Polypharmacy  and  the  Management  of  Mul4ple  

Chronic  Condi4ons  

Cara  Tannenbaum  MD,  MSc  Paula  Rochon  MD,  MPH,  FRCPC  

Barbara  Farrell  BScPhm,  PharmD,  FCSHP  

Panel  

Cara  Tannenbaum  MD,  MSc  Prac4cing  geriatrician,  Associate  Professor  of  Medicine  and  Pharmacy  Michel  Saucier  Endowed  Chair  on  Geriatric  Pharmacology  Health  and  Aging,  Université  de  Montréal.      

Paula  Rochon  MD,  MPH,  FRCPC  Vice  President  and  Senior  Scien4st,  Women’s  College  Research  Ins4tute,  Women’s  College  Hospital  Professor,  Department  of  Medicine,  University  of  Toronto.      

Barbara  Farrell  BScPhm,  PharmD,  FCSHP  Pharmacist,  Bruyère  Geriatric  Day  Hospital  and  Scien4st,  Bruyère  Research  Ins4tute  –  OOawa.    Assistant  Professor,  Department  of  Family  Medicine,  University  of  OOawa  and  Adjunct  Assistant  Professor,  School  of  Pharmacy,  University  of  Waterloo.    

Disclosures  

n  Cara  has  previously  consulted  for  Pfizer,  Allergen,  Watson  and  Ferring  Pharmaceu4cals  but  reports  no  conflicts  of  interest  for  this  presenta4on.  

n  Paula  has  no  conflicts  of  interest  for  this  presenta4on.  

n  Barbara  has  no  conflicts  of  interest  for  this  presenta4on.  

Polypharmacy  

n  Polypharmacy  is  a  risk  factor  for:  n  Drug-­‐drug  interac4ons  n  Prescribing  cascades  n  Difficulty  managing  the          complex  pa4ent  

n  Resul4ng  in:  n  Falls  and  cogni4ve  impairment  n  Emergency  room  visits  and  hospitaliza4ons  

Objec4ves  

n  Par4cipants  will  be  able  to:  1.  Recognize  “inappropriate”  prescribing  2.  Use  interprofessional  interven4ons  to  reduce  inappropriate  

prescribing  3.  Recognize  prescribing  cascades  4.  Iden4fy  poten4al  drug-­‐drug  and  drug-­‐disease  interac4ons  in  

clinical  prac4ce  guidelines  5.  Have  an  approach  to  tapering                          

or  stopping  medica4ons      

Outline  

n  “Inappropriate”  prescribing  n  Case  presenta4on  #1    n  Group  discussion  of  Beers  and  STOPP/START  

n  Prescribing  Cascades  n  Case  presenta4on  #2    n  Group/Panel  discussion  on  prescribing  cascades  

n  Avoiding  drug  interac4ons  in  clinical  prac4ce              guidelines  

n  Case  presenta4on  #3  n  Group/Panel  discussion  on  drug  interac4ons  

n  Take  home  4ps  

“Inappropriate”  Prescribing    Case  1    Mrs.  A    

}  Widow  living  alone  }  84  years  old  }  Severe  knee  pain  limi4ng  mobility  

}  Ocen  confused,  unable  to  get  out  of  bed  

}  3  falls  in  the  last  year  }  Doesn’t  want  to  go  out  anymore  

}  Not  always  taking  meds  }  Children  think  she  should  no  longer  be  living  alone  

}  ASA  81mg  daily  }  ibuprofen  400mg  bid*  }  dimenhydrinate  50mg  qhs  }  lorazepam  1mg  qhs*  }  warfarin  as  directed*  }  metoprolol  50mg  bid*  }  amlodipine  10mg  daily*  }  ramipril  5mg  daily*  }  Lakota  capsules  qid  }  furosemide  40mg  bid*  }  atorvasta4n  40mg  daily*  }  dextromethorphan  syrup  }  lansoprazole  30mg  daily*  }  oxybutynin  XL  10mg  daily*  }  vit.  B12  1200mcg  daily*    }  Potassium  daily*  }  calcium/vit  D  bid*  

 

Medica4ons  

•  Prescription Drugs

•  Over the Counter Products

•  Herbal Therapies

What do we mean by “Medications”?

Group  Discussion  Using  Beers  and  STOPP/START  

GROUP  1     GROUP  2  n Read  the  case  n Apply  the  Beers  criteria  to  iden4fy  medica4on  problems  

n Read  the  case  n Apply  the  STOPP/START  criteria  to  iden4fy  medica4on  problems  

9

Screening  tool  impressions  

n  Were  the  criteria  effec4ve  in  iden4fying  drug  therapy  problems?  

n  Were  there  other  problems  not  picked  up  by  these  screening  tools?  

n  What  are  the  limita4ons  of  these  screening  tools?  

10 years ago

•  Atrial fibrillation – metoprolol and warfarin •  Husband died - lorazepam

3-5 years ago

•  Knee pain - ibuprofen •  Hypertension – ramipril •  Cough – dextromethorphan •  Hypertension – amlodipine •  Daughter told her to take ASA for hypertension

2 years ago

•  Ankle swelling; furosemide •  Potassium low; potassium •  Nausea; dimenhydrinate •  Nausea (and taking ibuprofen): lansoprazole •  B12 levels low; B12 supplement •  Knee pain: Lakota •  Nocturia; oxybutynin •  Osteopenia: calcium/vitamin D

Mrs.  A’s  history  

11

A  prescribing  ‘web’  

           ASA        ramipril    dextromethorphan  

       amlodipine                  furosemide  potassium  

                             dimenhydrinate  

Ibuprofen                      oxybutynin                lorazepam        lansoprazole                    vitamin  B12  

Mrs.  A’s  medica4on  changes  

•  Stop ASA and Lakota

•  Decrease dimenhydrinate

Week 1

•  Switch ibuprofen to acetaminophen

•  Physio and exercise

•  Stop B12

Week 2 •  Document BP target

•  Begin amlodipine taper

•  Begin lansoprazole taper

Week 3

13

Mrs.  A’s  medica4on  changes  

•  Stop amlodipine •  Increase

acetaminophen dose

•  Start lorazepam taper

•  Provide sleep hygiene education

Week 4

•  Switch acetaminophen to small dose hydromorphone

•  Taper ramipril •  Start furosemide

taper •  Add lactulose

Week 5 •  Stop ramipril •  Stop

furosemide •  Stop potassium •  Taper

oxybutynin

Week 6

14

Mrs.  A’s  medica4on  changes  

•  Stop dextromethorphan and dimenhydrinate

•  Review and advise re: salt and calcium intake

•  Start HCTZ •  Continue lorazepam

taper

Week 7

•  Stop oxybutynin •  Stop lorazepam •  Change

lansoprazole to prn

•  Provide heartburn education

Week 8 •  Change metoprolol to bisoprolol

•  Combine calcium and vitamin D

•  Stop lansoprazole

Week 9

15

16

Acer  a  10  week  Day  Hospital  stay  

Mrs.  A’s  medica4ons  § Hydromorphone  0.5mg  q12h  § Hydrochlorothiazide  12.5mg  daily  § Bisoprolol  2.5mg  daily  § Warfarin  as  directed  § Caltrate  Select  with  Vitamin  D  twice  daily  § Lactulose  15ml  daily  

Mrs.  A’s  life:  § Knee  pain  much  improved  § Geong  out  of  the  house  now  § Urgency  and  nocturia  beOer  (up  1-­‐2x/night)  § Sleep  improved  (to  bed  10pm,  up  about  7am)  § Meal  4mes  normal  (8,  noon,  6)  § Bruising  and  gum  bleeding  gone  § No  heartburn,  nausea,  cough  or  swollen  ankles  

Examples  of  team  contribu4ons  to  managing  polypharmacy  

n  Physiotherapist  –  helping  to  manage  pain,  assis4ng  with  exercise  programs  

n  Social  Worker  –  helping  to  deal  with  anxiety,  depression,  isola4on  affec4ng  sleep  and  depression  

n  Occupa4onal  therapist  –  helping  with  mobility  aids  to  manage  pain  n  Die4cian  –  helping  to  use  dietary  approaches  instead  of  

supplementa4on  n  Nurse  –  monitoring  impact  of  medica4on  changes,  providing  

educa4on  re:  nonpharmacologic  approaches  (sleep  hygiene,  GERD  management)    

n  Recrea4on  therapist  –  helping  to  deal  with  isola4on,  access  to  programs  

n  Pharmacist  –  helping  to  iden4fy  drug-­‐related  problems,  develop  plans  for  medica4on  changes  and  monitoring  

Prescribing  Cascades    Case  2:    Mrs.  B  

 n  Mrs.  B  was  diagnosed  with  

vascular  demen4a  acer  a  stroke,  MMSE  16  

n  Her  son  read  on  the  internet  that  donepezil  improve  symptoms  of  vascular  demen4a  

n  She  is  prescribed  donepezil  to  improve  her  memory  

 n  On  subsequent  visit,  dose  of  

donepezil  is  increased  

n  2  months  later,  returns  for  visit  and  describes  problem  with  incon4nence  

n  Referral  sent  to  urology  to  assess  incon4nence  

Prescribing  Cascades    Case  2:    Mrs.  B  

Urologist  prescribes  oxybu4nin  to  treat  incon4nence  

     

Is  this  a  problem?  

Urologist  prescribes  oxybu4nin  to  treat  incon4nence  

n  Oxybu4nin  acts  by  blocking  cholinergic  receptors  and  preven4ng  s4mula4on  by  acetylcholine.  

n  Opposing  cholinergic  mechanisms  

n  Two  small  studies  found  no  clinical  deteriora4ons  in  the  MMSE  score  in  pa4ents  taking  both  cholinesterase  inhibitors  and  bladder  an4cholinergic  agents.    

Sakadkibara et al. J Am Geriatr Soc 2009 Isik et al. J Nutr Health Aging 2008

Cognitive Decline <----------> Improved Memory Urinary Retention <----------> Incontinence

An4cholinergics  and  cholinesterase  inhibitors  

An4cholinergic  toxidromes    “Mad  as  a  ha'er,  dry  as  a  bone,  the  bowel  and  bladder  lose  their  tone.”  

An4cholinergics  can  cause  confusion  and  urinary  reten4on  

http://en.wikipedia.org/wiki/Toxidrome

What  is  a  Prescribing  Cascade?  

Initial Drug Therapy

New Medical Condition

Further Medical Condition

New Drug Treatment

Rochon PA, Gurwitz JH. BMJ 1997

What prescribing cascades have

you seen?

Common  examples  

n  Ibuprofen  → hypertension  → an4hypertensive  

n Metoclopramide  → parkinsonism  → Sinemet  

n  Risperidone  →  parkinsonism  → an4parkinson  meds  

n  Amlodipine  → edema  → furosemide  

n  Lithium  → tremor  → propanolol    

Common  Examples  

n  Amitriptyline  → cogni4on  → donepezil  

n  Furosemide  → hypokalemia  → potassium  

n  Omeprazole →  low  B12  → B12  supplement    

Over  the  counter:  n  Narco4c  → cons4pa4on  → laxa4ves  

n  Lorazepam  → morning  drowsiness  → caffeine  

n  Enalapril  → cough  → dextromethorphan  

Mrs  B’s  Prescribing  Cascade  

Cholinesterase Inhibitors

Urinary Incontinence

Cognitive Decline and

Delirium

Anticholinergic Drug

Gill SS, Rochon PA et al. Arch Intern Med 2005

What  the  data  shows  

n  44884  older  adults  in  Ontario  with  demen4a    n  Average  age  more  than  80  n  Almost  65%  were  women  

Gill SS, Mamdani MM, Rochon PA et al Arch Intern Med 2005

Combined  use  of  ChI  with  overac4ve  bladder  medica4ons  may  worsen  func4on  

-1.62

-1.08

-1.8-1.6-1.4-1.2

-1-0.8-0.6-0.4-0.2

0ChI Alone ChI + OAB med

ChI AloneChI + OAB med

Sink KM, et al. J Am Geriatr Soc. 2008; 56: 847-853.

Change in activity of daily living score in fairly independent nursing home residents (top quartile)

Dai

ly li

ving

sco

re (u

nits

)

In high-functioning nursing home residents, dual use of cholinesterase inhibitors and overactive bladder medications may result in greater rates of functional decline.

Taking  pa4ent  preference  into  account  

n  What  would  you  do  for  Mrs.  B?  n  A)  con4nue  to  prescribe  both  donepezil  and  oxybutyn  n  B)  discon4nue  donepezil  n  C)  discon4nue  oxybutyn  n  D)  discon4nue  both  

Panel  Discussion  Is  there  always  a  right  or  wrong?  

Avoiding Drug Interactions in Clinical Practice Guidelines

n  Clinical  guidelines  typically  focus  on  a  single  disease  at  a  4me  

n  The  reality  is  that  people  ocen  have  mul4ple  coexis4ng  medical  condi4ons  

n  In  Canada:  n  1-­‐in-­‐4  seniors  has  >  3  condi4ons  n  Seniors  with  1-­‐2  chronic  condi4ons            take  3-­‐4  prescrip4on  medica4ons    n  Seniors  with  3  or  more  condi4ons              take  6  different  medica4ons  on  average  

Canadian Institute for Health Information. Seniors and the Health Care System: What is the Impact of Multiple Chronic Conditions. Ottawa, Ontario, 2011.

Avoiding Drug Interactions in Clinical Practice Guidelines Case 3: Mr. S

9  medical  condi4ons  n  Cardiovascular  disease  –  STEMI  

10  &  2  years  ago,  admiOed  last  year  for  heart  failure,  EF  30%  

n  Hypertension  x  20  years  n  Diabetes  Type  2  x  15  years  n  Hypercholesterolemia  x  15  years  n  Osteoporosis  x  10  years  n  Hypothyroidism  x  8  years  n  Post-­‐prostatectomy  for  prostate  

cancer  x  5  years  n  Urinary  incon4nence  x  1  year  n  Depression  x  6  months  

82 years old

16  medica4ons  n  Amiodarone  200  mg  bid,  Furosemide  40  mg  

bid,  ASA  80  mg  daily  n  Monopril  10  mg  daily,  Nifedipine  XL  30  mg  

daily  n  Atorvasta4n  10  mg  po  daily  n  Mewormin  500  bid,  Glyburide  5  mg  bid,  

Rosiglitazone  2  mg  bid  n  Alendronate  70  mg/wk,  Calcium  carbonate  

1000  mg/day,  Vitamin  D  800  IU/day  n  Pantoprozole  40  mg  daily  n  Levothyroxine  0.125  mg  daily  n  Oxazepam  15  mg  po  qhs  n  Started  on  paroxe4ne  40  mg  daily  6  months  

ago  

82 years old

Mr. S.

Great  job  following  the  guidelines!  

Chronic heart failure ACE inhibitor and diuretics                      (2012  Canadian  Cardiovascular  Society  guidelines)  

Hypertension target 130/80 ACE inhibitor and CCB (2011  Canadian  Hypertension  Educa4on  Program  recommenda4ons  for  pa4ents  with  diabetes)

        Diabetes target HbA1C < 7% Oral hypoglycemic agents

(2008  Canadian  Diabetes  Associa4on  clinical  prac4ce  guidelines)  

       

Dyslipidemia target LDL-C < 2.0 mmol/L Statin (2008  Canadian  Diabetes  Associa4on  clinical  prac4ce  guidelines  for  high  risk  diabe4c  pa4ents)

        Osteoporosis Bisphosphonate, Calcium, Vitamin D

(2010  Canadian  Osteoporosis  Society  guidelines)  

       

Urinary incontinence Kegel exercises! (2012  Interna4onal  Consulta4on  on  Incon4nence)

       

Use of ASA in elderly Proton Pump Inhibitor to reduce GI bleeding (2009  Canadian  Associa4on  of  Gastroenterology  Consensus  Group  on  long-­‐term  NSAID  therapy  and  gastroprotec4on)  

       

Read  the  case  again,  list  any  drug  interac4ons  

n  Drug-­‐food  interac4ons  

n  Drug-­‐disease  interac4ons  

n  Drug-­‐drug  interac4ons  n  Pharmacokine4cs  :  what  the  body  does  to  the  drug  n  Pharmacodynamics  :  what  the  drug  does  to  the  body  

Night-time diuretics Venous insufficiency

Interaction 1: Calcium inhibits levothyroxine absorption

Singh et al. JAMA 2000;283:2822-2825

Ca2++

Synthroid

X

Drug-food or drug-drug interaction

Interaction 2: Glitazone oral hypoglycemics increase risk of heart failure  

n  Health  Canada  warning  2001  on  Avandia®  (rosiglitazone  maleate):  n   Thiazolidinedione  (TZD)  class  of  oral  

hypoglycemic  agents  can  cause  fluid  reten4on,  which  can  exacerbate  or  lead  to  heart  failure  

 n  2012  Canadian  Cardiovascular  Society  

guidelines  recommend  against  the  use  of  glitazone  hypoglycemic  agents  in  pa4ents  with  chronic  heart  failure  

Drug disease interaction

http://www.hc-sc.gc.ca/dhp-mps/alt_formats/hpfb-dgpsa/pdf/medeff/avandia_hpc-cps-eng.pdf

Increases preload

Blood backs up, causing heart failure

Weakened heart muscle can’t squeeze as well

Interaction 3: ACE inhibitors , calcium channel blockers, loop diuretics contribute to

urinary incontinence  

Drug disease interaction

Tannenbaum C. BJUI online 2011

Interaction 4: Proton pump inhibitors reduce antifracture efficacy of bisphosphonates  

Abrahamsen et al. Arch Int Med 2011;171:998-1004

*17% of the population studied was male

Drug disease / drug-drug interaction

Risk of Hip Fracture with Alendronate in Adults > 70 years old

Lower Risk Higher Risk

0 0.50 1.00 1.50 2.00

No PPI

<1 year PPI

1-2 years PPI

> 2 years PPI

Any PPI

PPI’s increase gastric pH : diminished absorption of Ca2+

vitamin B12?

Cytochrome  interac4ons  5,6,7,8,9,10….  

Many  drugs  are  ac4vated  or  inac4vated  by  different  hepa4c  cytochrome  (CYP)  enzymes.    n  When  two  or  more  drugs  share  the  same  metabolic  pathway,  there  may  

be  compe44on  for  drug  metabolism  leading  to  changes  in  serum  levels  of  certain  drugs.  

CYP1A2

CYP2B6

CYP2C8

CYP2C9

CYP2C19

CYP2D6

CYP3A4

What  happens  when  each  cytochrome  gets  overloaded  by  too  many  drugs?  

Altered biotransformation → Drug levels too high → Side effects OR → Drug levels too low → Therapeutic failure

Each  medica4on  binds  differently  to  its  cytochrome  

Weak binding

Strong binding

Facilitator

Inhibitor Moderate binding

Most  frequent  interac4ons  are  with  cytochromes  CYP3A4  and  CYP2D6  

Cytochrome Proportion of interactions (%)

3A4 70.1

2D6 22.7

2C9 3.4

2C19 2.1

1A2 1.7

2B6 0

Zakrzewski-Jakubiak et al. Am J Ger Pharmacother 2011

Among 100 patients age 65+ with 5+ medications

Food  and  herbals  also  bind  to  different  cytochromes  

2D6, 2C9, 3A4 Inhibitor 3A4 Inhibitor

3A4 Inducer, 2C9 Inhibitor CYP 2C9

Cytochrome-­‐mediated  interac4ons  can  increase  toxicity  or  reduce  efficacy  

Medication CYP 1A2

CYP 2B6

CYP 2C8

CYP 2C9

CYP 2C19

CYP 2D6

CYP 3A4

Amiodarone

Furosemide No cytochrome metabolism

Alendronate No cytochrome metabolism

Paroxetine

Nifedipine

Levothyroxine No cytochrome metabolism

Oxazepam No cytochrome metabolism

Atorvastatin

Monopril No cytochrome metabolism

Glucophage No cytochrome metabolism

Glyburide

Rosiglitazone

Pantoprazole

Inhibitor Strong affinity substrate Moderate-weak affinity substrate ws-

ddi.i

nter

med

-rx.

ca

275  pa4ents  aged  65+  admiLed  to  an  acute  care  hospital  80%  had  cytochrome  drug-­‐drug  interac4ons    

     

Doan et al. Ann Pharmacotherapy 2013

The number of cytochrome drug-drug interactions increases as a function of the number of drugs consumed

Mr. S

Can  we  reduce  the  risk  of  drug-­‐drug  interac4ons  for  Mr.  S?  

>10 years ago

•  Hypertension– nifedipine XL •  Diabetes – metformin, glyburide, rosiglitazone •  High cholesterol - atorvastatin •  First myocardial infarction – ASA •  Isolated episode of atrial fibrillation in CCU - amiodarone

2-10 years ago

•  Osteoporosis screening – alendronate, calcium, Vit D •  Hypothyroidism – synthroid •  Second myocardial infarction, congestive heart failure –

lasix, monopril •  Insomnia during hospitalization – discharged with

oxazepam •  Gastroprotection – pantoprazole •  Radical prostatectomy for prostate cancer

>1 year ago

•  Urinary incontinence – Kegel’s •  Depression due to incontinence - paroxetine

Mr.  S’s  history  

49

Other  inappropriate/unnecessary  prescrip4ons  

n  Amiodarone  :  Beers  list,  prescribing  cascade  causing  hypothyroidism,  no  recurrence  of  A.  fib,  cytochrome  inhibi4on  

n  ASA:  Canadian  Cardiovascular  Society  recommends  to  avoid  in  pa4ents  with  reduced  ejec4on  frac4on  heart  failure    

n  Lasix  40  mg  bid:  Canadian  Cardiovascular  Society  recommends  dose  reduc4on  in  stable  pa4ents  

n  Alendronate:  5-­‐10  years  increases  the  risk  of  atypical  fractures,  is  it  being  absorbed?  

n  Paroxe4ne:  can  we  treat  the  cause  of  Mr.  S.’s  depression?  

What  to  do  first?  

n  Decide  what  should  be  tapered  or  stopped  n  Stop  the  easy  ones  (no  longer  needed,  have  long  half-­‐

lives,  don’t  cause  adverse  drug  withdrawal  events)  n  Amiodarone  n  Alendronate    n  ASA  

n  Stop  the  drugs  causing  side  effects  n  Drugs  that  can  cause  adverse  drug  withdrawal  events  

need  to  be  tapered  e.g.  beta-­‐blockers,  benzodiazepines,  SSRIs,  PPIs,  diure4cs,  narco4cs,  an4convulsants,  an4psycho4cs  

From  UpToDate  

PA Rochon. http://www.uptodate.com/contents/drug-prescribing-for-older-adults

Mr.  S’s  medica4on  changes  

•  Stop ASA •  Stop

rosiglitazone •  Stop

amiodarone •  Monitor glucose

Week 1

•  Provide sleep hygiene education

•  Teach heart failure self-management

•  Start glyburide taper 2.5 mg bid

Month 2 •  Begin twenty week oxazepam taper

•  Begin nifedipine XL taper 20 mg once daily

•  Stop alendronate

Month 4

53

Mr.  S’s  medica4on  changes  

•  Stop nifedipine •  Start bisoprolol 2.5

mg bid (not metabolized by CYP 450)

•  Switch atorvastatin to rosuvastatin (CYP2C9)

Month 6

•  Start elastic stockings

•  Start furosemide taper 20 mg bid

•  Discontinue glyburide

•  Increase dose of metformin 500 tid

Month 8 •  Start pantoprazole taper 20 mg daily

•  Increase dose of bisoprolol 5 mg bid

•  Discontinue oxazepam

•  Continue furosemide taper 20 mg daily

Month 10

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At  1  year  follow-­‐up  

Mr.  S’s  medica4ons  § Bisoprolol  5  mg  bid  § Monopril  10  mg  daily  § Lasix  20  mg  at  5  pm  § Mewormin  750  mg  4d  § Rosuvasta4n  10  mg  daily  § Synthroid  0.125  mg  –  repeat  TSH  yearly  § Calcium  and  Vitamin  D  (no  longer  given  at  same  4me  as  synthroid)  § Schedule  repeat  bone  density  in  6  months  

Mr.  S’s  life:  § Less  fluid  reten4on    § Less  fa4gued  § Urinary  urgency  and  urge  incon4nence  improved  § No  more  weakness/  unsteady  gait  § Lower  risk  of  falls  § Lower  risk  of  hypoglycemia  § Less  depressed:  taper  and  discon4nue  paroxe4ne  over  the  next  2  months  

Take  home  4ps  n  Use  screening  criteria  to  iden4fy  ‘poten4ally  

inappropriate  medica4ons’  n  For  every  sign  or  symptom,  always  ask  ‘can  this  be  caused  

by  a  drug’?      n  Review  the  chronology  of  all  prescrip4ons  n  Review  indica4ons  n  Subs4tute  with  drugs  not  metabolized  by  the  same  

cytochrome  n  Change  the  4me  of  administra4on  of  the  drug  n  Use  non-­‐pharmacologic  approaches  n  Work  as  a  team:  pharmacist,  nurse,  physio  etc.    

 

Resources  and  References  

n  Beers:  hOp://www.americangeriatrics.org/health_care_professionals/clinical_prac4ce/clinical_guidelines_recommenda4ons/2012      

n  STOPP/START:  hOp://www.biomedcentral.com/imedia/3973756062468072/supp1.doc    

n  InterMED-­‐Rx:    ws-­‐ddi.intermed-­‐rx.ca  

n  Drug  discon4nua4on  algorithm:    hOp://www.uptodate.com/contents/drug-­‐prescribing-­‐for-­‐older-­‐adults