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Safe medication practices
Drug Consult Safe Medication Practices: Administering Medications to Elders Who Have Difficulty Swallowing Carol A. Miller, RN-C, MSN
A
n often-overlooked aspect of safe medication practices is the correct administration of medications to ensure the effectiveness of the active ingredients. For some medications, effectiveness is significantly influenced by whether the medication is chewed, crushed, or swallowed intact. This issue is particularly relevant to gerontological nurses because many older adults have difficulty swallowing. Thus, nurses often have to identify creative ways to facilitate the administration of medications, especially those that are large. A medication error is defined as a “preventable mistake in prescribing or delivering medication to a patient, that is, an improper use of medicine or one that causes harm to a patient.”1 When a person receives a medication in a form that is not the prescribed form, there is increased risk of a medication error. Thus, an important responsibility of gerontological nurses is identifying appropriate methods of delivering medica-
Medication Type and Reason for Not Crushing
tions, especially when their patients have difficulty swallowing. This column will review some of the medication errors that are likely to occur and discuss tips for preventing these errors. Some examples of potential medication errors that gerontological nurses are likely to address in their work with older adults are: • Difficulty swallowing pills or capsules • Holding medications in the mouth (“cheeking”) for long periods after administration • Chewing medications or capsules before swallowing • Crushing medications whose active ingredients are altered by the change in form • Crushing medications that are light-sensitive and then not administering the medication immediately These practices to do not always alter the action of medications or affect the active ingredients, but when they
Examples
Enteric-coated: designed to pass through the stomach intact for any of the following reasons: ■ to delay onset of action ■ to prevent stomach irritation ■ to prevent destruction of the drug by stomach acids
Many drugs come in enteric-coated forms (usually designated with EC) – the same drugs are often available in other forms (eg, oral suspension). Some capsules that are EC can be opened and mixed with soft food for administration as long as they are are not crushed or chewed.
Modified (extended)-release: designed to allow the active ingredients to be released over a prolonged period
Tablets or capsules commonly designated with a suffix (eg, CD, CR, DM, LA, SA, SR, XL, XR, Sequels) Capsules with mixed-release pellets that dissolve at different times (often contain multicolored beads) Multiple-layer tablets that release the active ingredients as each layer dissolves (eg, Tavist-D, Traminic TR)
Sublingual or buccal: designed to dissolve quickly in the mouth
Small tablets often designated with SL (eg, isosorbide sublingual, nitrostat)
Effervescent tablets: designed to be dissolved in a designated amount of liquid
K-lyte, Psyllium effervescent powder.
Tablets or other forms that have a particularly bitter taste
Ceftin, Cipro, Colace capsule, Desyrel, Equanil, Geocillin, Motrin, Panmycin, Phenergan, ProBanthine, Wygesic
Medications that can irritate the mucous membrane
Feldene capsule, Fosamax, valproic acid slow-release capsule
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Geriatric Nursing
Volume 24
Number 6
do interfere with the medication, a medication error has occurred. The sidebar summarizes examples of medications that are likely to be affected by crushing: when a patient has difficulty swallowing any of these medications intact, then nurses must identify and use an alternative method of administering the medication. A good first-step approach to addressing medicationswallowing problems is to check with the pharmacist about the availability of a liquid form of the medication and request that the prescribing practitioner order liquid doses if they are available. Medications are increasingly becoming available in liquid forms (eg, as elixirs, suspensions, or syrups), and nurses need to ask pharmacists about new forms of medications that have only been available previously in pill or capsule form. For example, an oral solution form of the antidepressant escitalopram became available in 2003. When switching from solid to liquid doses, it is important to know the equivalency of the two forms, because they are not always the same. It is always advisable to check dose equivalency with a pharmacist or written reference. Also, if a solid-dose medication had been prescribed in an extended-release form and is changed to a liquid form, then the frequency of dosing may need to be adjusted. Another consideration with regard to liquid medications is that “elixir” forms typically include alcohol (eg, digoxin elixir is 10% alcohol). Oral suspensions also may include sorbitol as an additive, which acts as a laxative and can cause diarrhea if the daily doses is more than 7.5 g. In addition to traditional liquiddose forms, other forms of oral medications that are increasingly becoming available include buccal or sublingual forms. Another recently developed method for oral administration of medications is orally disintegrating tablets. For example, in 2003, an orally disintegrating tablet of clonazepam became available in strengths ranging from 0.125 mg to 2 mg. In addition to newer oral methods of administration, medications are increasingly becoming available in a variety of nonoral routes (eg, dermal, rectal, intranasal). For example, oxybutynin, a medication commonly used for overactive bladder with symptoms of urge urinary incontinence, has recently become available as a transdermal patch that delivers the medication on a continuous basis for several days. Vaginal rings for delivering estrogen over a 3-month period also are becoming more widely used. In 2003, flu vaccinations are available for intranasal administration for the first time. Another approach to addressing problems with medication administration is to see whether the length of time between doses can be lengthened, even beyond the once-daily extended-release formulations. For example, once-weekly dosing regimens have been approved for some antidepressants and for biphosphonate medications such as alendronate (Actonel) and residronate (Fosamax). In summary, gerontological nurses frequently address medication administration problems that are related to November—December 2003
swallowing difficulties. Increasingly, a variety of oral and nonoral methods of administering medications are available, as are a range of dosing regimens to minimize the frequency of medication administration. Pharmacists are excellent sources of information about the forms of medications (including newly approved forms) that are equivalent and simple to administer. If equivalent doses are not available in a form that is appropriate for the older person’s condition, then the pharmacist may be able to work with the prescribing practitioner to identify another medication that may be equally effective and more acceptable to the person who is taking the medication. Gerontological nurses can work closely with pharmacists and prescribing practitioners to identify simple and effective methods for administering medications and avoiding medication errors. REFERENCE 1. Lassetter JH, Warnick ML. Medical errors, drug-related problems, and medication errors: a literature review of quality of care and cost issues. J Nurs Care Qual 2003;18:175-83.
CAROL A. MILLER, RN-C, MSN, is a gerontologic nurse specialist with Care & Counseling, Miller/Wetzler Associates in Cleveland, Ohio. She invites questions for this column at [email protected]. © 2003 Mosby, Inc. All rights reserved. 0197-4572/2003 $30.00 + 0 doi:10.1016/j.gerinurse.2003.10.012
379
A
n often-overlooked aspect of safe medication practices is the correct administration of medications to ensure the effectiveness of the active ingredients. For some medications, effectiveness is significantly influenced by whether the medication is chewed, crushed, or swallowed intact. This issue is particularly relevant to gerontological nurses because many older adults have difficulty swallowing. Thus, nurses often have to identify creative ways to facilitate the administration of medications, especially those that are large. A medication error is defined as a “preventable mistake in prescribing or delivering medication to a patient, that is, an improper use of medicine or one that causes harm to a patient.”1 When a person receives a medication in a form that is not the prescribed form, there is increased risk of a medication error. Thus, an important responsibility of gerontological nurses is identifying appropriate methods of delivering medica-
Medication Type and Reason for Not Crushing
tions, especially when their patients have difficulty swallowing. This column will review some of the medication errors that are likely to occur and discuss tips for preventing these errors. Some examples of potential medication errors that gerontological nurses are likely to address in their work with older adults are: • Difficulty swallowing pills or capsules • Holding medications in the mouth (“cheeking”) for long periods after administration • Chewing medications or capsules before swallowing • Crushing medications whose active ingredients are altered by the change in form • Crushing medications that are light-sensitive and then not administering the medication immediately These practices to do not always alter the action of medications or affect the active ingredients, but when they
Examples
Enteric-coated: designed to pass through the stomach intact for any of the following reasons: ■ to delay onset of action ■ to prevent stomach irritation ■ to prevent destruction of the drug by stomach acids
Many drugs come in enteric-coated forms (usually designated with EC) – the same drugs are often available in other forms (eg, oral suspension). Some capsules that are EC can be opened and mixed with soft food for administration as long as they are are not crushed or chewed.
Modified (extended)-release: designed to allow the active ingredients to be released over a prolonged period
Tablets or capsules commonly designated with a suffix (eg, CD, CR, DM, LA, SA, SR, XL, XR, Sequels) Capsules with mixed-release pellets that dissolve at different times (often contain multicolored beads) Multiple-layer tablets that release the active ingredients as each layer dissolves (eg, Tavist-D, Traminic TR)
Sublingual or buccal: designed to dissolve quickly in the mouth
Small tablets often designated with SL (eg, isosorbide sublingual, nitrostat)
Effervescent tablets: designed to be dissolved in a designated amount of liquid
K-lyte, Psyllium effervescent powder.
Tablets or other forms that have a particularly bitter taste
Ceftin, Cipro, Colace capsule, Desyrel, Equanil, Geocillin, Motrin, Panmycin, Phenergan, ProBanthine, Wygesic
Medications that can irritate the mucous membrane
Feldene capsule, Fosamax, valproic acid slow-release capsule
378
Geriatric Nursing
Volume 24
Number 6
do interfere with the medication, a medication error has occurred. The sidebar summarizes examples of medications that are likely to be affected by crushing: when a patient has difficulty swallowing any of these medications intact, then nurses must identify and use an alternative method of administering the medication. A good first-step approach to addressing medicationswallowing problems is to check with the pharmacist about the availability of a liquid form of the medication and request that the prescribing practitioner order liquid doses if they are available. Medications are increasingly becoming available in liquid forms (eg, as elixirs, suspensions, or syrups), and nurses need to ask pharmacists about new forms of medications that have only been available previously in pill or capsule form. For example, an oral solution form of the antidepressant escitalopram became available in 2003. When switching from solid to liquid doses, it is important to know the equivalency of the two forms, because they are not always the same. It is always advisable to check dose equivalency with a pharmacist or written reference. Also, if a solid-dose medication had been prescribed in an extended-release form and is changed to a liquid form, then the frequency of dosing may need to be adjusted. Another consideration with regard to liquid medications is that “elixir” forms typically include alcohol (eg, digoxin elixir is 10% alcohol). Oral suspensions also may include sorbitol as an additive, which acts as a laxative and can cause diarrhea if the daily doses is more than 7.5 g. In addition to traditional liquiddose forms, other forms of oral medications that are increasingly becoming available include buccal or sublingual forms. Another recently developed method for oral administration of medications is orally disintegrating tablets. For example, in 2003, an orally disintegrating tablet of clonazepam became available in strengths ranging from 0.125 mg to 2 mg. In addition to newer oral methods of administration, medications are increasingly becoming available in a variety of nonoral routes (eg, dermal, rectal, intranasal). For example, oxybutynin, a medication commonly used for overactive bladder with symptoms of urge urinary incontinence, has recently become available as a transdermal patch that delivers the medication on a continuous basis for several days. Vaginal rings for delivering estrogen over a 3-month period also are becoming more widely used. In 2003, flu vaccinations are available for intranasal administration for the first time. Another approach to addressing problems with medication administration is to see whether the length of time between doses can be lengthened, even beyond the once-daily extended-release formulations. For example, once-weekly dosing regimens have been approved for some antidepressants and for biphosphonate medications such as alendronate (Actonel) and residronate (Fosamax). In summary, gerontological nurses frequently address medication administration problems that are related to November—December 2003
swallowing difficulties. Increasingly, a variety of oral and nonoral methods of administering medications are available, as are a range of dosing regimens to minimize the frequency of medication administration. Pharmacists are excellent sources of information about the forms of medications (including newly approved forms) that are equivalent and simple to administer. If equivalent doses are not available in a form that is appropriate for the older person’s condition, then the pharmacist may be able to work with the prescribing practitioner to identify another medication that may be equally effective and more acceptable to the person who is taking the medication. Gerontological nurses can work closely with pharmacists and prescribing practitioners to identify simple and effective methods for administering medications and avoiding medication errors. REFERENCE 1. Lassetter JH, Warnick ML. Medical errors, drug-related problems, and medication errors: a literature review of quality of care and cost issues. J Nurs Care Qual 2003;18:175-83.
CAROL A. MILLER, RN-C, MSN, is a gerontologic nurse specialist with Care & Counseling, Miller/Wetzler Associates in Cleveland, Ohio. She invites questions for this column at [email protected]. © 2003 Mosby, Inc. All rights reserved. 0197-4572/2003 $30.00 + 0 doi:10.1016/j.gerinurse.2003.10.012
379