POLYPHARMACY IN THE ELDERLY: When Too Many Becomes Deadly ROY J. CUISON, M.D., MBA, MFPM, FPCGM International Society of Internal Medicine Royal Colleges of Physicians of the United Kingdom Philippine College of Geriatric Medicine Philippine College of Physicians 46 th Annual Convention – May 1, 2016
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POLYPHARMACY IN THE ELDERLY:
When Too Many Becomes Deadly
ROY J. CUISON, M.D., MBA, MFPM, FPCGMInternational Society of Internal Medicine
Royal Colleges of Physicians of the United Kingdom
Philippine College of Geriatric Medicine
Philippine College of Physicians
46th Annual Convention – May 1, 2016
A GENTLE REMINDER
This slide set on POLYPHARMACY IN THE ELDERLY
is the intellectual property of
ROY J. CUISON, M.D., MBA, FPCPM, MFPM
Permission to use the information on these slides
is granted to selected individuals for
academic use PROVIDED
the corresponding CREDIT is acknowledged for
the AUTHOR.
F A C T S
• Over 3 billion prescriptions are filled per year
• Average prescription in 2000 was 28.5 per person per year
• Reached 38.5 per person per year in 2010
• 75% of people ages 45 or older take an average of 4
prescription medications/day
• Elderly patients account for 34% of all written prescriptions
• People over 65 take more prescription and OTC drugs than
any other age group
• Almost a ¼ million seniors are hospitalized per year due to
reactions between prescription drugs and OTC drugs
Rossoni, E. et al.
Univ. Of Rhode Island
Multiple Years
(Normal Aging)
Multiple Medical
Conditions
Multiple Physician
Contacts
Multiple Adverse
Drug Reactions
Multiple Pharmacy
Contacts
Multiple
Prescriptions
Reduced Quality
of Life
Multiple
HospitalizationsMultiple Deaths
(Iatrogenic)
THE CASCADE OF MULTIPLES
Lewandowski, Leon. 2009
OPTIMAL PHARMACOTHERAPY
• Balance between overprescribing and underprescribing
– Correct drug
– Correct dose
– Targets appropriate condition
– Is appropriate for the patient
Avoid “a pill for every ill”
Always consider non-pharmacologic therapy
Farho, Linda
RATIONAL DRUG USE
World Health Organization
Rational use of medicines requires that "patients
receive medications appropriate to their clinical
needs, in doses that meet their own individual
requirements, for an adequate period of time, and
at the lowest cost to them and their community".
Rational medication prescribing dictates that the
fewest medications be used to achieve the
therapeutic goals as determined by clinician and
patient.
Multiple medications not only add to the cost and
complexity of therapeutic regimens, but also place
patients at greater risk for adverse drug reactions
and drug- drug interactions.
Taskeen, M., et. al.
J Drug Del. & Therap 2012
Challenges of Geriatric Pharmacotherapy
• New drugs available each year
• FDA approved and off-label indications are
expanding
• Changing managed-care formularies
• Advanced understanding of drug-drug interactions
• Increasing popularity of “nutraceuticals”
• Multiple co-morbid states
• Polypharmacy
• Medication compliance
• Effects of aging physiology on drug therapy
• Medication costFarho, Linda
Univ. of Nebraska Medical Center
POLYPHARMACY DEFINED
Wide range of definitions; no consensus definition
Generally defined as “Administration of more
medications than clinically indicated, representing
unnecessary drug use.”
Five or more medications.
“The regular consumption of multiple medications
that are inappropriate for the patient, as well as the
consideration for duration of use because they are
associated with harms (falls, vehicle accidents) with little
efficacy for insomnia.
3. Sole use of sliding scale insulin without a background of
basal insulin due to hypoglycemia risk with little
improvement of hyperglycemia management.
4. Avoid PPIs for more than 8 weeks due to risk of C. difficile
infection, bone loss and fracture.
SUMMARY: AGS 2015 Beers Criteria
Table 1: Designations of quality of evidence and strength of
recommendations.
Table 2: PIMs for older adults outside the palliative care and
hospice settings.
Table 3: medications for older adults with specific diseases
or syndromes to avoid.
Table 4: medications to be used with caution.
Table 5: potentially clinically important non-anti-infective
drug-drug interactions
Table 6: non-anti-infective medications to avoid or which
dosage should be adjusted based on individual kidney
function.
Table 7-10: documenting differences between 2012 and
2015.
Steinman, Micheal, 2015
University of California, San Francisco
Clinicians using the Beers Criteria are advised to:
1. ask themselves why the patient is taking a
drug and whether it is truly needed,
2. whether there are safer alternatives, and –
3. whether the patient has characteristics that
would increase or mitigate the potential risks
of the drug.
WORDS OF ADVICE . . .
PHARMACODYNAMICS AND AGING
• However in spite of the Beers criteria:
– Numerous studies in the last 15 years have found
that PIMs continue to be used in 12% to 40% of
older patients in community and nursing home
settings (Raebel, Charles, Dugan, & et al, 2007).
– Administrative data from nearly 400 hospitals across
the United States reveals that nearly half of all older
patients hospitalized for 7 common conditions were
prescribed at least 1 PIM (Rothberg et al, 2008).
Bonifas, R. P.
Univ. Arizona School of Social Work
OTHER PROTOCOLS
S – Simple
A – Adverse
I – Indication
L – List
A – Assess
R – Review
M – Minimize
O – Optimize
R – Reassess
THE BROWN BAG
REDUCING POLYPHARMACY AND
PROMOTING MEDICATION ADHERENCE
THE “BROWN BAG”
• At least yearly, and more often if indicated, review all medications the elderly patients have at home (they often bring them in a big brown grocery bag, thus the name of this intervention!)
– Prescription medications
– Over-the-counter medications
– Vitamins supplements
– Herbal preparations
• Intervention has four components - listing medications, discussing patient‟s understanding of why the medication is prescribed, discussing potential side effects, and discussing the findings with the patient
Adapted from Bonifas, R. P.
Univ. Arizona School of Social Work
• Use of vitamins and herbal remedies is highly prevalent
among older adults!
• Usage is generally not reported to the physician since older
adults may not consider them to be medications.
• Some serious drug interactions are possible with common
herbal remedies, for example:
– Ginkgo biloba interactions include bleeding when combined
with warfarin (coumadin), raised blood pressure when
combined with a thiazide diuretics and coma when combined
with trazodone (desyrel).
Bonifas, R. P.
Univ. Arizona School of Social Work
WHAT TO DO WITH THE
“BROWN-BAG-FULL” OF MEDICATIONS?
• First: List the medications and the associated dosages
and administration schedules – using the Brown Bag
Patient Education Tool.
• Second: Ask the patient to tell you what the medications
are prescribed for. If you hear, “I don’t know…my
doctors told me to…” this is cause for concern -
additional patient education is needed!
Adapted from Bonifas, R. P.
Univ. Arizona School of Social Work
WHAT TO DO WITH THE
“BROWN-BAG-FULL” OF MEDICATIONS?
• Drug reactions in the elderly often produce effects that simulate the conventional image of growing old and may thus be overlooked.
Bonifas, R. P.
Univ. Arizona School of Social Work
Third: Ask patients about the following symptoms:
Tiredness, sleepiness, or
decreased alertness
Constipation, diarrhea, or
incontinence
Loss of appetite
Confusion
Falls
Depression or lack of interest in
usual activities
Weakness
Tremors
Visual or auditory hallucinations
Anxiety or excitability
Dizziness
Decreased sexual behavior
WHAT TO DO WITH THE
“BROWN-BAG-FULL” OF MEDICATIONS?
• Fourth: Report findings
– Discuss the findings with the patient (including
nursing home, hospice, primary care, inpatient
settings)
– the pharmacist can also be helpful in nursing home
settings.
Adapted from Bonifas, R. P.
Univ. Arizona School of Social Work
WHAT TO DO WITH THE
“BROWN-BAG-FULL” OF MEDICATIONS?
• Such irrational polypharmacy can arise from several
factors:
The prescriber hesitates to discontinue medications the
patient has been taking a long time.
The prescriber may add more drugs to the patient's regimen
without removing any.
The prescriber orders medication to alleviate adverse
reactions to other medications.
The patient may be influenced by anecdotal reports touting
the benefits of certain medications.
Bonifas, R. P.
Univ. Arizona School of Social Work
PHARMACODYNAMICS AND AGING
Personal:
health maintenance
a reaction to changes in eating habits or health status that arise
from acute or chronic conditions
as a way to prevent aging, and
as a way to have more control over personal health concerns.
Social:
higher rates of education
a demand for more information about a wider variety of products
Environmental:
increases in television and internet advertising
in available transportation
Haines, P.
School of Public Health
Univ. of South Carolina
SOME REASONS FOR DIETARY SUPPLEMENT USE
IN THE ELDERLY
individuals who are unsatisfied with current
medical care
people who prefer to follow the growing
movement for health promotion and the
use of complementary and alternative
medicine
individuals treating both real and perceived
symptoms of aging
those who are dealing with chronic conditions.
Haines, P.
School of Public Health
Univ. of South Carolina
CATEGORIES OF SUPPLEMENT USERS
Overall, older adults
appear to take
supplements due to
beliefs that they will
incur some benefit,
gain some element of
control, or improve
their overall quality of
life.
Haines, P.
School of Public Health
Univ. of South Carolina
THE TEN COMMANDMENTS
IN PRESCRIBING FOR THE ELDERLY
1. Know the pharmacology of the drug to be prescribed,
its route of metabolism and excretion.
2. Use the drug for the correct and absolute indication
and only when necessary for treatment.
3. Simplify the medication regimen to improve
compliance and reduce the likelihood of
interactions.
4. Use the lowest possible effective dose.
5. Reduce the number of drugs to be prescribed.
6. Discontinue all other unnecessary drugs.
7. Inform the patient and responsible companion on
the purpose of the drug, its expected and
desired effects and important side-effects.
8. Write dosage instructions about the prescribed drug/s
in legible print and provide the patient with a
copy.
9. Have the patient demonstrate that he/she is able to
open the medication container.
THE TEN COMMANDMENTS
IN PRESCRIBING FOR THE ELDERLY
10. NEVER, EVER withhold medications for the simple