Anthony Caprio, MD Division of Geriatric Medicine University of North Carolina at Chapel Hill...

Anthony Caprio, MDDivision of Geriatric Medicine

University of North Carolina at Chapel Hill

Prescribing for Older AdultsPrescribing for Older Adults

““Lunch and Learn” Training Module for PhysiciansLunch and Learn” Training Module for Physicians

Support for the production and design of this training module was provided by the

Donald W. Reynolds Foundation

All Rights Reserved © 2007 The University of North Carolina at Chapel Hill School of Medicine The Center for Aging and Health, Division of Geriatric Medicine


Learning Objectives

Identify risk factors for adverse drug events (ADEs).

Utilize strategies for shortening medication lists and enhancing adherence.

Identify and discontinue potentially harmful medications.

Recognize ADEs when new symptoms are reported by older adults.


Challenges of Prescribing for Older Adults

Multiple medical conditions

Multiple medications

Multiple prescribers

Different metabolisms and responses

Lack of evidence for use in elderly

Adherence and cost

Supplements, herbals, and over-the-counter drugs

Lancet. 1995;346(8966):32–36.


Lots of Medications

2/3 of older adults are on regular medications.

People aged >65 account for 1/3 of all prescriptions written, but they only represent 15% of the US population.

Health Care Financ Rev. 1990;11:1–41.

Question: How many of your older patients have…

1. More than six chronic conditions?

2. Nine or more medications?

3. Multiple medication doses?


Adverse Drug Events (ADEs)

Adverse symptoms

Adverse clinical outcomes– Doctor visits or hospitalizations

– Falls

– Functional decline

– Changes in cognition (delirium)

– Death

Poor adherence, poor quality of life

Increased cost


Prevalence of Adverse Drug Events (ADEs)for Older Adults in Primary Care

35% of community-dwelling older adults annually experience an ADE

In the emergency department, ADEs are experienced:– 2.0 per 1000 for adults under 65

– 4.9 per 1000 for aged 65 years or older

– 6.8 per 1000 for aged 85 years or older

JAMA 2006; 296:1858–1866JAGS 1997;45:945-948. JAGS 1996;44:194–197Am Pharm Assoc 2002;42:847–857


1.6 per 1000 older adults require hospitalization (7 times the younger adult rate) because of ADEs.

Nearly 1/3 of all geriatric hospital admissions are due to ADEs.

2/3 of nursing home patients experience an ADE (over a 4-year period)

Prevalence of Adverse Drug Events (ADEs)for Older Adults in Primary Care

JAMA 2006; 296:1858–1866JAGS 1997;45:945-948. JAGS 1996;44:194–197Am Pharm Assoc 2002;42:847–857


Medications Which Account forMost Adverse Drug Events in Older Adults

JAMA 2006; 296:1858–1866JAGS 2004;52:1349–1354NEJM 2003;348:1556–64

Antibiotics

Analgesics– Opioid

– NSAIDS

Anticoagulants

Antihistamines

Anticonvulsants

Antipsychotics

Cardiovascular medications

Diabetic medications– Insulins

– Oral agent


Potential Risk Factors for Adverse Drug Events (ADE)

>6 chronic disease

>12 doses/day

≥ 9 medications

Low BMI (<22kg/m2)

Age >85 years

Creatinine clearance < 50 mL/min

History of prior ADE

Consult Pharm 1997;12:1103–11.


Physiologic ChangesAssociated with Normal Aging

Less water

More fat

Less muscle mass

Slowed hepatic metabolism

Decreased renal excretion

Decreased responsiveness of the baroreceptors


Clinical Case: Mr. Johnson

Mr. Johnson is 83 years old. He complains of a “runny nose” during meals on a daily basis. He asks if there is a medication to stop his runny nose. Although inconvenient at mealtime, he is not bothered by this symptom at other times during the day.

Question: What do you prescribe?


Rhinitis

Likely diagnosis is vasomotor rhinitis and may respond to ipratropium (Atrovent) nasal spray.

Could be incorrectly diagnosed as allergic rhinitis and prescribed antihistamines.

“Sedating” antihistamines can have significant anticholinergic effects.

J Allergy Clin Immunol 1989 Jan;83(1):110–5.


Do You Need to Prescribe?

Does every condition need a drug?– Is it a benign or self-limiting condition?– How does this condition bother the patient?– Inconvenient, but not life-threatening– Individualize treatment plans

Consider non-drug alternatives for some conditions– Diet– Exercise– Lifestyle modification

Use caution with over-the-counter (OTC) medications– Not necessarily safer than prescription drugs– Uncertain safety and efficacy of herbals and supplements

Principle 1:“Less is More”Keep the Medication List Short

↑ number of medications = ↑ risk of ADE

Question the need for new medications, stop meds if possible

Prioritize treatments

- Avoid under treating conditions• Pain• Systolic hypertension• Anticoagulation and atrial fribrillation

- Weigh the benefits and risks of a new medication• Sedative hypnotic medications• “Tight” control of parameters (blood pressure, blood sugars)

Drugs Aging 2003; 20 (1): 23–57.Lancet 2000; 355: 865–872.

Ann Intern Med 1999;131:492–501.J Gen Intern Med 2005; 20:116–122.


Clinical Case: Mr. Connor

Mr. Connor is 80 years old. He has coronary artery disease, congestive heart failure, hypertension, and Alzheimer’s dementia. His wife is the primary caregiver. He is increasingly agitated, suspicious, and verbally abusive. He has difficulty sleeping at night and has wandered from the house on two occasions.

Medications: furosemide, enalapril, metoprolol, amlodipine, aspirin, atorvastatin, alprazolam, and donepezil (Aricept).

Question: What do you do?


Dementia and BehavioralDisturbances

Atypical antipsychotics (i.e. risperdone, quetiapine, olanzepine)

– FDA Black Box warning

– Increased risk of stroke, death

– ? Efficacy (modest at best)

Typical antipsychotics (i.e. haloperidol)

– May also carry increased risk of death

– ? Efficacy

Mood stabilizers (i.e. carbamazepine, valproate)

– Not effectiveJAMA. 2005;293:596-608NEJM 2005;353:2335-41

CMAJ 176: 627-632


Dementia and Behavioral Disturbances

Avoid benzodiazepines– Danger of paradoxical reaction

Consider depression– Difficult to evaluate in setting of dementia

– Apathy vs. depression

Acetylchoinesterase inhibitors (donepezil) might be helpful

Not clear if memantine (Namenda) is helpful

JAMA. 2005;293:596–608


Non-Pharmacologic Approach

Behavioral– Identify antecedents

– Behavioral and environmental interventions

– Sleep hygiene

Caregiver Support– Alzheimer’s association

– Respite

– Day programs


Stopping Medications

Why was it started?

Is it helping? (benefit)

Is it harmful? (risk)

Consider interactions with other medications

Is the dose within a therapeutic range?

Consider underlying renal and hepatic insufficiency


Stop Potentially Dangerous Drugs:The Beers Criteria

The Beers criteria is a consensus-based list of potentially inappropriate medications for older adults.

The Beers criteria were published 1991, revised 1997 and 2002.

Statistical association with adverse drug events has been documented.

Arch Intern Med 2003;163:2716–2724.Online link to this article is http:www.med.unc.edu/aging/Beerscriteria2003article.pdf

Pharmacotherapy 2005;25(6):831–838


Stop Potentially Dangerous Drugs:The Beers Criteria

Beers criteria have been adopted for nursing home regulation.

Does not account for the complexity of the entire medication regimen.

Arch Intern Med 2003;163:2716–2724.Online link to this article is http:www.med.unc.edu/aging/Beerscriteria2003article.pdf

Pharmacotherapy 2005;25(6):831–838


Criteria for Potentially Inappropriate Medication Use in Older Adults: (2002 Beers Criteria)

Table 1: Independent of disease or condition– Describes concern for prescribing certain drugs or

classes of drugs for older adults

– Gives severity rating (low or high)

Table 2: Considering diagnosis or condition– Describes drugs or classes of drugs that can cause

or worsen a particular disease or condition

– Gives severity rating (high or low)

Arch Intern Med 2003;163:2716–2724Tables available online at http:www.med.unc.edu/aging/Beerscriteria2003article.pdf


Beers: Anticholinergic Medications

Drug classes– Tricyclic antidepressants

– Antihistamines

– Antispasmodics and muscle relaxants

Adverse Effects– Urinary retention

– Constipation

– Confusion, delirium, behavior changes

– Exacerbation of dementia

Beers criteria Table 1: Arch Intern Med 2003;163:2719–2720.Link to the Beers criteria is at http:www.med.unc.edu/aging/Beerscriteria2003article.pdf


Beers: Benzodiazepines

Avoid entirely if possible

Challenging to stop for patients with long-term use

Long-acting– Prolonged half-life in older adults (days)

– Sedation, cognitive impairment, depression

– Increased risk of falls and fractures

Short-acting– Increased sensitivity in older adults

– If necessary, use lower doses

Beers criteria Table 1: Arch Intern Med 2003;163:2719–2720.Link to the Beers criteria is http:www.med.unc.edu/aging/Beerscriteria2003article.pdf


Beers: Pain Medications

Propoxyphene (Darvon) has limited efficacy and significant side effects

Caution with non-steroidal anti-inflammatory drugs (NSAIDS)– Indomethacin has significant CNS side effects

– Ketorolac (Toradol) can cause serious GI and renal effects

Meperidine (Demerol) has low oral efficacy, active metabolites and CNS effects

Beers criteria Table 1: Arch Intern Med 2003;163:2719–2720.Link to the Beers criteria is at http:www.med.unc.edu/aging/Beerscriteria2003article.pdfBMJ 1997;315:1565–1571.


Beers: Drugs Which Can Worsen Certain Diseases or Conditions

Parkinson’s disease: Metoclopramide (Reglan)

Stress incontinence: α-blockers

Hyponatremia: selective serotonin reuptake inhibitors (SSRIs)

Constipation: calcium channel blockers

Beers Criteria Table 2: Arch Intern Med 2003;163:2721.


Clinical Case: Mrs. Green

Mrs. Green is a 92-year-old African-American woman

with macular degeneration, dementia, CAD, CHF (lowEF),

and atrial fibrillation. She has been prescribed an ACE

inhibitor, furosemide, β-blocker, nitrates, hydralazine,

digoxin, aldactone (Spironolactone), warfarin, daily aspirin,

and a statin. Her daughter provides a strict low-sodium

diet.

Question: What else would you do for Mrs. Green?


Congestive Heart FailureHigh risk for adverse drug events (ADEs)– Digoxin is a Beers criteria medication– Dehydration and hypotension– Electrolyte disturbance– Bleeding

What is the incremental benefit of adding each medication– Life expectancy, number needed to treat, magnitude of benefit– Lipid lowering therapy, multi-drug CHF regimen?

Think about goals and adherence– Decreasing hospitalizations or extending life?– Cost?– Visual impairment?– Cognitive impairment and literacy?

Arch Intern Med. 1994;154(4):433–7.


Increasing Adherence

Keep the medication list short.

Try to use once-daily medications.

Encourage use of a pillbox.

Review bottles of medications.

Write indications for medications on prescriptions.

Medication management programs


Clinical Case: Mr. Jones

Mr. Jones is 82 years old with a history of herpes zoster

(shingles) 6 months ago. He continues to experience

severe daily pain in the same dermatomal distribution as

the original rash.

Question: What is your diagnosis?

Question: What is the treatment?


Post-Herpetic Neuralgia

Opiate (narcotic) medications– Effective, but constipating

– Propoxyphene (Darvon) is a Beers criteria medication.

Capsaicin– OTC alternative

– Topical (better than systemic)

– May be poorly tolerated due to local effects.

Neurology 2002;59(7):1015–21.Pain 1988;33(3):333–40.


Post-Herpetic Neuralgia

Tricyclic antidepressants– Effective, but have anticholinergic properties.

• Amitriptyline > nortriptyline > desipramine

– Amitriptyline is a Beers criteria medication.

Gabapentin (Neurontin)– Clinical trial doses 1800–3600 mg day in divided doses.

– Dose-reduce with renal insufficiency.

Neurology 1998;51(4):1166–71.JAMA 1998;280(21):1837–42.


Principle 2: Dosing “Start Low and Go Slow…”

Start one medication at a time.

Start with a low dose and increase gradually.

Once daily is usually best.

Monitor for response and adverse effects.

Assess adherence with regimen.


“…But, Go All The Way!”

Be conservative, but don’t miss the target!

What is your goal? Are you achieving it?

Can you keep increasing the dose or are you limited by side effects?

Are you observing a clinical benefit at lower doses?

Consider stopping if you can’t “go all the way” and the benefit is not clear.


Clinical Case: Mrs. Smith

Mrs. Smith is an 85-year-old woman with Alzheimer’s

Dementia. She was titrated to 10mg of donepezil (Aricept)

daily. Her daughter is now concerned about urinary

incontinence and asks about treatment. Her urinalysis is

normal.

Question: What would you do?


Prescribing Cascade: Prescribing a New Drug to Treat an Adverse Drug Event

1. Establish the correct diagnosis.– Incontinence is likely not a new diagnosis but an ADE.– Donepezil (Aricept) can worsen or precipitate urge

incontinence (pro-cholinergic effects on bladder).

2. Determine if treatment is necessary.– Incontinence is leading cause of nursing home

admission.– Incontinence is a significant caregiver burden.

Arch Intern Med 2005;165:808–813.BMJ 1997;315:1096–1099.

JAGS 2004; 52:2082–2087.


Prescribing Cascade: Prescribing a New Drug to Treat an Adverse Drug Event

3. Consider drug-drug interactions (opposing effects).

– Anticholinergics are often used to treat urge incontinence.

– Anticholinergics can cancel the pro-cholinergic effect of donepezil.

4. Plan: Try stopping or dose-reducing donepezil.

Arch Intern Med 2005;165:808–813.BMJ 1997;315:1096–1099.

JAGS 2004; 52:2082–2087.


Principle 3: “Think Drugs” Before Making a New Diagnosis

Consider adverse drug effect as etiology of new signs/symptoms.

Remember that over-the-counter drugs, supplements, and herbals can cause adverse drug effects.

Consider discontinuing or dose-reducing medications rather than treating an adverse drug effect with another medication.


Constipation

Incontinence

Memory loss

Syncope

Falls

Weight loss

CA Channel Blockers

Alpha blockers

Antihistamines

Tricyclics

Benzodiazepines

Fluoxetine (Prozac)

Common Conditions CouldReally Be Adverse Drug Effects


Things to Remember:Three Principles

1. Less is More!

2. Start Low and Go Slow, but Go All The Way!

3. Think Drugs! (before making a new diagnosis)


Clinical Pearls

Review and reconcile meds at every visit.– Indication for each medication?– Contraindications? (renal, dementia)– Can I STOP any medication?

Write indications for each prescription.

Beers criteria medications– Consider alternatives.– Use caution when prescribing.

The Beers criteria that are referred to in this training module are on the Center for Aging and Health webpage at the following link:www.med.unc.edu/aging/Beerscriteria2003article.pdf The Center for Aging and Health has obtained written permission to give this information on our training modules. Any use of the Beers criteria by other groups is prohibited except by obtaining written permission of the authors and editors of the article.


Funding:The Donald W. Reynolds Foundation

Author:Anthony J. Caprio, MD

Educational Development:Ellen Roberts, PhD, MPHWilliam Ashley Davis, BAChristopher Osmond, MA

Center for Aging and Health:Jan Busby-Whitehead, MDC. Glenn Pickard, MD

Acknowledgments

Online Learning Modules Available at http://www.med.unc.edu/aging/

Anthony Caprio, MD Division of Geriatric Medicine University of North Carolina at Chapel Hill...

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