BackgroundFollowing hospitalization, older adults are increasingly discharged to post-acute care facilities such as skilled nursing facilities (SNF). Medication reconciliation and obtaining the best possible medication history (BPMH) are key components of medication management for care transitions and essential for preventing medication errors and adverse drug events.ObjectiveTo assess medication discrepancies across care transitions after a Certified Pharmacy Technician (CPhT) obtains the BPMH on hospital admission.MethodsSingle-center, retrospective chart review and included adults ≥ 18 years admitted to the medicine service and discharged to a SNF between November 2016 and June 2017. Medication lists were evaluated for discrepancies across 3 transitions: hospital admission to hospital discharge (Time I), hospital discharge to SNF admission (Time II), and SNF admission to SNF discharge (Time III). Discrepancies were categorized by medication class, type of discrepancy, and whether it was potentially intentional or unintentional.ResultsIn 127 patients, the average age was 83.3 (SD 9.16), 61% (n = 77) were female, and 67% (n = 85) were white. Median hospital length of stay (LOS) was 6 days (IQR, 4-10) and SNF LOS 21 days (IQR, 15-30). Across 381 transitions, 6,322 medications were reviewed, and 2,602 discrepancies identified. Total number of medication discrepancies were 1,034 (Time I), 687 (Time II), and 881 (Time III), respectively. All patients had at least one medication discrepancy. Average number of potentially unintentional discrepancies per patient at each transition was 0.14, 0.2, and 0.16, respectively. Most common discrepancy type was omissions (39%) and highest number of discrepancies in the potentially intentional and unintentional discrepancy groups were gastrointestinal (21%) and cardiovascular medications (24%), respectively.ConclusionMedication discrepancies are common across all care transitions. Future studies are needed to evaluate the role of CPhT in obtaining the BPMH on hospital admission for reducing medication discrepancies across the continuum of care.

The American Geriatrics Society (AGS) Beers Criteria (R) (AGS Beers Criteria (R)) for Potentially Inappropriate Medication (PIM) Use in Older Adults are widely used by clinicians, educators, researchers, healthcare administrators, and regulators. Since 2011, the AGS has been the steward of the criteria and has produced updates on a 3-year cycle. The AGS Beers Criteria (R) is an explicit list of PIMs that are typically best avoided by older adults in most circumstances or under specific situations, such as in certain diseases or conditions. For the 2019 update, an interdisciplinary expert panel reviewed the evidence published since the last update (2015) to determine if new criteria should be added or if existing criteria should be removed or undergo changes to their recommendation, rationale, level of evidence, or strength of recommendation. J Am Geriatr Soc 67:674-694, 2019.

FigurePolypharmacy, use of multiple medications to treat chronic comorbid conditions in older adults (persons over age 65), has been described in the literature as a potential cause for an increase in drug–drug interactions, injurious falls, hospitalization, and morbidity. Polypharmacy has been defined by some authors as more than five medications (Gnjidic et al., 2012). It is imperative to constantly and consistently reevaluate medications prescribed to older adults. Deprescribing, the process of identifying and discontinuing drugs that can potentially harm rather than benefit a patient, should be considered in all older adults on an individual basis (Brandt, 2016). The aging population of the United States and the increase in remaining life expectancy at age 65 have major implications for all sectors of healthcare including home healthcare. With this population comes medical complexity including cognitive impairment, and diagnoses such as congestive heart failure and diabetes. Multimorbidity results in use of multiple medications. Home healthcare clinicians need to be prepared to manage the complex needs of this population including medication management. Ongoing medication review and reconciliation is crucial for older adults particularly after a hospital or skilled nursing stay (Murtaugh et al., 2009). The Beers Criteria was originally developed by Dr. Mark Beers in 1991 as a tool to identify medications that may be inappropriate for older adults. The updated criteria were recently completed by a 13-member interprofessional panel of experts in geriatric care (American Geriatrics Society [AGS], 2015). The panel used a modified Delphi method to systematically review and grade the evidence and reach a consensus on each existing and new criteria. The process followed an evidence-based approach using approved Institute of Medicine standards. The 2015 AGS Beers Criteria are applicable to all older adults with the exclusion of those in palliative or hospice care. The 2015 AGS Beers Criteria for Potentially Inappropriate Medications (PIM) Use in Older Adults is one of the most frequently consulted sources regarding the safety of medications for older adults. The criteria are widely used in geriatric clinical care, education, and research (AGS). The 2015 list also includes medications that may exacerbate a disease or syndrome, medications that may be inappropriate due to drug–drug interactions as well as medications that should be used with caution, and medications that should have dosages reduced due to varying degrees of kidney function. Pharmacokinetics and Pharmacodynamics in the Older Adult There are a number of physiologic changes that occur with aging that can affect both the pharmacokinetics and pharmacodynamics of medications. Pharmacokinetics involves the absorption, distribution, metabolism, and excretion of medications. In older adults, absorption from the gastrointestinal tract is not significantly affected. There may be delays in achieving peak drug levels, but there is no clinically significant decrease in total absorption. Decreased absorption from intramuscular injections or transdermal patches may occur due to decreased blood perfusion to muscles and skin, so it is important to monitor the clinical effects of the medication and adjust the dosage form if necessary. Distribution of medications in the body depends on whether the medication is water-soluble or lipid-soluble. With age, there is an increase in body fat. Therefore, the volume of distribution for lipid-soluble medications is increased in older adults. The clinical significance of this is that a lipid-soluble medication will accumulate in the body fat and when the medication is discontinued, will take longer to be totally eliminated from the body (Delafuente, 2008). Liver function may be decreased in older adults and some metabolic pathways can be decreased. For drugs metabolized to inactive metabolites, it is advised to start with the lowest possible dose when metabolism is decreased. Most significantly, renal function is generally decreased in older adults. Therefore, medications that are excreted unchanged in the urine will have a prolonged half-life. Medications excreted by the kidneys will often need to have dosage reductions in older adults. It is important to estimate creatinine clearance before initiating medications excreted by the kidneys. Pharmacodynamics involves the interaction of the medication with the body, particularly cellular receptors. In older adults, changes in the numbers of receptors or the sensitivity of receptors can affect the outcome of the medication. For example, older adults are generally more sensitive to the central nervous system (CNS) effects of medications. This can be explained though pharmacodynamics changes. The Role of the Home Healthcare Clinician Home healthcare clinicians are an integral part of the intraprofessional team for reviewing, reconciling, educating, and monitoring medications prescribed to older adults in the home or community setting. This article will focus on the use of the 2015 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults as a guideline for home healthcare clinicians when evaluating medications in a community setting. Using a case study example, the article will outline the steps in utilizing the criteria as an evaluation tool for medication review, and as a tool for shared decision making for clinicians and their patients. Case Study Example Glen is an 88-year-old male recently discharged from the hospital for pneumonia and heart failure. His past medical history includes: Type 2 diabetes, peripheral neuropathy, mild dementia, heart failure, stage III kidney disease, coronary artery disease, and a myocardial infarction with stenting in 2011. This was his fifth hospitalization in the last 8 months. He has also fallen five times over the last 3 months, without serious injury. Jane has been the home healthcare nurse for Glen for the past 2 years. She has an excellent rapport with Glen and his wife, Michele. Due to Glen's recent memory problems, Michele is now managing his medications. Glen sees many specialists including a nephrologist, cardiologist, and neurologist along with his primary care provider. Michele reports that since Glen has returned from the hospital, he has been sleeping a great deal and does not have much of an appetite. His blood glucose is also running low—as low as 46 mg/dL and he recently required a glucagon injection. Michele and Glen have questions about the new medications as well as the number of medications Glen is taking since his hospitalization. Glen is also complaining of generalized muscle aches, which began in the hospital. Michele has been giving him acetaminophen 325 mg two tablets every 4 hours. A prescription for acetaminophen/oxycodone 5/325 had been provided but was not filled as Glen and Michele do not want Glen to “get addicted.” Glen said the acetaminophen/oxycodone helped in the hospital but made him “loopy.” Glen's Medication List Glyburide (Diabeta) 5 mg by mouth twice a day Insulin Glargine (Lantus) 16 units subcutaneous at bedtime Pantoprazole (Protonix) 40 mg by mouth daily (prescribed during hospitalization 2 months ago) Lisinopril (Lisinopril) 10 mg by mouth twice a day (increased from 10 mg this hospitalization) Metoprolol Tartrate (Lopressor) 50 mg by mouth twice a day (increased from 50 mg this hospitalization) Furosemide (Lasix) 80 mg by mouth twice a day (increased from 120 mg daily this hospitalization) Spironolactone (Aldactone) 25 mg by mouth daily (new medication added this hospitalization) Potassium Chloride 20 meq by mouth twice a day Aspirin 81 mg by mouth daily Lorazepam (Ativan) 0.5 mg by mouth twice a day (new this hospitalization). Medications that were not prescribed on discharge; however, Glen was taking prior to hospitalization: Gabapentin (Neurontin) 300 mg by mouth at bedtime Sertraline (Zoloft) 50 mg by mouth daily Using the 2015 AGS Beers Criteria as a Guideline for Medication Reconciliation Medication reconciliation is vitally important particularly following an acute care stay. Transition of care is a critical area of management for older adults. This is mainly due to lack of communication between patients, families, and providers. Vulnerability is attributed to three main factors: 1) numerous changes in medications during a hospital stay, 2) low health literacy and/or low ability to communicate among both patients and caregivers, and 3) poor transmission of information among providers (Kripalani et al., 2007). Because Jane has been Glen's home healthcare nurse and is familiar with his medications and medical history, this is an ideal situation for accurate medication reconciliation and also addressing risk/benefits of current medications with patient, family, and provider. The Beers Criteria can be a starting point for discussing medication appropriateness. The process begins with a review of the criteria and applying it to Glen's situation. The key principles for using the criteria can be found in Table 1. It is important to remember the list is “potentially inappropriate” and must be applied to each individual case. The risks/benefits of every medication should be reviewed by providers at each visit or with any change in condition. Figure 1 illustrates how to read the Beers Criteria.Table 1.: Key Principles to Guide Optimal Use of the American Geriatrics Society (AGS) 2015 Beers CriteriaFigure 1.: How to Read the Beers CriteriaStep 1: Review the 2015 AGS Beers Criteria for PIM. An example of the criteria is presented in Supplemental Table 1 (Supplemental Digital Content [SDC] 1, available at: https://links.lww.com/HHN/A36). Step 2: Glen's medications that are on the 2015 AGS Beers Criteria List: Glyburide Lorazepam Pantoprazole Step 3: Addressing each medication individually for Glen (Table 2)Table 2.: Glen's Medications on the Beers ListStep 4: Using the 2015 AGS Beers Criteria as guide for monitoring of adverse effects and condition changes The Beers Criteria also address drug–disease and drug–syndrome PIMs. The nonbenzodiazepines, benzodiazepine receptor agonist hypnotics (e.g., zolpidem) have been added to the “avoid” list in older adults. Opioids have been added to the list of CNS medications that should be avoided in individuals with a history of falls or fractures. Antipsychotics are to be avoided as first-line treatment for behavior disturbances associated with dementia because of conflicting evidence on their effectiveness and potential of adverse effects. The drug–disease and drug–syndrome table can be found in Supplemental Table 2 (SDC 2, available at: https://links.lww.com/HHN/A37). Glen has a history of cognitive impairment and falls. The oxycodone/acetaminophen prescribed to him may not be appropriate, assuming acetaminophen is effective for his pain. He did report oxycodone/acetaminophen made him feel “loopy” in the hospital. An accurate pain assessment is imperative for evaluation and plan. He has a history of neuropathy for which he was taking gabapentin. Gabapentin is listed in Supplemental Table 2 (SDC 2: https://links.lww.com/HHN/A37) as a PIM for individuals with history of falls, and Glen does have a history of falls. This medication was discontinued in the hospital. The nurse should discuss with the provider the pain assessment, the omission, and rationale for discontinuation of the gabapentin and pain management plan. If the gabapentin is resumed, then close monitoring for adverse CNS effects is required. Explicit education about side effects should be provided to Glen and Michele. Sertraline is also listed in Supplemental Table 2 (SDC 2: https://links.lww.com/HHN/A37) due to its risk for inappropriate secretion of antidiuretic hormone syndrome. This medication was discontinued in the hospital and the omission and rationale should be discussed with provider. A discussion with Glen and Michele and assessment of depressive symptoms and the effectiveness of the medication is warranted. If the medication is resumed, monitoring for adverse effects and education as with gabapentin is crucial. It is important to remember that medication reconciliation protocols vary by health system and adherence is also variable. Some health systems and home healthcare agencies have linking electronic health records that give real-time access to current medication lists. The process also varies by provider. Providers must update the list routinely for changes and this does not always occur. Patients and family members tend to not seek clarification about medication changes due to insufficient knowledge, lack of opportunities, forgetfulness, and lack of insight of possible repercussions. It is not until medication problems occur that they realize the ramifications associated with not seeking clarification (Manias et al., 2014). Home healthcare clinicians often have continuity with patients, and medication reconciliation is a routine portion of posthospital visits. Patient and caregiver education on the importance of medication reconciliation and communication with providers in the outpatient and inpatient setting is imperative in avoiding medication misadventures. Because Glen has multiple providers, his wife may be the only constant in his care so she needs to understand the significance of medication reconciliation. New to the 2015 AGS Beers Criteria are drug–drug interactions (excluding anti-infective) that are highly associated with harmful outcomes in older adults (Hines & Murphy, 2011). The list is selective and not comprehensive, and should be considered a reminder to assess drug–drug interactions. In Glen's case, the use of spironolactone, lisinopril, and potassium has the potential for hyperkalemia and should be monitored closely by routine chemistries. The use of gabapentin and sertraline, if restarted, has the potential for a drug–drug interaction. Also new to the 2015 criteria are drugs to be avoided or for which the dose should be adjusted in individuals with a specific degree of kidney impairment. This list was adapted from published consensus guidelines developed by an expert group including two AGS Beers Criteria panelists (Hanlon et al., 2009). The AGS Beers panel reviewed the evidence and selected medications from these earlier consensus guidelines for inclusion, added additional medications, including several anticoagulants, and included spironolactone and triamterene, which were in the 2012 Beers Criteria. Glen is on spironolactone and has stage III kidney disease, so close monitoring of chemistries is needed to watch for worsening kidney function and the high potential for adverse effects. The Significant Role of the Pharmacist In all care settings, pharmacists have an important role in educating other healthcare professionals about the Beers Criteria and how to use them in clinical practice. In the hospital setting, computerized physician order entry systems with clinical decision support can be configured to flag the Beers medications. If a prescriber enters an order for a Beers medication for a patient >65 years old, the system will alert the prescriber with information about why this medication may not be recommended for this patient and possible alternatives. Beers medications can also be imbedded into dispensing, so the pharmacist is alerted to high-risk medications. The pharmacist would then contact the prescriber and offer alternative medications on formulary. If a Beers medication is truly indicated for the patient, the pharmacist can inform the prescriber about appropriate dosing guidelines and monitoring parameters. Community pharmacy computer systems can also imbed Beers medications to alert pharmacists of potentially inappropriate medications for patients >65 years old. To complete the entry of the prescription, the pharmacist would have to document that he or she either contacted the prescriber or reviewed the patient profile to override the alert. Because community pharmacists generally do not have access to laboratory values or past medical history, it is easier for them to monitor the “medications to avoid” list rather than the medications that should be avoided in specific disease states. Community pharmacists, because of their accessibility, can also be a resource to their patients about the implications of medications on the Beers list. It is important to stress to patients that they should not abruptly discontinue their medications just because it is on the Beers list. Rather, they should discuss it with their provider. The pharmacist can also offer to call the patient's provider to alert him or her about the Beers medication in question. AGS has developed patient education material to assist healthcare professionals when discussing Beers medications with their patients available at: http://geriatricscareonline.org/toc/ags-patient-handouts/H001/ Another role for the pharmacist in the community is working with Medicare Part D prescription plans. It has come to the attention of AGS that many Part D plans have placed some Beers medications on prior authorization lists or they do not cover them at all (Berger, 2014; McCormick, 2014). The pharmacist can either call the prescriber for an alternative medication or can facilitate getting prior approval when the medication is appropriate for the patient. This seems to be common with some of the CNS depressants such as the benzodiazepines, the nonbenzodiazepine hypnotics, and skeletal muscle relaxants. Shared Decision Making The Beers Criteria can be a starting point to not only discuss medication risks/benefits, but also to open a discussion about quality of life and care preferences for patients. Medication education requires active engagement of patients and caregivers for shared decision making. Glen has multiple medical comorbidities as well as multiple hospitalizations and frequent falls over the last several months. Both he and Michele have voiced their concerns regarding the number of medications that have been prescribed. Patient-centered care revolves around the wishes and needs of the patient. Frequently, adverse medication effects occur in patients, and caregivers aren't always able to make the connection until prompted by healthcare professionals. Jane has a rapport with Glen and Michele. She can ask what they understand about Glen's current condition and what their goals are for treatment. Remember the criteria deal with only a small portion of the many types of prescribing issues that older adults face—that is, medications that are providing them limited benefit or causing bothersome adverse effects, problems with medication adherence, medication costs that make it difficult to afford medications, and management of complex regimens. So, although the Beers Criteria is a useful tool, we need to stay attentive to these other types of problems as well. Home healthcare clinicians act as liaisons between patients and providers during transitions of care. The broad base of knowledge they possess, and their expertise and experience in all matters of direct patient care is what makes them so well suited to ensure safety during transitions of care and ongoing home healthcare. This expertise and experience combined with the longitudinal nature of their interactions with a home healthcare patient are why it is important to be knowledgeable about the Beers Criteria. A clear understanding of the 2015 AGS Beers Criteria and its application can play a vital role in the care and medication management of older adults in the home setting. Instructions for Taking the CE Test Online Medication Reconciliation and Education for Older Adults: Using the 2015 AGS Beers Criteria as a Guide Read the article. The test for this CE activity can be taken online at www.nursingcenter.com/ce/HHN. Tests can no longer be mailed or faxed. You will need to create a free login to your personal CE Planner account before taking online tests. Your planner will keep track of all your Lippincott Williams & Wilkins online CE activities for you. There is only one correct answer for each question. A passing score for this test is 12 correct answers. If you pass, you can print your certificate of earned contact hours and the answer key. If you fail, you have the option of taking the test again at no additional cost. For questions, contact Lippincott Williams & Wilkins: 1-800-787-8985. Registration Deadline: December 31, 2018 Disclosure Statement: The authors and planners have disclosed no potential conflicts of interest, financial or otherwise. Provider Accreditation: Lippincott Williams & Wilkins, publisher of Home Healthcare Now, will award 2.5 contact hours for this continuing nursing education activity. Lippincott Williams & Wilkins is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. This activity is also provider approved by the California Board of Registered Nursing, Provider Number CEP 11749 for 2.5 contact hours. Lippincott Williams & Wilkins is also an approved provider of continuing nursing education by the District of Columbia, Georgia, and Florida CE Broker #50-1223. Your certificate is valid in all states. Payment: The registration fee for this test is $24.95.

The association between blood pressure (BP), cardiovascular and cerebrovascular morbidity and mortality had been the focus of multiple studies in the older population, supporting the evidence for diagnosing and treating hypertension (HTN), regardless of age. The aim of this study is to explore potential adverse events (AE) of “tight” BP control in residents of long-term care facilities.

The updated AGS 2012 Beers Criteria now include insulin sliding scale (SSIs) as a “potentially inappropriate medication” (PIM) in elderly diabetics. We compared adverse drug events (ADEs) in SNF diabetics with and without SSIs.

Objective: To study medication discrepancies in clinical transitions across a large health care system.Design: Randomized chart review of electronic medical records and paper chart medication reconciliation lists across 3 transitions of care.Settings and participants: Subacute patient medication records were reviewed through 3 transition care points at a large health care system, including hospital admission to discharge (time I), hospital discharge to skilled nursing facility (SNF; time II) and SNF admission to discharge home or long term care (LTC; time III).Measurements: Medication discrepancies were identified and categorized by the principal investigator and a pharmacist. Discrepancies were defined as any unexplained documented change in the patients' medication lists between sites and unintentional discrepancies were defined as any omission, duplication, or failure to change back to original regimen when indicated.Results: We reviewed 1696 medications in the 132 transition records of 44 patients, identifying 1002 discrepancies. Average age was 71.4 years and 68% were female. Median hospital stay was 5.5 days and 14.5 SNF days. Total medications at hospital admission, hospital discharge, SNF admission, and SNF discharge were 284, 472, 555, and 392, respectively. Total medication discrepancies were 357 (time I), 315 (time II), and 330 (time III). All patients experienced discrepancies and 86% had at least 1 unintentional discrepancy. The average number of medications per patient increased at time I from 6.5 to 10.7 (P < .001), increased at time II from 10.7 to 12.6 (P < .0174), and decreased at time III from 12.6 to 8.9 (P < .001). Patients, on average, had 8.1, 7.2, and 7.6 medication discrepancies at times I, II, and III, respectively. Surgical patients had more discrepancies than medical at times I and III (8.94 vs 5.3, P < .019; 8.0 vs 5.8, P < .028). In the unintentional group, cardiovascular drugs represented the highest number of discrepancies (26%).Conclusion: This study is the first to follow medication changes throughout 3 transition care points in a large health care system and to demonstrate the widespread prevalence of medication discrepancies at all points. Our findings are consistent with previously published results, which all focused on single site transitions. Outcomes of the current reconciliation process need to be revisited to insure safe delivery of care to the complex geriatric patient as they transition through health care systems. Copyright (C) 2013 - American Medical Directors Association, Inc.

Background: The transition of care from the hospital to the community has been extensively studied, demonstrating medical errors in half of patients after hospital discharge. However, there has been a dearth of studies focusing on the transition of older patients from the hospital to skilled nursing facilities.