Geriatric Comprehensive Medication Review

Author: Kathleen Pace Murphy, PhD, MS, GNP-BC; Jennifer Larson, MSE

Definition

The National Medical Therapy Management (MTM) Advisory Board's (2011) definition of a Comprehensive Medication (CMR) Review is: 

…a systematic process of collecting patient-specific information, assessing medication therapies to identify medication-related problems, developing a prioritized list of medication-related problems, and creating a plan to resolve them with the patient, caregiver and/or prescriber.

 

Key Points

Older adults (aged 65 and older) use approximately 33% of prescription medications and 75% of all over the counter medications in the United States. 

Ninety percent of those aged 65 or older take at least one drug per week. Forty percent take five or more drugs per week, and 12% take more than ten medications per week. (Katzung, 2007, Pham & Dickman, 2007). 

Age influences medication therapy. As a person ages there are pharmacokinetic alterations that occur, such as, changes in drug absorption, distribution, excretion and metabolism. Advancing age may mean additional co-morbidities, which may further impair drug absorption, distribution, excretion and metabolism. 

Socio-economic changes may also affect an older adult's medication therapy plan and adherence. Co-morbidities may mean additional costly medical appointments with specialists as well as primary care physicians. Complicated daily medication routines and pharmaceutical cost can also influence the older adult's adherence and/or compliance to the medication therapy plan. 

Self-administration of complementary and over-the-counter medications and herbal remedies may further complicate the medication therapy plan if this information is not freely discussed between the older adult and the health care provider. 

Health care providers must utilize their pharmacology knowledge to understand potential adverse drug effects. Asking the right questions is always a good start. 

 

Assessment

Medication review questions to ask of patients include the following:
  1. Please tell me what prescribed medications you are on and for what problem?
  2. Please tell me about medications that you buy for yourself from the grocery store, drug store, health food store, or your favorite discount store? 
  3. Do you ever travel to a foreign country and buy medications there? If so, which medications did you purchase?
  4. Are you using eye drops, creams, lotions or other topical medications that I should know about?
  5. Has your eye doctor, podiatrist or dentist prescribed any medications for you?
  6. I noticed that you also have the following medical problems but are not receiving any medications for them - is that correct?
Medication review questions health care providers must ask themselves 
  1. Is there still an indication for this prescribed medication? 
  2. Is this prescribed medication appropriate for this specific condition?
  3. Is the efficacy and safety of this prescribed medication satisfactory?
  4. Is this the most cost-effective medication I can prescribe for this older adult?
  5. Does this medication need to be monitored (i.e. blood levels) and if so, do I have the steps in place for this to happen successfully? 
  6. Are there duplications in this older adult's medication therapy plan? 
  7. Can this medication therapy plan be simplified? 
  8. Are there potential drug-drug or drug-illness interactions?

Adapted from Hamdy, Moore, Whalen, Donnelly, Compton, & Testerman, et al., (1995).

 

Intervention

The following interventions are simple and easy to follow when caring for an older adult:

 

References

American Geriatric Society (2012). AGS Beers Criteria for potentially inappropriate medication use in older adults. Accessed September 17, 2013 at http://www.americangeriatric.org/health_care_professionals?clinical_practice/clinicalguidelines_recommendations/2012

CHAMP: Advancing Home Care Excellence (2009). Geriatric Medication Management Toolkit. Accessed September 19, 2013 at http://champ-program.org/page/101/geriatric-medication-management-toolkit 

Clinical medication review: A practice guide (February, 2013). NHS: Cumbria. Accessed September 18, 2013 at http://cumbria.nhs.uk/ProfessionalZone/MedicineManagement/GuidelinesReview-PracticeGuide2011.pdf 

Hamdy, R.C., Moore, S.W., Whalen, K., Donnelly, J.P., Compton, R., Testerman, F., et al. (1995). Reducing polypharmacy in extended care. South Med J, 88, 534–538. 

Katzung, B. (2007) Special aspects in geriatric pharmacology. In: Katzung, B. Basic and Clinical Pharmacology. 10th Ed. New York, NY: McGraw Medical; 983-990. 

National MTM Advisory Board, (2011). Definition of medication therapy management definition. Accessed September 19, 2013 at http://www.businesswire.com/news/home/20110804006226/en/National-MTM-Advisory-Board-Releases-Pharmacist-Service 

Pham, C. B., & Dickman, R. L. (2007). Minimizing adverse drug events in older patients. American Family Physician, 76(12), 1837-1844.