Polypharmacy and Medication Issues

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Polypharmacy and Medication Issues

• Lisa Killinger, DC
• Healthy Aging

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Polypharmacy

• Affects about 1 in 3 people over the age of 65
• Significant cause of death in the elderly
• May be the 3rd or 4th leading cause of death in
  American elderly

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The costs of drugging our seniors

• From 17-25 of all hospital admissions in the
  elderly are due to adverse drug reactions (Beard,
  K. Drugs and Aging, 1992.)
• Older persons may take an average of 5.7
  prescription meds plus 3.2 over the counter meds
  per day.
• (Everitt DE, Avorn J. Arch Int Med. 1986)

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Polypharmacy

• According to Healthy People 2010
• Polypharmacy is the principal drug safety issue
  problem in the United States, particularly in
  older persons.

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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)

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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 laxatives to stay regular.

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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.

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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!

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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

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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

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Inappropriate drugs for aged pts

• Slow acting Benzodiazepines-Diazepam
  (anti-anxiety CNS agent)
• Amitryptiline (anti-depr. w/ lots of side
  effects)
• Phenylbutazone-Other NSAIDs are less toxic
• Indomethacin-Indocin (anti-inflam/gastric prob)
• High doses of NSAIDS over long periods
• Some barbituates and sedative/hypnotics
• Pentobarbital, Pentazocine, Codeine, Morphine

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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 interventions

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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.

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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.

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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)

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Encourage and teach about alternatives

• Laughter IS the best medicine
• Biofeedback and relaxation techniques can help
• Volunteering decreases pain and improves overall
  health
• Teach your patients the wisdom of being in
  service, rather than in survival mode!
• Regular chiropractic care!!!

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Drug PreventionDisease 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!

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Open up lines of communication

• Ask a pharmacist to lunch
• Let them know that you understand and are
  concerned about polypharmacy
• Ask what YOU can do to help

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Communicate polypharmacy concerns to patients!

• Usually they dont realize the dangers
• Often, they are unaware of alternative choices
  (different drug, or natural methods of pain or
  disease control)
• Out of reverence to their MD, they are afraid to
  mention problems (He/she MUST know best!)
• They dont recognize or are ashamed about
  addiction to drugs.

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Dont forget the recreational drugs...

• Alcohol abuse is prevalent in the aged (and very
  dangerous)
• Addiction to caffiene or OTC drugs is not
  unusual.
• When hippies turn 60 (the story of Tom)
• Other issues?

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Great articles on this topic

• Gurwitz JH, et al. Incidence and preventability
  of adverse drug events among older persons in the
  ambulatory setting. JAMA Mar. 5,
  2003289(9)1107-1116.
• Sloan PD, et al. Inappropriate medication
  prescribing in residential care/assisted living
  facilities. JAGS. 2002501001-1011.
• Wilcox SA, et al. Inappropriate drug prescribing
  for the com. Dwelling elderly. JAMA.
  1994.22(4)292-296.

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Thank You For Your Attention!