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TABLE I
MEDICATION ISSUES OF PARTICULAR RELEVANCE
Excerpted from CMS State Operations Manual Appendix PP - Guidance to Surveyors for Long Term
Care Facilities
http://cms.hhs.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.pdf This table lists alphabetically, examples of some categories of medications that have the potential to cause
clinically significant adverse consequences, that may have limited indications for use, require specific
monitoring, and which warrant careful consideration of relative risks and benefit. Inclusion of a medication in
this table does not imply that it is contraindicated for every resident. Medications are identified by generic
rather than trade names.
NOTE:

This table is based on review of a variety of pharmaceutical references. It does not include all categories of medications or all medications within a category, and does not address all issues or considerations related to medication use, such as dosages. Medications other than those listed in this table may present significant issues related to indications, dosage, duration, monitoring, or potential for clinically significant adverse consequences. Since medication issues continue to evolve and new medications are being approved regularly, it is important to refer to a current authoritative source for detailed medication information such as indications and precautions, dosage, monitoring, or adverse consequences. The listed doses for psychopharmacological medications are applicable to older individuals. The facility is encouraged to initiate therapy with lower doses and, when necessary, only gradually increase doses. The facility may exceed these doses if it provides evidence to show why higher doses were necessary to maintain or improve the resident’s function and quality of life. Medication
Issues and Concerns
Analgesics
Dosage / Adverse Consequences
Daily doses greater than 4 grams/day from all sources (alone or as part of combination products) may increase risk of liver toxicity Monitoring
For doses greater than the maximum recommended daily dose, documented assessment should reflect periodic monitoring of liver function and indicate that benefits outweigh risks Indications
NSAID, including COX-2 inhibitors, should be reserved for symptoms and/or inflammatory conditions for which lower risk analgesics (e.g., acetaminophen) have either failed, or are not clinically indicated Medication
Issues and Concerns
Exception: Use of low dose aspirin (81–325 mg/day) as prophylactic
treatment for cardiovascular events such as myocardial infarct or

diclofenac diflunisal Interactions
Aspirin may increase the adverse effects of COX-2 inhibitors on the Some NSAIDS (e.g., ibuprofen) may reduce the cardioprotective effect of Monitoring
piroxicam salicylates Monitor closely for bleeding when ASA > 325 mg/day is being used with another NSAID or when NSAIDS are used with other platelet inhibitors or anticoagulants (See See 42 CFR 483.60(c) F428 for Table of Common Medication-Medication Interactions in Long Term Care) Adverse Consequences
May cause gastrointestinal (GI) bleeding in anyone with a prior history of, or with increased risk for, GI bleeding. Compared to nonselective NSAIDs, COX-2 inhibitors may reduce––but do not eliminate––risk of gastrointestinal bleeding May cause bleeding in anyone who is receiving warfarin, heparin, other anticoagulants, or platelets inhibitors (e.g., ticlopidine, clopidogrel, and dipyridamole) Any NSAID may cause or worsen renal failure, increase blood pressure, Prolonged use of indomethacin, piroxicam, tolmetin, and meclofenamate should be avoided because of central nervous system side effects, e.g., headache, dizziness, somnolence, confusion Indications
The initiation of longer-acting opioid analgesics is not recommended unless shorter-acting opioids have been tried unsuccessfully, or titration of shorter-acting doses has established a clear daily dose of opioid analgesic that can be provided by using a long-acting form hydrocodone hydromorphone Meperidine is not an effective oral analgesic in doses commonly used in Adverse Consequences
May cause constipation, nausea, vomiting, sedation, lethargy, weakness confusion, dysphoria, physical and psychological dependency, hallucinations and unintended respiratory depression, especially in individuals with compromised pulmonary function. These can lead to other adverse consequences such as falls Medication
Issues and Concerns
Meperidine use (oral or injectable) may cause confusion, respiratory depression even with therapeutic analgesic doses Active metabolite of meperidine (normerperidine) accumulates with repeated use and has been associated with seizures Indications
Limited effectiveness because it is a partial opiate agonist-antagonist; is not recommended for use in older individuals Adverse Consequences
This opioid analgesic causes central nervous system side effects (including confusion and hallucinations) more commonly than other opioid analgesics May cause dizziness, lightheadedness, euphoria, sedation, hypotension, Indications
Offers few analgesic advantages over acetaminophen, yet has the adverse effects, including addiction risk, of other opioid medications; is not recommended for use in older individuals Adverse Consequences
May cause hypotension and central nervous system effects (e.g., confusion, drowsiness, dizziness) that can lead to other adverse consequences such as falls Antibiotics
Indications
Use of antibiotics should be limited to confirmed or suspected bacterial Adverse Consequences
Any antibiotic may cause diarrhea, nausea, vomiting, anorexia, and hypersensitivity/allergic reactions Antibiotics are non-selective and may result in the eradication of beneficial microorganisms and the emergence of undesired ones, causing secondary infections such as oral thrush, colitis, and vaginitis Monitoring
Use must be accompanied by monitoring of renal function tests (which should be compared with the baseline) and by serum medication Medication
Issues and Concerns
Serious adverse consequences may occur insidiously if adequate Exception: Single dose administration prophylaxis
Adverse Consequences
May cause or worsen hearing loss and renal failure Indications
It is not the anti-infective/antibiotic of choice for treatment of acute urinary tract infection or prophylaxis in individuals with impaired renal function (CrCl <60 ml/min) because of ineffectiveness and the high risk of serious adverse consequences Adverse Consequences
May cause pulmonary fibrosis (e.g., symptoms including dyspnea, cough) Indications
Use should be avoided in individuals with prolonged QTc intervals or who are receiving antiarrhythmic agents in class Ia (e.g., procainamide), class Ic (e.g., flecainide) or class III (e.g., amiodarone) Adverse Consequences
May cause prolonged QTc interval May increase risk of hypo- or hyperglycemia in individuals age 65 or older, and in individuals with diabetes mellitus, renal insufficiency (CrCl < 60 ml/min), or those receiving other glucose-altering medications May increase risk of acute tendonitis Anticoagulants
Monitoring
Use must be monitored by Prothrombin Time (PT)/International Normalization Ratio (INR), with frequency determined by clinical circumstances, duration of use, and stability of monitoring results Adverse Consequences
Multiple medication interactions exist (See 42 CFR 483.60(c) F428 for Table of Common Medication-Medication Interactions in Long Term Care), which may: o Significantly increase PT/INR results to levels associated with o Decrease PT/INR results to ineffective levels, or o Increase or decrease the serum concentration of the interacting Medication
Issues and Concerns
Anticonvulsants
Indications
In addition to seizures, may also be used to treat other disorders, such as bipolar disorder, schizoaffective disorder, chronic neuropathic pain, and for prophylaxis of migraine headaches Need for indefinite continuation should be based on confirmation of the condition (for example, distinguish epilepsy from isolated seizure due to medical cause or distinguish migraine from other causes of headaches) and its potential causes (medications, electrolyte imbalance, Duration
If used to manage behavior, stabilize mood, or treat a psychiatric disorder, refer to Section V – Tapering of a Medication Dose/Gradual Dose Reduction (GDR) in the guidance Monitoring
Serum medication concentration monitoring is not required or available for all anticonvulsants. Only the following anticonvulsants should be monitored with periodic serum concentrations: phenytoin, phenobarbital, primidone, divalproex sodium (as valproic acid), and carbamazepine Serum medication concentrations may help identify toxicity, but significant signs and symptoms of toxicity can occur even at normal or low serum concentrations. When anticonvulsants are used for conditions other than seizure disorders (e.g., as mood stabilizers), the same concerns exist regarding the need for monitoring for effectiveness and side effects; but evaluation of symptoms––not serum concentrations––should be used to adjust doses. High or toxic serum concentrations should, however, be evaluated and considered for dosage adjustments Symptom control for seizures or behavior can occur with subtherapeutic Adverse Consequences
May cause liver dysfunction, blood dyscrasias, and serious skin rashes requiring discontinuation of treatment May cause nausea/vomiting, dizziness, ataxia, somnolence/lethargy, incoordination, blurred or double vision, restlessness, toxic encephalopathy, anorexia, headaches. These effects can increase the risk for falls Medication
Issues and Concerns
Antidepressants
Indications
Agents usually classified as “antidepressants” are prescribed for conditions other than depression including anxiety disorders, post- traumatic stress disorder, obsessive compulsive disorder, insomnia, neuropathic pain (e.g., diabetic peripheral neuropathy), migraine headaches, urinary incontinence, and others Dopamine-reuptake blocking Dosage
compounds, e.g.,

Use of two or more antidepressants simultaneously may increase risk of side effects; in such cases, there should be documentation of expected benefits that outweigh the associated risks and monitoring for any Duration
Duration should be in accordance with pertinent literature, including Prior to discontinuation, many antidepressants may need a gradual dose reduction or tapering to avoid a withdrawal syndrome (e.g., SSRIs, TCAs) If used to manage behavior, stabilize mood, or treat a psychiatric disorder, refer to Section V – Tapering of a Medication Dose/Gradual Dose Reduction (GDR) in the guidance Monitoring
All residents being treated for depression with any antidepressant should be monitored closely for worsening of depression and/or suicidal behavior or thinking, especially during initiation of therapy and during Interactions/Adverse Consequences
May cause dizziness, nausea, diarrhea, anxiety, nervousness, insomnia, somnolence, weight gain, anorexia, or increased appetite. Many of these effects can increase the risk for falls Bupropion may increase seizure risk and be associated with seizures in SSRIs in combination with other medications affecting serotonin (e.g., tramadol, St. John’s Wort, linezolid, other SSRI’s) may increase the risk for serotonin syndrome and seizures Indications/Contraindications
Should not be administered to anyone with a confirmed or suspected Medication
Issues and Concerns
cerebrovascular defect or to anyone with confirmed cardiovascular Should not be used in the presence of pheochromocytoma MAO Inhibitors are rarely utilized due to their potential interactions with tyramine or tryptophan-containing foods, other medications, and their profound effect on blood pressure Adverse Consequences
May cause hypertensive crisis if combined with certain foods, cheese, wine Exception: Monoamine oxidase inhibitors such as selegiline (MAO-B
inhibitors) utilized for Parkinson’s Disease, unless used in doses greater
than 10 mg per day

Interactions
Should not be administered together or in rapid succession with other MAO inhibitors, tricyclic antidepressants, bupropion, SSRIs, buspirone, sympathomimetics, meperidine, triptans, and other medications that affect serotonin or norepinephrine Indications
Because of strong anticholinergic and sedating properties, TCAs and combination products are rarely the medication of choice in older Exception: Use of TCAs may be appropriate if:
o The resident is being treated for neurogenic pain (e.g., trigeminal neuralgia, peripheral neuropathy), based on documented evidence to support the diagnosis; and o The relative benefits outweigh the risks and other, safer agents including non-pharmacological interventions or alternative therapies are not indicated or have been considered, attempted, and failed Adverse Consequences
Compared to other categories of antidepressants, TCAs cause significant anticholinergic side effects and sedation (nortriptyline and desipramine are less problematic) Antidiabetic medications
Monitoring
Use of anti-diabetic medications should include monitoring (for example, periodic blood sugars) for effectiveness based on desired goals for that Medication
Issues and Concerns
individual and to identify complications of treatment such as hypoglycemia, impaired renal function NOTE: Continued or long-term need for sliding scale insulin for non-
emergency coverage may indicate inadequate blood sugar Residents on rosiglitazone should be monitored for visual deterioration due to new onset and/or worsening of macular edema in diabetic patients Adverse Consequences
tolazamide tolbutamide Metformin has been associated with the development of lactic acidosis (a potentially life threatening metabolic disorder), which is more likely to o serum creatinine 1.5 mg/dL in males or 1.4 mg/dL in females o abnormal creatinine clearance from any cause, including shock, acute myocardial infarction, or septicemia o age 80 years unless measurement of creatinine clearance o radiologic studies in which intravascular iodinated contrast o congestive heart failure requiring pharmacological management o acute or chronic metabolic acidosis with or without coma (including diabetic ketoacidosis) Rosiglitazone and pioglitazone have been associated with edema and weight gain; therefore, their use should be avoided in residents with Stage III or Stage IV heart failure Sulfonylureas can cause the syndrome of inappropriate antidiuretic hormone (SIADH) and result in hyponatremia Indications
Chlorpropamide and glyburide are not considered hypoglycemic agents of choice in older individuals because of the long half-life and/or duration of action and increased risk of hypoglycemia Adverse Consequences
May cause prolonged and serious hypoglycemia (with symptoms including tachycardia, palpitations, irritability, headache, hypothermia, visual disturbances, lethargy, confusion, seizures, and/or coma) Antifungals
Indications
Medication
Issues and Concerns
Should be used in lowest possible dose for shortest possible duration, especially in anyone receiving other medications known to interact with Interactions/Adverse Consequences
Interaction with warfarin can cause markedly elevated PT/INR, increasing bleeding risk Multiple potentially significant medication interactions may occur, for example: o These medications when administered concurrently may increase the effect or toxicity of phenytoin, theophylline, sulfonylureas (hypoglycemics) o Other medications such as rifampin and cimetidine may decrease May cause hepatotoxicity, headaches, GI distress Monitoring
Enhanced monitoring may be required to identify and minimize adverse consequences when these antifungals are given with the following: o phenytoin (serum phenytoin levels) o theophylline (serum theophylline levels) o sulfonylureas (fasting blood glucose) Antimanic medications
Indications
Should generally not be given to individuals with significant renal or cardiovascular disease, severe debilitation, dehydration, or sodium depletion Monitoring
Toxic levels are very close to therapeutic levels. Serum lithium concentration should be monitored periodically, and dosage adjusted accordingly Interactions/Adverse Consequences
May cause potentially dangerous sodium imbalance Adverse consequences may occur at relatively low serum concentrations (1–1.5 mEq/L) Serum lithium concentration levels can be affected by many other Medication
Issues and Concerns
medications, e.g., thiazide diurectics, ACE inhibitors, NSAIDs Antiparkinson medications
Adverse Consequences
May cause significant confusion, restlessness, delirium, dyskinesia, nausea, dizziness, hallucinations, agitation Transferase (COMT) Inhibitors, e.g., Increased risk of postural hypotension and falls, especially when given in conjunction with antihypertensive medications bromocriptine ropinerole pramipexole Various dopaminergic combinations, e.g., carbidopa/levodopa carbidopa/levodopa/ Antipsychotic medications
Indications
An antipsychotic medication should be used only for the following conditions/diagnoses as documented in the record and as meets the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Training Revision (DSM-IV TR) or loxapine mesoridazine o Mood disorders (e.g. mania, bipolar disorder, depression with psychotic features, and treatment refractory major depression) thiothixene trifluoperazine Medication
Issues and Concerns
Second generation (atypical) agents o Dementing illnesses with associated behavioral symptoms o Medical illnesses or delirium with manic or psychotic symptoms and/or treatment-related psychosis or mania (e.g., thyrotoxicosis, In addition, the use of an antipsychotic must meet the criteria and applicable, additional requirements listed below: o Since diagnoses alone do not warrant the use of antipsychotic medications, the clinical condition must also meet at least one of the following criteria (A or B or C): A. The symptoms are identified as being due to mania or psychosis (such as: auditory, visual, or other hallucinations; delusions (such as paranoia or grandiosity)); OR B. The behavioral symptoms present a danger to the resident or C. The symptoms are significant enough that the resident is experiencing one or more of the following: inconsolable or persistent distress (e.g., fear, continuously yelling, screaming, distress associated with end-of-life, or crying); a significant decline in function; and/or substantial difficulty receiving needed care (e.g., not eating resulting in weight loss, fear and not bathing leading to skin breakdown or infection). When an antipsychotic medication is being initiated or used to treat an acute psychiatric emergency (i.e., recent or abrupt onset or exacerbation of symptoms) related to one or more of the aforementioned conditions/diagnoses, that use must meet one of the above criteria and all of the following additional requirements: The acute treatment period is limited to seven days or less; and A clinician in conjunction with the interdisciplinary team must evaluate and document the situation within 7 days, to identify and address any contributing and underlying causes of the acute psychiatric condition and verify the continuing Medication
Issues and Concerns
need for antipsychotic medication; and Pertinent non-pharmacological interventions must be attempted, unless contraindicated, and documented following the resolution of the acute psychiatric situation. o Enduring Psychiatric Conditions Antipsychotic medications may be used to treat an enduring (i.e., non-acute, chronic, or prolonged) condition, if the clinical condition/diagnosis meets the criteria in #1 above. In addition, before initiating or increasing an antipsychotic medication for enduring conditions, the target behavior must be clearly and specifically identified and monitored objectively and qualitatively, in order to ensure the behavioral symptoms are: Not due to a medical condition or problem (e.g., headache or joint pain, fluid or electrolyte imbalance, pneumonia, hypoxia, unrecognized hearing or visual impairment) that can be expected to improve or resolve as the underlying condition is treated; and Persistent or likely to reoccur without continued treatment; and C. Not sufficiently relieved by non-pharmacological Not due to environmental stressors (e.g., alteration in the resident’s customary location or daily routine, unfamiliar care provider, hunger or thirst, excessive noise for that individual, inadequate or inappropriate staff response, physical barriers) that can be addressed to improve the psychotic symptoms or maintain safety; and Not due to psychological stressors (e.g., loneliness, taunting, abuse), or anxiety or fear stemming from misunderstanding related to his or her cognitive impairment (e.g., the mistaken belief that this is not where he/she lives or inability to find his or her clothes or glasses) that can be expected to improve or resolve as the situation is addressed After initiating or increasing the dose of an antipsychotic medication, the behavioral symptoms must be reevaluated periodically to determine the effectiveness of the antipsychotic and the potential for reducing or discontinuing the dose Exception: When antipsychotic medications are used for behavioral
disturbances related to Tourette’s disorder, or for non-psychiatric indications
such as movement disorders associated with Huntington’s disease, hiccups,
nausea and vomiting associated with cancer or cancer chemotherapy, or

Medication
Issues and Concerns
adjunctive therapy at end of life. Inadequate Indications
In many situations, antipsychotic medications are not indicated. They should not be used if the only indication is one or more of the following: 1) wandering; 2) poor self-care; 3) restlessness; 4) impaired memory; 5) mild anxiety; 6) insomnia; 7) unsociability; 8) inattention or indifference to surroundings; 9) fidgeting; 10) nervousness; 11) uncooperativeness; or 12) verbal expressions or behavior that are not due to the conditions listed above and do not represent a danger to the resident or others Dosage
Doses for acute indications (for example, delirium) may differ from those used for long-term treatment, but should be the lowest possible to achieve the desired therapeutic effects Daily Dose Thresholds for Antipsychotic Medications Used to Manage
Behavioral Symptoms Related to Dementing Illnesses
Generic Medication
Dosage
First Generation
Second Generation
* Not customarily used for the treatment of behavioral symptoms Katz, I.R. (2004). Optimizing atypical antipsychotic treatment strategies in Medication
Issues and Concerns
the elderly. Journal of the American Geriatrics Society, 52, pp. 272-277. Schneider, L.S. (2005). Risk of death with atypical antipsychotic drug treatment for dementia. Meta-analysis of randomized placebo controlled trials. Journal of the American Medical Association, 294, pp. 1934-1943. Saltz, B.L., Woerner, M.G., Robinson, D.G., & Kane, J.M. (2000). Side effects of antipsychotic drugs: Avoiding and minimizing their impact in elderly patients. Postgraduate Medicine, 107, pp. 169-178. Duration
If used to manage behavior, stabilize mood, or treat a psychiatric disorder, refer to Section V – Tapering of a Medication Dose/Gradual Dose Reduction (GDR) in the guidance Monitoring/Adverse Consequences
The facility assures that residents are being adequately monitored for When antipsychotics are used without monitoring they may be considered unnecessary medications because of inadequate monitoring. Anxiolytics
Medication
Issues and Concerns
Indications
Anxiolytic medications should only be used when: Benzodiazepines, Short-acting, e.g., o Use is for one of the following indications as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Training Revision (DSM-IV TR) or subsequent editions: estazolam lorazepam c. Symptomatic anxiety that occurs in residents with another Benzodiazepines, Long acting, e.g., d. Sleep disorders (See Sedatives/Hypnotics) e. Acute alcohol or benzodiazepine withdrawal f. Significant anxiety in response to a situational trigger g. Delirium, dementia, and other cognitive disorders with flurazepam quazepam Are quantitatively and objectively documented; Are persistent; Are not due to preventable or correctable reasons; Other antidepressants except bupropion Constitute clinically significant distress or dysfunction to the resident or represent a danger to the resident or others Evidence exists that other possible reasons for the individual’s distress Use results in maintenance or improvement in the individual’s mental, physical or psychosocial well-being (e.g., as reflected on the MDS or other assessment tools); or There are clinical situations that warrant the use of these medications a long-acting benzodiazepine is being used to withdraw a esident from a short-acting benzodiazepine used for neuromuscular syndromes (e.g., cerebral palsy, tardive dyskinesia, restless leg syndrome or seizure disorders) symptom relief in end of life situations Dosage
Dosage is less than, or equal to, the following listed total daily doses unless higher doses (as evidenced by the resident’s response and/or the resident’s clinical record) are necessary to maintain or improve the Medication
Issues and Concerns
Total Daily Dose Thresholds for Anxiolytic Medications
Generic Medication
Dosage
Duration
If used to manage behavior, stabilize mood, or treat a psychiatric disorder, refer to Section V – Tapering of a Medication Dose/Gradual Dose Reduction (GDR) in the guidance Adverse Consequences
May increase risk of confusion, sedation, and falls Indications
Not appropriate for use as an anxiolytic Indications
Highly addictive and sedating medication; not indicated for use in older individuals Dosage/Duration
Those who have used meprobamate for prolonged periods may be physically and/or psychologically dependent and may need to be withdrawn slowly Cardiovascular medications
(including
antihypertensives)

Adverse Consequences
Cardiac antiarrhythmics can have serious adverse effects in older Medication
Issues and Concerns
individuals, including impaired mental function, falls, appetite, behavior, and heart function Indications
Only approved indication for use is to treat documented life-threatening recurrent ventricular arrhythmias that do not respond to other antiarrhythmic agents or when alternative agents are not tolerated Common off-label use to treat atrial fibrillation; however, literature suggests that in many higher risk individuals, alternative approaches to managing atrial fibrillation (rate control and anticoagulation) are equally effective and less toxic* * Goldschlager, N., Epstein, A.E., Naccarelli, G., Olshansky, B., & Singh, B. (2000). Practical guidelines for clinicians who treat patients with amiodarone. Archives of Internal Medicine, 160, pp. 1741-1748. * Denus, S., Sanoski, C.A., Carlson, J., Opolski, G., & Spinler, S.A. (2005). Rate vs rhythm control in patients with atrial fibrillation: A meta-analysis. Archives of Internal Medicine, 165, pp. 258-262. Dosage/Monitoring
It is critical to carefully consider risks and benefits, to use the lowest possible dose for the shortest possible duration, to closely monitor individuals receiving long-term amiodarone, and to seek and identify adverse consequences Interactions/Adverse Consequences
May cause potentially fatal toxicities, including pulmonary toxicity (hypersensitivity pneumonitis or interstitial/alveolar pneumonitis) and hepatic injury. May cause hypothyroidism, exacerbate existing arrhythmia, and worsen heart failure. Can also impair mental function and behavior May cause clinically significant medication interactions; for example, with digoxin and warfarin Toxicity increases with higher doses and longer duration of use Adverse Consequences
Disopyramide has potent negative inotropic effects (decreased force of heart contraction), which may induce heart failure in older individuals, and is also strongly anticholinergic Dosage/Monitoring
Doses of individual antihypertensives may require modification in order to achieve desired effects while minimizing adverse consequences, Medication
Issues and Concerns
especially when multiple antihypertensives are prescribed simultaneously When discontinuing some antihypertensives (e.g., clonidine, beta blockers), gradual tapering may be required to avoid adverse consequences caused by abrupt cessation Interactions/Adverse Consequences
May cause dizziness, postural hypotension, fatigue, and an increased risk for falls Many other medications may interact with antihypertensives to potentiate their effect (e.g., levodopa, nitrates) Adverse Consequences
Doxazosin, prazosin, and terazosin can cause significant hypotension and syncope during the first few doses. Therefore, these medications should be initiated at bedtime with a slow titration of dose Prazosin can cause more CNS side effects and generally should be Monitoring
Monitoring of serum potassium is necessary especially in individuals receiving ACE inhibitors with potassium, or potassium sparing diuretics Adverse Consequences
captopril enalapril May cause angioedema (signs and symptoms of immediate hypersensitivity), chronic persistent nonproductive cough, or may worsen lisinopril ramipril Potential for life-threatening elevation of serum potassium concentrations when used in combination with potassium supplements, potassium-sparing diuretics including spironolactone candesartan eprosartan irbesartan losartan olmesartan valsartan Adverse Consequences
o Bradycardia, especially in individuals receiving other medications that affect cardiac conduction (e.g., calcium channel blockers); o Dizziness, fatigue; depression, bronchospasm (especially, but not Medication
Issues and Concerns
o Cardiac decompensation that may require adjusting dose in residents with acute heart failure May mask tachycardia associated with symptomatic hypoglycemia May have increased effect or may accumulate in individuals with hepatic Adverse consequences
May cause clinically significant constipation isradipine amlodipine Some agents may cause generalized aching, headache, muscle pain Short acting/immediate release nifedipine increases the risk of cardiac complications and should not be used Indications
Alternate treatments for hypertension are preferred Adverse Consequences
May cause bradycardia and excessive sedation; may exacerbate depression in older individuals Indications
Digoxin is indicated only for the following diagnoses: congestive heart failure, atrial fibrillation, paroxysmal supraventricular tachycardia, or atrial flutter Should be used with caution in individuals with impaired renal function Dosage
Daily doses in older individuals should ordinarily not exceed 0.125 mg/day except when used to control atrial arrhythmia and ventricular rate Monitoring
Must be used cautiously in individuals with renal failure or fluid and electrolyte imbalance, with close monitoring for adverse consequences and monitoring, as indicated, of both renal function and serum medication concentration (“digoxin level”) Adverse consequences may occur even with therapeutic serum concentration, especially in older individuals Interactions/Adverse Consequences
Medication
Issues and Concerns
May interact with many other medications, possibly resulting in digoxin toxicity or elevated serum concentrations of other medications May cause significant bradycardia, especially when used in individuals taking other medications affecting cardiac conduction Toxicity may cause fatigue, nausea, vomiting, anorexia, delirium, cardiac arrhythmia Adverse Consequences
May cause fluid and electrolyte imbalance (hypo/hypernatremia, hypo/hyperkalemia, dehydration, etc.), hypotension; may precipitate or exacerbate urinary incontinence, falls hydrochlorothiazide metolazone spironolactone torsemide triamterene Adverse Consequences
May cause headaches, dizziness, lightheadedness, faintness, or symptomatic orthostatic hypotension, especially when initially started or when taken in combination with antihypertensive medications Cholesterol lowering
medications
Monitoring
Inhibitors (“statins”), e.g., Liver function monitoring should be performed consistent with manufacturer’s recommendations, generally accepted as: o Prior to initiation of therapy, at 12 weeks following both initiation of therapy and any increase in dose, and periodically (e.g., Adverse Consequences
May impair liver function; liver function tests should be monitored as May cause muscle pain, myopathy, and rhabdomyolysis (breakdown of skeletal muscle) that can precipitate kidney failure especially in combination with other cholesterol lowering medications. Interactions
May reduce the absorption of other medications being taken concurrently. Other medications, including diuretics, beta-blockers, Medication
Issues and Concerns
corticosteroids, thyroid hormones, digoxin, valproic acid, NSAIDs, sulfonylureas, and warfarin should be administered one hour before or four hours after cholestyramine administration to avoid this interaction Adverse Consequences
May cause constipation, dyspepsia, nausea or vomiting, abdominal pain Monitoring
Fenofibrate and clofibrate require regular monitoring of liver tests as well as evaluating the complete blood count (CBC) prior to and after initiation Monitoring
Monitor glucose and liver function tests regularly Adverse Consequences
Interferes with glucose control and can aggravate diabetes Can exacerbate active gallbladder disease and gout Cognitive Enhancers
Indications
As the underlying disorder progresses into advanced stages, the continued use of the medication should be reevaluated Duration
If used to manage behavior, stabilize mood, or treat a psychiatric disorder, refer to Section V – Tapering of a Medication Dose/Gradual Dose Reduction (GDR) in the guidance Adverse Consequences
May affect cardiac conduction, especially in individuals who already have a cardiac conduction disorder or who are taking other medications that affect heart rate May cause insomnia, dizziness, nausea, vomiting, diarrhea, anorexia, and weight loss Should be used with caution in individuals with severe asthma or obstructive pulmonary disease Indications
As the underlying disorder progresses into advanced stages, the continued use of the medication should be reevaluated Medication
Issues and Concerns
Adverse Consequences
May cause restlessness, distress, dizziness, somnolence, hypertension, headache, hallucinations, or increased confusion Cough, cold, and allergy
medications
Indications/Duration
Should be used only for a limited duration (less than 14 days) unless there is documented evidence of enduring symptoms that cannot otherwise be alleviated and for which a cause cannot be identified and corrected Indications
H-1 blocker antihistamines have strong anticholinergic properties and are not considered medications of choice in older individuals If appropriate and effective, topical instead of oral diphenhydramine should be considered for allergic reactions involving the skin Dosage/Duration
meclizine promethazine Should be used in the smallest possible dosage for the shortest possible duration, especially in individuals who are susceptible to anticholinergic side effects or who are receiving other medications with anticholinergic properties (see Table II) Adverse Consequences
May cause excessive sedation, confusion, cognitive impairment, distress, dry mouth, constipation, urinary retention. These may lead to other adverse consequences such as falls Adverse Consequences
May cause dizziness, nervousness, insomnia, palpitations, urinary retention, elevated blood pressure Should be used with caution in individuals who have insomnia or hypertension Gastrointestinal
medications
Indications
Use with caution in individuals with Parkinson’s disease, narrow-angle Adverse Consequences
Medication
Issues and Concerns
May cause sedation, dizziness, drowsiness, postural hypotension, and neuroleptic malignant syndrome Promethazine and prochlorperazine may cause anticholinergic effects, such as constipation, dry mouth, blurred vision, urinary retention May cause extrapyramidal symptoms, including medication-induced parkinsonism, acute dystonic reactions, akathisia, and tardive dyskinesia May alter cardiac conduction or induce arrhythmias Adverse Consequences
Relatively ineffective antiemetic that can cause significant extrapyramidal side effects in addition to lethargy, sedation, confusion Exception: May be indicated in patients with Parkinson’s Disease
taking apomorphine

Indications
High-risk medication with limited clinical indication and limited demonstrated effectiveness* Not recommended for first-line treatment of gastroesophageal reflux disease, especially in older individuals When used for diabetic gastroparesis, or other indications, relative benefits and risks should be assessed and documented * Lata, P.F., Pigarelli, D.L. (2003). Chronic metoclopramide therapy for diabetic gastroparesis. Ann Pharmacotherapy, 37(1), pp. 122-126. Adverse Consequences
Especially in older individuals, metoclopramide may cause restlessness, drowsiness, insomnia, depression, distress, anorexia, and extrapyramidal symptoms, and may lower the seizure threshold May increase seizures in individuals with seizure disorders or exacerbate symptoms in individuals with Parkinson’s Disease Monitoring
It is essential to closely monitor at-risk individuals for adverse consequences Indications
Indication for use should be based on clinical symptoms and/or When used to treat or prevent NSAID-induced gastritis or esophagitis, Medication
Issues and Concerns
documentation should exist that other, less GI-toxic analgesics have been tried or were not indicated Duration
If used for greater than 12 weeks, clinical rationale for continued need and/or documentation should support an underlying chronic disease (e.g., GERD) or risk factors (e.g., chronic NSAID use) Dosage
Dosing of histamine-H2 antagonists should be based on renal function Interactions
Cimetidine has higher incidence of medication interactions and should be avoided in older individuals Adverse Consequences
May cause or exacerbate headache, nausea, vomiting, flatulence, dysphagia, abdominal pain, diarrhea, or other gastrointestinal symptoms H-2 antagonists may cause confusion PPIs may increase the risk of clostridium difficile colitis Glucocorticoids
Duration/Monitoring
Necessity for continued use should be documented, along with monitoring for and management of adverse consequences Adverse Consequences
hydrocortisone methylprednisolone Intermediate- or longer-term use may cause hyperglycemia, psychosis, edema, insomnia, hypertension, osteoporosis, mood lability, or Hematinics
Indications
Assessment of causes and categories of anemia should precede or accompany the use of this medication Monitoring
Use must be monitored according to specific manufacturer’s instructions including blood pressure, baseline serum iron or ferritin level, and frequent complete blood count (CBCs) to permit tapering or discontinuation when hemoglobin/hematocrit reaches or exceeds target ranges Adverse Consequences
Medication
Issues and Concerns
Excessive dose or duration can lead to polycythemia, dangerous thrombotic events including myocardial infarction and stroke Indications
Iron therapy is not indicated in anemia of chronic disease when iron stores and transferrin levels are normal or elevated Dosage/Duration
Clinical rationale should be documented for long-term use (greater than two months) or administration more than once daily for greater than a week, because of side effects and the risk of iron accumulation in tissues Monitoring
Baseline serum iron or ferritin level and periodic CBC or hematocrit/ hemoglobin Adverse Consequences
May cause constipation, dyspepsia Can accumulate in tissues and cause multiple complications if given chronically despite normal or high iron stores Laxatives
Adverse Consequences
May cause flatulence, bloating, abdominal pain hyperosmolar agents, saline laxatives, stimulant Bulk forming laxatives and stool softeners may cause accumulation of stool and possible bowel obstruction, if not used with adequate fluids or in individuals with other causes of impaired bowel motility Muscle relaxants
Indications/Adverse Consequences
Most are poorly tolerated by older individuals due to anticholinergic side effects (see Table II), sedation, or weakness Long-term use in individuals with complications due to multiple sclerosis, spinal cord injuries, cerebral palsy, and other select conditions may be indicated, although close monitoring is still warranted Abrupt cessation of some muscle relaxants may cause or predispose individuals to seizures or hallucinations Exception: Periodic use (once every three months) for a short duration (not
more than seven days) may be appropriate, when other interventions or Medication
Issues and Concerns
alternative medications are not effective or not indicated Orexigenics (appetite
stimulants)
Indications
Use should be reserved for situations where assessment and management of underlying correctable causes of anorexia and weight loss is not feasible or successful, and after evaluating potential benefits/risks Monitoring
Appetite and weight should be monitored at least monthly and agent should be discontinued if there is no improvement. Adverse Consequences
Megesterol acetate may cause fluid retention, adrenal suppression, and symptoms of adrenal insufficiency Oxandrolone may cause virilization of females and feminization of males, excessive sexual stimulation, and fluid retention Dronabinol may cause tachycardia, orthostatic hypotension, dizziness, dysphoria, and impaired cognition, which may lead to falls Osteoporosis medications
Dosage
These medications must be taken according to very specific directions, including time of day, position, and timing relative to other medications Monitoring
Individuals receiving these medications should be monitored closely for gastrointestinal complications, including esophageal or gastric erosion Adverse Consequences
Potential to cause gastrointestinal symptoms including dysphagia, esophagitis, gastritis, or esophageal and gastric ulcers, especially when given to individuals who are also taking oral corticosteroids, aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs) Platelet inhibitors
Interactions/Adverse Consequences
May cause thrombocytopenia and increase risk of bleeding Common side effects include headache, dizziness, and vomiting Medication
Issues and Concerns
aspirin (as fixed-dose See discussion at NSAIDs regarding aspirin combination) Concurrent use with warfarin or NSAIDs may increase risk of bleeding aspirin clopidogrel Indication
Use may be appropriate in individuals who have had a previous stroke or have evidence of stroke precursors (i.e., transient ischemic attacks (TIAs)), and who cannot tolerate aspirin or another platelet inhibitor Adverse Consequences
Associated with more severe side effects and considerably more toxic than other platelet inhibitors; use should be avoided in older individuals Most serious side effects involve the hematologic system, including potentially life-threatening neutropenia May also cause nausea, vomiting, and diarrhea Respiratory medications
Interactions
Potentially significant interactions with many other medications may occur, especially various antibiotics, seizure medications, and cardiac medications Monitoring/Adverse Consequences
There should be monitoring for signs and symptoms of toxicity, such as arrhythmia, seizure, GI upset, diarrhea, nausea/vomiting, abdominal pain, nervousness, headache, insomnia, distress, dizziness, muscle cramp, tremor Periodic monitoring of serum concentrations helps identify or verify toxicity Adverse Consequences
Inhaled anticholinergics can cause xerostomia (dry mouth) Inhaled beta agonists can cause restlessness, increased heart rate, and Inhaled steroids can cause throat irritation and oral candidiasis, especially if the mouth is not rinsed after administration albuterol formoterol pirbuterol acetate Medication
Issues and Concerns
beclomethasone budesonide flunisolide fluticasone triamcinolone cromolyn nedocromil sodium Sedatives/Hypnotics (sleep
medications)
Indications
Most cases of insomnia are associated with underlying conditions (secondary or co-morbid insomnia) such as psychiatric disorders (e.g., depression), cardiopulmonary disorders (e.g., COPD, CHF), urinary frequency, pain, obstructive sleep apnea, and restless leg syndrome. Insomnia may be further described by the duration of symptoms Before initiating medications to treat insomnia, other factors potentially causing insomnia should be evaluated, including, for example: o environment, such as excessive heat, cold, or noise; lighting o facility routines that may not accommodate residents’ individual needs (e.g., time for sleep, awakening, toileting, medication treatments) o provision of care in a manner that disrupts sleep o caffeine or medications known to disrupt sleep Melatonin receptor agonists, e.g., o underlying conditions (secondary or co-morbid insomnia) such as psychiatric disorders (e.g., depression), cardiopulmonary disorders (e.g., COPD, CHF), urinary frequency, pain, obstructive sleep apnea, and restless leg syndrome It is expected that interventions (such as sleep hygiene approaches, individualizing the sleep and wake times to accommodate the person’s wishes and prior customary routine, and maximizing treatment of any underlying conditions) are implemented to address the causative Medication
Issues and Concerns
These guidelines apply to any medication that is being used to treat insomnia. Initiation of medications to induce or maintain sleep should be preceded or accompanied by other interventions to try to improve sleep. All sleep medications should be used in accordance with approved product labeling; for example, timing and frequency of administration relative to anticipated waking time The use of sedating medications for individuals with diagnosed sleep apnea requires careful assessment, documented clinical rationale, and close monitoring Exceptions:
Use of a single dose sedative for dental or medical procedures During initiation of treatment for depression, pain or other comorbid condition(s), short-term use of a sleep medication may be necessary until symptoms improve or the underlying aggravating factor can be identified and/or effectively treated Dosage
Daily Dose Thresholds For Sedative-Hypnotic Medications
Generic Medication
Oral Dosage
* These medications are not considered medications of choice for the management of insomnia, especially in older individuals. www.ahrq.gov/downloads/pub/evidence/pdf/insomnia/insomnia.pdf Medication
Issues and Concerns
Duration
If used to induce sleep or treat a sleep disorder, refer to Section V – Tapering of a Medication Dose/Gradual Dose Reduction (GDR) in the guidance NOTE: Refers to barbiturates used to induce sleep or treat anxiety disorder
Indications
Barbiturates should not be initiated in any dose for any individuals to treat anxiety or insomnia; as they are highly addictive and cause numerous adverse effects, especially in older individuals Exception: These guidelines do not apply to the use of
phenobarbital to treat seizure disorders (see Anticonvulsant section) Interactions/Adverse Consequences
May increase the metabolism of many medications (e.g., anticonvulants, antipsychotics), which may lead to decreased effectiveness and subsequent worsening of symptoms or decreased control of underlying illness May cause hypotension, dizziness, lightheadedness, “hangover” effect, drowsiness, confusion, mental depression, unusual excitement, nervousness, headache, insomnia, nightmares, and hallucinations Thyroid medications
Interactions
Many clinically significant medication interactions have been identified; therefore, re-evaluation of medication doses is indicated Dosage
Initiation of thyroid supplementation should occur at low doses and be increased gradually to avoid precipitating cardiac failure or adrenal crisis Monitoring
Assessment of thyroid function (e.g., TSH, serum T4 or T3) should occur prior to initiation and periodically thereafter, including when new signs and symptoms of hypo- or hyperthyroidism are present Urinary incontinence
medications
Indications
Medication
Issues and Concerns
Before or soon after initiating medication(s) to manage urinary incontinence, assessment of underlying causes and identification of the type/category of urinary incontinence needs to be documented These medications have specific, limited indications based on the cause and type/category of incontinence darifenecin oxybutynin Monitoring
Ongoing assessments of the effects of the medication on the individual’s urinary incontinence as well as lower urinary tract symptoms should be Adverse Consequences
Anticholinergics and TCAs may cause anticholinergic effects (see Table Estrogen Replacement Agents: oral agents may cause systemic side effects and increased risks (e.g., deep venous thrombosis, breast cancer); therefore, topical agents may be preferred Bethanechol may cause hypotension, increased sweating and salivation, headache, cramps, diarrhea, nausea and vomiting, and worsening of asthma antagonists (see antihypertensives)

Source: http://www.99309.info/files/CMS_Unnecessary_Medications-Table_1.pdf

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