Polypharmacy in the Geriatric Population

Maegan Rogers, PharmD, BCPS, CDEInternal Medicine Clinical Pharmacy Specialist

Regional One HealthMemphis, TN

Objectives

• Define polypharmacy

• Describe risk factors for geriatric patients

• Indentify common “offending” medications

• List available screening tools for polypharmacy

• Describe ways to limit adverse drug events in the elderly population

Definitions

• Geriatric Population– “Greatest generation”

– Baby Boomers?

• Polypharmacy– Prescribing multiple medications

– Five or more

• Inappropriate prescribing (IP)– Potentially inappropriate medications (PIM)

– Potential prescribing omissions (PPO)

C. Parsons. Ther Adv Drug Saf. 2017, Vol 8(1) 31-46

Definitions

Adverse Drug Events (ADE)

• Unintended and undesired effects

• Five categories

– Adverse drug reaction

– Medication error

– Allergic reactions

– Withdrawal

– Overdose

https://health.gov/hcq/ade.asp. Accessed April 2019

Anyone’s Grandma

Anyone’s Grandma

Geriatric Population

Now most live into 60s and beyond

http://www.searo.who.int/entity/health_situation_trends/data/chi/elderly-population/en/. Accessed April 2019

Pharmacokinetics

• Decreased function

– Renal

– Hepatic

• First-pass clearance

• Protein binding

• Absorption

Klotz U. Drug Metabolism Reviews. 2009, 41:2, 67-76

Polypharmacy in the Elderly

• 37% patients 75-85 years old

• Hospitals

– Five to eight meds – 41%

– One or more unnecessary – 59%

• > 50% nursing home residents

Maher Jr RL, et al. Expert Opin Drug Saf. 2014, Jan 13(1): doi:10.1517/14740338.2013.827660

Polypharmacy in the Elderly

Negative outcomes• Greater cost• Increased ADE

– Drug interactions– Non-compliance

• Reduced functional capacity– Activities of daily living (ADLs)– Nutrition

• Multiple geriatric syndromes– Cognitive impairment– Falls– Urinary incontinence

Maher Jr RL, et al. Expert Opin Drug Saf. 2014, Jan 13(1): doi:10.1517/14740338.2013.827660

Polypharmacy in the Elderly

• “Do the wrong thing for the right reason.”

– Guideline contributions

– Evidence-based medicine

• Two disease states – all it takes

– Diabetes

– Heart failure

– COPD

Adverse Drug Events

Each Year Cause

• 3.5 million physician office visits

• 1 million ER visits

• 125,000 hospital admissions

– 1 in 3 hospital adverse events

– Affect 2 million hospital stays

– Prolong hospital stay 2-5 days

https://health.gov/hcq/ade.asp

ADE in the Elderly

• Pharmacokinetics and polypharmacy unavoidable

• Steps to minimize

– Accurate records

– Balance polypharmacy

– Individualize doses

– Simple regimens

– Safe management by patients

– Therapeutic drug monitoring

– Inter-disciplinary

Brahma DK et al. J Pharmacol Pharmacother. 2013 Apr-Jun; 4(2): 91-94.

Decreasing Polypharmacy

• Education

– Providers

– Patients

• Clinical pharmacy

– Medication therapy management

– Multidisciplinary teams

– Medical homes

• Tools

Polypharmacy Screening Tools

• Beers list

• STOPP criteria

• START criteria

• Inappropriate prescribing in the elderly tool (IPET)

– Published in Canada

– 14 criteria

Beers Criteria

• Potentially Inappropriate Mediciations

• Most commonly used list– Organ system

– Therapeutic category

– Drugs

• Drug-disease

• Use with caution

• Interactions

• Renal impariment

2019 AGS Beers Criteria Update Expert Panel. J Am Geriatr Soc 00:1-21, 2019

Beers Medications

• Alpha-1 blockers• Amiodarone• Anticholinergics• Antidepressants

– Amitriptyline– Doxepin

• Antipsychotics• Antispasmodics• Barbiturates• Benzodiazepines• Benztropine• Clonidine• Digoxin

• Dipyridamole• Estrogen• Megestrol• Meperidine • Metoclopramide• Muscle relaxants• Nitrofurantoin• NSAIDs• Proton-pump inhibitors• Sedative hypnotics• Sulfonylureas • Testosterone

2019 AGS Beers Criteria Update Expert Panel. J Am Geriatr Soc 00:1-21, 2019

STOPP Criteria

• Screening Tool of Older persons’ Potentially inappropriate Prescriptions

• 65 clinical criteria

• ADEs significantly associated

Gallagher P et al. Arch Intern Med. 2011;171(11):1013-1019

START Criteria

• Screening Tool to Alert doctors to Right Treatments

• 22 clinical criteria

• Used with STOPP criteria

• Correct treatments

Barry PJ et al. Age and Ageing. 2007; 36:632-638

• Prospectively over 4 months

• 600 patients– 329 ADEs in 158 patients (26.3%)

– 66.6% contributed to admission

• STOPP criteria associated with avoidable ADE (p<0.001)

• Beers criteria not associated with reduction (p=0.11)

• Prospective study • Oct 2016 - April 2017• 234 patients ≥ 75 years• Pharmacist intervention• Primary outcomes

– Polypharmacy (≥ 5 drugs)– Hyperpolypharmacy (≥ 10 drugs)– Number of medications– Medication-related problems– STOPP/START criteria– Discharge

Results• 234 patient • Medication appropriateness

– 2469 admission medications– 2344 discharge medications

• 802 drugs discontinued (32.5%)• Improvement (p ≤ 0.001)

– Polypharmacy (-10.2%, 95% CI -15.3, -5.2)– Hyperpolypharmacy (-16.6%, 95% CI -22.3 -11.0)– Number of medications (-1.4, 95% CI -1.8, -1.0)– STOPP criteria (-19.2%, 95% CI -24.9, -13.6)– START criteria (-6.8%, 95% CI -10.1, -3.5)– Medication-related problems (-2.7, 95% CI, -2.9, -2.4)

Conclusions

• A systematic pharmacist-led intervention at hospital admission with a comprehensive geriatric assessment was associated with a decrease in polypharmacy, medication-related problems, and potentially inappropriate prescribing

Anticholinergics

• Reduced clearance

• Tolerance

• Risk

– Confusion

– Dry mouth

– Constipation

• Diphenhydramine may be used sparingly

Anticoagulants

• Warfarin– Interactions

• Antibiotics• Anticonvulsants• Amiodarone• Diet – Vitamin K• NSAIDs – Aspirin

– Monitoring– Fall/bleed risk

• Direct-oral anticoagulants– Preferred if appropriate– Still fall/bleed risk

Antidiabetic

• Goal HgA1c < 7%?

• NO GLYBURIDE!!!

• Titrate insulin carefully

• Watch for hypoglycemia

• Consider ADE

– Thiazolidinediones

– SGLT2 inhibitiors

Practical Considerations

• Avoid medications to treat effects of other medications

• Ask about OTC medications

• Review lists regularly

• “Start low and go slow”

• Use Beers list, STOPP, and START criteria

Pretorius RW et al. Am Fam Physician. 2013;87:331-336

Questions