The Bagful of Pills: Polypharmacy in the Elderly

1. The Bagful of Pills: Polypharmacy in the Elderly Oana Marcu DO Swedish Family Medicine March 7, 2006

2. 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!

3. 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

4. Adverse Drug Reaction (ADR) ADRs occur as a result of • Drug-drug interactions • Drug-disease interactions • Drug-food interactions • Drug side effects • Drug toxicity

5. 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

6. 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

7. “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

8. Unique Pharmacokinetics: normal part of the aging process • Absorption • Distribution • Metabolism • Excretion Evaluate the pharmacokinetic characteristics of each medication carefully “Start low, go slow”!

9. 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!

10. 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!

11. Analgesics - NSAIDs - Narcotics - Muscle relaxants Narrow Therapeutic Index - digoxin - phenytoin - warfarin - theophylline - lithium High Risk Medications: Drug Classes

12. Cardiovascular Antihypertensives Calcium channel blockers Propranolol Diuretics Psychotropics - TCAs - Antipsychotics - Benzodiazepines - Sedative/Hypnotics High Risk Medications: Drug Classes

13. High Risk Medications: Other • H2 Blockers: mental confusion, disorientation • Anticholinergic Effects: dry mouth, constipation, urinary retention, delirium • Gastrointestinal Antispasmodics • Antibiotics (aminoglycosides) • Hypoglycemics

14. 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!

15. 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!

16. CARE: Avoiding Polypharmamcy • Adjust the Dose • Start low and go slow- titrate! • Unique pharmacokinetics in elderly • Altered: Absorption Distribution Metabolism Excretion

17. 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?

18. 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!

19. 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…

20. 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

21. 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!

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. Assessment and Plan: 1. Fever with Delirium 2. Polypharmacy Continue infectious workup and treatment. Start simplifying the medical regimen

32. 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

33. 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!

34. 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