Transcript Module 13. Polypharmacy of Older Adults

Polypharmacy of
Older Adults
Objectives
•
Describe the demographics of medication
usage
•
Identify the effects of physiologic changes on
drug absorption, distribution, and clearance
•
Describe adverse reactions to medications
•
Identify iatrogenic problems associated with
multigeriatric syndromes and their
medication regimens.
Objectives
• Discuss strategies for preventing
polypharmacy and enhancing medication
compliance / adherence.
• Appreciate complex cost issues related to
medications
• Discuss effects of tricyclic antidepressant
drugs on older adults
Polypharmacy
“many drugs”…indicates the
use of more medication than is
clinically indicated or warranted.
5+ drugs
2000 = 200 million visits to the
doctor
– No prescription (30%)
– Prescription of 1 - 2 drugs (30%)
– Prescription of 3+ drugs (30%)
The Typical Older Adult…..
• Takes 4 to 5 prescription and 2 OTC drugs
at a time; fills 12 – 17 prescriptions/year
• Is on fixed income, whose main source of
income is Social Security
• Spends an average of $955 for
medications
• In ambulatory: 2 – 4 prescription drugs
• In long term care: 2 – 20 prescription
drugs
Physician Factors
• Presuming patient expects prescription
medication and no medication review
• Prescribing without sufficient
investigation of clinical situation
• Unclear, complex, incomplete
instruction; not simplifying the regimen
• Ordering automatic refills
• Lack of knowledge of geriatric clinical
pharmacology……inappropriate
prescribing
Patient Factors
• Seeing multiple physicians and pharmacies
• Hoarding of medications
• Inaccurate reporting of ALL medicines
concurrently being taken
• Assuming that when medication starts, they
can continue indefinitely
• Changes in daily habits
• Changes in cognition, depression, insufficient
funds, declining function, living alone
Polypharmacy leads to…
• Adverse drug reactions
• Drug-drug interactions
• Decreased medication
compliance
• Poor quality of life
• Unnecessary drug expense
Effects of Physiologic Aging
• Absorption
– Delayed gastric emptying;
decreased gastric acidity;
decreased splanchic blood flow
• Drug Distribution
– Higher percentage of fat; decreased
total body water; decreased plasma
albumin concentration
Effects of Physiologic Aging
• Serum Concentration
– Change in body composition
changes serum concentration of
water-soluble drugs
– Change in fat mass affect
concentration of fat-soluble
medications
• Drug Clearance
– Altered liver metabolism;
decreased renal excretion of drugs
Adverse Drug Reactions
• Simulate conventional image of
‘growing old’: unsteadiness,
confusion, nervousness, fatigue,
insomnia, drowsiness, falls,
depression, incontinence,
malaise
• Criteria for potentially
inappropriate medication use in
older adults (US Consensus
Panel of Experts, 2003)
Adverse Drug Reactions
• Fifth leading cause of death in
older adults
• Falls from orthostatic hypotension
• Confusion and disorientation
• Hepatic toxicity
• Renal toxicity
• *Creatinine clearance formula
Iatrogenic Problems
• Anticholinergics: confusion;
orthostatic hypotension; dry
mouth; blurred vision; urinary
retention
• Tricyclics: confusion and unstable
gait
• Antiemetics: confusion; orthostatic
hypotension; blurred vision; falls;
dry mouth; urinary retention
Iatrogenic Problems
• Digoxin: toxicity
• H2 Blockers: confusion
• Benzodiazepines: CNS toxicity
• Narcotics: constipation; “start low;
go slow”
Preventing polypharmacy
• Requires social and nursing
support
• Enhancing compliance:
– Patient education – written
instruction
– Sensitivity to lack of money to buy
medications
– Counseling
– Need to take medication even if
‘feeling good’
Enhancing compliance
• Improve provider-patient
communication: more time with
physician and pharmacist
• No pill sharing
• Assess other remedies patient uses
• Support Systems: Medication Event
Monitoring systems (MEMS)
• At least yearly, ask patient to bring ALL
medications for review
Cost of Medications
• 65% of noninstitutionalized Medicare
beneficiaries – have some form of
prescription drug coverage
– Spend less ($310/year) than those
without drug coverage ($590/year)
– 60% employer-sponsored or private
policy
– 20% Medicare + Choice HMO
– 20% supplemental Medicaid, other
public programs
Cost of Medications
Medicare Prescription Drug,
Improvement and Modernization
Act of 2003 (comprehensive plan
will be effective 1/2006)
The Discount Card Program
– NOT a comprehensive benefit
– Voluntary and temporary
– Immediate assistance in lowering
drug costs for 2004 and 2005
Cost of Medications
The Discount Card Program
• Medicare will contact private companies:
10% – 25% savings
• Choose a prescription drug plan; pay a
premium $35.00
• Pay $250.00 deductible; Medicare will pay
75% of cost from $250 to $2,250
• Recipient will pay 100% from $2,250 $3,600
• Medicare will pay 95% after recipient
spends $3,600
MEDICAID PRESCRIPTION
DRUG COVERAGE COST
STRATEGIES
Formularies
Preferred
Drug List
Imposing
Co-payments
Federal Drug
Rebate Program
Preauthorization
Access to
Prescription
Drugs for lower
Income seniors
Dispensing
Limits
FAIL FIRST
Generic
Substitution
Cost of Medications
• Older adults save money on
prescription drugs by
– Cutting medications in half
– Borrowing money from friends
– Discontinuing certain medications
because they ‘feel good’
Tricyclic antidepressants
• Cause adverse anticholinergic effects
• Caution when using in older adults
with glaucoma and cardiac
arrhythmias
• Hypotension, tachycardia, and
arrhythmia
• Sedation, fatigue, anxiety, impaired
cognitive function, seizures,
extrapyramidal symptoms
Summary
• Demographics of medication usage
• Physiologic changes of aging and
effects on drug absorption, distribution
and clearance
• Adverse drug reactions
• Iatrogenic problems
• Preventing polypharmacy / enhancing
compliance
• Cost Issues
• Effects of tricyclic antidepressants
QUESTIONS?