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Principles of Drug Use: Prescribing for the Elderly Thomas R. Clark, RPh, MHS

Principles of Drug Use: Prescribing for the Elderly Thomas R. Clark, RPh, MHS ASCP Director of Policy & Advocacy. “Medications are probably the single most important health care technology in preventing illness, disability, and death in the geriatric population”.

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Principles of Drug Use: Prescribing for the Elderly Thomas R. Clark, RPh, MHS

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  1. Principles of Drug Use: Prescribing for the Elderly Thomas R. Clark, RPh, MHS ASCP Director of Policy & Advocacy

  2. “Medications are probably the single most important health care technology in preventing illness, disability, and death in the geriatric population” Avorn, J. Medication use and the elderly: current status and opportunities. Health Affairs. 1995(Spring):278-86.

  3. Aging of population High use of drugs in elderly Prevalence of medication therapy problems Shift from nursing facility to home and community-based services Importance of geriatric drug therapy

  4. THE PROPORTION OF OLDER AMERICANS IS GROWING Source: Health, United States, 2005. Figure 2. www.cdc.gov/nchs/data/hus/hus05.pdf

  5. Those over 85 will grow by 106%, from 3.4 million in 2000 to close to 7 million by 2020 By 2050, nearly 20 million Americans will be age 85 or over Aging Trends

  6. About half those age 85 and over need assistance with daily living About half those age 85 and over have some degree of cognitive impairment About one out of five live in NF Aging Trends

  7. 1940: Seven percent 2050: Forty two percent Persons Surviving to Age 90

  8. Rx Use in the US Source: Center on an Aging Society, Georgetown University, 2000

  9. 1998 - 34.4% of 2.733 billion Rxs 933 million Rxs for seniors Rx Use and Seniors US Population Rxs for seniors Seniors Rxs for non-seniors Source: IMS 1998

  10. In 2005, seniors comprised 12.5% of the population and consumed 37% of prescriptions By 2020, seniors will comprise 16% of the population and will consume 49% of prescriptions Source: US Census, IMS National Prescription Audit, July 2005 Rx Use and Seniors

  11. Typical NF Resident 75-85+ years of age Average number of routine prescription medications: 8.1 Average number of PRN prescription medications: 3.2 Percent of residents receiving 9+ routine medications per day: 41.1 Rx Use and Seniors

  12. Assisted Living 13 medications/resident Rx Use and Seniors

  13. Polypharmacy: drug use without indication Undertreatment: indication without drug use Dose too low Dose too high Adverse drug reaction Medication Therapy Problems

  14. Drug interaction Inappropriate drug Lack of adherence or compliance Medication error Medication Therapy Problems

  15. “As older patients move through time, often from physician to physician, they are at increasing risk of accumulating layer upon layer of drug therapy, as a reef accumulates layer upon layer of coral” Jerry Avorn, quoted in Arch Intern Med 164:1957–59 Polypharmacy

  16. “The desire to take medicine is perhaps the greatest feature which distinguishes man from animals.” Sir William Osler, in H. Cushing, Life of Sir William Osler (1925) Polypharmacy

  17. “One of the first duties of the physician is to educate the masses not to take medicine.” Sir William Osler, Aphorisms from his Bedside Teachings (1961) p. 105. Polypharmacy

  18. “I firmly believe that if the whole materia medica as now used could be sunk to the bottom of the sea, it would be all the better for mankind—and all the worse for the fishes.” Oliver Wendell Holmes, 1860 Polypharmacy

  19. “Over the past few years, the pendulum has swung from concern about the risks of excessive prescribing of inappropriate or unnecessary drug therapy to concerns about the consequences of underprescribing of potentially beneficial therapies to seniors (65 years and older).” Rochon PA, Gurwitz JH. Prescribing for seniors: neither too much nor too little. JAMA, 1999;282:113-5 Undertreatment

  20. Pain management Pneumococcal and flu vaccine Depression Secondary heart attack prevention Examples of Undertreatment

  21. Vulnerable elders receive about half of recommended care Preventive care suffers the most Physicians often fail to prescribe recommended medications Care for geriatric conditions (e.g. falls, incontinence) is poorer than care for medical conditions such as hypertension Source: Rand Researchhttp://rand.org/pubs/research_briefs/2005/RB9051.pdf Quality of Health Care for Older Adults

  22. “Any symptom in an elderly patient should be considered a drug side effect until proved otherwise.” Gurwitz J, Monane M, Monane S, Avorn J. Polypharmacy. In: Morris JN, Lipsitz LA, Murphy K, et al. Quality Care in the Nursing Home. St. Louis, MO: Mosby Year Book;1997:13-25. Adverse Effects

  23. Rate of ADEs requiring an ER visit for persons 65 and over is more than twice the rate for persons under age 65 Rate of ADEs requiring hospitalization is nearly seven times greater for persons age 65 or over versus persons under age 65. Source: JAMA 2006;296(15):1858–66 Adverse Drug Events (ADE)

  24. Antibacterial to treat a viral infection “Beers medications” - medications considered potentially inappropriate for older adults based on risk versus benefit (expert consensus) Ref: Arch Intern Med 2003;163:2716–24 Inappropriate Drugs

  25. 21% of older adults take one or more medications categorized by Beers as generally inappropriate Source: Arch Intern Med 2004;164:1621–25. Inappropriate Drugs

  26. Social and economic factors Health care system-related factors Condition-related factors Therapy-related factors Patient-related factors Medication Adherence

  27. More than 10% of hospital admissions for older adults may be due to nonadherence Nonadherence costs the U.S. health care system $100 billion per year Source: Vermiere E. et al. Patient adherence to treatment: three decades of research, a comprehensive review. J Clin Pharm Ther 2001;26:331–42. Medication Adherence

  28. Ask: Is treatment warranted? Are nonpharmacologic alternatives available? Consider risk vs. benefit of drug therapy Establish goals of therapy Quality of care Quality of life Functional status Principles of Drug Use

  29. “Is it quality of life or quantity of life? Truthfully, if my destiny is to feel great now and maybe shorten my future, I’d rather feel well now.” Source:Nancy Richardson, 60, of Wayland, Mass., referring to risk versus benefit of estrogen therapy. Quoted in New York Times, December 18, 2006 article by Gina Kolata, “Breast Cancer News Brings a Range of Reactions” Goals of Therapy

  30. Consider the whole person, not just one disease or one drug Be aware of assumptions behind clinical practice guidelines Disease management may not be adequate or appropriate if multiple chronic diseases are present Principles of Drug Use

  31. Questions?

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