Transcript Prescribing in Elderly Populations-Buchman

Prescribing in
Elderly
Populations
C H R I S T I N A B U C H M A N , P H A R M . D.
C l i n i c a l A s s i s t a n t P r o fe s s o r a t Wa s h i n g t o n S t a t e U n i v e r s i t y
C o l l e g e o f P h a r m a c y Ya k i m a E x t e n s i o n P r o g r a m
Learning Objectives
By the end of this seminar, the learner should be
able to:
◦ Identify risk factors present when prescribing to elderly
patients
◦ Discuss interventions to decrease ADEs in senior
populations
What Defines “Elderly”?
Age alone is not a good
description
Look at overall function with
categories
◦ youngest old (65-74)
◦ middle old (74-85)
◦ oldest old (85 and above)
Geriatric patients
◦ Gait abnormalities and/or falls
◦ Depression
◦ Fatigue
◦ Cognitive impairment
◦ Dementia with or without
behaviors
◦ Urinary incontinence
◦ Reduced strength
◦ Sedentary lifestyle
◦ Weight loss
Reference: http://my.clevelandclinic.org/services/medicine-institute/geriatric-medicine/patient-caregiver-education
Medication Use in the Elderly
Elderly make up 12%-13% of U.S. population
◦ Take 30% of all prescription drugs
Among people 65 years and older:
◦ 90% use at least 1 drug per week
◦ >40% use at least 5 drugs per week
◦ 12% use 10 or more drugs per week
40% of people who suffer adverse drug reactions
(ADRs) are over 60 years of age
◦ 1/6th of hospital admissions are related to ADRs
Pharmacodynamic/Pharmacokinetic
Differences in Geriatric Patients
Why do we focus on geriatric patients with regard
to medications?
◦ Decreased CLEARANCE
◦ Increased SENSITIVITY
◦ Multiple MEDICATIONS
◦
Geriatric Differences (cont.)
Greater likelihood of CONFUSION
Potential multiple MEDICAL CONDITIONS
◦ Increased risk of DRUG INTERACTIONS / SIDE EFFECTS
◦ Treatment more confusing for the patient
Physical LIMITATIONS
COST issues may be more likely
Adverse Drug Reactions
70% of ADRs Result From:
◦ Unnecessary Drugs
◦ Drug-Drug Interactions
◦ Contraindicated (drugs that should not be used in that person, e.g.,
people with certain heart conditions should not receive certain
drugs for the treatment of Alzheimer’s disease)
Likelihood
◦ 2 drugs used : 6%
◦ 5 drugs used : 50%
◦ 8 drugs used : 100%
◦ (must note that not all of these may result in harm or are always
critical)
Drug Classes of Concern in the Elderly
The Beers Criteria
Developed by the American Geriatrics Society and
last updated in 2015
3 categories of drugs
◦ Inappropriate – Always to be avoided
◦ Potentially inappropriate – To be avoided in certain
diseases or syndromes
◦ To be used with caution – Benefit may offset risk in some
patients
Beers Criteria Medications
Class
Drugs
Recommendation
Quality of Evidence/
Strength of Rec.
Anticholinergics
First gen antihistamines (diphenhydramine),
Antiparkinsonian agents (benztropine), Antispasmodics
(dicyclomine)
Avoid
Moderate/Strong
Antithrombotics
Dipyridamole, ticlopidine
Avoid
Moderate/Strong
Anti-infectives
Nitrofurantoin
Avoid long term use and if
CrCl<30
Low/Strong
Cardiovascular
Peripheral alpha-1 blockers (doxazosin), central alpha
blockers (clonidine)
Amiodarone/dronaderone, Digoxin
Avoid to control HTN
Moderate/Strong
Avoid as 1st-line
High/Strong
Antidepressants (TCAs, paroxetine), barbiturates,
benzodiazepines, sedative/hypnotics (z-drugs)
Antipsychotics (1st and 2nd gen)
Avoid
High/Strong
Avoid-unless dx need
Moderate/Strong
Endocrine
Androgens, Estrogen
Desiccated thyroid
Sliding scale insulin (↑risk, no benefit)
Sulfonylureas (long-acting)
Avoid
Moderate/Weak
High/Strong
Moderate/Strong
High/Strong
Gastrointestinal
Metoclopramide (EPS effects)
PPIs
Avoid
Avoid long term
Moderate/Strong
High/Strong
Pain Medications
NSAIDs (non-COX-selective)
Muscle relaxers
Avoid chronic use
Avoid
Moderate/Strong
CNS
STOPP-START Tool for Safe Prescribing
in the Elderly
Outlines criteria for stopping or starting medications in
patients 65 years and older
Many categories
◦ Cardiovascular
◦ Antiplatelet/Anticoagulant
◦ CNS and Psychotropic
◦ Others
Similar recommendations to Beers Criteria List
◦ Recommendations more specific and explicit
Validated by Delphi method
Most recent update in 2015
STOPP – Section B: Cardiovascular
System
Potentially inappropriate prescribing includes:
1. Digoxin for heart failure with normal systolic ventricular function (no clear evidence of benefit).
2. Verapamil or diltiazem with NYHA Class III or IV heart failure (may worsen heart failure).
3. Beta-blocker in combination with verapamil or diltiazem (risk of heart block).
4. Beta blocker with bradycardia (< 50/min), type II heart block or complete heart block (risk of complete heart block, asystole).
5. Amiodarone as first-line antiarrhythmic therapy in supraventricular tachyarrhythmias (higher risk of side-effects than beta-blockers,
digoxin, verapamil or diltiazem).
6. Loop diuretic as first-line treatment for hypertension (safer, more effective alternatives available).
7. Loop diuretic for dependent ankle edema without clinical, biochemical evidence or radiological evidence of heart failure, liver failure,
nephrotic syndrome or renal failure (leg elevation and /or compression hosiery usually more appropriate).
8. Thiazide diuretic with current significant hypokalemia (i.e. serum K+ < 3.0 mmol/l), hyponatremia (i.e. serum Na+ < 130 mmol/l)
hypercalcemia (i.e. corrected serum calcium > 2.65 mmol/l) or with a history of gout (hypokalemia, hyponatremia, hypercalcemia and gout
can be precipitated by thiazide diuretic).
9. Loop diuretic for treatment of hypertension with concurrent urinary incontinence (may exacerbate incontinence).
10. Centrally-acting antihypertensives (e.g. methyldopa, clonidine, guanfacine), unless clear intolerance of, or lack of efficacy with, other
classes of 2 antihypertensives (centrally-active antihypertensives are generally less well tolerated by older people than younger people).
11. ACE inhibitors or Angiotensin Receptor Blockers in patients with hyperkalemia.
12. Aldosterone antagonists (e.g. spironolactone, eplerenone) with concurrent potassium-conserving drugs (e.g. ACEI’s, ARB’s, amiloride,
triamterene) without monitoring of serum potassium (risk of dangerous hyperkalemia i.e. > 6.0 mmol/l – serum K should be monitored
regularly, i.e. at least every 6 months).
13. Phosphodiesterase type-5 inhibitors (e.g. sildenafil, tadalafil, vardenafil) in severe heart failure characterized by hypotension i.e. systolic
BP < 90 mmHg, or concurrent nitrate therapy for angina (risk of cardiovascular collapse).
Case 1
KH is a 78 year old female with a history of diabetes (type 2),
insomnia, hypertension, hypothyroid, and osteoarthritis. Her
current renal function (GFR) is estimated at 36 mL/min. She is
taking glyburide 5mg daily, levothyroxine 80mcg daily,
acetaminophen 1000mg TID, atenolol 50mg daily, diltiazem XR
120mg daily, amitriptyline 50mg at bedtime and Tylenol PM as
needed to sleep. She has no reported allergies.
Which of her current medications are concerning in the elderly?
A.
B.
C.
D.
E.
Acetaminophen
Tylenol PM
Atenolol
Amitriptyline
Glyburide
Drug-Related Problems in the Elderly
Prescribing Cascade
Drug 1
ADE interpreted as new
medical condition
Drug 2
ADE interpreted as new
medical condition
Drug 3
Prescribing Cascade Example
Drug-induced Parkinsonism can result from
commonly used antiemetics (metoclopramide,
promethazine) and antipsychotics (all except
quetiapine and clozapine)
Can lead to misdiagnosis as new onset Parkinson’s
disease and treatment with a new drug
◦  start acetylcholinesterase inhibitor (donepezil)
◦  new onset of urinary incontinence
◦  adding an anticholinergic medication (oxybutynin)
◦  and so on
Drug-Disease interactions
Disease
Drugs
Heart Failure (exacerbate HF or
promote fluid retention)
Cilostazol, NSAIDs (including COX-2 Inhibitors), donaderone, non-dihydropyridine Ca
channel blockers, thiazolidinediones
Syncope (risk of orthostatic
hypotension and bradycardia)
AChE Inhibitors, chlorpromazine, peripheral α-blockers, TCAs, olanzapine, thioridazine
Seizures/epilepsy (lowered seizure
threshold)
Bupropion, chlorpromazine, clozapine, maprotiline, olanzapine, thioridazine,
thiothixene, tramadol
Delirium (worsening)
TCAs, benzodiazepines, anticholinergic drugs, chlorpromazine, corticosteroids, H2
blockers, meperidine, sedative hypnotics, thioridazine
Dementia/Cognitive Impairment
Antipsychotics (chronic and as-needed use), benzodiazepines, anticholinergic drugs, H2
blockers, zolpidem
Hx of falls or fractures
Anticonvulsants, antipsychotics, benzodiazepines, nonbenzodiazepine hypnotics, TCAs,
SSRIs
Chronic Constipation
Antispasmodic and anticholinergic drugs, TCAs, first-generation antihistamines, nondihydropyridine Ca channel blockers, oral antimuscarinics for urinary incontinence
Urinary incontinence
Estrogen (in women), α-blockers
BPH/ urinary retention
Drugs that have strong anticholinergic effects (except antimuscarinics for urinary
incontinence), inhaled agents that have anticholinergic effects
Other Drug-Related Problems:
Drug-drug interactions
◦ The elderly take a large number of drugs and often take herbal and dietary supplements
◦ Drug-drug interactions are different in the elderly due to pharmacokinetic and pharmacodynamics
differences
Inadequate monitoring
◦ Documenting indications for new medications, keeping a current list, monitoring for efficacy and ADEs,
periodic review for necessity
Inappropriate drug selection
◦ START criteria can help guide agent choice
Lack of patient adherence
◦ Financial/physical constraints, cognitive decline, multiple drugs, multiple times a day dosing
Overdosage
◦ Renally cleared drugs, start low and go slow
Under prescribing
◦ Commonly under prescribed: opioids, β-blockers, antihypertensives, Alzheimer drugs, anticoagulants,
immunizations
Case 2
LT is a 69 year old male with a history of diabetes (type 2),
hypertension, hyperlipidemia, and gastroparesis secondary to
diabetes. His current medications include Lantus 80 units
QHS, metformin XR 1000mg daily, simvastatin 40mg daily,
benazepril 20mg daily, and metoclopramide 10mg prior to
meals. He came into the clinic last month with a new onset
tremor at rest and was diagnosed with new onset Parkinson’s
Disease. He started levodopa 250mg BID at that time and it
has since improved his symptoms.
What are the issues with this case?
What would you like to change in this case?
Bringing it all together
Case 3: “Spiraling out of control”
MM is an 86 y/o Asian woman who presents to the clinic with increased
confusion and agitation
Patient speaks fluent Cantonese and minimal English
Patient’s daughter is the primary source of patient’s medical history
Chief complaint: patient is “Spiraling out of control”
Daughter reports the following about MM:
◦
◦
◦
◦
◦
◦
worsening memory, difficult to manage
got lost on way home
non-adherent to medications
trouble sleeping
worsening bladder control
worsening OA pain (hands)
Case 3
Family/Social History: Lives at home with her 61 y/o
daughter who recently retired as a seamstress
Rx payment: Medicare Part D coverage with step
therapy
Pharmacy(ies) used: Uses multiple pharmacies
where patient’s daughter can get the lowest drug
prices
Case 3: Medications and OTC
Case 3: Physical Exam and Lab
Vital signs
◦ BP= 134/82 mm Hg; Pulse= 73 bpm, regular; Temp = 98.4 °F; RR = 18/min
◦ Height = 4’ 10” Weight = 90 lbs. BMI =18.8 kg/m2
Pain score 6/10
MMSE = 16/30 (21/30 4 months ago)
Lab test
◦
◦
◦
◦
Ca2+= 9.1 mg/dL | Mg = 2.2 mEq/L | PO4 = 4.2 mg/dL
Albumin = 3.8 d/dL | Bili = 0.8 mg/dL | Alk Phos = 88 U/L
AST= 32 U/L | ALT= 37 U/L
TSH = 0.22 μU/mL
Bone density screening from a community pharmacy event
◦ T-score: < -1 (Reference: > -1 Low risk; 0 to -1 Moderate risk; < -1 high risk)
Case 3: Review of Systems
General: confused and agitated
HEENT: diminishing vision
Musculoskeletal: pain in both hands, unable to grip
well and dropping things, some difficulty buttoning
blouse
GU: incontinence, with 3-5 accidents/week,
including evenings
Case 3: Caregiver Assessment
Daughter is the sole caregiver to MM
Daughter feels guilty about putting MM in a nursing
facility and wants to continue to care for her
mother in their own home
Cost for caring for MM is becoming a burden
Resorted to using herbal remedy and OTC
medication to minimize drug cost
Case 3: Dementia
What labs do we have that could contribute to her
worsening cognition?
What other labs should be drawn for MM to better
evaluate her declining cognition?
What is the most likely cause of her sudden
cognitive decline?
◦ MMSE = 16/30 (21/30 4 months ago) – moderate
dementia
Drug-induced Dementia
Diphenhydramine has strong anticholinergic properties, but
due to the low dose and frequency used, it is unlikely to
cause significant cognitive adverse effects
Valerian root is an herbal product used to aid in sleeping.
Valerian root has been shown to inhibit of CYP 3A4 in vitro
studies
Darifenacin for MM’s OAB is a CYP 3A4 substrate that also
strong anticholinergic properties
Valerian root could have exacerbated anticholinergic adverse
effect from Darifenacin
PLAN: discontinue valerian root tea
Dementia Treatment
MM is diagnosed with moderate Alzheimer’s
disease dementia. Which of the following would be
the best treatment for her?
A.
B.
C.
D.
Memantine 5 mg daily
Donepezil 5 mg at bedtime
Rivastigmine 4.6/24 hrmg patch daily
Donepezil 5 mg at bedtime plus memantine5 mg daily
Case 3: OAB
MM’s daughter also reports that her mother has
worsening bladder control. Which of the following
are possible predisposing factors?
A. Cognitive impairment, thyroid disease, and
constipation
B. Glaucoma, thyroid disease, and osteoarthritis
C. Poor medication adherence, glaucoma, and
constipation
D. Thyroid disease, glaucoma, and constipation
Treatment for OAB
Which of the following medications is best suited
for MM’s worsening OAB because of minimal
cognitive adverse effects and potential for drug
interaction?
A.
B.
C.
D.
Mirabegron
Fesoterodine
Tolterodine
Trospium
Case 3: Osteoarthritis
MM’s osteoarthritis pain is poorly controlled. Her
physician wants to discontinue the
acetaminophen/codeine due to concerns about
cognitive impairment and the risk for falling. Which of
the following would be the best recommendation to
treat MM’s OA pain?
A. Start diclofenac 1% gel 2 g 4 times a day to the affected
area
B. Start naproxen 500 mg po twice daily
C. Start tramadol 50 mg po every 6 hours
D. Increase the dose of plain acetaminophen from 650 mg po
three times daily to 650 mg po every 6 hours
Wrapping it up
MM has other conditions that need managed
today:
◦ Osteoporosis
◦ T-score of <-1 High risk at screening event.
◦ Glaucoma
◦ Daughter reports not being able to refill her mother’s prescription for
tafluprost due to its high cost ($165/month).
◦ Hypothyroid
◦ TSH was 0.22 μU/mL
Questions?
You can email questions to me at
[email protected]
Thanks!!
References
1.
2.
3.
4.
Ruscin JM, Linnebur SA. Drug Therapy in the elderly (June 2014). Merck
Manual Professional Version Web site. Available at:
http://www.merckmanuals.com/professional/geriatrics/drug-therapyin-the-elderly/introduction-to-drug-therapy-in-the-elderly. Accessed
February 16, 2017.
Rochon PA, Gurwitz JH. Optimizing drug treatment in elderly people:
the prescribing cascade. BMJ 1997;315:1097.
O'Mahony D, O'Sullivan D, Byrne S, O'Connor MN, Ryan C, Gallagher P.
STOPP/START criteria for potentially inappropriate prescribing in older
people: version 2. Age Ageing. 2015 Mar;44(2):213-218.
Clinical Pharmacology [database online]. Tampa, FL: Gold Standard, Inc.;
2017. URL: http://www.clinicalpharmacology.com.