Managing Medications in Clinically Complex EldersMichael A. Steinman, MD, Joseph T. Hanlon, PharmD, MSJAMA, Oct 13, 2010, Vol 304, No 14

Payal Patel

Mercer University, Doctor of Pharmacy Candidate 2012

RTR Medical Group

Patient Case Mr L. is an 84 year old male with dementia who presents to the

clinic with initial concerns of forgetfulness, difficulty walking, and falling

PMH atrial fibrillation, diabetes mellitus, hypertension, hyperlipidemia, CKD,

gastritis, GERD

Medications Glyburide, digoxin, warfarin, etodolac, docusate sodium, multivitamin, iron,

memantine, metoprolol, gabapentin, essential fatty acids, acetaminophen prn, lactulose

Family Hx Unable to obtain

Social Hx Retired writer, plays tennis, lives with his wife

Presentation

Vitals BP: 135/60 HR: 50s CrCl: 42 ml/min

MMSE: 13/29

A1C: 5.9%

Multiple Medication Use About 20% of elderly who live in the community age 65 years and older

take 10 or more medications

Greater use of inappropriate medications

Adherence problems

Increased frequency of adverse events Adverse drug events affect 5 – 35% of elderly patients living in the

community per year

Adverse health outcomes

Cost burden

Introduction

This article summarizes evidence-based literature regarding improving medication use and describes a systematic approach for how healthcare professionals can improve medication regimens for the benefit of the patients

Information Gathering

Assessing current medication use Communication gaps are responsible for 37% of

remediable adverse drug events Discrepancy between patients’ understanding of

what they should be taking, what they are taking and what is in physicians record

Little direct evidence as to which method is best for medication review

Brown bag review can be useful Review meds, how the patient takes it, assess efficacy

Information Gathering

Assessing adherence Approximately one-half of older patients have adherence

problems to at least 1 medication Patients often do not admit to nonadherence Observe medication organization, pill count and refill history Address reasons underlying adherence ex: cost, difficulty

opening bottles, etc. Contact pharmacists regarding concerns about patient

adherence

Information Gathering

Assess patients’ goals of medication use Medications that increase longevity vs negative

effect on QOL Assess what the patient and family want to

achieve Prioritize values

Structured medication management

6 studies performed to assess the efficacy of medication management

Overall, these programs reduce medication burden, prevented underuse/overuse of medications

In a large study, medication management reduced the rate of serious adverse drug events from 0.6 to 0.4 events/1000 person-days (p=0.02)

Less evidence of its effect on clinical outcomes such as QOL, major clinical events and utilizing health services

Changing the medication regimen

However, it is recommended to structurally manage medications Match medications to conditions

Identify overused, underused or misused drugs

Make improvements by changing the dose, frequency or substituting another drug with a better side effect profile

Discontinuation of unnecessary medications

Studies of community based older patients have shown that they have an average of 1 unnecessary medication on their regimen

A large study found that 44% of older patients were discharged with at least 1 unnecessary medication

Drugs that should be avoided in older patients are used in approximately 20 to 30% of adults age 65 years and older

Discontinuation of Medications Look for drugs that lack clear indications and

consider discontinuing them

Screen for drugs that may be harmful in the elderly

Look for drugs that provide limited benefit Drugs that cause troublesome symptoms / adverse

effects Decisions of stopping medications should be based

on case and common sense

Discontinuation of Medications

Limited evidence about the best way to stop medications

In one of the studies, 26% drug discontinuations lead to worsening of underlying disease and 4% lead to withdrawal reactions

Use a stepwise approach in discontinuing medications

It is important to slowly taper the drugs

Educate patients and monitor patients for adverse withdrawal events

Underuse of Beneficial Medications Patients are often not prescribed potentially

beneficial medications

Symptoms such as pain and depression should be treated

Primary prevention if appropriate Vitamin D repletion in deficient patients can

prevent falls and risk of fractures

Improving adherence Randomized controlled trials of strategies to improve compliance

have shown mixed results

Most data suggests that oral counseling or written instructions are often insufficient

A more useful approach is simplifying medication dosing schedules

Clinicians should prescribe longer acting mediations or combination drugs when possible to decrease frequency

Behavioral interventions – medication organizers, packaging, cues

Lower cost generics can also help patients with financial problems

Monitoring and Follow-up

Ongoing monitoring for drug toxicity and efficacy is important in providing patient care

Approximately 1/3rd -2/3rd patients receiving digoxin, carbamazepine and other drugs that need monitoring are not monitored regularly

Patient’s medication list should be reviewed regularly

Medication review should also be done when there is sudden decline in function or onset or worsening of certain syndromes

Conclusion

Managing medications for older patients is a complex task

A careful, step-wise approach should be taken to reduce the complexity and to help the patient achieve beneficial outcomes

Patient Case - Assessment/Plan Patient no longer had pain from his lumbar laminectomy

Tapering off etodolac and gabapentin while watching for increased reports of pain

Tapering off digoxin watching for his heart rate

Hemoglobin 13 g/dL Discontinue iron

Recommend yoga and gym twice weekly

Low serum 1,25-dihydroxyvitamin D level Added Vitamin D 800 IU/day to Mr L’s regimen

Dr. S asked Mrs L if memantine was helping Mr L’s memory and she wasn’t sure Dr. S tapered off memantine and Mr. L had diffculty with nouns and names so

he resumed memantine

Outcomes

Mr. L is now socially improved and feeling better

His activities of daily living have been stable