MTM Polypharmacy Assessment & Reduction 4 — Questions and Answers
Question 1: A pharmacy team is designing a polypharmacy reduction program for a long-term care facility. Which metric BEST measures the program's effectiveness over time?
- Mean number of medications per resident and rate of adverse drug events (Correct answer)
- Number of medication reconciliation forms completed
- Percentage of patients seen by a pharmacist monthly
- Total drug expenditure per patient per month
Correct answer: Mean number of medications per resident and rate of adverse drug events
Tracking both the mean medication count and adverse drug event rates provides outcome data reflecting both process and safety improvements.
Question 2: A 68-year-old patient with COPD is taking tiotropium, salmeterol/fluticasone, and albuterol PRN. The physician also prescribes ipratropium. Which pharmacist recommendation is MOST appropriate?
- Recommend discontinuing ipratropium since tiotropium provides equivalent long-acting anticholinergic coverage (Correct answer)
- Add ipratropium as needed for rescue therapy
- Switch salmeterol/fluticasone to vilanterol/umeclidinium
- Continue all medications and monitor for tachycardia
Correct answer: Recommend discontinuing ipratropium since tiotropium provides equivalent long-acting anticholinergic coverage
Tiotropium is a long-acting muscarinic antagonist (LAMA) that duplicates the mechanism of ipratropium (short-acting anticholinergic), making concurrent use therapeutic duplication.
Question 3: Which scenario BEST represents 'problematic polypharmacy' as distinguished from 'appropriate polypharmacy'?
- A patient taking 8 medications for a heart failure regimen where all agents have evidence-based indications and are well-tolerated
- A patient taking 3 medications for a single condition with one providing no measurable benefit (Correct answer)
- A patient taking 12 medications for multiple comorbidities, all with documented therapeutic goals
- A patient taking herbal supplements alongside prescription medications
Correct answer: A patient taking 3 medications for a single condition with one providing no measurable benefit
Problematic polypharmacy occurs when medications lack evidence of benefit, have no clear indication, or the risk-benefit ratio is unfavorable, regardless of the total number.
Question 4: A pharmacist is reviewing a patient who takes zolpidem 10 mg nightly for chronic insomnia. Per the Beers Criteria, what is the MOST appropriate recommendation?
- Recommend cognitive behavioral therapy for insomnia (CBT-I) as first-line and begin a gradual taper of zolpidem (Correct answer)
- Increase zolpidem to 12.5 mg extended-release for better sleep maintenance
- Add melatonin to supplement the zolpidem effect
- Continue zolpidem as it is the most effective insomnia treatment
Correct answer: Recommend cognitive behavioral therapy for insomnia (CBT-I) as first-line and begin a gradual taper of zolpidem
Benzodiazepine receptor agonists like zolpidem are listed in the Beers Criteria as potentially inappropriate in older adults due to fall and cognitive risks; CBT-I is the evidence-based first-line treatment.
Question 5: When prioritizing which medications to deprescribe first, which framework helps pharmacists rank medications by patient-specific risk and benefit?
- The GoodPalliativeCare.org.au deprescribing algorithm considering time-to-benefit and life expectancy (Correct answer)
- The WHO essential medicines list
- The HEDIS quality measures for chronic disease management
- The Medication Guides required by the FDA
Correct answer: The GoodPalliativeCare.org.au deprescribing algorithm considering time-to-benefit and life expectancy
Deprescribing frameworks that consider time-to-benefit relative to patient life expectancy help prioritize which medications to discontinue in patients with limited life expectancy.
Question 6: A pharmacist identifies that a 70-year-old patient's nausea and confusion began shortly after metoclopramide was added for gastroparesis. This presentation MOST likely represents which adverse effect?
- Extrapyramidal effects including tardive dyskinesia risk with long-term use (Correct answer)
- Serotonin syndrome from dopamine pathway interaction
- Cholinergic crisis from acetylcholinesterase inhibition
- Drug-induced SIADH causing hyponatremia
Correct answer: Extrapyramidal effects including tardive dyskinesia risk with long-term use
Metoclopramide blocks dopamine receptors and can cause extrapyramidal symptoms; the Beers Criteria recommends avoiding it in older adults due to risk of tardive dyskinesia.
Question 7: In the context of polypharmacy in older adults, what does the term 'drug burden index' (DBI) measure?
- Cumulative exposure to medications with anticholinergic and sedative properties (Correct answer)
- Total cost of a patient's medication regimen
- Number of pills taken per day
- Combined hepatotoxic potential of all medications
Correct answer: Cumulative exposure to medications with anticholinergic and sedative properties
The Drug Burden Index quantifies a patient's cumulative exposure to drugs with anticholinergic and sedative effects, which correlate with functional impairment in older adults.
MTM Polypharmacy Assessment & Reduction 4
A pharmacy team is designing a polypharmacy reduction program for a long-term care facility.
Which metric BEST measures the program's effectiveness over time?