Medication Management from the Geriatric Perspective

1. Medication Management from the Geriatric Perspective Jennifer Tjia, MD, MSCE, Division of Geriatric Medicine

2. What are we doing here today? Very few of you will be geriatricians… But many of you will care for geriatric patients, and the most common intervention you will be doing is prescribing..

3. The “Don’t Kill Granny List” A minimum set of standards that every medical student should be able to demonstrate before graduating and caring for elderly patients.

4. “…Often even experienced doctors are unaware that 80-year-olds are not the same as 50-year-olds. Pneumonia in a 50-year-old causes fever, cough and difficulty breathing; an 80-year-old with the same illness may have none of these symptoms, but just seem “not herself” — confused and unsteady, unable to get out of bed. She may end up in a hospital, where a doctor prescribes a dose of antibiotic that would be right for a woman in her 50s, but is twice as much as an 80-year-old patient should get, and so she develops kidney failure, and grows weaker and more confused. In her confusion, she pulls the tube from her arm and the catheter from her bladder.” http://www.nytimes.com/2009/07/02/opinion/02leipzig.html

5. “Instead of re-evaluating whether the tubes are needed, her doctor then asks the nurses to tie her arms to the bed so she won’t hurt herself. This only increases her agitation and keeps her bed-bound, causing her to lose muscle and bone mass. Eventually, she recovers from the pneumonia and her mind is clearer, so she’s considered ready for discharge — but she is no longer the woman she was before her illness. She’s more frail, and needs help with walking, bathing and daily chores. This shouldn’t happen.”

6. “All medical students are required to have clinical experiences in pediatrics and obstetrics, even though after they graduate most will never treat a child or deliver a baby. Yet there is no requirement for any clinical training in geriatrics, even though patients 65 and older account for 32 percent of the average doctor’s workload in surgical care and 43 percent in medical specialty care, and they make up 48 percent of all inpatient hospital days. Medicare, the national health insurance for people 65 and older, contributes more than $8 billion a year to support residency training, yet it does not require that part of that training focus on the unique health care needs of older adults.”

7. The “Don’t Kill Granny List” Medication Management Cognitive and Behavioral Disorders Self-Care Capacity Falls, Balance, Gait Disorders Health Care Planning and Promotion Atypical Presentation of Disease Palliative Care Hospital Care for Elders

8. Use of all medications* *Prescription medications, over-the-counter drugs, vitamins/minerals, and herbals/supplements, during the preceding week, by sex and age. . Adapted from Kaufman (2002)

9. Treatment regimen for a 79 year-old woman with HTN, DM, osteoporosis, OA, and COPD: 12 meds 5 dosing times Boyd C, et al. JAMA 2005; 294:716-724.

10. Medication Management Understand how age affects the metabolism and manifestation of the desired (and undesired) effects of the drug

11. Medication Management Understand how age affects the metabolism and manifestation of the desired (and undesired) effects of the drug Understand that some medications should be avoided in the elderly

12. Medication Management Understand how age affects the metabolism and manifestation of the desired (and undesired) effects of the drug Understand that some medications should be avoided in the elderly Do a medication review and write it down

13. “…Often even experienced doctors are unaware that 80-year-olds are not the same as 50-year-olds. Pneumonia in a 50-year-old causes fever, cough and difficulty breathing; an 80-year-old with the same illness may have none of these symptoms, but just seem “not herself” — confused and unsteady, unable to get out of bed. She may end up in a hospital, where a doctor prescribes a dose of antibiotic that would be right for a woman in her 50s, but is twice as much as an 80-year-old patient should get, and so she develops kidney failure, and grows weaker and more confused. In her confusion, she pulls the tube from her arm and the catheter from her bladder.” http://www.nytimes.com/2009/07/02/opinion/02leipzig.html

14. Pharmacokinetics in Older Persons Absorption Neuro & GI disease: impaired swallowing Diabetes, anticholinergics: delayed gastric emptying Frail: decreased subcutaneous fat affecting topical absorption Distribution (Volume of distribution ∝ half-life) Inactive, frail:  Fat mass Longer half life of lipophilic agents Higher serum concentration of water soluble agents CNS penetration

15. Volume of Distribution Age

16. Pharmacokinetics in Older Persons Metabolism Healthy older persons No change in hepatic glycosylation No definite change in P450 enzymes  Hepatic mass and blood flow: less first-pass effect and increased serum levels of unmetabolized drug Comorbid disease Further decrease in hepatic mass and blood flow Concomitant medications that induce or inhibit P450 enzymes Clearance Healthy older persons Renal: small decrease in GFR Comorbid disease Renal: Significant decrease in GFR, underestimated by serum creatinine GI: decreased transit time

17. Renal FunctionChanges with Aging Creatinine Clearance Age

18. What happens to drug half life? • t1/2 ~↑Vd/↓Clearance • Prolonged t1/2

19. And it takes less drug to get an effect… Pharmacodynamics Classic age-related pharmacodynamic change is increased benzodiazepine sensitivity at the receptor level

21. Summary of PD/PK “a dose of antibiotic that would be right for a woman in her 50s might be twice as much as an 80-year-old patient should get…”

23. Antihypertensive Drug Therapy and Quality of LifePhysician’s Assessment Percent Jachuck et al, 1982

24. Antihypertensive Drug Therapy and Quality of LifePatient’s Assessment Percent Jachuck et al, 1982

25. Antihypertensive Drug Therapy and Quality of LifeRelative’s Assessment Percent Jachuck et al, 1982

26. Inappropriate Prescribing Cascade 77 yo woman with urgency; gets nifedipine for HTN Edema, constipation, impaired bladder emptying Nocturia,  urgency, some UI OAB! Add antimuscarinic  constipation Add laxative....

27. Inappropriate Prescribing Cascade 77 yo woman with urgency; gets nifedipine for HTN Edema, constipation, impaired bladder emptying Nocturia,  urgency, some UI OAB! Add antimuscarinic  constipation Add laxative....

28. Clinical Pearl “In evaluating virtually any symptom in an older patient, the possibility of an adverse drug event should be considered in the differential diagnosis.”

29. Medication Management Understand how age affects the metabolism and manifestation of the desired (and undesired) effects of the drug Understand that some medications should be avoided in the elderly

30. Inappropriate Prescribing 12 - 25% outpatients receive at least one inappropriate medicine 92% of frail elderly VA inpatients received at least one inappropriate medicine Risk factors Number of medications Comorbidity Poor self-rated health 50% of ADRs linked to inappropriate meds

31. Examples of Drugs to Avoid in the Beers Criteria Propoxyphene Pentazocine Meperidine NSAIDs Indomethacin Ketorolac Naproxen Oxaprozin Piroxicam Short-acting benzos Lorazepam 3 mg Oxazepam 60 mg Alprazolam 2 mg Temazepam 15 mg Triazolam 0.25 mg Long-acting Chlordiazepoxide Flurazepam Diazepam • Fick DM Arch Intern Med 2003;163:2716-2724 • Beers MH Arch Intern Med 1997;157:1531-1536

32. Medication Management Understand how age affects the metabolism and manifestation of the desired (and undesired) effects of the drug Understand that some medications should be avoided in the elderly Know why you’re prescribing, do a medication review and write it down

33. What and Why in Prescribing Treatment Targets Acute illness Chronic disease Symptoms Risk factors Goals of Care Primary prevention Secondary prevention Slow disease progression Prolong life Prevent morbidity Prevent decline Comfort Sachs, GA. JAGS 1998; 46: 782-3.

34. Factors in Management - Ease of Use Tolerability Polypharmacy Pharmacology Impact on target disease, symptoms, quality of life Do these drugs work in older persons? Are there differences in adverse effects? Efficacy Aging Comorbidity Pathophysiology Pathophysiology

35. The right drug at the right time for the right person…

36. A pill for all…