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The Three-Drug Limit

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August 30, 2017

Several years ago, I taught a course on Normal Aging and Disease; one particular class had a most unusual student—a former physician from Russia who had decided not to pursue licensure as a physician in the United States, preferring instead to work as a social worker primarily serving the Russian immigrant population.

During a discussion of the increased risk of adverse drug reactions and drug-drug interactions, this student lamented, “In Russia, we could only prescribe three medications. If a patient needed another medication, the physician would need to discontinue a prescription already in use. That was the rule—a limit of three medications per person.” The student went on to describe some difficult situations in which she felt patient care was compromised by the limitations placed on prescribing behaviors.

Initially, the class was surprised by such rationale. After all, in America there are no similar rules. Many older adults are given 15 or more prescriptions as well as over-the-counter medications, herbs, supplements and other alternative treatments.

Rather than lament the lack of access to more than three medications, I wondered if the limitations would actually prove beneficial. More prescriptions exponentially increase the risk for adverse effects, therefore there must be a benefit realized with limiting the number of medications per person. What that magic number would be remains a mystery, although the Centers for Medicare and Medicaid Services has identified that nine or more drugs is a negative quality indicator.

The large number of medications administered by nurses in long-term care may contribute to problematic care. For example, nurses pressured by the need to administer medications within a two-hour window may struggle with trying to perform a hydration assessment on a resident before giving a diuretic; or they may not fully appreciate changes in vital signs from baseline prior to the administration of cardiac medications. In addition, they may not feel there is sufficient time to offer a nonpharmacological intervention before administering the prescription or may have difficulty performing a thorough pain assessment to determine if analgesics are needed. The list of how a high number of medications may detract rather than enhance resident care goes on and on.

But, in reality, how likely is a consulting pharmacist to recommend the elimination of medications, particularly those the resident has been taking for several years? What would the resident or family say in response to the suggestion that statins be discontinued for people over age 85 or that vitamin supplements may not be needed for those eating a well-balanced diet? As I watch nurses struggle to complete a medication administration pass within two hours, I think back to my Russian student and wonder if some compromise can be determined.


Ilene Warner-Maron, PhD, RN-BC, CWCN, CALA, NHA, FCPP, has been practicing nursing for 33 years, specializing in the care of geriatric patients. Dr. Warner-Maron is the president of the Institute for Continuing Education and Research, providing educational programs for individuals seeking licensure in nursing home administration.


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