Best Practices for Safe Prescribing in Older ED Patients

1. Best Practices for Safe Prescribing in Older ED Patients S. Nicole Hastings, M.D., M.H.S.

2. Safe Prescribing in Older ED Patients Review Beers’ Criteria, tool for identifying Potentially Inappropriate Medications Discuss most frequent medication problems in ED discharge medications Review strategies for reducing use of high risk medications in the ED

3. ED Discharge Medications • In VAMC EDs, 45-65% of older adults are prescribed at least one new medication at the time of ED discharge • 59% - 1 new medication • 27% - 2 new medications • 14% - 3 or more • Most common drug classes • Anti-infectives • Cardiovascular • Central nervous system

4. The Medication Maze New medications and dosage changes Different prescribers Multiple medications and chronic conditions Common ED discharge drugs (e.g. NSAIDs, opioid analgesics, antibiotics) are often risky for older patients Over the counter drugs Medication Reconciliation Across Transitions

5. Potentially Inappropriate Medications • Risk of adverse event outweighs clinical benefit • Identifying PIMs in older adults • Beers’ Criteria • STOPP/START Criteria • HEDIS • Medication Appropriateness Index

6. Beers’ Criteria • 2012 Update with AGS • Target audience – practicing clinician • Goal - Improve care by ↓ exposure to PIMS • Educational tool • Quality measure • Research tool

7. Beers’ Criteria American Geriatrics Society • Intended clinical use • Improve care of older adults by reducing exposure to PIMs • Guideline to identify medications for which risk > benefit • Not meant to supersede clinical judgment or individual patient’s values and needs • Serve as a reminder for closer monitoring

8. Beers’ Criteria Table 2 – Avoid

9. Anticholinergics • Diphenhydramine • Hydroxyzine • Meclizine • Promethazine • Prochlorperazine (Compazine) • Oxybutynin • Scopolamine • Cyclobenzaprine J Am Geriatr Soc 2012

10. Prescriber Beware….. • Drug-Drug Interactions • Warfarin, digoxin • QTc prolongation • Drug-Disease Interactions • NSAIDS-PUD • Anticholinergics/antihistamines and bladder outlet obstruction • Anticholinergics/antihistamines and cognitive impairment • Dose adjust for renal insufficiency • Cr overestimates GFR in older adults

11. ED Discharge Medication Problems

12. ED Discharge Medication Problems Beers’ drug – 11.6% Drug-drug interactions – 12.6% Drug-disease interactions – 5.7% Problem with monitoring - 17.6% One or more – 31.8%

13. ED Discharge Medication Problems

14. Suboptimal Pharmacotherapy Time until first adverse event (repeat ED visit, hospital admission or death) among patients with: (1) no new discharge drug, (2) new discharge drug but no suboptimal pharmacotherapy and (3) new discharge drug with suboptimal pharmacotherapy.

15. Before Prescribing, Consider… • Is a medication necessary? • Think drugs with any new geriatric syndrome • Do the benefits outweigh the risks? • Is it used to treat effects of another drug? • Could it interact with a disease, other drugs? • Does the patient know what it’s for, how to take it, and what ADEs to look for?

16. Free AGS Beers App Available at: Americangeriatrics.org

17. EQUiPPED Enhancing Quality of Prescribing in the Emergency Department 5 site QI program funded of Office of Geriatrics and Extended Care

18. Beers’ Meds Common in ED www.fanpop.com Courtesy: Loren Wilkerson, M.D. • Pain Meds • Non-COX selective NSAIDS • Indomethacin • Ketorolac (Toradol) • Skeletal Muscle relaxants • Amitriptyline/TCAs • Benzodiazepines • Anticholinergics/Antihistamines

23. Safe Prescribing in Older ED Patients Is a medication necessary? Is there a safer alternative? Does the risk outweigh the benefit? AGS Beers Criteria as a guideline Reduce PIM use in your ED through education, provider feedback, CPRS tools

24. Thanks for your Attention!

25. Bibliography “Review: Emergency Department Use by Older Adults: A Literature Review on Trends, Appropriatness, and Consequences of Unmet Health Care Needs,” AnreaGruneir, Mara J. Silver and Paula A. Rochon, Med Care Res Rev 2011 68:131 http://mcr.sagepub.com/content/682/131 “Older Adults in the Emergency Department: A Systematic Review of Patterns of Use, Adverse Outcomes, and Effectiveness of Interventions,” FaranakAminzadeh, William Dalziel, Annals of Emergency Medicine, March 2002;39:3,238-247. “How Frequent Emergency Department Use by US Veterans Can Inform Good Public Policy,” Jesse Pines, Annals of Emergency Medicine, 2013, pending publication.

26. Bibliography Survey: Many Elderly Are in the Dark at ED Discharge, http://www.acep.org/content.aspx?id=46032 “Health Services Use of Older Veterans Treated and Released from Veterans Affairs Medical Center Emergency Departments.” Hastings SN et al. J Am Geriatr Soc 2013; 61:1515-1521. “Quality of Pharmacotherapy and Outcomes for Among Older Veterans Discharged from the Emergency Department.” Hastings et al. J Am Geriatr Soc 2008; 56 (5):875-880. “Older Veterans and Emergency Department Discharge Information.” Hastings SN et al. BMJ QualSaf2012 Oct;21:835-842.

27. Questions/Comments