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Polypharmacy In Elderly Dr Faisal Saleh Al Adan Hospital MB,BCh, BAO,ABIM,FRCPC Objective – Define polypharmacy and ADR – Size and burden of polypharmacyon elderly – Unique Pharmacokinetics and pharmacodynamics of the elderly body – Polypharmacy and non compliance – Medication withdrawal Objective – The prescribing cascade – Drug utilization tools – Risk Reduction strategies – Prevention of polypharmacy: CARE strategy Mrs H 78 yrs oldFemale HTN , DM , MI 15 yrs ago , arthritis, GERD,bladder irritability ,COPD Had A visit to her local clinic with Inc SOB. Prescribed lasix and sent home followed her visit with sever postural dizziness. Mrs H Mrs H O/E • BP:80/40 ,P125 regular rhythm • was severely dehydrated Chest: bilateral wheeze andfine bibasilar crackle • Jvp: low • Cardiac : normal S1-S2,Systolic murmur @ Apex • Abd: Benign • LL: PPF, no Oedema • • • • • • • • • • • • • • Medication : Aspirin 81mg QD Norvasc 5mg poqday HCTZ 25mg poQd Digoxin 0.25mg poqday Lactulose 10 cc poqhsprn constipation Gavisconesyr 3 times per day prn GERD Steroid and ventolin inhalers 3 type of Diabetic med`s Paracetamol 325mg 2-4 tablets poprn arthritis KCL 20mEq po bid Oxybutanin 5mg po TDS Simvastatin 20 mg qday Lasix 40 mg BID recently added for increasing SOB . Initial Lab: Prerenal acute failure, Normal HGB, and LFT,Cardiac work up • CXR : hyperinflated, No CHF • Cardiogenic and septic shock were ruled out. • Was treated with IV Fluid and oral Moxifloxacilin for 5 days. • Improved clinical status and renal function. Mrs H • • • • • • • • • • • • • • • Medication : Aspirin 81mg QD Norvasc 5mg poqday HCTZ 25mg poQd Digoxin 0.25mg poqday Lactulose 10 cc poqhsprn constipation Gavisconesyr 3 times per day prn GERD Steroid and ventolin inhalers 3 type of Diabetic med`s Paracetamol 325mg 2-4 tablets poprn arthritis KCL 20mEq po bid Oxybutanin 5mg po TDS Simvastatin 20 mg qday Lasix 40 mg BID recently added for increasing SOB ACE inhibitor added Polypharmacy “If medication related problems were ranked as a disease, it would be the fifth leading cause of death in the US!” Beers MH. Arch Internal Med. 2003 Definition of polypharmacy Bushardt 2008 Challenges in prescribing in elderly • Heterogeneous group • Multiple co morbidity Nearly 92% of older adults have at least one chronic condition, and 77% have at least two • Multiple prescription • Altered pharmacokinetics (drugabsorbtion,distrebution,metabolism and elimination) • Altered pharmacodynamics (physiological effect of the drugs) Growth of Geriatric around the globe %40 %35 %30 اليابان %25 إيطاليا ألمانيا %20 فرنسا المملكة المتحدة %15 الواليات المتحدة الصين %10 الدول النامية %5 0 1950 1970 1990 2010 2030 2050 DRUG USE IN THE ELDERLY 12% of the population is aged 65+ 1 2 DRUG USE IN THE ELDERLY 12% of the population is aged 65+ 30% of all prescription drug use is among those aged 65+ 1 2 1 2 DRUG USE IN THE ELDERLY 12% of the population is aged 65+ 30% of all prescription drug use is among those aged 65+ 1 2 50% of all OTC drug use is among those aged 65+ 1 2 DRUG USE IN THE ELDERLY • Average use for persons of 65 • 2 to 6 prescription drugs • 1 to 3.4 over-the-counter medicine Christilles et al journal of gerontology 1992,47,137-144 • Average American spends $955/year for pharmaceuticals • In the community population, medication-related problems cost $177.4 billion a year. Who is at risk? Kaufman 2002 Prevalence of polypharmacy • Steinman 2006 – – – – Evaluated 196 patients taking 1,582 medications 65% of patients were taking one or more inappropriate meds 64% missing beneficial meds 42% taking inappropriate meds AND were missing beneficial meds – 13% had appropriate therapy!! Prevalence of polypharmacy • Hajjar2005 – 384 frail, elderly patients’ medication regimens evaluated at hospital discharge – 44% had at least one unnecessary drug • Almost 75% of these patients were on this unneeded drug prior to hospitalization – 18% had 2 or more inappropriate meds Unique pharmacokinetics normal part of aging process • • • • Absorption Distribution Metabolism Excretion Unique pharmacokinetics normal part of aging process • • Absorption : Age-related GI and skin changes seem to be of minor clinical significance for medication usage. • • • Distribution Metabolism Excretion Unique pharmacokinetics normal part of aging process • • Absorption Distribution: – – – • • Decrease in Lean Body Mass and TBW Increased percentage Body Fat decrease plasma protein ( Albumin) Metabolism Excretion Unique pharmacokinetics normal part of aging process • Increase in volume of distribution for lipophilic drugs, such as sedatives that penetrate CNS. • Hydrophilic drugs (Ethanol,Lithium,Digoxine,&acebutalol) may have reduced VD and consequent increase in plasma concentration. • Protein Binding changes Amer J Of Thersp2007 14,488-498 Unique pharmacokinetics normal part of aging process • Absorption • Distribution • Metabolism : • some overall decline in metabolic capacity Decreased liver mass and hepatic blood flow • Excretion Unique pharmacokinetics normal part of aging process • • • • Absorption Distribution Metabolism Excretion: – Age-related decreased renal blood flow an GFR iswell-established. Pharmacodynamics and aging • “What the Drug Does to the Body” • Generally, lower drug doses are required to achieve the same effect with advancing age. • Receptor numbers, affinity, or post-receptor cellular effects may change. • Changes in homeostatic mechanisms can increase or decrease drug sensitivity. Potential hazard of Polypharmacy • Adverse drug reaction (ADR) Non adherence Increase cost /morbidity / mortality • • • • • • • • Falls/decreased mobility Cognitive loss/Delirium Dehydration Constipation Depression hip fractures loss of functional capacity, poor quality of life nursing home placement Potential hazard of Polypharmacy Adverse Drug Reaction (ADR): A response to a drug that is: noxious and Unintended ,occurs in doses normally used for the treatment, prophylaxis, or diagnosis of disease, or the modification of physiological function. (WHO ) Potential hazard of Polypharmacy • ADRsoccur as a result of Drug-drug interactions Drug-disease interactions Drug-food interactions 1. Drug side effects 2. Drug toxicity Warfarin/Aspirin Gout/Lasix lipitor and grapefruite Potential hazard of polypharmacy Estimate of as many as high as 200.000 people die of (ADR) each yr. in united state Simonson et al Drug& Aging 2005 In ambulatory elderly: • 35% of experience ADRs In nursing facilities: • 2/3 of residents experience ADRs • 1:7 require hospitalization Up to 30% of elderly hospital admissions involve ADRs Beers MH. Arch Internal Med. 2003 Potential hazard of polypharmacy The most consistent risk factor for adverse drug reactions is: • number of drugs being taken Risk rises exponentially as the number of drugs increases. • 1.2% with 1 drug • 10% with 9 drugs • 50% with 10 drugs Nonadherence Big deal? In CHF and DM patient study: 15% when the patient took 1 med 25% when taking 2-3 meds 35% when > 4 meds Hulka et al J Chronic Dis 2006 o o o Patient outcomes Poor quality of life High rate of symptoms / risk of hospitalization (Unnecessary) drug expense Non compliance / Non adherence Osterberg L, Blaschke T. NEJM. 2005; 353: 487-97. Non compliance / Non adherence • Strong Correlation with number of meds, rather than age. • The greater the number of meds, the greater the non adherence. • Adherence inversely proportional to frequency of dosing • Osterberg L, Blaschke T. NEJM. 2005; 353: 487-97. Non compliance / Non adherence • Elderly: 26-59% with non adherence • 33-69% of drug-related admissions result from non adherence (for all patients) OsterbergNJ, Blaschke T. NEJM. 2005 Factor contributing toPolypharmacy • Health care provider: • No med review with patient on regular bases/ Automatic refill • Limited time for discussion • Presume that patient expect meds • Not enough/sufficient investigation of the clinical situation • Provider unclear, complex or incomplete instruction about why and how to take the medication • Lack of knowledge of geriatric clinical pharmacology • No effort to simplify meds regimen Factor contributing toPolypharmacy Patient factor: • Under / over reporting symptoms • Underreporting meds. • Use of multiple providers/pharmacy • Use of others’ medications. • The power of inertia • Change in activities, smoking , food and fluid intake can affect action of meds. The prescribing Cascade – Part of the risk of polypharmacy may be the unintentional practice of prescribing additional drugs for the adverse effects of other drugs. BMJ 1997;315:1096-1099. The prescribing Cascade BMJ 1997;315:1096-1099. Medication Withdrawal • There is evidence for the benefit of reducing exposure to some classes of medications in older people • RCT : withdrawal of psychotropic medications in older subjects taking, on average, 5–6.5 medications each, it was found that there was a 76% reduction in falls over 44 weeks Campbell et al , J. Am. Geriatr. Soc. (1999) 47 850–853 Medication Withdrawal Another study of 333 elderly (70–84 years) hypertensive patients found that antihypertensive therapy could be withdrawn for up to 5 years in 20% of subjects. During the state of 'no treatment’ subjects had lower total mortality risk than the matched treated group Ekbom et al J. Intern. Med. (1994) 235 581–588. Drug utilization review tools • Beers’ List • Medication Appropriateness Index • STOPP – Screening Tool of Older Persons’ potentially inappropriate Prescriptions • Hyperpharmacotherapy Assessment Tool • START – Screening Tool to Alert doctors to the Right Treatment • Assessment of Underutilization Index • Geriatric Evaluation Beers Drug Criteria • Originally compiled by Dr. Mark Beers in 1991for nursing homes • Most recently updated in 2012 • a panel of 13 independent experts in geriatrics care and pharmacology. Arch Intern Med 2003;163:2716-2724. Beers’ List • Lists of medication considered potentially inappropriate medications in elderly patients 1. Drugs to avoid in elderly 2. Drugs to avoid in elderly with certain disease states 3. Drugs to be used with caution in the elderly • a guideline only Fick 2012 Beers Drug Criteria • Medication that should be avoided or to be used with specific dose and duration Beer`s Drug Criteria • Medication to be avoided with concomitant disease Beers Drug Criteria potentially inappropriate medication for certain diagnosis and condition • Medication to be avoided with concomitant disease MEASURES TO REDUCE MEDICATION- RELATED PROBLEMS IN ELDERLY PATIENTS • Health systems design • CARE strategy Federal Study of Adherence to Medications in the Elderly (FAME) • Prospective randomized trial • June 2004 and August 2006 • Addresses medication adherence in patients aged ≥ 65 years • ≥ 4 chronic medications • Living independently • Men & Women Federal Study of Adherence to Medications in the Elderly (FAME) • Patient education • Regular follow-up • Customized blister packs for administration of blood pressure and lipid-lowering regimens Result: • Increased adherence over 6 months from 60% to ≥96% • Resulted in reductions of SBP and LDL-C The short term effect of interdisciplinary medication review on function and cost in elderly patient • RCT N=140 • an average of 1.5 drugs reduction in intervention group. • No differences in functioning were observed between groups. • Intervention subjects saved an average $26.92 per month medication costs; control subjects saved $6.75 per month (P<.006). JAGS. 2004;52:93-98. The impact of prescribing safety alert for elderly person in an electronic medical record • The objective of this study was to examine the effects of computerized provider order entry with clinical decision support in reducing the use of potentially contraindicated agents in elderly persons. • 39-month period, HMO in the north west • The intervention was computerized warning alerts that preferred alternative to Benzo`s& TCA in elderly persons. Arch Intern Med 2006;166:1098-1104. The impact of prescribing safety alert for elderly person in an electronic medical record • Alert : Arch Intern Med 2006;166:1098-1104. The impact of prescribing safety alert for elderly person in an electronic medical record • Result: Arch Intern Med 2006;166:1098-1104. Effectiveness of telephone counseling by a pharmacist in reducing mortality in patient receivingPolypharmacy(RCT) Primary outcome : mortality Intervention: pharmacist call 10-15 min NNT=16 BMJ 2006 ;333: 522-527 CARE : strategy to Avoid polypharmacy Caution and Compliance • Understand side effect profiles • Identify risk factors for an ADR • Consider a risk to benefit ratio • Keep dosing simple- QD or BID • Ask about compliance! • Carful written medication instructions • Discourage pill-sharing • Tie to scheduled daily activities, meals, sleep/wake CARE : strategy to Avoid polypharmacy • Review Regimen Regularly • Avoid automatic refills • Look for other sources of medications- OTC/herbal/Vit`s • Caution with multiple providers • Don’t use medications to treat side effects of other meds • What can you discontinue or substitute for safer med? CARE : strategy to Avoid polypharmacy • • • • • • Educate Talk to your patient about potential ADRs Warn them for potential side effects Educate the family and caregiver Ask pharmacist for help identifying interactions Assist your patient in making and updating a medication list- personal medical record! Take Home Messege • Polypharmacy is common and important • Can present non specifically. • There are tools like the Medication Appropriateness Index and Beers criteria to guide prescribing in the elderly. • Beware of the prescribing cascade. • Electronic Alert on medical record and pharmacist intervention help reducing polypharmacy. Thank you Questions ….???