Transcript Managing multi-morbidity and multiple medications in geriatrics

Avoiding Hobson’s choice
in older patients:
Managing multi-morbidity and
multiple medications in geriatrics
Marilyn N. Bulloch, PharmD, BCPS
Assistant Clinical Professor
Harrison School of Pharmacy
Auburn University
The Hobson’s Choice in
Geriatric Pharmacotherapy
Don’t
Prescribe It
Prescribe It
Objectives
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Discuss the impact of the aging population on
healthcare utilization.
Understand age-related pharmacokinetic and
pharmacodynamics changes that may affect
pharmacotherapy in older adults
Describe complications of chronic medication
therapy in the aging patient.
Identify strategies to optimize benefit and
minimize harm with chronic medication therapy in
older adults.
Our Patients Are Aging
Population 65+ by Age: 1900-2050
Source: U.S. Bureau of the Census
100,000,000
90,000,000
80,000,000
Number of Persons 65+
70,000,000
60,000,000
50,000,000
40,000,000
30,000,000
20,000,000
10,000,000
0
1900
1910
1920
1930
1940
1950
1960
Age
65-74
1970
Age
75-84
1980
1990
2000
2010
2020
2030
2040
2050
Age
85+
Available: http://www.aoa.gov/Aging_Statistics/future_growth/future_growth.aspx#age (Accessed April 2013)
Patients Are Living Older Longer
Available: http://www.aoa.gov/Aging_Statistics/future_growth/future_growth.aspx#age (Accessed April 2013)
Chronic Conditions in
Older Adults
Available: http://www.aoa.gov/Aging_Statistics/future_growth/future_growth.aspx#age (Accessed April 2013)
Multi-morbidity
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Co-occurrence of:
 Index
disease
 Preexisting age-related health condition
or diseases
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Impact
 Affect
disease progression
 Decrease quality of life
 Increase risk and severity of disability
 Increase risk of mortality
Shi et al. Eur J Clin Pharmacol 2008;64:183-199
Patients with Multi-morbidity
2009-2010
60.00%
50.00%
45.30%
2009-2010
60.00%
49.00%
42.50%
40.00%
30.00%
30.00%
20.00%
20.00%
10.00%
10.00%
0.00%
0.00%
Men
Women
45.10% 42.40%
50.00%
40.00%
Total
51.60%
Black
White
Hispanic
Adapted from Figure 1. Fried et al. NCHS Data Brief 2012;100:1
Adapted from Figure 2. Fried et al. NCHS Data Brief 2012;100:2
Multiple Medications in Older Adults
Exhibit 13. IMS Institute for Healthcare Informatics. Avoidable Costs in U.S. Healthcare: The $200 Billion Opportunity from Using
Medicines More Responsibly. June 2013. Available http://www.imshealth.com (accessed 20 June 2013)
Evidence-Based Geriatric
Medicine
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Studies involving geriatrics
 3%
randomized, controlled studies
 1% meta-analyses
Make up 2-9% study subjects
 In 2000
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 3.45%
of controlled trials
 1.2% of meta-analysis
Le Couteur et al. Aus Fam Phys 2004;33:777-781
Applying EBM to Older Adults
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Does your patient resemble the studied population?
How many older adults with multi-morbidity
were included?
What are the intended outcomes – are these applicable to
older patients?
Are there clinically important variation in baseline factors
that affect intended outcome?
Are the risks of the intervention known in older adults with
multi-morbidity?
What is known about the comparator intervention in
older adults?
What is the time until benefit or harm?
Adapted from Table 1. J Am Geriatr Soc 2012;60:1957-68
Age-Related Physiologic Changes
Adapted from Figure 1. Huang A. 28th Annual Scientific Meeting of the Canadian Geriatric Society 2008;11(10):7
Absorption Changes
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↓ saliva production
↓ gastric acid secretion
↓ gastrointestinal blood flow
Delayed gastric emptying
Intestinal atrophy
Changes in body fat and lean muscle
Pulmonary changes
Skin changes
Conjunctiva changes
Hubbard et al. Eur J Clin Pharmacol 2013;69:319-326
McLean et al. Pharmacol Rev 2004;56:163-184
Corsonello et al. Cur Med Chem 2010;17:571-584
Distribution Changes
↑ body fat
 ↓ lean muscle
 ↓ total body water
 ↓ albumin
 ↑ CNS penetration
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Hubbard et al. Eur J Clin Pharmacol 2013;69:319-326
Sitar. Expert Rev Clin Pharmacol 2012;5:397-402
McLean et al. Pharmacol Rev 2004;56:163-184
Corsonello et al. Cur Med Chem 2010;17:571-584
Metabolism Changes
↓ hepatic blood flow
 ↓ liver volume
 ↓ plasma esterase quantity & activity
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 Associated
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more with health status than age
Phase I pathways more impacted than
Phase II
McLean et al. Pharmacol Rev 2004;56:163-184
Elimination Changes
↓ glomeruli causes ↓kidney mass
 ↓ GFR in 2/3 of patients
 ↑ drug elimination half-life
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McLean et al. Pharmacol Rev 2004;56:163-184
Pharmacokinetic
Questions
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How readily absorbed is the medication?
What is the onset and duration of desired
therapeutic action?
What is the patient’s body composition?
Is the medication excreted unchanged?
What is the major route of elimination?
Does the medication have an metabolite?
 Is
the metabolite active or toxic?
 How is the metabolite eliminated?
Adapted from Table 2. Lamy. J Am Ger Soc 1982;11;s11-
Pharmacodynamic Changes
Receptor down regulation
 Change in receptor sensitivity
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 Increased
 Decreased
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Impaired homeostatic mechanisms and/or
physiologic reserves
COMPLICATIONS OF
GERIATRIC MEDICATION USE
Polypharmacy
Quantity
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≥ X Medications
Limiting - assumes > X is
incorrect
Quality
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More medications than is
clinically indicated
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No indication
Lack efficacy
Duplications
Requires more thorough
review of medications
DeSovo et al. Prim Care Clin Office Pract 2012;39:345-362
Reasons for Polypharmacy
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Age
Ethnicity
Rural residence
Education level
Insurance
Multiple healthcare
providers
Poor health status
Provider visits
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Chronic diseases
 Anemia
 Angina
 Asthma
 Depression
 Diabetes
 Diverticulosis
 Gout
 Hypertension
 Osteoarthritis
DeSovo et al. Prim Care Clin Office Pract 2012;39:345-362
Avoidable Costs of Polypharmacy
Exhibit 12. IMS Institute for Healthcare Informatics. Avoidable Costs in U.S. Healthcare: The $200 Billion Opportunity from Using
Medicines More Responsibly. June 2013. Available http://www.imshealth.com (accessed 20 June 2013)
Adverse Drug Reactions
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Unwanted and/or harmful effects that can occur
at standard doses
Gurwitz et al
 50.1
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ADRs per 1000 person years
13.8 preventable ADRs per 1000 person years
VA GEM Study
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33% of patients experienced an ADR within 12
months of hospital discharge
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38% considered preventable
Boparai MK et al. Mt Sinai J Med 2011;78:613-626
Gurwitz et al. JAMA 2003;289:1107-1116
Steinman et al. J Gerontol A Biol Sci Med Sci 2011;66:444-451
Risks for ADRs
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Prior ADR
Polypharmacy
Dementia/cognitive
impairment
Multi-morbidity
Frailty
CrCl < 50 mL/min
Female
Fragmented care
Altered stimuli-induced
adaptation capacity
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Recent hospital admission
Age ≥ 85 years
Low body weight
≥ 1 oz alcohol intake/ day
Vision or hearing
impairment
Compliance
Regimen complexity
DeSovo et al. Prim Care Clin Office Pract 2012;39:345-362
Boparai MK et al. Mt Sinai J Med 2011;78:613-626
Medications Causing ADRs
Preventable ADRs
Total ADRs
40%
35%
30%
25%
20%
15%
10%
5%
0%
Gurwitz JH, et al. JAMA 2003;289;107-116
Types of ADRs Occurring
Figure 1. Percent patients suffering selected injuries commonly studied among patients who experienced adverse drug events:
Reducing and Preventing Adverse Drug Events To Decrease Hospital Costs. March 2001. Agency for Healthcare Research and
Quality, Rockville, MD. http://www.ahrq.gov/research/findings/factsheets/errors-safety/aderia/figure1.html (Accessed April 24, 2013)
ADR Consequences
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Health care utilization
 10%
of emergency room visits
 10-17% of hospitalizations
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$1.33 to manage medication-related morbidity
and mortality for each $1 spent on older adults
in nursing homes
Can be fatal
Symptoms should be considered ADRs until
proven otherwise.
Le Couteur et al. Aus Fam Phys 2004;33:777-781
Budnitz et al. N Eng J Med 2011;365”2002-2012
Boparai MK et al. Mt Sinai J Med 2011;78:613-626
Drug Interactions
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Many types
15-46% patients have ≥ 1 interaction
1
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in 25 community patients at risk for severe interaction
Over 26% cause ADRs that require hospitalization
 25%
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serious or life-threatening
Approximately 20% occur in the hospital
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Potential for drug-drug interaction in over 6% of
medication orders
McDonnell, et al. Ann Pharmacother 2002;36:1331-1336
Qato et al. JAMA 2008;300:2867-2878
Reimche et al. Clin Pharmacol 2011;51:1043-1050
Lindblad et al. Clin Therapeu 2006;28:1133-1143
Drug Interactions
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Age
years – 24%
 ≥ 80 years – 36%
 60-74
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Risk increases with # medications
≥
2 medications – 13%
 > 6 medications – 82%
 ≥ 8 medications – almost 100%
Boparai MK et al. Mt Sinai J Med 2011;78:613-626
Stegemann et al. Age Research Rev 2010;9:284-298
Minimizing ADRs and
Interactions
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Know allergies – including
reactions
Evaluate cognitive function
Have a drug information source
Use safest/most effective
medication
Match medications to indications
Use fewest medications possible
Use simple dosing
Do not start 2 medications at the
same time
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Screen for DDIs routinely
Dose for renal & hepatic function
Recognize a symptom as an ADR
Give prophylaxis for known side
effects when able
Stop medications without benefit
Stop PRN medications not used
in past month
Medication lists
Involve caregivers
Adapted from: Boparai MK et al. Mt Sinai J Med 2011;78:613-626
Non-Adherence
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Adherence in patients with
chronic conditions only 50-60%
Responsible for up to 70.4%
of medication-related ER visits
May account for 39-69%
of drug-related hospitalizations
each year
Costs $100 billion/year
Coleman et al. J Manag Care Pharm 2012;18:527-539
Orwig et al. Gerontologist 2006;46:66
Cost of Non-Adherence
Exhibit 3. IMS Institute for Healthcare Informatics. Avoidable Costs in U.S. Healthcare: The $200 Billion Opportunity from Using
Medicines More Responsibly. June 2013. Available http://www.imshealth.com (accessed 20 June 2013)
Types of Non-adherence
Forgetfulness
 Confusion over dosage schedule
 Intentional underuse
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Primary non-adherence
 Non-persistence
 Nonconforming non-adherence
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Intentional overuse
Coleman et al. J Manag Care Pharm 2012;18:527-539
Risk Factors for Non-Adherence
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Communication
Regimen complexity
Patient-provider
relationship
Transition of care
Health literacy
Mental health
disorders
Cognition
Smoking
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Asymptomatic chronic
diseases
Age
Physical impairment
Lack of social support
Minority demographic
Patient beliefs
Sensory changes
Product use
Dysphagia
Dosing Influence on Adherence
Frequency of
Daily Dosing
Taking
Adherence
Regimen
Adherence
Timing
Adherence
Once daily
93%
81.8%
76.9%
Twice daily
85.6%
74.2%
59.3%
3 times daily
80.1%
62.8%
35.9%
4 times daily
84.4%
68.2%
18.8%
Coleman et al. J Manag Care Pharm 2012;18:527-539
Overcoming Adherence Barriers
Barrier
Solution
Forgetfulness
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Patient beliefs
• Establish shared goals of care
• Provide literacy appropriate materials
• Simplify regimen/reduce pill burden
Difficulty Taking
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Cost
• Generics
Pill organizers
Medication Calendar/Cues
Dispensing Devices
Family/caregiver involvement
Internet-linked or electronic adherence aid
Change formulation
Easy off caps
Pill cutters
Simplify regimen
Syringe magnification
Spacer
Steinman et al. JAMA 2010;304:1592-1601
EVALUATING MEDICATION
MANAGEMENT ABILITY
Drug Regimen Unassisted
Grading Scale (DRUGS)
Medication List
(container or chart)
Medication List
(patient-reported)
Identification
Total Medications:
Total Doses:
Maximum Score:
Total Score:
Access
Dosage
Timing
Summary Score:
(Total Score/Maximum Score) X 100
Time:
Adapted from Edelberg et al. J Am Geriatr Soc 1999;47:592-596
MedTake Test
Drug
Name,
dose,
SIG
Patient
description
of how to
take drug
Dose
(25%)
Indication
(25%)
Food/water
coingestion
(25%)
Regimen
(25%)
Score
per
drug
Comment
(0-100%)
1.
2.
3.
4.
5.
Scoring: 1 = correct, 0 = incorrect
Composite (Mean) MedTake Score (0-100%): _____%
Adapted from Appendix I. Raehl et al. Pharmacotherapy 2002;22:1239-1248
Perfectly
correct
Mostly
correct
Somewhat
correct
Somewhat
incorrect
Mostly
incorrect
Totally
incorrect
MedTake Test
Dose
+0
+5
+10
+15
+20
+25
Indication
+0
+5
+10
+15
+20
+25
Co-ingestion with food or water
+0
+5
+10
+15
+20
+25
Regimen and schedule
+0
+5
+10
+15
+20
+25
Sum of points (0-100)
Knowledge score for individual
drug
Adapted from Appendix I. Raehl et al. Pharmacotherapy 2002;22:1239-1248
Medication Regimen
Complexity Index
Checklist style tool to evaluate regimen
 Only for prescribed medications
 Medication Regimen Complexity = Total
(A) + Total (B) + Total (C)
 Open index
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# medications and directions vary by patient
George et al. Ann Pharmacother 2004;38:1369-1376
MRCI Section A: Dosage Forms
Adapted from Appendix II. George et al. Ann Pharmacother 2004;38:1374-1375
MRCI Section B: Dose Frequency
Adapted from Appendix II. George et al. Ann Pharmacother 2004;38:1374-1375
MRCI Section C: Directions
Adapted from Appendix II. George et al. Ann Pharmacother 2004;38:1374-1375
Medication Management Instrument
for Deficiencies in the Elderly
What a Patient Knows About Their Medications
Yes No
1. Name all daily medications – Rx and OTC
2. State time of day each prescription medication is taken
3. State how each medication is taken (po, with water, ect)
4. State indication for each medication
5. State amount of each medication to be taken at each dose
6. Identify if there are problems with medications (ADRs)
7. Does patient get help with medications
By whom:_____________ Type:__________________
8. Other medications on hand (outdated, unused, discontinued)
“No” selection for 1-5 credited to Total Deficiency Score
Adapted from Orwig et al. Gerontologist 2006;46:661-668
Medication Management Instrument
for Deficiencies in the Elderly
If a Patient Knows How to Take Their Medications
Yes
No
Yes
No
1. Can fill a glass with water
2. Can remove top from medication container
3. Can count out required number of pills into hand or cup
4. Can put hand with medication to open mouth; put hand to eye for eye
drops; hand to mouth for inhaler; draw up insulin; place a transdermal
patch
5. Can sip enough water to swallow medication
6. How are medications currently stored
If a Patient Knows How to Get Their Medications
1. Identify a refill exists on a prescription
2. Identify who to contact to refill a prescription
3. Does patient have resources to obtain medications
“No” selection for Part 1: 1-5 and Part 2: 1-3 credited to Total Deficiency Score
Adapted from Orwig et al. Gerontologist 2006;46:661-668
Hopkins Medications Schedule
Appendix. Carlson et al. J Gerontol A Biol Sci Med Sci 2005;60;223
AUXILIARY LABELS & THE
IMPORTANCE OF VERBAL
COUNSELING
In Conclusion
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We have a lot of older patients
 Patients
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are staying older longer
Older patients need medications
 They
respond differently than younger patients
 There is not a lot of EBM to guide decisions or
answer questions on geriatric medication use
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Try to optimize medication prescribing and use
to minimize complications before taking the
Hobson’s Choice
Questions
“All substances are poisons;
there is none which is not. The
right dose differentiates a
poison from a remedy”
-Paracelsus (1493-1541)