Medication Use and Safety Medication Use and Safety in the Elderlyin the Elderly

Amy N. Thompson, PharmD, Amy N. Thompson, PharmD, BCPSBCPS

ACOVE 5ACOVE 5

Medical University of South Medical University of South CarolinaCarolina

ObjectivesObjectives

• Understand the physiologic changes Understand the physiologic changes associated with agingassociated with aging

• Recognize potentially dangerous Recognize potentially dangerous medications for the elderlymedications for the elderly

• Identify risk factors for adverse drug Identify risk factors for adverse drug events in the elderlyevents in the elderly

• Identify proper monitoring parameters Identify proper monitoring parameters for high risk medications in the elderlyfor high risk medications in the elderly

Challenges of Prescribing for Challenges of Prescribing for Older AdultsOlder Adults• Multiple medical conditionsMultiple medical conditions

• Multiple prescribersMultiple prescribers

• Adherence and costAdherence and cost

• Lack of evidenceLack of evidence

• Supplements, herbals and over-the-Supplements, herbals and over-the-counter medicationscounter medications

• Different metabolisms and distributionDifferent metabolisms and distribution

Physiologic ChangesPhysiologic Changes

• Less body water more body fatLess body water more body fat

• Less muscle massLess muscle mass

• Decreased hepatic metabolism and Decreased hepatic metabolism and renal excretionrenal excretion

• Decreased responsiveness and Decreased responsiveness and sensitivity of the baroreceptor reflexsensitivity of the baroreceptor reflex

DistributionDistribution

• Decreased body waterDecreased body water– Decreased volume of distributionDecreased volume of distribution

•Higher concentration of water soluble agentsHigher concentration of water soluble agents

• Increased body fatIncreased body fat– Increased volume of distributionIncreased volume of distribution

• Increased half-life of fat soluble agentsIncreased half-life of fat soluble agents

• Decreased serum proteinsDecreased serum proteins– Increased concentration of agents that Increased concentration of agents that

are highly protein boundare highly protein bound

MetabolismMetabolism

• Slowed phase I metabolismSlowed phase I metabolism– Oxidation, reduction, dealkylationOxidation, reduction, dealkylation

• Unchanged phase II metabolismUnchanged phase II metabolism– Conjugation, acetylation, methylationConjugation, acetylation, methylation

ExcretionExcretion

• Reduced kidney clearanceReduced kidney clearance– 30-40% fall in functioning glomeruli by 80 30-40% fall in functioning glomeruli by 80 – 1% (at age 20) ->30% sclerotic glomeruli1% (at age 20) ->30% sclerotic glomeruli

• Serum creatinine not accurate Serum creatinine not accurate predictor of renal function due to predictor of renal function due to decreased muscle massdecreased muscle mass– Creatinine secretion reduced ~40%Creatinine secretion reduced ~40%

Pharmacodynamics

• Alterations are complex and poorly studied• Generally the elderly are more sensitive to

drug effects – Anticholinergics– Benzodiazepines

• Homeostasis is more effected by drugs – Postural BP– EPS– Cognition

Therapeutic Response

Toxic Response

Therapeutic Window

Age

Medication UseMedication Use

• People over the age of 65 consume 30% People over the age of 65 consume 30% of all prescriptions in the US and 40% of of all prescriptions in the US and 40% of all over-the-counter medicationsall over-the-counter medications– While they only represent 15% of the US While they only represent 15% of the US

populationpopulation

• Clinical trialsClinical trials– Elderly frequently not included due to Elderly frequently not included due to

unpredictable drug metabolism and effectsunpredictable drug metabolism and effects

•GF is a 68 y/o AAF – PMH: Type 2 Diabetes, HTN, GERD, HLP– Medications: Metformin, glipizide, and

hydrochlorothiazide, simvastatin

•Diagnosed today with AFib– Started on warfarin 5 mg daily – Diltiazem 240 mg daily

•One week later:– GF presents to the ER with bilateral LE

edema– Given a prescription for Lasix 20 mg

daily

•What is going on?

Medication SafetyMedication Safety

• Think about the medication regimen Think about the medication regimen before making a new diagnosisbefore making a new diagnosis– Consider ADE as etiology of new s/sxConsider ADE as etiology of new s/sx– Consider reducing dose or stopping Consider reducing dose or stopping

medications before treating a ADE with medications before treating a ADE with another medicationanother medication

Risk Factors for Adverse Drug Risk Factors for Adverse Drug EventsEvents

• >6 chronic disease states>6 chronic disease states

• >12 doses/day>12 doses/day

• >9 Medications>9 Medications

• Low BMI (<22 kg/mLow BMI (<22 kg/m22))

• Creatinine clearance <50 mL/minCreatinine clearance <50 mL/min

• FemaleFemale

Arch Intern Med.2003;163:2716-Arch Intern Med.2003;163:2716-25.25.

Adverse Drug EventsAdverse Drug Events

• Linked to preventable problems in Linked to preventable problems in the elderly, such as:the elderly, such as:– DepressionDepression– ConstipationConstipation– FallsFalls– ImmobilityImmobility– ConfusionConfusion– Hip fracturesHip fractures

J Am Geriatr Soc 2012; J Am Geriatr Soc 2012; 60(4):616-31.60(4):616-31.

Avoiding Potentially Dangerous Avoiding Potentially Dangerous Drugs: Beers CriteriaDrugs: Beers Criteria

• Consensus-based list of potentially Consensus-based list of potentially inappropriate medications for older adultsinappropriate medications for older adults

• Published 1991; revised in 1997, 2002, 2012Published 1991; revised in 1997, 2002, 2012• Criteria covered 2 types of statements:Criteria covered 2 types of statements:

– Medications that should generally be avoided Medications that should generally be avoided because they are either ineffective or they pose because they are either ineffective or they pose a high riska high risk

– Medications that should not be used in older Medications that should not be used in older persons known to have specific medical persons known to have specific medical conditionsconditions

Beers Criteria: Anticholinergic Beers Criteria: Anticholinergic AgentsAgents

• Drug classesDrug classes– Tricyclic antidepressantsTricyclic antidepressants– AntihistaminesAntihistamines– Antispasmodics and muscle relaxantsAntispasmodics and muscle relaxants

• Adverse eventsAdverse events– Urinary incontinenceUrinary incontinence– ConstipationConstipation– Confusion, delirium, behavior changesConfusion, delirium, behavior changes– Exacerbation of dementiaExacerbation of dementia

Beers Criteria: Beers Criteria: BenzodiazepinesBenzodiazepines• Avoid entirely if at all possibleAvoid entirely if at all possible• Challenging to stop for patients with long-Challenging to stop for patients with long-

term useterm use• Long-actingLong-acting

– Prolonged half-life in older adults (days)Prolonged half-life in older adults (days)– Sedation, cognitive impairment, depressionSedation, cognitive impairment, depression– Increased risk of falls and fracturesIncreased risk of falls and fractures

• Short-actingShort-acting– Increased sensitivity in older adultsIncreased sensitivity in older adults– If necessary, use lower dosesIf necessary, use lower doses

Beers Criteria: Pain Beers Criteria: Pain MedicationsMedications• Non-steroidal anti-inflammatory drugs Non-steroidal anti-inflammatory drugs

(NSAIDS) that should be avoided (NSAIDS) that should be avoided completely:completely:– Indomethacin has significant CNS side Indomethacin has significant CNS side

effectseffects– Ketorolac (Toradol) can cause serious GI Ketorolac (Toradol) can cause serious GI

and renal effectsand renal effects

Beers Criteria: Pain medications•Long-term use of NSAIDS

– Potential for GI bleed– Renal failure– Heart failure– High blood pressure

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

Beers Criteria: Cardiovascular Agents

•Digoxin– Should not exceed 0.125 mg/day except

when treating atrial arrhythmias– Decreased renal clearance, increase in

toxic effects

•Amiodarone– Associated with QT interval problems– Lack of efficacy in older adults

Beers Criteria: Disease Beers Criteria: Disease SpecificSpecific• Parkinson’s disease:Parkinson’s disease:

– metoclopromide and anti-psychoticsmetoclopromide and anti-psychotics

• Stress incontinenceStress incontinence– alpha-blockersalpha-blockers

• HyponatremiaHyponatremia– SSRIsSSRIs

• ConstipationConstipation– calcium channel blockerscalcium channel blockers

• Cognitive impairmentCognitive impairment– Anticholinergics, antispasmodics, and muscle Anticholinergics, antispasmodics, and muscle

relaxantsrelaxants

2012 Update

•Released March 1, 2012•Removed medications that are no longer

available– Propoxyphene

•Additions to medications that should be avoided:– Megestrol– Glyburide– Avoid sliding scale insulin

American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication use in Older Adults, J Am Geriatr Soc, 2012

2012 Update•Additions to patients with particular

disease state:– TZDs with CHF– ACH inhibitors with hx of syncope– SSRIs with hx of falls/fractures

•Added 3rd category:– Medications that should be used with

caution in the elderly– All of which have ‘weak’

recommendations due to insufficient data

2012 Update

– Aspirin for primary prevention •Lack of benefit vs risk in patients >80

– Dabigatran•>risk of bleeding than warfarin in patients >75•Lack of evidence in patients with CrCl <30

– Prasugrel•Greater risk of bleeding; benefit may be

greater in higher risk elderly (prior MI or DM)

– SIADH risk– Risk of syncope with vasodilators

JAMA. 2006;296:1858-1866JAMA. 2006;296:1858-1866

Adverse Drug EventsAdverse Drug Events

• National surveillance of ED visits for National surveillance of ED visits for outpatient ADEoutpatient ADE– 2 year study, 21,000 ADEs reported2 year study, 21,000 ADEs reported

•3,500 required hospitalization3,500 required hospitalization

– People >65People >65•ED visits were twice that of those youngerED visits were twice that of those younger

– 4.9 per 1,000 vs. 2.7 per 1,00004.9 per 1,000 vs. 2.7 per 1,0000

•Hospitalizations nearly 7 times higherHospitalizations nearly 7 times higher– 1.6 per 1,000 vs. 0.23 per 1,0001.6 per 1,000 vs. 0.23 per 1,000

Adverse Drug EventsAdverse Drug Events

• Drugs for which regular outpatient Drugs for which regular outpatient monitoring is used to prevent acute monitoring is used to prevent acute toxicity accounted for 54% of toxicity accounted for 54% of hospitalizationshospitalizations

• Three medications caused 1/3 of ED Three medications caused 1/3 of ED visitsvisits– InsulinInsulin– WarfarinWarfarin– DigoxinDigoxin

Adverse Drug Events

•Cardiovascular medications

•Psychotropic medications

•Antibiotics

•Anticoagulants

•NSAIDS

•Anti-seizure medications

JAGS.2007; 55:S383–S391.JAGS.2007; 55:S383–S391.

NSAID Use and GI Bleeds

• Several risk factors place the elderly population at increased risk for GI bleeds– >75 years of age– History of PUD– History of GI bleed– Concomitant use of warfarin – Long term glucocorticoid use

• These patients warrant treatment with misoprostol or PPI

Medication SafetyMedication Safety

• Prescribe one medication at a timePrescribe one medication at a time

• Start the dose low and titrate up Start the dose low and titrate up slowlyslowly

• Use once daily dosing if possibleUse once daily dosing if possible– Increases patient adherenceIncreases patient adherence

• Monitor the patient for response and Monitor the patient for response and adverse effectsadverse effects

•3 weeks later….•GF falls in the middle of the night

while trying to get to the bathroom, she is subsequently admitted to the hospital

•Upon discharge her medications have been changed – D/C lasix, diltiazem– Start amiodarone 400 mg BID

•Given her current treatment plan would you recommend any changes?

•Most current medication list– Warfarin 5 mg daily– Hydrochlorothiazide 25 mg daily– Simvastatin 40 mg daily– Amiodarone 400 mg BID

J Am Geriatr Soc. J Am Geriatr Soc. 1996;44(8):944–9481996;44(8):944–948

Medication SafetyMedication Safety

• Avoid drug-drug interactions that are Avoid drug-drug interactions that are associated with hospitalizationsassociated with hospitalizations– ACE Inhibitor plusACE Inhibitor plus

•Potassium sparing diuretic or potassium Potassium sparing diuretic or potassium supplementsupplement

– BenzodiazepineBenzodiazepine•Antidepressant and antipsychoticsAntidepressant and antipsychotics

– WarfarinWarfarin•New antibiotic, potent CYP inhibitors/inducersNew antibiotic, potent CYP inhibitors/inducers

• It has been 1 month since hospital discharge and GF is returning to clinic for follow-up

•She complains today of feeling very weak and have dark stools for the past week

•What is the most likely cause?

Medication Safety

•Educate the patient– Indication– Why it is being used– What they need to watch for– Provide the patient with an up-to-date

medication list at each visit

•Always assess compliance

Medication SafetyMedication Safety

• Always assess the Risk vs. BenefitAlways assess the Risk vs. Benefit– Appropriate medication use requires that Appropriate medication use requires that

benefits of therapy clearly outweigh the benefits of therapy clearly outweigh the associated risksassociated risks

– Benefit-to-risk ratio is unique to an individual; Benefit-to-risk ratio is unique to an individual; the very medication and dosage that helps one the very medication and dosage that helps one patient may harm anotherpatient may harm another

• Remember that supplements, herbal and Remember that supplements, herbal and OTC agents can cause ADEOTC agents can cause ADE

• Know what your patient is takingKnow what your patient is taking

• Its been three months and GF has been doing well. After her last discharge her amiodarone was stopped and metoprolol 25 mg BID was started

•Her INR has been stable between 2 and 2.5 since her GI bleed

• She presents to the ER today with signs and symptoms of a stroke– INR on presentation 1.4

• Current medications– Warfarin 5 mg daily– Simvastatin 20 mg daily– Hydrochlorothiazide 25 mg daily– Metoprolol 25 mg BID– St Johns Wort 1 tablet daily

• What is going on?

Medication SafetyMedication Safety

• Common herbal agents that can be Common herbal agents that can be hazardoushazardous– Garlic, gingko, green teaGarlic, gingko, green tea

• Increased bleeding timeIncreased bleeding time

– St. John’s WortSt. John’s Wort• Increased clearance of medications Increased clearance of medications

metabolized by CYP-3A4metabolized by CYP-3A4

– Chromium, gingko, nettleChromium, gingko, nettle•HypoglycemiaHypoglycemia

Quality IndicatorsQuality Indicators

• All elders should have an up-to-date All elders should have an up-to-date medication list in the medical recordmedication list in the medical record

• If an elder is prescribed a drug, then If an elder is prescribed a drug, then the prescribed drug should have a the prescribed drug should have a defined indicationdefined indication

• If an elder is prescribed a drug, then If an elder is prescribed a drug, then they should receive appropriate they should receive appropriate education about its useeducation about its use

Quality IndicatorsQuality Indicators

• If an elder receives a new If an elder receives a new prescription for a medication known prescription for a medication known to be high risk, proper monitoring to be high risk, proper monitoring should be performedshould be performed

SkillsSkills

• Medication reconciliation done at patient visit Medication reconciliation done at patient visit and hospitalizationand hospitalization– All prescribed medicationsAll prescribed medications– Topical agents/transdermal patchesTopical agents/transdermal patches– OTC medicationsOTC medications– Herbal products and supplementsHerbal products and supplements– Eye and ear dropsEye and ear drops– InhalersInhalers

• Drug list will be printed from Oacis each day Drug list will be printed from Oacis each day when on inpatient servicewhen on inpatient service

Medication SafetyMedication Safety

• Is patient taking any over-the-Is patient taking any over-the-counter medications or herbal counter medications or herbal supplements?supplements?– Did you evaluate for harm and drug Did you evaluate for harm and drug

interactions?interactions?

SkillsSkills

• Dose advisor should be used to Dose advisor should be used to ensure proper dosing for any new ensure proper dosing for any new medicationmedication

SkillsSkills

• Anytime a new medication is started Anytime a new medication is started the patient will be given a patient the patient will be given a patient education sheet from Micromedexeducation sheet from Micromedex®®

http://www.thomsonhc.com.ezproxy.musc.edu/carenotes/librarian

SkillsSkills

• Any new medication prescribed to an Any new medication prescribed to an elder will have the indication written elder will have the indication written in the directionsin the directions– This will aid in patient education and This will aid in patient education and

adherenceadherence

SkillsSkills

• Any high risk medication will be Any high risk medication will be appropriately monitoredappropriately monitored

Medication SafetyMedication Safety

• Is the patient currently on Is the patient currently on amiodarone therapy?amiodarone therapy?– Is the patient on warfarin?Is the patient on warfarin?

•Has the dose been appropriately adjusted?Has the dose been appropriately adjusted?

– Is the patient on digoxin?Is the patient on digoxin?•Has the dose been appropriately adjusted?Has the dose been appropriately adjusted?

– Is the patient on simvastatin?Is the patient on simvastatin?• Is the patient on 20mg/or less a day?Is the patient on 20mg/or less a day?

Medication SafetyMedication Safety

• If warfarin is prescribedIf warfarin is prescribed– PT/INR should be drawn within 4 days PT/INR should be drawn within 4 days

for new startsfor new starts– Has a PT/INR been drawn in the past 30 Has a PT/INR been drawn in the past 30

days?days?• If not, did you schedule an appointment with If not, did you schedule an appointment with

the PharmD today?the PharmD today?

Medication Safety

• If a hypoglycemic agent is prescribedIf a hypoglycemic agent is prescribed– Has an A1C been checked within the last 6 Has an A1C been checked within the last 6

months?months?• If not, have you ordered one to be drawn today?If not, have you ordered one to be drawn today?

– Did you ask the patient about s/sx of Did you ask the patient about s/sx of hypoglycemia?hypoglycemia?• If patient is experiencing s/sx of hypoglycemia, If patient is experiencing s/sx of hypoglycemia,

what did you do to address this issue?what did you do to address this issue?– Reduce the dose of the hypoglycemic agentReduce the dose of the hypoglycemic agent– Refer to a CDE for further managementRefer to a CDE for further management

Medication SafetyMedication Safety

• Is patient currently receiving NSAID Is patient currently receiving NSAID therapy?therapy?– Did you ask about the signs/symptoms Did you ask about the signs/symptoms

of GI bleeding?of GI bleeding?– Does patient have a history of PUD?Does patient have a history of PUD?

•Are they being treated with a PPI?Are they being treated with a PPI?– If not, did you start one today?If not, did you start one today?

Medication Safety

• Is patient currently receiving digoxin?Is patient currently receiving digoxin?– Did you ask the patient about s/sx of Did you ask the patient about s/sx of

digoxin toxicity?digoxin toxicity?•Did patient have s/sx of toxicity?Did patient have s/sx of toxicity?

– If so, did you order a digoxin level today?If so, did you order a digoxin level today?

Skills

•Each patient will receive an Aging Q3 pillbox to aid in patient adherence

Patient Survey

•Surveyors to randomly select elders after check-out process occurs:– Do you know who your doctor is?– Were you given a medication list today?– Were you started on a new medicine

today?– If so, were you given an information sheet

on this medication?– Do you know what this medicine is for?

Take Home PointsTake Home Points

• Review and reconcile medications at each Review and reconcile medications at each visit:visit:– Indication for each medication?Indication for each medication?– Contraindications? (renal, dementia)Contraindications? (renal, dementia)– Can I STOP any medication?Can I STOP any medication?– Is the patient on any OTCs, herbals or Is the patient on any OTCs, herbals or

supplements?supplements?

• Write indications on prescriptionsWrite indications on prescriptions– Increase patient knowledge and complianceIncrease patient knowledge and compliance

Take Home PointsTake Home Points

• Avoid high-risk medications if possibleAvoid high-risk medications if possible– Beers criteriaBeers criteria– If high-risk medications is used, monitor If high-risk medications is used, monitor

appropriatelyappropriately

• When prescribing new medicationWhen prescribing new medication– Are there any drug-drug interactions?Are there any drug-drug interactions?– Is it appropriately dosed?Is it appropriately dosed?

• Remember to look for ADERemember to look for ADE

Questions???????????