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Medication Use in the Older Adult

Kim Shehan, Pharm D

Methodist Hospital, Clinical Care Pharmacist

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Objectives

• Review physiologic changes in the older adult and medication considerations

• Describe medication management in the older adult

• Discuss the concept, “Start low, Go slow, Always follow”

• Summarize the 2019 American Geriatric Society Beers Criteria: Potentially Inappropriate Medication Use in the Older Adult

• Use the Age-Friendly Health System to evaluate appropriate mediation use

• Recognize and de-prescribe inappropriate medications

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America is Aging

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By 2030, the US population aged 65-74 will nearly

double

1 in 5people will be

over 65 in 2030

1 in 8people will be 75 and over

in 2040

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• Over 10,000 prescription medications and 100,000 over-the-counter (OTC) medications are available

• Older adults currently comprise 13% of the U.S. population but account for:

• 34% of medication use

• 30% of over-the-counter (OTC) medication use

• 20% emergency department visits

• 36% hospitalizations

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Physiologic Changes Associated with Aging

and Medication Considerations

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Not all Geriatric patients are created equal

Not all older adults are created equal

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Musculoskeletal System

Decrease in lean body mass

Increase in total body fat• Increase in volume of distribution and elimination half-life of highly lipophilic drugs

• eg. Diazepam, chlordiazepoxide, verapamil

• Risk of falls

• Volume of distribution: is defined as the distribution of a medication between plasma and the body after dosing

• Half life: Time it takes for the concentration of the drug in the plasma or the total amount in the body to be reduced by 50%

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Decrease in total body water content• Lower volume of distribution for hydrophilic drugs

• eg. Aminoglycosides (gentamicin, amikacin, and tobramycin)

Musculoskeletal System

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Musculoskeletal System

Bone loss in men and women• Osteoporosis

• Physical exercise, alcohol moderation, smoking cessation

• Adequate daily intake of calcium and vitamin D• Calcium

• Women > 51 years of age - 1200 mg• Men 51 - 70 years of age - 1000 mg• Men > 71 years of age - 1200 mg

• Vitamin D • Men and Women > 50 years of age 800 - 1000 iu

• Medications for prevention and treatment of osteoporosis• eg. Bisphosphonates (eg. alendronate, ibandronate, risedronate, zoledronic acid)

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Musculoskeletal System

Decrease in serum albumin and protein binding

• Pharmacologic effect• Drug binds to Albumin = Inactive = No pharmacologic action• Drug unbound (free drug) to albumin = Active = Has pharmacologic action

• Highly bound drugs• eg. Phenytoin, warfarin, digoxin

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Gastrointestional System

Decreased gastric mobility and delayed emptying• eg. Gastroparesis, constipation

Decreased esophageal acid clearance and saliva production• Gastroesophogeal Reflux Disease (GERD)

• Antacids• Pro-motility agents • Proton Pump Inhibitors (PPIs)

• eg. Esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole, dexlansoprazole• Long term risk of PPIs: Pneumonia, Clostridum difficile, bone fracture, hypomagnesemia, Vit. B12 deficiency

Impaired gastric mucosal defense• Increase use of Non-Steroidal Anti-inflammatory Drugs (NSAIDs)

• NSAID-induced GI bleeds and ulceration• GI bleeding in the older adult is increase by 4 fold

Gastrointestional System

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Decrease in hepatic mass and blood flow• Reduced first-pass metabolism

• Potential for lowering the safe dosage of some medications• eg. Morphine, nitroglycerin, propranolol, phenobarbital

Decrease in Cytochrome P-450 enzyme activity• Hepatic metabolism clearance decreases by 30 - 40%

• CYP 450 metabolizes 80% of medications• eg. Acetaminophen, amitriptyline, verapamil

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Renal and Genitourinary Systems

Decreases in kidney mass and blood flow

Decreased renal clearance• After age 40, creatinine clearance (CrCl) decreases an average of

8 mL/min/1.73 m2/decade• Acute kidney disease

• eg. Vancomycin, ACE Inhibitors/ARBs, Contrast dye

• Chronic kidney disease • eg. NSAIDS, amlodipine, verapamil, spironolactone, digoxin

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Renal and Genitourinary Systems

Reduced bladder elasticity, muscle tone, and capacity• Urinary incontinence

• eg. Oxybutynin, tolterodine, darifenacin• Dry mouth, constipation, drowsiness, sedation, confusion, delirium, hallucinations

Medication Management in the Older Adult

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• Polypharmacy• Adverse Drug Reactions• Drug-Drug Interactions• Adherence

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Polypharmacy

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Defined as “The use of multiple drugs or more than are medically necessary”

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The average number of prescriptions taken by individuals between the ages of 65 and 69 is around 14

Between the ages of 80 and 84, the average number is 18 over a single year

Polypharmacy

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Adverse Drug Reactions (ADRs)• ADR: Any response to a drug which is noxious and unintended, and which occurs at

doses normally used

• Prevalence of ADRs increases with age

• ADR occurrence in older adults• 2 medications = 13% risk• 4 medications = 38% risk• 7 or more medications = 82% risk

• The Prescribing Cascade• ADRs are misinterpreted as a symptom of a new disorder

• Antipsychotics (haloperidol, chlorpromazine, perphenazine) Parkinson disease

• Cholinesterase Inhibitors (eg. Donepezil, rivastigmine, galantamine) Diarrhea, urinary incontinence

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Drug-induced side effects should be considered when a patient presents with a new complaint.

• Fall

• GI distress

• Incontinence

• Constipation

• Depression

• Anxiety

• Confusion

• Insomnia

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ADR Pearl

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Drug - Drug InteractionsCombination Risk

ACE Inhibitor + potassium Hyperkalemia

ACE Inhibitor + K sparing diuretic Hyperkalemia; hypotension

Digoxin + antiarrhythmic Bradycardia; arrhythmia

Digoxin + diuretic Antiarrythmic + diuretic

Electrolyte imbalance; arrhythmia

Diuretic + Diuretic Electrolyte imbalance; dehydration

Benzodiazepine + antidepressantBenzodiazepine + antipsychotic

Sedation; confusion; falls

CCB/ nitrate/vasodilator/diuretic Hypotension

Ginkgo biloba extract + warfarin Risk of bleeding

St. John’s wort + SSRIs, SNRIs, TCAs, MAOIs Risk of serotonin syndrome

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Non-Adherence Sequelae

• Disease progression• Treatment failure• Hospitalization• Adverse drug events

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Factors that Affect Medication Adherence

Social and Economic• Low health literacy

• Medication cost

• Unstable living conditions

Healthcare System• Provider-patient relationship

• Provider communication skills

• No care continuity

Comorbidities• Chronic conditions

• Lack of symptoms

• Psychiatric disorders

Therapy-related• Complexity of medication regimen

• Duration of therapy

• Medications with social stigma

Patient-related• Visual impairment

• Cognitive impairment

• Psychosocial stress

• Anxiety

• Anger

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Start LowGo SlowAlways Follow

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Start Low, Go Slow, Always Follow

Considerations

• Start one medication at a time

• Start with a low dose and increase gradually

• You can always give more, but you can’t “take back”

• Monitor for therapeutic response and adverse effects

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The Beers Criteria: Potentially Inappropriate Medications

• Originally conceived by Dr. Mark Beers• Updated by The American Geriatrics Society (AGS)

• Published in 1991 and updated every 3 years since 2011

• Potentially Inappropriate Medications• Should generally be avoided in person 65 years or older

• Either ineffective or they pose unnecessarily high risks

• Criteria applies in ambulatory, acute, institutional setting

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The Beers Criteria: Potentially Inappropriate Medications

Anticholinergics• eg. Hydroxyzine, diphenhydramine (DPH) (oral)

Avoid highly anticholinergic drugs; risk of confusion, dry mouth, constipation, and other effectsDPH in situations such as acute tx of severe allergic rxn may be appropriate

Anti-infectives• nitrofurantoin

Avoid in CrCl 30mL/min; potential for pulmonary toxicity, hepatotoxicity, and peripheral neuropathy with long term use

Cardiovascular• Digoxin (1st line treatment of Atrial fibrillation)

Avoid digoxin as 1st line because more effective drug alternatives available

Benzodiazepines (All) Avoid due to increased sensitivity and decreased metabolism to long acting agents

Z-Drugs• Eszopiclone, Zaleplon, Zolpidem

Avoid due to increased risk of falls, delirium, and fractures. Increased ER visits/hospitalizations, MVA

Androgens• Testosterone

Avoid unless indicated for confirmed hypogonadism with clinical symptoms. Potential for cardiac problems. Contraindicated in men with prostate cancer

Sulfonylureas• Chlorpropamide, glimepiride, glyburide

Chlorpropamide: prolonged half life in older adults; can cause prolonged hypoglycemia; Causes SIADHGlimepiride/glyburide: high risk of prolonged hypoglycemia

Non-Cyclooxygenase-selective NSAIDS• eg. Diclofenac, ibuprofen, meloxicam

Avoid chronic use unless alternatives are not effective and can be used with PPI or misoprostolIncreased risk of GI bleeding, peptic ulcer

Therapeutic Class and Drug(s) Recommendation

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Age Friendly Health System• Initiative of the John A Hartford Foundation and the Institute for Healthcare Improvement in

partnerships with the American Hospital Association and the Catholic Health Association of the United States

Spread the 4Ms Framework to 20% of US hospitals and medical practices by 2020

• The 4 Ms Framework• What Matters: Know and align care with each older adult’s specific health outcome goals and

care preferences including, but not limited to, end-of-life care, and across settings of care

• Medications: If medications are necessary, use age-friendly medications that do not interfere with What Matters, Mentation or Mobility

• Mentation: Prevent, identify, treat and manage depression, dementia and delirium across settings of care

• Mobility: Ensure that older adults move safely every day in order to maintain function and do What Matters

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High-Risk Medications that Interfere with the 4 Ms

• Benzodiazepines

• Opioids

• Anticholinergics

• Muscle Relaxants

• Tricyclic antidepressants

• Antipsychotics

• Sedatives and sleep medications

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Age-Friendly Health Systems

Hospital• Medications

• Review for high-risk medication use daily• Deprescribe or do not prescribe high-risk medications• Use non-pharmacological interventions if possible

Ambulatory• Medications

• Review for high-risk medication use at least annually or change of condition• Deprescribe or do not prescribe high-risk medications• Use non-pharmacological interventions if possible

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Deprescribing

• Patient-centered approach with shared decision making

• Includes both dose reduction and medication discontinuation

• Use alternatives before prescribing high-risk medications

• Remove unnecessary medications upon discharge

• Consult your pharmacist when needed

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Clinical Pearls• Physiologic changes in the older adult have an impact on the dosing of

medications, bioavailability, and their side effects

• Older adults take more medications than any other age group

• The risk of an adverse drug reaction increases with the number ofmedications taken

• Always consider the possibility that a new symptom or sign could be dueto drug therapy

• Utilize available resources when taking care of older adults (eg. BeersCriteria, 4Ms, Pharmacist)

• Assess medications and deprescribe if possible

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References

Barclay, Kelsey, et al. “Polypharmacy in the Elderly: How to Reduce Adverse Drug Events.” Clinician Reviews, 4 Feb. 2019, https://www.mdedge.com/clinicianreviews/article/157265/geriatrics/polypharmacy-elderly-how-reduce-adverse-drug-events.

Chait, M. M. (2015). Gastroesophageal reflux disease in the older patient. Journal of Liver: Disease & Transplantation, 04(03). doi: 10.4172/2325-9612.c1.004

Demontiero, O., Vidal, C., & Duque, G. (2011). Aging and bone loss: new insights for the clinician. Therapeutic Advances in Musculoskeletal Disease, 4(2), 61–76. doi: 10.1177/1759720x11430858

For Older People, Medications Are Common; Updated AGS Beers Criteria® Aims to Make Sure They're Appropriate, Too. Retrieved from https://www.americangeriatrics.org/media-center/news/older-people-medications-are-common-updated-ags-beers-criteriar-aims-make-sure

Hutchison, L. C., & Sleeper, R. B. (2015). Fundamentals of geriatric pharmacotherapy. Bethesda: American Society of Health-System Pharmacists.

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References

Lo, A. X., Flood, K. L., Biese, K., Platts-Mills, T. F., Donnelly, J. P., & Carpenter, C. R. (2016). Factors Associated With Hospital Admission for Older Adults Receiving Care in U.S. Emergency Departments. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. doi: 10.1093/gerona/glw207

Medication Errors and Adverse Drug Events. Retrieved from https://psnet.ahrq.gov/primers/primer/23/Medication-Errors-and-Adverse-Drug-Events

Pharmacokinetics in Older Adults - Geriatrics. Retrieved from https://www.merckmanuals.com/professional/geriatrics/drug-therapy-in-older-adults/pharmacokinetics-in-older-adults

US Census Bureau. (2018, October 1). From Pyramid to Pillar: A Century of Change, Population of the U.S. Retrieved from https://www.census.gov/library/visualizations/2018/comm/century-of-change.html

What Is an Age-Friendly Health System? Retrieved from http://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/default.aspx

Wongrakpanich, S., Wongrakpanich, A., Melhado, K., & Rangaswami, J. (2018). A Comprehensive Review of Non-Steroidal Anti-Inflammatory Drug Use in The Elderly. Aging and Disease, 9(1), 143. doi: 10.14336/ad.2017.0306