Demetra Antimisiaris, PharmD Dept. Family Medicine and Geriatrics

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A recent study of 1,601 patients over the age of 65 years

use a total of 11,180 prescribed drugs =7 drug per person

24 combinations per person (I calculate 30 but the article said 24)

46% of patients with 1 or more known drug–drug interactions identified

The number of combinations leading to subtherapeutic effects was approximately equal to the number leading to potential adverse drug reactions

-K. Bjorkman, J. Fastbom, I.K. Schmidt and C.B. Bernsten, Drug-drug interactions in the elderly, Ann Pharmacother 36 (2002), pp. 1675–1681. ©

Source: Novartis, January, 2008.

Kentucky ranks 3nd in the nation in prescriptions per person in 2008

11.112

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Cardiovascular diseases (all types): $171.1 billion Cancer (all types): $104 billion

Alzheimer’s Disease: $100 billion

Diabetes: $92 billion

Medication-related problems: $88.2 billion

Osteoarthritis (all musculoskeletal conditions): $64.8 billion Stroke: $30 billion

Osteoporosis: $14 billion

Parkinson’s Disease: $5.6 billion *1995 dollars Sources: Alzheimer’s Disease Foundation and Referral (ADEAR) Center; National Cancer Institute; American Diabetes Association; Arthritis Foundation; National Center for Health Statistics, 1994; National Parkinson Foundation; National Stroke Foundation

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2,216,000 hospitalized patients/year experience serious ADR

106,000/year die from an ADR ADRs rank as 4-6th leading cause of death (95% CI)

Ranking after heart disease, cancer, stroke, (pulmonary disease and accidents)

▪ Ahead of diabetes and pneumonia

-Lazarou J, Pomeranz BH, Corey PN. Incidence of adverse drug reactions in hospitalized patients. JAMA 1998;279:1200-5. -Miller RR. Boston collaborative drug surveillance program. Arch Intern Med 1974;134:219-24. -Pirmohamed M, James S, Meakin S, et al. Adverse drug reactions as cause of admission to hospital: prospective analysis of 18,820 patients. BMJ 2004;329:15-19

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“All substances are poisons;

there is none which is not a

poison.

The right dose differentiates a

poison from a remedy.”

Paracelsus (1493-1541) Occupation alchemist, physician,

astrologer, and general occultist

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1840’s ether anesthetic dosing. 1920’s one compartment kinetics. 1950’s distribution, elimination, accumulation, dosing schedules. 1960’s acceleration of PK understanding: leading to better titration of dose Pharamacogenetics Physiology of aging: health ABC study ©

As a comparison, in another

study of NH residents, drug

levels in excess of 0.83 ng/ml of

atropine equivalents were

shown to have a significant

effect on the capacity for self

care in demented elders.

*the levels are likely to

underestimate antimuscurinic

effects since potentially active

metabolites of each parent

compound were not assayed.

Tune L, Carr S, Hoag E, Cooper B.A. Anticholinergic Effects of Drugs Commonly Prescribed for the Elderly: Potential Means for Assessing Risk of Delirium. Am J Of Psych Oct 1992; 149, 10;1393-1394. ©

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Increasing anticholinergic and sedative burden was associated with poorer physical and poorer cognitive function

Each additional unit of drug burden had a negative effect on physical function (health ABC score)

▪ similar to that of 3 additional physical comorbidities and a greater effect than anxiety, depression or cognitive impairment.

Each additional unit of drug burden had a negative effect on cognitive task performance (DSST score)

▪ Similar to that of 4 additional physical comorbidities and half the effect of anxiety, depression or cognitive impairment.

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MMSE Tune et al

AChE + no anticholinergics

lost 3.08 pts/2 yrs

Ache + 1 or > anticholinergics

lost 7.0 pts/2 years

Natural Progression=3.5

pts over 2 years ©

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Neurodegenerative dz and/or dementias other than AD. frequent smoker and/or frequent consumer of caffeine. Hypothyroidism or folic acid deficiency or B12 deficiency. Hx or presence of stroke and/or epilepsy.

Hx of > 1 MI within 5 years.

Tx w potential memory enhancing drugs within 2 weeks before screening.

Regular thx w other psychotropic meds w/i 2 wks, including

antidepressants.

Thx w NMDA receptor antagonists, cholinomimetic drugs, AChEIs, cholinergic agonists, cholinergic precursor loadings such as lecithin, antichol. Meds or other choinergic agents w/I 2 wks of screening.

Severe hypotension or hypertension requiring thx.

Uncontrolled afib and AV block higher than 1st degree.

Thx w an investigational drug or device w/i 3 months before screening.

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CR, an 84 year old female PMH

CHF, CRF, DM, CAD, HTN, GERD, s/p CVA, MCI, Depression

Medications Metformin, Actos®, Triamterene/HCTZ, Liptor®, Metoprolol XL, Lisinopril, Sertraline, Ambien CR®, Plavix®, Ginko, Vit C, Calcium, Omeprazole

•Can we predict how this

mix of medications will

effect this individual

patient?

•Is there any evidence or

literature offering

definitive guidance on

this cocktail of drugs?

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C. A. Bond, PharmD, FASHP, FCCP; Cynthia L. Raehl, PharmD, FASHP, FCCP. Adverse Drug Reactions in United States Hospitals; Pharmacotherapy. 2006;26(5):601-608

The more drugs the more risk of ADR

The more diagnosis the more risk of ADR

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Garfinkle, D et al. The War against Polypharmacy: A New Cost-Effective Geriatric-Palliative Approach for Improving Drug Therapy in Disabled Elderly People. IMAJ 2007; 9: 430-434

Average of 2.8 drugs discontinued per patient

Overall rate of DC failure was 18% of patients and 10% of all drugs 1 year mortality rate 45% in control and 21% in study group Annual referral rate to acute care was 30% in control group and 11.8% in study group

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The elderly are more susceptible to toxicity The 4-7 year rule The evidence for use of medications is tested in

a different population…almost ALWAYS Protection against end organ damage-there

may not be any organs to prevent damage of

Furthermore the prevention therapy may actually worsen overall quality of life.

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NSAIDS Any highly protein bound drugs: (anticonvulsants,

warfarin) Antihypertensives

Guidelines for HTN management in patients over 80 HYVET study?

Bisphosphonates Fluoroquinolones Antidepressants Ginko, Genseng

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Proton Pump Inhibitors are widely used

not always with a clear indication.

Approximately 30% of patients receiving PPI with no documented indication

George MD, Appropriate Proton Pump Inhibitor Use Among Older Adults: A Retrospective Chart Review The American Journal of Geriatric Pharmacotherapy Volume 6, Issue 5, December 2008, Pages 249-254

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71-84% of patients in general medicine wards are receiving some form of AST without an appropriate indication.

Anticoagulant therapy has been identified

as a risk factor for GI bleed: prophylaxis with AST not been found to lower risk.

-George MD, Appropriate Proton Pump Inhibitor Use Among Older Adults: A Retrospective Chart Review The American Journal of Geriatric Pharmacotherapy Volume 6, Issue 5, December 2008, Pages 249-254 -Qadeer MA, Richter JE, Brotman DJ. Hospital-acquired gastrointestinal bleeding outside the critical care unit: risk factors, role of acid suppression, and endoscopy findings. J Hosp Med. 2006; 1:13-20. -ASHP therapeutic guidelines on stress ulcer prophylaxis. Am J Health-Syst Pharm. 1999; 56:347-79. -Nardino RJ, Vender RJ, Herbert PN. Overuse of acid-suppressive therapy in hospitalized patients. Am J Gastroenterol. 2000; 95:3118-22. -Foxworth J. Stress ulcer prophylaxis in intensive care patients: an evidence-practice mismatch? Crit Care Nurs Q. 2000; 22:39-46. - Parente F, Cucino C, Gallus S et al. Hospital use of acid-suppressive medications and its fall-out on prescribing in general practice: a 1-month survey. Aliment Pharmacother. 2003; 17:1503-6.

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PPI use for active GI bleeds

Note: pH > 6 necessary for platelet aggregation

Give high dose PPI in active GI bleed (eg Omeprazole 80mg bolus followed by 8mg/hr for 72 hrs after

endoscopic therapy)

Patients should be tested for H.Pylori and receive eradication therapy if H.Pylori present*

more effective than antisecretory non-erdication therapy in preventing recurrent bleeding

-Clinical Guidelines Consensus Recommendations for Nonvariceal Upper Gastrointestinal Bleeding: 18 November 2003 Annals of Internal Medicine Volume 139 • Number 10 -Helicobacter pylori eradication therapy vs. antisecretory non-eradication therapy (with or without long-term maintenance antisecretory therapy) for the prevention of recurrent bleeding from peptic ulcer: Cochrane Library ISSN 1464-780X ©

Upper GI Bleed is a disease of the elderly Median age is 70 years old with 20-30 fold increase from 3rd-9th decades of life

Men more than women

NSAID use in >50% Outcomes: importance of co morbidities

After control of active PUD bleed with

EGD Rx and PPI

7 day re bleed rate driven by other medical conditions ▪ 2.5% in healthy patients

▪ 25% with one major co morbidity (ICU, vascular insufficiency, Rheumatic disease, COPD, gastric cancer)

▪ > 50% with > 2

Clinical Guidelines Consensus Recommendations for Nonvariceal Upper Gastrointestinal Bleeding: 18 November 2003 Annals of Internal Medicine Volume 139 • Number 10

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H.Pylori eradication increases ulcer healing & reduces recurrence

Triple therapy: 7 (14) days twice daily

full dose PPI +

Amoxicillin +

Clarithromycin/Metronidazole

Effective in 80-85%

Helicobacter pylori eradication therapy vs. antisecretory non-eradication therapy (with or without long-term maintenance antisecretory therapy) for the prevention of recurrent bleeding from peptic ulcer: Cochrane Library ISSN 1464-780X

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FDA Recommendations

Medication Dosage Duration of Therapy for GERD

Esomeprazole (Nexium®) 20mg daily 4 weeks

Lansoprazole (Prevacid®) 15mg daily 8 weeks

Rabeprazole (Aciphex®) 20mg daily 4-8 weeks

Pantoprazole (Protonix®) 20mg daily Up to 8 weeks

Sebastian SS, Kernan N, Qasim A et al. Appropriateness of gastric antisecretory therapy in hospital practice. Ir J Med Sci. 2003; 172:115-7. Naunton M, Peterson GM, Bleasel MD. Overuse of proton pump inhibitors. J Clin Pharm Ther. 2000; 25:333-40. Walker NM, McDonald J. An evaluation of the use of proton pump inhibitors. Pharm World Sci. 2001; 23:116-7. Qadeer MA, Richter JE, Brotman DJ. Hospital-acquired gastrointestinal bleeding outside the critical care unit: risk factors, role of acid suppression, and endoscopy findings. J Hosp Med. 2006; 1:13-20 ©

PPIs (or any AST) can alter drug and nutrient absorption

Possible B12 and Iron absorption alteration

Ca++ absorption

Weak bases requiring acid for absorption ▪ Griseofulvin, ketoconazole, itraconazole, cefpodoxime for example

HIV medications very sensitive to gastric pH

Any Enteric Coated or delayed release drug may have altered kinetics ©

Chronic use of PPIs: associated with some serious accusations.

Increased risk of community acquired C.Diff infection and other GI infections

Esomeprazole can cross the BBB and has been associated with central fever and severe myalgia

Gastric Suppression and increased risk of CAP

Long-Term PPI use and risk of hip fracture ▪ Ca absorption

▪ In addition to the secretory canaliculi of the gastric parietal cells, the osteoclastic resorption vacuole may be the only other place in which proton pump inhibition by PPIs is known to take place

-Detsky ME, Juurlink DN. Does gastric acid suppression increase the risk of community-acquired pneumonia? Can Med Assoc J 2005;172: 331 -Dial S, Delaney C, Schneider V, et al. Proton pump inhibitor use and risk of community-acquired Clostridium difficile–associated disease defined by prescription for oral vancomycin therapy. Can Med Assoc J 2006;175:745-8. -Dial S, Delaney JA, Barkun AN et al. Use of gastric acid-suppressive agents and the risk of community-acquired Clostridium difficile-associated disease. JAMA. 2005; 294:2989-95 -Yang Y, Lewis JD, Epstein S, et al. Long-term proton pump inhibitor therapy and risk of hip fracture. JAMA 2006;296:2947-53.

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Alternate or adjunct therapy for GERD

Corley, DA, MD PhD et al. Barrett’s Esophagus and Medications that Relax the Lower Esophageal Sphincter. The Am Journal of Gastroenterology Vol 101, 5, 987-944, 2006

3 meals per day

Avoid eating 3 hours before

bedtime

Avoid: fatty foods, milk chocolate, mints, caffeine,

carbonated drinks, citrus fruits, pepper seasoning, tomato

based foods, fried foods

Nicotine

Avoid tight clothes and

obesity

Medications: ca++blockers, anticholinergics, nitrates,

benzodiazepines, “asthma meds and theophylline”

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PPIs are quite active buggers at CYP enzyme pathways

-Juurlink DN, Gomes T, Ko D, et al. A population-based study of the drug interaction between proton pump inhibitors and clopidogrel. CMAJ 2009;180(7). DOI:10.1503/cmaj.082001 -Aubert RE, Epstein RS, Teagarden JR et al. Abstract 3998: Proton pump inhibitors effect on clopidogrel effectiveness: the clopidogrel medco outcomes study. Circulation. 2008;118:S815 -Gilard M, Arnaud B, Cornily JC, et al. Influence of omeprazole on the antiplatelet action of clopidogrel associated with aspirin. J Am Coll Cardiol 2008;51:256-60. O'Donoghue ML, et al. Pharmacodynamic effect and clinical efficacy of clopidogrel and prasugrel with or without a proton-pump inhibitor: An analysis of two randomized trials. (TRITON-TIMI 38 & PRINCIPLE-TIMI 44) Lancet 2009; DOI:10.1016/S0140-6736(09)61525-7. -Dunn SP, Macaulay TE, Brennan DM et al. Abstract 3999 :Baseline proton pump inhibitors use is associated with increased cardiovascular events with and without the use of clopidogrel in the CREDO trial. Cirsulation 2008; 118:s_815

Study Conclusions

CMAJ: A population-based oveservational

study of the drug interaction between proton pump inhibitors and clopidogrel

Increased risk of recurrent MI w/I 90 days, pantoprozole not associated w increased risk

Cautionary

Medco Outcomes Stent patients taking PPIs with clopidogrel showed a 32.5% incidence of a major CV event within one year vs. 21.2% of patients not taking PPIs

Cautionary

Aubert RE et al Among angioplasty patients on ASA and clopidogrel, omeprazole significantly reduced the clopidogrel effect

Cautionary

TRITON-TIMI 33% of patients with clopidogrel or prasugrel found no association between PPI use and primary endpoint (CV death, MI or stroke)

No difference

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Most likely to interact w Plavix®

3A4 Interactions

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-Thomas MC. Diuretics, ACE inhibitors and NSAIDs – the triple whammy. Med J Aust 2000; 172: 184–5. - K. K. Loboz & G. M. Shenfield Drug combinations and impaired renal function – the ‘triple whammy’ Br J Clin Pharmacol 59 :2 239–243

Glomerular filtration rate

Glomerular blood flow

Blood Volume and Cardiac Output

Prostaglandin mediated afferent

arteriolar vasodilation

Angiotensin II mediated efferent arteriolar vasoconstriction

DiureticsCHF

NSAIDS, ASA

ACEs & ARBs

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- K. K. Loboz & G. M. Shenfield Drug combinations and impaired renal function – the ‘triple whammy’ Br J Clin Pharmacol 59 :2 239–243

Mean age 72 hospitalized patients upon admission (n=300) •An association with heart failure or any diagnosis other than renal failure was not sustained on multivariate analysis. •Strength of association found between renal function and number of target drugs suggests a true relationship

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ACEs and ARBs CrCl<10ml/min dosing not defined

“caution advised”

Watch K levels

Contraindicated in bilateral RAS NSAIDS

Don’t use in elders anyway

Monitor your patient’s use of OTCs Diuretics

Reserve for CHF management not HTN

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Statins and cognitive function-sleep

Effect on cholesterol synthesis

Patients with vascular disease and elderly

Decrease CQ10 levels

Lipophilicity (thus ability to cross BBB)

▪ Pravastatin, fluvastatin preferable

▪ Simvastatin, lovastatin, atorvastatin higher lipophilicity and more cyp enzyme interactions

George MD, Appropriate Proton Pump Inhibitor Use Among Older Adults: A Retrospective Chart Review The American Journal of Geriatric Pharmacotherapy Volume 6, Issue 5, December 2008, Pages 249-254 -Muldoon MF, Ryan CM, Sereika SM, et al. Randomized trial of the effects of simvastatin on cognitive functioning in hypercholesterolemic adults. Am J Med 2004;117:823-9. -Muldoon M, Barger S, Ryan C, et al. Effects of lovastatin on cognitive function and psychological well-being. Am J Med 2000;108:538-47. -Stewart R, Sharples K, North F, et al. Long-term assessment of psychological well-being in a randomized placebo-controlled trial of cholesterol reduction with pravastatin. Arch Intern Med 2000;160:3144-52. ©

Consider Holding the Statin and finding out! Up to six weeks does not appear to increase the risk of

cardiac events in stable patients

Check your elderly patient’s Lipid Profile

You’d be surprised!

Monitor for muscle pain

Is just old age or might it be the statin?

-McGowan MP. There is no evidence for an increase in acute coronary syndromes after short term abrupt discontinuation of statins in stable cardiac patients. Circulation 2004;110:2333–5. ©

Use of statins in the over 80 crowd?

JUPITER the age of elders was only 60-71 yrs

Statins exert a class effect in CHF which is protective, used at relatively low dose. Favorable effect largely independent of drug dose. Median Age 66 yrs

4S, CARE, LIPID, HPS, PLAC I, REGRESS, FLARE, LIPS, PROSPER max age 82yrs, mean age 67-75yrs

-Rinfret, S, MD et al. Class Effects of Statins in Elderly Patients with Congestive Heart Failure: A poluation-Based Analysis. American Heart Journal 2008; 155 (2): 316-323. -Alfilalo, J, MD et al. Statins for Secondary Prevention in Elderly Patients A Heirarchical Bayesian Meta-Analysis. J Am Coll Cardiol, 2008;51:37-45 Ridker PM, Danielson E., Fonseca FA., et al. Rosuvastatin to Prevent Vascular Events in Men and Women with Elevated C-Reactive Protein. n engl j med 359;21 www.nejm.org november 20, 2008 2195-2207.

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Mrs. E, an 80 y.o. woman living in ALF presents to ULH with MS changes

Two weeks ago housekeeper noted wet toilet paper everywhere, kitchen sink w jar of urine beside it. Found patient throwing objects at her own reflection in the mirror and demanded to get the other person out of the room. Increasing verbal abuse, hit the nurse, refuse to bathe CT showed generalized atrophy RPR=(-), HA1C=6.4, fasting bg=95mg/dl PE revealed LLQ tenderness, post void residual volume 792mls, urine culture was – for bacteria dry skin and eyes bp=142-155/87-98

acutely delirious acute renal failure ©

PMH: depression, GERD, hyperlipidemia, HTN, Alzheimer-type dementia (moderate to severe), OA, and DM

Med List:

amitriptyline, atorvastatin, olmesartan with hydrochlorothiazide, fexofenadine, lisinopril, meloxicam, celecoxib, memantine, oxybutinin extended release, and lansoprazole

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Admission: She was agitated and delirious, thus all medications were stopped except memantine, and esmoperazole plus trazadone was added for sleep.

Day 3 of hospital stay

Attentive but disoriented, no longer aggressive

Required intermittent cath for urinary retention

Cooperative, nursing encouraged toileting

Day 4

blood pressure normalized, without treatment 125/84 & SCr normalized

Discharged to SNF unit of her ALF on three medications, plus prn APAP for pain, with normal bp, normal bg and Ha1c, pleasantly demented, with improving bladder residual

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Medication Indication concern

Amytriptyline Depression Strange choice

Olmesartan & HCTZ HTN Locked into HCTZ due to combo, HCTZ markedly decreases in efficacy with age, hyponatremia, hypokalemia, elevated glucose a risk also.

Atorvastatin hyperlipidemia Highly lipophilic, strong cyp interactions

Fexofenadine -No clear indication -Can be anticholinergic & needs adjustment in dose at CrCl<80ml/min

Lisinopril HTN -ACE and ARB and diuretic? -Etiology of HTN turned out to be NSAID use

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Medication Indication concern

Memantine 10 BID Alzheimer’s dementia Adjust dose in CrCl<30ml/min

Oxybutinine ER -No clear indication documented -Exercise caution in demented patients when prescribing anticholinergic bladder medications

Lansoprazole GERD 2C19 -amytriptyline, 3A4-meloxicam, atorvastatin, olmesartan and both – celecoxib

Meloxicam OA Cardovascular and bp risk, renal impairer, GI upsetter

Celecoxib OA ditto ©

Drugs for which there’s no clear indication

Drug with no measurable efficacy

Drug for which there’s only modest evidence of utility

Drugs which are solely to modify disease process in a frail elder or the

oldest old

Drug added to an already heavy drug burden in any single patient Too many drugs started at once

▪ Or abrupt discontinuation of multiple drugs- unless the patient is delirious, in ARF, or some other grave condition.

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January 12, 2010 87 year old female presented w 2 week h/o

dyspnea on exertion, nochturnal dyspnea and 2-pillow orthopnea. Denies chest pain, but having a non productive cough. Does complain of some palpitation. Has not seen primary MD for 2 years

NKDA Current Medications: none

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PHYSICAL EXAMINATION: General: She is awake, alert, oriented, and hard of hearing. Patient is in mild respiratory distress. Neck: Positive jugular venous distention. Chest and Lungs: Patient has diffuse

expiratory wheezing and crackles especially on the bases. Heart: Irregular rate and rhythm, tachycardic. No murmur, rubs, or gallops heard. Abdomen: Normoactive bowel sounds. Soft, nontender, nondistended. Extremities: No cyanosis, clubbing, or edema. Neurologic: Grossly nonfocal. LABORATORY DATA: Patient had a chest x-ray, which showed cardiomegaly with

mild bibasilar atelectasis and mild blunting of the costophrenic angles. Positive effusion.

Patient also had an EKG, which showed atrial fibrillation with rapid ventricular

response at the rate of 135. Her CBC is normal. INR is 1.2. glucose is 140, BUN 21, sodium 124, potassium 4.4, chloride 91, CO2 of 22, creatinine 1.7, calcium 9.1. CK is 308, CK-MB 10.8, myoglobin

185. The last 3 were all elevated. The troponin, however, is normal.

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Impression and Plan Afib with RVR-started on Cardizem drip Possible non-ST elevation MI: cardiology consulted,

continue to monitor cardiac enzymes Started on Lovenox 1 mg/kg q 12 hours Checking fasting lipids, and TSH Reactive airway diesase: IV Solumedrol® and

Levaquin ® 500mg q24, nebulization therapy and O2 Possible acute CHF exacerbation of new onset

monitor for IV furosemide Hyperglycemia: insulin ss checking HA1c

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January 19, 2010 CHF, RVR, possible pneumonia

Anticoagulated, cardioverted, rate controlled

and diuresed with some improvement

Diagnosis at discharge: Afib, s/p cardioversion in NSR, CKD stable,& Weakness

“Discharged to NH for PT, patient stable with maximum hospital benefit for cardiac condition”

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Medications at January discharge to NH: Finish prednisone taper

ASA 81mg

Multaq 400mg BID

Ranitidine 150mg BID

Crestor 20mg QD

Warfarin 3 mg QD (after loading doses of 5mg daily till therapeutic INR)

Nitrostat SL prn.

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In hospital 5 days with afib thus, anticoagulation therapy indicated (even in an 87 year old)

initially given Lovenox 30mg q 12 when should have been q24 with her renal function

Coumadin® 5mg QD loading dose (that brings us to day 4 of 5, and discharged on 3mg daily

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Returns to the emergency department 2/11/2010

Transferred from NH for increasing weakness with diffuse ecchymotic rash (mainly upper and lower extremities)

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The patient initially did well at NH for the 1st week or 2.

Subsequently, started to experience some dyspnea and feeling tired. In the last 10 days or so, she has developed severe diffuse erythematous rash with some petechial aspects. Approximately 3 to 4 days ago, underwent a skin biopsy and the results of this are pending.

At some point during her nursing home stay near the beginning of this month, high INR was noted. The patient received 2 doses of vitamin K IM and her Coumadin has been held since that time. Despite these measures, she has continued to deteriorate and was brought into the emergency room today with diffuse rash, hypotension, and bradycardia.

Previous to January, she was not on any medications. She has no history of diabetes, hypertension, and no history of smoking in the past.

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• Hypotensive with sinus bradycardia, given DA, and atropine and transferred to ICU w ARF and intubated

Prognosis. Patient in severe shock with multi-

organ failure, including cardiovascular, renal, liver, lactate, and coagulation system. Therefore, prognosis is unfortunately extremely poor.

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EXAMINATION: General: Sedated.

Vital Signs: Temperature 95.3; pulse 65; blood pressure 101/27, on dopamine. Intubated, mechanically

ventilated. Tidal volume 500, rate of 14, FiO2 of 100%, PEEP of 5, peak pressure 22.

Neck: No JVD. Lungs: Clear to auscultation anteriorly.

Heart: Irregularly irregular. Bradycardic.

Abdomen: Soft, nontender.

Extremities: Lower extremities, severe upper and lower extremity ecchymotic rash with 2+ pitting edema.

LABORATORY DATA: Sodium 134; potassium 5.7; chloride 96; bicarb 15; BUN 105 from 43 on January 18,

2010; creatinine 5.6 from 1.7 on January 18, 2010.

Anion gap is 23. Lactate is 64.

AST 2071, ALT 2025, alk phos 349, total bilirubin 4.20. CK 261, myoglobin 1051, troponin is negative. D-dimer has increased. Fibrinogen decreased.

INR is 40 and PTT is 47. Platelets 88, hemoglobin 11, hematocrit 33, and white count is 8.8 from 6.2 on January 18, A chest x-ray showed congestive heart failure with left lower lobe atelectasis/effusion. No obvious infiltrates.

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Garfinkle, D et al. The War against Polypharmacy: A New Cost-Effective Geriatric-Palliative Approach for Improving Drug Therapy in Disabled Elderly People. IMAJ 2007; 9: 430-434 ©

When an elderly patient presents with a status change, unless proven otherwise, it should be assumed to be a medication related problem.

Jerry Gurwitz MD, director of Meyers Primary Care Institute, @ UMASS: nationally recognized expert on the

safe use of medications in the elderly.

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