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Medication Management

Patricia W. Slattum, PharmD, PhDProfessor of Pharmacotherapy and Outcomes Science

Director, Geriatric Pharmacotherapy Program

Who are we talking about?• Older adults are a heterogenous group!

Medications: The Right Balance

“Medications are probably the single most important health care technology in preventing illness and disability in the older population.”

"Any symptom in an elderly patient should be considered a drug side effect until proven otherwise."

Avorn J. Health Affairs, Spring 1996; J Gurwitz, M Monane, S Monane, J Avorn. Brown University Long-term Care Quality Letter 1995

Geriatric Syndromes• Clinical conditions in older persons that 

do not fit into exact disease categories• Geriatric syndromes include:

– Falls– Delirium– Frailty– Dizziness– Syncope– Urinary incontinence

Inouye SK, Studenski S, Tinetti ME, Kuchel GA. JAGS 2007;55:780-91Sleeper RB. Consult Pharm 2009;24:447-462.

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Geriatric Syndromes• Highly prevalent, especially in frail older adults• Substantially impact quality of life and disability• Caused by multiple underlying factors • Challenge the traditional way of viewing clinical care

• Can be mistaken for normal aging• May be caused or worsened by medications

Inouye SK, Studenski S, Tinetti ME, Kuchel GA. JAGS 2007;55:780-91.Sleeper RB. Consult Pharm 2009;24:447-462.

Pharmacokinetics, Pharmacodynamics and Aging

Drug

Concentrationin the

Circulation

PK

•Absorption•Distribution•Metabolism•Excretion

Drug

Effect

PD

•Drug-receptor interactions

•Concentration at receptor

•Homeostatic mechanisms

Desirable

Therapeutic

Outcome

Efficacy

•disease characteristics

•adherence

Medication Use Process What is a Medication-Related Problem ?

An undesirable event experienced by a 

patient that involves or is suspected to 

involve drug therapy and actually or 

potentially interferes with a desired patient 

outcome.

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Risk Factors for Medication-Related Problems

• More than 6 current medical diagnoses• More than 12 doses of medications per day• 9 or more total medications• History of adverse drug reactions in the past• Low body weight• Age 85 years• Low kidney function

Fouts M, et al. Consult Pharm 1997;12:1103-11

Risk Factors for Adverse Drug Eventsin Outpatients

• PATIENT CHARACTERISTCS– Polypharmacy– Dementia– Multiple chronic diseases– CrCl < 50 ml/min– Recent hospitalization– Age ≥ 85 years– Multiple prescribers– Regular use of alcohol (> 1 fl oz/d)– Prior ADR

Hajjar ER, et al. Am J Geriatr Pharmacother 2003;1:82‐9)

Other Factors Contributing to Medication-Related Problems in Older Adults

• Changes in the body that occur with aging• Multiple prescibers• Limited evidence base• Limited health professional expertise in aging

Symptoms of a Medication-Related Problem in Older Adults

• Altered mental status/confusion • Fatigue• Falling• Constipation• Blurred vision• Depression• Dizziness

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Types of Medication-Related Problems

• Inappropriate Prescribing

• Polypharmacy

• Underuse

• Adverse Drug Events

• Drug Interactions

• Non‐adherencehttp://www.merckmanuals.com/professional/sec23/ch341/ch341e.html

Inappropriate Prescribing for Older Adults

Inappropriate prescribing defined as:• Prescribing of meds where the potential risk

outweighs the potential benefit• Prescribing that does not agree with accepted medical

standards

Approaches to measure inappropriate prescribing:• Drugs to avoid• Clinical review using explicit criteria

Hanlon JT et al. JAGS 2001; 49:200-209

Inappropriate Prescribing for Older Adults

Drugs to avoid in older adults: The Beers criteria• Developed by an expert consensus panel• First published in 1991 for nursing home patients• Updated in 1997 to apply to older adults in all

clinical settings. Updated in 2003, 2012 and 2015.

• Included severity rating reflecting the likelihood of an adverse outcome & the clinical significance of the outcome for each prescribing concern

http://geriatricscareonline.org/ProductAbstract/american-geriatrics-society-updated-beers-criteria-for-potentially-inappropriate-medication-use-in-older-adults/CL001

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Applying Multiple Practice Guidelines to the Care of the Complex Older Adult Patient

• Most clinical practice guidelines are:– Based on clinical evidence and expert consensus– Designed by specialty‐dominated committees – Focused on single diseases (almost never address more than 2)

– Lacking sufficient evidence regarding our oldest old patients

– Lack discussion of burden on patients and caregivers

• Do current CPGs provide an appropriate, evidence‐based foundation for assessing quality of care in older adults with several chronic diseases?

http://www.americangeriatrics.org/health_care_professionals/clinical_practice/multimorbidity

Overuse of Medication

Polypharmacy defined as:

• Concurrent use of multiple medications

• Administration of more medications than are needed

Hanlon JT et al. JAGS 2001; 49:200-209

Overuse of Medication• Overuse can also occur when:

• Doses are too high• Unintentional duplicate

therapies are prescribed– Two drugs of the same class are

prescribed for high blood pressure– Two medications prescribed for sleep by

different doctors

Prescribing Cascades

DRUG 1

Rochon PA, Gurwitz JH. BMJ 1997;315:1096-9.

Adverse Event Misinterpreted as New Medical Condition

DRUG 2

Adverse Drug Event

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Underuse of Medications

• Omission of drug therapy that is needed for the treatment or prevention of a disease or symptom.

• Ex: Pain management

Hanlon JT et al. JAGS 2001;49:200-9; Lipton HL et al. Ann Rev Gerontol Ger 1992; 12:95-108; Cherubini A, et al. Drugs Aging 2012; 29:463-475

Adverse Drug Events

• Unwanted effects of medications or “side effects”

• More common in older adults• May be mistaken for normal aging or new medical conditions

• Can occur when first starting a new medication or after taking a medication for a long time.

Drug Allergies• An allergy is an “overreaction” by the body’s immune system to a foreign substance, such as a drug.

• Less than 10% of adverse drug events are drug allergies.

• Reactions can range from a mild skin rash to a life threatening emergency (usually difficulty breathing).

• It is very important to recognize drug allergies!

Pay Close Attention to High Risk Drugs

•Medication use leading to ER visits–3.6% due to Beer’s list drugs–33.3% due to warfarin, insulin and digoxin

•Emergency hospitalization due to ADEs–Half among those  80 years–67% due to warfarin, insulin, antiplatelet agents and oral hypoglycemic agents–1.2% due to Beer’s list drugsAnn Intern Med. 2007;147:755-765;N Engl J Med 2011;365:2002-12

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More Evidence onHigh Risk Drugs

•ADEs among hospitalized Medicare recipients

– 8.2% of patients exposed to warfarin– 13.6% exposed to heparin– 10.7% exposed to insulin/hypoglycemic agents– 0.5% exposed to digoxin

Joint Commission Journal on Quality and Patient Safety 2010;36:12-21

Drug Interactions• Prevalence increases as number of prescribed drugs 

increases• 5 to 7 drugs = 4 fold greater risk• 8 to 10 drugs = 8 fold greater risk

• Can’t prevent all drug interactions• Patient groups at increased risk

– older adults– those seeing multiple prescribers– those being infrequently or inadequately monitored– those with impaired pathways of drug elimination– those with certain pharmacogenetic patterns

Mallet L, et al. Lancet 2007;370:185-91.http://www.fda.gov/downloads/ForConsumers/ConsumerUpdates/ucm096391.pdf

Role of Alternative Medicines? OTC Products and Older Adults• Sedating antihistamines

• Decongestants• Nonsteroidal anti‐inflammatory drugs

• Acetaminophen• Acid‐suppressing drugs

http://www.nyam.org/agefriendlynyc/docs/OTC‐list‐for‐pharmacists‐NYAM.pdf

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Drug‐Food Interactions– As a rule, drugs are absorbed better when taken with water.

– Acidic fruit juices, vegetable juices, carbonated beverages, caffeinated beverages and milk products can interfere with the absorption of some drugs.

– Not taking enough fluids with medications can also delay drug absorption or cause stomach irritation.  Medications should be taken with at least ½ cup of water unless patient has order for limited fluid intake.

http://www.usatoday.com/story/news/nation/2013/01/20/food‐drug‐interactions/1827229/

Medication Adherence

Causes of nonadherence• Older adults may be more prone

because of higher proportion of prescribed meds

• Poor patient-healthcare provider relationships

• Multiple providers• Multiple pharmacies

Almost 40% of seniors are unable to read a prescription label, and 67% are unable to understand information given to them.

Vik SA et al. Ann Pharmacother 2004;38:303-12. McLaughlin et al. Drug Aging 2005;22:231-255.

Crushing Medications• Some medications are less effective if crushed or mixed with food, milk or juice.

• Some medications taste bad when crushed.

• Some medications may be harmful to the individual crushing them if the particles are accidentally inhaled.

• The pharmacist or prescriber can help to identify liquid or other dosage forms that can be more easily swallowed if necessary.

Timing of Medication Administration• There are some medications where timing is particularly critical:– Insulin– Medications for Parkinson’s disease– Pain medications– Sleep medications– Osteoporosis medications

• Alendronate (Fosamax®)• Risedronate (Actonel®)• Ibandronate (Boniva®)• Pamidronate (Aredia®)

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The Medication History• An accurate medication history is important and can take some detective work to obtain!

• The current medication list should include:– Prescription medications– Over the counter medications– Dietary supplements/herbal products– Alcohol

• For each medication, record the dose, time(s) taken each day, frequency of use for as needed medications and indication.

http://www.medsandaging.org/documents/PersonalMedList_000.pdf

Safely Discontinue Excess Meds • Most medications can simply be discontinued without causing an adverse drug withdrawal event

• Following long‐term use, some drugs should be tapered slowly; days to weeks

• Benzodiazepines• Antidepressants• Other psychotropic drugs• Beta blockers

Bain KT, et al. JAGS 2008;56:1946‐52.

Preventing Medication‐Related Problems• Improve communication between patient 

and health care providers, including ability to pay for medications.

• Designate a medication manager and have regular medication “check ups”.

• Keep a medication list and take all medications to appointments with doctors.

• Consult with a doctor or pharmacist before using over‐the‐counter medication or herbal supplements.

• Get all prescriptions filled at one pharmacy.

Reducing the Caregiving “Hassles” of Medication Management

• Talk with your pharmacist– Keeping up with refills– Specialized packaging– Knowing when medications can be crushed, mixed with food, etc.

– Planning a medication administration schedule that works with your daily routine

– Options for paying for medications– Knowing why a medication is being given and what to expect

The Gerontologist (2003)Vol. 43, No. 3, 360–368

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Reasons MRPs may not be addressed in elderly patients

• “My patient has been taking this medication for many years without a problem”– The balance between benefit and risk shifts as people age, due to physiologic changes associated with aging and chronic disease.

– The benefits and risks of each medication should be assessed regularly and alternatives with the lowest potential risk should be prescribed.

McLeod PJ et.al. Can Med Assoc J 1997;156:385-91; Vestal RE. Cancer 1997;80:1302-10.

Reasons MRPs may not be addressed in elderly patients

• “I did not prescribe all of the medications my patient is taking”– Elderly patients’ medication management is often complicated by the fact that they seek medical care from multiple physicians, sometimes for the same medical problem.

– Review all medications at each visit and assist patients in designating a “medication manager” from among their providers to coordinate their care.

Knight and Avorn. Ann Intern Med 2001;135:703-710; Chutka DS et.al. Mayo Clin Proc 1995;70:685-93.

Reasons MRPs may not be addressed in elderly patients

• “The risk of discontinuing the medication is greater than the benefit.”– Approximately 75% of chronic medication discontinuations result in no adverse outcomes.

– Adverse outcomes are most likely when several medications are discontinued simultaneously.

– Exacerbation of cardiovascular disease is the most common adverse outcome.

– Some medications require a gradual withdrawal to avoid physiologic withdrawal reactions.

Hanlon JT et al. J Clin Epidemiol 1992;45:1045-51; Graves T et.al. Arch Intern Med 1997;157:2205-10; Davidson HE. Consult Pharm 1998;13:209-10.

Reasons MRPs may not be addressed in elderly patients

• “My patients resist changes in their drug therapy.”– Many of the common ailments that elderly patients seek a physician’s care for have no cure.

– Patients often have the expectation that something be done and physicians often have the perception of needing to do something.

– Motivated patients can successfully withdraw with appropriate education and monitoring.

– Although patients may be resistant, they may greatly benefit from the change.

Chutka DS et al. Mayo Clin Proc 1995;70:685-93; Cormack MA et.al. Br J Gen Pract 1994;44:5-8.

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Reasons MRPs may not be addressed in elderly patients

• “My patient is not experiencing adverse effects usually seen with this medication.”– Elderly patients may experience atypical adverse effects from medications including confusion, forgetfulness, loss of balance, falls, incontinence, constipation or fatigue.

– Other medications may be added to regimens to treat unrecognized adverse effects.

– Medications should be suspected whenever elderly patients experience new symptoms and signs.

Chutka DS et al. Mayo Clin Proc 1995;70:685-93; Rochon PA and Gurwitz JH. BMJ 1997;315:1096-9.

Improving the Quality of Medication Use in Elderly Patients: A Not‐So‐Simple Prescription

“Putting the pieces of the puzzle together to create a solution remains a formidable, but not insurmountable task….All the pieces of the puzzle lie before us; it remains for us to find a way to fit them together”

Jerry H. Gurwitz, M.D.

Gurwitz JH, Arch Intern Med 2002; 162:1670-3

Quality Indicators for Appropriate Medication Use in Vulnerable Elders

• Indicator 1: Medication List– The outpatient medication record of every 

physician and the hospital medication record should contain an up‐to‐date medication list, including over the counter medications.

• Indicator 2: Periodic Drug Regimen Review– All vulnerable elders should have a drug regimen 

review at least annually.• Indicator 3: Drug indication

– When a new drug is prescribed, a clearly defined indication should be documented in the record.

Shrank, Polinski & Avorn. J Am Geriatr Soc 2007;55:S373-S382.

Quality Indicators for Appropriate Medication Use in Vulnerable Elders

• Indicator 4: Patient Education– When a new drug is prescribed, the patient or 

caregiver should receive education about the purpose, directions for use and important adverse reactions.

• Indicator 5: Response to Therapy– Every new drug prescribed on an ongoing basis 

for a chronic medical condition should have a documentation of the response to therapy.

Shrank, Polinski & Avorn. J Am Geriatr Soc 2007;55:S373-S382.

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Summary• Older adults are at risk for experiencing geriatric syndromes and medication‐related problems.

• Some of these problems are preventable!• All members of the healthcare team, including the patient, contribute to the optimal use of medications.