Polypharmacy of Older Adults

Objectives

• Describe the demographics of medication usage

• Identify the effects of physiologic changes on drug absorption, distribution, and clearance

• Describe adverse reactions to medications

• Identify iatrogenic problems associated with multigeriatric syndromes and their medication regimens.

Objectives

• Discuss strategies for preventing polypharmacy and enhancing medication compliance / adherence.

• Appreciate complex cost issues related to medications

• Discuss effects of tricyclic antidepressant drugs on older adults

Polypharmacy

“many drugs”…indicates the use of more medication than is clinically indicated or warranted. 5+ drugs

2000 = 200 million visits to the doctor– No prescription (30%)– Prescription of 1 - 2 drugs (30%)– Prescription of 3+ drugs (30%)

The Typical Older Adult…..

• Takes 4 to 5 prescription and 2 OTC drugs at a time; fills 12 – 17 prescriptions/year

• Is on fixed income, whose main source of income is Social Security

• Spends an average of $955 for medications

• In ambulatory: 2 – 4 prescription drugs• In long term care: 2 – 20 prescription

drugs

Physician Factors

• Presuming patient expects prescription medication and no medication review

• Prescribing without sufficient investigation of clinical situation

• Unclear, complex, incomplete instruction; not simplifying the regimen

• Ordering automatic refills

• Lack of knowledge of geriatric clinical pharmacology……inappropriate prescribing

Patient Factors

• Seeing multiple physicians and pharmacies

• Hoarding of medications

• Inaccurate reporting of ALL medicines concurrently being taken

• Assuming that when medication starts, they can continue indefinitely

• Changes in daily habits

• Changes in cognition, depression, insufficient funds, declining function, living alone

Polypharmacy leads to…

• Adverse drug reactions

• Drug-drug interactions

• Decreased medication compliance

• Poor quality of life

• Unnecessary drug expense

Effects of Physiologic Aging

• Absorption– Delayed gastric emptying;

decreased gastric acidity; decreased splanchic blood flow

• Drug Distribution– Higher percentage of fat; decreased

total body water; decreased plasma albumin concentration

Effects of Physiologic Aging

• Serum Concentration– Change in body composition

changes serum concentration of water-soluble drugs

– Change in fat mass affect concentration of fat-soluble medications

• Drug Clearance– Altered liver metabolism;

decreased renal excretion of drugs

Adverse Drug Reactions

• Simulate conventional image of ‘growing old’: unsteadiness, confusion, nervousness, fatigue, insomnia, drowsiness, falls, depression, incontinence, malaise

• Criteria for potentially inappropriate medication use in older adults (US Consensus Panel of Experts, 2003)

Adverse Drug Reactions

• Fifth leading cause of death in older adults

• Falls from orthostatic hypotension

• Confusion and disorientation

• Hepatic toxicity

• Renal toxicity

• *Creatinine clearance formula

Iatrogenic Problems

• Anticholinergics: confusion; orthostatic hypotension; dry mouth; blurred vision; urinary retention

• Tricyclics: confusion and unstable gait

• Antiemetics: confusion; orthostatic hypotension; blurred vision; falls; dry mouth; urinary retention

Iatrogenic Problems

• Digoxin: toxicity

• H2 Blockers: confusion

• Benzodiazepines: CNS toxicity

• Narcotics: constipation; “start low; go slow”

Preventing polypharmacy

• Requires social and nursing support

• Enhancing compliance:– Patient education – written

instruction– Sensitivity to lack of money to buy

medications– Counseling– Need to take medication even if

‘feeling good’

Enhancing compliance

• Improve provider-patient communication: more time with physician and pharmacist

• No pill sharing

• Assess other remedies patient uses

• Support Systems: Medication Event Monitoring systems (MEMS)

• At least yearly, ask patient to bring ALL medications for review

Cost of Medications

• 65% of noninstitutionalized Medicare beneficiaries – have some form of prescription drug coverage

– Spend less ($310/year) than those without drug coverage ($590/year)

– 60% employer-sponsored or private policy

– 20% Medicare + Choice HMO

– 20% supplemental Medicaid, other public programs

Cost of Medications

Medicare Prescription Drug, Improvement and Modernization Act of 2003 (comprehensive plan will be effective 1/2006)

The Discount Card Program– NOT a comprehensive benefit

– Voluntary and temporary

– Immediate assistance in lowering drug costs for 2004 and 2005

Cost of Medications

The Discount Card Program

• Medicare will contact private companies: 10% – 25% savings

• Choose a prescription drug plan; pay a premium $35.00

• Pay $250.00 deductible; Medicare will pay 75% of cost from $250 to $2,250

• Recipient will pay 100% from $2,250 - $3,600

• Medicare will pay 95% after recipient spends $3,600

ImposingCo-payments

Federal DrugRebate Program

DispensingLimits

FAIL FIRST

Generic Substitution

Preauthorization

FormulariesPreferred Drug List

Access toPrescription

Drugs for lowerIncome seniors

MEDICAID PRESCRIPTION DRUG COVERAGE COST STRATEGIES

Cost of Medications

• Older adults save money on prescription drugs by

– Cutting medications in half

– Borrowing money from friends

– Discontinuing certain medications because they ‘feel good’

Tricyclic antidepressants

• Cause adverse anticholinergic effects

• Caution when using in older adults with glaucoma and cardiac arrhythmias

• Hypotension, tachycardia, and arrhythmia

• Sedation, fatigue, anxiety, impaired cognitive function, seizures, extrapyramidal symptoms

Summary

• Demographics of medication usage

• Physiologic changes of aging and effects on drug absorption, distribution and clearance

• Adverse drug reactions

• Iatrogenic problems

• Preventing polypharmacy / enhancing compliance

• Cost Issues

• Effects of tricyclic antidepressants

QUESTIONS?