The Bagful of Pills: Polypharmacy in the Elderly. Oana Marcu DO Swedish Family Medicine March 7, 2006. Objectives. Discuss the profound medical and economic consequences of polypharmacy Discuss unique pharmacokinetics in the elderly and identify high risk medications
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The Bagful of Pills: Polypharmacy in the Elderly Oana Marcu DO Swedish Family Medicine March 7, 2006
Objectives • Discuss the profound medical and economic consequences of polypharmacy • Discuss unique pharmacokinetics in the elderly and identify high risk medications • Propose a plan for preventing ADRs and improving quality of life!
Definitions Polypharmacy: use of more then 5 medications • inappropriate prescribing of duplicative medications where interactions are likely Adverse Drug Reaction (ADR): • drug interaction that results in an undesirable/unexpected event that requires a change in management
Adverse Drug Reaction (ADR) ADRs occur as a result of • Drug-drug interactions • Drug-disease interactions • Drug-food interactions • Drug side effects • Drug toxicity
Consequences: Quality of Life • In ambulatory elderly: 35% of experience ADRs and 29% require medical intervention • In nursing facilities: 2/3 of residents experience ADRs and 1:7 require hospitalization • Up to 30% of elderly hospital admissions involve ADRs *Beers MH. Arch Internal Med. 2003
Consequences:Economic • In 2000: ADRs caused 10,600 deaths • Annual cost of $85 billion • $76.6 billion in ambulatory care • $20 billion in hospitals • $4 billion in SNF *Beers MH. Arch Internal Med. 2003
“If medication related problems were ranked as a disease, it would be the fifth leading cause of death in the US!” *Beers MH. Arch Internal Med. 2003
Unique Pharmacokinetics: normal part of the aging process • Absorption • Distribution • Metabolism • Excretion Evaluate the pharmacokinetic characteristics of each medication carefully “Start low, go slow”!
Geriatric Rx Principles • First consider non-drug therapies • Match drugs to specific diagnoses • Reduce meds when ever possible • Avoid using a drug to treat side effects of another • Review meds regularly (at least q3 months) • Avoid drugs with similar actions / same class • Clearly communicate with pt and caregivers • Consider cost of meds!
High Risk Medications: Beers • Beers and Canadian criteria are the most widely used consensus data for inappropriate medication use in the elderly • Original 1991, revised 1997, 2002, and 2003 • Excellent well researched reference • Easily available to you!
Analgesics - NSAIDs - Narcotics - Muscle relaxants Narrow Therapeutic Index - digoxin - phenytoin - warfarin - theophylline - lithium High Risk Medications: Drug Classes
Cardiovascular Antihypertensives Calcium channel blockers Propranolol Diuretics Psychotropics - TCAs - Antipsychotics - Benzodiazepines - Sedative/Hypnotics High Risk Medications: Drug Classes
High Risk Medications: Other • H2 Blockers: mental confusion, disorientation • Anticholinergic Effects: dry mouth, constipation, urinary retention, delirium • Gastrointestinal Antispasmodics • Antibiotics (aminoglycosides) • Hypoglycemics
SO… • There are profound medical and economic consequences of polypharmacy and adverse drug events • Elderly have unique pharmacokinetics • There are particular high risk medications • So, lets propose a plan for preventing ADRs and improving quality of life!
CARE: Avoiding Polypharmamcy • Caution and Compliance • Understand side effect profiles • Identify risk factors for an ADR • Consider a risk to benefit ratio • Keep dosing simple- QD or BID • Ask about compliance!
CARE: Avoiding Polypharmamcy • Adjust the Dose • Start low and go slow- titrate! • Unique pharmacokinetics in elderly • Altered: Absorption Distribution Metabolism Excretion
CARE: Avoiding Polypharmamcy • Review Regimen Regularly • Avoid automatic refills • Look for other sources of medications- OTC • Caution with multiple providers • Don’t use medications to treat side effects of other meds • What can you discontinue or substitute for safer med?
CARE: Avoiding Polypharmamcy • Educate • Talk to your patient about potential ADRs • Warn them for potential side effects • Educate the family and caregiver • Ask pharmacist for help identifying interactions • Assist your patient in making and updating a medication list- personal medical record!
Personal Health Record • It will reduce polypharmacy and ADRs • Multiple specialist involved in care • Transitions in care from independent living, hospitals, nursing homes and assisted living facilities • Great aid in emergency care • Provides the patient with more piece of mind…
Personal Health Record • Developed by Dr. Eric Coleman, UCHSC, HCPR : http://caretransitions.org/document/phr.pdf • Patient should bring this with them to every medical visit and present it to their provider • Each provider should update list with any changes
Personal Health Record Includes: • Patient identifying information • Doctors contacts • Caregiver contacts • Past Medical History and Allergies • List of all medications, dose, reason they are taking it and whether it is new!
Questions Which of the pharmacologic parameters may be associated with ADRs in the elderly? • Altered free serum concentration of drug • Diminished volume of distribution • Altered renal drug clearance • Prolonged absorption due to decreased gastric mobility • All of the above
Questions Which of the following is (are) examples of ADRs in elderly? • Drug side effects • Drug toxicity • Drug disease interaction • Drug-drug interaction • All of the above
Questions Which of the following combinations are most commonly associated with ADRs in elderly? • Cardiovascular drugs, psychotropics, and antibiotics • Cardiovascular drugs, psychotropics, and analgesics • Gastrointestinal drugs, psychotropics, and analgesics • Gastrointestinal drugs, psychotropics, and antibiotics
Case 80 yr. widow who now lives with her daughter comes to your office to establish care and complains of being a nervous wreck and not being able to turn off her mind for the past 2 yrs. She brings with her a bag of all her meds. PMHx: CHF, irritable bowel syndrome, depression, HTN, recurrent UTIs, stress incontinence, anemia, occipital headaches, osteoarthritis, generalized weakness Meds: sucralfate 1gm TID, cimetidine 300mg QID, enteric asa 325mg, atenolol 100mg, digoxin 0.25, alprazolam 0.5mg, naproxen 500mg TID, oxybutynin 5mg BID, dicyclomine 10mg TID, lasix 40mg , Tylenol #2 prn
Medication Red Flags: • High risk drugs: alprazolam, oxybutynin, tylenol #2 (narcotics), dicyclomine, NSAIDS • Digoxin at a higher then recommended dose (0.125mg) • naproxen and aspirin carry the potential drug related adverse events of gastritis/GIB and sucralfate and cimetidine are being used to treat these side effects
Case Mrs. Jones is a 72 yr living in an assisted living facility where she has been recently complaining of increasing confusion, lightheadedness in the am and difficulty sleeping at night. PMHx: CHF, NIDDM, OA, glaucoma, depression, and stress incontinence Meds: furosemide, timolol gtts, metformin, ibuprofen, paroxetine, oxybutynin, propoxyphene/actetaminophen prn pain, and diphenhydramine prn insomnia
Medication Red Flags: • Diphenhydramine: sedative, anticholinergic properties which effect cognition • Oxybutynin: anticholinergic which is known to cause confusion at higher doses • Propoxyphene- dangerous narcotic! • Watch for Digoxin toxicity- blurred vision, CNS disturbances, anorexia
Case Mr. Wilson is a 81 yr who had an URI and subsequently was admitted for acute confusion and disorientation. He then began wandering and having hallucinations while spiking a fever. PMHx: CAD with MI, COPD, DJD, Hypothyroidism, Depression/anxiety, chronic anemia and diarrhea, aortic valve replacement, gout, neuropathy, bilateral total knee replacements
Meds: aggrenox, neurontin, theophylline, synthroid, allopurinol, prozac, combivent, colchicine, Imodium prn, metamucil, calcium, iron, multivitamin, codeine • Medical workup: significant for negative head CT, EKG with no acute changes, UA, CBC, LP, Chem10 and CPP are wnl, CXR shows possible RLL infiltrate
Assessment and Plan: 1. Fever with Delirium 2. Polypharmacy Continue infectious workup and treatment. Start simplifying the medical regimen
Medication Red Flags: • Theophylline: low therapeutic index and considered less effective then inhaled therapies • Iron deficiency anemia is more rare in men, so check levels and maybe discontinue supplement • Chronic diarrhea: iatragenic? From colchicine? Also Imodium is anticholinergic • Cost: estimated monthly drug bill $430
TAKE HOME POINTS! • Polypharmacy and ADRs have profound medical and economic consequences • Elderly have unique pharmacokinetics • High risk medications include cardiovascular, analgesic, psychotropics, and meds with a low therapeutic index • Use the CARE guidelines in prescribing • Advocate for the Personal Medical Record • Start improving your patients' quality of life!
References • Swanson’s Family Practice Review. Fourth Ed. A. Tallia, D. Cardone, D. Howarth, K Ibsen; Mosby 2001. • Geriatrics: 20 common problems. A. Adelman, M. Daly; McGraw Hill 2001. • Primary Care Geriatrics: A Case- Based Approach. Third Ed. R. Ham, P. Sloane; Mosby 1997. • Essentials of Clinical Geriatrics. Fourth Ed. RL Kane, JG Ouslander, IB Abrass; McGraw Hill 1999. • Polypharmacy. Didactic at SFM by Dr. Pat Borman • Holland EG, Degruy FV. Drug- Induced Disorders. American Family Physician Vol 56, Nov 1, 1997. • Beers MH. Updating the Beers Crieria for 003Potentially Inappropriate Medication Use in Older Adults. Arch Internal Med. 2003: 2716-2724. • Personal Medical Record developed by Dr. Eric Coleman, UCHSC, HCPR : http://caretransitions.org/document/phr.pdf