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Drug therapy considerations for the older adult
Julia Bareham, MSc, BSP
julia@rxfiles.ca
For older adults…
Discuss the risks & benefits presented by tx options
to improve sleep complaints
Understand the risks ...
Difficulty falling asleep, staying asleep, waking up
too early, or sleep that is non-restorative
Sleep difficulty, lasti...
Manage any underlying cause of insomnia or
associated comorbidities
Address any medication/substance use that may
be wor...
Encourage & facilitate as many non-drug measures as
possible
Non-pharmacological methods are essential for long-
term su...
Try to reserve for situations where poor
quality sleep is negatively impacting daytime
functioning
Use the lowest effective dose, short-term (ideally ≤
2 weeks)
Re-evaluate chronic sedative use for efficacy &
potential ...
Trytophan
Might ↓ sleep latency & improve mood in healthy people
with insomnia compared to placebo
 insufficient reliab...
Benefits: improve short-term sleep outcomes
Estimate: ↓ sleep onset latency by 10 to 20 minutes
Estimate: ↑ total sleep...
Harms – a costly trade-off with the benefits:
Rebound insomnia when stopped abruptly may be a
trigger for chronic use
D...
Harms – a costly trade-off with the benefits:
Hangover effects (varies between agents, strongly dependent
on dose & dura...
Recommended starting dose has been ↓ to 3.75 mg
The lowest effective dose for each pt should be used
The prescribed dos...
Reserve for when other treatments fail or when
insomnia is associated with a co-morbid condition (e.g.
depression, pain) ...
Trazodone
Sedative dose lower than those used to treat depression
Lacks anticholinergic effects but is associated with ...
Mirtazapine
Role in major depression with associated insomnia
Useful alternative or co-prescription for patients with
i...
Tolerance to sedative effects occurs after day 3 to 4 of
continuous use
Avoid especially if glaucoma, asthma, & urinary
...
A number of sleep studies have found that atypical antipsychotics,
as a class, can improve aspects of sleep in normal con...
Ensure the individual has symptomatic versus
asymptomatic bacteriuria by looking for
symptoms!
http://www.rxfiles.ca/rxfiles/uploads/documents/ltc/HCPs/UTI/Sask%20Health%20UTI%20Guidelines.pdf
1. Allergies
2. Risk for infections with resistant organisms
Recent antibiotics (<3 – 6 months)
Recent hospitalization
...
1. Allergies
2. Risk for infections with resistant organisms
3. Local antibiogram
4. Renal function
Prevalence of CKD
30...
1. Allergies
2. Risk for infections with resistant organisms
3. Local antibiogram
4. Renal function
5. Drug-Drug/Drug-Dise...
Clinically significant  hyperkalemia
SMX/TMP, trimethoprim alone
watch for high doses
older age
renal insufficiency
...
Clinically significant  serious bleeding
(hospitalization)
WARFARIN interacts with many abx’s used to treat
UTIs:
HIGH...
Remember: any antibiotic can ↑ INR (by reducing GI
flora)
Empiric dosing changes not recommended
Monitor INR on day 3-5...
1. Allergies
2. Risk for infections with resistant organisms
3. Local antibiogram
4. Renal function
5. Drug-Drug/Drug-Dise...
If pain is chronic non-cancer, consider both pain &
function!
Elimination of pain is often not realistic, & if pursued,
...
 ↓ mobility & functional status
 sleep disturbance
 may contribute to depression, anxiety, agitation
 may interfere wi...
 Multiple age-related changes to the body can greatly
affect how medications work in the elderly
 Expect ↑ drug levels /...
 Analgesic but NOT for inflammation
 Useful for musculoskeletal type pain (OA, LBP, etc.)
 Well tolerated @ recommended...
 Maximum daily dose ≤ 4g/day. For chronic dosing
consider limiting to ≤3.25g/day.
 Monitor: Liver function tests if used...
 Potential for side effects needs to be seriously
considered with benefits vs. risks weighed
 Heart – worsen heart failu...
 GI effects: constipation, bowel obstruction, nausea
 Bowel regimen is essential (e.g. laxatives)
 CNS: sedation, cogni...
 Addiction to pain medicine in older adults is RARE
(particularly if no history of substance abuse) when that medicine is...
Respect for the pt’s values, preferences, & expressed
needs
Clear, high-quality information & education for the
patient ...
Do something? Do nothing?
Statin everyday for
primary prevention?
Genetic & cancer
screening tests?
↑ pt’s awareness & understanding of treatment options &
possible outcomes
Online, paper, videos
Can efficiently help pa...
http://shareddecisions.mayoclinic.org
Succinct, easy to use tools that provide
graphic displays of the benefits &
harms o...
↓ polypharmacy
↓ risk of adverse events
↓ risk of drug interactions
↓ pill burden
↓ medication costs
In some circums...
Medicines can be grouped as:
1. Those that keep the pt well and improve day-to-
day QOL
2. Those that are used for the pre...
Factors to consider when deciding if a
medicine can be stopped include:
The wishes of the pt
Clinical indication & bene...
82 year old female
Type II Diabetes (diagnosed 3 years ago)
Glycemic targets
A1c 6.5%?
A1c 7.0%?
A1c 8.5%?
↓ cardiovascular events
(MI, stroke, CV death, HF)
↓ all-cause mortality
↓ hospitalizations
↓ new / worsening nephrop...
UKPDS-34 (metformin vs standard tx in obese
T2DM)
↓ all-cause mortality NNT=14/10.7 years
↓ stroke NNT=48/10.7 years
 ...
.
*Priority = Hypoglycemia prevention
When individualizing targets, consider:
Limited life expectancy
Functional dependency
Extensive CAD at high-risk of CV...
What to do when it comes to statins
& older adults??
This is an area of some controversy….
 RCT studies only include up t...
Cardiovascular Disease
Older adults have ↑ risk of CV disease. However,
epidemiological studies suggest that the relative...
Shorter life expectancy than younger adults
Chronological age often given greater weight than
physiological age
Substan...
Competing causes of mortality mask the potential
benefits of some therapies
Frailty may exacerbate adverse effects of th...
Are there other risk factors?
 Smoking
 Hypertension
 Diabetes
 Shared-informed decision-making
 Risks versus benefi...
1° Prevention
Statins lower risk of CV events in moderate to high risk
pts without a prior CV event
 Absolute benefits ar...
julia@rxfiles.ca
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My pees smells funny

  1. 1. Drug therapy considerations for the older adult Julia Bareham, MSc, BSP julia@rxfiles.ca
  2. 2. For older adults… Discuss the risks & benefits presented by tx options to improve sleep complaints Understand the risks & benefits of the various antibiotic tx options for UTIs Explore the various tx & scheduling options for analgesics Discuss shared-decision making, QoL issues, T2B & the role of 1° prevention in CV risk reduction
  3. 3. Difficulty falling asleep, staying asleep, waking up too early, or sleep that is non-restorative Sleep difficulty, lasting ≥ 1 month (for 3 nights/week), occurs despite adequate opportunity for sleep Insomnia is clinically relevant if associated with significant distress or daytime impairment (fatigue, mood, cognitive, social/work dysfunction, etc…)
  4. 4. Manage any underlying cause of insomnia or associated comorbidities Address any medication/substance use that may be worsening sleep
  5. 5. Encourage & facilitate as many non-drug measures as possible Non-pharmacological methods are essential for long- term success (~75% of those treated will benefit) Avoid the assumption that patients expect a sedative prescription & are unwilling to modify sleep-related behaviours. • Sleep hygiene • Light therapy • Stimulus control • Sleep restriction • Relaxation techniques • CBT
  6. 6. Try to reserve for situations where poor quality sleep is negatively impacting daytime functioning
  7. 7. Use the lowest effective dose, short-term (ideally ≤ 2 weeks) Re-evaluate chronic sedative use for efficacy & potential harm Taper & discontinue gradually if previously used long-term
  8. 8. Trytophan Might ↓ sleep latency & improve mood in healthy people with insomnia compared to placebo  insufficient reliable evidence!! Melatonin Minimally effective, but reasonable option in terms of safety 1 to 3mg (max 5mg) 2-3 hours before bedtime Age, neurodegenerative disorders (Alzheimer’s), T2DM, can ↓ melatonin secretions
  9. 9. Benefits: improve short-term sleep outcomes Estimate: ↓ sleep onset latency by 10 to 20 minutes Estimate: ↑ total sleep time by ~30 minutes
  10. 10. Harms – a costly trade-off with the benefits: Rebound insomnia when stopped abruptly may be a trigger for chronic use Development of tolerance, dependence & withdrawal reactions: continuing long-term may serve only to prevent withdrawal symptoms as effectiveness is progressively reduced ~10-30% of chronic benzodiazepine users develop physical dependence 50% suffer withdrawal symptoms ↑ risk with drugs of shorter duration of action, older patients, daily long-term use, higher doses, alcoholism, etc.
  11. 11. Harms – a costly trade-off with the benefits: Hangover effects (varies between agents, strongly dependent on dose & duration of effect) Other serious adverse effects: fall risk, fractures & memory or performance impairment. Whether zopiclone or zolpidem is any safer than benzos is uncertain If using a benzo for elderly, short to intermediate-acting agents (e.g. lorazepam, temazepam) are preferred  AVOID those with a very long half-life as well as those that are very short- acting
  12. 12. Recommended starting dose has been ↓ to 3.75 mg The lowest effective dose for each pt should be used The prescribed dose should not exceed 5 mg in elderly pts, in pts with hepatic or renal impairment or those currently treated with potent CYP3A4 inhibitors. Dose adjustment may be required with concomitant use with other CNS-depressant drugs. http://healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2
  13. 13. Reserve for when other treatments fail or when insomnia is associated with a co-morbid condition (e.g. depression, pain) or in patients with a history of substance abuse Unknown whether sleep improves in elderly with 1° insomnia There is no single antidepressant or class of antidepressants that is most effective for insomnia in those with depression
  14. 14. Trazodone Sedative dose lower than those used to treat depression Lacks anticholinergic effects but is associated with CV adverse effects (e.g. orthostatic hypotension), next-day sedation (longer half-life in the elderly), & priapism (rare) Start low & go slow  e.g. initial dose: 25-50mg Usual sedative dose: 50-100mg  Lower than antidepressant dose which ranges from 150-600mg in divided doses Half-life ~6.4 hrs in younger adults & 11.6 hrs in elderly
  15. 15. Mirtazapine Role in major depression with associated insomnia Useful alternative or co-prescription for patients with insomnia induced by other antidepressants (e.g. bupropion, some SSRIs) Associated with increased appetite & weight gain Long half-life may cause daytime sedation caution: driving Anecdotally: ≤ 15mg may be more sedating than higher doses because of increased affinity for anticholinergic receptors at the lower dose Doxepin SILENOR 3,6mg New ultra-low dose of old TCA indicated for insomnia
  16. 16. Tolerance to sedative effects occurs after day 3 to 4 of continuous use Avoid especially if glaucoma, asthma, & urinary retention It is unknown if these agents improve sleep quality in older adults; poor evidence of efficacy & lacking long- term safety data
  17. 17. A number of sleep studies have found that atypical antipsychotics, as a class, can improve aspects of sleep in normal controls & those with psychiatric disorders. However, quetiapine’s sleep effects in older adults, especially with dementia, are relatively unstudied. The PK alterations due to aging may contribute to ↑ AEs; use lowest dose  Extended-release agents may not be an optimal choice due to slowed motility of GIT & altered pharmacokinetic parameters Many drug interactions are possible  May ↑ levels/effects of: alcohol, anticholinergics, CNS depressants, methylphenidate, QTc-prolonging agents, quinine.  May ↓ levels/effects of: amphetamines, anti-parkinson’s agents (dopamine agonist) AEs include: ↑ risk of stroke, QT-prolongation, diabetes & death
  18. 18. Ensure the individual has symptomatic versus asymptomatic bacteriuria by looking for symptoms!
  19. 19. http://www.rxfiles.ca/rxfiles/uploads/documents/ltc/HCPs/UTI/Sask%20Health%20UTI%20Guidelines.pdf
  20. 20. 1. Allergies 2. Risk for infections with resistant organisms Recent antibiotics (<3 – 6 months) Recent hospitalization Travel outside Canada/US within last 6 months
  21. 21. 1. Allergies 2. Risk for infections with resistant organisms 3. Local antibiogram 4. Renal function Prevalence of CKD 30% age 65 or older living in community 50% amongst nursing home residents. Of the 1st & 2nd line antimicrobial agents for treatment of UTI, only one agent does not require consideration for kidney function Assess renal function to guide drug selection & dosing!
  22. 22. 1. Allergies 2. Risk for infections with resistant organisms 3. Local antibiogram 4. Renal function 5. Drug-Drug/Drug-Disease Interactions
  23. 23. Clinically significant  hyperkalemia SMX/TMP, trimethoprim alone watch for high doses older age renal insufficiency combination with other drugs that cause ↑ K+ (e.g. ACEI) Often occurs within 4 to 5 days of starting therapy monitor or select an alternative antibiotic when possible Canadian Pharmacist’s Letter. Sept 2010; Vol 26.
  24. 24. Clinically significant  serious bleeding (hospitalization) WARFARIN interacts with many abx’s used to treat UTIs: HIGH—RISK of interaction: Cipro / levofloxacin, TMP--SMX LOW—RISK of interaction: cephalexin, amoxicillin VERY LOW—RISK of interaction: nitrofurantoin, trimethoprim, fosfomycin The American Journal of Medicine (2014), doi:10.1016/j.amjmed.2014.01.044.
  25. 25. Remember: any antibiotic can ↑ INR (by reducing GI flora) Empiric dosing changes not recommended Monitor INR on day 3-5, again if needed, and as needed for any warfarin dose adjustments made
  26. 26. 1. Allergies 2. Risk for infections with resistant organisms 3. Local antibiogram 4. Renal function 5. Drug-Drug/Drug-Disease Interactions 6. Adverse effects 7. Comparative costs 8. Duration of therapy Community-based adults LTC uncomplicated LTC complicated
  27. 27. If pain is chronic non-cancer, consider both pain & function! Elimination of pain is often not realistic, & if pursued, may come at a cost of functional impairment & adverse events (e.g. confusion/fall risk)  Pain reduction: ↓ 30-50%  Improved Function Self Report of Pain: important due to subjective nature of pain
  28. 28.  ↓ mobility & functional status  sleep disturbance  may contribute to depression, anxiety, agitation  may interfere with personal relationships  overall lower quality of life / needless suffering “Pain is inevitable; suffering is optional.” – M. Kathleen Casey
  29. 29.  Multiple age-related changes to the body can greatly affect how medications work in the elderly  Expect ↑ drug levels / prolonged drug levels leading to greater risk of side effects  Decreases in kidney function  Changes in the way the liver metabolises drugs  Body composition changes (e.g. fat stores) Elderly often require ½ -1/3 of the usual adult dose
  30. 30.  Analgesic but NOT for inflammation  Useful for musculoskeletal type pain (OA, LBP, etc.)  Well tolerated @ recommended doses  Short- & long-acting formulations available  e.g. Tylenol Arthritis, 2 phase release  1st layer of caplet provides quick relief, 2nd layer slowly provides medicine over time – option for night/early morning pain  Can be found in combination  e.g. Tylenol #3: acetaminophen & codeine; Caffeine; Cough & cold  Always be mindful of total daily dose from all sources
  31. 31.  Maximum daily dose ≤ 4g/day. For chronic dosing consider limiting to ≤3.25g/day.  Monitor: Liver function tests if used long-term OR with high alcohol consumption
  32. 32.  Potential for side effects needs to be seriously considered with benefits vs. risks weighed  Heart – worsen heart failure, ↑ events (heart attacks)  Kidney – acute renal failure  Gastrointestinal – upset stomach, ulcers, bleeds  CNS – e.g. indomethacin (gout) – dizziness, vertigo, confusion  Monitor: new onset of breathing difficulty, swollen ankles – fluid retention, signs of bleeding  Topicals
  33. 33.  GI effects: constipation, bowel obstruction, nausea  Bowel regimen is essential (e.g. laxatives)  CNS: sedation, cognitive dysfunction, confusion  Most likely to occur upon starting & with dose changes  ↑ risk of falls / fractures  Normal responses to continued exposure of opioids:  Tolerance: results in ↓ of one or more of the drug’s effects over time.  Will likely not develop to constipation; tolerance in a few days to sedative/cognitive/nauseous effects; tolerance can happen to the pain relieving effect requiring a dosage ↑  Dependence: (physical) withdrawal effects START LOW & GO SLOW!!!
  34. 34.  Addiction to pain medicine in older adults is RARE (particularly if no history of substance abuse) when that medicine is used as prescribed for relief of acute or chronic conditions.  Pain medications can be misused in any population, but treatment of significant pain is appropriate and not a misuse.  Be mindful of the fear of addiction, the language you use to describe opioids & be confident in providing reassurance to your patients
  35. 35. Respect for the pt’s values, preferences, & expressed needs Clear, high-quality information & education for the patient and family Involves at minimum a clinician & the pt Both parties share information Clinician: offers options & describes their risks & benefits Pt: expresses his/her preferences & values “What matters to you?” as well as “What is the matter?” Barry MJ, Edgman-Levitan S. Shared decision making--pinnacle of patient-centered care. N Engl J Med. 2012 Mar
  36. 36. Do something? Do nothing? Statin everyday for primary prevention? Genetic & cancer screening tests?
  37. 37. ↑ pt’s awareness & understanding of treatment options & possible outcomes Online, paper, videos Can efficiently help patients absorb relevant clinical evidence & aid them in developing & communicating informed preferences Result of using these tools (Cochrane review):  ↑ knowledge  More accurate risk perceptions  ↑ # of decisions consistent with pt’s values  ↓ level of internal decisional conflict for pts  Fewer pts remaining passive or undecided Barry MJ, Edgman-Levitan S. Shared decision making--pinnacle of patient-centered care. N Engl J Med. 2012 Mar 1;366(9):780-1.
  38. 38. http://shareddecisions.mayoclinic.org Succinct, easy to use tools that provide graphic displays of the benefits & harms of different options organised around concerns that are important to patients
  39. 39. ↓ polypharmacy ↓ risk of adverse events ↓ risk of drug interactions ↓ pill burden ↓ medication costs In some circumstances, the only way to know whether or not to stop a medicine is to actually stop it & see what happens Alexander GC, Sayla MA, Holmes HM, Sachs GA. Prioritizing and stopping prescription medicines. CMAJ 2006;174(8):1083-4.
  40. 40. Medicines can be grouped as: 1. Those that keep the pt well and improve day-to- day QOL 2. Those that are used for the prevention of illness in the future A practical guide to stopping medicines in older people. Best Practice Journal 2012;27
  41. 41. Factors to consider when deciding if a medicine can be stopped include: The wishes of the pt Clinical indication & benefit Priority of medications to be discontinued Appropriateness Duration of use Adherence The prescribing cascade
  42. 42. 82 year old female Type II Diabetes (diagnosed 3 years ago) Glycemic targets A1c 6.5%? A1c 7.0%? A1c 8.5%?
  43. 43. ↓ cardiovascular events (MI, stroke, CV death, HF) ↓ all-cause mortality ↓ hospitalizations ↓ new / worsening nephropathy ↓ retinopathy ↓ neuropathy ↓ foot care complications
  44. 44. UKPDS-34 (metformin vs standard tx in obese T2DM) ↓ all-cause mortality NNT=14/10.7 years ↓ stroke NNT=48/10.7 years  A1C achieved was 7.4% vs 8% ~10 years ADVANCE (mostly gliclazide ± metformin) ↓ microvascular events NNT=67/5 years  A1C: 6.5 vs7.3 ~5 years
  45. 45. . *Priority = Hypoglycemia prevention
  46. 46. When individualizing targets, consider: Limited life expectancy Functional dependency Extensive CAD at high-risk of CV events Multiple co-morbidities History of recurrent, severe hypoglycemia Hypoglycemia unawareness Available support & resources
  47. 47. What to do when it comes to statins & older adults?? This is an area of some controversy….  RCT studies only include up to age ≤82  Risk vs benefit of lowering cholesterol in the very old is not well established. Is lower always better?  Risk of myopathy with: ↑ age & ↓ renal function  If treating, does the pt tolerate the statin well enough to maintain an active lifestyle (relative to previous degree of activity tolerated)?  some patients may "stop walking" if too much myalgia
  48. 48. Cardiovascular Disease Older adults have ↑ risk of CV disease. However, epidemiological studies suggest that the relative risk for CHD associated with high cholesterol ↓ with age. In old age, there is an inverse relationship between high cholesterol & the risk of stroke & there are conflicting data on the relationship between high cholesterol & non-CV mortality. Kronmal RA, Cain KC, Ye Z, Omenn GS. Total serum cholesterol levels and mortality risk as a function of age. A report based on the Framingham data. Arch Intern Med 1993;153:1065-73. Lewington S, Whitlock G, Clarke R, Sherliker P, Emberson J, Halsey J, et al. Blood cholesterol and vascular mortality by age, sex, and blood pressure: a meta-analysis of individual data from 61 prospective studies with 55,000 vascular deaths. Lancet 2007;370:1829-39.
  49. 49. Shorter life expectancy than younger adults Chronological age often given greater weight than physiological age Substantial variation in physiological age between individuals attributable to frailty, comorbid disease, & cognitive decline Risk factors for ASCVD do not predict outcomes as well as they do for younger individuals
  50. 50. Competing causes of mortality mask the potential benefits of some therapies Frailty may exacerbate adverse effects of therapy Polypharmacy may result in ↑ DIs & ↑ pill burden Musculoskeletal function, pain, & cognition AEs of therapies (not restricted to statins) are more severe in older individuals because these factors predispose to reduced physical activity, sarcopenia, & falls.
  51. 51. Are there other risk factors?  Smoking  Hypertension  Diabetes  Shared-informed decision-making  Risks versus benefits
  52. 52. 1° Prevention Statins lower risk of CV events in moderate to high risk pts without a prior CV event  Absolute benefits are modest relative to 2° prevention  Mortality: NNT = NS over ~5yrs  CV Events: NNT = 91 over ~3.3yrs ASCOT Those with lower CV risk have less absolute benefit from a statin which must be weighed against the uncertainties regarding potential benefits versus harms over longer durations  Statins have not been well studied in very elderly patients (>age 82)  Consider ↑ potential for AEs, patient values, etc.
  53. 53. julia@rxfiles.ca

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