Principles of Drug Use: Prescribing for the Elderly Thomas R. Clark, RPh, MHS ASCP Director of Policy & Advocacy. “Medications are probably the single most important health care technology in preventing illness, disability, and death in the geriatric population”.
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Principles of Drug Use:
Prescribing for the Elderly
Thomas R. Clark, RPh, MHS
ASCP Director of Policy & Advocacy
“Medications are probably the single most important health care technology in preventing illness, disability, and death in the geriatric population”
Avorn, J. Medication use and the elderly: current status and opportunities. Health Affairs. 1995(Spring):278-86.
Aging of population
High use of drugs in elderly
Prevalence of medication therapy problems
Shift from nursing facility to home and community-based services
Source: Health, United States, 2005. Figure 2. www.cdc.gov/nchs/data/hus/hus05.pdf
Those over 85 will grow by 106%, from 3.4 million in 2000 to close to 7 million by 2020
By 2050, nearly 20 million Americans will be age 85 or over
About half those age 85 and over need assistance with daily living
About half those age 85 and over have some degree of cognitive impairment
About one out of five live in NF
1940: Seven percent
2050: Forty two percent
Source: Center on an Aging Society, Georgetown University, 2000
1998 - 34.4% of 2.733 billion Rxs
933 million Rxs for seniors
Rxs for seniors
Rxs for non-seniors
Source: IMS 1998
In 2005, seniors comprised 12.5% of the population and consumed 37% of prescriptions
By 2020, seniors will comprise 16% of the population and will consume 49% of prescriptions
Source: US Census, IMS National Prescription Audit, July 2005
Typical NF Resident
75-85+ years of age
Average number of routine prescription medications: 8.1
Average number of PRN prescription medications: 3.2
Percent of residents receiving 9+ routine medications per day: 41.1
Polypharmacy: drug use without indication
Undertreatment: indication without drug use
Dose too low
Dose too high
Adverse drug reaction
Lack of adherence or compliance
“As older patients move through time, often from physician to physician, they are at increasing risk of accumulating layer upon layer of drug therapy, as a reef accumulates layer upon layer of coral”
Jerry Avorn, quoted in Arch Intern Med 164:1957–59
“The desire to take medicine is perhaps the greatest feature which distinguishes man from animals.”
Sir William Osler, in H. Cushing, Life of Sir William Osler (1925)
“One of the first duties of the physician is to educate the masses not to take medicine.”
Sir William Osler, Aphorisms from his Bedside Teachings (1961) p. 105.
“I firmly believe that if the whole materia medica as now used could be sunk to the bottom of the sea, it would be all the better for mankind—and all the worse for the fishes.”
Oliver Wendell Holmes, 1860
“Over the past few years, the pendulum has swung from concern about the risks of excessive prescribing of inappropriate or unnecessary drug therapy to concerns about the consequences of underprescribing of potentially beneficial therapies to seniors (65 years and older).”
Rochon PA, Gurwitz JH. Prescribing for seniors: neither too much nor too little. JAMA, 1999;282:113-5
Pneumococcal and flu vaccine
Secondary heart attack prevention
Vulnerable elders receive about half of recommended care
Preventive care suffers the most
Physicians often fail to prescribe recommended medications
Care for geriatric conditions (e.g. falls, incontinence) is poorer than care for medical conditions such as hypertension
Source: Rand Researchhttp://rand.org/pubs/research_briefs/2005/RB9051.pdf
“Any symptom in an elderly patient should be considered a drug side effect until proved otherwise.”
Gurwitz J, Monane M, Monane S, Avorn J. Polypharmacy. In: Morris JN, Lipsitz LA, Murphy K, et al. Quality Care in the Nursing Home. St. Louis, MO: Mosby Year Book;1997:13-25.
Rate of ADEs requiring an ER visit for persons 65 and over is more than twice the rate for persons under age 65
Rate of ADEs requiring hospitalization is nearly seven times greater for persons age 65 or over versus persons under age 65.
Source: JAMA 2006;296(15):1858–66
Antibacterial to treat a viral infection
“Beers medications” - medications considered potentially inappropriate for older adults based on risk versus benefit (expert consensus)
Ref: Arch Intern Med 2003;163:2716–24
21% of older adults take one or more medications categorized by Beers as generally inappropriate
Source: Arch Intern Med 2004;164:1621–25.
Social and economic factors
Health care system-related factors
More than 10% of hospital admissions for older adults may be due to nonadherence
Nonadherence costs the U.S. health care system $100 billion per year
Source: Vermiere E. et al. Patient adherence to treatment: three decades of research, a comprehensive review. J Clin Pharm Ther 2001;26:331–42.
Ask: Is treatment warranted?
Are nonpharmacologic alternatives available?
Consider risk vs. benefit of drug therapy
Establish goals of therapy
Quality of care
Quality of life
“Is it quality of life or quantity of life? Truthfully, if my destiny is to feel great now and maybe shorten my future, I’d rather feel well now.”
Source:Nancy Richardson, 60, of Wayland, Mass., referring to risk versus benefit of estrogen therapy. Quoted in New York Times, December 18, 2006 article by Gina Kolata, “Breast Cancer News Brings a Range of Reactions”
Consider the whole person, not just one disease or one drug
Be aware of assumptions behind clinical practice guidelines
Disease management may not be adequate or appropriate if multiple chronic diseases are present