American Society of Consultant Pharmacists America’s Senior Care Pharmacists® Principles of Drug Use: Prescribing for the Elderly Thomas R. Clark, RPh,

American Society of Consultant Pharmacists America’s Senior Care Pharmacists®

Principles of Drug Use:Principles of Drug Use:

Prescribing for the ElderlyPrescribing for the Elderly

Thomas R. Clark, RPh, MHSThomas R. Clark, RPh, MHS

ASCP Director of Policy & AdvocacyASCP Director of Policy & Advocacy


““Medications are probably the Medications are probably the single most important health care single most important health care technology in preventing illness, technology in preventing illness, disability, and death in the disability, and death in the geriatric population”geriatric population”

Avorn, J. Medication use and the Avorn, J. Medication use and the elderly: current status and elderly: current status and opportunities. Health Affairs. opportunities. Health Affairs. 1995(Spring):278-86.1995(Spring):278-86.


Importance of geriatric drug therapyImportance of geriatric drug therapy

Aging of populationAging of population High use of drugs in elderlyHigh use of drugs in elderly Prevalence of medication therapy Prevalence of medication therapy

problemsproblems Shift from nursing facility to home and Shift from nursing facility to home and

community-based services community-based services


THE PROPORTION OF OLDER THE PROPORTION OF OLDER AMERICANS IS GROWINGAMERICANS IS GROWING

YearYear % of People 65 & Older% of People 65 & Older

19501950 8.38.320002000 12.412.420042004 12.712.720502050 20.620.6

Source: Health, United States, 2005. Figure 2. www.cdc.gov/nchs/data/hus/hus05.pdf


Aging TrendsAging Trends

Those over 85 will grow by 106%, Those over 85 will grow by 106%, from 3.4 million in 2000 to close to 7 from 3.4 million in 2000 to close to 7 million by 2020million by 2020

By 2050, nearly 20 million Americans By 2050, nearly 20 million Americans will be age 85 or overwill be age 85 or over


Aging TrendsAging Trends

About half those age 85 and over About half those age 85 and over need assistance with daily livingneed assistance with daily living

About half those age 85 and over About half those age 85 and over have some degree of cognitive have some degree of cognitive impairmentimpairment

About one out of five live in NFAbout one out of five live in NF


Persons Surviving to Age 90Persons Surviving to Age 90

1940: Seven percent1940: Seven percent 2050: Forty two percent 2050: Forty two percent


Rx Use in the USRx Use in the USRx Use in the USRx Use in the US

Source: Center on an Aging Society, Georgetown University, 2000

3

6

13

20

22

0 5 10 15 20 25

18-34

35-49

50-64

65-79

80+

Ag

e R

an

ge

Number of Prescriptions Filled per Year


Rx Use and SeniorsRx Use and SeniorsRx Use and SeniorsRx Use and Seniors

1998 - 34.4% of 2.733 billion Rxs1998 - 34.4% of 2.733 billion Rxs– 933 million Rxs for seniors

Rxs for seniors

Rxs for non-seniorsSource: IMS 1998

US Population

Seniors



In 2005, seniors comprised 12.5% In 2005, seniors comprised 12.5% of the population and consumed of the population and consumed 37% of prescriptions37% of prescriptions

By 2020, seniors will comprise By 2020, seniors will comprise 16% of the population and will 16% of the population and will consume 49% of prescriptionsconsume 49% of prescriptions

Source: US Census, IMS National Prescription Audit, July 2005Source: US Census, IMS National Prescription Audit, July 2005



Typical NF ResidentTypical NF Resident 75-85+ years of age75-85+ years of age Average number of routine prescription Average number of routine prescription

medications: 8.1medications: 8.1 Average number of PRN prescription Average number of PRN prescription

medications: 3.2medications: 3.2 Percent of residents receiving 9+ routine Percent of residents receiving 9+ routine

medications per day: 41.1medications per day: 41.1


Rx Use and SeniorsRx Use and Seniors

Assisted LivingAssisted Living 13 medications/resident13 medications/resident


Medication Therapy ProblemsMedication Therapy Problems

Polypharmacy: drug use without Polypharmacy: drug use without indicationindication

Undertreatment: indication without Undertreatment: indication without drug usedrug use

Dose too lowDose too low Dose too highDose too high Adverse drug reactionAdverse drug reaction


Medication Therapy ProblemsMedication Therapy Problems

Drug interactionDrug interaction Inappropriate drugInappropriate drug Lack of adherence or complianceLack of adherence or compliance Medication errorMedication error


PolypharmacyPolypharmacy

“ “As older patients move through time, As older patients move through time, often from physician to physician, they are often from physician to physician, they are at increasing risk of accumulating layer at increasing risk of accumulating layer upon layer of drug therapy, as a reef upon layer of drug therapy, as a reef accumulates layer upon layer of coral”accumulates layer upon layer of coral”

Jerry Avorn, quoted in Arch Intern Med 164:1957–59Jerry Avorn, quoted in Arch Intern Med 164:1957–59



“ “The desire to take medicine is The desire to take medicine is perhaps the greatest feature which perhaps the greatest feature which distinguishes man from animals.”distinguishes man from animals.”

Sir William Osler, in H. Cushing, Life of Sir Sir William Osler, in H. Cushing, Life of Sir William Osler (1925)William Osler (1925)



“ “One of the first duties of the One of the first duties of the physician is to educate the masses physician is to educate the masses not to take medicine.”not to take medicine.”

Sir William Osler, Aphorisms from his Bedside Sir William Osler, Aphorisms from his Bedside Teachings (1961) p. 105.Teachings (1961) p. 105.



“ “I firmly believe that if the whole I firmly believe that if the whole materia medica as now used could be materia medica as now used could be sunk to the bottom of the sea, it sunk to the bottom of the sea, it would be all the better for mankind—would be all the better for mankind—and all the worse for the fishes.”and all the worse for the fishes.”

Oliver Wendell Holmes, 1860Oliver Wendell Holmes, 1860


UndertreatmentUndertreatment

“Over the past few years, the pendulum has swung from concern about the risks of excessive prescribing of inappropriate or unnecessary drug therapy to concerns about the consequences of underprescribing of potentially beneficial therapies to seniors (65 years and older).”

Rochon PA, Gurwitz JH. Prescribing for seniors: neither too much nor too little. JAMA, 1999;282:113-5


Examples of UndertreatmentExamples of Undertreatment

Pain managementPain management Pneumococcal and flu vaccinePneumococcal and flu vaccine DepressionDepression Secondary heart attack preventionSecondary heart attack prevention


Quality of Health Care for Older AdultsQuality of Health Care for Older Adults

Vulnerable elders receive about half of Vulnerable elders receive about half of recommended carerecommended care

Preventive care suffers the mostPreventive care suffers the most Physicians often fail to prescribe recommended Physicians often fail to prescribe recommended

medicationsmedications Care for geriatric conditions (e.g. falls, Care for geriatric conditions (e.g. falls,

incontinence) is poorer than care for incontinence) is poorer than care for medical medical conditions such as conditions such as hypertensionhypertension

Source: Rand ResearchSource: Rand Research http://rand.org/pubs/research_briefs/2005/RB9051.pdfhttp://rand.org/pubs/research_briefs/2005/RB9051.pdf


Adverse EffectsAdverse Effects

“ “Any symptom in an elderly patient Any symptom in an elderly patient should be considered a drug side should be considered a drug side effect until proved otherwise.”effect until proved otherwise.”

Gurwitz J, Monane M, Monane S, Avorn J. Gurwitz J, Monane M, Monane S, Avorn J. Polypharmacy. In: Morris JN, Lipsitz LA, Murphy Polypharmacy. In: Morris JN, Lipsitz LA, Murphy K, et al. Quality Care in the Nursing Home. St. K, et al. Quality Care in the Nursing Home. St. Louis, MO: Mosby Year Book;1997:13-25.Louis, MO: Mosby Year Book;1997:13-25.


Adverse Drug Events (ADE)Adverse Drug Events (ADE)

Rate of ADEs requiring an ER visit for Rate of ADEs requiring an ER visit for persons 65 and over is more than twice the persons 65 and over is more than twice the rate for persons under age 65rate for persons under age 65

Rate of ADEs requiring hospitalization is Rate of ADEs requiring hospitalization is nearly seven times greater for persons age nearly seven times greater for persons age 65 or over versus persons under age 65.65 or over versus persons under age 65.

Source: JAMA 2006;296(15):1858–66Source: JAMA 2006;296(15):1858–66


Inappropriate DrugsInappropriate Drugs

Antibacterial to treat a viral infectionAntibacterial to treat a viral infection “ “Beers medications” - medications Beers medications” - medications

considered potentially inappropriate for considered potentially inappropriate for older adults based on risk versus benefit older adults based on risk versus benefit (expert consensus)(expert consensus)

Ref: Arch Intern Med 2003;163:2716–24Ref: Arch Intern Med 2003;163:2716–24


Inappropriate DrugsInappropriate Drugs

21% of older adults take one or more 21% of older adults take one or more medications categorized by Beers as medications categorized by Beers as generally inappropriategenerally inappropriate

Source: Arch Intern Med 2004;164:1621–25.Source: Arch Intern Med 2004;164:1621–25.


Medication AdherenceMedication Adherence

Social and economic factorsSocial and economic factors Health care system-related factorsHealth care system-related factors Condition-related factorsCondition-related factors Therapy-related factorsTherapy-related factors Patient-related factorsPatient-related factors


Medication AdherenceMedication Adherence

More than 10% of hospital More than 10% of hospital admissions for older adults may be admissions for older adults may be due to nonadherencedue to nonadherence

Nonadherence costs the U.S. health Nonadherence costs the U.S. health care system $100 billion per yearcare system $100 billion per year

Source: Vermiere E. et al. Patient adherence to treatment: Source: Vermiere E. et al. Patient adherence to treatment: three decades of research, a comprehensive review. J Clin three decades of research, a comprehensive review. J Clin Pharm Ther 2001;26:331–42.Pharm Ther 2001;26:331–42.


Principles of Drug UsePrinciples of Drug Use

Ask: Is treatment warranted?Ask: Is treatment warranted? Are nonpharmacologic alternatives Are nonpharmacologic alternatives

available?available? Consider risk vs. benefit of drug therapyConsider risk vs. benefit of drug therapy Establish goals of therapyEstablish goals of therapy

– Quality of care

– Quality of life

– Functional status


Goals of TherapyGoals of Therapy

“Is it quality of life or quantity of life? Truthfully, if my destiny is to feel great now and maybe shorten my future, I’d rather feel well now.”

Source: Nancy Richardson, 60, of Wayland, Mass., referring to Nancy Richardson, 60, of Wayland, Mass., referring to risk versus benefit of estrogen therapy. Quoted in New York risk versus benefit of estrogen therapy. Quoted in New York Times, December 18, 2006 article by Gina Kolata, “Breast Times, December 18, 2006 article by Gina Kolata, “Breast Cancer News Brings a Range of Reactions”Cancer News Brings a Range of Reactions”


Principles of Drug UsePrinciples of Drug Use

Consider the whole person, not just Consider the whole person, not just one disease or one drugone disease or one drug

Be aware of assumptions behind Be aware of assumptions behind clinical practice guidelinesclinical practice guidelines

Disease management may not be Disease management may not be adequate or appropriate if adequate or appropriate if

multiple multiple chronic diseases are chronic diseases are presentpresent


Questions?Questions?

American Society of Consultant Pharmacists America’s Senior Care Pharmacists® Principles of Drug Use: Prescribing for the Elderly Thomas R. Clark, RPh,

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