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Medication Management in Older Adults

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4Ms Framework

u Identify unsafe medications u Report opportunities to

deprescribeu Enhance medication

adherenceu Use screening tools

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Objectives

1. Discuss impact of polypharmacy on older adults

2. Identify high risk medication classes that contribute to polypharmacy and adverse drug events

3. Review available resources to aid deprescribing efforts

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Inappropriate prescriptions pose health risks for older adults, leading to unnecessary hospitalizations and cost

u Emergency hospitalizations for adverse drug events in older Americans. NEJM 2011;365(21):2002-12

Van Gogh, St Paul Asylum

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Why does polypharmacy occur in older adults ?

u Medications started in middle ageu Multiple prescribers

uAverage 5 specialty visits and 2.4 primary care visits annually

u Multiple Chronic Conditions & guidelinesuExample: heart failure B block, ACE,

spironolactone, statinu Standing orders remain

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NHANES study: polypharmacy doubles each decade

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2000 2011

Prevalence

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Polypharmacy = 5 or more medications

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5 - 9 Rx > 10 Rx

Percent of 65 +

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Prescribing cascadeUSE ANOTHER MEDICATION TO TREAT SIDE EFFECTS OF A PREVIOUS PRECRIPTION

The Wilds of Lake SuperiorThomas Moran, 1871

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Prescribing Cascade

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Polypharmacyu OTC and supplementals

u 50% of patients do not tell their provider

u Example: ginseng lowers FBS by 21 mg / dL and HA1c by 0.5% in diabetics with potential for hypoglycemia

Jeremiah White, ColoradoJeremiah White

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Why reduce medication burden ?u Drugs may become unsafe with aging

uChange in kidney functionuDrug – drug interactionsuMetabolic changes

u Changes in priorities: What Mattersu Primary prevention is no longer a goalu Reduce costs

Diego Rivera

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Few medication studies for chronic conditions in older adults

Leonardo Da Vinci

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Opportunities for deprescribing

The Alchemist by Jacob Toorenvliet. fec 1684.

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Statins

u Good for secondary preventiono CVD: heart disease and stroke

u Uncertain for primary preventiono 23 % older adults given statin for primary prevention

u 10 year risk for 75+ does not meet guideline thresholds

u ALLHAT trial of statins found no efficacy

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Class Example

Antihistamines Diphenhydramine, hydroxyzine, meclizine

Anti parkinsons BenztropineMuscle relaxants Cyclobenzaprine,

methocarbamolAnti depressants Amitryiptyline, imipramine,

paroxetineAntipsychotics Abilify, haldolAntimuscarinics Oxybutynin, tolterodine,

trospiumAntiemetics Prochlorperzaine,

promethazineAntispasmodics Hyoscamine, scopalamine

ANTICHOLINERGICS

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High anti-cholinergic burden

ConfusionDeliriumPoor physical functionLoss of independenceBrain atrophyMemory lossImpulsivity

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Antagonistic therapy with Incontinence meds at odds with anticholinesterase dementia treatment

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The notorious benzo’s

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Benzos

u Mostly primary care prescribers

u 8% of populationu Anxiety, agitation,

insomnia

Too Many Sheep to Sleep -Hiroko Sakai, San Francisco

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List 3 bad things that happen with benzodiazepines

Jacob Peter Gowy The Flight of Icarus(1635–1637)

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List 3 bad things that can happen with benzodiazepines

u Fallsu Amnesiau Dementiau Impaired drivingu Hip fracturesu Dependency u Loss of REM sleep

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Antipsychotics

Théodore Géricault, “The Hyena of la Salpêtrière,” 1819

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Antipsychotics

u Increasing off label useu Only 11% effective in

managing dementia –related agitation

u Increase mortality risku 50% higher risk of

serious fall and non vertebral fracture

u Tardive dyskinesia

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Alternatives to anti-psychotics

Girl Before a Mirror, Pablo Picasso 1932

• Mirror imaging: Go with the flow

• Distract and Divert

• Treat empirically for pain

• Positive body language

• Do not argue or reprimand

• Do not rationalize

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PPIu Up to 70 % prescriptions with no

apparent indicationu Up to 50 % of hospitalized patients

sent out with PPIsu Long term use only for

uErosive esophagitisuBarrett’s esophagitisuGastrinoma / hypersecretionuRefractory reflux

Ghost of a Genius, Pall Klee, 1922

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Adverse effects of PPIsu C. difficile colitisu Community acquired pneumoniau Hip fracturesu Vitamin B12 deficiencyu Atrophic gastritisu CKDu Dementia

Alberto Giacometti

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Watch Out !

Drugs Rationale for avoidance

ASA, dabigatran, rivaroxaban, prasugrel

Risk of bleeding increases with older age

SSRI, SNRI, TCAs, diuretics, antipsychotics, carbamazepine, tramadol

SIADH and hyponatremia

Trimethoprim -sulfamethoxazole

Hyperkalemia with ACE or ARB and low eGFR

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Approach to polypharmacyHPI or ROS: Consider patient symptoms as drug – related

u Fatigue / Tirednessu Fallsu Poor sleepu Decreased alertnessu Constipation u Diarrhea u Incontinenceu Loss of appetite / weight loss u Confusion u Depression / interest in usual activities

John Henry Fuseli, “The Nightmare,” 1781

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Strategies to prevent polypharmacyu Medication list with diagnosisu Brown bag visitu Pharmacist consult, including ONE Rx referralu Check list: Beer’s criteriau Transition of care reconciliationu Align medication regimen to What Matters

Carol Josefiak

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Deprescribing

u90% of patients willing to stop medication if physician says it is possibleu Reeve E, et al. (2018) “Assessment of attitudes

toward deprescribing in older Medicare beneficiaries in the United States.” JAMA Internal Medicine

Chuck Close

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Tools for deprescribing

u Algorithmsu Pamphletsu Checklistsu Research

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Tools for deprescribing

https://deprescribing.org

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Beers List: framework

POTENTIALLY INAPROPRIATE MEDICATIONS

AVOID

CAUTION

DRUG-DRUG INTERACTIONS

DRUG – DISEASE INTERACTIONS

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Potentially Inappropriate Medications (PIMs)

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Drug – disease list

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Beers List: 30 drugs to avoid in general / 40 to use cautiouslyuSNRIs à fallsuMetoclopramide à antidopaminergicuSliding scale insulin à hypoglycemiauSulfonylureas à hypoglycemiauNSAIDs, especially with diuretics or HF

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Beers List: Combos to avoid

uOpioids with benzodiazepines or gabapentinoidsuMore than 3 CNS active RxsuMacrolides & Cipro with warfarin (bleeding)uSMX – TMP and phenytoin (Dilantin toxicity)uSMX – TMP with ACE / ARB and CKD (hyperkalemia)

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Beers List: medications to avoid or reduce with CKDMedication Side effect RecommendationCiprofloxacin CNS changes, tendon rupture Reduce doseNitrofurantoin Organ toxicity, neuropathy Avoid, especially long term useTMP - SMX Hyperkalemia, kidney faiure Reduce dose CrCL 15 -29 mL / min

Avoid if < 15 mL / minH2 blockers Mental status changes Reduce doseGabapentin / Pregabalin CNS changes Reduce dose

Duloxetine CNS changes Reduce dose

Colchicine GI side effects, BM toxicity, Neuromuscular effects

Reduce dose

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STOPP/START List

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Examples of STOPP / START

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STOPP / START protocol

u 41 – 67 % hospitalized patients with Potentially Inappropriate Medication (4 RCTs)

u Protocol impactuFall reductionuReduced drug costsuReduced adverse drug events from 24 to 12.5 %

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Consider

§ What Matters to the patient

§ Functional status

§ Life expectancy

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Goals

u Identify unsafe medications u Report opportunities to deprescribeu Enhance medication adherenceu Use screening tools

Image from Pixabay

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4Ms Framework

High-quality Geriatrics healthcare with 4Ms

Need to be delivered reliably with every older adult encounter across the continuum.

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