The consultant pharmacist and the consultant dietitian have valuable information to exchange, but they must create opportunities to share their expertise.
Two members of the interdisciplinary health care team who have the most in common may be the consultant pharmacist and the consultant dietitian. Like us, a registered dietitian must review the chart of each nursing facility resident upon admission and regularly thereafter. Like us, the dietitian never overlooks lab values on a resident's chart. Like us, the dietitian is usually not a full-time member of the nursing facility staff, but a contracted health care professional who works in more than one nursing facility. Like us, the dietitian probably feels that time runs too short to implement all of the sophisticated clinical programs we'd like to offer our facilities.
But what forges the bond between the consultant pharmacist and consultant dietitian are the clinical issues we each face with every resident who presents with a nutritional problem-clinical issues that always involve an assessment of the drugs the resident has been prescribed.
Unfortunately, the conflicts in our work schedules and the number of facilities we serve make it difficult for the consultant pharmacist and dietitian to meet to discuss patients with nutritional problems, even though the consultant pharmacist can be one of the dietitian's most valued resources. We are the ones who understand and can explain the confounding problems each drug in the regimen can impose on the nutritionally at-risk patients, and we have the ability to develop pharmaceutical care plans that support nutritional interventions.
Problems in nutrition are never as simple as "weight loss," because a problem seldom stands alone. Weight loss is usually complicated by the inability to feed oneself, a disease process, a mental condition, or social problems. But no matter what the cause, the drug regimen is implicated in either the problem or the solution, or both.
Because of the dramatic effect medications can have on appetite, nutrient absorption, and functionality, dietitians depend heavily on our counsel and expertise for drug information (see Table 1). Certainly, we should be using these skills to develop and provide drug information programs that serve the nutrition professional, the facility, and the resident. But how can we best offer our support to this team member?
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Table 1. Drugs that May be Implicated in Nutritional Problems Drugs that may cause depression and influence weight include:
Drugs that may delay gastric emptying time:
Prokinetic drugs that may increase gastric emptying time:
Drugs that can cause folate deficiency:
Drugs that can cause drowsiness and may cause missed meals:
Drugs that may cause nausea and vomiting:
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One of the best ways to develop a drug-related nutritional risk
information program is to begin with a complete understanding
of the Nutritional Status Resident Assessment Protocol (RAP) guideline
that is part of the Resident Assessment Instrument (RAI). It suggests
that functional limitations, rehabilitative problems, disease
state processes, and daily care needs all be evaluated using the
drug regimen as a possible cause (see Tables 2 and 4).
| Table 2. Selected Drug-Nutrient Interactions in the Elderly | |
| Folic acid + phenytoin | Folic acid may reduce effectiveness of phenytoin |
| Vitamin B6 + levodopa | Vitamin B6 decreases levodopa unless used with carbidopa |
| Vitamin D + phenobarbital | Vitamin D levels decreased due to + phenytoin increased rate of vitamin D metabolism |
| Fat-soluble vitamins + cholestyramine | Cholestyramine reduces absorption of fat-soluble vitamins (A,D,E,K) |
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Table 3. Drug-Tube Feeding Formula Interactions
Other commonly used medications are physically incompatible with tube feeding formulas and form a material that clogs the tubing:
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Table 4. Drug-Food Interactions
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For example, as soon as a weight loss problem is identified, medications that may cause drug-induced anorexia must be evaluated. Drug side effects that alter taste, decrease the ability to smell food, cause a dry mouth, or modify the oral mucosa should be assessed as a cause of loss of appetite. Medications that cause depression might also be the cause for a loss of interest in food. In the elderly, laxative dependency is always a consideration when evaluating a decline in nutritional status.
Drugs such as beta blockers or calcium channel blockers that delay gastric emptying time can cause a sense of satiety and fullness, leading to weight loss. The prokinetic drugs that increase gastric emptying time may cause a loss of absorption of nutrients.
Selective serotonin reuptake inhibitors, which can cause nausea, can affect a resident's ability to eat, as can many other drugs that cause nausea and vomiting, including antibiotics, antineoplastic agents, opioid derivatives, and theophylline.
Other drugs with narrow therapeutic indices that commonly cause toxicity in the elderly, such as digoxin and phenytoin, must be evaluated immediately when significant weight loss has been recognized. Drugs that cause movement side effects may increase expenditure of calories, placing the resident at risk of losing weight.
Drugs that cause drowsiness often cause missed meals. Drowsiness may also alter residents' functional ability to feed themselves, may increase the time it takes to eat (there is nothing appetizing about food that is not at the right temperature), or may impair residents' ability to recognize or communicate that they are hungry. On the other hand, noncompliance in taking psychotropics may cause a return of behavioral problems that interfere with the ability to sit quietly and concentrate on eating. Increased wandering or pacing may also increase nutritional requirements.
Another consideration for the pharmacist and dietitian evaluating nutritional risk is the management of disease states. Dose adjustments in antiparkinsonian agents, for example, may help maintain the patient's ability to swallow. Proper medication regimens for chronic obstructive pulmonary disease may decrease the caloric needs of a resident who finds it difficult to breathe and may also keep the resident from becoming fearful of choking when eating or drinking, enabling him to eat more comfortably. New anti-nausea drugs may help maintain the appetite of a patient receiving chemotherapy. Management of diabetes through an individualized pharmaceutical care plan is sure to keep the patient with diabetes at minimal nutritional risk.
Residents over 65 years old with comorbidities take many more medications than those who are younger. This increases risk of drug interactions that alter therapeutic drug levels, causes drug toxicity or subtherapeutic blood levels (which may result in altered functionality or mental state of the resident), and places the resident at nutritional risk. When a physician adds a dietary supplement or vitamin to the drug regimen at the request of the dietitian, the risk increases even further.
Drug-tube feeding formula interactions should be reviewed with the dietitian (see Table 3). The interactions between phenytoin and enteral formulas, or between digoxin and formulas with fiber, are well known to consultant pharmacists but may be less obvious to another practitioner.
There are also drugs that are physically incompatible with tube-feeding formulas and form materials that clog the tubing and prevent delivery of the nutrients. These drug incompatibilities should be reviewed each time a resident on a tube feeding has lost weight. Provided that the tube feeding is being administered according to a physician's orders, there should be a clinical reason why a patient on an ideal feeding program is suffering from weight loss.
Finally, review with the dietitian foods that interact with medications. Foods rich in vitamin C can increase the risk of bleeding. Charcoal-broiled foods can reduce the amount of drug absorbed. Coffee, tea, chocolate, and cola can increase nervousness and insomnia. Foods rich in vitamin B6, such as peas, beans, avocado, and pork, can reverse the drug activity of levodopa. Lithium in combination with salty foods can lead to manic behavior. And, of course, there is the consideration posed by potassium-sparing diuretics and foods rich in potassium, such as flounder, lima beans, oranges, and bananas.
Besides the educational information we have to offer the consultant dietitian, we can strengthen our link to this health care provider by making sure we receive a list every month of residents deemed to be at nutritional risk and review their drug information accordingly. Always consider whether weight loss or weight gain commenced with the start or discontinuance of a drug, or with a change in a drug.
Observing the medication pass for an individual resident will determine if a drug is being administered properly. Review all quarterly Minimum Data Set (MDS) reports for changes in weight or mental status, or abnormal lab values, to help pinpoint a possible cause. Evaluate whether a pharmaceutical care plan can augment the interdisciplinary team's care plan for a planned weight gain.
Re-evaluate drug doses after a planned or unplanned weight loss. Attend the care conference of the resident for whom you have uncovered the cause of a shift in weight, and take your rightful place at the table to help establish goals and approaches for that resident.
Almost all nursing facilities use an assessment screening tool to identify a resident at nutritional risk. It is performed upon admission, upon readmission, and with every change-of-status MDS. Review the assessment tool to make sure it addresses drugs known to alter appetite or that have a narrow therapeutic index. If you have an opportunity to improve the assessment instrument, seize it, and offer to provide an inservice for staff on guidelines you have provided.
A system of communication between dietitian and consultant pharmacist requires a commitment from both of us if we are to be valuable to one another and to the residents we serve. Meet with the dietitians in your facilities to set up a communication system. Trade beeper numbers. Ask him or her to review your comments with each chart review, and make your monthly report available to the dietitian, as well as the medical director and director of nursing. Don't overlook the dietitian's progress notes during monthly drug regimen reviews.
Above all, remember that to be a real asset, the consultant pharmacist must communicate with the consultant dietitian much more often than at the facility's quarterly quality improvement meeting. It's up to both of you to make this communication happen, but when you do, you'll be rewarded with a mutually beneficial professional relationship and, most important, vastly improved resident care.
Nancy Losben, RPh, FASCP, is a consultant pharmacist practicing
with Genesis HealthCare in the Philadelphia area. She represents
ASCP on the Long-Term Care Professional and Technical Advisory
Committee (PTAC) of the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) and frequently lectures on the MDS 2.0.
Copyright © 1997, American Society of Consultant Pharmacists,
Inc. All rights reserved.