Polypharmacy and Medication-Related Challenges in the Geriatric Patient

Polypharmacy and Medication-Related Challenges in the Geriatric PatientRobyn Bryson, PharmDKerri Hagedorn, PharmD, BCPSPolypharmacyMany different drugs, often duplicativeDrugs in excess of that which is clinically-indicatedExcessive number of inappropriate drugsIncludes Rx, OTC, nutraceuticalsDiffers from polymedicine or polytherapy, which refers to multiple meds which are all clinically-indicated and appropriate

PolypharmacyIn general:5+ Rx drugs is considered clinically-relevant polypharmacy10+ Rx drugs is considered excessive polypharmacyPts and providers often only consider chronic txCAM, short-term meds, topicals, and PRNs often excludedPolypharmacy in SeniorsComprise 13% of population but account for 34% of Rx and 30% OTC med use90% of Medicare beneficiaries use Rx meds29% of 57-85yo and 40% of Medicare beneficiaries take 5+ Rx drugs46% of seniors use both Rx and OTC meds52% use Rx meds and supplements (vitamins, herbals)Of women over age 65:57% take 5+ meds (Rx, CAM, OTC)12% take 10+ medsPolypharmacy in SeniorsDue to longer life expectancy and the aging baby boomer population, by 2030, the number of Americans 65+ y.o. is expected to double to 71 million85+ y.o. represent the fastest-growing segment of populationMultimorbidityMajority of older adults have 3+ chronic conditions or diseasesabout 20% have 5+ chronic conditionsmultimorbidity adds complexity 5Consequences of Polypharmacy12% of hospital admissions for seniors are due to ADRsADR is the 4th most common cause of hospital-related deathInteractions:Potential for drug-drug interactions increases exponentially with the number of drugsDrug-diet: caffeine, alcohol, grapefruit, vit KDrug-herbDrug-disease w/ multimorbidity Consequences of PolypharmacyInappropriate med use increases w/ more medsPer Beers study, 12% in community elderly40% of nursing home ptsNonadherence increases with more medsPotential for underuse of appropriate meds

Factors Associated with PolypharmacyHealth System-relatedLonger life span means more elderly patients with chronic diseasesMore treatment options due to medical developmentsPrimary and Secondary prevention strategiesIncreased use of healthcare services means more hospitalizations (known risk factor for polypharmacy)Factors Associated with PolypharmacyPatient-relatedAge: one of most common risk factors for excessive polypharmacyFemale genderMore pronounced in younger populationsEvens out ~age 70Race84% of white Americans use meds57% Asian descentSocioeconomicconflicting dataHigher risk with good insurance coverageLess wealthyLess educated

Factors Associated with PolypharmacyPatient-relatedClinical conditionsCardiovascular disease (Odds Ratio 4.5)Anemia (4.1)Respiratory disease (3.6)Depression, HTN, asthma, angina, diverticulitis, osteoarthritis, gout, DMMedication therapy5 most prevalent drug groups for patients with 5+ meds: Abx, analgesics, psycholeptics, antithrombotics, B-blockersSelf-treatment1/3 of 75yo in community use 3+ OTC drugs daily37% take Rx drugs without PCPs knowledgeOld prescription use, borrowing/sharing often unreportedFactors Associated with PolypharmacyPhysician-relatedPractice environment: lack of time and high workload results in meds remaining in pt records longer than necessaryEducation and competence levelsHowever, age or time in practice is not associatedMale genderDifficulty applying guidelines to patients with multiple diseasesFactors Associated with PolypharmacyPhysician-relatedPrescribing habitsPatient expectation of a prescriptionADRs resulting in prescribing cascadeImproper medical reviewLack of communication between PCPs, specialists, and hospitalistsSkepticism regarding new guidelines, resulting in fall-back on older prescribing practices (improper dosing, multiple meds)Factors Associated with PolypharmacyRelated to Physician-Patient InteractionAdherence depends on confidence in physicianPt failure to review entire med list with physicianLack of continuity due to multiple health providers, prescribers, and pharmaciesPt expectation of a prescription for each medical visitPt requesting specific medicationsDisagreement between pt and provider regarding treatment

Reducing PolypharmacyNursing homes and Care homesAcademic detailing with face-to-face interaction between experts and prescribersNursing workshopsFamily educationComputerized clinical decision support systemsMultidisciplinary team meetingsReducing PolypharmacyCommunity and HospitalMultidisciplinary case conferences involving geriatricianCombination of following likely required:EducationRegular med review, MTMImportant when Rx drug plan formularies changeGeriatrics consultationMultidisciplinary team meetingsComputerized decision support systemsRegulatory policies and proceduresImproved documentation of medication indicationIncreased vigilance during transitions of careBeers CriteriaProsEasy to useEasy to incorporate into computer systems and drug reviewsConsIncludes some older drugsHarm from some drugs may be minor compared to inappropriate prescribing of meds not on the listSTART/STOPPSTART22 indicators of drugs commonly omittedSTOPP--65 indicators--Focuses on drug-drug, drug-disease interactions, fall risk, and med duplicationLowers rates of polypharmacy and drug-drug interactions, improves correct dosingMore sensitive than Beers Criteria (one study only)Easy to use, takes ~3 min to complete

ARMORUsed for nursing home residentsFocus on clinical profiles and functional statusUsed for:Patients with 9+ medsInitial assessmentsFalls or behavioral disturbancesAdmission for rehabGoal is improved functional status and mobilityLimited data shows reduced polypharmacy, healthcare costs and hospitalizations

ARMORAAssess Beers criteria -blockers Pain medications Antidepressants Antipsychotics Other psychotropics Vitamins and supplements RReview Drugdisease interactions Drugdrug interactions Adverse drug reactions MMinimize Number of medications according to functional status rather than evidence-based medicine OOptimize For renal/hepatic clearance, PT/PTT, -blockers, pacemaker function, anticonvulsants, pain medications, and hypoglycemics; gradual dose reduction for antidepressants RReassess Functional/cognitive status in 1 week and as needed Clinical status and medication complianceGood Palliative-Geriatric Practice AlgorithmReduction in mortality, hospitalization, and costAvg 2.8 drugs discontinued without significant adverse effects82% discontinuation success

Medication Appropriateness IndexOnly 3 components are needed to detect polypharmacy: indication, effectiveness, and duplicationCan be used for inpatient and ambulatory patientsTakes ~10 min to completeDoes not address underuse of appropriate prescribingMedication Appropriateness IndexItemWeightIs there an indication for the drug?3Is the medication effective for the condition?3Is the dosage correct?2Are the directions correct?2Are the directions practical?1Are there clinically significant drug-drug interactions?2Are there clinically significant drug-disease/condition interactions?2Is there unnecessary duplication with other drug(s)?1Is the duration of therapy acceptable?1Is this drug the least expensive alternative compared to others of equal utility?1Anticholinergic Risk ScaleSpecific meds in patients regimen are assigned a value based on anticholinergic properties and talliedThe higher the ARS score, the lower the physical function scoreEasy to calculateTime consuming and impractical in clinical settings3 Points2 Points1 PointAmitriptyline hydrochlorideAmantadine hydrochlorideCarbidopa-levodopaAtropine productsBaclofenEntacaponeBenztropine mesylateCetirizine hydrochlorideHaloperidolCarisoprodolCimetidineMethocarbamolChlorpheniramine maleateClozapineMetoclopramide hydrochlorideChlorpromazine hydrochlorideCyclobenzaprine hydrochlorideMirtazapineDicyclomine hydrochlorideLoperamide hydrochlorideParoxetine hydrochlorideDiphenhydramine hydrochlorideLoratadinePramipexole dihydrochlorideFluphenazine hydrochlorideNortriptyline hydrochlorideQuetiapine fumarateHydroxyzine hydrochloride and hydroxyzine pamoateOlanzapineRanitidine hydrochlorideHyoscyamine productsProchlorperazine maleateRisperidoneImipramine hydrochloridePseudoephedrine hydrochloridetriprodlidine hydrochlorideSelegiline hydrochlorideMeclizine hydrochlorideTolterodine tartrateTrazodone hydrochlorideOxybutynin chlorideZiprasidone hydrochloridePerphenazinePromethazine hydrochlorideThioridazine hydrochlorideThiothixeneTizanidine hydrochlorideTrifluoperazine hydrochlorideDrug Burden IndexSimilar to ARSdescribes anticholinergic and sedative drug burdenHigher DBI associated with reduced physical and cognitive functionPotential to be incorporated into DUR software, but not readily available to most cliniciansNeed studies to determine if improving DBI score results in better outcomesFit for the Aged Criteria (FORTA)medications are graded: A: indispensible, with obvious benefitB: proven efficacy but limited effects or possible safety concerns;C: questionable efficacy or safetyD: avoidno significant decrease in the total number of prescribed drugs or in the number of negatively assessed drugssignificant increase in positively assessed drugs as well as appropriate prescribingneed further validation Other ConsiderationsPhysiologic changesDecline in Renal and Hepatic functionReduced clearanceAccumulationMore severe side effects if doses are not adjustedReduced body weight, muscle mass, fluidAltered drug distributionabx, phenytoinIncreased fatty tissueProlonged half-life of lipophilic drugs, i.e. diazepam

Other ConsiderationsPhysiologic changesVision impairment40% unable to read Rx labelHearing impairmentDifficult to understand counselingLoss of dexterityCognitive ImpairmentDifficulty understanding and remembering medication instructions, complex regimens67% unable to understand information givenVisioninsulin

Dexteritymanipulation of syringes, Rx bottle caps

COGNITIVETALK W/ CAREGIVERS, FAMILY IF POSSIBLE, USE PILL ORGANIZERS29Other ConsiderationsMedication Errorselderly are 4X as likely as those < 65 years of age to be hospitalized for a medication errorNonadherenceInadequate Monitoring/Follow-upINR, dig levels, etcAccidental Overdose85% of elderly who present to ER with accidental overdose were taking antidiabetics, warfarin, antiepileptics, digoxin, theophylline, or lithiumInsulinPens/prefilled syringes vs. vialsSimplify regimen, premixed insulinsIf regimen changes ensure pt knows to stop taking previously-prescribed insulinStart low and go slow

Nonadherence on the patient's part contributes to medication errors as well. This type of error includes patients taking the wrong dose, continuing a drug despite the prescriber's order to discontinue, taking a drug despite adverse effects, taking someone else's medication, etc30Other ConsiderationsMedication ErrorsDevice Problems40% errors related to product or device issuesPensUsed like a vialUsed as a single dose product (Forteo)Labeling (Apokyn mg vs. mL)InhalersDose counter malfunction (Asmanex Twisthaler)Institute of Safe Medication Practices (ismpinfo@ismp.org)FDA MedWatch (www.fda.gov/Safety/MedWatch/HowToReport/default.htm)

Other ConsiderationsNonadherence55% of Medicare beneficiaries are nonadherentUp to 40% who skip doses or stop drug do not tell providerReasons:ForgetfulnessSide effectsPerceived inefficacyCost76% more likely to have decline in overall healthOther ConsiderationsGoals of carePt/family goals and values may not match clinician expectationQuality of life and functional status may be more important than maximally extending life expectancyEx: recognition of advanced dementia as terminal illnessVBP may financially penalize providers who take this into considerationRisk vs. BenefitConsider remaining life expectancy, time to achieve benefit from medication, and pt goalsReferencesAmerican Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. American Geriatrics Society 2012 Beers Criteria Update Expert Panel. J Am Geriatr Soc. 2012 Apr;60(4):616-31.Clark, TR. Tough decisions about medications. Aging Well magazine, Winter 2010.Gokula M, Holmes HM. Tools to reduce polypharmacy. Clin Geriatr Med. 2012 May;28(2):323-41.Hovstadius B, Petersson G. Factors leading to excessive polypharmacy. Clin Geriatr Med. 2012 May;28(2):159-72.Medication Errors in Specific Situations and Populations. Pharmacists Letter. Volume 2011, Course Number 313.Patient-centered care for older adults with multiple chronic conditions: a stepwise approach from the American Geriatrics Society: American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity. J Am Geriatr Soc. 2012 Oct;60(10):1957-68. PL Detail-Document, Potentially Harmful Drugs in the Elderly: Beers List. Pharmacists Letter/Prescribers Letter. June 2012.PL Detail-Document, STARTing and STOPPing Medications in the Elderly. Pharmacists Letter/Prescribers Letter. September 2011.American Society of Consultant Pharmacists Geriatric Pharmacotherapy Practice Resource Center, available www.ascp.com/articles/geriatric-pharmacotherapyMedication Use Safety Training For Seniors, available www.mustforseniors.orgPhoto, www.caregivercollege.orgPhoto, dangersofpolypharmacy.wordpress.comQuestions?