Transcript No Slide Title

Principles of Drug Use:
Prescribing for the Elderly
Thomas R. Clark, RPh, MHS
ASCP Director of Policy & Advocacy
American Society of Consultant Pharmacists
America’s Senior Care Pharmacists®
“Medications are probably the
single most important health care
technology in preventing illness,
disability, and death in the
geriatric population”
Avorn, J. Medication use and the
elderly: current status and
opportunities. Health Affairs.
1995(Spring):278-86.
American Society of Consultant Pharmacists
America’s Senior Care Pharmacists®
Importance of geriatric drug therapy




Aging of population
High use of drugs in elderly
Prevalence of medication therapy
problems
Shift from nursing facility to home and
community-based services
American Society of Consultant Pharmacists
America’s Senior Care Pharmacists®
THE PROPORTION OF OLDER
AMERICANS IS GROWING
Year
% of People 65 & Older
1950
2000
2004
2050
8.3
12.4
12.7
20.6
Source: Health, United States, 2005. Figure 2. www.cdc.gov/nchs/data/hus/hus05.pdf
American Society of Consultant Pharmacists
America’s Senior Care Pharmacists®
Aging Trends
Those
over 85 will grow by 106%,
from 3.4 million in 2000 to close to 7
million by 2020
 By 2050, nearly 20 million Americans
will be age 85 or over
American Society of Consultant Pharmacists
America’s Senior Care Pharmacists®
Aging Trends
About half those age 85 and over
need assistance with daily living
 About half those age 85 and over
have some degree of cognitive
impairment
 About one out of five live in NF

American Society of Consultant Pharmacists
America’s Senior Care Pharmacists®
Persons Surviving to Age 90
1940: Seven percent
 2050: Forty two percent

American Society of Consultant Pharmacists
America’s Senior Care Pharmacists®
Rx Use in the US
22
Age Range
80+
20
65-79
50-64
13
35-49
6
18-34
3
0
5
10
15
20
25
Number of Prescriptions Filled per Year
Source: Center on an Aging Society, Georgetown
University, 2000
American Society of Consultant Pharmacists
America’s Senior Care Pharmacists®
Rx Use and Seniors

1998 - 34.4% of 2.733 billion Rxs
US Population
– 933 million Rxs for seniors
Rxs for seniors
Seniors
Rxs for non-seniors
Source: IMS 1998
American Society of Consultant Pharmacists
America’s Senior Care Pharmacists®
Rx Use and Seniors

In 2005, seniors comprised 12.5%
of the population and consumed
37% of prescriptions

By 2020, seniors will comprise
16% of the population and will
consume 49% of prescriptions
Source: US Census, IMS National Prescription Audit, July 2005
American Society of Consultant Pharmacists
America’s Senior Care Pharmacists®
Rx Use and Seniors
Typical NF Resident

75-85+ years of age

Average number of routine prescription
medications: 8.1

Average number of PRN prescription
medications: 3.2

Percent of residents receiving 9+ routine
medications per day: 41.1
American Society of Consultant Pharmacists
America’s Senior Care Pharmacists®
Rx Use and Seniors
Assisted Living
 13 medications/resident
American Society of Consultant Pharmacists
America’s Senior Care Pharmacists®
Medication Therapy Problems





Polypharmacy: drug use without
indication
Undertreatment: indication without
drug use
Dose too low
Dose too high
Adverse drug reaction
American Society of Consultant Pharmacists
America’s Senior Care Pharmacists®
Medication Therapy Problems




Drug interaction
Inappropriate drug
Lack of adherence or compliance
Medication error
American Society of Consultant Pharmacists
America’s Senior Care Pharmacists®
Polypharmacy

“As older patients move through time,
often from physician to physician, they are
at increasing risk of accumulating layer
upon layer of drug therapy, as a reef
accumulates layer upon layer of coral”

Jerry Avorn, quoted in Arch Intern Med 164:1957–59
American Society of Consultant Pharmacists
America’s Senior Care Pharmacists®
Polypharmacy

“The desire to take medicine is
perhaps the greatest feature which
distinguishes man from animals.”

Sir William Osler, in H. Cushing, Life of Sir
William Osler (1925)
American Society of Consultant Pharmacists
America’s Senior Care Pharmacists®
Polypharmacy

“One of the first duties of the
physician is to educate the masses
not to take medicine.”

Sir William Osler, Aphorisms from his Bedside
Teachings (1961) p. 105.
American Society of Consultant Pharmacists
America’s Senior Care Pharmacists®
Polypharmacy


“I firmly believe that if the whole
materia medica as now used could be
sunk to the bottom of the sea, it
would be all the better for mankind—
and all the worse for the fishes.”
Oliver Wendell Holmes, 1860
American Society of Consultant Pharmacists
America’s Senior Care Pharmacists®
Undertreatment

“Over the past few years, the pendulum has
swung from concern about the risks of
excessive prescribing of inappropriate or
unnecessary drug therapy to concerns about
the consequences of underprescribing of
potentially beneficial therapies to seniors (65
years and older).”

Rochon PA, Gurwitz JH. Prescribing for seniors:
neither too much nor too little. JAMA, 1999;282:113-5
American Society of Consultant Pharmacists
America’s Senior Care Pharmacists®
Examples of Undertreatment




Pain management
Pneumococcal and flu vaccine
Depression
Secondary heart attack prevention
American Society of Consultant Pharmacists
America’s Senior Care Pharmacists®
Quality of Health Care for Older Adults





Vulnerable elders receive about half of
recommended care
Preventive care suffers the most
Physicians often fail to prescribe recommended
medications
Care for geriatric conditions (e.g. falls,
incontinence) is poorer than care for medical
conditions such as hypertension
Source: Rand Research
http://rand.org/pubs/research_briefs/2005/RB9051.pdf
American Society of Consultant Pharmacists
America’s Senior Care Pharmacists®
Adverse Effects

“Any symptom in an elderly patient
should be considered a drug side
effect until proved otherwise.”

Gurwitz J, Monane M, Monane S, Avorn J.
Polypharmacy. In: Morris JN, Lipsitz LA, Murphy
K, et al. Quality Care in the Nursing Home. St.
Louis, MO: Mosby Year Book;1997:13-25.
American Society of Consultant Pharmacists
America’s Senior Care Pharmacists®
Adverse Drug Events (ADE)
Rate of ADEs requiring an ER visit for
persons 65 and over is more than twice the
rate for persons under age 65
 Rate of ADEs requiring hospitalization is
nearly seven times greater for persons age
65 or over versus persons under age 65.


Source: JAMA 2006;296(15):1858–66
American Society of Consultant Pharmacists
America’s Senior Care Pharmacists®
Inappropriate Drugs
Antibacterial to treat a viral infection
 “Beers medications” - medications
considered potentially inappropriate for
older adults based on risk versus benefit
(expert consensus)


Ref: Arch Intern Med 2003;163:2716–24
American Society of Consultant Pharmacists
America’s Senior Care Pharmacists®
Inappropriate Drugs

21% of older adults take one or more
medications categorized by Beers as
generally inappropriate

Source: Arch Intern Med 2004;164:1621–25.
American Society of Consultant Pharmacists
America’s Senior Care Pharmacists®
Medication Adherence





Social and economic factors
Health care system-related factors
Condition-related factors
Therapy-related factors
Patient-related factors
American Society of Consultant Pharmacists
America’s Senior Care Pharmacists®
Medication Adherence



More than 10% of hospital
admissions for older adults may be
due to nonadherence
Nonadherence costs the U.S. health
care system $100 billion per year
Source: Vermiere E. et al. Patient adherence to treatment:
three decades of research, a comprehensive review. J Clin
Pharm Ther 2001;26:331–42.
American Society of Consultant Pharmacists
America’s Senior Care Pharmacists®
Principles of Drug Use




Ask: Is treatment warranted?
Are nonpharmacologic alternatives
available?
Consider risk vs. benefit of drug therapy
Establish goals of therapy
– Quality of care
– Quality of life
– Functional status
American Society of Consultant Pharmacists
America’s Senior Care Pharmacists®
Goals of Therapy


“Is it quality of life or quantity of life?
Truthfully, if my destiny is to feel great now
and maybe shorten my future, I’d rather feel
well now.”
Source: Nancy Richardson, 60, of Wayland, Mass., referring to
risk versus benefit of estrogen therapy. Quoted in New York
Times, December 18, 2006 article by Gina Kolata, “Breast
Cancer News Brings a Range of Reactions”
American Society of Consultant Pharmacists
America’s Senior Care Pharmacists®
Principles of Drug Use



Consider the whole person, not just
one disease or one drug
Be aware of assumptions behind
clinical practice guidelines
Disease management may not be
adequate or appropriate if multiple
chronic diseases are present
American Society of Consultant Pharmacists
America’s Senior Care Pharmacists®
Questions?
American Society of Consultant Pharmacists
America’s Senior Care Pharmacists®