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The use of drugs among the elderly: the role of pharmacists THEORY

The use of drugs among the elderly: the role of pharmacists THEORY. < 12%. < 14%. < 16%. < 17%. > 17%. Proportion of citizens aged ≥ 65 years in Europe. Source: European Health For All Database, WHO/Europe, various years (1997-2004). Use of drugs in Italy by age and sex

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The use of drugs among the elderly: the role of pharmacists THEORY

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  1. The use of drugs among the elderly: the role of pharmacists THEORY

  2. < 12% < 14% < 16% < 17% > 17% Proportion of citizens aged ≥ 65 years in Europe Source: European Health For All Database, WHO/Europe, various years (1997-2004)

  3. Use of drugs in Italy by age and sex 2007 (Report OsMed 2007 – Agenzia Italiana del Farmaco) A patient of 75 years or older takes 17 times more drugs compared to a young adult of 25-34 years.

  4. BENEFIT RISK The paradox of drugs: “Medication is probably the single most important healthcare technology in preventing injury, disability and death in the geriatric population.” (Avorn J. Medication use and the elderly: current status & opportunities. Health Aff, 1995) “Any symptom in an elderly patient should be considered a drug side effect until proved otherwise.” (Gurwitz et al. Long-term Care Quality Letter - Brown University, 1995)

  5. Scientific evidence Polytherapy  pharmaceutical interactions  adherence to treatment Inappropriate drugs Adverse reactions Limits to pharmaceutical therapies for the elderly… Physiological alterations

  6. Problems related to drug therapy for elderly people Elderly people have a risk of developing adverse effects almost double that of younger people (Br J Clin Pharmacol, 2002) 20%of older people in Europe receive at least one inappropriate drug (JAMA, 2005) 30% of hospital admissions among elderly people are caused by adverse effects of drugs, which is considered thefifth leading cause of death in hospitals (J Am Geriatr Soc, 2001) It has been estimated that in 1994, in the USA alone over 100,000 people died due to an adverse reaction to a drug (JAMA, 1998)

  7. Which drugs?(Pirmohamed M et al. Adverse drug reaction as cause of admission to hospital. BMJ, 2004)

  8. More than 2/3 of adverse reactions to drugs are FORESEEABLE and AVOIDABLE(Ger and Soc, 2002 – BMJ, 2004 – Pharmacotherapy, 2006).

  9. Physiologcal changes in elderly people (Mangoni AA, Jackson SH – Age-Related Changes in Pharmacokinetics: Basic Principals & Practical Applications. Br J Clin Pharmacol, 2004) • Change in numbers of hepatocytes • Reduced production of albumen • Reduced gastric motility • Reduced secretion of acid/enzymes • Reduced number of functioning glomeruli • Reduced blood flow • Alterations in neurochemical transmission • Reduced cognitive capacity and ability

  10. Physiological alterations in elderly people: what to do? Consider… • …the use of well-known drugs about which enough is known regarding the risk/benefit balance for elderly patients. • …the presence of organ insufficiencies. • …recourse to non pharmacuetical treatments (diet advice, smoking cessation, physical activity).

  11. Some medicines are absoutely to be avoided… • Flurazepam (Dalmadorm) and Diazepam (Valium):  prolonged sedation and higher rates of falls and femoral fractures. • Ketoralac (Toradol, Lixidol):  risk of gastrointestinal bleeding even in the short term. • Naprossene and Piroxicam :  risk of gastrointestinal bleeding, renal insufficiency and hypertension if used oved the long term. • Ticlopidina (Tiklid):  risk of neutropenia.

  12. … or with particular conditions • Gastrointestinal disturbances • Constipation • Avoid: anticolinergics, antidepressants tricyclics • Ulcers • Avoid: FANS, aspirin, K+ integrators • Endocrine Disturbances • Diabetes • Avoid: corticosteroids, -blockers • Cardiovascolar Disturbances • Cardiac arrhythmia • Avoid: antidepressants tricyclics • Urinary Disturbances • Incontinence • Avoid: -blockers • Respiratory Disturbances • Athsma o COPD • Avoid: -blockers ¼of elderly surgery patients, and 40%of those in care homesreceive inappropriate drugs according to the Beers criteria. (Willcox SM et al – JAMA, 1994 Dhall J et al – Pharmacotherapy, 2002Hamilton H - BMC Geriatrics, 2009)

  13. Inappropriate drugs: what to do? avoid prescribing drugs which appear on the Beers list Favour other, safer, therapies

  14. Polytherapy: possible causes • Presence of pluripathologies. • Expectations of the patient and medical prescription. • “Fragmentation of cures”. • Recourse to self-medication. • Adverse reactions treated as pathologies.

  15. 64,9 51,9 46,4 45,2 37,9 38,0 34,9 28,6 21,3 18,9 18,8 16,7 12,9 12,8 12,2 12 8,7 8,1 6,9 6,8 6,4 4,1 3,9 3,9 arrythmia, arthritis diabetes hypertension osteoarthritis heart disease nervous diseases (women only) 60-64 65-74 75 and over Average, total population Elderly people and Chronic Pathologies (data ISTAT 2005)

  16. Fragmentation of cures (Viktil K et al. The Janus face of polypharmacy: overuse vs underuse of medication. Norsk Epidemiol, 2008) • In 2000, in the USA, elderly patients made more than 200 million visits to the dotor: - 1/3 of visits  no prescription - 1/3 of visits 1-2 drugs prescribed - 1/3 of visits  3 or more drugs prescribed • The number of drugs increases as the number of doctors looking after the same patient increases. ...but not only this!!!

  17. Every day I take pills for my blood pressure, drops to help me sleep, ‘happy pills’ and I stuff myself with vitamins… and I’m still getting older!!!

  18. The iceberg effect Known drugs Over the counter medicines Herbal products Particular foods Alcohol

  19. The prescription ‘snowball’ For the collateral effects of the last drug I gave you, take this other one, and then if there are any side effects I’ll prescribe you a third to help with them… Can’t I just have my old illness back?!

  20. FANS ANTI-HYPERTENSION DRUG HCT FANS HYPERTENSION GOUT ARRYTHMIAA HYPERTENSION ANTI-ARRYTHIMIA DRUG MACROLIDE Some examples of the prescription ‘snowball’

  21. Always remember: “Any symptom in an elderly patient should be considered a drug side effect until proved otherwise.” (Gurwitz et al. Long-term Care Quality Letter - Brown University, 1995) • Numerous syndromes in old age are actually consequences of pharmacological therapies: • delirium  use of SNC drugs (eg. Anticolinergic drugs, opiates) • falls and fractures  benzodiazepins, anti-hypertension drugs • urinary incontinence  eg. diuretics

  22. Polytherapy and interactions between drugs “An interaction between drugs becomes important for the patient and the doctor when it interferes with the expected efficacy or diminishes the safety of a treatment” At the moment of the commercial authorisation of the drug, the safety profile for elderly people is limited. The risk of potential interactions alomst exponentiallyas age and the number of drugs used increase. (Karas S - Ann Emerg Med, 1981; Sloan RW – Am Fam Physician, 1983) The risk of interaction triplesin patients who receive prescriptions from two doctors simultaneously. (Recalde J.M., Aten Prim, 1998)

  23. Patients in ULSS 16 treated with warfarin: 8,736 Drugs and Herbs: principal herbal products which cause interactions between drugs ST JOHN’S WORT: warfarin, digossin, antidepressants, ansiolitici, oestrogen, antivirals, immunesuppressants, anti-tumorals, anaesthetics, teofilin. CRANBERRIES: warfarin GINKGO: warfarin, calcium channel blocker, anti-inflammatories, antidepressants, salicylics. GARLIC: warfarin, ACE inhibitors, antivirals, anti-inflammatories. GINSENG: warfarin, anti-platelets, anti-depressives, anti-epileptics. GREEN TEA: warfarin.

  24. Common interactions between drugs and foods • Foods rich in K+:bananas, oranges, leafy greens • ACE-inhibitors • Diuretics • Sartans • K+ savers • Foods rich in Ca2+: milk, yogurt, cheese • Digossin • Diuretics • Thyroid Hormones • Some antibiotics • Foods rich in vitamin K:apples, spinach, nuts, kiwis, broccoli, cabbage • Warfarin

  25. Food and Drugs: the case of grapefruit juice… (Stump AL, et al. Management of grapefruit-drug interactions. Am Fam Physisican 2006) benzodiazepine  AUC,  Cmax  strengthens the effects of BDZ Calcium channel blockers Immune-supressants  Haematic levels  (headaches, hypotension, tachycardia)  Adverse effects  nefrotoxicity, liver disease statins  AUC (16 times)  cefalea, myopathy Antidepressants tricyclics arrythmia,antihistamines  Levels of liver disease  Prolonged QT  Levels of liver disease

  26. Polytherapy and interactions: what to do? • Treat the pathologies in order of priority. • Use drugs when strictly necessary to reduce risk. • Ask the patients if they are using over the counter medicines or herbal medicines. • Inform the patient about foods to avoid. • Monitor the response periodically and compare the appearance of adverse reactions. • Review treatment periodically.

  27. Polytherapy and therapy adherence: a real problem Adherence = “match between the behaviour of the patient and the medical prescription” Change in timing or frequency of doses by the patient Mistaken consumption 40-60% of elderly patients do not follow their prescription properly (Vik SA et al. Ann Pharmacoter, 2004)

  28. Reasons for not following a prescription correctly AGE DOESN'T COUNT but... • …the number of drugs taken  Polytherapy • …the frequency of doses • …the cost of the medicine • …the relationship between doctor and patient

  29. Polytherapy and adherence to treatment (1): what to do ? For Mary Smith 1 pill after meals for 7 days

  30. Polytherapy and adherence to treatment (2): what to do ?

  31. PRACTICAL PART 31

  32. Polytherapy and adherence to treatment (3): what to do?

  33. Exercise An 87-yar old woman suffers from arterial hypertension, atrial fibrilation and has worn a pacemaker for two years. The patient comes to the pharmacy periodically to buy the following drugs: • gliclazide: 1 pill before meals 3 times a day • ramipril 5 mg : 1 pill after breakfast • digoxin 0,125 mg : 1 pill at 4pm • furosemide 25 mg :1 pill at breakfast and 1 at 4pm • pantoprazolo 20 mg : 1 pill before breakfast (on an empty stomach) • amlodipina 5 mg : ½ pill after lunch • warfarin 5 mg : 1 pill after dinner • metoprolol 100 mg : ½ pill before breakfast + ½ before dinner • simvastatina 20 mg : 1 pill after dinner • triazolam 0,25 mg : 1 pill before bed • Using the diary, help the patient to plan her intake of prescribed drugs and give relevant advice on food/products to avoid while taking these drugs. • The patient asks for advice regarding the sudden appearance of a pain in her knee despite the topical use of NSAID. What drug/advice can be given to the patient?

  34. Diary

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