GERIATRIC POLYPHARMACY

1. GERIATRIC POLYPHARMACY GARY A. SMITH, MD, MMM, FAAFP MEDICAL DIRECTOR, MESA FIRE & MEDICAL DEPARTMENT MEDICAL DIRECTOR, AT STILL UNIVERSITY PHYSICIAN ASSISTANT STUDIES ASSOCIATE PROFESSOR, AT STILL UNIVERSITY SCHOOL OF MEDICINE

2. OBJECTIVES • Recognize factors leading to polypharmacy • Define inappropriate medications for elderly • Describe screening tools for polypharmacy • Describe best practices for limiting ADE’s if “necessary” medications • Comprehensive Geriatric Assessment • Role of the Paramedic and Integrated Healthcare Provider (NP) • Solutions to polypharmacy

3. OBJECTIVES

4. OVERVIEW

5. REDUCING MEDICATION RISK • Discuss with patients the need to: • keep an accurate list of all medications, including generic and brand names, dosages, dosing frequency, and reason for taking the drug • keep a complete list of medical providers and their contact information • post the name and telephone number of the local pharmacy.

6. REDUCING OVERMEDICATION RISK Teach patients about: • potential adverse effects and interactions of each medication • each medication, including its’ name, appearance, purpose and side effects • importance of contacting the healthcare provider with concerns or questions • potential drug-related problems that warrant emergency care • importance of taking medications exactly as directed • importance of using only one pharmacy to obtain drugs.

7. REDUCING OVERMEDICATION RISK Organization: To help patients manage their drugs, caution them to:avoid sharing medications • store medications in a secure, dry location away from sunlight • refrigerate medications if necessary • dispose of old medications properly.

8. THE PROBLEM! • 1 in 10 ED visits are the result of ADE’s • 70% are preventable • 57% >65 yrs take 5+ medications daily • 15% elderly take 10+ medications • Most Commonly used include: • Acetaminophen • Aspirin • Ibuprofen • Drug-Drug, Drug-Herbal Interactions • Non-adherence to prescriptions

9. POLYPHARMACY • More than 5 medications • The use of at least one potentially inappropriate medication • Underutilization of medications ($$$$$) • 35% of elderly patients experience adverse drug effects annually

10. RISKS FOR POLYPHARMACY • Age • Chronic diseases: • Dementia • CHF, CAD • CVA • Diabetes • COPD • Arthritis • Multiple prescribers • Lack of organization • Uninformed caregiver (typical elderly)

11. RISKS OF POLYPHARMACY • Medication/Herbal Interactions • Compliance • Depression, Confusion, Dementia • Immobility, Falls • Sedation • Hospitalization • Adverse Drug Events • Death

12. PREVALENCE OF POLYPHARMACY • A direct correlation exists between the age of the patient and the number of daily medications. • At least 90% of older adults take at least 2 prescriptions daily, and most take 3 or more. • Difficulty opening medication containers leads to non-compliance. • Lack of understanding due to being uniformed and not familiar with the use of technology.

13. PHARMACOKINETICS PHARMACODYNAMICS What the medication does to the body End organ response to meds Increased receptor response • What the body does to the medication • Most drugs absorb passively • Concomitant medication use • Many affect GI motility • Age related changes • Volume of distribution • Metabolism • Clearance (elimination)

14. SCREENING TOOLS FOR POLYPHARMACY • BEERS Criteria • Most Comprehensive Pharmacy Evaluation • STOPP Criteria • Screening Tool of Older Person’s Prescriptions • START Criteria • Screening Tool to Alert doctors to Right Treatment

15. BEERS POLYPHARMACY EVALUATION

16. POLYPHARMACY IN HOSPITALIZED ELDERS • 17% of admissions are related to ADE’s • 8 different meds on a hospital admission • 19% of major complications are related to ADE’s • Delirium is commonly caused by medications • Delirium is associated with longer hospital stays • At discharge, ½ of previous meds are D/C’ed • Transition of care errors are common • Iatrogenic pharmaceutical complications occur in 38% of elderly

17. COMPREHENSIVE GERIATRIC ASSESSMENT • History • Demographics • Past Medical/Surgical History • Allergies • Medications • Family History • Social History • Vocation/Education • Chief Complaint • Review of Systems • Physical Appearance • Physical Examination • Nutrition/Dietary Assessment • Habits • Transportation • Caregiver Needs • Sleep Habits • Substance Abuse • CAGE Assessment • Home Assessment • Ambient Lighting • Throw Rugs • Extension Cords • Smoke/CO Detectors

18. INDEPENDENCE OF ACTIVITIES OF DAILY LIVING Katz Index of Independence in Activities of Daily Living

19. CASE STUDY #1Walk-In At The Fire Station • Mrs. H is a 72 year old female has recently been discharged from the hospital and her daughter brings her to the fire station for you to take her blood pressure. She has been admitted 2 times in the last 3 months for altered mental status and “gait instability” with falls. On the last admit she had a UTI/acute on chronic kidney injury and was discharged on nitrofurantoin. • PMH includes dementia, DM, COPD, anemia, hypertension, mood disorder with schizoaffective personality, neuropathy, CVA and congestiveheart failure. • Her daughter is visually upset about her falls, hospitalizations and her mother’s confusion. • Her recent lab work reveals a Creatinine of 1.6, otherwise CMP and CBC unremarkable. Recent Hg A1C 8.1. • MMSE: 23/30 • Vital signs BP 120/76, HR 80, R 16 Ht 5’6 Wt 155 The patient is seated in a wheelchair and sedated but responsive. • Her discharge medications are as follows: • Donepezil 5 mg po daily, Fluticasone proprionate and salmeterol  250/50 1 puff bid, Amlodipine 10 mg po daily, Losartan 50 mg po daily, Metoprolol 25 mg po bid, Valproic Acid ER 500 mg po daily, Gabapentin 300 mg tid, Paroxetine 20 mg po daily, Quetiapine 200 mg po bid, Furosemide 20 mg po daily, Insulineglargine 30 units qhs, Insulin aspart 10 units with meals, Cloprodigrel 75 mg po daily, Nitrofurantoin ER 100 m gpo bid X 7days, Multivitamin po daily, Iron sulfate 325 mg po bid

20. CASE STUDY #1 • With the patient’s recent admits for sedation, delirium and recurring UTIs are there any adverse medication effectsyou might suggest? • The patient and her daughter are uncertain of some of the medications the patient is or isn’t taking….what could you do to find out what medications she is taking? • What could you suggest or do to increase medication compliance? • What is your next step? Transport? Services?

21. Case study #2 • Mrs. T is a pleasant 84 year old who resides alone. You know her by name. Her son relays to you that Mrs T has had a hard week as she “fell” two nights ago. Upon investigation Mrs. T suddenly felt hot and sweatywhile grabbing her newspaper from the nightstand. The next thing she remembers is being on the floor next to the bed. She is unsure if she lost consciousness. The only recent change to her meds is the addition of megestrol for weight gain as the patient has not been eating well. • Vitals 130/78, 132/80, 130/80 (lying, sitting and standing) HR 67, 70, 69 (lying, sitting and standing) RR 16 Ht 5’4’ Wt 167 • Medications: Atenolol 25 mg po bid, furosemide 40 mg po daily, lisinopril 40 mg po daily, glyburide 5 mg po daily, ASA 81 mg daily, ibuprofen 400 mg potid prn pain, pantoprozole 40 mg po daily

22. Case study #2Adverse drug effect (ADE) • What do you think is the likely cause of her“fall”? • Are there any medications you would consider changing? • What about if you apply the recent 2012 BEERS list of medications?

23. Case study #3Loyalty Customer • Igor Sinkovich is a 79 year old retired laborer who is well known to you. He has progressive symptoms of memory compromise and combative behavior for about two years. He looks ten years younger than his real age. He is cordial with you during the interview but most of the history is given by his wife. He has little concept of dates and time. He has enjoyed good health during his life. He drank to excess during his younger years and would drink more now than the limited amount of wine and beer his family lets him have. He and his wife have lived in the same house for nearly 50 years. His physical examination and laboratory screen are essentially normal. • MMSE score is 15/30. He completed only grade school, and that in the old country. • He roams the house at night and is obsessed that intruders may break in. Amitriptyline did help him to sleep at night but caused him difficulties with urination and he was seen twice in Emergency Service for acute urinary retention. Alprazolam made him more tractable but it was hard to get him to take it, he thought he was being poisoned by the little white tablets. Lorazepam made him quite unsteady and he fell twice, once needing stitches on his head. His family, particularly his wife, wants him to be in his home but they are at their wits end.

24. Case study #3 • What is happening here? • Can you think ways to modify his behavior other than use of medications? • What do you do? • Transport? Leave at home? Refer to PCP? • Remember BEERS criteria…

25. MOBILE INTEGRATED HEALTHCARE COMMUNITY INTEGRATED PARAMEDIC MID-LEVEL PROVIDER (NURSE PRACTITIONER/PHYSICIAN ASSISTANT MENTAL HEALTH SPECIALIST SOCIAL WORKER

26. GERIATRIC FALL PREVENTION TOOLKIT • Berg Balance Scale • Missouri Alliance Fall Risk • International Falls Efficacy Scale • Timed Up and Go (TUG) Test • Fall Prevention Awareness • Home Fall Prevention Checklist • Improve Your Balance in 10 Minutes Daily • Household Safety Checklist

27. HOUSEHOLD SAFETY INSPECTION • Lamps/Light Fixtures • Electrical Cords/Outlets • Furniture • Appliances • Floor Surfaces • Stairways • Bathrooms • Kitchen • Doors • Exterior of home • Security Measures http://unmc.edu/intmed/geriatrics/safety_checklist.htm

28. HOUSEHOLD SAFETY INSPECTION

30. MOBILE INTEGRATED HEALTHCARE • Post-Hospital Transitional Care • Community Resources • Treat and Refer to PCP • Have Patience • Take Your Time • Review Medications • Communicate with Healthcare Professionals • Become a Part of the Solution • AVOID POLYPHARMACY

31. ENDLESS POSSIBILITIES • Identify the “gaps” in your current state of affairs • Work together with all stakeholders • Address common or universal programs • Identify community specific missions • Identify all of the unique components: • Medical Direction • Telepresence/Health/Monitoring • Health Information Exchange (HIE) • Patient Centered Access • Capacity of Navigation • Transportation • Performance Measurement • Establish benchmarks and performance metrics