A Practical Approach to a Geriatric Patient Tatyana Gurvich, Pharm.D., CGP USC School of Pharmacy UCI Sr. Health Center Queenscare Family Clinics Glendale.

A Practical Approach to A Practical Approach to a Geriatric Patienta Geriatric Patient

Tatyana Gurvich, Pharm.D., CGPTatyana Gurvich, Pharm.D., CGPUSC School of PharmacyUSC School of Pharmacy

UCI Sr. Health CenterUCI Sr. Health CenterQueenscare Family ClinicsQueenscare Family ClinicsGlendale Adventist FPRPGlendale Adventist FPRP

Medication-Related Problems Medication-Related Problems in the Elderlyin the Elderly

Common, Costly and PreventableCommon, Costly and Preventable Total estimated healthcare expenditure related Total estimated healthcare expenditure related

to potentially inappropriate medications is to potentially inappropriate medications is $7.2billion $7.2billion

27% of adverse events in primary care settings27% of adverse events in primary care settings

42% of adverse events in long term care42% of adverse events in long term care

380,000-450,000 adverse drug events occur 380,000-450,000 adverse drug events occur annually in hospitals.annually in hospitals.

JAGS 2012JAGS 2012Arch Int Med 2009Arch Int Med 2009

Contributing FactorsMultiple Medical conditions

An average of 6-7 Rx and 3-4 OTC daily40% have used some form of dietary

supplementADR’s more common when taking 5 or

more meds dailyMultiple providersTime ConstraintsPatient driven prescribing

Prescribing challenges for Prescribing challenges for older patientsolder patients

Is pharmacotherapy is beneficialIs pharmacotherapy is beneficialAdverse reaction/Drug interaction Adverse reaction/Drug interaction

potentialpotentialPrescribing CascadesPrescribing CascadesAge related changes which alter drug Age related changes which alter drug

response in older adultsresponse in older adultsDosing of medicationsDosing of medications

Prescribing challenges for Prescribing challenges for older patients (cont)older patients (cont)

Cost of medications/MediCare issuesCost of medications/MediCare issues

New vs. Established MedicationsNew vs. Established Medications

Limitations of Pre-marketing Trials Limitations of Pre-marketing Trials

Problem MedicationsProblem Medications

Geriatric Pharmacology:Geriatric Pharmacology:PharmacokineticsPharmacokinetics

AbsorptionAbsorptionUse of PPI, H2Blockers, AntacidsUse of PPI, H2Blockers, AntacidsMedications with anti-cholinergic profileMedications with anti-cholinergic profile

DistributionDistributionFat soluble medications: an extended Fat soluble medications: an extended

t1/2t1/2Water soluble medications: Higher Water soluble medications: Higher

concentrations concentrations Dose adjustments are necessaryDose adjustments are necessary

Metabolism: Drug Metabolism: Drug InteractionsInteractions

Differences in metabolism/drug Differences in metabolism/drug interaction potential within a drug classinteraction potential within a drug classStatins: Crestor/Pravachol fewer problemsStatins: Crestor/Pravachol fewer problemsSSRI’s: Celexa/ Lexapro fewer problemsSSRI’s: Celexa/ Lexapro fewer problemsH2blockers: Cimetidine more problemsH2blockers: Cimetidine more problemsAntibiotics: MixedAntibiotics: Mixed

Additive effectAdditive effectSerotonin syndrome/ QT prolongationSerotonin syndrome/ QT prolongation

Plavix and PPI’s/ CodeinePlavix and PPI’s/ Codeine

PK: ExcretionPK: Excretion Creatinine clearance declines with ageCreatinine clearance declines with age

Serum Cr is a poor indicator of indicator and can Serum Cr is a poor indicator of indicator and can overestimate renal functionoverestimate renal function

Dosing adjustment with reduced renal functionDosing adjustment with reduced renal function Vague guidelines which lack clinical practicalityVague guidelines which lack clinical practicality

BisphosphonatesBisphosphonates MacrodantinMacrodantin

PharmacodynamicsPharmacodynamicsBlood Brain Barrier PermeabilityBlood Brain Barrier Permeability Increased Sensitivity medicationsIncreased Sensitivity medications

CNS acting medicationsCNS acting medicationsDiabetes medicationsDiabetes medications

Consequences of low Blood GlucoseConsequences of low Blood GlucoseHTN medsHTN meds

Consequences of low Blood PressureConsequences of low Blood PressureDrugs with anti-cholinergic profileDrugs with anti-cholinergic profile

PharmacodynamicsPharmacodynamicsExamples of altered response in Examples of altered response in

geriatricsgeriatricsOxybutininOxybutininDiphenydramineDiphenydramineAlbuterol InhalerAlbuterol InhalerTimoptic eye dropsTimoptic eye drops

Polypharmacy/PolymedicinePolypharmacy/Polymedicine What is “polypharmacy”?What is “polypharmacy”?

The use of unnecessary medications The use of unnecessary medications which is independent of the number of which is independent of the number of medications being takenmedications being taken

Increases the risk of:Increases the risk of: Adverse reactionsAdverse reactions Drug/Drug InteractionsDrug/Drug Interactions Prescribing cascadesPrescribing cascades ComplianceCompliance

The prescribing cascadeThe prescribing cascade Drug induced adverse events which mimic symptoms Drug induced adverse events which mimic symptoms

of other diseases or can precipitate confusion, and of other diseases or can precipitate confusion, and or falls.or falls. Prozac TO a FALLProzac TO a FALL

Prozac for depression. Ativan for Prozac induced Prozac for depression. Ativan for Prozac induced anxiety and insomnia. Pt became dizzy, fell and anxiety and insomnia. Pt became dizzy, fell and broke a hipbroke a hip

Plendil TO a diagnosis of GERD and an ORTHO Plendil TO a diagnosis of GERD and an ORTHO work upwork up

Plendlil for HTN; ORTHO work up ordered for Plendil Plendlil for HTN; ORTHO work up ordered for Plendil induced edema; PPI was added for GERDinduced edema; PPI was added for GERD

Verapamil TO HaldolVerapamil TO HaldolVerapamil for HTN; Lasix for Verapamil induced Verapamil for HTN; Lasix for Verapamil induced

CHF/Edema; Ditropan for diuretic induced CHF/Edema; Ditropan for diuretic induced incontinence; Haldol for Ditropan induced confusion incontinence; Haldol for Ditropan induced confusion and agitation due to its anti-cholinergic effects and agitation due to its anti-cholinergic effects

ACOVE: Assessing Care of ACOVE: Assessing Care of Vulnerable EldersVulnerable Elders

Document drug indicationDocument drug indicationProvide adequate pt educationProvide adequate pt educationMaintain current medication listMaintain current medication listDocument response to therapyDocument response to therapyReview ongoing need for therapyReview ongoing need for therapy

Medication ConsiderationsMedication ConsiderationsBenzodiazepines: Long and short actingBenzodiazepines: Long and short acting

Risk of confusion, falling, dependenceRisk of confusion, falling, dependence

Non-BZD hypnotics: Avoid chronic useNon-BZD hypnotics: Avoid chronic useMore focus on behavioral managementMore focus on behavioral management

Opioids: Increased risk of falls/fracturesOpioids: Increased risk of falls/fracturesTramadol Clcr 30ml/min: SE/Seizure riskTramadol Clcr 30ml/min: SE/Seizure risk

Medication ConsiderationsMedication ConsiderationsFocus on Neuropathic pain Focus on Neuropathic pain

alternatives:alternatives:SNRI’s/Gapapentin/Pregabalin/Capsaicin/SNRI’s/Gapapentin/Pregabalin/Capsaicin/

Lidocaine Lidocaine Gabapentin/Pregabalin Clcr less Gabapentin/Pregabalin Clcr less

60ml/min60ml/minIncreased risk of CNS side effectsIncreased risk of CNS side effects

Duloxetine less Crcl 30ml/minDuloxetine less Crcl 30ml/minMore nausea/diarrheaMore nausea/diarrhea

Medication ConsiderationsMedication ConsiderationsMirtazapine/SNRI/ SSRI’s: SIADH; Check Mirtazapine/SNRI/ SSRI’s: SIADH; Check

Na when starting/changing doseNa when starting/changing doseSSRI’s: Increased risk of fallingSSRI’s: Increased risk of fallingOTC Sympathomimetics: Stimulant effectsOTC Sympathomimetics: Stimulant effects

Insomnia, anxiety, agitationInsomnia, anxiety, agitationAntipsychotics for behavior managementAntipsychotics for behavior management

Risk of CVA and mortality; Risk vs. BenefitRisk of CVA and mortality; Risk vs. Benefit

Medications ConsiderationsNSAID’s

PPI/misoprostol doesn’t ELIMINATE riskIndomethacin/Toradol CHF and CKD risk Increase in blood pressure with chronic

useSkeletal muscle relaxants

Poorly tolerated, all on the Beer’s listPotentially habit forming

Medication ConisderationsMedication Conisderations

Ca channel blockers: Ca channel blockers: constipation/edemaconstipation/edema

Verapamil/Diltiazem and CHFVerapamil/Diltiazem and CHFBeta blockers: Hypoglycemia; FatigueBeta blockers: Hypoglycemia; FatigueThiazides: SE and CrCl<30ml/minThiazides: SE and CrCl<30ml/minClonidine: Bradycardia, orthostasisClonidine: Bradycardia, orthostasisAlpha Blockers: OrthostasisAlpha Blockers: Orthostasis

Medicaton Considerations Miscelaneous GI medications

Reglan, Tigan, Lomotil*DA antagonist; Anticholinergic side effects

Mineral oilAbsorption of fat soluble vitamins; risk of aspiration

H2 antagonists in dementia/deliriumAniticholinergic effects

Na Containing AntacidsNa Containing AntacidsSubstantial sodium load: Edema and increase in BPSubstantial sodium load: Edema and increase in BP

Medication ConsiderationsMedication ConsiderationsEndocrine

Sliding scale insulin, GlyburideActos/Avandia for CHF riskDesiccated thyroidEstrogen/Megace/TestosteroneEstrogen/Megace/Testosterone

Lack of cardio-protective/cognitive effectLack of cardio-protective/cognitive effectLack of weight gain/increased thrombosisLack of weight gain/increased thrombosisCardiac risk/prostate cancerCardiac risk/prostate cancer

Drugs with Strong Anti-cholinergic Properties

1st Generation antihistamines/Loratadine*

Artane/CogentinSkeletal muscle relaxantsTCA’s/Paroxetine*Old antipsychotics Compazine, Promethazine, ZyprexaUrinary and GI antispasmodicsThe concept of “anti-cholinergic load”

Steps to Reducing Poly-Steps to Reducing Poly-pharmacy pharmacy

““Brown Bag” all medications at each Brown Bag” all medications at each office visit. Keep accurate recordsoffice visit. Keep accurate records

Identify all medications by Identify all medications by brand/generic name and drug classbrand/generic name and drug class

All drugs prescribed should have a All drugs prescribed should have a clinical indicationclinical indication

Stop any drug without known benefitStop any drug without known benefitConsider what effect drug therapy Consider what effect drug therapy

has on quality of lifehas on quality of life

Steps to Reducing Poly-Steps to Reducing Poly-pharmacy (CONT)pharmacy (CONT)

Know the side effects of the drugs Know the side effects of the drugs prescribed and what to expect from themprescribed and what to expect from them

Understand the PK and pharmacodynamics Understand the PK and pharmacodynamics of drugs prescribedof drugs prescribed

Substituting drugs within classes can Substituting drugs within classes can eliminate DI’s and ADR’seliminate DI’s and ADR’s

Be aware for the prescribing cascadeBe aware for the prescribing cascade““ONE DISEASE, ONE DRUG, ONCE DAILY”ONE DISEASE, ONE DRUG, ONCE DAILY”““START LOW, GO SLOW, BUT GO”START LOW, GO SLOW, BUT GO”