Polypharmacy and Medication Issues

1. Polypharmacy and Medication Issues Lisa Killinger, DC Healthy Aging

2. Polypharmacy • Affects about 1 in 3 people over the age of 65 (HP 2010) • May be the 4th-6th leading cause of death in American elderly (Lazerou, Pomeranz. JAMA 1998) • Over 100,000 deaths in US in 1994 (“ “) Fontanarosa PB. Postmarketing surveillance: Lack of vigilance, lack of trust. JAMA 2004, 292:2647-50.

3. The costs of drugging our seniors • Approx 18-24% of all hospital admissions in the elderly are due to adverse drug reactions(Manesse CK. Age Ageing 2000; 29:35-39) • Older persons may take an average of 5.7 prescription meds plus 3.2 over the counter meds per day. (Bennett, CL et al. RADAR Project: JAMA May 4, 2005; 293:2131-40) www.rad-ar.or.jp

4. Polypharmacy According to “Healthy People 2010” : Polypharmacy is the principal drug safety issue in the United States, particularly in older persons.

5. Polypharmacy defined… • Taking too many different meds • When 2 drugs are taken, the chance of negative interaction is 5% • When 5 drugs are taken, chances of negative interactions are 50% • When 8 or more meds are taken, there is nearly a 100% chance of negative interaction (Chrischilles EA, et al. J Gerontol. 1992.Stewart RD, Cooper JW. Drugs Aging. 1984)

6. Polypharmacy defined… • Taking several meds for the side effects of other meds: • Example: Esther is taking acetominophen and codeine for her arthritis. Due to the constipation caused by codeine, she has to take 2 forms of laxitives to stay regular.

7. Polypharmacy defined… • Taking meds or other drugs that have negative interactions or dangerous side effects when combined- Example: Iris likes to have a “nightcap” (or two) every night before bed. She is also taking NSAIDS for her back pain, and is on an antihypertensive. She ends up extremely hypotensive and develops an ulcer due to these bad drug combinations.

8. Polypharmacy Defined… • Taking meds prescribed by several different providers Example: Wilma takes antihypertensives and NSAIDS for her blood pressure and arthritis. She goes to the dentist, and he prescribes a narcotic analgesic. She then sees a psychologist for her depression and she prescribes amitryptiline. YIKES!

9. Some common drug side effects in aging patients • Dizziness • Confusion • Orthostatic hypotension • Tardive dyskinesia • Constipation and/or dehydration • Heart disorders: brady/tachycardia, arrhythmias • Renal or hepatic failure; GI ulceration

10. Drugs, Toxicity, and Aging: A Bad Combination • How drugs are metabolized differently in aging patients • Increased storage in fatty tissues • Less lean body mass to utilize drugs • Slower gastric motility, fewer enzymes • Decreased blood flow to target tissues • Decreased total water content in body

11. Inappropriate drugs for aged pts • Slow acting Benzodiazepines- Diazepam (anti-anxiety; CNS agent) • Amitryptiline (anti-depressant) • Phenylbutazone • Indomethacin-Indocin (anti-inflam) • High doses of NSAIDS over long periods • Some barbituates and sedative/hypnotics • Pentobarbital, Pentazocine, Codeine, Morphine

12. So, are drugs always bad? • NO! Drugs sometimes save lives. • Drugs should be used after natural methods have failed. Chiropractic Philosophy: Least invasive to most invasive Drug may become the appropriate/least invasive intervention for some situations.

13. So, how can we help? • Co-sponsor an annual or semi-annual “brown bag event”. (patients bring all of their prescriptions in a brown bag for assessment/update of your files) • Encourage patients to use ONE pharmacy. • Encourage patients to ALWAYS communicate about their meds to all providers they see.

14. Screen your patients: Med Checklist • I do not know if I should take my meds before or after eating. • I take 3 or more meds/day • I have gained or lost 10 lbs. since I started taking my meds. • I go to more than one pharmacy. • I have not discussed my use of supplements/herbs with my doctor.

15. Med Checklist: -cont. • I drink 2 or more alcoholic beverages per day. • I take insulin or pills for diabetes and sometimes skip meals or bedtime snacks. • I cannot read the labels on some of my meds. • I take: Digoxin, Lithium, Theophylline, or Dilantin, and my doctor does not regularly check my blood levels. *If a patient agrees with more than 2 of these statements they are at risk for adverse drug reactions. (Nutrition Screening Initiative: Amer. Acad of Family Physicians & National Council on Aging)

16. Encourage and teach about alternatives to drugs… • General Health: Regular chiropractic care • Pain/Depression: Laughter IS the best medicine • Stress/Anxiety: Biofeedback and relaxation techniques • Pain/General Health: Volunteering • General Wellness: Live in service, rather than in survival mode!

17. Drug Prevention=Disease Prevention • Educate patients on natural ways to prevent disease and promote health (HPP) • E.G: Heart disease, stroke, arthritis, osteoporosis: Physical activity/Healthy diet!!!!!! • Diabetes-small frequent meals and snacks that include protein, limit refined/processed sugars/flours, drink water, physical activity!

18. Open up lines of communication • Ask a pharmacist to lunch • Let them know that you are concerned about polypharmacy • Ask what you can do to help

19. Thank You For Your Attention!