Polypharmacy in the Elderly - Mannor Law Group · 5 • ADR: noxious and unintended response that...
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1 Ina J. Golden BSN RN CEN EMT-P TCF Polypharmacy in the Elderly 1. Carol, age 76, with high dose prednisone 2. Hannah, age 69, with dementia and on 23 different medications; agitated with outbursts 3. Beatrice, age 81, with a history of high blood pressure, in rehab with a post-op fractured hip 4. Esther, age 83, with a “going” problem who saw an ad in a magazine for a pill to “fix it” } How does it happen? } What are the risks to older adults } How do we minimize those risks?
Transcript of Polypharmacy in the Elderly - Mannor Law Group · 5 • ADR: noxious and unintended response that...
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Ina J. Golden BSN RN CEN EMT-P TCF
Polypharmacy in the Elderly
1. Carol, age 76, with high dose prednisone2. Hannah, age 69, with dementia and on 23
different medications; agitated with outbursts
3. Beatrice, age 81, with a history of high blood pressure, in rehab with a post-op fractured hip
4. Esther, age 83, with a “going” problem who saw an ad in a magazine for a pill to “fix it”
} How does it happen?
} What are the risks to older adults
} How do we minimize those risks?
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“concurrent use of several different medications consumed by a person.”
www.homehealthcarenow.org, Volume 33, Number 10, pp 524-529
1. Prescription medications2. Over-the-counter medications3. Vitamins4. Herbals5. Supplements6. Insulin7. Suppositories8. Patches9. Inhaled
} Multiple Physicians} Herbs and Supplements} Self-Medicating} Medicine-Dependent Culture} Medication Administration Errors} Over-the-Counter Medicine Usage} Hospitalizations} Treating Medication Side Effects with Other Meds
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} Absorption may take longer
} Metabolize/break down drugs slower à higher levels of drugs in the body
} Excrete drug slower à drug stays in the body longer
} Become more sensitive to medications
} Medicare beneficiaries with multimorbidity comprise 90% of all Medicare spending◦ More medicines à greater drug expenditure
} Increased risk of potentially inappropriate medication àincreased risk of outpatient visits, hospitalizations, duration of hospital stay
Weiss CO, et al. JAMA 2007;298:1158-62.Akazawa M, et al. Am J Geriatr Pharmacother 2010;8:145-60.
Lu WH, et al. CMAJ 2015;187:E130-7..
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} Rehab physician or LTC physician hesitates to change the medication prescribed by the hospital physician
Hospitalized for aheart attack
Prescribed Prilosec to prevent stomach ulcers in
the ICU
Discharged with Prilosec, no indication for drug
1. Prescribing of medications that does not agree with accepted medical standards (Johnson & Johnson law suits)
2. Prescribing of medications where potential risks outweigh potential benefits
Likelihood of potentially inappropriate medication selection increases with number of medications
3. Error in transcribing
AARP Bulletin/Real Possibilities, Prescription for Abuse July-Aug 2014. Kuijpers MA, et al. Br J Clin Pharmacol 2007;65:130-133.O’Mahony D, Gallagher PF. Age Ageing 2008;37:138-141.
Rochon PA, et al. BMJ 1997;315:1096-1099.
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• ADR: noxious and unintended response that occurs at normal doses of a medication
• Common culprits: heart meds, blood pressure drugs, diuretics, NSAIDS, anticoagulants, antibiotics, anticonvulsants, antidiabetics
• Risk for ADR increases with number of medications
• ~30% of all unplanned hospitalizations in the elderly are attributed to adverse drug reactions!
Naples JG, et al. Geriatric Pharmacotherapy. In: Brocklehurst’s Textbook of Geriatric Medicine. 7th Ed. (in preparation)
Marcum ZA, et al. J Am Geriatr Soc 2012;60:34-41.
Nonadherence à disease progression, treatment failure, hospitalization, adverse drug events
$100 billion in preventable costs associated with nonadherence
Polypharmacy à complex regimens that ↓ adherence(Neighbor that asked for help – discharged to home post 3 month ICU admission on 13 different meds and no additional support)
Vik SA, et al. Ann Pharmacother 2004;38:303-12.Hajjar ER, et al. Am J Geriatr Pharmacother 2007;5:345-51.
Salazar JA, et al. Expert Opin Drug Saf 2007;6:695-704..
How can we minimize the risks?
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Condition Drug _____ Nonpharm Option____Behavior Issues Antipsychotics Massage/touch or
music therapy__________
Depression Tricyclic antidepressant, paroxetine *CBT___________
Pain Tricyclic antidepressant **PENS, ***TENS, acupuncture, *CBT______
Sleep Antihistamines ____ Sleep hygiene, exercise__
Semla T et al. J Amer Geriatr Soc 2015 (in press).
*CBT = cognitive behavioral therapy**PENS = Percutaneous electrical nerve stimulation***TENS = transcutaneous electrical nerve stimulation
} What is the name? Is this the brand or generic name?
} What is it for? } How and when do I take it?} How should I take it?} What foods, drinks, other
medicines, dietary supplements, or activities should I avoid while taking this medicine?
National Council on Patient Information and Education: www.talkaboutrx.org.
} When should it start working?} How will I know if it is working?} Are there any tests required with
this medicine?} What are the side effects? } What should I do if I have side
effects? } Will it work safely with any dietary/
herbal supplements I am taking?
National Council on Patient Information and Education: www.talkaboutrx.org.
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} Will I be able to refill the medication?
} When should I order a refill?} How should I store this medicine?} Is there any written information
available about the medicine? } Is the information available in large
print or a language other than English?
National Council on Patient Information and Education: www.talkaboutrx.org.
} Don’t take any new drug until it has been on the market for several years
} Bring a record of all medications (prescription, over-the-counter, and supplements) to all doctor’s appointments
} Show a pharmacist the complete list whenever starting or stopping a medication
} If needed, ask for easy to open caps } Take medication as directed (with food, without
food)
} Ask for generics & drugs on the insurance formulary
} Have pharmacists review drug profile and make suggestions to healthcare provider for less costly but effective alternatives
} Don’t ask for samples (only available for new and expensive drugs)
} Buy in bulk (e.g., 90 day supply)} Consider signing up for Medicare Part D if there is
no other prescription drug coverage
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1. Carol, age 76, with high dose prednisone2. Hannah, age 69, with dementia and on 23
different medications; agitated with outbursts
3. Beatrice, age 81, with a history of high blood pressure, in rehab with a post-op fractured hip
4. Esther, age 83, with a “going” problem who saw an ad in a magazine for a pill to “fix it”
By Rachel DeSimpelareCertified Elder Care Coordinator
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} Communication◦ With Doctors� Does the doctor truly “hear” and understand the
patient? � Does the doctor understand the situation? � Does the doctor have all the relevant information?� Does communication happen between Dr. & patient?� Is what the doctor says understood by the patient?
} Do the relevant people understand the plan◦ Family◦ Social Worker and Discharge Planner◦ Accepting facility or care agency
} Care Conferences } Understand the issues involved
} Do the patient and relevant people understand the prognosis and the disease trajectory?
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Gradual decline affecting memory, ADL’s and behavior
Func
tion
Time
High
Low
◦ Sometimes suddenly after a stroke, often combined with other types of dementia
◦ Memory loss may or may not be significant ◦ Confusion, disorientation, difficulty speaking◦ Step-wise decline
Func
tion
Time
High
Low
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◦ Often occurs at a younger age, only lasts about a decade
◦ Affects judgment, behavior, inhibition, reasoning, planning, emotions, understanding and speech.
◦ Behavior increases, then tapers. ◦ Often confused with mental health
Func
tion
Time
High
Low
◦ Affects reasoning, muscle movement, hallucinations, negative personality
◦ Hard on caregivers & family ◦ Difficulty interpreting visual
stimulus ◦ Often sudden rapid decline
} Do the patient and relevant people understand the level of care that is needed?
} Do they understand the different levels of care?◦ Skilled in home care◦ Private duty◦ Independent Living◦ Assisted Living◦ Memory Care◦ Rehab/Skilled Nursing Facility
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} Does the patient understand how services are paid for?◦ Medicare vs. Medicaid ◦ Private Pay
} Can we come up with a plan to make long term care sustainable?◦ Patient’s financial advisor◦ Veteran’s Benefits◦ MI Choice Waiver◦ Community Resources◦ Long Term Care Medicaid
Ina J. Golden BSN RN CEN EMT-P TCF
Elder Care CoordinatorMannor Law Group
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◦ Improve quality of life for seniors◦ Maintain independence longer and more
economically◦ Reduce hospitalizations and improve health◦ Have better access to care◦ Reduce Medicare and Insurance expenditures◦ Provide better care at home
} Mannor Law Group and I do not endorse or recommend any commercial products, processes, or services contained in this presentation.
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} Over 27% of community-resident seniors have difficulty performing one or more ADL:◦ Bathing, dressing, eating, and getting around
} Another 13% have difficulties with instrumental activities of daily living (IADL):◦ Meal prep, shopping, managing money, using the
telephone, housework, taking medications
} 93% of institutionalized seniors have difficulties with ADLs
}Body}Mind}Spirit} Integrated Systems}Apps for phone or tablet
} Our senses: seeing and hearing
} Nutrition: eating and drinking
} Mobility: exercise and how we get around
} Safety and Security
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} More light} Less glare} Cooler lights} Lights with less
contrast} More task lights} “Scene” controls
with 1 switch◦ Daytime◦ Evening – TV◦ Cooking◦ Eating◦ Crafts, reading
Serene Innovations HD-40P Amplified Photo Phone
$79.95
Harriscomm.com
} Hearing aids} Environmental modifications to
dampen echos} Hearing Aid for Cell Phones
◦ Iphone technology◦ Devices to amplify signals and suppress background
noise◦ Church with special wiring and headphones
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Smart Spoon
Wii-Fit
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} Anti Scald Device
} Automatically shuts water off at 117 ‘F
} Sink or showerhead available
} $51.95} http://www.alzstore.com/anti-
scald-device-p/0200.htm
Moen Touchless Water Faucet
} Battery operated device that sounds alarm when sensor is in contact with water
} Place on sink or tub
} $14.95
} http://testproducts.com/flood-alarm-battery-operated-utl2002-white-with-remote-sensor-cord-p-264.html
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} RAB LOS800 Smart Switch 800 Watts, 3 Wire Motion Sensor Light Switch
} $28.57
} http://www.elights.com/los800.html
} Turns any door into a book case in the eyes of the individual who might wander, deterring them from entering or exiting.
} $39.95
} http://www.murals4less.com/BIBLIOTHEQUE%20601.htm
} Properly designed technological interventions can restore some functions and compensate for others
} Memory Aids
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Annals of Internal Medicine, Americans are failing to comply with medication prescriptions for a variety of reasons -- and it's costing them anywhere between $100 billion to $289 billion a year.
http://www.theatlantic.com/health/archive/2012/09/the-289-billion-cost-of-medication-noncompliance-and-what-to-do-about-it/262222/
} Alarmed, automated dispenser
} Stores medication under lock and key
} Can deliver 7 days worth, up to 4X / day
} $149.00
http://www.forgettingthepill.com/products/medready-pill-dispenser-item-353
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} “The Vibrating Wristwatch that will privately cue you through your day”.
} 65 pre-programmed messages
} Waterproof
} $69.00
} www.watchminder.com
} Provide a sense of:
◦ Purpose
◦ Predictability
◦ Control
} Volunteer – telephone reassurance} Wisdom Circle – online advice offered by
Elders} Tutor inner city children} Social networking} Church services – live or delayed
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} Sense of satisfaction and well being◦ Participation in social events
} Strong social support◦ even from a distance
} “Augmentative & Alternative Communication”
} Creates voices from recordings of a patient’s natural voice.
} Allows individuals who are losing their speech to have a synthetic voice.
Telikin “Touch” Computer$1079.00 WOW “Touch”
Computer$1099.00
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} Self check health applications} “I Know You” - upload photos } “Voice Over” – names Icons outloud} Zoom, black-on-white, white-on-black} Mono audio – use with earphones} Speak It! Text to speech} Email} Facebook} Skype
} iOS 8.3 Accessibility Features for Vision} Note: These features do not work in all apps or on all webpages.
All info obtained from Apple or on the iPad directly.} Accessibility Shortcut Read First} Changing Font Size and Boldness } Button Shapes} Changing Color and Contrast} Speech} Zoom} VoiceOver} Video Description} Accessibility Shortcut IMPORTANT READ FIRST} When you triple-click the Home Button, you will be able to toggle
these checked items on/off. You must set this first before turning any other Accessibility Features on or you may have difficulty turning them off.
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} “Smart Care” apartment} “Granny Pod”, “Med Cottage”
} Sensors underneath tiles on the floor◦ evaluate changes in
gait and weight} Camera in the
bathroom mirror ◦ facial expression◦ Heart rate◦ skin color◦ Lift chair◦ Exercise equipment◦ Automated beds
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} Pageonce – keeps track and organizes bills} BugMe! - appointment reminders} Find my Ipad – locate Ipad with Iphone} Words with Friends – Scrabble on-line} iTunesU – college lectures} Luminosity – brain games to stay sharp} WeatherBug – Forecasts & alerts} iBooks – Turns iPad into eReader} Kindle – eBook reader, holds 100’s of books} Art – art museum and art history course} Goodreads – book reviews, recommendations} WebMD – health information} Motion Doctor – shows simple stretches and exercises} HeartWise Blood Pressure Tracker – record blood pressures} Magnifying Glass – turns Ipad into a magnifying glass} Big Calculator – really big buttons} More…
} Caring Bridge – bridge that allows you and your loved ones to stay in touch
} Caregivers Touch – store and update info, can synch to family’s smartphone
} My Health Care Wishes – from American Bar Association – readily accessible advance directives
} Taskit-HHC – stop “Did you take your meds” calls. Caregiver taps and administrator sees it. Assigned tasks are checked off and communicated
} Unfrazzle – “to do” list & journals} Lostsa Helping Hands – painless way to organize help} Dementia Caregiver Solutions – Informational, developed by aging
expert, addresses difficult behaviors} Elder411 – video and audio tops for caregivers, Q&A from a doctor,
searchable, can share content} BioMed – detailed log of senior’s medical information} Pain Care – track and manage loved one’s pain; location, intensity, etc.} Stress Stopper Pro – strategies and breathing exercises to help reduce
stress} More
THAT’S ALL!
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Casell, C (2015, Sept 3). Technology for AIP, in How Technology, Universal Design and Occupational Therapy Support and Enhance Aging in Place Features in One’s Home. Webinar sponsored by American Society on Aging Network on Environments, Services and Technologies (NEST)
Furphy, K., Lindstrom-Hazel, D., & Burdick, D. (2015) Assistive technology and older adults. In Barney, K. F. & Perkinson, M.A. (Eds.). Occupational Therapy with Aging Adults: Enhancing Quality of Life through Collaborative Practice. London, San Diego: Elsevier, Inc.
Kutzik, D. & Burdick, D.C. (2014). Use of technology in long-term care. In Yee-Melichar, D, Cabigao, E.P. & Flores, C. M. (Eds.) Long-Term Care Admin & Management: Options, Issues and Trends in Eldercare. NY: Springer.
Mayhorn, C., Rogers, W., & Fisk, A. (2004). Designing Technology Based on Cognitive Aging Principles. In D. Burdick & S. Kwon, (Eds.), Gerotechnology: NY: Springer.
Schieber, R. (2002). Human factors and aging: compensating for age-related deficits in sensory and cognitive function. Available: https://www.researchgate.net/publication/228724902_Human_factors_and_aging_Identifying_and_compensating_for_age-related_deficits_in_sensory_and_cognitive_function
Shireley, P. (2008). Assistive Technologies for dementia and Mental Illness (Powerpoint). North Dakota Interagency Program for Assistive Technology. www.ndipat.org
} American Society on Aging’s NEST (Network on Environments, Services, and Technology) www.asaging.org/nest
} Center for Aging Services Technology (CAST) www.leadingage.org/cast.aspx
} Gerontological Society of America’s Technology and Aging Formal Interest Group
} SPRY Foundation – web design, computer training. www.spry.org
