Good Drugs, Old Drugs, & Bad Drugs Partnering For a Better

Future in Medication Use in Older Adults

New Jersey Council of Teaching Hospitals

Donna Fick, PhD, RN, FGSAThe Pennsylvania State University School of Nursing and School of Medicine, Department of Psychiatry

Gerontology Center, Faculty Affiliate

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

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)

# 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)

# 2 INCREASED FOCUS ON ADVERSE EVENTS CREATING TUG SAFETY/QUICK

DRUG APPROVAL

# 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

# 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

# 5 CHALLENGE OF ATYPICAL PRESENTATIONS IN OLDER ADULTS

• Pneumonia• Congestive Heart failure• Myocardial Infarction• Urinary Track Infection• Depression• Adverse Drug reaction

DELIRIUM

# 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

# 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

# 8 MULTIPLE PLAYERS

# 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

# 10 APPROPRIATE MEDICATION USE

• Overuse• Underuse• Misuse• Rights-drug,

patient, time, way, dosage, price

Beers CriteriaOriginal author Mark Beers et al 1990Explicit 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!

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

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 update4) Medications added by Panelists in

first and second rounds

Where To Find 2003 Beers Medications*

• SeniorJournal– http://www.seniorjournal.com/NEWS/Eldercare/5-01-06BeersCriteria03-Tb2.ht

m• 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. 2003;163:2716-2724.

– http://archinte.ama-assn.org/cgi/content/full/163/22/2716

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

•Our Data on High Alert Medications–Sedative Hypnotics

–CNS-active

Medication Use in Hospitalized Persons with Dementia (N = 272)

0 10 20 30 40 50 60Percent

59.3

36.7

8.9

35.2

35.229.5

26.7

AnticholinergicsAtypical Antipsychotics

Conventional AntipsychoticsNarcotic Analgesics

AntidepressantsBenzodiazepines

Acetylcholinsterase Inhibitors

• We examined association of DRPs with administrative data for analyzing strength of association, specificity, temporality, and biologic plausability of the DRPs in N=960 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).

METHODS

Aged 65 years or older

From managed care database

January 1, 1998

N=76, 388

ICD-9 code dementia diagnosis

N=7,347 (10%)

Continuously enrolled

36 months with prescription drug coverage N=960

No central nervous system medications

N=194

Central nervous system medications

N=766

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

Incidence of drug-related problems within 45 days of a CNS prescription, n=766.

Prescription Type Frequency Percent

Any CNS related Diagnosis within 45 days 429 56.0

Altered Consciousness 91 11.9 Syncope 159 20.8Sleep Disturbance 46 6.0

Fatigue 133 17.4Urine Retention 33 4.3Constipation 61 8.0Nervousness 1 0.1Adverse Effect NEC 10 1.3Bradycardia 26 3.4Dry Mouth 2 0.3Falls 42 5.5Fractures 45 5.9Bowel Hemorrhage 34 4.4nCocussion 3 0.4Hypoglycemia 12 1.6Hypotension 11 1.4Drug Induced Syndrome 10 1.3Poisoning 0 0.0Confusion 63 8.2

Delirium 92 12.0Depression 25 3.3

Table 3: McNemar’s Test, Odd Ratio and 95% Confidence Interval for Differences in Drug Related Problems 45 days before versus 45 days after a CNS prescription (n=766)

Drug Related Problem

DRP 45 days before CNS

prescription

DRP 45 days after CNS prescription

McNemar’s p-value

McNemar’s OR and 95% CI

NoN (%)

YesN (%)

Any CNS DRP No 268 (34.99) 197 (25.72) <0.0001 2.37 (1.81 – 3.12)

Yes 83 (10.84) 218 (28.46)

Syncope No 578 (75.46) 92 (12.01) <0.0001 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) <0.0001 2.57 (1.57 – 4.28)

Yes 26 (3.39) 19 (2.48)

Falls No 717 (93.60) 36 (4.70) <0.0001 4.00 (1.76 – 9.76)

Yes 9 (1.17) 4 (30.77)

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.

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

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.

Interventions for improving drug use in older adults

• Many physician based interventions in managed care—focus 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 alerts—must also

have culture change

Hospital Based Interventions in Older Adults

1. 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), 43–48.

• 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

Interventions in Older Adults1. Raebel et al. 2007 Randomized Trial to

Improve Prescribing Safety in Ambulatory Elderly Patients, JAGS

2. Fick et al., 2004 Am J Man Care3. Spinewine et al., 2007, JAGS

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

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

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

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

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

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

To Our Many Collaborative Partners

and Panel Experts

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“Knowing is not enough;we must apply.

Willing is not enough;we must do.”

- Goethe