week 13

Polypharmacy — definition?

Taking 5+ medications; also defined by appropriateness of medications, not just number.

4 negative outcomes of polypharmacy?

Adverse drug reactions, nonadherence, decreased functional status, increased costs.

What is a prescribing cascade?

Adverse drug event misinterpreted as a new condition → unnecessary new medication prescribed → more side effects.

Prescribing cascade — who's most at risk?

Older adults with chronic comorbidities and multiple prescribers/specialists.

5 risks of polypharmacy?

Adverse drug events, drug-drug interactions, impaired mobility/fall risk, poor adherence, decreased quality of life.

Why are older adults more prone to medication side effects?

Altered drug responses due to aging physiology (renal/hepatic changes), higher frailty, more comorbidities.

3 prescribing guideline tools used in pharmacy?

Beers Criteria 2023 (inappropriate meds), START Criteria 2023 (underused treatments), STOPP Criteria 2023 (potentially inappropriate meds).

Beers Criteria — originally targeted to what setting?

Long-term care; now widely used to identify potentially inappropriate medications for older adults.

6 pharmacist roles in polypharmacy?

Accurate medication history, medication reconciliation, evaluate appropriateness, bridge knowledge gap, deprescribe (with providers), patient education.

Anticholinergic effects — 5 key ones to know?

Dry mouth, delirium/memory impairment, constipation, urinary difficulty, increased heart rate. Also: dilated pupils, dry skin, increased body temp.

5 examples of strong anticholinergic medications?

Diphenhydramine (Benadryl), oxybutynin, amitriptyline, meclizine, cyclobenzaprine (muscle relaxant).

Why are anticholinergics especially risky in older adults?

Increased blood-brain barrier permeability with aging → higher risk of delirium and cognitive effects.

What drug classes increase fall risk in older adults?

Anticholinergics, sedative/hypnotics, opioids, antihypertensives, antidepressants, antipsychotics.

Polypharmacy and falls — relationship?

Risk of falls increases as number of medications increases (longitudinal evidence from UK study).

What is deprescribing?

Supervised reduction or elimination of medications that are no longer needed or are causing harm.

Hormone Replacement Therapy (HRT) — updated FDA guidance (2025)?

FDA removed black box warning about CVD, endometrial cancer, and dementia risk. Now considered safe for symptomatic women

Vitamins/supplements — 3 safety tips?

Look for USP-labeled products; patients must tell medical team what they're taking; monitor for adverse effects.

Ramona case — 2 medication red flags?

Duplicate therapy (2 different doses of losartan AND 2 doses of metoprolol); high-risk anticoagulant (Eliquis/apixaban).

What is Eliquis (apixaban) and why is it high-risk?

Anticoagulant used for atrial fibrillation. High risk due to bleeding risk, strict dosing, and serious adverse effects if taken incorrectly.

3 client factors required for medication management?

Cognition (memory, sequencing), sensory (vision to read labels), motor and movement (fine motor to open bottles).

Michon's 3 levels applied to medication management?

Operational (basic physical tasks — open bottle, swallow pill), tactical (rules — correct dose/time/frequency), strategic (unexpected — travel supply, insurance change).

OT evaluation for medication management — 3 key screening questions?

Do you take medications? How do you remember when/how to take them? Have you ever missed a dose or taken the wrong amount?

7 OT interventions for medication management?

Remediate underlying limitations, compensatory techniques, adaptive equipment (pill organizers, auto dispensers, rubber grips), environmental mods (lighting, large print), activity modification, motivational interviewing for nonadherence, patient education.

What OT CANNOT do with medications?

Prescribe medications, recommend specific medications, fill pillboxes, or hand medications to patients.

What OT CAN do with medications?

Recommend patient discuss options/side effects/changes with prescribing provider; train in medication management skills.

5 determinants of OT scope of practice?

Education (ACOTE), ethical practice, legislation (state licensure/NBCOT), employer policies, payer requirements.

WHAT/WHY/WHICH for medication management — example?

WHAT: not taking meds as prescribed. WHY: fear of side effects → use MI/education. WHY: forgetfulness → build routine + reminders.

OT medication management LTG example — key components?

Connects IADL (medication mgmt) to functional outcome (e.g., improve blood glucose control for diabetes self-management).

What is medication reconciliation?

Process of comparing a patient's medication orders to all medications the patient has been taking, to avoid discrepancies.

What is the pill burden?

The physical and cognitive load of managing many medications — impacts adherence and quality of life.

What is a skilled nursing facility (SNF)?

Inpatient facility providing 24-hour nursing care, therapy, and medical services post-hospitalization.

Director of Rehabilitation (DOR) — 3 clinical responsibilities?

Meet new residents/families, attend IDT/PDPM meetings, provide clinical mentorship and direct patient care.

Director of Rehabilitation — 3 operational responsibilities?

Manage therapy team (hiring/performance), monitor productivity and documentation, set plan to meet financial goals.

72-hour IDT — what is it?

Initial interdisciplinary team care plan meeting within 72 hours of SNF admission.

PDPM — what does it stand for and when used?

Patient-Driven Payment Model — weekly Medicare meetings to review skilled resident progress, barriers, and discharge plan.

Quarterly MDS assessment — purpose?

Report resident functional levels (ADLs, locomotion, toileting) to Medicare; screens for functional changes.

Clinical meeting at SNF — purpose?

Daily meeting with nursing + IDT to discuss new admissions, changes of condition, and clinical concerns.

Stand-up meeting at SNF — purpose?

Daily all-department heads meeting for operational updates, admissions, staffing, and announcements.

3 key clinical roles at a SNF?

Administrator (runs facility), Director of Nursing (manages resident care/nursing staff), DOR (therapy oversight).

Social Services Director role at SNF?

Connects residents/families to community, leads care plan meetings, handles discharge arrangements, resident concerns.

Restorative Nursing Assistant role?

CNA trained to provide ROM, ambulation, splinting, and assisted dining to long-term residents post-therapy discharge.

SNF Quality Measure — what is it?

Standardized metrics (e.g., fall rate, pressure ulcer rate, weight loss rate) tracked by CMS to assess facility quality.

CMS Star Rating — what does it reflect?

Overall quality of care at a SNF: 1 star (low) to 5 stars (high), based on health inspections, staffing, and quality measures.

Bay View SNF problem — key quality issue?

High rate of new/worsening pressure ulcers (4.48% vs. state avg 1.09%) + short LOS and poor staff retention.

Fountain Valley SNF problem — key quality issue?

High rate of residents losing too much weight (25% vs. state avg 5.51%); dietary issues with late/wrong-texture meals.

Cedar Point Gardens SNF problem — key quality issue?

High fall rate (35.56% vs. state avg 26.64%); falls cluster around shift changes, mealtimes, and bathrooms.

Sunset Care Center SNF problem — key quality issue?

High rate of increased ADL assistance needed (29.09% vs. state avg 8.33%); CNAs not getting residents up in AM.

Program development — OT's role in SNF beyond direct care?

Lead departmental programming, collaborate with IDT, address systemic quality issues, advocate for residents.

What is the IDT in a SNF?

Interdisciplinary Team — includes OT, PT, SLP, nursing, social work, dietary, activities, medical director, etc.

OT in SNF — 4 factors that define what you can do clinically?

Education, ethical practice, state licensure/NBCOT, employer policy, payer requirements.

SP#3 reflection — 3 things to improve in practicum sessions?

Clear beginning/middle/end with wrap-up; time management; purposeful activities with clear rationale connected to client goals.

Motivational Interviewing (MI) — when used in med management?

When patient is nonadherent due to ambivalence or fear; MI explores readiness for change without confrontation.

Environmental modifications for medication management — 3 examples?

Better lighting, color-coded bottles, large-print labels.

Adaptive equipment for medication management — 3 examples?

Automatic pill dispenser, pill organizer/pillbox, rubber grip for opening bottles.

Vitamins/herbs — why important for OT to know?

Older adults may take OTC supplements that interact with prescribed meds; OT should ask and flag for medical team.

What does USP label on vitamins mean?

United States Pharmacopeia — third-party verified for purity, potency, and quality.

How does polypharmacy affect functional status?

Cognitive/physical side effects of multiple meds → reduced ADL performance, increased fall risk, decreased independence.

OT role summary in medication management?

Evaluate barriers, train compensatory strategies, recommend adaptive equipment, educate patient, use MI for nonadherence, refer to pharmacist/provider as needed.

Discharge care plan meeting at SNF — purpose?

IDT meets with resident/family to discuss discharge location, current rehab progress, and barriers to discharge.

Skilled mix at a SNF — what does it mean?

Percentage of residents currently receiving active therapy services (e.g., 21% skilled mix = 21% in active rehab).