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Jan 26, 2021

The 4M's Framework: MEDICATION

with Ayo Bankole PhD, RN

and Tahira I. Lodhi MD


"Do the Brown Bag with your pharmacist too; because there are drug-drug interactions, drug-food interactions, and drug-supplement interactions to be aware of. Make sure that you're very clear about everything you are taking" 


Melissa Batchelor, PhD, RN, FNP-BC, FGSA, FAAN 



We all hear about the increasing rates of health care services and how costly prescription medications can be, especially for older adults. But these costs can grow higher if you don't take the prescription correctly.

The figures are especially troubling for older adults. Roughly 23% of nursing home admissions are attributed to an older individual's failure to self-manage their prescribed drugs at home. About 21% of drug-related health problems are induced by patients, whether by mistake or failing to stick to their prescription regimens. Also, while having their medicines, up to 58 % of older adults commit some fundamental mistake, with 26% committing errors.

These statistics are alarming, and that is the primary reason why Medication is such a critical part of the 4M's Framework and part the Age-Friendly Systems are highly encouraged in nursing homes and health care systems.

In today's episode, we are joined by Drs. Ayo Bankole PhD, RN, and Tahira I. Lodhi, MD. Join us as we engage in meaningful discussions about one component of the 4M's Framework: Medication and learn how to make sure that your medications are age-friendly. 


Part One of 'The 4M's Framework: MEDICATION'.


Overview of Medication as an Essential Component of the 4M's Framework 


In implementing the 4M's Framework to achieve an age-friendly healthcare system, we want to ensure that Medication does not interfere with the other M's, which are: What Matters, Mentation and Mobility across care settings.

To do that, we should have a clear definition of the terms associated with the medication. Two of these terms are polypharmacy and medication reconciliation. 

What is Polypharmacy?


Tahira I. Lodhi MD explained that polypharmacy is too many medications in simple terms. She also said that when you see a patient with a medication that does not have a corresponding diagnosis documented, that's also polypharmacy by one definition. 


"Whichever situation you are in, whether you are by the bedside in the hospital, in outpatient or long-term care settings, be very aware of the definitions of polypharmacy and be ready to address them." -Tahira I. Lodhi, MD (03:21-03:35)


What is Medication Reconciliation?


Ayo Bankole, PhD, RN, expounded that medication reconciliation involves reviewing the medications a patient is taking and comparing them to the medicines on file. Medication reconciliation ensures no discrepancies, such as medication duplication, missing prescriptions, and inappropriate medications.  


Patient Education: Things to Look for or to Report to a Provider


Use a Medication Administration Sheet


When you get that medication list from the hospital or your provider, it often comes in a list. This can be overwhelming, so using a “real time” document can help reduce medication errors - particularly if there is more than one person trying to help the older adult. Write down your medications in the order you would need to take them in a day, rather than trying to use the list in the format typically given to patients. And write 

[Can we link this form?] Crystal - we created this document for EP21, but doesn’t seem to be included in the brand article? 

Keep a Medication List


With that, Ayo Bankole PhD, RN suggests keeping a medication list. Your medication list should include the following;

  • Any medications you're taking, and this includes vitamins and supplements or herbal supplements.
  • The medication list is not only the medicines that are prescribed by a physician or a nurse practitioner. It also includes other medications that might be over-the-counter supplements that your patient might be taking.
  • Include the name of the medications you are taking, the dose, and where the medicine is used.
  • Include the name of the prescribing doctor 
  • Have phone numbers of your pharmacist or your doctors on the list as well. 


Teach the “Brown Bag” Review


Aside from keeping medication lists, Tahira I. Lodhi MD also suggests teaching patients the Brown Bag review. She pointed out that doing the Brown Bag Review leads your patient to gather all the medications, put them in the bag, and bring them on every visit. Once they are in the clinic, either your medical assistant or you take out those medications, put them on a table where the patient can see them. 


The review brings you and your patient on the same page about what medications they are taking, what supplements they are taking, etc. This is an excellent opportunity to know whether your patient is aware of why they're taking this medicine, what doses they're taking. Furthermore, Brown Bag Review is a unique tool a provider can use to avoid polypharmacy in their patients. 


What To Look For Or Report To Providers?


For patients experiencing polypharmacy, monitoring for any side effects and signs and symptoms is essential. 

The following are the signs to look out for and should be reported to providers ASAP;

  • Loss of appetite
  • Diarrhea
  • Fatigue 
  • Weakness
  • Change in mental status
  • Confusion
  • Hallucinations 
  • Changing mood and behavior


Part Two of 'The 4M's Framework: MEDICATION'.


Medication Assessment


For the second part of the interview, Drs. Lodhi and Bankole mentioned Medication Assessments. They shared that there are assessments or tools students or practicing providers can use when prescribing medications to older adults. These criteria are validated tools and are widely used. Two of them are Beer's criteria and the STOPP and START criteria.


Beer's Criteria 

Beer's Criteria for medications is a medication list that is put out by the American Geriatric Society. This is a list of potentially inappropriate medications for older adults. These medications carry different side effects, potential complications, and medication interactions, which account for many adverse drug reactions in the more aging adult population. 

"I would tell students to be careful about Beer's criteria. The list of medications doesn't mean they are contraindicated. It means they are to be used very carefully, to be prescribed very carefully."- Tahira I. Lodhi MD(14:02-14:19)

STOPP and START Criteria

STOPP (Screening Tool of Older Persons' Prescriptions) and START (Screening Tool to Alert to Right Treatment) are more commonly used in Europe and was developed by the European Consensus Group. Still, it could also be used by providers and practitioners in the United States. 

The STOPP criteria are similar to the specifications of medications that could be stopped or suggest medicines for discontinuation. On the other hand, the START part is the right treatment. Those are the recommended treatments for older adults, including the pneumonia vaccine and those recommended treatments for the more aging adult population. 

Interventions and Best Practices

After you've done a medication reconciliation and reviewed the Beers Criteria, Dr. Lodhi shared some of the best practices that providers can use.


  • Deprescribing (both dose reduction and medication discontinuation)


First, she advised that you should look at the medications the patient is taking. Make sure there is no polypharmacy. Then, be ready to adjust the dose on every visit. Assess how they are doing in terms of the medication. For example, with antihypertensive, look at the patient's self-monitoring of blood pressure. If it's consistently on the low side or there are signs of orthostatic hypotension, decrease the dose and at the same time have a plan of how you're going to follow in the future.



  • Pharmacy Consult


Secondly, Dr. Lodhi stressed out that your pharmacist is your friend and never hesitate to call them. She says, "Your pharmacists oversee your patient's prescriptions. They regularly make their recommendations because it's regular monitoring and quality control in long-term care settings." So make sure you reach out to your pharmacist frequently.


  • Re-evaluate on each visit with every provider


Lastly, Dr. Lodhi emphasized that every provider should guarantee that the medications are used as prescribed. Moreover, providers should also ensure that they'll go back to the patient's chart whenever they're asked to refill a prescription. They should always double-check for schedules and indications when to continue medications.

 About Tahira I. Lodhi MD 

I graduated from medical school in 1999. My Family Medicine training was at Virginia Commonwealth University and Geriatrics fellowship training at George Washington University. 

My interest is Geriatrics primary care practice and teaching. Since graduating from Fellowship in Geriatrics in 2011, I have had medical students, residents and fellows join me in traditional and non-traditional settings, including hospital, clinic and classrooms but also assisted living, post-acute and long term care settings.

I am also interested in workflow improvement through deploying available technology. My goal is to help my patients get simplified, patient-centered care, while collaborating with an interdisciplinary team.

 About Ayo Okanlawon Bankole Ph.D, RN

Ayo Okanlawon Bankole Ph.D, RN is a clinical assistant professor at GW Nursing. She is also one of the faculty members affiliated with the George Washington University/Medstar Washington Hospital Center academic partnership and scholarship program, W-squared. Dr. Bankole has practiced as a nurse in multiple areas within the acute care and community care setting. She is also committed to nursing education and she has been teaching nursing students since 2013 (in both part-time adjunct and full time appointments). Dr. Bankole's overall research goal is to contribute to research that improves health outcomes and wellbeing for older adults with complex healthcare needs. Her specific research interest are: aging, chronic disease self-management, theoretical approaches to chronic disease self-management and multi-morbidity.

 About Melissa Batchelor, PhD, RN, FNP,  FGSA, FAAN

I earned my Bachelor of Science in Nursing ('96) and Master of Science in Nursing ('00) as a Family Nurse Practitioner (FNP) from the University of North Carolina Wilmington (UNCW) School of Nursing (SON). I genuinely enjoy working with the complex medical needs of older adults. I worked full-time for five years as FNP in geriatric primary care across many long-term care settings (skilled nursing homes, assisted living, home, and office visits), then transitioned into academic nursing in 2005, joining the faculty at UNCW SON as a lecturer. I obtained my PhD in Nursing and a post master's Certificate in Nursing Education from the Medical University of South Carolina College of Nursing ('11) and then joined the faculty at Duke University School of Nursing as an Assistant Professor. My family moved to northern Virginia in 2015 and led to me joining the faculty at George Washington University (GW) School of Nursing in 2018 as a (tenured) Associate Professor, where I am also the Director of the GW Center for Aging, Health, and Humanities. Find out more about her work at