Medications in Older Persons

1. Medications in Older Persons Kenneth Brummel-Smith, M.D. Professor and Chair, Department of Geriatrics FSU College of Medicine Geriatric Workforce Enhancement Program Healthcare Network of SW Florida

2. Objectives • Describe warning signs that nurses can observe that could indicate a medication problem • Describe 3 common problems in geriatric medication usage • Describe two techniques that can be used to assess an older patient’s understanding of the goal of treatment • Describe four steps that nurses can use to educate older patients on safe medication usage

3. One person’s drugs

4. Problems in Geriatrics Medication • Older patients take twice as many drugs as younger ones • 28% of acute geriatric hospital admissions due to adverse drug events (ADE) • 35% of community-dwelling elderly persons experience an ADE • In nursing homes, $1.33 spent on ADE for every $1.00 spent on medications

5. ADE Cascade DRUG 1 given (e.g., donepezil) - Adverse drug effect (e.g. – dizziness) misinterpreted as a new medical condition DRUG2 given (e.g., meclizine) Adverse drug effect- (e.g., constipation) misinterpreted as a new medical condition

6. Risk of ADE • Age >85 • Decreased BMI • > 6 diagnoses • Creatine clearance < 50ml/min • 9 or more meds • 12 or more doses a day • Prior ADE

7. Changes in Aging • Absorption • Slower, so drugs may take longer to reach peak effect • Distribution • Less water, more fat • Water-soluble drugs – need a lower dose (digoxin) • Fat-soluble drugs can build up – diazepam • Protein-binding • Always look at the albumin level

8. Changes in Aging • Metabolism • Liver – often decreased function • Alcohol – metabolized in liver, same dose gives greater effect • Other common diseases can affect metabolism • Heart failure • Elimination • Kidney is most common method of elimination • Serum creatinine is NOT a good indication of kidney function

9. Polypharmacy • Old way of thinking - # of drugs • 4 • 10 • New way of thinking – taking more drugs than is clinically indicated • Goals and Targets • Symptoms and Prevention

10. Goals and Targets • Goals – patient-generated desired outcomes • Avoid a stroke or heart attack • Not having bad side effects • Targets– prescriber-generated measurements that are proxies for the goal • BP, A1C level • The best outcomes happen when these are in alignment – collaborative approach

11. Symptoms and Prevention • Symptom goals • To FEEL better (less pain, less sadness, easier breathing) • Expect to results of treatment today • Prevention goals • To NOT have something bad happen (stroke, heart attack, die) • Takes time to achieve (usually) • Time-to-benefit

12. Time To Benefit • Most prevention treatments only start to show differences after years of treatment • Statins – 1-3 years • Blood pressure – 5-7 years • Some start showing benefits pretty quickly • Fewer asthma attacks with beta-agonists • Sometimes prevention and symptom treatments are simultaneous • Asthma

13. Prescribing & Deprescribing • Indications to treat • Example – hypertension after patient has tried to lower BP through life style changes and not be able to change behavior or no effect on BP even with changed behavior • Goal? • Indications to discontinue treatment • Example – patient with dementia has entered later stages and donepezil is not working • Goals?

14. Risky & Dangerous Situations • Risky • Greater than 4 medications • Physical frailty • Dangerous • 10 or more medications • 2 or more psychotropics • 2 or more CNS drugs • Any new Sx that starts soon after a new drug

15. amitriptylene barbituates chlordiazepoxide chlorpropamide diazepam doxepin flurazepan hysocyamine meperidine methyldopa pentazocine ticlopidine Beer’s Drugs (High Severity) American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, JAGS, 2015

16. Overprescribed Drugs

17. Underprescribed Drugs

18. Common Geriatric Problems • Dementia and incontinence • Do NOT prescribe an cholinesterase inhibitor if the patient is on an anticholinergic drug • E.g., donepezil with tolteradine • Effectively negate one another

19. Common Geriatric Problems • Long term PPI use • 2/3 of scrips probably inappropriate • Increased risk of hip, spine and wrist fractures • Increased risk of C. defficile infections • Increased risk of pneumonia • Magnesium deficiency (cardiac risk) • No evidence for routine use for stress ulcer prevention in hospitalized patients • Must taper off it (weeks)

20. Common Geriatric Problems • Hypertension treatment • Always consider NSAIDs as the cause of hypertension before starting treatment • Atypical presentations - even when orthostatics are normal – e.g., lethargy, memory problems, depression • Adjust targets • No one below 130/85 • Better target: below 150/90

21. Common Geriatric Problems • Type 2 Diabetes • No clear evidence that tight control reduces macrovascular events • No evidence that daily BS measurement is beneficial • Good evidence of risk of hypoglycemia • Better targets • A1C greater than 7% for all, above 7.5 for complex, and 8 to 9 for frail AGS, Choosing Wisely, www.choosingwisely.org

22. Harder Problems • Stopping drugs in someone “trained” to watch the numbers • Higher A1C level in older diabetic having metformin side effects • Low BP readings in someone with a fear of strokes • Stopping drugs in people near the end-of-life • New goal – a death that “could be prevented”

23. Idealized Prescribing • There is evidence that the patient’s problem is responsive to a drug • The patient agrees to a drug-approach • The patient is motivated to take the drug • The drug causes no side effects • The drug is affordable and available • The drug works in this patient

24. Teach Your Patients • Bring in all your medicines to every visit • Keep a list of your drugs in your wallet or purse • Use only one pharmacy • Don’t ask for any drug that is advertised on TV or in magazines • If a new drug is started: • Ask how long the drug has been on the market • Don’t take any drug until it’s been out for at least 2 years • Ask if there are other things besides taking a drug you can do • Ask if you should stop any current drugs

25. Why Bring in Drugs? Prescription written: Diltiazem 24hr ER 30 mg Take one capsule every day

26. References • Geriatric Nursing Review Syllabus, American Geriatric Society • American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2015;63(11):616–631. • Brandt N. Optimizing medication use through deprescribing: tactics for this approach. J GerontolNurs. 2016;42(1):10–14. • O’Mahoney D, O’Sullivan D, Byrne S, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2014;44(2):213–218.