Transcript Medication Management in the Older Patient

Medication Management in the
Older Patient
Older adults are more likely to have an
Adverse Drug Reaction
• More likely to be on 5 or more medications
Hazzard, Principles of Geriatric Medicine and Gerontology
Older adults are more likely to have an
Adverse Drug Reaction
• Altered pharmacokinetics
– Declines in hepatic blood flow & hepatic oxidation
– Declines in renal function
– Changes in amount of body fat
• Altered pharmacodynamics
– Decreased baroreceptor reflex
– Decreased sensitivity to beta adrenergic effects
– Increased CNS sensitivity to anticholinergics
Podrazik, P. CHAMP (Curriculum for the Hospitalized Aging Medical Patient): DRUGS AND AGING. POGOe - Portal of Geriatric Online
Education; 2009 Available from: http://www.pogoe.org/productid/20105
ADRs in older adults can be due to…
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Amplified drug effects
Side Effects
Drug-disease interaction
Drug-drug interaction
Drug-nutrient interaction
Podrazik P. Drugs and Aging, CHAMP 2007
Mrs. G
• 78 year old woman with dementia
• Starts on donepezil for her dementia
• 6 weeks later she presents for follow up
appointment complaining of urinary
incontinence and anorexia
• She is given oxybutynin for UI and megestrol
for anorexia
Bad stuff that happened here
• Side effects
– Anorexia and UI are side effects of donepezil
• Polypharmacy
– Prescribing cascade: oxybutynin and megestrol
were added to treat side effects of donepezil
• Drug-disease interaction
– Oxybutynin is anticholinergic, but dementia is
already a low acetylcholine state
• Drug-drug interactions
– Donepezil vs. oxybutynin
Step 1: Know what your patient is
taking
• Multiple pharmacies often used
• Over the counter medications, herbals,
supplements not always reported
• Medications belonging to others sometimes
taken
• Best way to overcome all this is to do a
“Brown Bag Review”
Step 2: Identify problems
• Match medications with the patient’s
conditions
• Identify potentially inappropriate medications
• Identify prescribing omissions
• Ensure renal dosing if needed
• Look for
– Drug-disease interactions
– Drug-drug interactions
– Drug-nutrient interactions
Steinman MA & Hanlon JT. JAMA 2010
Matching Drug to Condition
• 75 year old woman with atrial fibrillation,
hypertension, depression, and osteoporosis
• Independent with ADLs/IADLs
• Active social life
• Goal is to stay healthy and active
• Medication list
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Digoxin 0.125mg QD
Metoprolol 50mg BID
Atorvastatin 20mg QD
Amitriptyline 50mg QHS
Alendronate 70mg Qwk
CONDITION
DRUG
POTENTIAL
PROBLEM
NOTES
ATRIAL FIBRILLATION
Digoxin 0.125mg QD
OVERUSE?
High potential for
ADRs in elders
Metoprolol 50mg BID
MISUSE
Consider change to
extended release for
ease of administ’n
UNDERUSE
Add warfarin
HYPERLIPIDEMIA
Atorvastatin 20mg QD
OK
DEPRESSION
Amitriptyline 50mg QHS
MISUSE
OSTEOPOROSIS
Alendronate 70mg QWk
OK
UNDERUSE
Nortriptyline is less
anticholinergic
Add Calcium,
Vitamin D
Beers list, STOPP criteria
• Developed by an expert panel
• These are lists of high risk/low benefit drugs
– meds/classes of meds that should generally be
avoided in patients over 65
• ineffective
• high risk with a safer alternative available
– meds to avoid due to specific medical condition
The American Geriatrics Society 2012 Beers Criteria Update Expert Panel. J Am Geriatr
Soc. 2012; Hamilton H et al. Arch Int Med 2011
Examples of Potentially
Inappropriate Medications
• Top 3 drug classes resulting in ADEs
– Musculoskeletal drugs
• NSAIDs
• muscle relaxants
– CNS active drugs
• benzodiazepines
• anticholinergic drugs
– Cardiovascular drugs
• antihypertensives
• antiarrhythmics
• Narrow safety margins
• Warfarin, insulin, digoxin
Academic Detailing
Step 3: Maximize adherence
• Is the regimen too complicated?
• Does the patient have physical problems that
affect prescribing?
– Low vision (large print labels)
– Arthritis (no child safety bottles)
– Swallowing problems (small pills, liquids)
• Is the cost of medications prohibitive?
3 Steps for Medication Management
• Know what your patient is taking
– Brown bag review
• Identify problems
– Match drug to condition
– Look for potentially inappropriate medications
• Maximize adherence
Useful References
• Steinman MA & Hanlon JT. Managing medications in
clinically complex elders: “There’s got to be a happy
medium.” JAMA 2010 Oct 3; 304(14):1592-1601.
• Hamilton H, Gallagher P, Ryan C, Byrne S, O’Mahony D.
Potentially inappropriate medications defined by STOPP
criteria and the risk of adverse drug events in older
hospitalized patients. Archives Internal Medicine. 2011;
171(11):1013-1019.
• The American Geriatrics Society 2012 Beers Criteria Update
Expert Panel. American Geriatrics Society updated Beers
Criteria for potentially inappropriate medication use in
older adults. J Am Geriatr Soc. 2012; 60(4): 616-631.