Transcript Polypharmacy and Medication-Related Challenges in the Geriatric

Robyn Bryson, PharmD
Kerri Hagedorn, PharmD, BCPS
Many different drugs, often
duplicative
 Drugs in excess of that
which is clinicallyindicated
 Excessive number of
inappropriate drugs
 Includes Rx, OTC,
nutraceuticals
 Differs from polymedicine
or polytherapy, which
refers to multiple meds
which are all clinicallyindicated and appropriate

 In
general:
• 5+ Rx drugs is considered “clinically-relevant”
polypharmacy
• 10+ Rx drugs is considered “excessive”
polypharmacy
 Pts
and providers often only consider
chronic tx
 CAM, short-term meds, topicals, and
PRNs often excluded
 Comprise
13% of population but account for
34% of Rx and 30% OTC med use
 90% of Medicare beneficiaries use Rx meds
 29% of 57-85yo and 40% of Medicare
beneficiaries take 5+ Rx drugs
 46% of seniors use both Rx and OTC meds
 52% use Rx meds and supplements
(vitamins, herbals)
 Of women over age 65:
• 57% take 5+ meds (Rx, CAM, OTC)
• 12% take 10+ meds
 Due
to longer life expectancy and the
aging baby boomer population, by 2030,
the number of Americans 65+ y.o. is
expected to double to 71 million
 85+ y.o. represent the fastest-growing
segment of population
 Multimorbidity
• Majority of older adults have 3+ chronic
conditions or diseases
• about 20% have 5+ chronic conditions
 12%
of hospital admissions for seniors
are due to ADRs
 ADR is the 4th most common cause of
hospital-related death
 Interactions:
• Potential for drug-drug interactions increases
exponentially with the number of drugs
• Drug-diet: caffeine, alcohol, grapefruit, vit K
• Drug-herb
• Drug-disease w/ multimorbidity
 Inappropriate
med
use increases w/
more meds
• Per Beers study, 12%
in community elderly
• 40% of nursing home
pts
 Nonadherence
increases with more
meds
• Potential for underuse
of appropriate meds
 Health
System-related
• Longer life span means more elderly patients
with chronic diseases
• More treatment options due to medical
developments
• Primary and Secondary prevention strategies
• Increased use of healthcare services means
more hospitalizations (known risk factor for
polypharmacy)
 Patient-related
• Age: one of most common risk factors for excessive
polypharmacy
• Female gender
 More pronounced in younger populations
 Evens out ~age 70
• Race
 84% of white Americans use meds
 57% Asian descent
• Socioeconomic—conflicting data
 Higher risk with good insurance coverage
 Less wealthy
 Less educated

Patient-related
• Clinical conditions
 Cardiovascular disease (Odds Ratio 4.5)
 Anemia (4.1)
 Respiratory disease (3.6)
 Depression, HTN, asthma, angina, diverticulitis, osteoarthritis,
gout, DM
• Medication therapy
 5 most prevalent drug groups for patients with 5+ meds: Abx,
analgesics, psycholeptics, antithrombotics, B-blockers
• Self-treatment
 1/3 of 75yo in community use 3+ OTC drugs daily
 37% take Rx drugs without PCP’s knowledge
 Old prescription use, borrowing/sharing often unreported
 Physician-related
• Practice environment: lack of time and high
workload results in meds remaining in pt records
longer than necessary
• Education and competence levels
 However, age or time in practice is not associated
• Male gender
• Difficulty applying guidelines to patients with
multiple diseases
 Physician-related
• Prescribing habits
 Patient expectation of a prescription
 ADRs resulting in prescribing cascade
• Improper medical review
• Lack of communication between PCPs,
specialists, and hospitalists
• Skepticism regarding new guidelines, resulting
in fall-back on older prescribing practices
(improper dosing, multiple meds)
 Related
to Physician-Patient Interaction
• Adherence depends on confidence in physician
• Pt failure to review entire med list with physician
• Lack of continuity due to multiple health
providers, prescribers, and pharmacies
• Pt expectation of a prescription for each medical
visit
• Pt requesting specific medications
• Disagreement between pt and provider
regarding treatment
 Nursing
homes and Care homes
• Academic detailing with face-to-face interaction
•
•
•
•
between experts and prescribers
Nursing workshops
Family education
Computerized clinical decision support systems
Multidisciplinary team meetings
 Community and Hospital
• Multidisciplinary case conferences involving
geriatrician
• Combination of following likely required:
 Education
 Regular med review, MTM
 Important when Rx drug plan formularies change






Geriatrics consultation
Multidisciplinary team meetings
Computerized decision support systems
Regulatory policies and procedures
Improved documentation of medication indication
Increased vigilance during transitions of care
 Pros
• Easy to use
• Easy to incorporate into computer systems and
drug reviews
 Cons
• Includes some older drugs
• Harm from some drugs may be minor compared
to inappropriate prescribing of meds not on the
list
 START—22
indicators of drugs commonly
omitted
 STOPP--65 indicators--Focuses on drugdrug, drug-disease interactions, fall risk,
and med duplication
 Lowers rates of polypharmacy and drugdrug interactions, improves correct dosing
 More sensitive than Beers Criteria (one
study only)
 Easy to use, takes ~3 min to complete
 Used for nursing home residents
 Focus on clinical profiles and functional
status
 Used for:
•
•
•
•
Patients with 9+ meds
Initial assessments
Falls or behavioral disturbances
Admission for rehab
 Goal
is improved functional status and
mobility
 Limited data shows reduced polypharmacy,
healthcare costs and hospitalizations
A
R
Assess
• Beers criteria
• β-blockers
• Pain medications
• Antidepressants
• Antipsychotics
• Other psychotropics
• Vitamins and supplements
Review
• Drug–disease interactions
• Drug–drug interactions
• Adverse drug reactions
M Minimize
• Number of medications according to functional status
rather than evidence-based medicine
O Optimize
• For renal/hepatic clearance, PT/PTT, β-blockers,
pacemaker function, anticonvulsants, pain medications, and
hypoglycemics; gradual dose reduction for antidepressants
R
• Functional/cognitive status in 1 week and as needed
• Clinical status and medication compliance
Reassess
 Reduction
in mortality, hospitalization,
and cost
 Avg 2.8 drugs discontinued without
significant adverse effects
 82% discontinuation success
 Only
3 components are needed to detect
polypharmacy: indication, effectiveness,
and duplication
 Can be used for inpatient and
ambulatory patients
 Takes ~10 min to complete
 Does not address underuse of
appropriate prescribing
Item
Weight
Is there an indication for the drug?
3
Is the medication effective for the condition?
3
Is the dosage correct?
2
Are the directions correct?
2
Are the directions practical?
1
Are there clinically significant drug-drug interactions?
2
Are there clinically significant drug-disease/condition
interactions?
2
Is there unnecessary duplication with other drug(s)?
1
Is the duration of therapy acceptable?
1
Is this drug the least expensive alternative compared to others of
equal utility?
1
 Specific
meds in patient’s regimen are
assigned a value based on
anticholinergic properties and tallied
 The higher the ARS score, the lower the
physical function score
 Easy to calculate
 Time consuming and impractical in
clinical settings
3 Points
2 Points
1 Point
Amitriptyline hydrochloride
Amantadine hydrochloride
Carbidopa-levodopa
Atropine products
Baclofen
Entacapone
Benztropine mesylate
Cetirizine hydrochloride
Haloperidol
Carisoprodol
Cimetidine
Methocarbamol
Chlorpheniramine maleate
Clozapine
Metoclopramide hydrochloride
Chlorpromazine hydrochloride
Cyclobenzaprine hydrochloride
Mirtazapine
Dicyclomine hydrochloride
Loperamide hydrochloride
Paroxetine hydrochloride
Diphenhydramine hydrochloride
Loratadine
Pramipexole dihydrochloride
Fluphenazine hydrochloride
Nortriptyline hydrochloride
Quetiapine fumarate
Hydroxyzine hydrochloride and hydroxyzine
Olanzapine
pamoate
Ranitidine hydrochloride
Hyoscyamine products
Prochlorperazine maleate
Risperidone
Imipramine hydrochloride
Pseudoephedrine hydrochloride–triprodlidine
hydrochloride
Selegiline hydrochloride
Meclizine hydrochloride
Tolterodine tartrate
Trazodone hydrochloride
Oxybutynin chloride
Perphenazine
Promethazine hydrochloride
Thioridazine hydrochloride
Thiothixene
Tizanidine hydrochloride
Trifluoperazine hydrochloride
Ziprasidone hydrochloride
 Similar
to ARS—describes
anticholinergic and sedative drug
burden
 Higher DBI associated with reduced
physical and cognitive function
 Potential to be incorporated into DUR
software, but not readily available to most
clinicians
 Need studies to determine if improving
DBI score results in better outcomes
 medications are graded:
• A: indispensible, with obvious benefit
• B: proven efficacy but limited effects or possible
safety concerns;
• C: questionable efficacy or safety
• D: avoid
 no
significant decrease in the total number
of prescribed drugs or in the number of
negatively assessed drugs
 significant increase in positively assessed
drugs as well as appropriate prescribing
 need further validation
 Physiologic
changes
• Decline in Renal and Hepatic function
 Reduced clearance
 Accumulation
 More severe side effects if doses are not adjusted
• Reduced body weight, muscle mass, fluid
 Altered drug distribution—abx, phenytoin
• Increased fatty tissue
 Prolonged half-life of lipophilic drugs, i.e. diazepam
 Physiologic
changes
• Vision impairment—40% unable to read Rx label
• Hearing impairment
 Difficult to understand counseling
• Loss of dexterity
 Cognitive
Impairment
• Difficulty understanding and remembering
medication instructions, complex regimens
• 67% unable to understand information given

Medication Errors
• elderly are 4X as likely as those < 65 years of age to be
hospitalized for a medication error
• Nonadherence
• Inadequate Monitoring/Follow-up
 INR, dig levels, etc
• Accidental Overdose
 85% of elderly who present to ER with accidental overdose were
taking antidiabetics, warfarin, antiepileptics, digoxin, theophylline,
or lithium
• Insulin
 Pens/prefilled syringes vs. vials
 Simplify regimen, premixed insulins
 If regimen changes ensure pt knows to stop taking previouslyprescribed insulin
 “Start low and go slow”

Medication Errors
• Device Problems
 40% errors related to product or
device issues
 Pens
 Used like a vial
 Used as a single dose product (Forteo)
 Labeling (Apokyn mg vs. mL)
 Inhalers
 Dose counter malfunction (Asmanex
Twisthaler)
• Institute of Safe Medication
Practices ([email protected])
• FDA MedWatch
(www.fda.gov/Safety/MedWatch/H
owToReport/default.htm)
 Nonadherence
• 55% of Medicare beneficiaries are nonadherent
• Up to 40% who skip doses or stop drug do not
tell provider
• Reasons:
 Forgetfulness
 Side effects
 Perceived inefficacy
 Cost—76% more likely to have decline in overall
health
 Goals
of care
• Pt/family goals and values may not match clinician
expectation
• Quality of life and functional status may be more
important than maximally extending life expectancy
 Ex: recognition of advanced dementia as terminal illness
• VBP may financially penalize providers who take this
into consideration
• Risk vs. Benefit
 Consider remaining life expectancy, time to achieve
benefit from medication, and pt goals
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American Geriatrics Society updated Beers Criteria for potentially
inappropriate
medication use in older adults. American Geriatrics Society 2012 Beers Criteria Update
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Gokula M, Holmes HM. Tools to reduce polypharmacy. Clin Geriatr Med. 2012
May;28(2):323-41.
Hovstadius B, Petersson G. Factors leading to excessive polypharmacy. Clin Geriatr
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Medication Errors in Specific Situations and Populations. Pharmacist’s Letter. Volume
2011, Course Number 313.
Patient-centered care for older adults with multiple chronic conditions: a stepwise
approach from the American Geriatrics Society: American Geriatrics Society Expert
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Oct;60(10):1957-68.
PL Detail-Document, Potentially Harmful Drugs in the Elderly: Beers List. Pharmacist’s
Letter/Prescriber’s Letter. June 2012.
PL Detail-Document, STARTing and STOPPing Medications in the Elderly. Pharmacist’s
Letter/Prescriber’s Letter. September 2011.
American Society of Consultant Pharmacists’ Geriatric Pharmacotherapy Practice
Resource Center, available www.ascp.com/articles/geriatric-pharmacotherapy
Medication Use Safety Training For Seniors, available www.mustforseniors.org
Photo, www.caregivercollege.org
Photo, dangersofpolypharmacy.wordpress.com