Polypharmacy in the Elderly

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Polypharmacy in the Elderly

• Rosemary D. Laird, MD
• Assistant Professor of Medicine
• University of Kansas Medical Center
• Center on Aging

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Polypharmacy in the Elderly

• Overview of Polypharmacy
• The Brown Bag
• Medications and the Elderly
• Polypharmacy and Non-adherence
• The role of the PCP
• Prescribing Pearls

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The Brown Bag

• Verapamil 300mg po qday
• Lasix 20mg po qday
• Digoxin 0.25mg po qday
• KCL 20mEq po bid
• Proscar 5mg po qday
• MOM 30 cc po qhs prn constipation
• Aleve 200mg 2-4 tablets po prn arthritis
• TUMS extra-strength 0-8 per day prn GERD
• was there more??

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Polypharmacy in the Elderly By definition.

• Polypharmacy means "many drugs.
• The use of more medication than is clinically
  indicated or warranted.
• 5 or more drugs
• 7 or more drugs

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Polypharmacy in the Elderly WHY?

• The elderly use more drugs because illness is
  more common in older persons.
• Cardiovascular disease
• Arthritis
• Gastrointestinal disorders
• Bladder dysfunction

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Polypharmacy in the Elderly How Bad Can It Be?

• Elderly 12 of population but
• 32 of prescriptions
• Average use for persons ?65
• 2 to 6 prescription drugs
• 1 to 3.4 over-the-counter medicine
• Average American senior spends 670/year for
  pharmaceuticals.

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Polypharmacy in the Elderly Whats the big deal?

• Polypharmacy leads to
• More adverse drug reactions
• Decreased adherence to drug regimens
• Patient outcomes
• Poor quality of life
• High rate of symptomatology
• (Unnecessary) drug expense

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Adverse Drug Reactions

• The most consistent risk factor for adverse drug
  reactions is
• number of drugs being taken
• Risk rises exponentially as the number of drugs
  increases.

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Pharmacokinetics and Aging

• What the Body Does to the Drug
• Absorption
• Distribution
• Metabolism
• Excretion

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Pharmacokinetics and Aging

• Absorption
• Age-related gastrointestinal tract and skin
  changes seem to be of minor clinical significance
  for medication usage.

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Pharmacokinetics and Aging

• Distribution
• Important Age-Related Changes
• Decrease in Lean Body Mass and TBW
• Increased percentage Body Fat
• Increase in volume of distribution for lipophilic
  drugs, such as sedatives that penetrate CNS.
• Protein Binding changes are of modest
  significance for most drugs, especially at
  steady-state.

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Pharmacokinetics and Aging

• Metabolism
• Though liver function tests are unchanged with
  age, there is some overall decline in metabolic
  capacity.
• Decreased liver mass and hepatic blood flow
• Highly variable, no good estimation algorithm
• Minimal clinical manifestations

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Pharmacokinetics and Aging

• Renal Excretion
• Age-related decreased renal blood flow and GFR is
  well-established.
• Decreased lean body mass leads to decreased
  creatinine production.

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Pharmacokinetics and Aging

• Thus, serum creatinine may appear normal even
  when significant renal impairment exists.
• Cr clearance(140-age)(IBW)/creatinine(72)
• (multiply by 0.85 for women)
• Example 70kg 75 year old man
• Cr Clearance (140-75)(70)/1.0(72)63

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Pharmacodynamics and Aging

• What the Drug Does to the Body
• Generally, lower drug doses are required to
  achieve the same effect with advancing age.
• Receptor numbers, affinity, or post-receptor
  cellular effects may change.
• Changes in homeostatic mechanisms can increase or
  decrease drug sensitivity.

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(Potentially)Inappropriate Medications for Older
Adults

• Propoxephene
• Diphenhydramine
• Amitryptiline
• Alprazolam
• Diazepam
• Beers, MH et al. Arch Intern Med 1511825,1991.

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(Potentially)Inappropriate Medications for Older
Adults

• Diphenhydramine
• should generally be avoided in older adults
• Dry mouth, confusion, urinary retention,
  constipation
• source of in-hospital morbidity/delirium
• is in many OTC products for sleep/URI/allergy
• Digoxin
• can cause anorexia, confusion even at therapeutic
  drug levels
• Renal excretion can change over time as
  age-related renal function declines.
• 0.125mg/day most often adequate

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(Potentially)Inappropriate Medications for Older
Adults
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(Potentially)Inappropriate Medications for Older
Adults
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Polypharmacy in the Elderly

• Overview
• The Brown Bag
• Medications and the Elderly
• Polypharmacy and Non-adherence
• The Role of the PCP
• Prescribing Pearls

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Polypharmacy and Non-adherence

• Non-adherence
• Is a two-way street!
• Physician factors
• Patient factors

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Polypharmacy and Non-adherence

• Factors contributing to Polypharmacy
• Underreporting symptoms
• Use of multiple providers
• Use of others medications
• Limited time for discussion, diagnostics
• Limited knowledge of geriatric pharmacology
• The power of inertia

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Polypharmacy and Non-adherence

• Strongest predictor is number of medications
• Rates estimated at 25-50
• Intentional about 75 of the time
• Changes in regimen made by patients to increase
  convenience, reduce adverse effects, or decrease
  refill expense

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Factors contributing to Non-adherence

• Large number of medications
• Expensive medications
• Complex or frequently changing schedule
• Adverse reactions
• Confusion about brand name/trade name
• Difficult-to-open containers
• Rectal, vaginal, SQ modes of administration
• Limited patient understanding

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Polypharmacy in the Elderly

• Overview of Polypharmacy
• The Brown Bag
• Medications and the Elderly
• Polypharmacy and Non-adherence
• The Role of the PCP
• Prescribing Pearls

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Polypharmacy and the Primary Care Provider

• Annual Brown Bag
• At least yearly, and more often if indicated, ask
  elderly patients to bring in all medications they
  have at home.
• Prescription
• Over-the-counter
• Vitamins supplements
• Herbal preparations

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Vitamin and Herbal Use in Older Adults

• Highly prevalent among older adults
• 77 in Johnson and Wyandotte county community
  dwelling elderly
• Generally not reported to the physician
• Some serious drug interactions possible
• Warfarin, gingko biloba, vitamin E

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What to do with the Brown Bag full of bottles?

• Document and determine indication
• Prioritize
• Vital vs. optional
• Cure vs. relieve symptom
• Discuss with patient, caregiver
• Plan for medication reduction
• Vital vs. optional
• Cure vs. relieve symptom

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Polypharmacy in the making.Why are you taking
this?

• I dont knowthe doctor told me to
• Digoxin
• Allopurinol
• Antidepressants
• Anticonvulsants
• Anxiolytics

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Polypharmacy in the making

• Discontinuing unnecessary medications is one of
  the most important aspects of decreasing
  polypharmacy
• Drugs without indications should be stopped!

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Polypharmacy in the Making

• Drug reactions in the elderly often produce
  effects that simulate the conventional image of
  growing old
• unsteadiness drowsiness
• dizziness falls
• confusion depression
• nervousness incontinence
• fatigue malaise
• insomnia

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Polypharmacy in the Making

• Avoid treating adverse reactions/side effects of
  drug with more drugs!
• Example
• Dizziness from anti-hypertensive treated with
  meclizine
• Edema from a calcium-channel blocker treated with
  furosemide and KCL

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Polypharmacy in the Making

• Drugs most frequently associated with adverse
  reactions in the elderly
• psychotropic drugs-benzodiazepines
• anti-hypertensive agents
• diuretics
• digoxin
  
• NSAIDS
• corticosteroids
  
• warfarin
• theophylline

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Polypharmacy in the Elderly

• Overview of Polypharmacy
• The Brown Bag
• Medications and the Elderly
• Polypharmacy and Non-adherence
• The Role of the PCP
• Prescribing Pearls

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Prescribing Pearls

• Use single daily dose regimens
• Limit the use of PRN medications
• Consider all new medicines as a therapeutic trial
  
• Discontinue a drug if it is ineffective or
  intolerable adverse effects occur
• Provide legible written instructions
• Instruct caregivers as needed

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Prescribing Pearls

• Attempt to prescribe a drug that will treat more
  than one existing problem
• Examples
• calcium channel blocker or beta blocker to treat
  both hypertension and angina pectoris
• ACE-inhibitor to treat both hypertension, heart
  failure, and or for renal protection in diabetes
• Alpha-blocker to treat both hypertension and
  prostatism

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Patient Education

• Use one pharmacist/pharmacy
• Use your PCP as intendedavoid seeing multiple
  physicians
• Do not use medications from others
• Report symptoms
• All medicines, even over-the-counter, have
  adverse effects
• Report all products used

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Avoiding Polypharmacy

• Simple
• Use least frequent dosing needed
• Tie to scheduled daily activities, meals,
  sleep/wake
• Support
• Educate
• Medication Flowsheet
• Encourage use of one pharmacist
• Enlist family, friends as needed
• Medication organization equipment
• Survey
• Periodic review

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Ways to Decrease Drug Costs

• Generics ok
• Change dosing regimen, e.g. one-a-day may be more
  expensive
• Older drugs, e.g. beta blockers, diuretics,
  acetaminophen
• Double duty drugs, e.g. beta and alpha blockers,
  ACE-inhibitors
• Avoid non-regulated products

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The Brown Bag

• HTN, MI 15 yrs ago, arthritis, GERD, BPH with
  nocturia
• Verapamil 300mg po qday
• Lasix 20mg po qday
• Digoxin 0.25mg po qday
• KCL 20mEq po bid
• Proscar 5mg po qday
• MOM 30 cc po qhs prn constipation
• Aleve 200mg 2-4 tablets po prn arthritis
• TUMS extra-strength 0-8 per day prn GERD
• was there more??

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The Brown Bag

• HTN, MI 15 yrs ago, arthritis, GERD, BPH with
  nocturia
• Verapamil 300mg po qday
• Can change to beta blocker or alpha blocker(?)
• Lasix 20mg po qday
• Digoxin 0.25mg po qday
• KCL 20mEq po bid
• D/C
• Proscar 5mg po qday
• D/C

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The Brown Bag

• HTN, MI 15 yrs ago, arthritis, GERD, BPH with
  nocturia
• MOM 30 cc po qhs prn constipation
• May not need
• Aleve 200mg 2-4 tablets po prn arthritis
• Tylenol 1gram qid or Arthritis formula BID
• TUMS extra-strength 0-8 per day prn GERD
• May not need after d/c NSAID
• was there more??

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The New Brown Bag

• Beta-blocker qday
• Atenolol 25-100 mg
• ?Alpha-blocker
• titrate to nocturia, BP
• Tylenol Arthritis 2 tabs bid

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References

• Geriatrics at your Fingertips
• http//www.americangeriatrics.org/products/gayf2.s
  html
• Essentials of Clinical Geriatrics, 4th Edition.
  Kane, Ouslander, Abrass, Eds. McGraw-Hill.