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Avoiding Hobson’s choice in older patients: Managing multi-morbidity and multiple medications in geriatrics. Marilyn N. Bulloch, PharmD , BCPS Assistant Clinical Professor Harrison School of Pharmacy Auburn University. The Hobson’s Choice in Geriatric Pharmacotherapy. Objectives. - PowerPoint PPT Presentation
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Avoiding Hobson’s choice in older patients:
Managing multi-morbidity and multiple medications in geriatrics
Marilyn N. Bulloch, PharmD, BCPSAssistant Clinical Professor
Harrison School of Pharmacy
Auburn University
The Hobson’s Choice in Geriatric Pharmacotherapy
Don’t Prescribe It
Prescribe It
Objectives Discuss the impact of the aging population on
healthcare utilization. Understand age-related pharmacokinetic and
pharmacodynamics changes that may affect pharmacotherapy in older adults
Describe complications of chronic medication therapy in the aging patient.
Identify strategies to optimize benefit and minimize harm with chronic medication therapy in older adults.
Our Patients Are Aging
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 20500
10,000,000
20,000,000
30,000,000
40,000,000
50,000,000
60,000,000
70,000,000
80,000,000
90,000,000
100,000,000
Population 65+ by Age: 1900-2050Source: U.S. Bureau of the Census
Age65-74
Age75-84
Age85+
Num
ber o
f Per
sons
65+
Available: http://www.aoa.gov/Aging_Statistics/future_growth/future_growth.aspx#age (Accessed April 2013)
Patients Are Living Older Longer
Available: http://www.aoa.gov/Aging_Statistics/future_growth/future_growth.aspx#age (Accessed April 2013)
Chronic Conditions in Older Adults
Available: http://www.aoa.gov/Aging_Statistics/future_growth/future_growth.aspx#age (Accessed April 2013)
Multi-morbidity
Co-occurrence of: Index diseasePreexisting age-related health condition
or diseases Impact
Affect disease progressionDecrease quality of life Increase risk and severity of disability Increase risk of mortality
Shi et al. Eur J Clin Pharmacol 2008;64:183-199
Patients with Multi-morbidity
Total Men Women0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%45%
49.00%43%
2009-2010
Black White Hispanic0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00% 51.60%45.10% 42.40%
2009-2010
Adapted from Figure 1. Fried et al. NCHS Data Brief 2012;100:1Adapted from Figure 2. Fried et al. NCHS Data Brief 2012;100:2
Multiple Medications in Older Adults
Exhibit 13. IMS Institute for Healthcare Informatics. Avoidable Costs in U.S. Healthcare: The $200 Billion Opportunity from Using
Medicines More Responsibly. June 2013. Available http://www.imshealth.com (accessed 20 June 2013)
Evidence-Based Geriatric Medicine Studies involving geriatrics
3% randomized, controlled studies1% meta-analyses
Make up 2-9% study subjects In 2000
3.45% of controlled trials 1.2% of meta-analysis
Le Couteur et al. Aus Fam Phys 2004;33:777-781
Applying EBM to Older Adults Does your patient resemble the studied population? How many older adults with multi-morbidity
were included? What are the intended outcomes – are these applicable to
older patients? Are there clinically important variation in baseline factors
that affect intended outcome? Are the risks of the intervention known in older adults with
multi-morbidity? What is known about the comparator intervention in
older adults? What is the time until benefit or harm?
Adapted from Table 1. J Am Geriatr Soc 2012;60:1957-68
Age-Related Physiologic Changes
Adapted from Figure 1. Huang A. 28th Annual Scientific Meeting of the Canadian Geriatric Society 2008;11(10):7
DRUGADMINISTRATION
Absorption Changes ↓ saliva production ↓ gastric acid secretion ↓ gastrointestinal blood flow Delayed gastric emptying Intestinal atrophy Changes in body fat and lean muscle Pulmonary changes Skin changes Conjunctiva changes
Hubbard et al. Eur J Clin Pharmacol 2013;69:319-326McLean et al. Pharmacol Rev 2004;56:163-184
Corsonello et al. Cur Med Chem 2010;17:571-584
Distribution Changes
↑ body fat ↓ lean muscle ↓ total body water ↓ albumin ↑ CNS penetration
Hubbard et al. Eur J Clin Pharmacol 2013;69:319-326Sitar. Expert Rev Clin Pharmacol 2012;5:397-402
McLean et al. Pharmacol Rev 2004;56:163-184Corsonello et al. Cur Med Chem 2010;17:571-584
Metabolism Changes
↓ hepatic blood flow ↓ liver volume ↓ plasma esterase quantity & activity
Associated more with health status than age Phase I pathways more impacted than
Phase II
McLean et al. Pharmacol Rev 2004;56:163-184
Elimination Changes
↓ glomeruli causes ↓kidney mass ↓ GFR in 2/3 of patients ↑ drug elimination half-life
McLean et al. Pharmacol Rev 2004;56:163-184
Pharmacokinetic Questions How readily absorbed is the medication? What is the onset and duration of desired
therapeutic action? What is the patient’s body composition? Is the medication excreted unchanged? What is the major route of elimination? Does the medication have an metabolite?
Is the metabolite active or toxic? How is the metabolite eliminated?
Adapted from Table 2. Lamy. J Am Ger Soc 1982;11;s11-s19
Pharmacodynamic Changes
Receptor down regulation Change in receptor sensitivity
IncreasedDecreased
Impaired homeostatic mechanisms and/or physiologic reserves
COMPLICATIONS OF GERIATRIC MEDICATION USE
Polypharmacy
Quantity ≥ X Medications Limiting - assumes > X is
incorrect
Quality More medications than is
clinically indicated No indication Lack efficacy Duplications
Requires more thorough review of medications
DeSovo et al. Prim Care Clin Office Pract 2012;39:345-362
Reasons for Polypharmacy
Age Ethnicity Rural residence Education level Insurance Multiple healthcare
providers Poor health status Provider visits
Chronic diseases Anemia Angina Asthma Depression Diabetes Diverticulosis Gout Hypertension Osteoarthritis
DeSovo et al. Prim Care Clin Office Pract 2012;39:345-362
Avoidable Costs of Polypharmacy
Exhibit 12. IMS Institute for Healthcare Informatics. Avoidable Costs in U.S. Healthcare: The $200 Billion Opportunity from Using
Medicines More Responsibly. June 2013. Available http://www.imshealth.com (accessed 20 June 2013)
Adverse Drug Reactions
Unwanted and/or harmful effects that can occur at standard doses
Gurwitz et al 50.1 ADRs per 1000 person years
13.8 preventable ADRs per 1000 person years
VA GEM Study 33% of patients experienced an ADR within 12
months of hospital discharge 38% considered preventable
Boparai MK et al. Mt Sinai J Med 2011;78:613-626Gurwitz et al. JAMA 2003;289:1107-1116
Steinman et al. J Gerontol A Biol Sci Med Sci 2011;66:444-451
Risks for ADRs Prior ADR Polypharmacy Dementia/cognitive
impairment Multi-morbidity Frailty CrCl < 50 mL/min Female Fragmented care Altered stimuli-induced
adaptation capacity
Recent hospital admission Age ≥ 85 years Low body weight ≥ 1 oz alcohol intake/ day Vision or hearing
impairment Compliance Regimen complexity
DeSovo et al. Prim Care Clin Office Pract 2012;39:345-362Boparai MK et al. Mt Sinai J Med 2011;78:613-626
Medications Causing ADRs
Cardio
vasc
ular
Antimicr
obial
Diuretic
Nonopioid analgesic
s
Hypoglyc
emics
Stero
ids
Opioid a
nalgesics
Antidepre
ssants
Antiepile
ptics
Antihyp
erlipidem
ics
Antineoplasti
c
Other
0%
5%
10%
15%
20%
25%
30%
35%
40%
Preventable ADRs Total ADRs
Gurwitz JH, et al. JAMA 2003;289;107-116
Types of ADRs Occurring
Figure 1. Percent patients suffering selected injuries commonly studied among patients who experienced adverse drug events: Reducing and Preventing Adverse Drug Events To Decrease Hospital Costs. March 2001. Agency for Healthcare Research and
Quality, Rockville, MD. http://www.ahrq.gov/research/findings/factsheets/errors-safety/aderia/figure1.html (Accessed April 24, 2013)
ADR Consequences
Health care utilization 10% of emergency room visits 10-17% of hospitalizations
$1.33 to manage medication-related morbidity and mortality for each $1 spent on older adults in nursing homes
Can be fatal Symptoms should be considered ADRs until
proven otherwise.Le Couteur et al. Aus Fam Phys 2004;33:777-781Budnitz et al. N Eng J Med 2011;365”2002-2012Boparai MK et al. Mt Sinai J Med 2011;78:613-626
Drug Interactions
Many types 15-46% patients have ≥ 1 interaction
1 in 25 community patients at risk for severe interaction Over 26% cause ADRs that require hospitalization
25% serious or life-threatening Approximately 20% occur in the hospital
Potential for drug-drug interaction in over 6% of medication orders
McDonnell, et al. Ann Pharmacother 2002;36:1331-1336Qato et al. JAMA 2008;300:2867-2878
Reimche et al. Clin Pharmacol 2011;51:1043-1050Lindblad et al. Clin Therapeu 2006;28:1133-1143
Drug Interactions
Age60-74 years – 24%≥ 80 years – 36%
Risk increases with # medications≥ 2 medications – 13%> 6 medications – 82% ≥ 8 medications – almost 100%
Boparai MK et al. Mt Sinai J Med 2011;78:613-626Stegemann et al. Age Research Rev 2010;9:284-298
Minimizing ADRs and Interactions Know allergies – including
reactions Evaluate cognitive function Have a drug information source Use safest/most effective
medication Match medications to indications Use fewest medications possible Use simple dosing Do not start 2 medications at the
same time
Screen for DDIs routinely Dose for renal & hepatic function Recognize a symptom as an ADR Give prophylaxis for known side
effects when able Stop medications without benefit Stop PRN medications not used
in past month Medication lists Involve caregivers
Adapted from: Boparai MK et al. Mt Sinai J Med 2011;78:613-626
Non-Adherence Adherence in patients with
chronic conditions only 50-60% Responsible for up to 70.4%
of medication-related ER visits May account for 39-69%
of drug-related hospitalizations each year
Costs $100 billion/year
Coleman et al. J Manag Care Pharm 2012;18:527-539Orwig et al. Gerontologist 2006;46:66
Cost of Non-Adherence
Exhibit 3. IMS Institute for Healthcare Informatics. Avoidable Costs in U.S. Healthcare: The $200 Billion Opportunity from Using
Medicines More Responsibly. June 2013. Available http://www.imshealth.com (accessed 20 June 2013)
Types of Non-adherence
Forgetfulness Confusion over dosage schedule Intentional underuse
Primary non-adherence Non-persistence Nonconforming non-adherence
Intentional overuse
Coleman et al. J Manag Care Pharm 2012;18:527-539
Risk Factors for Non-Adherence Communication Regimen complexity Patient-provider
relationship Transition of care Health literacy Mental health
disorders Cognition Smoking
Asymptomatic chronic diseases
Age Physical impairment Lack of social support Minority demographic Patient beliefs Sensory changes Product use Dysphagia
Dosing Influence on Adherence
Frequency of Daily Dosing
Taking Adherence
Regimen Adherence
Timing Adherence
Once daily 93% 81.8% 76.9%
Twice daily 85.6% 74.2% 59.3%
3 times daily 80.1% 62.8% 35.9%
4 times daily 84.4% 68.2% 18.8%
Coleman et al. J Manag Care Pharm 2012;18:527-539
Overcoming Adherence BarriersBarrier Solution
Forgetfulness
• Pill organizers• Medication Calendar/Cues• Dispensing Devices• Family/caregiver involvement• Internet-linked or electronic adherence aid
Patient beliefs• Establish shared goals of care• Provide literacy appropriate materials• Simplify regimen/reduce pill burden
Difficulty Taking
• Change formulation• Easy off caps• Pill cutters• Simplify regimen• Syringe magnification• Spacer
Cost • Generics
Steinman et al. JAMA 2010;304:1592-1601
EVALUATING MEDICATION MANAGEMENT ABILITY
Drug Regimen Unassisted Grading Scale (DRUGS)
Medication List(container or chart)
Medication List(patient-reported) Identification Access Dosage Timing
Total Medications: Total Doses:
Maximum Score: Total Score:
Summary Score:(Total Score/Maximum Score) X 100
Time:
Adapted from Edelberg et al. J Am Geriatr Soc 1999;47:592-596
MedTake Test
Adapted from Appendix I. Raehl et al. Pharmacotherapy 2002;22:1239-1248
Drug Name, dose, SIG
Patient description of how to take drug
Dose(25%)
Indication(25%)
Food/water co-
ingestion(25%)
Regimen(25%)
Score per
drug(0-100%)
Comment
1.
2.
3.
4.
5.
Scoring: 1 = correct, 0 = incorrect
Composite (Mean) MedTake Score (0-100%): _____%
MedTake Test
Totally incorr
ect
Mostly
incorrect
Somewhat incorr
ect
Somewha
t corre
ct
Mostly
correct
Perfectly
correct
Dose +0 +5 +10 +15 +20 +25
Indication +0 +5 +10 +15 +20 +25
Co-ingestion with food or water +0 +5 +10 +15 +20 +25
Regimen and schedule +0 +5 +10 +15 +20 +25
Sum of points (0-100)Knowledge score for individual drug
Adapted from Appendix I. Raehl et al. Pharmacotherapy 2002;22:1239-1248
Medication Regimen Complexity Index Checklist style tool to evaluate regimen Only for prescribed medications Medication Regimen Complexity = Total
(A) + Total (B) + Total (C) Open index
# medications and directions vary by patient
George et al. Ann Pharmacother 2004;38:1369-1376
MRCI Section A: Dosage Forms
Adapted from Appendix II. George et al. Ann Pharmacother 2004;38:1374-1375
MRCI Section B: Dose Frequency
Adapted from Appendix II. George et al. Ann Pharmacother 2004;38:1374-1375
MRCI Section C: Directions
Adapted from Appendix II. George et al. Ann Pharmacother 2004;38:1374-1375
Medication Management Instrument for Deficiencies in the Elderly
What a Patient Knows About Their Medications Yes No
1. Name all daily medications – Rx and OTC
2. State time of day each prescription medication is taken
3. State how each medication is taken (po, with water, ect)
4. State indication for each medication
5. State amount of each medication to be taken at each dose
6. Identify if there are problems with medications (ADRs)
7. Does patient get help with medicationsBy whom:_____________ Type:__________________
8. Other medications on hand (outdated, unused, discontinued)
“No” selection for 1-5 credited to Total Deficiency Score
Adapted from Orwig et al. Gerontologist 2006;46:661-668
Medication Management Instrument for Deficiencies in the Elderly
If a Patient Knows How to Take Their Medications Yes No
1. Can fill a glass with water
2. Can remove top from medication container
3. Can count out required number of pills into hand or cup
4. Can put hand with medication to open mouth; put hand to eye for eye drops; hand to mouth for inhaler; draw up insulin; place a transdermal patch
5. Can sip enough water to swallow medication
6. How are medications currently stored
If a Patient Knows How to Get Their Medications Yes No
1. Identify a refill exists on a prescription
2. Identify who to contact to refill a prescription
3. Does patient have resources to obtain medications
“No” selection for Part 1: 1-5 and Part 2: 1-3 credited to Total Deficiency Score
Adapted from Orwig et al. Gerontologist 2006;46:661-668
Hopkins Medications Schedule
Appendix. Carlson et al. J Gerontol A Biol Sci Med Sci 2005;60;223
AUXILIARY LABELS & THE IMPORTANCE OF VERBAL
COUNSELING
In Conclusion We have a lot of older patients
Patients are staying older longer Older patients need medications
They respond differently than younger patients There is not a lot of EBM to guide decisions or answer
questions on geriatric medication use Try to optimize medication prescribing and use
to minimize complications before taking the Hobson’s Choice
Questions
“All substances are poisons; there is none which is not. The right dose differentiates a poison from a remedy”-Paracelsus (1493-1541)