best practices for safe prescribing in older ed patients

Best Practices for Safe Prescribing in Older ED PatientsS. Nicole Hastings, M.D., M.H.S.

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Safe Prescribing in Older ED Patients

• Review Beers’ Criteria, tool for identifying Potentially Inappropriate Medications

• Discuss most frequent medication problems in ED discharge medications

• Review strategies for reducing use of high risk medications in the ED

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ED Discharge Medications

• In VAMC EDs, 45-65% of older adults are prescribed at least one new medication at the time of ED discharge• 59% - 1 new medication• 27% - 2 new medications• 14% - 3 or more

• Most common drug classes• Anti-infectives • Cardiovascular• Central nervous system

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The Medication Maze

New medications and dosage

changes

Common ED discharge drugs (e.g. NSAIDs,

opioid analgesics, antibiotics) are often risky for older patients Medication

Reconciliation Across Transitions

Differentprescribers

Multiple medications and

chronic conditions

Over thecounter drugs

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Potentially Inappropriate Medications

• Risk of adverse event outweighs clinical benefit

• Identifying PIMs in older adults– Beers’ Criteria– STOPP/START Criteria– HEDIS– Medication Appropriateness Index

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Beers’ Criteria

• 2012 Update with AGS• Target audience – practicing clinician• Goal - Improve care by ↓ exposure to

PIMS– Educational tool– Quality measure– Research tool

Beers’ Criteria

• Intended clinical use– Improve care of older adults by reducing

exposure to PIMs– Guideline to identify medications for which

risk > benefit– Not meant to supersede clinical judgment

or individual patient’s values and needs– Serve as a reminder for closer monitoring

American Geriatrics Society

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Beers’ Criteria

Table 2 – AvoidDrug or Class

Rationale Recommendation

Quality of Evidence

Strength of Recommendation

First generation antihistaminesExamples:-Diphenhydramine-Hydroxyzine-Promethazine

Highly anticholinergic; clearance reduced with advanced age..greater risk of confusion, dry mouth, constipation, etc (urinary retention)

Avoid Hydroxyzine and promethazine: high; all others, moderate

Strong

Anticholinergics

• Diphenhydramine• Hydroxyzine• Meclizine• Promethazine• Prochlorperazine

(Compazine)• Oxybutynin• Scopolamine• Cyclobenzaprine

J Am Geriatr Soc 2012

Prescriber Beware…..• Drug-Drug Interactions

– Warfarin, digoxin– QTc prolongation

• Drug-Disease Interactions– NSAIDS-PUD– Anticholinergics/antihistamines and bladder

outlet obstruction– Anticholinergics/antihistamines and cognitive

impairment• Dose adjust for renal insufficiency

– Cr overestimates GFR in older adults

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ED Discharge Medication Problems

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ED Discharge Medication Problems

• Beers’ drug – 11.6%• Drug-drug interactions – 12.6%• Drug-disease interactions – 5.7%• Problem with monitoring - 17.6% • One or more – 31.8%

ED Discharge Medication Problems

Quality Problem Examples

Drug to avoid cyclobenzaprine, diphenhydramine, indomethacin

Drug-drug interaction lisinopril - naproxenDrug-disease interaction

amitryptyline – benign prostatic hyperplasia

Therapeutic duplication ibuprofen - naproxenInadequate monitoring no potassium, creatinine check after new

prescription for diuretic

Suboptimal Pharmacotherapy

Time until first adverse event (repeat ED visit, hospital admission or death) among patients with: (1) no new discharge drug, (2) new discharge drug but

no suboptimal pharmacotherapy and (3) new discharge drug with suboptimal pharmacotherapy.

Before Prescribing, Consider…

• Is a medication necessary?– Think drugs with any new geriatric

syndrome• Do the benefits outweigh the risks?• Is it used to treat effects of another

drug?• Could it interact with a disease, other

drugs?• Does the patient know what it’s for, how

to take it, and what ADEs to look for?

Free AGS Beers App

Available at:Americangeriatrics.org

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EQUiPPED

• Enhancing Quality of Prescribing in the Emergency Department

• 5 site QI program funded of Office of Geriatrics and Extended Care

Beers’ Meds Common in ED

• Pain Meds– Non-COX selective NSAIDS– Indomethacin– Ketorolac (Toradol)– Skeletal Muscle relaxants– Amitriptyline/TCAs

• Benzodiazepines• Anticholinergics/Antihistamines

www.fanpop.com

Courtesy: Loren Wilkerson, M.D.

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Safe Prescribing in Older ED Patients

• Is a medication necessary?• Is there a safer alternative?• Does the risk outweigh the benefit?• AGS Beers Criteria as a guideline • Reduce PIM use in your ED through

education, provider feedback, CPRS tools

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Thanks for your Attention!

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Bibliography

• “Review: Emergency Department Use by Older Adults: A Literature Review on Trends, Appropriatness, and Consequences of Unmet Health Care Needs,” Anrea Gruneir, Mara J. Silver and Paula A. Rochon, Med Care Res Rev 2011 68:131 http://mcr.sagepub.com/content/682/131

• “Older Adults in the Emergency Department: A Systematic Review of Patterns of Use, Adverse Outcomes, and Effectiveness of Interventions,” Faranak Aminzadeh, William Dalziel, Annals of Emergency Medicine, March 2002;39:3,238-247.

• “How Frequent Emergency Department Use by US Veterans Can Inform Good Public Policy,” Jesse Pines, Annals of Emergency Medicine, 2013, pending publication.

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Bibliography

• Survey: Many Elderly Are in the Dark at ED Discharge, http://www.acep.org/content.aspx?id=46032

• “Health Services Use of Older Veterans Treated and Released from Veterans Affairs Medical Center Emergency Departments.” Hastings SN et al. J Am Geriatr Soc 2013; 61:1515-1521.

• “Quality of Pharmacotherapy and Outcomes for Among Older Veterans Discharged from the Emergency Department.” Hastings et al. J Am Geriatr Soc 2008; 56 (5):875-880.

• “Older Veterans and Emergency Department Discharge Information.” Hastings SN et al. BMJ Qual Saf 2012 Oct;21:835-842.

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Questions/Comments