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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

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Polypharmacy of Older Adults

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  1. Polypharmacy of Older Adults

  2. 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.

  3. 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

  4. 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%)

  5. 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

  6. 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

  7. 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

  8. Polypharmacy leads to… • Adverse drug reactions • Drug-drug interactions • Decreased medication compliance • Poor quality of life • Unnecessary drug expense

  9. 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

  10. 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

  11. 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)

  12. 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

  13. 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

  14. Iatrogenic Problems • Digoxin: toxicity • H2 Blockers: confusion • Benzodiazepines: CNS toxicity • Narcotics: constipation; “start low; go slow”

  15. 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’

  16. 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

  17. 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

  18. 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

  19. 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

  20. MEDICAID PRESCRIPTION DRUG COVERAGE COST STRATEGIES

  21. 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’

  22. 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

  23. 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

  24. QUESTIONS?

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