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Bagful Of Pills
1. The Bagful of Pills: Polypharmacy in the Elderly Oana Marcu DO Swedish Family Medicine March 7, 2006
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Editor's Notes
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
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