Screening for Polypharmacy in the Elderly Population

Abstract

Background. The population of 65 years and older has increased exposure to polypharmacy, with data showing up to 42% taking five or more medications. Polypharmacy increases the frequency of potentially inappropriate medications prescribed which are associated with adverse drug events and higher healthcare costs. The Screening Tool of Older Persons’ Prescriptions and Screening to Alert to Right Treatment criteria have demonstrated effectiveness in identifying potentially inappropriate medications and preventing adverse drug events. Local Problem. A large, academic medical center neurology practice site used a standard medication reconciliation for its patients over the age of 65. They did not have an enhanced medication screening process for that population. Interventions. The quality improvement project used the Screening Tool of Older Persons’ Prescriptions and Screening to Alert to Right Treatment criteria to augment the medication reconciliation process on the general neurology inpatient service. The transtheoretical model was used to guide interventions based on the stages of change to produce this change in behavior towards enhanced medication screening. During the seven-week implementation, patients over age 65 admitted to the service were screened by providers using the tool’s criteria. A clinical pharmacist consultation was to be initiated for positive findings. Results. During the implementation, 29 of the 73 patients admitted to the service were eligible for screening. The providers completed nine screenings for an overall compliance of 31%, falling below the goal of 80%. Five (55%) of the patients screened positive, resulting in three consults to the clinical pharmacist for an overall consult compliance of 60%. Two of the positive screenings resulted in medication changes for the patients. Following the implementation, the providers evaluated the Screening Tool of Older Persons’ Prescriptions and Screening to Alert to Right Treatment criteria using the System Usability Scale with a final average score of 86.25 out of 100, indicating the process was highly usable. Conclusions. Despite the low compliance with screening, the presence of a potentially inappropriate medication in 55% of the patients screened suggests this population is at a high risk for polypharmacy exposure and enhanced medication reconciliation is warranted. A behavior change was not fully established among the physician team as they remained in the contemplative stage of change while the nurse practitioner on the team progressed to the action stage. The results from the System Usability Scale survey indicated the criteria were easy to use and are a viable option for sustained integration into the medication reconciliation process. The loss of the provider champion greatly impacted the ability of the project lead to achieve buy-in with the neurology team. The results of this project are limited based on the small sample size and a complete turnover of resident physicians during the implementation. A focus on achieving provider buy-in is necessary to achieve sustainability. Future work should be aimed at the development of an automated version of the criteria, integrating the process into established workflow, and the evaluation of the impact of medication screening on patient outcomes such as medication costs and adverse drug events.