Polypharmacy and Medication-Related Challenges in the Geriatric Patient

1. Polypharmacy and Medication-Related Challenges in the Geriatric Patient Robyn Bryson, PharmD Kerri Hagedorn, PharmD, BCPS

2. Polypharmacy • Many different drugs, often duplicative • Drugs in excess of that which is clinically-indicated • Excessive number of inappropriate drugs • Includes Rx, OTC, nutraceuticals • Differs from polymedicine or polytherapy, which refers to multiple meds which are all clinically-indicated and appropriate

3. Polypharmacy • In general: • 5+ Rx drugs is considered “clinically-relevant” polypharmacy • 10+ Rx drugs is considered “excessive” polypharmacy • Pts and providers often only consider chronic tx • CAM, short-term meds, topicals, and PRNs often excluded

4. Polypharmacy in Seniors • Comprise 13% of population but account for 34% of Rx and 30% OTC med use • 90% of Medicare beneficiaries use Rx meds • 29% of 57-85yo and 40% of Medicare beneficiaries take 5+ Rx drugs • 46% of seniors use both Rx and OTC meds • 52% use Rx meds and supplements (vitamins, herbals) • Of women over age 65: • 57% take 5+ meds (Rx, CAM, OTC) • 12% take 10+ meds

5. Polypharmacy in Seniors • Due to longer life expectancy and the aging baby boomer population, by 2030, the number of Americans 65+ y.o. is expected to double to 71 million • 85+ y.o. represent the fastest-growing segment of population • Multimorbidity • Majority of older adults have 3+ chronic conditions or diseases • about 20% have 5+ chronic conditions

6. Consequences of Polypharmacy • 12% of hospital admissions for seniors are due to ADRs • ADR is the 4th most common cause of hospital-related death • Interactions: • Potential for drug-drug interactions increases exponentially with the number of drugs • Drug-diet: caffeine, alcohol, grapefruit, vit K • Drug-herb • Drug-disease w/ multimorbidity

7. Consequences of Polypharmacy • Inappropriate med use increases w/ more meds • Per Beers study, 12% in community elderly • 40% of nursing home pts • Nonadherence increases with more meds • Potential for underuse of appropriate meds

8. Factors Associated with Polypharmacy • Health System-related • Longer life span means more elderly patients with chronic diseases • More treatment options due to medical developments • Primary and Secondary prevention strategies • Increased use of healthcare services means more hospitalizations (known risk factor for polypharmacy)

9. Factors Associated with Polypharmacy • Patient-related • Age: one of most common risk factors for excessive polypharmacy • Female gender • More pronounced in younger populations • Evens out ~age 70 • Race • 84% of white Americans use meds • 57% Asian descent • Socioeconomic—conflicting data • Higher risk with good insurance coverage • Less wealthy • Less educated

10. Factors Associated with Polypharmacy • Patient-related • Clinical conditions • Cardiovascular disease (Odds Ratio 4.5) • Anemia (4.1) • Respiratory disease (3.6) • Depression, HTN, asthma, angina, diverticulitis, osteoarthritis, gout, DM • Medication therapy • 5 most prevalent drug groups for patients with 5+ meds: Abx, analgesics, psycholeptics, antithrombotics, B-blockers • Self-treatment • 1/3 of 75yo in community use 3+ OTC drugs daily • 37% take Rx drugs without PCP’s knowledge • Old prescription use, borrowing/sharing often unreported

11. Factors Associated with Polypharmacy • Physician-related • Practice environment: lack of time and high workload results in meds remaining in pt records longer than necessary • Education and competencelevels • However, age or time in practice is not associated • Male gender • Difficulty applying guidelines to patients with multiple diseases

12. Factors Associated with Polypharmacy • Physician-related • Prescribing habits • Patient expectation of a prescription • ADRs resulting in prescribing cascade • Improper medical review • Lack of communication between PCPs, specialists, and hospitalists • Skepticism regarding new guidelines, resulting in fall-back on older prescribing practices (improper dosing, multiple meds)

13. Factors Associated with Polypharmacy • Related to Physician-Patient Interaction • Adherence depends on confidence in physician • Pt failure to review entire med list with physician • Lack of continuity due to multiple health providers, prescribers, and pharmacies • Pt expectation of a prescription for each medical visit • Pt requesting specific medications • Disagreement between pt and provider regarding treatment

14. Reducing Polypharmacy • Nursing homes and Care homes • Academic detailing with face-to-face interaction between experts and prescribers • Nursing workshops • Family education • Computerized clinical decision support systems • Multidisciplinary team meetings

15. Reducing Polypharmacy • Community and Hospital • Multidisciplinary case conferences involving geriatrician • Combination of following likely required: • Education • Regular med review, MTM • Important when Rx drug plan formularies change • Geriatrics consultation • Multidisciplinary team meetings • Computerized decision support systems • Regulatory policies and procedures • Improved documentation of medication indication • Increased vigilance during transitions of care

16. Beers Criteria • Pros • Easy to use • Easy to incorporate into computer systems and drug reviews • Cons • Includes some older drugs • Harm from some drugs may be minor compared to inappropriate prescribing of meds not on the list

17. START/STOPP START—22 indicators of drugs commonly omitted STOPP--65 indicators--Focuses on drug-drug, drug-disease interactions, fall risk, and med duplication Lowers rates of polypharmacy and drug-drug interactions, improves correct dosing More sensitive than Beers Criteria (one study only) Easy to use, takes ~3 min to complete

18. ARMOR • Used for nursing home residents • Focus on clinical profiles and functional status • Used for: • Patients with 9+ meds • Initial assessments • Falls or behavioral disturbances • Admission for rehab • Goal is improved functional status and mobility • Limited data shows reduced polypharmacy, healthcare costs and hospitalizations

19. ARMOR

20. Good Palliative-Geriatric Practice Algorithm Reduction in mortality, hospitalization, and cost Avg 2.8 drugs discontinued without significant adverse effects 82% discontinuation success

22. Medication Appropriateness Index Only 3 components are needed to detect polypharmacy: indication, effectiveness, and duplication Can be used for inpatient and ambulatory patients Takes ~10 min to complete Does not address underuse of appropriate prescribing

23. Medication Appropriateness Index

24. Anticholinergic Risk Scale Specific meds in patient’s regimen are assigned a value based on anticholinergic properties and tallied The higher the ARS score, the lower the physical function score Easy to calculate Time consuming and impractical in clinical settings

26. Drug Burden Index Similar to ARS—describes anticholinergic and sedative drug burden Higher DBI associated with reduced physical and cognitive function Potential to be incorporated into DUR software, but not readily available to most clinicians Need studies to determine if improving DBI score results in better outcomes

27. Fit for the Aged Criteria (FORTA) • medications are graded: • A: indispensible, with obvious benefit • B: proven efficacy but limited effects or possible safety concerns; • C: questionable efficacy or safety • D: avoid • no significant decrease in the total number of prescribed drugs or in the number of negatively assessed drugs • significant increase in positively assessed drugs as well as appropriate prescribing • need further validation

28. Other Considerations • Physiologic changes • Decline in Renal and Hepatic function • Reduced clearance • Accumulation • More severe side effects if doses are not adjusted • Reduced body weight, muscle mass, fluid • Altered drug distribution—abx, phenytoin • Increased fatty tissue • Prolonged half-life of lipophilic drugs, i.e. diazepam

29. Other Considerations • Physiologic changes • Vision impairment—40% unable to read Rx label • Hearing impairment • Difficult to understand counseling • Loss of dexterity • Cognitive Impairment • Difficulty understanding and remembering medication instructions, complex regimens • 67% unable to understand information given

30. Other Considerations • Medication Errors • elderly are 4X as likely as those < 65 years of age to be hospitalized for a medication error • Nonadherence • Inadequate Monitoring/Follow-up • INR, dig levels, etc • Accidental Overdose • 85% of elderly who present to ER with accidental overdose were taking antidiabetics, warfarin, antiepileptics, digoxin, theophylline, or lithium • Insulin • Pens/prefilled syringes vs. vials • Simplify regimen, premixed insulins • If regimen changes ensure pt knows to stop taking previously-prescribed insulin • “Start low and go slow”

31. Other Considerations • Medication Errors • Device Problems • 40% errors related to product or device issues • Pens • Used like a vial • Used as a single dose product (Forteo) • Labeling (Apokyn mg vs. mL) • Inhalers • Dose counter malfunction (AsmanexTwisthaler) • Institute of Safe Medication Practices (ismpinfo@ismp.org) • FDA MedWatch (www.fda.gov/Safety/MedWatch/HowToReport/default.htm)

32. Other Considerations • Nonadherence • 55% of Medicare beneficiaries are nonadherent • Up to 40% who skip doses or stop drug do not tell provider • Reasons: • Forgetfulness • Side effects • Perceived inefficacy • Cost—76% more likely to have decline in overall health

33. Other Considerations • Goals of care • Pt/family goals and values may not match clinician expectation • Quality of life and functional status may be more important than maximally extending life expectancy • Ex: recognition of advanced dementia as terminal illness • VBP may financially penalize providers who take this into consideration • Risk vs. Benefit • Consider remaining life expectancy, time to achieve benefit from medication, and pt goals

34. References American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. American Geriatrics Society 2012 Beers Criteria Update Expert Panel. J Am Geriatr Soc. 2012 Apr;60(4):616-31. Clark, TR. Tough decisions about medications. Aging Well magazine, Winter 2010. Gokula M, Holmes HM. Tools to reduce polypharmacy.ClinGeriatr Med. 2012 May;28(2):323-41. Hovstadius B, Petersson G. Factors leading to excessive polypharmacy.ClinGeriatr Med. 2012 May;28(2):159-72. Medication Errors in Specific Situations and Populations. Pharmacist’s Letter. Volume 2011, Course Number 313. Patient-centered care for older adults with multiple chronic conditions: a stepwise approach from the American Geriatrics Society: American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity. J Am Geriatr Soc. 2012 Oct;60(10):1957-68.   PL Detail-Document, Potentially Harmful Drugs in the Elderly: Beers List. Pharmacist’s Letter/Prescriber’s Letter. June 2012. PL Detail-Document, STARTing and STOPPing Medications in the Elderly. Pharmacist’s Letter/Prescriber’s Letter. September 2011. American Society of Consultant Pharmacists’ Geriatric Pharmacotherapy Practice Resource Center, available www.ascp.com/articles/geriatric-pharmacotherapy Medication Use Safety Training For Seniors, available www.mustforseniors.org Photo, www.caregivercollege.org Photo, dangersofpolypharmacy.wordpress.com

35. Questions?