polypharmacy in the geriatric population
TRANSCRIPT
Polypharmacy in the Geriatric Population
Maegan Rogers, PharmD, BCPS, CDEInternal Medicine Clinical Pharmacy Specialist
Regional One HealthMemphis, TN
Objectives
• Define polypharmacy
• Describe risk factors for geriatric patients
• Indentify common “offending” medications
• List available screening tools for polypharmacy
• Describe ways to limit adverse drug events in the elderly population
Definitions
• Geriatric Population– “Greatest generation”
– Baby Boomers?
• Polypharmacy– Prescribing multiple medications
– Five or more
• Inappropriate prescribing (IP)– Potentially inappropriate medications (PIM)
– Potential prescribing omissions (PPO)
C. Parsons. Ther Adv Drug Saf. 2017, Vol 8(1) 31-46
Definitions
Adverse Drug Events (ADE)
• Unintended and undesired effects
• Five categories
– Adverse drug reaction
– Medication error
– Allergic reactions
– Withdrawal
– Overdose
https://health.gov/hcq/ade.asp. Accessed April 2019
Anyone’s Grandma
Anyone’s Grandma
Geriatric Population
Now most live into 60s and beyond
http://www.searo.who.int/entity/health_situation_trends/data/chi/elderly-population/en/. Accessed April 2019
Pharmacokinetics
• Decreased function
– Renal
– Hepatic
• First-pass clearance
• Protein binding
• Absorption
Klotz U. Drug Metabolism Reviews. 2009, 41:2, 67-76
Polypharmacy in the Elderly
• 37% patients 75-85 years old
• Hospitals
– Five to eight meds – 41%
– One or more unnecessary – 59%
• > 50% nursing home residents
Maher Jr RL, et al. Expert Opin Drug Saf. 2014, Jan 13(1): doi:10.1517/14740338.2013.827660
Polypharmacy in the Elderly
Negative outcomes• Greater cost• Increased ADE
– Drug interactions– Non-compliance
• Reduced functional capacity– Activities of daily living (ADLs)– Nutrition
• Multiple geriatric syndromes– Cognitive impairment– Falls– Urinary incontinence
Maher Jr RL, et al. Expert Opin Drug Saf. 2014, Jan 13(1): doi:10.1517/14740338.2013.827660
Polypharmacy in the Elderly
• “Do the wrong thing for the right reason.”
– Guideline contributions
– Evidence-based medicine
• Two disease states – all it takes
– Diabetes
– Heart failure
– COPD
Adverse Drug Events
Each Year Cause
• 3.5 million physician office visits
• 1 million ER visits
• 125,000 hospital admissions
– 1 in 3 hospital adverse events
– Affect 2 million hospital stays
– Prolong hospital stay 2-5 days
https://health.gov/hcq/ade.asp
ADE in the Elderly
• Pharmacokinetics and polypharmacy unavoidable
• Steps to minimize
– Accurate records
– Balance polypharmacy
– Individualize doses
– Simple regimens
– Safe management by patients
– Therapeutic drug monitoring
– Inter-disciplinary
Brahma DK et al. J Pharmacol Pharmacother. 2013 Apr-Jun; 4(2): 91-94.
Decreasing Polypharmacy
• Education
– Providers
– Patients
• Clinical pharmacy
– Medication therapy management
– Multidisciplinary teams
– Medical homes
• Tools
Polypharmacy Screening Tools
• Beers list
• STOPP criteria
• START criteria
• Inappropriate prescribing in the elderly tool (IPET)
– Published in Canada
– 14 criteria
Beers Criteria
• Potentially Inappropriate Mediciations
• Most commonly used list– Organ system
– Therapeutic category
– Drugs
• Drug-disease
• Use with caution
• Interactions
• Renal impariment
2019 AGS Beers Criteria Update Expert Panel. J Am Geriatr Soc 00:1-21, 2019
Beers Medications
• Alpha-1 blockers• Amiodarone• Anticholinergics• Antidepressants
– Amitriptyline– Doxepin
• Antipsychotics• Antispasmodics• Barbiturates• Benzodiazepines• Benztropine• Clonidine• Digoxin
• Dipyridamole• Estrogen• Megestrol• Meperidine • Metoclopramide• Muscle relaxants• Nitrofurantoin• NSAIDs• Proton-pump inhibitors• Sedative hypnotics• Sulfonylureas • Testosterone
2019 AGS Beers Criteria Update Expert Panel. J Am Geriatr Soc 00:1-21, 2019
STOPP Criteria
• Screening Tool of Older persons’ Potentially inappropriate Prescriptions
• 65 clinical criteria
• ADEs significantly associated
Gallagher P et al. Arch Intern Med. 2011;171(11):1013-1019
START Criteria
• Screening Tool to Alert doctors to Right Treatments
• 22 clinical criteria
• Used with STOPP criteria
• Correct treatments
Barry PJ et al. Age and Ageing. 2007; 36:632-638
• Prospectively over 4 months
• 600 patients– 329 ADEs in 158 patients (26.3%)
– 66.6% contributed to admission
• STOPP criteria associated with avoidable ADE (p<0.001)
• Beers criteria not associated with reduction (p=0.11)
• Prospective study • Oct 2016 - April 2017• 234 patients ≥ 75 years• Pharmacist intervention• Primary outcomes
– Polypharmacy (≥ 5 drugs)– Hyperpolypharmacy (≥ 10 drugs)– Number of medications– Medication-related problems– STOPP/START criteria– Discharge
Results• 234 patient • Medication appropriateness
– 2469 admission medications– 2344 discharge medications
• 802 drugs discontinued (32.5%)• Improvement (p ≤ 0.001)
– Polypharmacy (-10.2%, 95% CI -15.3, -5.2)– Hyperpolypharmacy (-16.6%, 95% CI -22.3 -11.0)– Number of medications (-1.4, 95% CI -1.8, -1.0)– STOPP criteria (-19.2%, 95% CI -24.9, -13.6)– START criteria (-6.8%, 95% CI -10.1, -3.5)– Medication-related problems (-2.7, 95% CI, -2.9, -2.4)
Conclusions
• A systematic pharmacist-led intervention at hospital admission with a comprehensive geriatric assessment was associated with a decrease in polypharmacy, medication-related problems, and potentially inappropriate prescribing
Anticholinergics
• Reduced clearance
• Tolerance
• Risk
– Confusion
– Dry mouth
– Constipation
• Diphenhydramine may be used sparingly
Anticoagulants
• Warfarin– Interactions
• Antibiotics• Anticonvulsants• Amiodarone• Diet – Vitamin K• NSAIDs – Aspirin
– Monitoring– Fall/bleed risk
• Direct-oral anticoagulants– Preferred if appropriate– Still fall/bleed risk
Antidiabetic
• Goal HgA1c < 7%?
• NO GLYBURIDE!!!
• Titrate insulin carefully
• Watch for hypoglycemia
• Consider ADE
– Thiazolidinediones
– SGLT2 inhibitiors
Practical Considerations
• Avoid medications to treat effects of other medications
• Ask about OTC medications
• Review lists regularly
• “Start low and go slow”
• Use Beers list, STOPP, and START criteria
Pretorius RW et al. Am Fam Physician. 2013;87:331-336
Questions