Transcript Mod II: Drug Therapy in the Elderly

UMMS CRIT Module II: Drug Therapy in the Elderly
Jerry H. Gurwitz, MD
Chief, Division of Geriatric Medicine
University of Massachusetts Medical School
UMass Memorial Medical Center
It is much easier to write upon a disease than upon a remedy.
The former is in the hands of nature and a faithful observer with
an eye of tolerable judgement cannot fail to delineate a likeness.
The latter will ever be subject to the whim, the inaccuracies and
the blunder of mankind.
William Withering (1741-1799)
UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
A desire to take medicine is, perhaps, the great feature which
distinguishes man from other animals.
Sir William Osler, 1891
UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
“I know of no way to end an office visit as satisfactorily and as
efficiently as by writing a prescription. The patient knows that
the visit is over and is expected to leave. He has something in
his hand that he thinks will help him and obtaining it required
an office visit.”
Marcus Reidenberg, MD
Editor Emeritus, CP&T
UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Drug Use in the Elderly
• 57% of all elderly use > 5 drugs per week
• 19% of elderly use > 10 drugs per week
UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Suboptimal Medication Use
• Overuse
• Inappropriate prescribing
• Underuse
Hanlon JT et al. JAGS. 2001;49: 200-9.
Fisk D et al. Arch Intern Med. 2003;163: 2716-2724.
UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Polypharmacy
Polypharmacy is not necessarily bad!
UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Drug Regimen Changes ~They are very common!
• Any transition - hospitalizations, discharges, ER visits, subacute
care stays
• New meds, different doses…
• Changes from generic to brand- nomenclature, color and/or shape
UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Why so many changes?
• The more providers and visits, the more medications are
prescribed
• 2/3 of all physician visits end with a prescription
• Expectations of the patient to receive a prescription
• Lack of communication between prescribers
• Self-treatment: unbeknownst to the physician
UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Impact on the Patient
• Increased risk of adverse drug events and near-misses
• Noncompliance or nonadherence leading to poor outcomes
• Increased costs
UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Factors Influencing Drug Effects and Risk of
Adverse Effects in the Elderly
• Multiple co-existing illnesses
• Polypharmacy: redundant effects and drug-drug interactions
• Adverse drug effects nonspecific
• Pharmacologic changes with aging
• Medical error
UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Pharmacokinetics: Changes with Aging
• Absorption
• Distribution
• Metabolism
• Excretion
UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Body Composition Changes in Adult Men with Aging
Age Group
Body Weight
(kg)
Body Fat (kg)
Muscle Mass
(kg)
20-29
80
15
24
30-49
81
19
20
60-69
79
23
17
70-79
80
25
13
Data adapted from Cohn et al, 1980
UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Hepatic Metabolism of Drugs
Changes with Aging
• Phase I reactions- primarily oxidative reactions
– Decline in efficiency with aging
• Phase II reactions- conjugation reactions
– No decline in efficiency with aging
UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
CREATININE CLEARANCE
Renal Function: Changes with Aging
Age
UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
t1/2 ~ Vd/Clearance
UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Pharmacodynamics: Changes with Aging
UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Clinical Pearl
Any new symptom in an elderly patient should be
considered a drug side effect until proven
otherwise.
Jerry Avorn, MD
UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
The Prescribing Cascade
Drug 1
ADE
Drug 2
UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
The Prescribing Cascade
Metoclopramide
Extrapyramidal Effects
Levodopa Rx
UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Case-Control Study Design
CLASSIFY/COMPARE
BEGIN
Metoclopramide:
Yes or No?
L-dopa
Rx
Metoclopramide:
Yes or No?
Controls
UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Results
Metoclopramide users were over three times more
likely to begin use of L-dopa therapy compared with
non-users (OR=3.09; 95% CI 2.25 to 4.26).
UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Likelihood of L-dopa Treatment by Metoclopramide Dose
UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Conclusion
Metoclopramide confers an increased risk for the
initiation of treatment generally reserved for the
managment of idiopathic Parkinson’s disease.
Avorn et al, JAMA, 1995
UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Improving the Quality of Prescribing to Older Adults
• Medication reconciliation – at time of transitions
• Anticipate errors – prescribing & monitoring
• Watch out for prescribing cascades
• Simplify the medication regimen
• Identify obstacles (costs, cognitive impairment)
• Enlist family/nursing/PCP support & involvement
• Make sure there is good follow-up
UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Lessons from the Case
UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation