Transcript Help! Mama ain*t right! Pearls for Geriatric Prescribing
Geriatric Polypharmacy: A Pill for Every ill
Amelie Hollier, DNP, FNP-BC, FAANP President, APEA
Geriatric Patients US Life Expectancy
• •
Women: 80 years Men: 75 years
Natl Vital Stat Rep. 2010;58:1-136
Geriatric Patients 2011
• •
The “Baby Boomers” turned 65 years old in 2011 Elderly population increases by 30% each year from now until 2050!!!
Geriatric Patients
• •
20% of people aged > 65 years take at least 10 medications Termed: the “P” word
Patterns of medication use in the United States, 2006. A report from the Slone Survey. www.bu.edu/slone/SloneSurvey/ AnnualRpt/ SloneSurveyWebReport2006.pdf. Accessed February 1, 2013.
Geriatric Patients
• •
As the number of medications increases, so does the risk of adverse drug events (ADEs)
ADEs:
weight loss, falls, changes in cognition, loss of independence, hospitalization
It is MORE difficult to prescribe medications in Elderly Patients
• • • •
Inter-individual variability Polypharmacy Concomitant diseases Physiological changes associated with aging (renal, hepatic dysfunction)
•
Multiple Prescribers!
A Reasonable Approach:
Always answers these 3 Questions before Prescribing
• • •
First: What is the Diagnosis? Second: What drug?
Third: What dose?
First Question?
What Diagnosis?
What Disease?
Unrecognized ADEs
•
In older adults,
drug induced symptoms
are commonly mistaken for a new disease or worsening of an existing disease
•
Some drug induced symptoms are
indistinguishable
adult illnesses from common older
Diagnosis in the Elderly
•
New onset of disease in an elderly patient usually affects an organ that has been weakened by a different disease process Ex: Elderly adult develops anemia
Harrison’s Principles of Internal Medicine
Example 1: Mr. Smith
80 year old male who is mostly independent; he has a number of chronic diseases that are stable.
He has developed iron deficiency anemia over the last 3 months from a “slow bleeding” polyp in large intestine.
How does an older adult with anemia present?
In older adults we see:
•
Shortness of breath
•
Chest pain (angina)
•
Fatigue (“I’m getting older”)
Example 2: Mrs. Jones
80 year old female who is very independent; she has several chronic diseases that are stable with medications.
She has developed hypothyroidism over the last 4 months.
Diagnosis in Elderly
Elderly Adults have “atypical presentation” of diseases Disease Elderly Presentation Anemia Hypothyroidism UTI SOB, Angina, Fatigue Cardiac conduction defects, cognitive changes, looks depressed Confusion, anorexia Non-Elderly Presentation Fatigue Menstrual changes, constipation, changes in hair and skin Burning, frequency, urgency
Diagnosis in the Elderly
New onset of disease in an elderly patient usually affects an organ that has been weakened by a different disease process
Harrison’s Principles of Internal Medicine
First Question?
What Diagnosis?
What Disease?
Second Question?
What Drug?
(or do we even need a drug?)
Example: Pain in Older Adults
• • • • • •
Nonpharmacologic Management
Ice Heat Massage Relaxation Biofeedback PT interventions: exercise, splints, braces
Second Question?
What Drug?
•
Beers Criteria
•
Most widely used criteria (since 1991) to assess inappropriate drug prescribing in elderly AGS Updated 2012 Beers Criteria for
Potentially Inappropriate Medication (PIMS )
Use in Older Adults
Beers Criteria
•
Goal is to improve care of older adults by reducing exposure to PIMs
Inappropriate Medications
Anti-cholinergic Side Effects
Memory impairment, confusion, hallucinations, dry mouth, blurred vision, urinary retention, constipation, tachycardia, acute angle glaucoma
“An Ode to an Anticholinergic Med”
Oh this drug, it makes me pink, Sometimes, I can’t think or even blink.
I can’t see, I can’t pee I can’t spit I can’t (**it) (“defecate”)
Mrs. Thomas
80 year old female who is completely independent; she has a several chronic diseases that are stable with medications.
She complains of difficulty sleeping when her arthritic knee aches. She takes an OTC medication with diphenhydramine for sleep.
Mrs. Thomas
Is this harmful if she uses this only three times weekly?
Potentially Inappropriate Medications AVOID
Antihistamines (First Generations)
•
Brompheniramine (Bromfed)
•
Carbinoxamine (Chlor-Trimeton)
•
Diphenhydramine (Benadryl)
•
Hydroxyzine (Atarax, Vistaril)
•
Promethazine (Phenergan)
•
Others
2012 Beers Criteria Update Expert Panel J AM Geriatr Soc. 2012;60(4):616-631
Anti-Histamines
• • •
What’s the Problem with these?
They are highly anti-cholinergic Clearance reduced with advanced age Tolerance develops when used as hypnotic
2012 Beers Criteria Update Expert Panel J AM Geriatr Soc. 2012;60(4):616-631
High Risk Medications
Diphenhydramine: impaired cognition, urinary retention (next day sedation, impaired driving)
Good Rule: “Avoid First Generation Anti-histamines” Suppose Mrs. Thomas had an acute allergic reaction after eating boiled crawfish in South Louisiana?
Anti-Histamines
2 nd Gen Anti-Histamine Cetirizine Loratadine Fexofenadine Levocetirizine Desloratadine Sedative Effect ++ + 0 ++ +
Good Rule of Thumb
Choose an agent from a different generation; or the least potent in the medication class
“Hay Fever”
: Consider a topical nasal anti-histamine {Asteline (Azelastine)}
Good Rule of Thumb
• •
Consider a
different class
of medication What about a topical nasal steroid?
Mrs. Jones is 75 years old. She is diagnosed with a UTI. Her CrCl is 50 mL/min. Which anti-infective should be avoided in her because of inadequate
drug concentration
in the urine?
1. Sulfa drug 2. Ciprofloxacin 3. Amoxicillin
4. Nitrofurantoin
2012 Beers Criteria Update Expert Panel J AM Geriatr Soc. 2012;60(4):616-631
Mrs. Jones is 75 years old. She is diagnosed with a UTI. Her CrCl is 50 mL/min.
• •
Beers Criteria recommends nitrofurantion avoidance: CrCl < 60 mL/min For long-term suppression
2012 Beers Criteria Update Expert Panel J AM Geriatr Soc. 2012;60(4):616-631
What about drugs that need dose adjustment due to renal insufficiency?
Excretion
• • •
Age related changes in kidney function Decreases in renal mass Decreases in renal blood flow (1-2% decline/year after age 40)
Measure of
Kidney Function
•
Creatinine production is related to muscle mass
•
Creatinine production decreases with advancing age & loss of muscle mass. This produces decreased serum Cr levels
•
So…..Normal serum Cr, but impaired renal function
What Affects Creatinine Levels?
•
What you look like
•
What you eat
•
Who you are
What affects serum Cr?
More Muscle Mass Less More muscle mass, more serum creatinine Less muscle mass, less serum creatinine
What affects serum Cr?
Diet Meat Eater Vegetarian Diet Creatinine
Increases
but may be temporary Creatinine Decreases
What affects serum Cr?
Age and Gender Creatinine decreases as you age (due to less muscle mass) Creatinine greater in males due to greater muscle mass
How does obesity affect serum creatinine?
a.
c.
Increases Cr b.
Decreases Cr Has no effect
•
So…. many Factors Affect Creatinine Levels A better measure of kidney function is CrCl (mL/min)
• •
Most accurate CrCl is collected over a 24 hour period, but it’s a major drag to collect!!
GFR (Glomerular filtration rate = mL/min) can be used to estimate CrCl
(Not Perfect, but it’s pretty good!)
GFR is usually estimated by Labs: eGFR
• •
eGFR Normal Range > 60mL/min/1.73m
2 About 38% of individuals aged 70 years or older without HTN or DM, had GFRs of < 60mL/min/1.73m
2
Prevalence of chronic kidney disease and decreased kidney function in the adult US population: Third National Health and Nutrition Examination Survey. Coresh J, Astor BC, Greene T, Eknoyan G, Levey AS. Am J Kidney Dis. 2003;41(1):1.
Excretion
•
Decrease in GFR (50% decline between 50 and 90 years)
•
Decrease in Creatinine Clearance
Mrs. Jones is 75 years old. She is diagnosed with a UTI. Her CrCl is < 50 mL/min. Which anti-infective should be avoided in her because of inadequate drug concentration in the urine?
1. Sulfa drug (none as long as CrCl > 30 mL/min) 2. Ciprofloxacin (none as long as CrCl > 30 mL/min) 3. Amoxicillin (none as long as CrCl > 30 mL/min)
4. Nitrofurantoin (AVOID!)
• • • • • • • •
Known Decreased Renal Clearance in Elderly Acetaminophen Anti-arrhythmics Anti-convulsants Anti-depressants Anti-psychotics Benzos, beta blockers, theophylline Warfarin Many, many others!
Excretion
•
Many drugs with dosage adjustments
: allopurinol, many antibiotics, digoxin, lithium, gabapentin, H2 blockers, anti arrhythmics
Good Rule of Thumb
Be familiar with the medications you prescribe!
Remember: Some drugs require renal dosing and hepatic dosing
What patient is most likely to present with benign prostatic hyperplasia?
a.
c.
20 year old b.
40 year old 60 year old d.
80 year old
Benign Prostatic Hyperplasia
•
What medication class do we prescribe to improve urinary flow?
•
What’s the most common side effect?
Beers Criteria Recommends “Avoid” alpha blockers for routine treatment of hypertension OK to use alpha blockers for BPH with education and precautions Non-selective Alpha Blocker Doxazosin Prazosin Terazosin
2012 Beers Criteria Update Expert Panel J AM Geriatr Soc. 2012;60(4):616-631
Medications Cardura Minipress Hytrin
Alpha Blockers for treatment of BPH or Urinary outflow problems Uro-specific Alpha Blockers *Uroxatral *Flomax (generic) *Rapaflo Comments Alfuzosin (needs renal and hepatic dose adjustments) Tamsulosin (no renal or hepatic precautions); sulfa allergy precaution Silodosin (needs renal and hepatic dose adjustments) *Possible intraoperative floppy iris syndrome (IFIS) during cataract surgery
Good Rule of Thumb
Choose an agent that is most specific in the medication class for the problem you are treating.
“Mrs. Dash”
73 year old female who has osteoarthritis in both knees. She is still mobile but complains of daily pain in her knees. She is not a surgical candidate at this time. She self-medicates with ibuprofen and she reports good pain control using 400 mg ibuprofen 2-3 times daily.
Is this a Problem?
Beers Criteria “Avoid”: NSAIDs
• • • • • •
Non-COX selective NSAIDs, oral
Aspirin > 325 mg daily Ibuprofen Diclofenac, Etodolac Meloxicam Naproxen Ketorolac, Indomethacin (most adverse GI effects)
2012 Beers Criteria Update Expert Panel J AM Geriatr Soc. 2012;60(4):616-631
Gastrointestinal Risk
• •
Treated 3-6 months: 1% risk of Upper GI ulcers, bleeding or perforation Treated 1 year: 2-4%
Proton Pump Inhibitors
• • •
Very effective at preventing ulcers Once daily Usually better tolerated than misoprostol; slightly less effective
Hooper L, Brown TJ, Elliott R, et al. The effectiveness of five strategies for the prevention of gastrointestinal toxicity induced by non-steroidal anti-inflammatory drugs: systematic review. BMJ 2004; 329:948.
PPI OTC and Rx
• • • •
Omeprazole and Na bicarb (Zegerid)
Na bicarb = baking soda Allows omeprazole to be absorbed a little bit faster Each cap contains 300 mg Na Avoid in HTN, HF, or other patients in whom Na should be restricted
PPI plus clopidogrel
• • •
Absolutely not omeprazole (inh 2C19 activity)! Reduces conversion of clopidogrel
antiplatelet activity Do not use esomeprazole (Nexium) Use dexlansoprazole, lansoprazole, pantoprazole, or HD famotidine
PPI Use
• •
Increases pH
Alters the absorption of many drugs Calcium, Fe, Vitamin B12
PPI Harms
• • • •
Fracture Risk
in patients > 50 years, high doses, or use > 1 year 25% increase in all fractures 47% increase in spinal fractures FDA requires fracture risk info added to labeling in OTC and Rx PPIs
PPI Harms
•
Fracture Risk
in patients > 50 years, high doses, or use > 1 year
WHY???
PPI Harms
• •
Possible decreased calcium absorption caused by PPIs Inconclusive relationship between PPIs and bone density
PPI Harms
• •
Infection
Pneumonia/C. difficile: R/T gastric acid suppression may allow bacterial growth Care in use with patients with COPD, asthma, increased age, immunosuppression
What about Vitamin B12
•
Deficient Patients on PPIs?
Consider using a different mucus membrane
•
Sublingual, intranasal
…Back to “Mrs. Dash”
73 year old female who has osteoarthritis in both knees. She self-medicates with ibuprofen and she reports good pain control using 400 mg ibuprofen 2-3 times daily.
IF GI risks high: consider PPI IF CV risks high….
AHA Recommends for Pain
CV disease or risk factors for ischemic heart disease 1. Acetaminophen 2. Aspirin 3. Tramadol 4. Opioids 5. Nonacetylated salicylates (Diflunisal) 6. NSAIDs with low COX-2 selectivity 7. NSAIDs with some COX-2 selectivity 8. COX-2 selective agents
Beers: Aspirin for Primary Prevention of cardiac events
Lack of evidence of benefit versus risk in individuals aged > 80 years
FYI: Strength of recommendation is “weak” Quality of Evidence is Low
Beers: “Avoid” Drug-Disease or Drug Syndrome Interactions
• • • • • •
Heart Failure Syncope Dementia and Cognitive Impairment Falls and Fractures Insomnia Constipation
Beers Criteria “Avoid”:
Heart Failure
Digoxin > 0.125 mg daily
Higher doses associated with no additional benefit and may increase toxicity
2012 Beers Criteria Update Expert Panel J AM Geriatr Soc. 2012;60(4):616-631
Age Related Change in Pharmacokinetics
As aging occurs, there is a DECREASE total body water
(10-15%)
in
Distribution
Decrease in total body water
(10-15%)
So, smaller distribution of water soluble drugs
Increased Drug Concentration!
Serum levels increase
due to decreased volume of distribution Examples: Digoxin
Mrs. Boudreaux
78 year old female who is very active and enjoys playing cards with her friends one evening per week. During the card game she has dinner and a couple of glasses of wine. She states that this has been her habit for several years but now she becomes dizzy before finishing her second glass of wine. She has had no change in weight, medications (or wine).
What is going on with Mrs. Boudreaux?
a.
The wine glasses are getting bigger.
b.
She just can’t hold her liquor anymore.
c.
This is an age related change with EtOH metabolism.
Distribution
Decrease in total body water
(10-15%)
So, smaller distribution of water soluble (EtOH) drugs
1. Increased EtOH Concentration!
Serum levels increase due to decreased volume of distribution Examples: EtOH (Mrs. Boudreaux’ wine)
• • •
2. Changes in EtOH Metabolism
Liver mass decreases Hepatic blood flow decreases First pass metabolism decreases
3. Decreased Production of CYP 450 enzymes
Can decrease up to 30% in elderly!
What is going on with Mrs. Boudreaux?
a.
The wine glasses are getting bigger.
b.
She just can’t hold her liquor anymore.
c.
This is an age related change with EtOH metabolism.
Beers: “Avoid” Drug-Disease or Drug Syndrome Interactions
• • • •
Heart Failure Syncope Dementia and Cognitive Impairment Falls and Fractures
• •
Insomnia
Constipation
Sleep Complaints in Older Adults
• • • •
50% of older adults complain of at least one sleep complaint Impairs functional ability Increases risk of accidents and falls 1/3 of elderly patients in North America receive a benzo hypnotic for insomnia (or non-benzo)
Beers Criteria “Avoid”: Benzos Hypnotics
• •
Benzodiazepines:
Avoid for insomnia, agitation, or delirium Avoid in dementia (worsens symptoms)
•
Increased sensitivity to these and slower metabolism
•
Increased risk of falls, cognitive impairment
•
A short acting agent can behave like an intermediate or long acting agent
2012 Beers Criteria Update Expert Panel J AM Geriatr Soc. 2012;60(4):616-631
Agent Alprazolam Benzodiazepines Brand Xanax Lorazepam Oxazepam Clonazepam Diazepam Flurazepam Ativan Serax Klonopin Valium Dalman Duration Short/intermedi ate Short/Intermedi ate Short/Intermedi ate Long Long Long
But if you just have to use one for anxiety…
• •
Generally speaking, consider 1/3 to ½ adult dose for elderly, titrate Lorazepam (Ativan): Pharmacokinetics are not significantly affected by age Avoid doses over 3 mg
Ottawa (ON): Canadian Pharmacists Association; c2011. Benzodiazepine monograph [October 2009]. http://www.e-therapeutics.ca. (Accessed February 8, 2013).
Potentially harmful drugs in the elderly: Beers list and more. Pharmacist's Letter/Prescriber's Letter 2007;23(9):230907.
Sleep Changes in Older Adults
• • • • •
Take longer to fall asleep Have less total nighttime sleep Increased nighttime wakefulness Daytime sleepiness Awaken early
Sleep Changes in Older Adults
• • • • • •
Common Causes
Arthritic pain Depression Shortness of breath (HF, COPD, angina) Parkinson’s (nightmares, night terrors, levodopa) Medications: SSRIs, SNRIs, theophylline, cimetidine, phenytoin, steroids, bronchodilators Dementia: nighttime wandering
First Steps
• • • • • •
Non-Pharmacologic
Avoidance of nicotine, alcohol, and caffeine Increasing daytime exercise and light exposure Limit or eliminate daytime napping Reduce light and noise Comfortable room temperature Meals > 2-3 hours before bedtime
Beers Criteria “Avoid”: Non-benzo Hypnotics (aka: Z-drugs)
• • •
Benzodiazepine Receptor Agonists:
Less rebound insomnia, tolerance, and dependence than benzos Eszopiclone (Lunesta), Zolpidem (Ambien), Zaleplon (Sonata) Elderly patients have same side effects as with benzos (delirium, falls, fractures)
2012 Beers Criteria Update Expert Panel J AM Geriatr Soc. 2012;60(4):616-631
Sleep Changes in Older Adults
• • •
Pharmacologic
Melatonin No serious adverse events Interacts with warfarin, ASA, clopidogrel, ticlopidine, antidiabetic agents (decreased glucose tolerance and insulin sensitivity)
High Risk Medications
•
Insulin and SUs: Aggressive glycemic control often yields more harm than good
Target A1C
• •
A1C: goal is <7% in most patients (but not all elderly!) >7% for some patients with many co-morbids or too abbreviated a lifespan to benefit from intensive therapy
• • • • •
What do these drugs all have in common?
Macrolides, quinolones, telithromycin, sulfonamides Amitriptyline, citalopram, paroxetine, sertraline, venlafaxine, fluoxetine Albuterol, levalbuterol, salmeterol Phenylephrine, pseudoephedrine Cocaine
QT Prolongation
•
Long QT Syndrome (LQTS)
•
Increased risk of ventricular tachycardia
Torsades de Pointes
• •
Polymorphic V-tach Many drugs are culprits, but often it is combo of drugs
What increases the risk?
• • •
Low potassium, magnesium Bradycardia Anything that prolongs myocardial repolarization
What DRUGS increase the risk?
• •
Quinolones Risk is additive with other drugs or conditions that increase risk
WHO is at risk?
•
Elderly
•
Psychiatric patients
•
Patients with eating disorders (electrolyte imbalances)
Osteoporosis
Bisphosphonates
•
Osteoporosis
•
Efficacy wanes with time
•
What’s optimal duration?
•
New labeling from FDA (no consensus what it should say!)
Bisphosphonates
FLEX Trial
•
Compared bisphos with stopping after 5 years of continuous use
•
Alendronate > 5 years did not provide much additional protection against fractures
Black DM, Schwartz AV, Ensrud KE, et al. Effects of continuing or stopping alendronate after 5 years of treatment. The Fracture Intervention Trial Long-term Extension (FLEX): a randomized trial. JAMA 2006;296:2927-38
What dose?
Most drug studies do not include geriatric patients in clinical trials
Underprescribing
• • •
“Unintended underutilization” Example: Patient with MI: BB, ACE, ASA, statin plus other meds Don’t underprescribe to improve compliance
Take Home Points!
Consider ADEs for ANY NEW symptom in an elderly patient!!!
Take Home Points!
Follow the Beers list to keep elders from unintended harm! And PIMs!
Final Take Home Points!
Do we really need a drug?
safer drug be used instead?
Can a
Questions???
Amelie Hollier, DNP, FNP-BC, FAANP Advanced Practice Education Associates [email protected]