Transcript Medication Management of the Older Adult: Making Health Care Safer

Medication Management of the
Older Adult: Making Health Care
Safer
Ron Stock MD
Dept. of Family Medicine
OHSU
[email protected]
April 12, 2013
Mrs. BJ
Mrs. BJ is an 80 year old woman who has been
healthy most of her life. She worked as a
housewife, has four grown children (who live far
away), is recently widowed, and lives alone. She still
drives, plays bridge with friends weekly, does most
of her housework, and manages her own money.
She has smoked 1 pack of cigarettes daily for 66
years, and drinks one – two Manhattens daily. She
has high blood pressure, mild type 2 diabetes,
osteoarthritis of the knees, cataracts, and some
COPD. She is slightly obese and has some difficulty
walking.
Mrs. BJ
• She is on 10 medications
– Albuterol/ipratropium
Inhaler QID
– Benzapril 10 mg QD
– Aspirin 325 mg QD
– Metoprolol 50 BID
– Simvastatin 20mg QD
– Tylenol PM at HS
– Paxil 20 mg QD
– Celecoxib 200 mg prn
– Metformin 500 mg BID
– Calcium/vitamin D TID
Well Elder
Vulnerable
Frail
The Nature of Chronic
Conditions
Condition Onset
Health
Capacity
Normal
Aging
Accelerated Loss of
Health Reserves
Progressive Conditions
Complex Care
Management
Disability
Acute Event
Time
Death
Health System Fails Seniors
End of Life Care
Falls
Dementia
Osterarthritis
Depression
Pneumonia
Heart Disease
9%
34%
35%
% time
appropriate
care given
31%
31%
49%
55%
0%
10%
20%
30%
40%
50%
60%
Wenger NS et al. Annals of Internal Medicine 2003 Nov
4;139(9):740-7
Aging & Meds
• Persons >65 yrs purchase 33% of prescription
drugs
• Drug regimens are more complex
• Older adults receive on average 13 Rx’s/year
and are on 5-7 Rx/day
• 30-50% discrepancy rate between med record
and patient’s home med list
• 30-50% of patients with chronic disease don’t
take meds as prescribed
• 48% of study participants misunderstood
instructions on prescription labels.
Aging & Meds
• At least 10% admitted to hospitals for an ADE
• Ambulatory setting ADEs occur commonly and
many are preventable
• >20% of elders receive at least one potentially
inappropriate med
• LTC: for every $1 spent on Rx, $1.33 in
healthcare resources to tx morbidity/mortality
• The “prescribing cascade”
Aging & Meds
What makes it so challenging?
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Polypharmacy
Little research on med effects in elders
Absorption
Distribution
Metabolism
Excretion (kidney and liver function)
Compliance barriers (social; economic;
family; memory)
The Medication Prescribing
Cycle of Life
Pharmacy
Primary Care Clinic
Specialist 2
Pharmacy
Specialist 1
Pharmacy
Pharmacy
Hospital Admit
(ICU to Stepdown unit to
Med-Surg unit)
Naturopath
Pharmacy
Pharmacy
Emergency
Department
Taking Medications
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Function
Splitting/crushing pills
Generic vs Brand
With or without food
Timing
Swallowing
Institute for Safe Medication
Practices (ISMP)
• www.ismp.org
– “Do not crush” medication list
– Guidelines for timing of meds
• GlobalRPh Drug-Food Interaction Table
– http://www.globalrph.com/drugfoodrxn.htm
Absorption of the med
• Overall amount absorbed through GI tract
not effected by age
• Rate may be slowed
• Greatest impact on absorption from:
– How it’s taken
– What it’s taken with
– Pts comorbid illnesses
Distribution in the body
• Water soluble drugs (hydrophilic) eg ethanol,
lithium, digoxin
• Fat soluble drugs (lipophilic) eg diazepam,
flurazepam, thiopental, trazodone
• Binding to proteins eg dilantin
Metabolism of the drug
• Liver most common site
– Smaller with age
– Reduced blood flow by as much as 45-50%
• Breakdown to drugs that have a greater or lesser effect
(Phase I)
• Breakdown to a drug that’s inactive (Phase II)
Elimination of the drug
• Hepatic/GI
• Renal
– Decr’d renal size; blood flow
– Use of serum Cr is limited
– Cockroft-Gault equation
• CrCl=(140-age)X wt/ 72(Cr)
– MDRD equation
Case
• GF is a 68 y/o F
– PMH: Type 2 Diabetes, HTN, GERD, HLP
– Medications: Metformin, glipizide, and
hydrochlorothiazide, simvastatin
• Diagnosed today with AFib
– Started on warfarin 5 mg daily
– Diltiazem 240 mg daily
• One week later:
– GF presents to the ER with bilateral LE
edema
– Given a prescription for Lasix 20 mg daily
• What is going on?
• 3 weeks later….
• GF falls in the middle of the night while
trying to get to the bathroom, she is
subsequently admitted to the hospital
• Upon discharge her medications have
been changed
– D/C lasix, diltiazem
– Start amiodarone 400 mg BID
• Given her current treatment plan would
you recommend any changes?
• Most current medication list
– Warfarin 5 mg daily
– Hydrochlorothiazide 25 mg daily
– Simvastatin 40 mg daily
– Amiodarone 400 mg BID
• It has been 1 month since hospital
discharge and GF is returning to clinic for
follow-up
• She complains today of feeling very weak
and have dark stools for the past week
• What is the most likely cause?
• Its been three months and GF has been
doing well. After her last discharge her
amiodarone was stopped and metoprolol
25 mg BID was started
• Her INR has been stable between 2 and
2.5 since her GI bleed
• She presents to the ER today with signs and
symptoms of a stroke
– INR on presentation 1.4
• Current medications
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Warfarin 5 mg daily
Simvastatin 20 mg daily
Hydrochlorothiazide 25 mg daily
Metoprolol 25 mg BID
St Johns Wort 1 tablet daily
• What is going on?
Adverse Drug Events
• Drugs for which regular outpatient
monitoring is used to prevent acute toxicity
accounted for 54% of hospitalizations
• Three medications caused 1/3 of ED visits
– Insulin
– Warfarin
– Digoxin
Adverse Drug Events
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Cardiovascular medications
Psychotropic medications
Antibiotics
Anticoagulants
NSAIDS
Anti-seizure medications
Most common drugs leading to
hospitalization
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Diuretics
Benzodiazepines
ACE inhibitors and hyperkalemia
Sulfonylurias and hypoglycemia
Digoxin
Overused drugs
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Sleepers
Antipsychotics for dementia
Tricyclic Antidepressants
Digoxin
Diuretics for edema
NSAIDs
H-2 blockers/ PPI’s
Laxatives/ Stool Softeners
Underused Meds
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ACE inhibitors
Anticoagulants
Beta-blockers
Antihypertensives
Bronchodilators
PPI or misoprostol for NSAID protection
Vitamin D and calcium
Drug-Drug Interactions
• Most common drugs: cardiovascular and
psychotropic
• Most common ADEs: delirium; hypotension;
ARF
• The cytochrome P-450 isoenzyme system
– 3A4 type metabolizes >50% of meds
– “rev’ed up” by dilantin, tegretol, St John’s Wort
– Inhibited by e-mycin, anti-fungals, grapefruit juice
Drug-Disease Interactions
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Obesity
Liver Cirrhosis
CHF
Renal insufficiency
Dementia
Assessing Care of Vulnerable
Elders (ACOVE)
ACOVE-3
Quality Indicators
1. Maintain a current list, including OTC’s,
reviewed annually
2. Have clearly defined “indications”
3. Patient education
4. Medication continuity
5. Avoid chronic or high-dose benzodiazepines
6. Avoid strong anticholinergics
7. Avoid barbiturates
8. Antipsychotic medication response
Tools
• Geriatrics At Your Fingertips
– http://www.geriatricsatyourfingertips.org/
• The Beer’s Criteria (List)
• Office-based key process components for med
management
• Stock R, Scott J, and Gurtel S. Using an
Electronic Prescribing System to Ensure
Accurate Medication Lists in a Large
Multidisciplinary Medical Group. J Comm Pt
Saf, 2009, 35(5): 271-277.
Key Process Components at
every Ambulatory Visit
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All patients will be asked to provide a current list of
meds, including OTC’s, herbals.
Clinic personnel will review the meds with patient at
beginning of office visit.
The pt’s med list and EMR med list will be reconciled
and documented.
Any new meds will be checked for interactions/conflicts
with an updated, reconciled med list in the EMR.
The patient will leave the ambulatory clinic encounter
with a paper copy of an updated, reconciled med list.
John Turner, MD
67 y/o
“I think physicians have a
responsibility to sell health
at least as much as they
sell pills.”
Growing Old is Not for Sissies
Etta Clark
Pomegranate Books
Petaluma, CA 1990