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Suboptimal Drug Use in Long Term Care Facility Patients

Suboptimal Drug Use in Long Term Care Facility Patients. Joseph T. Hanlon PharmD, MS Professor, Departments of Medicine (Geriatrics) and Pharmacy and Therapeutics, University of Pittsburgh and Pittsburgh VA CHERP and GRECC. Learning Objectives.

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Suboptimal Drug Use in Long Term Care Facility Patients

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  1. Suboptimal Drug Use in Long Term Care Facility Patients Joseph T. Hanlon PharmD, MS Professor, Departments of Medicine (Geriatrics) and Pharmacy and Therapeutics, University of Pittsburgh and Pittsburgh VA CHERP and GRECC

  2. Learning Objectives At the end of the talk the participants should be able to: • List the different types of suboptimal drug use • Describe the prevalence of polypharmacy (9+ drugs) in long term care patients • Discuss the underuse of medications in long term care patients • Summarize drugs that are potentially inappropriate or unnecessary as per new CMS Guidelines for LTCF • Discuss principles to optimize drug use in long term care patients

  3. Types of Suboptimal Drug Use 1.Overutilization(polypharmacy) 2.Underutilization 3.Inappropriateutilization HanlonJT,etal.JAmGeriatrSoc2001;49:200-9; SpinewineA,etal.Lancet2007;370:173-184

  4. % Taking 9+ Meds in LTCFs Percent of NHR CMS data, 1st quarter, 2005, VA NHCU data FY 04-05

  5. Top Medication Classes Used in LTCF Doshi JA, et al. J Am Geriatr Soc. 2005;53:438-44.

  6. Top Medication Classes Used in VA NHCU FY 2005 (n=6554) French DD, et al. J Am Med Dir 2007; 8:515-8

  7. Daily Use of Specific Medication Classes in LTCF Patients per MDS Drug ClassVA %National % Diuretics29.834.0 Antidepressants43.048.4 Antipsychotics 25.9 24.9 Antianxiety agents9.612.8 Hypnotics3.83.7 CMS data, 2nd quarter, 2007, VA NHCU data FY 04-05

  8. Risks Associated with Polypharmacy • Functional status decline • ADRs • Inappropriate drug use • Increased medication administration errors • Increased risk of geriatric syndromes

  9. Learning Objectives At the end of the talk the participants should be able to: • List the different types of suboptimal drug use • Describe the prevalence of polypharmacy (9+ drugs) in long term care patients • Discuss the underuse of medications in long term care patients • Summarize drugs that are potentially inappropriate or unnecessary as per new CMS Guidelines for LTCF • Discuss principles to optimize drug use in long term care patients

  10. Underutilization of Medication • Undiagnosed and untreated condition • Diagnosed condition but omitted treatment • Underuse of preventive treatment

  11. Examples of Medication Under-Use in LTCFs • Warfarin for stroke prevention (McCormick et al, 2001) • Hypoglycemics for diabetes (Spooner et al, 2000) • Calcium and other treatment for osteoporosis (Jachna et al, 2005)

  12. Inappropriate Prescribing • Prescribing of medications that does not agree with accepted medical standards

  13. MDS Quality Indicator Report Medication UseNational %VA% Antipsychotic Use w/o Psychosis 22.019.9 Sxs of Depression w/o antidepressant4.83.9 Hypnotic use > 2x in previous week4.24.1

  14. CMS Recommended Antianxiety and Sedative/Hypnotic Maximum Daily Dosage Generic NameDosage (mg) Alprazolam0.75 Clonazepam7.5 Lorazepam1-2 Oxazepam15-30 Temazepam7.5-15 Zaleplon5 Zolpidem5

  15. Indications for Antipsychotics in the Elderly Nursing Home Patients 1. Disorders such as delirium, schizophrenia, paraphrenia, dementia With 2. Thinking and behavior disturbances such as delusions, hallucinations, paranoia And 3. Severe enough to be of harm to the patient and/or others

  16. Antipsychotic Guidelines in Nursing Home Elderly • Residents should receive gradual dose reductions, behavior interventions unless clinically contraindicated • Avoid use of highly anticholinergic antipsychotics (e.g., olanzapine, chlorpromazine, thioridazine, clozapine) • Specific doses recommended • Monitor for metabolic and EPS problems

  17. Weight Gain, Diabetes an Dyslipidemias with Atypical Antipsychotics Clozapine=Olanzapine>Quetiapine> Paliperidone=Risperidone>Ziprasidone=Aripiprazole

  18. ADA-APA Monitoring Guidelines MeasureBaseline4wks8wks12wks1/4lyYrly BMI x x x x x Waist Circ. x x BP x x x FG x x x Lipids x x

  19. CMS Recommended Selected Antipsychotic Maximum Daily Dosage NameDosage (mg)  Fluphenazine4 Haloperidol 2 Perphenazine8 Quetiapine 150 Risperidone2

  20. CARDIOVASCULAR Reserpine, Methyldopa, Disopyramide ANTIPLATELETS Dipyridamole, Ticlopidine DEMENTIA TREATMENTS GASTROINTESTINAL Antispasmodics (e.g., Donnatal®) Trimethobenzamide (Tigan®) ANALGESICS Indomethacin , Phenylbutazone Propoxyphene , Pentazocine, Meperidine ORAL HYPOGLYCEMICS Chlorpropamide (Diabinese®) PSYCHOTROPICS Long acting benzodiazepines Meprobamate, Barbiturates Amitriptyline, Doxepin Antidepressant/neuroleptic Comb. SKELETAL MUSCLE RELAXANTS ANTIHISTAMINES Diphenhydramine (Benadryl® ) GU ANTISPASMODICS Oxybutynin Inappropriate Medication Use Defined by Explicit Criteria (Beers MH, et al. 1997)

  21. Use of Beers Criteria Drugs in Nursing Homes J Am Geriatr Soc. 2005;53:991-6.

  22. Predictive Validity of Inappropriate Drug Use

  23. ANTIINFECTIVE Nitrofurantoin CARDIOVASCULAR Amiodarone (unless VT/Fib),Disopyramide, Methyldopa, Nifedipine (SA), Prazosin ANTIPLATELETS Ticlopidine GASTROINTESTINAL Antispasmodics (e.g., Donnatal®), Cimetidine, Metoclopramide, Trimethobenzamide (Tigan®) ANALGESICS NSAIDs, Propoxyphene , Pentazocine, long acting opioids (fentanyl patch, methadone, SR products) ORAL HYPOGLYCEMICS Chlorpropamide, Glyburide PSYCHOTROPICS Barbiturates, Meprobamate, TCA’s, MAOIs SKELETAL MUSCLE RELAXANTS ANTIHISTAMINES Chlorpheniramine, Cyproheptadine, Diphenhydramine, Hydroxyzine, Meclizine, Promethazine Inappropriate Medication Use Defined by CMS Criteria 2006

  24. Unnecessary Medications • Defined as a medication with excessive dose or duration; inadequate monitoring or indication for use; presence of adverse consequences which indicate the dose should be reduced or d/ced

  25. CMS Recommended Maximum Daily Dosage Generic NameDaily Dosage (mg) APAP4000 Digoxin0.125 (unless Afib) H2 blockersbased on renal function Ironqd Metforminbased on renal function

  26. CMS Guidelines For Drugs with Maximum Duration Limits Drug ClassDuration (days) ACHEI? Revaluate as dx progresses Analgesics ? acute use Anti-infectives? Antiemetics? Cough/Cold14 H2 blocker/PPI84 (unless GERD/NSAID use) Iron56

  27. CMS Guidelines for Monitoring Medication Use DrugMonitoring ACE-I K+ AEDS (older)levels Aminoglycosides Scr, levels AntidiabeticsBlood sugar AntipsychoticsEPS, TD APAP (>4gm/d)LFTS Appetite stimulantsweight, appetite Digoxin Scr, level DiureticK+ Erythropoiesis stimulantsBP, iron, ferritin, CBC FibratesLFTS, CBC Ironiron, ferritin, CBC Lithiumlevel Niacinblood sugar, LFTs StatinsLFTs Theophyllinelevels Thyroid replacementTFTs Warfarin INR

  28. CMS Drug-Drug Interactions Drug EffectedPrecipitantDrug (s) ASANSAIDs ACE-IK supplements, K sparing diuretics AnticholinergicAnticholinergic Antihypertensiveslevodopa, nitrates AntiplateletNSAID CNS medCNS med Digoxinamiodarone, verapamil LithiumACEI, thiazide diuretics, NSAIDs MeperidineMAOI Phenytoinimidazoles QuinolonesType IA,C, II antiarrhythmics SSRItramadol, st john wort Sulfonylureasimidazoles Theophyllineimidazoles, quinolones, barbiturates Warfarin amiodarone, NSAIDs, sulfonamides, macrolides, quinolones, phenytoin, imidazoles

  29. Clinically Important Drug-Disease Interactions Determined by Expert Panel Consensus DrugDisease • Alpha blockersSyncope • AnticholinergicsBPH, constipation, dementia, glaucoma (narrow angle) • AspirinPUD • BarbituratesDementia • Benzodiazepines Dementia, falls • BupropionSeizures • CCB 1st generation CHF (systolic dysfunction) • CorticosteroidsDM • DigoxinHeart block Lindblad C, Hanlon J et al. Clin Ther 2006;28:1133-43.

  30. Clinically Important Drug-Disease Interactions Determined by Expert Panel Consensus DrugDisease • MetoclopramideParkinson’s disease • Non-aspirin NSAIDsCRF, PUD • Opioid analgesicsConstipation • Sedative/hypnoticsFalls • ThioridazinePostural hypotension • Tricyclic antidepressants BPH, constipation dementia, falls, heart block postural hypotension • Typical antipsychotics Falls Lindblad C, Hanlon J et al. Clin Ther 2006;28:1133-43.

  31. Medications with Anticholinergic Activity • Anti-emetics/anti-vertigo - (e.g., meclizine) • Antiparkinsonians - (e.g., trihexyphenidyl) • Antispasmodics- (e.g., belladonna) • Cold and allergy drugs- (e.g., hydroxyzine) • Sleep aids- (e.g., diphenhydramine) • Skeletal muscle relaxants - (e.g., cyclobenzaprine)

  32. Atypical Antipsychotic Medications and Risk of Falls in Residents of Aged Care Facilities Medication Adj Hazard Ratio95% CI Olanzapine 1.74 (1.04–2.90) Risperidone 1.32 (0.57–3.06) Typ. antipsychotics 1.35 (0.87–2.09) Antidepressants 1.45 (1.09–1.93) Sed/anxiolytics 1.19 (0.94–1.50) Hien LTT, et al. J Am Geriatr Soc 2006;53: 1290-1295.

  33. Antipsychotic Medications and Risk of Hip Fractures in NH Residents Medication Adj. OR95% CI Atypicals1.371.11-1.69 Olanzapine 1.34 0.87–2.07 Risperidone 1.42 1.12–1.80 Conv. antipsychotics 1.35 1.06–1.71 Haloperidol1.53 1.18–2.26 Liperoti R, et al. J Clin Psych 2007;68: 929-34.

  34. Learning Objectives At the end of the talk the participants should be able to: • List the different types of suboptimal drug use • Describe the prevalence of polypharmacy (9+ drugs) in long term care patients • Discuss the underuse of medications in long term care patients • Summarize drugs that are potentially inappropriate or unnecessary as per new CMS Guidelines for LTCF • Discuss principles to optimize drug use in long term care patients

  35. Principles for Optimizing Drug Use in the Elderly • Consider whether drug therapy is necessary • Promote the use of a small number of drugs to treat common problems • Adjust doses and or/dosage intervals for medications • Establish reasonable therapeutic endpoints and monitor for desired outcome • Monitor for adverse drug reactions • Regularly review the need for chronic medications

  36. A Model for Appropriate Prescribing for Patients Late in Life Holmes HM, et al. Arch Intern Med 2006;166:605-609.

  37. Chronic Medication Review Steps • Assess whether ADRs are the cause of any symptoms • Match problem list with drug list • If on drug but no match with problem list consider whether drug is necessary • If has a chronic condition and not on a medication consider whether there is an evidence based drug to tx the condition • Assess the monitoring for efficacy/safety/appropriateness of the remaining medications

  38. Assessing Prescribing Appropriateness Using the MAI • Is there an indication for the drug? • Is the medication effective for the condition? • Is the dosage correct? • Are the directions correct? • Are the directions practical? • Are there clinically significant drug-drug interactions? • Are there clinically significant drug-disease interactions? • Is there unnecessary duplication with other drugs? • Is the duration of therapy acceptable? • Is this drug the least expensive alternative compared to others of equal utility?

  39. Effect of an Interdisciplinary Team on Suboptimal Prescribing in a VA LTCF (n=23)

  40. Learning Objectives At the end of the talk the participants should be able to: • List the different types of suboptimal drug use • Describe the prevalence of polypharmacy (9+ drugs) in long term care patients • Discuss the underuse of medications in long term care patients • Summarize drugs that are potentially inappropriate or unnecessary as per new CMS Guidelines for LTCF • Discuss principles to optimize drug use in long term care patients

  41. To Register for this Program and get CE Credit • Non-VA listeners go to: https://www.ees-learning.net • VA listeners go to: https://www.lms.va.gov/plateau/user/login.jsp 1) Log in. (If you have not done this before, contact your local LMS Administrator.) 2) On the upper right, where it says “Search Catalog” type in “GERIATRICS” and click on “GO” 3) Scroll down to “Suboptimal Drug Use in Long Term Care Facility Patients” 4) Click on “Link to Evaluation and Certificate” If listeners experience difficulty with the above, please contact the LMS Help Desk: 1-866-496-0463 or email: EESLMSHELP@VA.GOV

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