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Geriatric Pharmacotherapy-Part 2.ppt-slides
- 1. Geriatric Pharmacotherapy Lecture 2 Dr.Abrar Aleikish
- 2. Polypharmacy and Deprescribing Polypharmacy= ≥5 medications …but the real issue is inappropriate polypharmacy. Prevalence: ↑ from 30% (2005) → 36% (2011) Common causes: multimorbidity, multiple prescribers, supplements Risks: • ADRs, falls, confusion, cost, nonadherence Distinguish between: • Appropriate (beneficial, evidence-based) • Inappropriate (duplicated, no indication, unsafe)
- 3. Novel approach toinvolve precision medicine for patients with polypharmacy. DDI, drug–drug interaction; eMR, electronic medical record. https://www.cambridge.org/core/journals/cambridge-prisms-precision-medicine/article/polypharmacy-and-precision-medicine/25D6C6B2A25E38175BEDDD3BAE8BE414
- 4. Underuse & STARTCriteria • Underprescribing = Missing beneficial drugs • Occurs in 20–70% of older adults • Commonly underused meds: • Antiplatelets, statins, osteoporosis meds, ACE inhibitors • Causes: • Age bias, fear of polypharmacy, lack of geriatric data • Use START criteria → ensures essential, evidence-based drugs are prescribed
- 5. Nonadherence • Even appropriatetherapy fails without adherence • Common (6–55% in older adults) • Causes: • Cognitive or sensory decline • Cost, complex regimens, low literacy • Swallowing or dexterity issues • Pharmacist actions: • Simplify schedules • Use pill boxes, calendars, large labels • Engage caregivers and check understanding Ask: 1.How do you take your meds? 2.How do you remember? 3.How do you afford them? 4.How often do you miss doses?
- 6. Comprehensive Geriatric Assessment (CGA) •Holistic review to optimize pharmacotherapy • Steps: Collect a complete medication and supplement history Match each drug to its indication Identify PIMs and omissions (Beers / STOPP / START) Assess adherence, interactions, and duplicate therapy Set age-appropriate goals (symptom control > prevention in frailty)
- 7. Deprescribing (Applied) • Systematicwithdrawal of unnecessary medications • Done when: • Risks > benefits • Misaligned with patient’s goals or life expectancy • Steps: • Identify candidate meds (use Beers, STOPP) • Discuss with patient/caregiver • Taper or stop gradually (avoid withdrawal reactions) • Document and monitor outcomes • Be alert for Adverse Drug Withdrawal Events (ADWEs) — e.g., rebound HTN, insomnia
- 8. Pharmacist’s Role • Pharmacists= Medication Safety Advocates • Identify, prevent, and report ADRs • Conduct medication reconciliation at care transitions • Provide MTM (Medication Therapy Management) and deprescribing plans • Educate patients, families, and healthcare teams • Use tools & evidence to personalize therapy
- 9. Targeting High-Risk Patients •Prioritize medication review for: • ≥5 chronic meds • Using anticoagulants, opioids, insulin, NSAIDs, antipsychotics • Frailty, cognitive decline, frequent hospitalizations • Recent medication changes or multiple prescribers • Goal: Focus resources on those most likely to benefit from intervention
- 10. Tools and Criteriafor Safe Geriatric Prescribing •Beers Criteria (American Geriatrics Society) •STOPP/START Criteria (Screening Tool of Older Persons’ Prescriptions) •Medication Appropriateness Index (MAI) •FRIDs (Fall-Risk-Increasing Drugs) lists
- 11. Common Therapeutic Areasand Considerations 1.Cardiovascular: Hypertension, heart failure, anticoagulant management 2.Endocrine: Diabetes management (individualized A1C goals) 3.Neuropsychiatric: Dementia, depression, insomnia (avoid anticholinergics, benzodiazepines) 4.Pain Management: NSAID risks, opioid precautions 5.Antibiotics: Dosing adjustments for renal function 6.Vaccinations: Influenza, pneumococcal, shingles, COVID-19 boosters
- 12. Communication and Counseling Assess health literacy and hearing/vision limitations Simplify medication regimens and labeling Encourage use of pill organizers, medication charts Involve caregivers in counseling
- 13. Adverse Drug ReactionPrevention • 7 Key Prevention Strategies: • Assess comorbidities, cognition, frailty • Adjust doses for renal/hepatic function • Limit number of meds • Monitor drug effects/labs • Watch for atypical symptoms (e.g., confusion = UTI or ADR) • Match therapy to life expectancy • Identify self-medication & OTC use
- 14. Undertreatment (Underprescribing) • Commonomissions: • Anticoagulants for Afib (bleeding fear) • β-blockers in HF • Statins for ASCVD • Analgesics for pain • Antihypertensives for stroke prevention
- 15. • Textbooks 1.Pharmacotherapy: APathophysiologic Approach by DiPiro et al. (12th Ed.) • Chapter: e23 “Geriatrics: Physiology of Aging” 2.Geriatric Dosage Handbook by Lexicomp 3.Goodman & Gilman’s The Pharmacological Basis of Therapeutics (14th Ed.)
- 16.
Editor's Notes
- #2 Polypharmacy Definition: Use of ≥5 medications or any unnecessary/duplicated therapy. Common in older adults due to multiple chronic diseases. Consequences: ↑ Risk of adverse drug reactions (ADRs) ↑ Drug–drug and drug–disease interactions ↓ Adherence and ↑ medication costs Functional decline, confusion, falls, and hospitalizations Principles of Safe Medication Review Review all current medications and their indications. Identify high-risk drugs (anticholinergics, benzodiazepines, NSAIDs, hypoglycemics). Assess ongoing need and benefit versus harm. Check for duplication, interactions, and alignment with patient goals. Deprescribing Process (Mini-Algorithm) List all meds + indication. Identify PIMs / duplicates / interactions. Align with patient goals (function, comfort, safety). Trial taper/stop highest-risk, lowest-benefit drug first. Monitor & document outcomes; involve patient & caregiver. Beers Criteria → avoid high-risk drugs STOPP → identify meds to stop START → identify meds to start Clinical Example: Case: 79-year-old female with HTN, DM, insomnia, arthritis. Meds: Amlodipine, Metformin, Glyburide, Diclofenac, Diazepam, Diphenhydramine. Actions: Stop diphenhydramine (anticholinergic, fall risk). Taper diazepam (sedation, dependence). Switch glyburide → glipizide (lower hypoglycemia risk). Review diclofenac use; consider safer pain alternatives. Key Takeaways “Start low, go slow, but go!” — don’t stop everything at once. Reassess renal, hepatic, and cognitive status regularly. Engage patients and caregivers in shared decision-making. Document rationale and follow-up every 2–4 weeks.
- #3 Polypharmacy and precision medicine
- #6 Beers, STOPP/START, MAI (Medication Appropriateness Index)
- #11 Example: 79-year-old female, HTN, diabetes, insomnia, arthritis. Meds: amlodipine, metformin, glyburide, diclofenac, diazepam, diphenhydramine (OTC sleep aid). Patient: 79-year-old female Chronic conditions: hypertension, diabetes, insomnia, arthritis Current Medications: Amlodipine Metformin Glyburide Diclofenac Diazepam Diphenhydramine (OTC sleep aid) Step 1 – List all meds + indications Amlodipine → Hypertension Metformin → Type 2 Diabetes Glyburide → Type 2 Diabetes Diclofenac → Arthritis pain Diazepam → Insomnia Diphenhydramine → Sleep aid Step 2 – Identify PIMs / duplicates / interactions Glyburide: high risk of hypoglycemia in elderly Diazepam + Diphenhydramine: additive CNS depression → confusion, falls Diclofenac: GI bleed and renal risk in long-term use Step 3 – Align with goals Maintain BP and glucose control Improve sleep without sedation or falls Reduce pain safely Minimize pill burden and adverse events Step 4 – Trial taper / stop (highest-risk, lowest-benefit first) Taper diazepam over 2–4 weeks → replace with sleep hygiene or melatonin Stop diphenhydramine → anticholinergic burden Switch glyburide → glipizide (shorter acting, safer) Review need for diclofenac → consider acetaminophen or topical NSAID Step 5 – Monitor & document outcomes Reassess glucose, pain, and sleep in 2–4 weeks Ask about alertness, falls, mood, and adherence Update medication list and communicate with caregiver
- #12 se Tools to Guide Deprescribing: Beers Criteria → avoid high-risk drugs STOPP → identify meds to stop START → identify meds to start MAI → assess appropriateness Anticholinergic burden scales → assess cognitive risk
- #17 1 — SMART Aim & Measurement SMART Aim: Reduce high-risk ADRs in adults ≥65 by 25% in 12 weeks on Ward/Clinic ___. Population: ≥65 years OR ≥5 meds OR using high-risk drugs (anticoagulants, hypoglycemics, opioids, anticholinergics, FRIDs). Measures Outcome: ADRs/100 patient-days; falls w/ injury; hypoglycemia <70 mg/dL; AKI (KDIGO); 30-day med-related ED visits/readmits. Process: Med rec completed ≤24 h (yes/no) Renal dose verified (CG CrCl used & weight choice documented) Beers/STOPP flag recorded Anticholinergic burden score (e.g., ACB) documented % discharges with indication + stop date on each med Balancing: sleep disturbance score, uncontrolled pain, length of stay, time burden. Team: Pharmacist (lead), MD/NP, RN, QI, IT/EMR, PT/OT (falls), Case Mgmt. 2 — PDSA 1: Admission Med Rec + Beers Screen Plan Pharmacy-led Best Possible Medication History within 24 h. 1-page checklist: indication match, duplicate therapy, Beers/STOPP flags, ACB score. Do Pilot on 1 unit for 2 weeks; weekday hours only. Study % med rec ≤24 h PIMs identified/patient; # actions (hold/stop/change) Early ADR signals (confusion, orthostasis) Act Spread to weekends; add quick order phrases “Avoid per Beers (reason)”. 3 — PDSA 2: Renal Dosing Safety-Stop Plan Cockcroft–Gault auto-calc (actual/ideal/adjusted weight rule embedded). Hard-stop pharmacist verification for renally cleared meds (e.g., DOACs, gabapentin, TMP-SMX, digoxin). Do Turn on alert for ≥65 years or SCr change ≥0.3 mg/dL/48 h. Study % appropriate renal dosing at first order AKI-linked ADRs/100 pt-days Alert acceptance rate & override reasons Act Tweak thresholds; add creatinine trend banner; target high-override prescribers with tip sheet. 4 — PDSA 3: FRIDs → Safer Sleep & Fall Bundle Plan STEADI screen; deprescribe benzos/Z-drugs/diphenhydramine where feasible. Non-drug sleep bundle (lights/noise, mobilize, pain plan, melatonin PRN). Do Night shift nurse checklist + pharmacist bedtime MAR sweep. Study Sedative DDD/100 pt-days; ACB score change; falls/1000 pt-days. Act Standardize zolpidem stop + CBT-I handout on discharge; add PT balance class referral. 5 — PDSA 4: Safer Discharge & 72-h Call Plan Discharge med list must include indication & stop date for antibiotics, steroids, PPIs, sleep meds. Teach-back + printed “When to call us” card. Do Pharmacist phones patient/caregiver at 72 h to reconcile fills, side effects, adherence barriers. Study % discharges with complete med list; post-discharge med issues found/corrected; 30-day med-related ED/Readmit. Act Auto-populate indications from problems list; enroll high-risk pts into follow-up calls. 6 — Tools & Checklists (What to Use) Beers (AGS), STOPP/START, MAI, ACB scale CrCl calculator with weight logic: Normal BMI → actual or ideal (per policy) Underweight → actual Obese → adjusted (IBW + 0.4×[ABW–IBW]) Med Rec form: Drug–Indication–Risk–Action–Monitoring Deprescribing algorithms (benzos, PPIs, anticholinergics) STEADI screen card; Teach-Back script 7 — Data & Visuals (how to track quickly) Daily tally sheets → weekly run charts for: ADRs/100 pt-days Renal-dose-verified rate ACB average per patient Falls/1000 pt-days Annotate chart with P, D, S, A dates to see impact. 8 — Common Barriers → Fast Fixes Alert fatigue: limit to high-harm meds; require reasoned overrides. Time pressure: technician-assisted med rec; use home pharmacy fill history. Clinician buy-in: share 1-minute case of avoided harm each huddle. Patient factors: low literacy → pictogram med list; cost → $4 list/manufacturer assistance. 9 — Mini PDSA Card (print for huddles) PLAN: Aim, who/where, 2 measures, prediction DO: Dates, what changed, issues STUDY: Data vs prediction, brief learning ACT: Adopt / Adapt / Abandon; next test 10 — Example Results Statement (to model) “After 6 weeks, renal-dose verification rose from 62% → 91%; AKI-linked ADRs fell 38%; balancing: no increase in undertreatment (stable pain/sleep scores). We’ll adopt the alert and adapt weight logic for extreme BMI.”
- #18 Koda-Kimble and Young’s Applied Therapeutics: The Clinical Use of Drugs Clinical Guidelines & Databases American Geriatrics Society (AGS) Beers Criteria® (2023 Update) https://geriatricscareonline.org STOPP/START Criteria (2nd or 3rd Edition) https://pubmed.ncbi.nlm.nih.gov/ Lexicomp / Micromedex / UpToDate — for drug dosing and interactions NCBI Bookshelf / PubMed — for open-access reviews and case studies National Institute on Aging (NIA) — https://www.nia.nih.gov/ World Health Organization (WHO) – Medication Safety in the Elderly Journals and Articles Drugs & Aging (Springer) Journal of the American Geriatrics Society (JAGS) Age and Ageing (Oxford Academic) Annals of Pharmacotherapy