Avoiding Hobson’s choice in older patients:

Managing multi-morbidity and multiple medications in geriatrics

Marilyn N. Bulloch, PharmD, BCPSAssistant Clinical Professor

Harrison School of Pharmacy

Auburn University

The Hobson’s Choice in Geriatric Pharmacotherapy

Don’t Prescribe It

Prescribe It

Objectives Discuss the impact of the aging population on

healthcare utilization. Understand age-related pharmacokinetic and

pharmacodynamics changes that may affect pharmacotherapy in older adults

Describe complications of chronic medication therapy in the aging patient.

Identify strategies to optimize benefit and minimize harm with chronic medication therapy in older adults.

Our Patients Are Aging

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 20500

10,000,000

20,000,000

30,000,000

40,000,000

50,000,000

60,000,000

70,000,000

80,000,000

90,000,000

100,000,000

Population 65+ by Age: 1900-2050Source: U.S. Bureau of the Census

Age65-74

Age75-84

Age85+

Num

ber o

f Per

sons

65+

Available: http://www.aoa.gov/Aging_Statistics/future_growth/future_growth.aspx#age (Accessed April 2013)

Patients Are Living Older Longer

Available: http://www.aoa.gov/Aging_Statistics/future_growth/future_growth.aspx#age (Accessed April 2013)

Chronic Conditions in Older Adults

Available: http://www.aoa.gov/Aging_Statistics/future_growth/future_growth.aspx#age (Accessed April 2013)

Multi-morbidity

Co-occurrence of: Index diseasePreexisting age-related health condition

or diseases Impact

Affect disease progressionDecrease quality of life Increase risk and severity of disability Increase risk of mortality

Shi et al. Eur J Clin Pharmacol 2008;64:183-199

Patients with Multi-morbidity

Total Men Women0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%45%

49.00%43%

2009-2010

Black White Hispanic0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00% 51.60%45.10% 42.40%

2009-2010

Adapted from Figure 1. Fried et al. NCHS Data Brief 2012;100:1Adapted from Figure 2. Fried et al. NCHS Data Brief 2012;100:2

Multiple Medications in Older Adults

 Exhibit 13. IMS Institute for Healthcare Informatics. Avoidable Costs in U.S. Healthcare: The $200 Billion Opportunity from Using

Medicines More Responsibly. June 2013. Available http://www.imshealth.com (accessed 20 June 2013)

Evidence-Based Geriatric Medicine Studies involving geriatrics

3% randomized, controlled studies1% meta-analyses

Make up 2-9% study subjects In 2000

3.45% of controlled trials 1.2% of meta-analysis

Le Couteur et al. Aus Fam Phys 2004;33:777-781

Applying EBM to Older Adults Does your patient resemble the studied population? How many older adults with multi-morbidity

were included? What are the intended outcomes – are these applicable to

older patients? Are there clinically important variation in baseline factors

that affect intended outcome? Are the risks of the intervention known in older adults with

multi-morbidity? What is known about the comparator intervention in

older adults? What is the time until benefit or harm?

Adapted from Table 1. J Am Geriatr Soc 2012;60:1957-68

Age-Related Physiologic Changes

Adapted from Figure 1. Huang A. 28th Annual Scientific Meeting of the Canadian Geriatric Society 2008;11(10):7

DRUGADMINISTRATION

Absorption Changes ↓ saliva production ↓ gastric acid secretion ↓ gastrointestinal blood flow Delayed gastric emptying Intestinal atrophy Changes in body fat and lean muscle Pulmonary changes Skin changes Conjunctiva changes

Hubbard et al. Eur J Clin Pharmacol 2013;69:319-326McLean et al. Pharmacol Rev 2004;56:163-184

Corsonello et al. Cur Med Chem 2010;17:571-584

Distribution Changes

↑ body fat ↓ lean muscle ↓ total body water ↓ albumin ↑ CNS penetration

Hubbard et al. Eur J Clin Pharmacol 2013;69:319-326Sitar. Expert Rev Clin Pharmacol 2012;5:397-402

McLean et al. Pharmacol Rev 2004;56:163-184Corsonello et al. Cur Med Chem 2010;17:571-584

Metabolism Changes

↓ hepatic blood flow ↓ liver volume ↓ plasma esterase quantity & activity

Associated more with health status than age Phase I pathways more impacted than

Phase II

McLean et al. Pharmacol Rev 2004;56:163-184

Elimination Changes

↓ glomeruli causes ↓kidney mass ↓ GFR in 2/3 of patients ↑ drug elimination half-life

McLean et al. Pharmacol Rev 2004;56:163-184

Pharmacokinetic Questions How readily absorbed is the medication? What is the onset and duration of desired

therapeutic action? What is the patient’s body composition? Is the medication excreted unchanged? What is the major route of elimination? Does the medication have an metabolite?

Is the metabolite active or toxic? How is the metabolite eliminated?

Adapted from Table 2. Lamy. J Am Ger Soc 1982;11;s11-s19

Pharmacodynamic Changes

Receptor down regulation Change in receptor sensitivity

IncreasedDecreased

Impaired homeostatic mechanisms and/or physiologic reserves

COMPLICATIONS OF GERIATRIC MEDICATION USE

Polypharmacy

Quantity ≥ X Medications Limiting - assumes > X is

incorrect

Quality More medications than is

clinically indicated No indication Lack efficacy Duplications

Requires more thorough review of medications

DeSovo et al. Prim Care Clin Office Pract 2012;39:345-362

Reasons for Polypharmacy

Age Ethnicity Rural residence Education level Insurance Multiple healthcare

providers Poor health status Provider visits

Chronic diseases Anemia Angina Asthma Depression Diabetes Diverticulosis Gout Hypertension Osteoarthritis

DeSovo et al. Prim Care Clin Office Pract 2012;39:345-362

Avoidable Costs of Polypharmacy

 Exhibit 12. IMS Institute for Healthcare Informatics. Avoidable Costs in U.S. Healthcare: The $200 Billion Opportunity from Using

Medicines More Responsibly. June 2013. Available http://www.imshealth.com (accessed 20 June 2013)

Adverse Drug Reactions

Unwanted and/or harmful effects that can occur at standard doses

Gurwitz et al 50.1 ADRs per 1000 person years

13.8 preventable ADRs per 1000 person years

VA GEM Study 33% of patients experienced an ADR within 12

months of hospital discharge 38% considered preventable

Boparai MK et al. Mt Sinai J Med 2011;78:613-626Gurwitz et al. JAMA 2003;289:1107-1116

Steinman et al. J Gerontol A Biol Sci Med Sci 2011;66:444-451

Risks for ADRs Prior ADR Polypharmacy Dementia/cognitive

impairment Multi-morbidity Frailty CrCl < 50 mL/min Female Fragmented care Altered stimuli-induced

adaptation capacity

Recent hospital admission Age ≥ 85 years Low body weight ≥ 1 oz alcohol intake/ day Vision or hearing

impairment Compliance Regimen complexity

DeSovo et al. Prim Care Clin Office Pract 2012;39:345-362Boparai MK et al. Mt Sinai J Med 2011;78:613-626

Medications Causing ADRs

Cardio

vasc

ular

Antimicr

obial

Diuretic

Nonopioid analgesic

s

Hypoglyc

emics

Stero

ids

Opioid a

nalgesics

Antidepre

ssants

Antiepile

ptics

Antihyp

erlipidem

ics

Antineoplasti

c

Other

0%

5%

10%

15%

20%

25%

30%

35%

40%

Preventable ADRs Total ADRs

Gurwitz JH, et al. JAMA 2003;289;107-116

Types of ADRs Occurring

Figure 1. Percent patients suffering selected injuries commonly studied among patients who experienced adverse drug events: Reducing and Preventing Adverse Drug Events To Decrease Hospital Costs. March 2001. Agency for Healthcare Research and

Quality, Rockville, MD. http://www.ahrq.gov/research/findings/factsheets/errors-safety/aderia/figure1.html (Accessed April 24, 2013)

ADR Consequences

Health care utilization 10% of emergency room visits 10-17% of hospitalizations

$1.33 to manage medication-related morbidity and mortality for each $1 spent on older adults in nursing homes

Can be fatal Symptoms should be considered ADRs until

proven otherwise.Le Couteur et al. Aus Fam Phys 2004;33:777-781Budnitz et al. N Eng J Med 2011;365”2002-2012Boparai MK et al. Mt Sinai J Med 2011;78:613-626

Drug Interactions

Many types 15-46% patients have ≥ 1 interaction

1 in 25 community patients at risk for severe interaction Over 26% cause ADRs that require hospitalization

25% serious or life-threatening Approximately 20% occur in the hospital

Potential for drug-drug interaction in over 6% of medication orders

McDonnell, et al. Ann Pharmacother 2002;36:1331-1336Qato et al. JAMA 2008;300:2867-2878

Reimche et al. Clin Pharmacol 2011;51:1043-1050Lindblad et al. Clin Therapeu 2006;28:1133-1143

Drug Interactions

Age60-74 years – 24%≥ 80 years – 36%

Risk increases with # medications≥ 2 medications – 13%> 6 medications – 82% ≥ 8 medications – almost 100%

Boparai MK et al. Mt Sinai J Med 2011;78:613-626Stegemann et al. Age Research Rev 2010;9:284-298

Minimizing ADRs and Interactions Know allergies – including

reactions Evaluate cognitive function Have a drug information source Use safest/most effective

medication Match medications to indications Use fewest medications possible Use simple dosing Do not start 2 medications at the

same time

Screen for DDIs routinely Dose for renal & hepatic function Recognize a symptom as an ADR Give prophylaxis for known side

effects when able Stop medications without benefit Stop PRN medications not used

in past month Medication lists Involve caregivers

Adapted from: Boparai MK et al. Mt Sinai J Med 2011;78:613-626

Non-Adherence Adherence in patients with

chronic conditions only 50-60% Responsible for up to 70.4%

of medication-related ER visits May account for 39-69%

of drug-related hospitalizations each year

Costs $100 billion/year

Coleman et al. J Manag Care Pharm 2012;18:527-539Orwig et al. Gerontologist 2006;46:66

Cost of Non-Adherence

 Exhibit 3. IMS Institute for Healthcare Informatics. Avoidable Costs in U.S. Healthcare: The $200 Billion Opportunity from Using

Medicines More Responsibly. June 2013. Available http://www.imshealth.com (accessed 20 June 2013)

Types of Non-adherence

Forgetfulness Confusion over dosage schedule Intentional underuse

Primary non-adherence Non-persistence Nonconforming non-adherence

Intentional overuse

Coleman et al. J Manag Care Pharm 2012;18:527-539

Risk Factors for Non-Adherence Communication Regimen complexity Patient-provider

relationship Transition of care Health literacy Mental health

disorders Cognition Smoking

Asymptomatic chronic diseases

Age Physical impairment Lack of social support Minority demographic Patient beliefs Sensory changes Product use Dysphagia

Dosing Influence on Adherence

Frequency of Daily Dosing

Taking Adherence

Regimen Adherence

Timing Adherence

Once daily 93% 81.8% 76.9%

Twice daily 85.6% 74.2% 59.3%

3 times daily 80.1% 62.8% 35.9%

4 times daily 84.4% 68.2% 18.8%

Coleman et al. J Manag Care Pharm 2012;18:527-539

Overcoming Adherence BarriersBarrier Solution

Forgetfulness

• Pill organizers• Medication Calendar/Cues• Dispensing Devices• Family/caregiver involvement• Internet-linked or electronic adherence aid

Patient beliefs• Establish shared goals of care• Provide literacy appropriate materials• Simplify regimen/reduce pill burden

Difficulty Taking

• Change formulation• Easy off caps• Pill cutters• Simplify regimen• Syringe magnification• Spacer

Cost • Generics

Steinman et al. JAMA 2010;304:1592-1601

EVALUATING MEDICATION MANAGEMENT ABILITY

Drug Regimen Unassisted Grading Scale (DRUGS)

Medication List(container or chart)

Medication List(patient-reported) Identification Access Dosage Timing

Total Medications: Total Doses:

Maximum Score: Total Score:

Summary Score:(Total Score/Maximum Score) X 100

Time:

Adapted from Edelberg et al. J Am Geriatr Soc 1999;47:592-596

MedTake Test

Adapted from Appendix I. Raehl et al. Pharmacotherapy 2002;22:1239-1248

Drug Name, dose, SIG

Patient description of how to take drug

Dose(25%)

Indication(25%)

Food/water co-

ingestion(25%)

Regimen(25%)

Score per

drug(0-100%)

Comment

1.

2.

3.

4.

5.

Scoring: 1 = correct, 0 = incorrect

Composite (Mean) MedTake Score (0-100%): _____%

MedTake Test

Totally incorr

ect

Mostly

incorrect

Somewhat incorr

ect

Somewha

t corre

ct

Mostly

correct

Perfectly

correct

Dose +0 +5 +10 +15 +20 +25

Indication +0 +5 +10 +15 +20 +25

Co-ingestion with food or water +0 +5 +10 +15 +20 +25

Regimen and schedule +0 +5 +10 +15 +20 +25

Sum of points (0-100)Knowledge score for individual drug

Adapted from Appendix I. Raehl et al. Pharmacotherapy 2002;22:1239-1248

Medication Regimen Complexity Index Checklist style tool to evaluate regimen Only for prescribed medications Medication Regimen Complexity = Total

(A) + Total (B) + Total (C) Open index

# medications and directions vary by patient

George et al. Ann Pharmacother 2004;38:1369-1376

MRCI Section A: Dosage Forms

Adapted from Appendix II. George et al. Ann Pharmacother 2004;38:1374-1375

MRCI Section B: Dose Frequency

Adapted from Appendix II. George et al. Ann Pharmacother 2004;38:1374-1375

MRCI Section C: Directions

Adapted from Appendix II. George et al. Ann Pharmacother 2004;38:1374-1375

Medication Management Instrument for Deficiencies in the Elderly

What a Patient Knows About Their Medications Yes No

1. Name all daily medications – Rx and OTC

2. State time of day each prescription medication is taken

3. State how each medication is taken (po, with water, ect)

4. State indication for each medication

5. State amount of each medication to be taken at each dose

6. Identify if there are problems with medications (ADRs)

7. Does patient get help with medicationsBy whom:_____________ Type:__________________

8. Other medications on hand (outdated, unused, discontinued)

“No” selection for 1-5 credited to Total Deficiency Score

Adapted from Orwig et al. Gerontologist 2006;46:661-668

Medication Management Instrument for Deficiencies in the Elderly

If a Patient Knows How to Take Their Medications Yes No

1. Can fill a glass with water

2. Can remove top from medication container

3. Can count out required number of pills into hand or cup

4. Can put hand with medication to open mouth; put hand to eye for eye drops; hand to mouth for inhaler; draw up insulin; place a transdermal patch

5. Can sip enough water to swallow medication

6. How are medications currently stored

If a Patient Knows How to Get Their Medications Yes No

1. Identify a refill exists on a prescription

2. Identify who to contact to refill a prescription

3. Does patient have resources to obtain medications

“No” selection for Part 1: 1-5 and Part 2: 1-3 credited to Total Deficiency Score

Adapted from Orwig et al. Gerontologist 2006;46:661-668

Hopkins Medications Schedule

Appendix. Carlson et al. J Gerontol A Biol Sci Med Sci 2005;60;223

AUXILIARY LABELS & THE IMPORTANCE OF VERBAL

COUNSELING

In Conclusion We have a lot of older patients

Patients are staying older longer Older patients need medications

They respond differently than younger patients There is not a lot of EBM to guide decisions or answer

questions on geriatric medication use Try to optimize medication prescribing and use

to minimize complications before taking the Hobson’s Choice

Questions

“All substances are poisons; there is none which is not. The right dose differentiates a poison from a remedy”-Paracelsus (1493-1541)