiline to help control his symptoms.          15 Which of the following should always be                 tive.
d) Increase the dose of levodopa-carbidopa to            included in a pharmacist’s medication review for       b) Switch to galantamine as it is better in later
    help control the freezing.                           a resident of a LTC facility?                              stages of disease.
                                                         a) a suggestion for how to reduce the number of        c) Decrease the dose of donepezil to reduce the
11 DC is an 87-year-old male who has atrial fib-            medications the resident is taking                      likelihood of adverse effects.
rillation, osteoarthritis, hypertension, diabetes        b) an interview with the resident’s physician to       d) Evaluate the benefits of donepezil by review-
and history of stroke. He is currently taking war-          get an accurate history                                 ing MMSE results compared to baseline.
farin 3 mg daily, celecoxib 100 mg BID,                  c) a review of medical conditions to ensure that
hydrochlorothiazide 25 mg daily and metformin               the resident is receiving all necessary therapies   20 In a resident with chronic pain, the pharma-
500 mg BID. He just received his annual influ-           d) all of the above                                    cist should ensure that:
enza vaccination. DC’s INR is now measured                                                                      a) the resident has a doctor’s order for a laxative
every month. On his last INR test, the result was        16 Which of the following is true regarding pain       b) there is an order for “prn” analgesic in addi-
6.2; previously, he was well-controlled with an          symptoms and their management in LTC facility             tion to regular analgesic
INR averaging 2.6. DC has no signs of bleeding.          residents?                                             c) the resident is on an anticonvulsant or anti-
What should the pharmacist recommend?                    a) It is difficult to assess specific pain symptoms       depressant
a) Discontinue warfarin and start ASA 325 mg                in cognitively impaired residents; signs such       d) the resident is not receiving chronic opioid
    daily.                                                  as irritability and vocalizations can help to          therapy

8      Answer online at                                                                                   Pharmacy Practice | July 2006

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