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Good Drugs, Old Drugs,

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Title: Good Drugs, Old Drugs,


1
Good Drugs, Old Drugs, Bad Drugs Partnering For
a Better Future in Medication Use in Older
AdultsNew Jersey Council of Teaching
HospitalsOctober 4, 2007
  • Donna Fick, PhD, RN, FGSA
  • The Pennsylvania State University School of
    Nursing and School of Medicine, Department of
    Psychiatry
  • Gerontology Center, Faculty Affiliate

2
Objectives
  • At the conclusion of this session, the
    participant will be able to
  • 1. discuss the scope of polypharmacy and it's
    significance to the health and quality of life of
    the geriatric population
  • 2. discuss outcomes for inappropriate
    medication use in older adults
  • 3. identify barriers and facilitators to safe
    medication use in older adults
  • 4. identify strategies for interdisciplinary
    management and safe use of medications in older
    adults using high alert medications and other
    tools

3
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4
Why Older Adults?
  • Growing population----over 40 of hospitalized
    patients 65 and older
  • LARGEST CONSUMER OF MEDICATIONS
  • More vulnerable to errors and drug-related
    problems (chronic disease, aging changes)

5
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6
1 KEEPING UP WITH NEW DRUGS ON THE MARKET
  • Internet Drug Sales
  • Direct marketing to consumers
  • Are new drugs always better?
  • Long term effects versus clinical trial results
  • Media/marketing role (94 of 3000 MDs reported
    relationship with Pharm industry)

7
2 INCREASED FOCUS ON ADVERSE EVENTS CREATING
TUG SAFETY/QUICK DRUG APPROVAL

8
3 VALUE PLACED ON NON-PHARMACOLOGICAL TREATMENTS
  • Non-pharmacological sleep protocols
  • Supplemental pain interventions
  • Need-dementia based model of care for behavior
    problems in persons with dementia
  • Drugs should not always be the first line of
    treatment

9
4 AGING CHANGES
  • Increase in body fat and decrease in lean body
    mass
  • Decrease in total body water
  • Decrease in GFR and CO
  • Decrease plasma protein, esp Albumin
  • Decrease in liver mass and blood flow may slow
    metabolism
  • Most changes lead to increased toxicity

10
  • 5 CHALLENGE OF ATYPICAL PRESENTATIONS IN OLDER
    ADULTS
  • Pneumonia
  • Congestive Heart failure
  • Myocardial Infarction
  • Urinary Track Infection
  • Depression
  • Adverse Drug reaction

DELIRIUM
11
6 MEASUREMENT CHALLENGES
  • Unlikeliness of an event in a given pt or disease
  • Absence of prodromal signs before the drug
    exposure
  • Consistency with drug properties and injury
  • Recurrence of event with rechallenge of drug
  • Event goes away with discontinuance of drug
  • Known relationship with underlying mechanism of
    drug action
  • Related toxicity seen in vitro on animal studies

12
7 ATTITUDES KNOWLEDGE IN AGING
  • In a study of Nurse knowledge of delirium
    utilizing standardized case vignettes---41
    recognized hypoactive delirium and 32 said they
    would call the physician to medicate the patient
    (Fick, Hodo, Lawrence, Inouye, 2007)
  • Only 21 recognized delirium superimposed on
    dementia and 26 said they would call for a
    medication

13
8 MULTIPLE PLAYERS
Physicians
Industry
Pharmacists
Nurses
FDA
PATIENT
Insurers
Allied Health
Family
Researchers
Internet
14
9 GERIATRIC EDUCATION
  • Shortage of geriatric trained professionals
  • Reduction in geriatric funding
  • Growing population of older adults
  • Earlier pre-clinical diagnoses of disease
  • Costs and benefits of treatments
  • Consumer knowledge and literacy

15
10 APPROPRIATE MEDICATION USE
  • Overuse
  • Underuse
  • Misuse
  • Rights-drug, patient, time, way, dosage, price

16
Beers Criteria
  • Original author Mark Beers et al 1990
  • Explicit criteria (and list) of medications to
    AVOID in older adults. Should have a safer
    alternative.
  • Widely cited and used medication criteria
  • Loved and hated all at the same time!

17
Expert Panel
  • 16 potential participants with national expertise
    in geriatric pharmacology, geriatric medicine,
    psychopharmacology, acute and longterm care
  • Our response rate was 75 (12/16) and all that
    responded agreed to participate

18
5 Parts In Survey For Experts to Consider
  • 1) Old Criteria medications to avoid with and
    without diagnoses
  • 2) New drugs out since criteria last updated
  • 3) New evidence since last update
  • 4) Medications added by Panelists in first and
    second rounds

19
Where To Find 2003 Beers Medications
  • SeniorJournal
  • http//www.seniorjournal.com/NEWS/Eldercare/5-01-0
    6BeersCriteria03-Tb2.htm
  • Duke Center for Clinical and Genetic Economics
  • http//www.dcri.duke.edu/ccge/curtis/beers.html
  • Fick DM, Cooper JW, Wade WE, Waller JL, Maclean
    JR, Beers MH. Updating the Beers criteria for
    potentially inappropriate medication use in older
    adults results of a US consensus panel of
    experts. Arch Intern Med. 20031632716-2724.
  • http//archinte.ama-assn.org/cgi/content/full/163/
    22/2716

20
HIGH ALERT MEDICATIONS
  • anticoagulants, narcotics and opiates, insulins,
    and sedatives
  • Patients 65 and older more likely to be harmed by
    high alert medications even when used
    appropriately

21
  • Our Data on High Alert Medications
  • Sedative Hypnotics
  • CNS-active

22
Medication Use in Hospitalized Persons with
Dementia (N 272)
AnticholinergicsAtypical AntipsychoticsConventio
nal AntipsychoticsNarcotic AnalgesicsAntidepress
antsBenzodiazepinesAcetylcholinsterase
Inhibitors
59.3
36.7
8.9
35.2
35.2
29.5
26.7
0 10 20 30 40 50 60
Percent
23
METHODS
  • We examined association of DRPs with
    administrative data for analyzing strength of
    association, specificity, temporality, and
    biologic plausability of the DRPs in N960 older
    adults in MCO
  • Claims data were collected for three years on
    all identified cases with dementia and each
    included age, gender, medical diagnosis for each
    claim (ICD-9 code) and prescription drugs (NDC).

24
Aged 65 years or older From managed care
database January 1, 1998 N76, 388
ICD-9 code dementia diagnosis N7,347 (10)
Continuously enrolled 36 months with prescription
drug coverage N960
No central nervous system medications N194
Central nervous system medications N766
25
RESULTS
  • Over 79 of PWD in this sample were on a
    CNS-active medication during the three-year time
    period (period prevalence).
  • 62 were on a PIM as defined by 2003 Beers
    criteria (Fick et al, 2003)
  • 55.7 were on a COMBINATION of CNS drugs over the
    3 year period

26
Incidence of drug-related problems within 45 days
of a CNS prescription, n766. Prescription
Type Frequency Percent Any CNS related
Diagnosis within 45 days 429 56.0 Altered
Consciousness 91 11.9 Syncope 159 20.8 Slee
p Disturbance 46 6.0 Fatigue 133 17.4 Urine
Retention 33 4.3 Constipation 61 8.0 Nervousne
ss 1 0.1 Adverse Effect NEC 10 1.3 Bradycardia
26 3.4 Dry Mouth 2 0.3 Falls 42 5.5 Fractur
es 45 5.9 Bowel Hemorrhage 34 4.4 nCocussion
3 0.4 Hypoglycemia 12 1.6 Hypotension 11 1.4
Drug Induced Syndrome 10 1.3 Poisoning 0 0.0 C
onfusion 63 8.2 Delirium 92 12.0 Depression
25 3.3
27
Table 3 McNemars Test, Odd Ratio and 95 Confidence Interval for Differences in Drug Related Problems 45 days before versus 45 days after a CNS prescription (n766) Table 3 McNemars Test, Odd Ratio and 95 Confidence Interval for Differences in Drug Related Problems 45 days before versus 45 days after a CNS prescription (n766) Table 3 McNemars Test, Odd Ratio and 95 Confidence Interval for Differences in Drug Related Problems 45 days before versus 45 days after a CNS prescription (n766) Table 3 McNemars Test, Odd Ratio and 95 Confidence Interval for Differences in Drug Related Problems 45 days before versus 45 days after a CNS prescription (n766) Table 3 McNemars Test, Odd Ratio and 95 Confidence Interval for Differences in Drug Related Problems 45 days before versus 45 days after a CNS prescription (n766) Table 3 McNemars Test, Odd Ratio and 95 Confidence Interval for Differences in Drug Related Problems 45 days before versus 45 days after a CNS prescription (n766)
Drug Related Problem DRP 45 days before CNS prescription DRP 45 days after CNS prescription DRP 45 days after CNS prescription McNemars p-value McNemars OR and 95 CI
Drug Related Problem DRP 45 days before CNS prescription No N () Yes N () McNemars p-value McNemars OR and 95 CI
Any CNS DRP No 268 (34.99) 197 (25.72) lt0.0001 2.37 (1.81 3.12)
Yes 83 (10.84) 218 (28.46)
Syncope No 578 (75.46) 92 (12.01) lt0.0001 2.42 (1.61 3.67)
Yes 38 (4.96) 58 (7.57)
Fatigue No 598 (78.07) 83 (10.84) 0.0001 2.08 (1.38 3.14)
Yes 40 (5.22) 45 (5.87)
Delirium No 653 (85.25) 62 (8.09) 0.0003 2.21 (1.36 3.65)
Yes 28 (3.66) 23 (3.00)
Altered Consciousness No 654 (85.38) 67 (8.75) lt0.0001 2.57 (1.57 4.28)
Yes 26 (3.39) 19 (2.48)
Falls No 717 (93.60) 36 (4.70) lt0.0001 4.00 (1.76 9.76)
Yes 9 (1.17) 4 (30.77)
28
STUDY CITATIONS
  • Fick, DM, Kolanowski, AM, Waller, JL, (2007).
    High prevalence of inappropriate central nervous
    system medications in community-dwelling older
    adults with dementia over a three year period.
    Aging and Mental Health. 11 (5), 588-595.
  • Penrod, J, Yu, F, Kolanowski, AM, Fick, DM, Loeb,
    S, Hupcey, J. (2007). Reframing Person-Centered
    Nursing Care for Persons with Dementia. Research
    and Theory in Nursing Practice. Vol 21 (1),
    61-76.
  • Kolanowski, AM, Fick, DM, Waller, J, Ahern, F
    (2006). Outcomes of Anti-psychotic Drug Use in
    Community-dwelling Elders with Dementia. Arch of
    Psych Nurs, 20, (5), 217-225.

29
What our data has shown so far
  1. Inappropriate medication use, CNS-active and
    sedative hypnotic medications are common in older
    adults and in PWD
  2. Poor outcomes are associated with the use in PWD
  3. Medications are often the first line of treatment
    for behavioral problems in PWD
  4. Nurses and physicians often do not recognize
    delirium

30
General Principles for Reducing Harm from
High-Alert Medications
  • Hospitals and other care settings should employ
    the following principles of a safe system
  • 1. Design processes to prevent errors and harm.
  • 2. Design methods to identify errors and harm
    when they occur.
  • 3. Design methods to mitigate the harm that may
    result from the error.

31
Interventions for improving drug use in older
adults
  • Many physician based interventions in managed
    carefocus on only 1 player
  • DADE project state of New York
  • Challenges in addressing medication use in acute
    care for older adults
  • Most are based on computer alertsmust also have
    culture change

32
Hospital Based Interventions in Older Adults
  • Joseph V. Agostini MD, Ying Zhang MD, MPH, Sharon
    K. Inouye MD, MPH (2007) Use of a Computer-Based
    Reminder to Improve Sedative-Hypnotic Prescribing
    in Older Hospitalized Patients Journal of the
    American Geriatrics Society 55 (1), 4348.
  • Use real-time computer based reminders to use
    non-pharm sleep protocol
  • measured freq of prescribing 4 sed/hyp
    (diphenhydramine, diazepam, lorazepam, trazodone)
  • Decreased 18-15 post intervention

33
Interventions in Older Adults
  1. Raebel et al. 2007 Randomized Trial to Improve
    Prescribing Safety in Ambulatory Elderly
    Patients, JAGS
  2. Fick et al., 2004 Am J Man Care
  3. Spinewine et al., 2007, JAGS

34
Decreasing Anti-cholinergic Drug Use in Older
Adults (DADE)
  • Focus on providers AND patients
  • State of New York CMS-designated quality
    improvement organization
  • Interdisciplinary Expert Panel

35
EDUCATION
  • NICHE
  • GERO-NURSE ONLINE
  • HARTFORD FOUNDATION
  • REYNOLDS FOUNDATION
  • ASCP
  • CONTINUOUS FEEDBACK

36
Future of Drug Use In Older Adults?
  • Broader interdisciplinary view
  • Drug burden scales incorporating dosages and
    cumulative affect
  • Genetic targeting-personalized databases
  • Gurwitz et al 2006
  • Interdisciplinary approach and incentives
  • IT-Electronic alerts, interventions, and
    education

37
PATIENT CARE PEARLS
  • Limit the overall number of medications
  • Use of non-pharmacological approaches first
  • Better use of technology to reconcile meds
  • Good Communication between disciplines
  • Continual assessment of Mental Status and
    Function
  • Special care at transitions and assess HOME
  • Consider problem of underuse as well

38
NON-PHARMACOLOGICAL ALTERNATIVES
  • Sleep protocol (see McDowell, Mion, Inouye, 1998)
  • Therapeutic Activity Program---http//www.atra-tr.
    org/dementiapractice/recommendations.htm
  • Mobilize early and often
  • Vision and Hearing aides
  • Remove and camouflage invasive devices
  • HELP--http//elderlife.med.yale.edu/public/public-
    main.php

39
TAKE HOME PEARLS
  • Appropriateness as DYNAMIC concept
  • We must include more older adults in clinical
    trials and develop system for reliable post
    market data
  • Geriatric education valued and funded
  • Shared incentives and communication among players
  • Organization/SYSTEM culture change

40
Thank You
To Our Many Collaborative Partnersand Panel
Experts
41
References
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  • Gurwitz, J, et al, Incidence and preventability
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42
Knowing is not enoughwe must apply.Willing
is not enoughwe must do. - Goethe
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