Download Aging Q3 Med Use and Safety Detailing Sheet2 - 86 KB

Medication Use and Safety in the Elderly
Americans aged 65 and over consumer 30% of all prescriptions and 40% of all OTC medications. They are at higher risk
for adverse drug events, drug-drug interactions, and therapeutic duplication.
Medication Use and Patient Safety
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Challenges of Prescribing for Older Adults
• Multiple chronic medical problems
• Multiple medications and prescribers
• Different metabolism and responses
• Adherence and cost
• Supplements, herbals, and OTC drugs
Physiologic Changes Associated with Normal Aging
• Less Water
• More Fat
• Less muscle mass
• Slowed hepatic metabolism
• Decreased renal excretion
• Decreased responsiveness and sensitivity of the
baroreceptor reflex
Dangers of Multiple Medications:
“Polypharmacy”
• Adverse effects (side effects)
• Drug-drug interactions
• Duplication of drug therapy
• Poor adherence
• Cost
• Decreased quality of life
Adverse Drug Events (ADEs)
 Adverse symptoms
 Adverse patient outcomes
o Doctor visits or hospitalizations
o Falls
o Functional decline
o Changes in cognition (delirium)
o Death
 ↑ number of medications = ↑ risk of ADEs (even
if all the meds are “clinically indicated”)
References:
1. Budnitz, DS, et al. (2006) “National Surveillance of Emergency
Department Visits for Outpatient Adverse Drug Events.” JAMA 296 (15)
2. Beers, J Am Geriatr Soc. 2012
Funded by DW Reynolds
Foundation
The most common cause of adverse medication events
that result in emergency department use in the elderly:
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Hypoglycemic agents: Decreased renal clearance leads to
drug accumulation and hypoglycemic episodes so ask
patients about signs and symptoms of hypoglycemia.
Digoxin (Lanoxin): Accumulates in the elderly
population can lead to toxicity (nausea, anorexia,
vomiting, and rarely yellow vision) Digoxin should be
dosed at ≤ 0.125mg/day unless treating atrial arrhythmias.
Ask patients about nausea, anorexia, vomiting and, if
present, check a digoxin level.
Warfarin (Coumadin): Make sure all patients on
warfarin are enrolled in pharmaco- therapy clinic.
Amiodarone (Cordarone): A major CYP-3A4 inhibitor
resulting in multiple drug-drug interactions. Dose
reductions are necessary for many medications
including: Warfarin- 35-65% dose reduction, Digoxin50% dose reduction and Simvastatin- maximum dose of
20 mg.
NSAIDs: Increase incidence of GI bleed, acute renal
failure and HTN in the elderly with risk factors for GI
bleed: age >75 years, previous GI bleed, concomitant use
of warfarin, long term glucocorticoid use, history of PUD.
Risk factors warrant therapy with misoprostol or PPI.
Herbal products: Not regulated by FDA, many have the
potential to be dangerous. Rarely considered by patients
as medications and their use is often not discussed with a
physician.
Garlic and Gingko Biloba: Increase bleeding time
St John’s Wort: Increased clearance of medications
metabolized through CYP3A4
Chromium, Gingko Biloba, Nettle: Hypoglycemia
Know what your patients are taking and evaluate for
potential harm.
Other agents commonly associated with ED visits and
hospitalizations in the elderly: 1
Opioid and non-opioid analagesics
Antibiotics
ACE Inhibitors/ARBs
Antihistamines
Decongestants/ remedies
AVOID THESE MEDICATIONS IN OLDER PATIENTS WHENEVER POSSIBLE!2
MEDICATIONS
Pain Relievers
Meperidine
(Demerol®)
Muscle Relaxants
Carisoprodol (Soma®), cyclobenzapine (Flexeril®),
metaxalone (Skelaxin®)
Antidepressants
Tricyclic Antidepressants (TCAs): ie, amitriptyline (Elavil®)
Fluoxetine (Prozac®)
Sleeping Pills and Antianxiety Medications
Benzodiazepines: ie,
Alprazolam (Xanax®), lorazepam (Ativan®), zolpidem
(Ambien®)
Heart Medications
Digoxin (Lanoxin®) doses above 0.125 mg
Dipyridamole (Persantine®)
Methyldopa (Aldomet®)
Amiodarone (Cordarone®)
Diabetes Medications
Glipizide (Glucotrol®), glyburide (Diabeta®), glimiperide
(Amaryl®), insulin
Stomach and Intestinal Medications
Dicyclomine (Bentyl®), hyoscyamine (Levsin®),
promethazine (Phenergan®)
Antihistamines
Chlorpheniramine (Chlor-Trimeton®), diphenhydramine
(Benadryl®), hydroxyzine (Vistaril®, Atarax®),
cyproheptadine (Periactin®)
Constipation
Calcium channel blockers
REASON THAT USE IS A PROBLEM
Not effective oral pain reliever, many disadvantages compared to
other narcotics. AVOID IN ELDERLY.
Poorly tolerated due to severe anticholinergic SE.
Can cause sedation, weakness, BP changes, several anticholinergic
SE.
Long half-life leading to prolonged CNS stimulation, sleep
disturbance, anxiety.
Increased sensitivity in the elderly. Should use lowest dose possible
if used.
Decreased renal clearance may lead to toxicity; nausea, anorexia.
May cause orthostatic hypotension
May cause bradycardia and exacerbate depression in the elderly.
Increased risk of QT prolongation and Torsades
Decreased renal clearance may result in prolonged hypoglycemia.
Monitor closely.
Can cause sedation, weakness, BP changes, several anticholinergic
SE.
Can cause sedation, weakness, BP changes, several anticholinergic
SE.
Avoid if possible. Safer alternatives are available for cough and
cold.
Worsen constipation
Cognitive impairment
Anticholinergics, antispasmodics, muscle relaxants
Parkinson’s disease
Metoclopramide (Reglan®)
Antipsychotics
Bladder outflow obstruction
Anticholinergics, antihistamines, antispasmodics
Syncope/Falls
Tricyclic antidepressants
Benzodiazepines
Concern due to CNS-altering effects
Due to cholinergice/antidopaminergic activity
Increased urinary retention
Increased risk for falls; ataxia; impaired psychomotor function