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Landon Center on Aging
Landon Center on Aging  :  Geriatric Education & Training

Geriatric Skills Fair

Station 3

Preceptor Guide

Brown Bag Assessment

Printable Versions of Materials needed to create station:

Guide for Preceptors:

NOTE: the information posted just below is identical to that in the printable version of the preceptor guide above.

This station takes the students through a brown bag medication review. Multiple prescription bottles were collected and labels made to indicate the instructions below; one was expired, and there are several different prescribers and pharmacies utilized. The students are given the laminated card with the case history and general conceptual ideas of how to evaluate a medication list.

The brown bag contents include bottles marked:

  • Stelazine® 2 mg qhs
  • Percocet® 5/325 mg, 1-2 tabs po q4 hrs prn
  • Propanolol 10 mg po QD
  • Milk of Magnesia ® 5-10 cc po QD prn constipation
  • Aspirin 81 mg po QD
  • Lipitor® 10 mg po QD
  • Tylenol PM ® one tab at night
  • Omega 3 fatty acids, one tab TID
  • Metoprolol 50 mg po BID
  • Prilosec® 20 mg po QD
  • Imipramine 25 mg po qhs
  • Valium® 2 mg po qhs
  • Darvocet® one tab po QID prn
  • Reglan® 20 mg po QID before meals
  • Fish oil 2 tabs QID
  • Senokot-S® two tabs po QD
  • Calcium 600 mg one tab po BID
  • Over the counter famotidine 20 mg tab po QD - the label is marked with an expired date

10 Steps to Reducing Polypharmacy

  1. Have patients "brown bag" all medications at each office visit, and keep an accurate record of all medications, including over-the-counter medications and herbs.
  2. Get into the habit of identifying all drugs by generic name and drug class,
  3. Make certain the drug being prescribed has a clinical indication.
  4. Know the side-effect profile of the drugs being prescribed.
  5. Understand how pharmacokinetics and pharmacodynamics of aging increase the risk of adverse drug events.
  6. Stop any drug without known benefit.
  7. Stop any drug without a clinical indication.
  8. Attempt to substitute a less toxic drug.
  9. Be aware of the prescribing cascade (treating an adverse drug reaction as an illness with another drug).
  10. As much as possible, use the motto, "one disease, one drug, once-a-day."

Information from Carlson JE. Perils of poly pharmacy: 10 steps to prudent prescribing. Geriatrics 1996;51;26-30,35.
http://www.aafp.org/afp/20021115/1917.html - November 15, 2002

They are asked to suggest 5 changes to the list. Possibilities include but are not limited to:

  • Safety
    • Several come from different pharmacies on the labeling, and this could present a risk
    • One is expired (OTC famotidine)
    • One does not have dose on it, which could lead to error at refill (Darvocet)

  • Duplication
    • Several compounds containing acetaminophen
    • Two beta blockers
    • Multiple pain medications
    • Two fish oil compounds
    • Two acid controlling medications
    • Two laxatives

  • Indication (? If present)
    • Why the pain medications?
    • Why the stelazine, imipramine, valium?
    • Why the acid reducers?

  • Serious side effect profile
    • Stelazine, imipramine, Tylenol PM ® -anti-cholinergic, patient is a fall risk and complains of cognitive impairment
    • Valium - long acting benzodiazepine, see above
    • Darvocet - possible exacerbation of cognitive impairment
    • Reglan - high dose and renally cleared in this patient who likely does not have normal renal function, potential for extrapyramidal symptoms and confusion in this patient
    • Beta blockers (duplicate) - bradycardia

There is a didactic session focused on the tenet of polypharmacy later in the rotation. However, if that doesn't occur at your location, you may wish to take this opportunity to discuss further some of the physiologic changes with aging and how they may relate to side effects.

  • Dosing schedule
    This is a patient who is feeling confused and now has poor eyesight, with a dosing regimen that includes QD, Q hs, BID, TID, QID before meals, and prn, which is likely to be problematic.

  • Cost
    This is an opportunity to discuss concerns about the cost of medications for patients. Students can identify certain medications that may be available on widespread "$4 lists" or generically; they may also identify that the over the counter medication use can contribute significantly to medication costs. This list has several older medications that are less expensive but more problematic in terms of side effects, so cheaper is not always better in this situation but requires thoughtful consideration and discussion. Several medications can be stopped, thus decreasing the cost.

  • Prescribing cascade
    • Students may be able to identify that her bloating could be caused by the fish oil supplements. Did someone not recognize that and added the Reglan?
    • The reglan could cause a tremor - could that be why the Propanolol was added?
    • Did the medications cause delirium, and was that why the anti-psychotic was added?
    • Multiple meds can cause constipation - perhaps that's why MOM and Senna-S were added.

In reality, the three main psychotropic meds listed here have been in place for many years per the patient, for anxiety. This would be a good time to discuss why this kind of review is so important - so that things that are no longer needed or are harmful can be scrutinized and stopped.

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