Drug Use in the Elderly
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Transcript of Drug Use in the Elderly
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UMMS CRIT Module II: Drug Therapy in the Elderly
Jerry H. Gurwitz, MDChief, Division of Geriatric MedicineUniversity of Massachusetts Medical SchoolUMass Memorial Medical Center
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UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
It is much easier to write upon a disease than upon a remedy.
The former is in the hands of nature and a faithful observer with
an eye of tolerable judgement cannot fail to delineate a likeness.
The latter will ever be subject to the whim, the inaccuracies and
the blunder of mankind.
William Withering (1741-1799)
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UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
A desire to take medicine is, perhaps, the great feature which
distinguishes man from other animals.
Sir William Osler, 1891
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UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
“I know of no way to end an office visit as satisfactorily and as efficiently as by writing a prescription. The patient knows that the visit is over and is expected to leave. He has something in his hand that he thinks will help him and obtaining it required an office visit.”
Marcus Reidenberg, MDEditor Emeritus, CP&T
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UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Drug Use in the Elderly
• 57% of all elderly use > 5 drugs per week
• 19% of elderly use > 10 drugs per week
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UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• Overuse
• Inappropriate prescribing
• Underuse
Suboptimal Medication Use
Hanlon JT et al. JAGS. 2001;49: 200-9. Fisk D et al. Arch Intern Med. 2003;163: 2716-2724.
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UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Polypharmacy is not necessarily bad!
Polypharmacy
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UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• Any transition - hospitalizations, discharges, ER visits, subacute
care stays
• New meds, different doses…
• Changes from generic to brand- nomenclature, color and/or shape
Drug Regimen Changes ~They are very common!
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UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• The more providers and visits, the more medications are prescribed
• 2/3 of all physician visits end with a prescription
• Expectations of the patient to receive a prescription
• Lack of communication between prescribers
• Self-treatment: unbeknownst to the physician
Why so many changes?
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UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• Increased risk of adverse drug events and near-misses
• Noncompliance or nonadherence leading to poor outcomes
• Increased costs
Impact on the Patient
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UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• Multiple co-existing illnesses
• Polypharmacy: redundant effects and drug-drug interactions
• Adverse drug effects nonspecific
• Pharmacologic changes with aging
• Medical error
Factors Influencing Drug Effects and Risk of Adverse Effects in the Elderly
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UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• Absorption• Distribution• Metabolism• Excretion
Pharmacokinetics: Changes with Aging
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UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Body Composition Changes in Adult Men with Aging
Age Group Body Weight (kg) Body Fat (kg) Muscle Mass
(kg)
20-29 80 15 24
30-49 81 19 20
60-69 79 23 17
70-79 80 25 13
Data adapted from Cohn et al, 1980
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UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
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UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• Phase I reactions- primarily oxidative reactions– Decline in efficiency with aging
• Phase II reactions- conjugation reactions– No decline in efficiency with aging
Hepatic Metabolism of DrugsChanges with Aging
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UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Renal Function: Changes with Aging
AgeCR
EAT
ININ
E C
LE
AR
AN
CE
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UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
t1/2 ~ Vd/Clearance
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UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Pharmacodynamics: Changes with Aging
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UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Clinical Pearl
Any new symptom in an elderly patient should be considered a drug side effect until proven otherwise.
Jerry Avorn, MD
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UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
The Prescribing Cascade
Drug 1
ADE
Drug 2
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UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
The Prescribing Cascade
Metoclopramide
Extrapyramidal Effects
Levodopa Rx
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UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Case-Control Study Design
Metoclopramide:Yes or No?
Metoclopramide:Yes or No?
BEGIN
L-dopaRx
Controls
CLASSIFY/COMPARE
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UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Results
Metoclopramide users were over three times more
likely to begin use of L-dopa therapy compared with
non-users (OR=3.09; 95% CI 2.25 to 4.26).
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UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Likelihood of L-dopa Treatment by Metoclopramide Dose
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UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Conclusion
Metoclopramide confers an increased risk for the
initiation of treatment generally reserved for the
managment of idiopathic Parkinson’s disease.
Avorn et al, JAMA, 1995
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UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• Medication reconciliation – at time of transitions
• Anticipate errors – prescribing & monitoring
• Watch out for prescribing cascades
• Simplify the medication regimen
• Identify obstacles (costs, cognitive impairment)
• Enlist family/nursing/PCP support & involvement
• Make sure there is good follow-up
Improving the Quality of Prescribing to Older Adults
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UMMS CRIT 2012 Module II: Drug Therapy in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Lessons from the Case