Title: The Bagful of Pills: Polypharmacy in the Elderly
1The Bagful of Pills Polypharmacy in the Elderly
- Oana Marcu DO
- Swedish Family Medicine
- March 7, 2006
2Objectives
- Discuss the profound medical and economic
consequences of polypharmacy - Discuss unique pharmacokinetics in the elderly
and identify high risk medications - Propose a plan for preventing ADRs and improving
quality of life!
3Definitions
- Polypharmacy use of more then 5 medications
- inappropriate prescribing of duplicative
medications where interactions are likely - Adverse Drug Reaction (ADR)
- drug interaction that results in an
undesirable/unexpected event that requires a
change in management
4Adverse Drug Reaction (ADR)
- ADRs occur as a result of
- Drug-drug interactions
- Drug-disease interactions
- Drug-food interactions
- Drug side effects
- Drug toxicity
5Consequences Quality of Life
- In ambulatory elderly 35 of experience ADRs and
29 require medical intervention - In nursing facilities 2/3 of residents
experience ADRs and 17 require hospitalization - Up to 30 of elderly hospital admissions involve
ADRs - Beers MH. Arch Internal Med. 2003
6ConsequencesEconomic
- In 2000 ADRs caused 10,600 deaths
- Annual cost of 85 billion
- 76.6 billion in ambulatory care
- 20 billion in hospitals
- 4 billion in SNF
- Beers MH. Arch Internal Med. 2003
7- If medication related problems were ranked as a
disease, it would be the fifth leading cause of
death in the US! - Beers MH. Arch Internal Med. 2003
8Unique Pharmacokinetics normal part of the aging
process
- Absorption
- Distribution
- Metabolism
- Excretion
- Evaluate the pharmacokinetic characteristics of
each medication carefully - Start low, go slow!
9Geriatric Rx Principles
- First consider non-drug therapies
- Match drugs to specific diagnoses
- Reduce meds when ever possible
- Avoid using a drug to treat side effects of
another - Review meds regularly (at least q3 months)
- Avoid drugs with similar actions / same class
- Clearly communicate with pt and caregivers
- Consider cost of meds!
10High Risk Medications Beers
- Beers and Canadian criteria are the most widely
used consensus data for inappropriate medication
use in the elderly - Original 1991, revised 1997, 2002, and 2003
- Excellent well researched reference
- Easily available to you!
11High Risk Medications Drug Classes
- Analgesics
- - NSAIDs
- - Narcotics
- - Muscle relaxants
- Narrow Therapeutic Index
- - digoxin
- - phenytoin
- - warfarin
- - theophylline
- - lithium
12High Risk Medications Drug Classes
- Cardiovascular
- Antihypertensives
- Calcium channel blockers
- Propranolol
- Diuretics
- Psychotropics
- - TCAs
- - Antipsychotics
- - Benzodiazepines
- - Sedative/Hypnotics
-
13High Risk Medications Other
- H2 Blockers mental confusion, disorientation
- Anticholinergic Effects dry mouth, constipation,
urinary retention, delirium - Gastrointestinal Antispasmodics
- Antibiotics (aminoglycosides)
- Hypoglycemics
14SO
- There are profound medical and economic
consequences of polypharmacy and adverse drug
events - Elderly have unique pharmacokinetics
- There are particular high risk medications
- So, lets propose a plan for preventing ADRs and
improving quality of life!
15CARE Avoiding Polypharmamcy
- Caution and Compliance
- Understand side effect profiles
- Identify risk factors for an ADR
- Consider a risk to benefit ratio
- Keep dosing simple- QD or BID
- Ask about compliance!
16CARE Avoiding Polypharmamcy
- Adjust the Dose
- Start low and go slow- titrate!
- Unique pharmacokinetics in elderly
- Altered
- Absorption
- Distribution
- Metabolism
- Excretion
17CARE Avoiding Polypharmamcy
- Review Regimen Regularly
- Avoid automatic refills
- Look for other sources of medications- OTC
- Caution with multiple providers
- Dont use medications to treat side effects of
other meds - What can you discontinue or substitute for safer
med?
18CARE Avoiding Polypharmamcy
- Educate
- Talk to your patient about potential ADRs
- Warn them for potential side effects
- Educate the family and caregiver
- Ask pharmacist for help identifying interactions
- Assist your patient in making and updating a
medication list- personal medical record!
19Personal Health Record
- It will reduce polypharmacy and ADRs
- Multiple specialist involved in care
- Transitions in care from independent living,
hospitals, nursing homes and assisted living
facilities - Great aid in emergency care
- Provides the patient with more piece of mind
20Personal Health Record
- Developed by Dr. Eric Coleman, UCHSC, HCPR
http//caretransitions.org/document/phr.pdf - Patient should bring this with them to every
medical visit and present it to their provider - Each provider should update list with any changes
21Personal Health Record Includes
- Patient identifying information
- Doctors contacts
- Caregiver contacts
- Past Medical History and Allergies
- List of all medications, dose, reason they are
taking it and whether it is new!
22Questions
- Which of the pharmacologic parameters may be
associated with ADRs in the elderly? - Altered free serum concentration of drug
- Diminished volume of distribution
- Altered renal drug clearance
- Prolonged absorption due to decreased gastric
mobility - All of the above
23Questions
- Which of the following is (are) examples of ADRs
in elderly? - Drug side effects
- Drug toxicity
- Drug disease interaction
- Drug-drug interaction
- All of the above
24Questions
- Which of the following combinations are most
commonly associated with ADRs in elderly? - Cardiovascular drugs, psychotropics, and
antibiotics - Cardiovascular drugs, psychotropics, and
analgesics - Gastrointestinal drugs, psychotropics, and
analgesics - Gastrointestinal drugs, psychotropics, and
antibiotics
25Case
- 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. - PMHx CHF, irritable bowel syndrome, depression,
HTN, recurrent UTIs, stress incontinence, anemia,
occipital headaches, osteoarthritis, generalized
weakness - 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
26Medication Red Flags
- High risk drugs alprazolam, oxybutynin, tylenol
2 (narcotics), dicyclomine, NSAIDS - Digoxin at a higher then recommended dose
(0.125mg) - 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
27Case
- 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. - PMHx CHF, NIDDM, OA, glaucoma, depression, and
stress incontinence - Meds furosemide, timolol gtts, metformin,
ibuprofen, paroxetine, oxybutynin,
propoxyphene/actetaminophen prn pain, and
diphenhydramine prn insomnia
28Medication Red Flags
- Diphenhydramine sedative, anticholinergic
properties which effect cognition - Oxybutynin anticholinergic which is known to
cause confusion at higher doses - Propoxyphene- dangerous narcotic!
- Watch for Digoxin toxicity- blurred vision, CNS
disturbances, anorexia
29Case
- 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. - PMHx CAD with MI, COPD, DJD, Hypothyroidism,
Depression/anxiety, chronic anemia and diarrhea,
aortic valve replacement, gout, neuropathy,
bilateral total knee replacements
30- Meds aggrenox, neurontin, theophylline,
synthroid, allopurinol, prozac, combivent,
colchicine, Imodium prn, metamucil, calcium,
iron, multivitamin, codeine - 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
31Assessment and Plan
- 1. Fever with Delirium
- 2. Polypharmacy
- Continue infectious workup and treatment.
- Start simplifying the medical regimen
32Medication Red Flags
- Theophylline low therapeutic index and
considered less effective then inhaled therapies - Iron deficiency anemia is more rare in men, so
check levels and maybe discontinue supplement - Chronic diarrhea iatragenic? From colchicine?
Also Imodium is anticholinergic - Cost estimated monthly drug bill 430
33TAKE HOME POINTS!
- Polypharmacy and ADRs have profound medical and
economic consequences - Elderly have unique pharmacokinetics
- High risk medications include cardiovascular,
analgesic, psychotropics, and meds with a low
therapeutic index - Use the CARE guidelines in prescribing
- Advocate for the Personal Medical Record
- Start improving your patients' quality of life!
34References
- Swansons Family Practice Review. Fourth Ed. A.
Tallia, D. Cardone, D. Howarth, K Ibsen Mosby
2001. - Geriatrics 20 common problems. A. Adelman, M.
Daly McGraw Hill 2001. - Primary Care Geriatrics A Case- Based Approach.
Third Ed. R. Ham, P. Sloane Mosby 1997. - Essentials of Clinical Geriatrics. Fourth Ed. RL
Kane, JG Ouslander, IB Abrass McGraw Hill 1999. - Polypharmacy. Didactic at SFM by Dr. Pat Borman
- Holland EG, Degruy FV. Drug- Induced Disorders.
American Family Physician Vol 56, Nov 1, 1997. - Beers MH. Updating the Beers Crieria for
003Potentially Inappropriate Medication Use in
Older Adults. Arch Internal Med. 2003 2716-2724.
- Personal Medical Record developed by Dr. Eric
Coleman, UCHSC, HCPR http//caretransitions.org/
document/phr.pdf