10/16/2015 1 GERIATRIC PHARMACONSIDERATIONS John C. Darnell PharmD, BCACP Objectives Evaluate the safety and efficacy of various medications in the older adult patient population Identify medications to be used cautiously or avoided altogether in older adult patients Recommend safer alternatives for specific conditions Providence Health 3 Providence Health & Services- Large, integrated health system Oregon Region • 8 acute care facilities (25-500 beds) • Providence Portland Medical Center (483 beds) • Providence St. Vincent Medical Center (523 beds) • Over 100 medical clinics (Oregon, SW Washington) • Specialty Pharmacy and Home Services • Ambulatory Geriatrics clinics • Providence Health Plan- >400,000 member lives
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10/16/2015
1
GERIATRIC PHARMACONSIDERATIONS
John C. Darnell PharmD, BCACP
Objectives
� Evaluate the safety and efficacy of various
medications in the older adult patient population
� Identify medications to be used cautiously or avoided altogether in older adult patients
� Recommend safer alternatives for specific conditions
Providence Health
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Providence Health & Services- Large, integrated health system
Oregon Region• 8 acute care facilities (25-500 beds)
• Providence Portland Medical Center (483 beds)
• Providence St. Vincent Medical Center (523 beds)
• Over 100 medical clinics (Oregon, SW Washington)
• Specialty Pharmacy and Home Services
• Ambulatory Geriatrics clinics
• Providence Health Plan- >400,000 member lives
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PMG Clinical Pharmacy Department
• A non-distribution pharmacy service providing
clinical, educational and operational support to the PMG employed physician practices
• Employs a combination of centralized and de-centralized services
• Goal: To support high-quality, evidence-based, cost-effective medication therapy
Acknowledgements
� Kristy Butler, PharmD, BCPS, BCACP, FASHP
� Jonathan White, PharmD, BCACP
� Chelsea Mannebach, PharmD, BCPS
� Vickie Poremba, PharmD
� Johanna Thompson, PharmD,
Outline
� Background
� Metabolic changes in the elderly
� Beers List Updates:
� Pearls in Prescribing:
� Diabetes Mellitus
� Hypertension
� Hyperlipidemia
� Benzodiazepines
� Anticoagulants
� Anticholinergics
� Take Home Principles
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Polypharmacy
� Unclear definition as there is no “minimum number”
� 5 – 10?
� Any inappropriate, unnecessary, or excessive medication
different classes have anticholinergic side effects
� More important to recognize possible medication side effects vs symptoms of a separate disorder
Take Home Points/Principles
Take Home Points
� Avoid > 1 med in same class
� Consider meds that treat more than 1 problem
� Start low, go slow
� But keep going� ACE-Is, beta-blockers, antidepressants
� Or stay low� Li, anticonvulsants, digoxin, opioids, BZDs
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Take Home Points
� Stop/taper meds if not indicated/effective
� Taper 25-50% every 5 half lives
� Change one medication at a time
� Schedule f/u for monitoring of adverse effects, withdrawal, improvement, worsening
� Summarize changes in writing
� Once daily meds or combination products
Take Home Principles
� ALWAYS assess the evidence for its use
� ALWAYS assess the risk
� ALWAYS factor in quality of life
References
1. Ferner RE, Aronson JK. Communicating information about drug safety. BMJ 2006;333(7559):143.
2. Tinetti ME, Bogardus ST Jr, et al. Potential pitfalls of disease-specific guidelines for patients with multiple conditions. N Engl J Med 2004; 351(27):2870.
3. American Geriatrics Society 2015 updated Beers Criteria for potentially inappropriate medication use in older adults. American Geriatrics Society 2015 Beers Criteria Update Expert Panel. J Am Geriatr Soc 2015;1-20.
4. Elliot DP. Pharmacokinetics and pharmacodynamics in the elderly. In: Schumock G, Brundage D, et al., eds. Pharmacotherapy Self Assessment Program, 5th ed. Lenexa, KS: American College of Clinical Pharmacy, 2004:115-130.
5. Beers MH, Ouslander JG, Rollingher I, et al. Explicit criteria for determining inappropriate medication use in nursing home residents. UCLA Division of Geriatric Medicine. Arch Intern Med 1991; 151:1825-32.
6. Kirkman MS, Briscoe VJ, Clark N et al. Diabetes in older adults. Diabetes Care 2012; 35(12): 2650-2664
7. Cefalu WT, Bakris G, Blonde L, et al. Standards of medical care in diabetes. Diabetes Care 2015; 38(1)
8. Currie CJ, Peters JR, Tynan A et al. Survival as a function of HbA(1c) in people with type 2 diabetes: a retrospective cohort study. Lancet 2010;375(9713):481-9
9. James PA, Oparil S, Carter BL, et al. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults. JAMA 2014;311(5):507-520.
10. Eknoyan G, Eckardt K, Kasiske BL, et al. KDIGO Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease. Kidney International Supplements 2012; 2.
11. Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. Circulation 2013
12. Gotto AM. Statin therapy and the elderly: SAGE advice? Circulation 2007;115:681-683.
13. Acharjee S, Welty FK. Atorvastatin and cardiovascular risk in the elderly – patient considerations. Clin Interv Aging 2008 Jun; 3(2): 299–314.
14. Hilmer S, Gnjidic D. Statins in older adults. Australian Prescriber 2013; 36:79–82.
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References
15. Holmquist IB, Svensson B, Hoglund P: Psychotropic drugs in nursing and old age homes: relationships between needs of care and mental health status. European Journal of Clinical Pharmacology 59:669–676, 2003
16. Bogunovic OJ, Greenfield SF. Use of benzodiazepines among elderly patients. Practical Geriatrics 55:233-235.
17. Greenblatt DJ, Shader RI: Benzodiazepines in the elderly: pharmacokinetics and drug sensitivity, in Anxiety in the Elderly. Edited by Salzman C, Lebowitz BD. New York, Springer, 1991.
18. Gray S, Lai K, Larson E: Drug- induced cognition disorders in the elderly. Drug Safety 21:101–122, 1999
19. Cumming RG, Le Couter DG: Benzodiazepines and risk of hip fractures in older people: a review of the evidence. CNS Drugs 825–837, 2003
20. Schweizer E, Case WG, Rickels K: Benzodiazepine dependence and withdrawal in elderly patients. American Journal of Psychiatry 146:1242–1243, 1989
21. Budlovsky J, Wong RY. Novel Oral Anticoagulants in the Elderly. CGS Journal of CME 2014; Vol 4, Issue 1: 18-20.
22. Weitz JI, Eikelboom JW, Samama, MM. New Antithrombotic Drugs: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. CHEST Feb 2012.
23. Sura SD, Carnahan RM, et al. Prevalence and determinants of anticholinergic medication use in elderly dementia patients. Drugs Aging 2013 Oct;30(10):837-44.
24. Sardar P, Chatterjee S, Chaudhari S, et al. New Oral Anticoagulants in Elderly Adults: Evidence From a Meta-analysis of Randomized Trials. J Am Geriatr Soc 2014;62(5):857-864.