Transcript A Practical Approach to a Geriatric Patient

A Practical Approach to a
Geriatric Patient
Tatyana Gurvich, Pharm.D., CGP
USC School of Pharmacy
UCI Sr. Health Center
Queenscare Family Clinics
Glendale Adventist FPRP
Medication-Related Problems in
the Elderly

Common, Costly and Preventable

Total estimated healthcare expenditure related to
potentially inappropriate medications is $7.2billion

27% of adverse events in primary care settings

42% of adverse events in long term care

380,000-450,000 adverse drug events occur annually
in hospitals.
JAGS 2012
Arch Int Med 2009
Contributing Factors

Multiple Medical conditions
 An
average of 6-7 Rx and 3-4 OTC daily
 40% have used some form of dietary
supplement
 ADR’s more common when taking 5 or more
meds daily
Multiple providers
 Time Constraints
 Patient driven prescribing

Prescribing challenges for older
patients
Is pharmacotherapy is beneficial
 Adverse reaction/Drug interaction
potential
 Prescribing Cascades
 Age related changes which alter drug
response in older adults
 Dosing of medications

Prescribing challenges for older
patients (cont)

Cost of medications/MediCare issues

New vs. Established Medications

Limitations of Pre-marketing Trials

Problem Medications
Geriatric Pharmacology:
Pharmacokinetics

Absorption
 Use
of PPI, H2Blockers, Antacids
 Medications with anti-cholinergic profile

Distribution
 Fat
soluble medications: an extended t1/2
 Water soluble medications: Higher
concentrations
 Dose adjustments are necessary
Metabolism: Drug Interactions

Differences in metabolism/drug interaction
potential within a drug class
 Statins:
Crestor/Pravachol fewer problems
 SSRI’s: Celexa/ Lexapro fewer problems
 H2blockers: Cimetidine more problems
 Antibiotics: Mixed

Additive effect
 Serotonin

syndrome/ QT prolongation
Plavix and PPI’s/ Codeine
PK: Excretion

Creatinine clearance declines with age

Serum Cr is a poor indicator of indicator and can
overestimate renal function
Dosing adjustment with reduced renal
function
 Vague guidelines which lack clinical
practicality



Bisphosphonates
Macrodantin
Pharmacodynamics
Blood Brain Barrier Permeability
 Increased Sensitivity medications

 CNS
acting medications
 Diabetes medications
 Consequences
 HTN
of low Blood Glucose
meds
 Consequences
 Drugs
of low Blood Pressure
with anti-cholinergic profile
Pharmacodynamics
 Examples
of altered response in geriatrics
 Oxybutinin
 Diphenydramine
 Albuterol
Inhaler
 Timoptic eye drops
Polypharmacy/Polymedicine

What is “polypharmacy”?
The use of unnecessary medications which
is independent of the number of medications
being taken
 Increases the risk of:

Adverse reactions
 Drug/Drug Interactions
 Prescribing cascades
 Compliance

The prescribing cascade

Drug induced adverse events which mimic symptoms of
other diseases or can precipitate confusion, and or falls.
 Prozac TO a FALL
 Prozac for depression. Ativan for Prozac induced anxiety and
insomnia. Pt became dizzy, fell and broke a hip
 Plendil TO a diagnosis of GERD and an ORTHO work up
 Plendlil for HTN; ORTHO work up ordered for Plendil induced
edema; PPI was added for GERD
 Verapamil TO Haldol
 Verapamil for HTN; Lasix for Verapamil induced CHF/Edema;
Ditropan for diuretic induced incontinence; Haldol for
Ditropan induced confusion and agitation due to its anticholinergic effects
ACOVE: Assessing Care of
Vulnerable Elders
 Document
drug indication
 Provide adequate pt education
 Maintain current medication list
 Document response to therapy
 Review ongoing need for therapy
Medication Considerations

Benzodiazepines: Long and short acting
 Risk

of confusion, falling, dependence
Non-BZD hypnotics: Avoid chronic use
 More

focus on behavioral management
Opioids: Increased risk of falls/fractures
 Tramadol
Clcr 30ml/min: SE/Seizure risk
Medication Considerations

Focus on Neuropathic pain alternatives:
 SNRI’s/Gapapentin/Pregabalin/Capsaicin/Lidoc
aine

Gabapentin/Pregabalin Clcr less 60ml/min
 Increased

risk of CNS side effects
Duloxetine less Crcl 30ml/min
 More
nausea/diarrhea
Medication Considerations
Mirtazapine/SNRI/ SSRI’s: SIADH; Check
Na when starting/changing dose
 SSRI’s: Increased risk of falling
 OTC Sympathomimetics: Stimulant effects

 Insomnia,

anxiety, agitation
Antipsychotics for behavior management
 Risk
of CVA and mortality; Risk vs. Benefit
Medications Considerations

NSAID’s
 PPI/misoprostol
doesn’t ELIMINATE risk
 Indomethacin/Toradol
 CHF and CKD risk
 Increase in blood pressure with chronic use

Skeletal muscle relaxants
 Poorly
tolerated, all on the Beer’s list
 Potentially habit forming
Medication Conisderations
Ca channel blockers: constipation/edema
 Verapamil/Diltiazem and CHF
 Beta blockers: Hypoglycemia; Fatigue
 Thiazides: SE and CrCl<30ml/min
 Clonidine: Bradycardia, orthostasis
 Alpha Blockers: Orthostasis

Medicaton Considerations

Miscelaneous GI medications

Reglan, Tigan, Lomotil*


Mineral oil


Absorption of fat soluble vitamins; risk of aspiration
H2 antagonists in dementia/delirium


DA antagonist; Anticholinergic side effects
Aniticholinergic effects
Na Containing Antacids

Substantial sodium load: Edema and increase in BP
Medication Considerations

Endocrine
 Sliding
scale insulin, Glyburide
 Actos/Avandia for CHF risk
 Desiccated thyroid
 Estrogen/Megace/Testosterone
 Lack
of cardio-protective/cognitive effect
 Lack of weight gain/increased thrombosis
 Cardiac risk/prostate cancer
Drugs with Strong Anti-cholinergic
Properties
 1st
Generation antihistamines/Loratadine*
 Artane/Cogentin
 Skeletal muscle relaxants
 TCA’s/Paroxetine*
 Old antipsychotics
 Compazine, Promethazine, Zyprexa
 Urinary and GI antispasmodics
 The concept of “anti-cholinergic load”
Steps to Reducing Poly-pharmacy
“Brown Bag” all medications at each office
visit. Keep accurate records
 Identify all medications by brand/generic
name and drug class
 All drugs prescribed should have a clinical
indication
 Stop any drug without known benefit
 Consider what effect drug therapy has on
quality of life

Steps to Reducing Polypharmacy (CONT)
Know the side effects of the drugs
prescribed and what to expect from them
 Understand the PK and
pharmacodynamics of drugs prescribed
 Substituting drugs within classes can
eliminate DI’s and ADR’s
 Be aware for the prescribing cascade
 “ONE DISEASE, ONE DRUG, ONCE DAILY”
 “START LOW, GO SLOW, BUT GO”
