Geriatric Pharmacotherapy: Managing Older Adults on

Multiple Medications

Lynne E. Kallenbach, M.D.Lynne E. Kallenbach, M.D.Asst. Professor of MedicineAsst. Professor of Medicine

University of Kansas Medical CenterUniversity of Kansas Medical CenterLandon Center on AgingLandon Center on Aging

October 5, 2007October 5, 2007

Overview

What is “polypharmacy”?What is “polypharmacy”? Relevant pharmacology Relevant pharmacology Medication use issues with multiple RxsMedication use issues with multiple Rxs Potentially inappropriate medicationsPotentially inappropriate medications Approach to modifying medication profilesApproach to modifying medication profiles Quality prescribingQuality prescribing

What is polypharmacy?

““As older patients move through time, often As older patients move through time, often from physician to physician, they are at from physician to physician, they are at increasing risk of accumulating layer upon increasing risk of accumulating layer upon layer of drug therapy, as a reef accumulates layer of drug therapy, as a reef accumulates layer upon layer of coral.”layer upon layer of coral.”

Jerry Avorn, MDJerry Avorn, MD

From Gurwitz J. Arch Intern Med Oct 11, 2004From Gurwitz J. Arch Intern Med Oct 11, 2004

Why Geriatric Pharmacotherapy Is Important

0102030405060708090

100

Present 2040

People 65+ 65+ share of prescriptionsPeople <65 <65 share of presciptions

Now, people age 65+ are 13% of US population, buy 33% of prescription drugsNow, people age 65+ are 13% of US population, buy 33% of prescription drugsBy 2040, will be 25% of population, will buy 50% of prescription drugsBy 2040, will be 25% of population, will buy 50% of prescription drugs

The Burden of Injuries From Medications

ADEs occur in 35% of ADEs occur in 35% of community-dwelling community-dwelling

elderly personselderly persons

Incidence of ADEs: Incidence of ADEs: 26/1000 hospital beds 26/1000 hospital beds

(2.6%)(2.6%)

Adverse Drug Events in Older Adults Serious or fatal ADEs occur in 18.5% of Serious or fatal ADEs occur in 18.5% of

adults aged 55-64 and in adults aged 55-64 and in 41.9% of adults 41.9% of adults aged >85 years.aged >85 years.

Drug related mortality is the 9th leading Drug related mortality is the 9th leading cause of death for people >65 years of age.cause of death for people >65 years of age.

It is estimated that ~30% of ADEs are It is estimated that ~30% of ADEs are preventable.preventable.

Pharmacologic Changes with Aging

Pharmacokinetics

AbsorptionAbsorption DistributionDistribution MetabolismMetabolism ExcretionExcretion

Altered by changes in body make-upAltered by changes in body make-up Decreased lean mass, relatively increased Decreased lean mass, relatively increased

fatfat

Aging and Absorption

Actual amount absorbed not changedActual amount absorbed not changed

Peak concentrations may be alteredPeak concentrations may be altered

Effects of Aging on Volume of Distribution

body water body water lower VD for hydrophilic drugs lower VD for hydrophilic drugs

lean body mass, lean body mass, plasma protein (albumin) plasma protein (albumin) higher percentage of drug that is unbound higher percentage of drug that is unbound (active)(active)

fat stores fat stores higher VD for lipophilic drugs higher VD for lipophilic drugs

Aging and Metabolism Metabolic clearance of a drug by the liver Metabolic clearance of a drug by the liver

may be reduced because: may be reduced because:

• Aging decreases liver blood flow, size, and Aging decreases liver blood flow, size, and massmass

• The liver is the most common site of drug The liver is the most common site of drug metabolismmetabolism

• Phase II pathways generally preferable for Phase II pathways generally preferable for older patientolder patient

The Effects of Aging on the Kidney

kidney sizekidney size

renal blood flowrenal blood flow

number of functioning nephronsnumber of functioning nephrons

renal tubular secretionrenal tubular secretion

Result: Lower glomerular filtration rateResult: Lower glomerular filtration rate

Serum Creatinine Does Not ReflectClearance

lean body mass lean body mass lower creatinine production lower creatinine production

andand

glomerular filtration rate (GFR)glomerular filtration rate (GFR)

Result: In older persons, serum creatinine stays in Result: In older persons, serum creatinine stays in normal range, masking change in creatinine clearance normal range, masking change in creatinine clearance (CrCl)(CrCl)

Pharmacodynamics• Definition:Definition: Time course and intensity of the Time course and intensity of the

pharmacologic effect of a drugpharmacologic effect of a drug

• May change with aging, eg:May change with aging, eg: Benzodiazepines may cause more sedation and Benzodiazepines may cause more sedation and

poorer psychomotor performance in older adults. poorer psychomotor performance in older adults.

Older patients may experience higher levels of Older patients may experience higher levels of morphine with longer pain reliefmorphine with longer pain relief

Decreased homeostatic reserve

Impacts ability to tolerate medicationsImpacts ability to tolerate medicationsPostural hypotensionPostural hypotensionFluid and electrolyte problemsFluid and electrolyte problemsResponse to hypoglycemia Response to hypoglycemia Temperature regulationTemperature regulation

Medication Use Issues with Multiple Prescriptions

(and OTCs…herbals…etc)

General types of medication-related problems

Unnecessary drugUnnecessary drug Not prescribing new needed RxNot prescribing new needed Rx Contraindicated drugContraindicated drug Dose too low or too highDose too low or too high Adverse drug event/ drug interactionAdverse drug event/ drug interaction NonadherenceNonadherence Prescribing cascadePrescribing cascade

From Williams CM, Am Fam Phys Nov 15, From Williams CM, Am Fam Phys Nov 15, 20022002

Prescribing Cascade

Misinterpretation of an adverse drug reaction as a Misinterpretation of an adverse drug reaction as a symptom of another conditionsymptom of another condition prescribing of prescribing of another Rxanother Rx

Example:Example: Persons receiving a cholinesterase inhibitor had Persons receiving a cholinesterase inhibitor had

>50% increase risk for subsequent >50% increase risk for subsequent anticholinergic drug for incontinenceanticholinergic drug for incontinence

Gill et al. Arch Intern Med 2005, April 11Gill et al. Arch Intern Med 2005, April 11

Adverse Drug Events during Care Transitions

Med changes between hosp and NHMed changes between hosp and NH Mean # of Rx changed:Mean # of Rx changed:

3.1 from nursing home to hospital3.1 from nursing home to hospital 1.4 from hospital to nursing home1.4 from hospital to nursing home

Most were discontinuationsMost were discontinuations ADE attributable to medication changes ADE attributable to medication changes

occurred in 20%; usually occurred after occurred in 20%; usually occurred after readmission to the NH readmission to the NH

Characteristics of Older Adults with Medication-related Problems

85 years and older85 years and older 6 or more active chronic conditions6 or more active chronic conditions Estimated creat clearance < 50 ml/minEstimated creat clearance < 50 ml/min Low body weightLow body weight Nine or more medicationsNine or more medications More than 12 doses of medication dailyMore than 12 doses of medication daily Previous adverse drug reactionPrevious adverse drug reaction

From Williams CM, Am Fam Phys 2002, adapted from Fouts, From Williams CM, Am Fam Phys 2002, adapted from Fouts, Consult Pharm, 1997Consult Pharm, 1997

Risk Factors for High Risk for ADE in Older Outpatients from an Expert Consensus Panel

Medication FactorsMedication Factors Patient factorsPatient factors

warfarinwarfarin polypharmacypolypharmacy

nonselective NSAIDSnonselective NSAIDS multiple chronic illnessesmultiple chronic illnesses

anticholinergicsanticholinergics prior ADRprior ADR

benzodiazepinesbenzodiazepines dementiadementia

opioidsopioids

From Hajjar et al. Am J Geriatr Pharmacother 2003, Dec

Drug-Drug Interactions• May lead to ADEsMay lead to ADEs

• Likelihood Likelihood as number of medications as number of medications

• Most common: cardiovascular and psychotropic Most common: cardiovascular and psychotropic drugsdrugs

Case A

75 year old woman with hypertension, 75 year old woman with hypertension, diabetes mellitus, dyslipidemia, coronary diabetes mellitus, dyslipidemia, coronary heart disease, congestive heart failure, heart disease, congestive heart failure, osteoporosis, arthritis and chronic back osteoporosis, arthritis and chronic back pain, depression, and seasonal allergiespain, depression, and seasonal allergies

Case A: 15 meds

glyburideglyburide atenololatenolol NSAIDNSAID

pioglitazonepioglitazone aspirinaspirin tramadoltramadol

NPH at hsNPH at hs furosemidefurosemide senokotsenokot

lisinoprillisinopril alendronatealendronate sertralinesertraline

HCTZHCTZ calcium & vit Dcalcium & vit D loratidineloratidine

Case B

85 year old woman with hypertension, 85 year old woman with hypertension, dependent edema, dizzy spells, chronic dependent edema, dizzy spells, chronic back pain, insomnia, and constipation back pain, insomnia, and constipation

Case B: 15 meds

HCTZHCTZ oxycodoneoxycodone MiralaxMiralax

Felodipine Felodipine Metamucil Metamucil indomethacinindomethacin

Furosemide prnFurosemide prn Senokot Senokot ranitidineranitidine

meclizinemeclizine Colace Colace ambienambien

propoxyphenepropoxyphene Exlax OTCExlax OTC trazodonetrazodone

How many meds is too many?

Med count won’t distinguish cases A & BMed count won’t distinguish cases A & B Med count won’t distinguish treatment Med count won’t distinguish treatment

based on disease-management guidelines based on disease-management guidelines from symptom-management medsfrom symptom-management meds

Won’t distinguish prescriber decision-Won’t distinguish prescriber decision-making from patient-generated demandmaking from patient-generated demand

Won’t distinguish appropriate from Won’t distinguish appropriate from inappropriate medication useinappropriate medication use

Manageable Dosing Regimens

Manageable number of dosing times/dayManageable number of dosing times/day Once daily formulations if feasibleOnce daily formulations if feasible Reduce number of medications that can’t Reduce number of medications that can’t

be taken at same time as any othersbe taken at same time as any others Use of reminders, medication box set-upUse of reminders, medication box set-up Feasible to keep track of and filledFeasible to keep track of and filled Affordable so patient does not skip doses to Affordable so patient does not skip doses to

make the supply ‘stretch’ between refillsmake the supply ‘stretch’ between refills

Potentially Inappropriate Medication Use

Inappropriate Medications in Older Adults: “Beers List”

““potentially or generally inappropriate”potentially or generally inappropriate” ““suboptimal prescribing”suboptimal prescribing” Overall risks outweigh potential benefitsOverall risks outweigh potential benefits

May be ineffective and/or poorly toleratedMay be ineffective and/or poorly tolerated May be justified in some circumstancesMay be justified in some circumstances

ControversialControversial Expert opinion by pharmacists’ groupExpert opinion by pharmacists’ group Limited evidence-base for many drugsLimited evidence-base for many drugs

Beer’s List: Two Groups of Drugs

Unconditionally inappropriateUnconditionally inappropriate Generally best avoided regardless of Generally best avoided regardless of

circumstancescircumstances

Conditioned upon disease state or doseConditioned upon disease state or dose May only be inappropriate in specific May only be inappropriate in specific

contextcontext

Beer’s List

1992—many drugs no longer used1992—many drugs no longer used 19971997 20032003

Now the basis for consultant pharmacy Now the basis for consultant pharmacy review in nursing facilitiesreview in nursing facilities

Beer’s List Selected Highlights: 1997

Propoxyphene Propoxyphene (but not included in Rx review guidelines for NH)(but not included in Rx review guidelines for NH)

Indomethcin, phenylbutazone, pentazocineIndomethcin, phenylbutazone, pentazocine Trimethobenzamide Trimethobenzamide Muscle relax/antispasmodics, including ditropan Muscle relax/antispasmodics, including ditropan FlurazepamFlurazepam Amitriptyline & combinations; doxepinAmitriptyline & combinations; doxepin MeprobamateMeprobamate Particular doses of other sedative hypnoticsParticular doses of other sedative hypnotics Chlordiazepoxide, diazepamChlordiazepoxide, diazepam

Selected 1997 drugs, continued DisopyramideDisopyramide Digoxin above 0.125 mg except for atrial arrythDigoxin above 0.125 mg except for atrial arryth DipyridamoleDipyridamole Methyldopa, reserpineMethyldopa, reserpine ChlorpropamideChlorpropamide GI antispasmodicsGI antispasmodics Nonprescription & many Rx antihistaminesNonprescription & many Rx antihistamines MeperidineMeperidine TiclopidineTiclopidine All barbiturates except phenobarbitalAll barbiturates except phenobarbital

Updates to Beer’s List in 2003 (selected additions since 1997)

ToradolToradol TagametTagamet

NorflexNorflex Ferrous sulfate > 325 mgFerrous sulfate > 325 mg

MacrodantinMacrodantin Short-acting nifedipineShort-acting nifedipine

CarduraCardura Daily fluoxetineDaily fluoxetine

ClonidineClonidine AmiodaroneAmiodarone

Mineral oilMineral oil Non-COX-selective NSAIDS!Non-COX-selective NSAIDS!

EstrogensEstrogens Clarification that XL Ditropan Clarification that XL Ditropan is excluded from this listis excluded from this list

2003: selected conditionally “inappropriate” by disease state

Benzodiazepines (all)Benzodiazepines (all) fallsfalls

Calcium channel blockersCalcium channel blockers constipationconstipation

PhenylpropanolaminePhenylpropanolamine hypertensionhypertension

OlanzapineOlanzapine obesityobesity

Muscle relaxants, Muscle relaxants, antispasmodicsantispasmodics

cognitive impairmentcognitive impairment

CNS stimulantsCNS stimulants anorexia, malnutrition & anorexia, malnutrition & cognitive impairmentcognitive impairment

Potentially Inappropriate Medications for Older Persons

High Potential for High Potential for Severe ADEsSevere ADEs AmitriptylineAmitriptyline ChlorpropamideChlorpropamide Digoxin > 0.125 mg/dayDigoxin > 0.125 mg/day DisopyramideDisopyramide GI antispasmodicsGI antispasmodics MeperidineMeperidine MethyldopaMethyldopa PentazocinePentazocine TiclopidineTiclopidine

High Potential forHigh Potential forLess Severe ADEsLess Severe ADEs AntihistaminesAntihistamines DiphenhydramineDiphenhydramine DipyridamoleDipyridamole Ergot mesylatesErgot mesylates IndomethacinIndomethacin Meperidine, oralMeperidine, oral Muscle relaxantsMuscle relaxants

Prevalence and health consequences of “inappropriate”

medication use

Findings in Kansas Medicaid Data

Any unconditional inappropriate medication use Any unconditional inappropriate medication use during study year:during study year: CommunityCommunity 21%21% HCBS HCBS 48%48% Nursing Facility Nursing Facility 38%38%

Most common: propoxyphene, antihistamines, Most common: propoxyphene, antihistamines, amitriptyline, muscle relaxants, and oxybutyninamitriptyline, muscle relaxants, and oxybutynin

Rigler et al. 2005 Ann PharmacoRxRigler et al. 2005 Ann PharmacoRx

Inappropriate Medication in Frail Elderly Inpatients

11 VAMCs11 VAMCs 92% had at least one problem:92% had at least one problem:

Expense (70%)Expense (70%) Impractical directions (55%)Impractical directions (55%) Incorrect dosages (51%)Incorrect dosages (51%)

Most common drug types:Most common drug types: GI, CV, CNSGI, CV, CNS

Higher risk with fair/poor self-rated healthHigher risk with fair/poor self-rated health

Hospitalization and Death

MEPS 1996, nursing home componentMEPS 1996, nursing home component Persons ≥ 65 in NH for 3 months or morePersons ≥ 65 in NH for 3 months or more Persons receiving inappropriate Rx:Persons receiving inappropriate Rx:

OR 1.27 for hospitalization in following monthOR 1.27 for hospitalization in following month OR 1.80 for hosp if Rx received for 2 monthsOR 1.80 for hosp if Rx received for 2 months OR 1.28 for deathOR 1.28 for death Analyses adjusted for other key risk factorsAnalyses adjusted for other key risk factors

Lau et al. Arch Intern Med Jan 10, 2005Lau et al. Arch Intern Med Jan 10, 2005

Approach to the Older Patient with Multiple Medications

Approach to Multiple Medications

Brown bag med review at each visitBrown bag med review at each visit Including herbals and OTCsIncluding herbals and OTCs

Determine clinical indication for eachDetermine clinical indication for each Motto “One disease, one drug, once daily”Motto “One disease, one drug, once daily” Avoid the prescribing cascadeAvoid the prescribing cascade Eliminate drugs without benefit or indicationEliminate drugs without benefit or indication Substitute less toxic drugs where ableSubstitute less toxic drugs where able

From Carlon JE, Geriatrics, 1996; 51:26-30From Carlon JE, Geriatrics, 1996; 51:26-30

“NO TEARS” Approach for Medication Review

From Lewis T, BMJ Aug 21, 2004From Lewis T, BMJ Aug 21, 2004NNeed and indicationeed and indicationOOpen questionspen questions

TTests and monitoringests and monitoringEEvidence and guidelinesvidence and guidelinesAAdverse eventsdverse eventsRRisk reduction or preventionisk reduction or preventionSSimplification and switchesimplification and switches

Interdisciplinary Medication Review

Ambulatory older adultsAmbulatory older adults Intervention versus control groupsIntervention versus control groups Regimen changesRegimen changes Function? Cost? Function? Cost? Results: reduced mean Rx by 1.5 Results: reduced mean Rx by 1.5 No impact on functioningNo impact on functioning Savings $27 per month per personSavings $27 per month per person

Williams et al. JAGS Jan 2004Williams et al. JAGS Jan 2004

Regulatory Scrutiny

Mandated drug review already in LTCMandated drug review already in LTC Medicare drug benefitMedicare drug benefit Provider profiling increasingly commonProvider profiling increasingly common Pay for performance modelsPay for performance models Patient satisfaction monitoringPatient satisfaction monitoring Increasing use of electronic recordsIncreasing use of electronic records Can expect increased scrutiny of the medication Can expect increased scrutiny of the medication

profiles of your patientsprofiles of your patients

The Obvious Do’s and Don’ts

Use effective medications to treat diseaseUse effective medications to treat disease Use effective therapies to prevent diseaseUse effective therapies to prevent disease

Do not use unsafe medicationsDo not use unsafe medications Do not use ineffective medicationsDo not use ineffective medications

If only it were this simple…

Safe & Safe & tolerabletolerable

Potential tolerability Potential tolerability problems with problems with advanced ageadvanced age

EffectiveEffective Use if patient Use if patient agreeableagreeable

Hmmm…weigh risk Hmmm…weigh risk versus benefitversus benefit

Not effectiveNot effective Nope!Nope! Nope!Nope!

Quality Prescribing

OutcomesOutcomes Adverse Drug EventsAdverse Drug Events Drug-Drug InteractionsDrug-Drug Interactions Unrecognized symptomsUnrecognized symptoms Decreased quality of lifeDecreased quality of life Non-adherenceNon-adherence CostCost Adding beneficial medicationsAdding beneficial medications

Quality of Life: Outcomes related to Beer’s criteria medications

Two phase study of 2305 older patientsTwo phase study of 2305 older patients Patients reported their medications in “Round Patients reported their medications in “Round

1”1” Patients reported their health status in “Round Patients reported their health status in “Round

2”2” Patients who were on medications on the Patients who were on medications on the

Beers list in Round 1 reported significantly Beers list in Round 1 reported significantly worse health status in Round 2 (P<0.01)worse health status in Round 2 (P<0.01)

–Fu, JAGS, 2004Fu, JAGS, 2004

Quality Prescribing

Preventing excess morbidity and mortality by Preventing excess morbidity and mortality by reducing harmful medicationsreducing harmful medications Reduce total number of medicationsReduce total number of medications Reduce complexity of regimenReduce complexity of regimen Eliminate poorly tolerated medicationsEliminate poorly tolerated medications Eliminate drugs inappropriate for older Eliminate drugs inappropriate for older

adultsadults Avoid drug interactionsAvoid drug interactions

“And now, for the rest of the story….”

Under-utilization of effective therapies in Under-utilization of effective therapies in older adults is widespreadolder adults is widespread

“Polypharmacy: A New Paradigm for Quality Drug

Therapy in the Elderly” Under-use of beneficial Rx in older adultsUnder-use of beneficial Rx in older adults

ACEI in CHFACEI in CHF Anticoagulants in AfibAnticoagulants in Afib Antiresorptive Rx in osteoporosisAntiresorptive Rx in osteoporosis

Disease management guidelines often favor Disease management guidelines often favor more than one Rx for a conditionmore than one Rx for a condition

Gurwitz J. Arch Intern Med 2004, Oct 11Gurwitz J. Arch Intern Med 2004, Oct 11

Average Life Expectancies

65 year old woman65 year old woman 19 years19 years 75 year old woman75 year old woman 12 years12 years 85 year old woman85 year old woman 6 years 6 years

65 year old man65 year old man 16 years16 years 75 year old man75 year old man 10 years10 years 85 year old man85 year old man 5 years 5 years

Underuse of medication

Failure to recommend or provide a Failure to recommend or provide a recommended therapy either intentionally recommended therapy either intentionally or unintentionallyor unintentionally

Error of omission: medical error resulting in Error of omission: medical error resulting in increased risk of adverse event resulting increased risk of adverse event resulting from too little treatment e.g. subtherapeutic from too little treatment e.g. subtherapeutic drug dosingdrug dosing

Hayward et al, JGIM 2005 ; 20:686-691

Treatment benefits in older adults

NNT may be smaller in older adults NNT may be smaller in older adults because of higher disease prevalencebecause of higher disease prevalence

More bang for your buckMore bang for your buck Treat older adults because that is where Treat older adults because that is where

many diseases are most prevalent many diseases are most prevalent

(Rob the bank because that is where the money is)

Darned if you do, darned if you don’t?

Specialist heart failure care:Specialist heart failure care: More appropriate pharmacotherapy for CHF by More appropriate pharmacotherapy for CHF by

guidelines, but…..guidelines, but….. Increased polypharmacy, drug interaction Increased polypharmacy, drug interaction

potential, drug-kidney, drug-liver interactionspotential, drug-kidney, drug-liver interactions Ledwidge et al. Eur J Heart Fail March 2004Ledwidge et al. Eur J Heart Fail March 2004

““And an ARB makes nine: polypharmacy in And an ARB makes nine: polypharmacy in patients with heart failure”patients with heart failure” Clev Clinic J Med Aug 2004Clev Clinic J Med Aug 2004

What is being done to address prescribing quality for older adults? New initiativesNew initiatives Implications for Pay-for-PerformanceImplications for Pay-for-Performance

Mike Steinman, MD; University of California, San Francisco

Quality Indicators

Assessing Care of Vulnerable Elders Assessing Care of Vulnerable Elders (ACOVE) from RAND (ACOVE) from RAND Health/collaboratorsHealth/collaborators

236 if/then indicators in 4 domains236 if/then indicators in 4 domains 43 indicators re: pharmacologic care43 indicators re: pharmacologic care

Higashi, T. et. al. Ann Intern Med 2004;140:714-720Medication Quality Indicators, Number of Eligible Patients, and Pass Rates

A few ACOVE indicators involving medication use ACE-I use in HF or proteinuriaACE-I use in HF or proteinuria Beta-blocker for patient with MIBeta-blocker for patient with MI Osteoporosis treatmentOsteoporosis treatment Ca/vit D for patients on long term steroidsCa/vit D for patients on long term steroids Outpatient ophthalmology Rx continued when Outpatient ophthalmology Rx continued when

hospitalizedhospitalized OthersOthers

Pass Rates from 2 managed care organizations (Higashi et al, Ann Intern Med 2004)

Prescribing indicated medicationsPrescribing indicated medications 50%50%

Avoiding inappropriate medicationsAvoiding inappropriate medications 97%97%

Education, continuity, documentationEducation, continuity, documentation 81%81%

Medication monitoringMedication monitoring 64%64%

Quality Improvement and Performance Measurement Quality improvement for medication Rx driven by Quality improvement for medication Rx driven by

performance measurementperformance measurement weak financial incentives to excelweak financial incentives to excel strong financial, regulatory incentives not to failstrong financial, regulatory incentives not to fail

Focus on items easily measurable in large Focus on items easily measurable in large populationspopulations

Substantial implications for quality measurement Substantial implications for quality measurement in eldersin elders

Quality Improvement and Performance Measurement CMS CMS Physician Quality Reporting InitiativePhysician Quality Reporting Initiative

Voluntary quality reporting programVoluntary quality reporting program Bonus of up to 1.5%Bonus of up to 1.5% 74 measures; providers select relevant 74 measures; providers select relevant

ones to reportones to report Disease-specific: e.g., LDL <100 in diabetesDisease-specific: e.g., LDL <100 in diabetes Medication reconciliationMedication reconciliation Plan of care for urinary incontinence in Plan of care for urinary incontinence in ♀ ♀ age 65+age 65+

Quality Improvement and Performance Measurement JCAHOJCAHO

Medication reconciliationMedication reconciliation Long-term careLong-term care

minimize use of antipsychotic minimize use of antipsychotic medicationsmedications

Quality Improvement and Performance Measurement HEDIS measuresHEDIS measures

““Effectiveness of care” measuresEffectiveness of care” measures ~16 primarily related to medication use~16 primarily related to medication use

Annual monitoring for patients on Annual monitoring for patients on persistent medspersistent meds

Drugs-to-avoid in elderlyDrugs-to-avoid in elderlyPotentially harmful drug-drug interactions Potentially harmful drug-drug interactions

in elderlyin elderly

CASES

Case #1

A new patient arrives in clinic for consultation. He A new patient arrives in clinic for consultation. He is an 80 yo man with a PMH of early stage is an 80 yo man with a PMH of early stage Alzheimer’s disease, HTN, osteoarthritis, BPH s/p Alzheimer’s disease, HTN, osteoarthritis, BPH s/p TURP years ago, and hearing loss. TURP years ago, and hearing loss.

Medication list includes:Medication list includes:Donepezil Donepezil clonidine (oral) amlodipine clonidine (oral) amlodipine propxyphene/ APAPpropxyphene/ APAP lansoprazole lansoprazole

naproxennaproxen oxybutynin oxybutynin furosemide furosemidemeclizinemeclizine

Case #2

An 89 yo female arrives in clinic to establish a An 89 yo female arrives in clinic to establish a new PCP. She has recently been discharged from new PCP. She has recently been discharged from the hospital after suffering a GI bleed due to the hospital after suffering a GI bleed due to AVMs. While hospitalized, she suffered an AVMs. While hospitalized, she suffered an occipital lobe stroke, and it was also discovered occipital lobe stroke, and it was also discovered that she had severe CAD for which she declined that she had severe CAD for which she declined aggressive intervention. Her other PMH includes aggressive intervention. Her other PMH includes macular degeneration.macular degeneration.

Her major symptoms are fatigue and a sense of Her major symptoms are fatigue and a sense of unsteadiness.unsteadiness.

Case #2, cont’d

Medication list includes:Medication list includes:Stelazine 5 mg bidStelazine 5 mg bidDalmane 30 mg qhsDalmane 30 mg qhsASA 81 mg QDASA 81 mg QDPropanolol 10 mg qdPropanolol 10 mg qdFish oil capsulesFish oil capsulesImipramine 150 mg QDImipramine 150 mg QDPercocet TID prnPercocet TID prnMetoclopramide 10 mg qac and hsMetoclopramide 10 mg qac and hs

Recommended Reading/ References

Williams CM. Using Medications Williams CM. Using Medications Appropriately in Older Adults. American Appropriately in Older Adults. American Family Physician 2002; 66(10):1917-24Family Physician 2002; 66(10):1917-24

GRS Review SyllabusGRS Review Syllabus Rigler, S. SGIM Workshop on Quality Rigler, S. SGIM Workshop on Quality

Pharmacotherapy in Older Adults, 2007Pharmacotherapy in Older Adults, 2007