Bagful Of Pills

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

1. Drug-drug interactions

2. Drug-disease interactions

3. Drug-food interactions

4. Drug side effects

5. 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


“If medication related problems were ranked as a disease, it

would be the fifth leading cause of death in the US!”


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!

High Risk Medications: Drug Classes

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: 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!


Adjust the Dose Start low and go slow- titrate! Unique pharmacokinetics in elderly Altered:

Absorption

Distribution

Metabolism

Excretion


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?


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?

a) Altered free serum concentration of drug

b) Diminished volume of distribution

c) Altered renal drug clearance

d) Prolonged absorption due to decreased gastric mobility

e) All of the above

Questions

Which of the following is (are) examples of ADRs in elderly?

a) Drug side effects

b) Drug toxicity

c) Drug disease interaction

d) Drug-drug interaction

e) All of the above

Questions

Which of the following combinations are most commonly associated with ADRs in elderly?

a) Cardiovascular drugs, psychotropics, and antibiotics

b) Cardiovascular drugs, psychotropics, and analgesics

c) Gastrointestinal drugs, psychotropics, and analgesics

d) 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


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


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!

References1. Swanson’s Family Practice Review. Fourth Ed. A. Tallia, D. Cardone,

D. Howarth, K Ibsen; Mosby 2001.2. Geriatrics: 20 common problems. A. Adelman, M. Daly; McGraw Hill

2001.3. Primary Care Geriatrics: A Case- Based Approach. Third Ed. R. Ham,

P. Sloane; Mosby 1997.4. Essentials of Clinical Geriatrics. Fourth Ed. RL Kane, JG Ouslander,

IB Abrass; McGraw Hill 1999.5. Polypharmacy. Didactic at SFM by Dr. Pat Borman6. Holland EG, Degruy FV. Drug- Induced Disorders. American Family

Physician Vol 56, Nov 1, 1997.7. Beers MH. Updating the Beers Crieria for 003Potentially Inappropriate

Medication Use in Older Adults. Arch Internal Med. 2003: 2716-2724. 8. Personal Medical Record developed by Dr. Eric Coleman, UCHSC,

HCPR : http://caretransitions.org/document/phr.pdf

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Bagful Of Pills