The Bagful of Pills: Polypharmacy in the Elderly

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The Bagful of Pills Polypharmacy in the Elderly

• Oana Marcu DO
• Swedish Family Medicine
• March 7, 2006

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Objectives

• 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!

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Definitions

• 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

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Adverse Drug Reaction (ADR)

• ADRs occur as a result of
• Drug-drug interactions
• Drug-disease interactions
• Drug-food interactions
• Drug side effects
• Drug toxicity

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Consequences 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

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ConsequencesEconomic

• 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

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• 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

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Unique Pharmacokinetics normal part of the aging
process

• Absorption
• Distribution
• Metabolism
• Excretion
• Evaluate the pharmacokinetic characteristics of
  each medication carefully
• Start low, go slow!

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Geriatric 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!

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High 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!

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High Risk Medications Drug Classes

• Analgesics
• - NSAIDs
• - Narcotics
• - Muscle relaxants

• Narrow Therapeutic Index
• - digoxin
• - phenytoin
• - warfarin
• - theophylline
• - lithium

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High Risk Medications Drug Classes

• Cardiovascular
• Antihypertensives
• Calcium channel blockers
• Propranolol
• Diuretics

• Psychotropics
• - TCAs
• - Antipsychotics
• - Benzodiazepines
• - Sedative/Hypnotics

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High Risk Medications Other

• H2 Blockers mental confusion, disorientation
• Anticholinergic Effects dry mouth, constipation,
  urinary retention, delirium
• Gastrointestinal Antispasmodics
• Antibiotics (aminoglycosides)
• Hypoglycemics

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SO

• 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!

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CARE 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!

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CARE Avoiding Polypharmamcy

• Adjust the Dose
• Start low and go slow- titrate!
• Unique pharmacokinetics in elderly
• Altered
• Absorption
• Distribution
• Metabolism
• Excretion

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CARE 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?

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CARE 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!

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Personal 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

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Personal 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

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Personal 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!

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Questions

• 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

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Questions

• 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

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Questions

• 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

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Case

• 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

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Medication 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

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Case

• 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

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Medication 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

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Case

• 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

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• 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

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Assessment and Plan

• 1. Fever with Delirium
• 2. Polypharmacy
• Continue infectious workup and treatment.
• Start simplifying the medical regimen

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Medication 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

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TAKE 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!

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References

1. Swansons Family Practice Review. Fourth Ed. A.
   Tallia, D. Cardone, D. Howarth, K Ibsen Mosby
   2001.
2. Geriatrics 20 common problems. A. Adelman, M.
   Daly McGraw Hill 2001.
3. Primary Care Geriatrics A Case- Based Approach.
   Third Ed. R. Ham, P. Sloane Mosby 1997.
4. Essentials of Clinical Geriatrics. Fourth Ed. RL
   Kane, JG Ouslander, IB Abrass McGraw Hill 1999.
5. Polypharmacy. Didactic at SFM by Dr. Pat Borman
6. Holland EG, Degruy FV. Drug- Induced Disorders.
   American Family Physician Vol 56, Nov 1, 1997.
7. Beers MH. Updating the Beers Crieria for
   003Potentially Inappropriate Medication Use in
   Older Adults. Arch Internal Med. 2003 2716-2724.
   
8. Personal Medical Record developed by Dr. Eric
   Coleman, UCHSC, HCPR http//caretransitions.org/
   document/phr.pdf