Medication Reconcilation

Medication reconciliation is a collaborative effort between patients, care-givers and prescribers that lists all medications (prescription and over the counter) and supplements such as vitamins. The list should include both the trade and generic names of medications as well as the doses and the time of day taken. Drug allergies should be noted. This reconciliation will guide prescribing decisions and will help prevent medication errors that could harm patients.

Older patients are at higher risk for medication errors since they may have several medical problems for which they see several physicians. The same medication may be ordered twice: once by the trade name and again as the generic. The medical reconciliation should also ensure that the patient is actually taking the medication (and if not, why not).

Adverse medication events include physical harm, mental harm or loss of function. The clinician should review the medication list at each visit and adjust medications as needed. All effort should be made to avoid high-risk drugs, unnecessary drugs, and drugs causing side effects. Computer programs are helpful in detecting potential drug-drug interactions and provide dosing guidelines if there is impaired kidney or liver function. The e-prescribing programs as also helpful but can be too inclusive: a potential drug-drug alert will pop up for an antibiotic that was used once three years prior.

Patients must take an active role in keeping their medication lists up to date. When in doubt, brown bag every medication bottle and bring it along to every doctor’s visit. Keep a list of medications in your wallet along with the list of allergies.

One study found that medication errors were responsible for 1.4 percent of hospital admissions, of which 28 percent were preventable. The FDA is developing systems to minimize errors. An excellent brochure (PDF) has recommendations and safety tips for patients. 

Blood Pressure

New goals for the treatment of high blood pressure were recently released. The standards were loosened a bit for patients older than 60, mainly because the panel that issued the recommendations was concerned about low blood pressure.

Our blood pressure is not static; it changes according to the body’s needs. In order not to pass out when you get out of bed, your heart needs to pump enough blood upstairs to perfuse your brain. If you need to suddenly run to catch a train, your body needs to get enough blood to your large leg muscles to get you going. On the other hand, one of the goals of blood pressure control can be to blunt this response since suddenly moving a large volume of blood can put a big strain on the heart.

The metabolism of blood pressure medications also changes with time. As we mature, we can expect kidney function to decrease. Therefore, medications that are metabolized by the renal system may appear to be ‘stronger’ to the body, requiring a change in dosage.  Tighter control of blood pressure may be important to prevent consequences of other diseases such as diabetes.

Blood pressure that is too low for the patient can have a dreaded consequence: a fall with a head injury. Breaking a hip or an arm is no fun either. Since diuretics are usually a part of blood pressure regimens, blood tests are needed to monitor electrolytes.

I like to see my hypertensive patients every three months for a blood pressure check. Depending on the individual patient, blood tests may be drawn at these visits. It’s a chance to monitor the patient’s weight and also review the potential side-effects of medication. Of course – the primary reason for the visit is to make sure that the blood pressure is in control.

More information:

A nice summary from Harvard Health Publications.

The full set of guidelines.

Unraveling

New year resolutions are always about change – doing or not doing something. I prefer to reframe the argument: make a resolution to strip away the layers to reveal your true self.  Don’t resolve to lose weight but instead figure out how to be the healthy sized person that you really are. Don’t resolve to quit smoking but rather take steps to become the non-smoker that you once were.

Every healthy full term baby starts out at a good weight. No one becomes fat overnight. What steps along the way led to weight gain? Can those behaviors be slowly unraveled? I suggest approaching the problem in reverse chronologic order. The most recent bad habit will be easier to change than one that dates back to childhood.

Starbucks introduced the Frappuccino in 1995 and the Frappuccino juice blend in 2006. McDonalds started serving fruit smoothies in 2011. Giving up a grande mocha Frappuccino will save 460 calories daily and will lead to a 3 lb weight loss in one month. And really, who needs a fruit smoothie (330 calories) when water is a far better thirst quencher?

Unravel the new unhealthy habits first. Once you have achieved that success, tackle an older one. If you think about it, it’s not your favorite food that Mom made that is getting you into trouble.

10-10-10

Keeping healthy is not easy – every minute there is another choice. What should I have for lunch? What time should I go to bed? Is it OK to have a second glass of wine? Can I skip the flu shot this year? In the abstract, the answers are clear but it’s not so easy to make a quick decision at the time. Suzy Welch has devised a way to evaluate these decisions: the rule of 10-10-10.

What are the consequences of my decision in 10 minutes? In 10 months? And in 10 years?

A very simple example: should I have a piece of cake for dessert? Let’s say that it’s your child’s birthday party and there is a Carvel ice cream cake. You have just served fifteen people and there is melted ice cream everywhere. Most of the kids didn’t finish their serving and you are busy wiping hands to minimize the mess. Should you have a piece? You feel you need a reward and ten minutes later you justify the treat. Who doesn’t like ice cream? In 10 months, you still haven’t lost the last few pounds. And in 10 years? Who remembers an individual Carvel cake? There are plenty more in the store, and you have been to dozens of birthday parties.

Another birthday party, your own. You and your special someone have been planning a trip to a destination restaurant for months. The dinner was exquisite. When the waiter hands you the dessert menu you defer, still thinking of those last few pounds. So what if the pastry chef is world-renowned. Ten minutes later you feel virtuous. Ten months later you are still thinking about your missed opportunity. Ten years later you realize that how silly you were.

In the first instance, skipping the cake would have been the right decision. In the second case, skipping the cake was wrong, wrong, wrong.

Concussions

Approximately 1.74 million people sustain a traumatic brain injury (TBI) in the United States every year. The incidence may be higher since so many injuries are unreported. Most TBI in adults are due to motor vehicle accidents and falls. Falls are more common in the elderly and motor vehicle accidents are the greatest cause in the young. Recreational accidents and sports injuries are also important causes in the younger population. In football, 10% of college players and 20% of high school athletes sustain brain injuries each year.

The hallmark symptoms of concussion are confusion and amnesia, sometimes with, but often without, preceding loss of consciousness. The amnesia almost always involves loss of memory for the traumatic event but frequently includes loss of recall for events immediately before (retrograde amnesia) and after (anterograde amnesia) the head trauma. TBI may cause a seizure disorder. Slow bleeding around the brain may lead to a space occupying blood clot.

Mild TBI and concussion may be unrecognized by both the injured and non-medically-trained observers, particularly if there is no loss of consciousness. There are standardized assessment tools to assess cognitive function. Imaging, such as CT or MRI, may be used to determine injury.

At the least, a responsible person must carefully observe a patient with TBI for 24 hours. More careful observation is possible in the hospital. The prognosis for complete recovery is good for an appropriately managed concussion. Nonetheless, there are a variety of short and long-term sequelae that have important implications. Close medical follow-up is essential.

For more information from The Mayo Clinic

A sample post-concusion worksheet