Bagful Of Pills


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  • Not enough attention paid to pharmacodynamic principles Regardless of semantics, polypharmacy is widely practiced, often unnecessary and yet sometimes required with the usual multiple medical conditions in the elderly!
  • Drugs that interfere with warfarin and cause increases in INR and bleeding risk! Not appropriately adjusting dosing for renal dysfunction Diet interfering with warfarin levels Drug toxicity especially in drugs with low therapeutic index These are the basic mechanisms by which ADRs occur but the truth is that they Have serious consequences to the elders’ quality of life and society’s pocketbook!
  • This is most common form of iatrogenic illness! Of course ADRs are linked to depression, constipation, falls, morbility, confusion, hip fractures And therefore significantly impaired quality of life!
  • The most common ADRs are dose-dependent, predictable and preventable! The first step is to understand that elderly pharmacokinetics are unique! We should be able to identify high risk drugs and be able to appropriately dose medications for the elderly
  • Absorption: Decreased gastric acid alters absorption of some medications Decreased gastric mobility can increase absorption Distribution: 10-15% decrease in Total Body Water and lean body mass: water soluble drugs have poor distribution in adipose cause increasing serum concentrations Increased body fat: lipid soluble drugs accumulate and prolong duration of action Decreased serum albumin: increases free serum concentrations which makes lab levels more challenging to interrupt Metabolism: Reduced metabolism within the liver and diminished enzyme activity increases serum drug effects Excretion: Diminished kidney function (GFR): calculate creatinine clearance (((140-age) x weight in kg)/72 x serum creatinine) x 0.85 (for women)
  • Use these principles to initiate and re-evaluate medications Inherent challenge: the elderly often have very complicated medical conditions which require the use of multiple medications- otherwise the provider feels they are not appropriately treating their patient…. I know hope difficult this challenge can be but If you are aware of the problems with polypharmacy, have a high degree of suspicion for ADRs, and Consider ADRs as a possible etiology of functional decline in elderly patients Then you will improving your pts quality of life! To start doing this, you should be aware of certain high risk medications!
  • Organized in tables of potentially inappropriate medications both independent of diagnoses and as they are related to certain medical problems. However thinking about this as four main high risk drug categories is easier to remember!
  • NSAIDs (gastritis, PUD/GIB, renal toxicity, salt and fluid retention) Narcotics (sedation, confusion, constipation) Propoxyphene- is a particularly addictive active ingredient in Darvocet that is both very addictive and not any more efficacious then Tylenol
  • Antihypertensives (orthostatic hypotension, sedation, falls, renal insufficiency) Calcium channel blockers (constipation, edema Propranolol (hallucinations) Diuretics (dehydration, hyponatremia and kalemia, incontinence) Psychotropics - TCAs (arrhythmias, confusion, delirium, anticholinergic effects, sedation, falls) - Antipsychotics (delirium, anticholinergic effects, extrapyramindal movement do, hypotension, sedation, falls) - Benzodiazepines (delirium, anticholinergic effects, sedation, falls) - Sedative/Hypnotics- research looking into the prevalence of inappropriate prescribing in the elderly shows that by far the most common problems are in this category! In addition- there are a few others that are commonly used including :
  • We need to learn some basic principles for improving polypharmacy and there is a mneumonic that can help us remember the key points!
  • This is a simple and obvious idea which is not currently being utilized!
  • Now- lets review some key points …
  • Patient wakes up in the morning feeling drowsy and hung over therefore more likely to fall and sleep through breakfast Narcotic of choice for breakthrough pain may be oxycodone starting at low doses such as 2.5mg
  • Patient wakes up in the morning feeling drowsy and hung over therefore more likely to fall and sleep through breakfast Narcotic of choice for breakthrough pain may be oxycodone starting at low doses such as 2.5mg
  • Bagful Of Pills

    1. 1. The Bagful of Pills: Polypharmacy in the Elderly Oana Marcu DO Swedish Family Medicine March 7, 2006
    2. 2. Objectives <ul><li>Discuss the profound medical and economic consequences of polypharmacy </li></ul><ul><li>Discuss unique pharmacokinetics in the elderly and identify high risk medications </li></ul><ul><li>Propose a plan for preventing ADRs and improving quality of life! </li></ul>
    3. 3. Definitions <ul><li>Polypharmacy : use of more then 5 medications </li></ul><ul><li>inappropriate prescribing of duplicative medications where interactions are likely </li></ul><ul><li>Adverse Drug Reaction (ADR): </li></ul><ul><li>drug interaction that results in an undesirable/unexpected event that requires a change in management </li></ul>
    4. 4. Adverse Drug Reaction (ADR) <ul><li>ADRs occur as a result of </li></ul><ul><li>Drug-drug interactions </li></ul><ul><li>Drug-disease interactions </li></ul><ul><li>Drug-food interactions </li></ul><ul><li>Drug side effects </li></ul><ul><li>Drug toxicity </li></ul>
    5. 5. Consequences: Quality of Life <ul><li>In ambulatory elderly: 35% of experience ADRs and 29% require medical intervention </li></ul><ul><li>In nursing facilities: 2/3 of residents experience ADRs and 1:7 require hospitalization </li></ul><ul><li>Up to 30% of elderly hospital admissions involve ADRs </li></ul><ul><li>* Beers MH. Arch Internal Med. 2003 </li></ul>
    6. 6. Consequences: Economic <ul><li>In 2000: ADRs caused 10,600 deaths </li></ul><ul><li>Annual cost of $85 billion </li></ul><ul><li>$76.6 billion in ambulatory care </li></ul><ul><li>$20 billion in hospitals </li></ul><ul><li>$4 billion in SNF </li></ul><ul><li>* Beers MH. Arch Internal Med. 2003 </li></ul>
    7. 7. <ul><li>“ If medication related problems were ranked as a disease, it would be the fifth leading cause of death in the US!” </li></ul><ul><li>* Beers MH. Arch Internal Med. 2003 </li></ul>
    8. 8. Unique Pharmacokinetics: normal part of the aging process <ul><li>Absorption </li></ul><ul><li>Distribution </li></ul><ul><li>Metabolism </li></ul><ul><li>Excretion </li></ul><ul><li>Evaluate the pharmacokinetic characteristics of each medication carefully </li></ul><ul><li>“ Start low, go slow”! </li></ul>
    9. 9. Geriatric Rx Principles <ul><li>First consider non-drug therapies </li></ul><ul><li>Match drugs to specific diagnoses </li></ul><ul><li>Reduce meds when ever possible </li></ul><ul><li>Avoid using a drug to treat side effects of another </li></ul><ul><li>Review meds regularly (at least q3 months) </li></ul><ul><li>Avoid drugs with similar actions / same class </li></ul><ul><li>Clearly communicate with pt and caregivers </li></ul><ul><li>Consider cost of meds! </li></ul>
    10. 10. High Risk Medications: Beers <ul><li>Beers and Canadian criteria are the most widely used consensus data for inappropriate medication use in the elderly </li></ul><ul><li>Original 1991, revised 1997, 2002, and 2003 </li></ul><ul><li>Excellent well researched reference </li></ul><ul><li>Easily available to you! </li></ul>
    11. 11. High Risk Medications: Drug Classes <ul><li>Analgesics </li></ul><ul><li>- NSAIDs </li></ul><ul><li>- Narcotics </li></ul><ul><li>- Muscle relaxants </li></ul><ul><li>Narrow Therapeutic Index </li></ul><ul><li>- digoxin </li></ul><ul><li>- phenytoin </li></ul><ul><li>- warfarin </li></ul><ul><li>- theophylline </li></ul><ul><li>- lithium </li></ul>
    12. 12. High Risk Medications: Drug Classes <ul><li>Cardiovascular </li></ul><ul><ul><li>Antihypertensives </li></ul></ul><ul><ul><li>Calcium channel blockers </li></ul></ul><ul><ul><li>Propranolol </li></ul></ul><ul><ul><li>Diuretics </li></ul></ul><ul><li>Psychotropics </li></ul><ul><li>- TCAs </li></ul><ul><li>- Antipsychotics </li></ul><ul><li>- Benzodiazepines </li></ul><ul><li>- Sedative/Hypnotics </li></ul>
    13. 13. High Risk Medications: Other <ul><li>H2 Blockers: mental confusion, disorientation </li></ul><ul><li>Anticholinergic Effects: dry mouth, constipation, urinary retention, delirium </li></ul><ul><li>Gastrointestinal Antispasmodics </li></ul><ul><li>Antibiotics (aminoglycosides) </li></ul><ul><li>Hypoglycemics </li></ul>
    14. 14. SO… <ul><li>There are profound medical and economic consequences of polypharmacy and adverse drug events </li></ul><ul><li>Elderly have unique pharmacokinetics </li></ul><ul><li>There are particular high risk medications </li></ul><ul><li>So, lets propose a plan for preventing ADRs and improving quality of life! </li></ul>
    15. 15. CARE: Avoiding Polypharmamcy <ul><li>Caution and Compliance </li></ul><ul><ul><li>Understand side effect profiles </li></ul></ul><ul><ul><li>Identify risk factors for an ADR </li></ul></ul><ul><ul><li>Consider a risk to benefit ratio </li></ul></ul><ul><ul><li>Keep dosing simple- QD or BID </li></ul></ul><ul><ul><li>Ask about compliance! </li></ul></ul>
    16. 16. CARE: Avoiding Polypharmamcy <ul><li>Adjust the Dose </li></ul><ul><ul><li>Start low and go slow- titrate! </li></ul></ul><ul><ul><li>Unique pharmacokinetics in elderly </li></ul></ul><ul><ul><li>Altered: </li></ul></ul><ul><ul><li>Absorption </li></ul></ul><ul><ul><li>Distribution </li></ul></ul><ul><ul><li>Metabolism </li></ul></ul><ul><ul><li>Excretion </li></ul></ul>
    17. 17. CARE: Avoiding Polypharmamcy <ul><li>Review Regimen Regularly </li></ul><ul><ul><li>Avoid automatic refills </li></ul></ul><ul><ul><li>Look for other sources of medications- OTC </li></ul></ul><ul><ul><li>Caution with multiple providers </li></ul></ul><ul><ul><li>Don’t use medications to treat side effects of other meds </li></ul></ul><ul><ul><li>What can you discontinue or substitute for safer med? </li></ul></ul>
    18. 18. CARE: Avoiding Polypharmamcy <ul><li>Educate </li></ul><ul><ul><li>Talk to your patient about potential ADRs </li></ul></ul><ul><ul><li>Warn them for potential side effects </li></ul></ul><ul><ul><li>Educate the family and caregiver </li></ul></ul><ul><ul><li>Ask pharmacist for help identifying interactions </li></ul></ul><ul><ul><li>Assist your patient in making and updating a medication list- personal medical record! </li></ul></ul>
    19. 19. Personal Health Record <ul><li>It will reduce polypharmacy and ADRs </li></ul><ul><li>Multiple specialist involved in care </li></ul><ul><li>Transitions in care from independent living, hospitals, nursing homes and assisted living facilities </li></ul><ul><li>Great aid in emergency care </li></ul><ul><li>Provides the patient with more piece of mind… </li></ul>
    20. 20. Personal Health Record <ul><li>Developed by Dr. Eric Coleman, UCHSC, HCPR : </li></ul><ul><li>Patient should bring this with them to every medical visit and present it to their provider </li></ul><ul><li>Each provider should update list with any changes </li></ul>
    21. 21. Personal Health Record Includes: <ul><li>Patient identifying information </li></ul><ul><li>Doctors contacts </li></ul><ul><li>Caregiver contacts </li></ul><ul><li>Past Medical History and Allergies </li></ul><ul><li>List of all medications, dose, reason they are taking it and whether it is new! </li></ul>
    22. 22. Questions <ul><li>Which of the pharmacologic parameters may be associated with ADRs in the elderly? </li></ul><ul><li>Altered free serum concentration of drug </li></ul><ul><li>Diminished volume of distribution </li></ul><ul><li>Altered renal drug clearance </li></ul><ul><li>Prolonged absorption due to decreased gastric mobility </li></ul><ul><li>All of the above </li></ul>
    23. 23. Questions <ul><li>Which of the following is (are) examples of ADRs in elderly? </li></ul><ul><li>Drug side effects </li></ul><ul><li>Drug toxicity </li></ul><ul><li>Drug disease interaction </li></ul><ul><li>Drug-drug interaction </li></ul><ul><li>All of the above </li></ul>
    24. 24. Questions <ul><li>Which of the following combinations are most commonly associated with ADRs in elderly? </li></ul><ul><li>Cardiovascular drugs, psychotropics, and antibiotics </li></ul><ul><li>Cardiovascular drugs, psychotropics, and analgesics </li></ul><ul><li>Gastrointestinal drugs, psychotropics, and analgesics </li></ul><ul><li>Gastrointestinal drugs, psychotropics, and antibiotics </li></ul>
    25. 25. Case <ul><li>80 yr. widow who now lives with her daughter comes to your office to establish care and complains of being a nervous wreck and not being able to turn off her mind for the past 2 yrs. She brings with her a bag of all her meds. </li></ul><ul><li>PMHx: CHF, irritable bowel syndrome, depression, HTN, recurrent UTIs, stress incontinence, anemia, occipital headaches, osteoarthritis, generalized weakness </li></ul><ul><li>Meds: sucralfate 1gm TID, cimetidine 300mg QID, enteric asa 325mg, atenolol 100mg, digoxin 0.25, alprazolam 0.5mg, naproxen 500mg TID, oxybutynin 5mg BID, dicyclomine 10mg TID, lasix 40mg , Tylenol #2 prn </li></ul>
    26. 26. Medication Red Flags: <ul><li>High risk drugs: alprazolam, oxybutynin, tylenol #2 (narcotics), dicyclomine, NSAIDS </li></ul><ul><li>Digoxin at a higher then recommended dose (0.125mg) </li></ul><ul><li>naproxen and aspirin carry the potential drug related adverse events of gastritis/GIB and sucralfate and cimetidine are being used to treat these side effects </li></ul>
    27. 27. Case <ul><li>Mrs. Jones is a 72 yr living in an assisted living facility where she has been recently complaining of increasing confusion, lightheadedness in the am and difficulty sleeping at night. </li></ul><ul><li>PMHx: CHF, NIDDM, OA, glaucoma, depression, and stress incontinence </li></ul><ul><li>Meds: furosemide, timolol gtts, metformin, ibuprofen, paroxetine, oxybutynin, propoxyphene/actetaminophen prn pain, and diphenhydramine prn insomnia </li></ul>
    28. 28. Medication Red Flags: <ul><li>Diphenhydramine: sedative, anticholinergic properties which effect cognition </li></ul><ul><li>Oxybutynin: anticholinergic which is known to cause confusion at higher doses </li></ul><ul><li>Propoxyphene- dangerous narcotic! </li></ul><ul><li>Watch for Digoxin toxicity- blurred vision, CNS disturbances, anorexia </li></ul>
    29. 29. Case <ul><li>Mr. Wilson is a 81 yr who had an URI and subsequently was admitted for acute confusion and disorientation. He then began wandering and having hallucinations while spiking a fever. </li></ul><ul><li>PMHx: CAD with MI, COPD, DJD, Hypothyroidism, Depression/anxiety, chronic anemia and diarrhea, aortic valve replacement, gout, neuropathy, bilateral total knee replacements </li></ul>
    30. 30. <ul><li>Meds: aggrenox, neurontin, theophylline, synthroid, allopurinol, prozac, combivent, colchicine, Imodium prn, metamucil, calcium, iron, multivitamin, codeine </li></ul><ul><li>Medical workup: significant for negative head CT, EKG with no acute changes, UA, CBC, LP, Chem10 and CPP are wnl, CXR shows possible RLL infiltrate </li></ul>
    31. 31. Assessment and Plan: <ul><li>1. Fever with Delirium </li></ul><ul><li>2. Polypharmacy </li></ul><ul><li>Continue infectious workup and treatment. </li></ul><ul><li>Start simplifying the medical regimen </li></ul>
    32. 32. Medication Red Flags: <ul><li>Theophylline: low therapeutic index and considered less effective then inhaled therapies </li></ul><ul><li>Iron deficiency anemia is more rare in men, so check levels and maybe discontinue supplement </li></ul><ul><li>Chronic diarrhea: iatragenic? From colchicine? Also Imodium is anticholinergic </li></ul><ul><li>Cost: estimated monthly drug bill $430 </li></ul>
    33. 33. TAKE HOME POINTS! <ul><li>Polypharmacy and ADRs have profound medical and economic consequences </li></ul><ul><li>Elderly have unique pharmacokinetics </li></ul><ul><li>High risk medications include cardiovascular, analgesic, psychotropics, and meds with a low therapeutic index </li></ul><ul><li>Use the CARE guidelines in prescribing </li></ul><ul><li>Advocate for the Personal Medical Record </li></ul><ul><li>Start improving your patients' quality of life! </li></ul>
    34. 34. References <ul><li>Swanson’s Family Practice Review. Fourth Ed. A. Tallia, D. Cardone, D. Howarth, K Ibsen; Mosby 2001. </li></ul><ul><li>Geriatrics: 20 common problems. A. Adelman, M. Daly; McGraw Hill 2001. </li></ul><ul><li>Primary Care Geriatrics: A Case- Based Approach. Third Ed. R. Ham, P. Sloane; Mosby 1997. </li></ul><ul><li>Essentials of Clinical Geriatrics. Fourth Ed. RL Kane, JG Ouslander, IB Abrass; McGraw Hill 1999. </li></ul><ul><li>Polypharmacy. Didactic at SFM by Dr. Pat Borman </li></ul><ul><li>Holland EG, Degruy FV. Drug- Induced Disorders. American Family Physician Vol 56, Nov 1, 1997. </li></ul><ul><li>Beers MH. Updating the Beers Crieria for 003Potentially Inappropriate Medication Use in Older Adults. Arch Internal Med . 2003: 2716-2724. </li></ul><ul><li>Personal Medical Record developed by Dr. Eric Coleman, UCHSC, HCPR : </li></ul>