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Contributing Factors Multiple Medical conditions An average of 6-7 Rx and 3-4 OTC daily 40% have used some form of dietary supplement ADR’s more common when taking 5 or more meds daily Multiple providers Time Constraints Patient driven prescribing
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A Practical Approach to A Practical Approach to a Geriatric Patienta Geriatric Patient
Tatyana Gurvich, Pharm.D., CGPTatyana Gurvich, Pharm.D., CGPUSC School of PharmacyUSC School of Pharmacy
UCI Sr. Health CenterUCI Sr. Health CenterQueenscare Family ClinicsQueenscare Family ClinicsGlendale Adventist FPRPGlendale Adventist FPRP
Medication-Related Problems Medication-Related Problems in the Elderlyin the Elderly
Common, Costly and PreventableCommon, Costly and Preventable Total estimated healthcare expenditure related Total estimated healthcare expenditure related
to potentially inappropriate medications is to potentially inappropriate medications is $7.2billion $7.2billion
27% of adverse events in primary care settings27% of adverse events in primary care settings
42% of adverse events in long term care42% of adverse events in long term care
380,000-450,000 adverse drug events occur 380,000-450,000 adverse drug events occur annually in hospitals.annually in hospitals.
JAGS 2012JAGS 2012Arch Int Med 2009Arch Int Med 2009
Contributing FactorsMultiple Medical conditions
An average of 6-7 Rx and 3-4 OTC daily40% have used some form of dietary
supplementADR’s more common when taking 5 or
more meds dailyMultiple providersTime ConstraintsPatient driven prescribing
Prescribing challenges for Prescribing challenges for older patientsolder patients
Is pharmacotherapy is beneficialIs pharmacotherapy is beneficialAdverse reaction/Drug interaction Adverse reaction/Drug interaction
potentialpotentialPrescribing CascadesPrescribing CascadesAge related changes which alter drug Age related changes which alter drug
response in older adultsresponse in older adultsDosing of medicationsDosing of medications
Prescribing challenges for Prescribing challenges for older patients (cont)older patients (cont)
Cost of medications/MediCare issuesCost of medications/MediCare issues
New vs. Established MedicationsNew vs. Established Medications
Limitations of Pre-marketing Trials Limitations of Pre-marketing Trials
Problem MedicationsProblem Medications
Geriatric Pharmacology:Geriatric Pharmacology:PharmacokineticsPharmacokinetics
AbsorptionAbsorptionUse of PPI, H2Blockers, AntacidsUse of PPI, H2Blockers, AntacidsMedications with anti-cholinergic profileMedications with anti-cholinergic profile
DistributionDistributionFat soluble medications: an extended Fat soluble medications: an extended
t1/2t1/2Water soluble medications: Higher Water soluble medications: Higher
concentrations concentrations Dose adjustments are necessaryDose adjustments are necessary
Metabolism: Drug Metabolism: Drug InteractionsInteractions
Differences in metabolism/drug Differences in metabolism/drug interaction potential within a drug classinteraction potential within a drug classStatins: Crestor/Pravachol fewer problemsStatins: Crestor/Pravachol fewer problemsSSRI’s: Celexa/ Lexapro fewer problemsSSRI’s: Celexa/ Lexapro fewer problemsH2blockers: Cimetidine more problemsH2blockers: Cimetidine more problemsAntibiotics: MixedAntibiotics: Mixed
Additive effectAdditive effectSerotonin syndrome/ QT prolongationSerotonin syndrome/ QT prolongation
Plavix and PPI’s/ CodeinePlavix and PPI’s/ Codeine
PK: ExcretionPK: Excretion Creatinine clearance declines with ageCreatinine clearance declines with age
Serum Cr is a poor indicator of indicator and can Serum Cr is a poor indicator of indicator and can overestimate renal functionoverestimate renal function
Dosing adjustment with reduced renal functionDosing adjustment with reduced renal function Vague guidelines which lack clinical practicalityVague guidelines which lack clinical practicality
BisphosphonatesBisphosphonates MacrodantinMacrodantin
PharmacodynamicsPharmacodynamicsBlood Brain Barrier PermeabilityBlood Brain Barrier Permeability Increased Sensitivity medicationsIncreased Sensitivity medications
CNS acting medicationsCNS acting medicationsDiabetes medicationsDiabetes medications
Consequences of low Blood GlucoseConsequences of low Blood GlucoseHTN medsHTN meds
Consequences of low Blood PressureConsequences of low Blood PressureDrugs with anti-cholinergic profileDrugs with anti-cholinergic profile
PharmacodynamicsPharmacodynamicsExamples of altered response in Examples of altered response in
geriatricsgeriatricsOxybutininOxybutininDiphenydramineDiphenydramineAlbuterol InhalerAlbuterol InhalerTimoptic eye dropsTimoptic eye drops
Polypharmacy/PolymedicinePolypharmacy/Polymedicine What is “polypharmacy”?What is “polypharmacy”?
The use of unnecessary medications The use of unnecessary medications which is independent of the number of which is independent of the number of medications being takenmedications being taken
Increases the risk of:Increases the risk of: Adverse reactionsAdverse reactions Drug/Drug InteractionsDrug/Drug Interactions Prescribing cascadesPrescribing cascades ComplianceCompliance
The prescribing cascadeThe prescribing cascade Drug induced adverse events which mimic symptoms Drug induced adverse events which mimic symptoms
of other diseases or can precipitate confusion, and of other diseases or can precipitate confusion, and or falls.or falls. Prozac TO a FALLProzac TO a FALL
Prozac for depression. Ativan for Prozac induced Prozac for depression. Ativan for Prozac induced anxiety and insomnia. Pt became dizzy, fell and anxiety and insomnia. Pt became dizzy, fell and broke a hipbroke a hip
Plendil TO a diagnosis of GERD and an ORTHO Plendil TO a diagnosis of GERD and an ORTHO work upwork up
Plendlil for HTN; ORTHO work up ordered for Plendil Plendlil for HTN; ORTHO work up ordered for Plendil induced edema; PPI was added for GERDinduced edema; PPI was added for GERD
Verapamil TO HaldolVerapamil TO HaldolVerapamil for HTN; Lasix for Verapamil induced Verapamil for HTN; Lasix for Verapamil induced
CHF/Edema; Ditropan for diuretic induced CHF/Edema; Ditropan for diuretic induced incontinence; Haldol for Ditropan induced confusion incontinence; Haldol for Ditropan induced confusion and agitation due to its anti-cholinergic effects and agitation due to its anti-cholinergic effects
ACOVE: Assessing Care of ACOVE: Assessing Care of Vulnerable EldersVulnerable Elders
Document drug indicationDocument drug indicationProvide adequate pt educationProvide adequate pt educationMaintain current medication listMaintain current medication listDocument response to therapyDocument response to therapyReview ongoing need for therapyReview ongoing need for therapy
Medication ConsiderationsMedication ConsiderationsBenzodiazepines: Long and short actingBenzodiazepines: Long and short acting
Risk of confusion, falling, dependenceRisk of confusion, falling, dependence
Non-BZD hypnotics: Avoid chronic useNon-BZD hypnotics: Avoid chronic useMore focus on behavioral managementMore focus on behavioral management
Opioids: Increased risk of falls/fracturesOpioids: Increased risk of falls/fracturesTramadol Clcr 30ml/min: SE/Seizure riskTramadol Clcr 30ml/min: SE/Seizure risk
Medication ConsiderationsMedication ConsiderationsFocus on Neuropathic pain Focus on Neuropathic pain
alternatives:alternatives:SNRI’s/Gapapentin/Pregabalin/Capsaicin/SNRI’s/Gapapentin/Pregabalin/Capsaicin/
Lidocaine Lidocaine Gabapentin/Pregabalin Clcr less Gabapentin/Pregabalin Clcr less
60ml/min60ml/minIncreased risk of CNS side effectsIncreased risk of CNS side effects
Duloxetine less Crcl 30ml/minDuloxetine less Crcl 30ml/minMore nausea/diarrheaMore nausea/diarrhea
Medication ConsiderationsMedication ConsiderationsMirtazapine/SNRI/ SSRI’s: SIADH; Check Mirtazapine/SNRI/ SSRI’s: SIADH; Check
Na when starting/changing doseNa when starting/changing doseSSRI’s: Increased risk of fallingSSRI’s: Increased risk of fallingOTC Sympathomimetics: Stimulant effectsOTC Sympathomimetics: Stimulant effects
Insomnia, anxiety, agitationInsomnia, anxiety, agitationAntipsychotics for behavior managementAntipsychotics for behavior management
Risk of CVA and mortality; Risk vs. BenefitRisk of CVA and mortality; Risk vs. Benefit
Medications ConsiderationsNSAID’s
PPI/misoprostol doesn’t ELIMINATE riskIndomethacin/Toradol CHF and CKD risk Increase in blood pressure with chronic
useSkeletal muscle relaxants
Poorly tolerated, all on the Beer’s listPotentially habit forming
Medication ConisderationsMedication Conisderations
Ca channel blockers: Ca channel blockers: constipation/edemaconstipation/edema
Verapamil/Diltiazem and CHFVerapamil/Diltiazem and CHFBeta blockers: Hypoglycemia; FatigueBeta blockers: Hypoglycemia; FatigueThiazides: SE and CrCl<30ml/minThiazides: SE and CrCl<30ml/minClonidine: Bradycardia, orthostasisClonidine: Bradycardia, orthostasisAlpha Blockers: OrthostasisAlpha Blockers: Orthostasis
Medicaton Considerations Miscelaneous GI medications
Reglan, Tigan, Lomotil*DA antagonist; Anticholinergic side effects
Mineral oilAbsorption of fat soluble vitamins; risk of aspiration
H2 antagonists in dementia/deliriumAniticholinergic effects
Na Containing AntacidsNa Containing AntacidsSubstantial sodium load: Edema and increase in BPSubstantial sodium load: Edema and increase in BP
Medication ConsiderationsMedication ConsiderationsEndocrine
Sliding scale insulin, GlyburideActos/Avandia for CHF riskDesiccated thyroidEstrogen/Megace/TestosteroneEstrogen/Megace/Testosterone
Lack of cardio-protective/cognitive effectLack of cardio-protective/cognitive effectLack of weight gain/increased thrombosisLack of weight gain/increased thrombosisCardiac risk/prostate cancerCardiac risk/prostate cancer
Drugs with Strong Anti-cholinergic Properties
1st Generation antihistamines/Loratadine*
Artane/CogentinSkeletal muscle relaxantsTCA’s/Paroxetine*Old antipsychotics Compazine, Promethazine, ZyprexaUrinary and GI antispasmodicsThe concept of “anti-cholinergic load”
Steps to Reducing Poly-Steps to Reducing Poly-pharmacy pharmacy
““Brown Bag” all medications at each Brown Bag” all medications at each office visit. Keep accurate recordsoffice visit. Keep accurate records
Identify all medications by Identify all medications by brand/generic name and drug classbrand/generic name and drug class
All drugs prescribed should have a All drugs prescribed should have a clinical indicationclinical indication
Stop any drug without known benefitStop any drug without known benefitConsider what effect drug therapy Consider what effect drug therapy
has on quality of lifehas on quality of life
Steps to Reducing Poly-Steps to Reducing Poly-pharmacy (CONT)pharmacy (CONT)
Know the side effects of the drugs Know the side effects of the drugs prescribed and what to expect from themprescribed and what to expect from them
Understand the PK and pharmacodynamics Understand the PK and pharmacodynamics of drugs prescribedof drugs prescribed
Substituting drugs within classes can Substituting drugs within classes can eliminate DI’s and ADR’seliminate DI’s and ADR’s
Be aware for the prescribing cascadeBe aware for the prescribing cascade““ONE DISEASE, ONE DRUG, ONCE DAILY”ONE DISEASE, ONE DRUG, ONCE DAILY”““START LOW, GO SLOW, BUT GO”START LOW, GO SLOW, BUT GO”