MEDICATING THE ELDERLY: UNRAVELING THE MED MAZE
Steven R. Smith, MS, RPh, BCPS
The elderly population
The proportion of elderly is increasing The mean age: 33 in 1990 to 44 by 2080 85+: 2.24 million in 1980 to 18.89 million in 2050 12% are 65+ and they use 30% of meds Women are living longer
Polypharmacy Definitions
The use of a number of different drugs by a patient who may have one or several health problems Administering many different medicines especially concurrently for the treatment of the same disease The mixing of many drugs in one prescription or shotgun prescription Drug use with no apparent indication Treating side effects of drugs with drugs
Factors that contribute to polypharmacy
Number of chronic medical conditions Female gender Multiple physicians, exp specialists Prescribing by brand and generic names Self medication with prescription and OTC medications Increased elder mobility Direct-to-the-consumer advertising ECF nurse requests Physician on call
Factors that contribute to polypharmacy - more
Physicians are reluctant to stop a medication started by another physician End points of drug therapy are seldom set and patients are not reevaluated for the need to continue medications "Start slow, Go slow" may yield failure to raise the dose to a therapeutic level Multiple pharmacies
How prevalent is polypharmacy?
1977: 4.3 Rxs per patient, 10.7 if 65+ 1986: 25 to 44 yrs old use 5 Rxs per yr, 12 if 65+ 1990: Elderly take 1.7 to 2.7 Rx drugs plus 1 OTC daily ECF residents take 4 to 16 drugs
ADEs and Drug interactions in the elderly
25% of the elderly at home complain SEs ADEs account for 2 to 8% of hospital admissions of all patients, If 65+, then 5 to 30% of hospital admissions 60% of patients admitted due to adverse drug reactions were taking 11 or more drugs Risk with 5 drugs is 4%, 6 to 10 drugs is 7%, 11 to 15 drugs is 24%, 16 to 20 drugs is 54% Elders in the hospital get more drugs so at even greater risk of ADE while an inpatient
Drug interactions
More common in the elderly simply because they take more drugs More than 20% of adverse drug reactions in the elderly are due to drug interactions Drug-drug interactions Drug-nutrient interactions Drug-alcohol interactions
Patient compliance by the elderly
Morbidity and disabilities from disease Complex regimens Drug characteristics Solutions
Morbidity and disabilities from disease
Movement disorders Amputations Impaired vision Comprehension and memory deficits Depression or psychosis
Complex medical regimens
Multiple medications Multiple administration times Complex administration Devices
Miscellaneous drug characteristics
Taste Cost Side effects Capsule or tablet size
Altered physiology in the elderly affects medications
Multiple organ system changes Pharmacodynamics Pharmacokinetics
Multiple organ system changes
Cardiovascular changes due to disease more so than aging Pulmonary system: disease more than normal aging Urinary system: aging more than disease GI tract Musculoskeletal Neurologic Special senses
Pharmacodynamics
Altered drug receptor sensitivity Fewer beta adrenergic receptors Beta adrenergic receptors are less sensitive Benzodiazepine receptors are more sensitive
Pharmacokinetics
Absorption Distribution Metabolism Excretion
Absorption
Reduced gastric acid and fluid- dissolution Delayed gastric emptying Reduced gastric acid - pH dependent absorption Reduced GI blood flow - absorption
Distribution
Decreased total body water Decreased lean body mass Increased total body fat CHF and impaired drug delivery
Metabolism
Hepatic blood flow First pass metabolism Liver enzyme system activity
Excretion
Reduced renal blood flow Age related decline in blood flow Clcr declines 1% per year after 40 Best data on drug dosing is for renal function
Solutions
Once a day medications Absolutely necessary medications only Education Involve family Review of medications at each visit Listening to the patient
Our medical system
Cost
New medications always cost more Inadequate assistance programs for the elderly Drugs excluded from health planning
Research
New drugs studied in the elderly on a limited basis New drugs studied in the “healthy” Little information on drug interactions for new drugs Research in the elderly primarily if it is a disease of the elderly Elderly excluded because . . .
Summary of this section
Magnitude of elderly drug use Polypharmacy Physiology ADME ADEs and Drug interactions Patient Compliance Complicated medical system
Take away messages
Understand why the elderly deserve special treatment First, do no harm ! Start low, Go slow, but Get there! Every medicine needs a problem on the list Check medicines regularly Ask about side effects and ability to take medicines When drug response doesn’t add up, think about why and then alternatives
Inappropriate Prescribing in the Elderly
A series of articles on this topic
• In the community setting • In the nursing home
Articles by Mark H. Beers, MD
• Developed statements from articles and textbooks on drug use in the elderly • Identified 14 participants, 13 completed the survey using a 5 point Likert Scale. • Came up with 23 drugs which are inappropriate for use in the elderly. • Published in 1991. Used by others for studies and publications since then.
Drugs from 1991 article not repeated in 1997 update
Avoid short acting benzodiazepines nightly for more than 4 weeks. Avoid triazolam in doses > 0.25mg Halodperidol in doses >3mg/day should be avoided unless psychosis. Thioridazine in doses >30mg/day should be avoided unless psychosis. Avoid HCTZ doses > 50mg/day Avoid propranolol except to control violent behaviors
Drugs from 1991 article not repeated in 1997 update
Isoxuprine use should be avoided. Avoid cimetidine in doses > 900mg/day and do not use > 12 weeks Avoid ranitidine in doses > 300mg /day and do not use > 12 weeks Avoid oral antibiotics > 4 weeks except when treating osteomyelitis, prostatitis, tuberculosis, or endocarditis Avoid decongestants (oxymetazoline, phenylephrine, pseudoephedrine) > 2 weeks
Inappropriate Prescribing in the Elderly
Beers updated this process in 1997 using a panel of 6 nationally recognized experts. I was NOT one of them. Medications or medication categories that should generally be avoided because they are either ineffective or because they pose unnecessarily high risk for elderly persons Dose, frequencies,or durations of therapies that generally govern the appropriate use in elderly persons of some medications Medications that should not be used in persons known to have specific medical conditions, even thought their use in the general population of elders might be appropriate.
Inappropriate Prescribing in the Elderly
What will be presented are the “statements” that the panel agreed with and a severity rating. The severity rating of yes or no states the panel’s opinion on the likelihood the adverse outcome would occur and the clinical significance of that outcome should it occur.
What the panel said:
Propoxyphene should generally be avoided in the elderly. It offers few analgesic advantages over acetaminophen, yet has the side effects of other narcotic drugs. Severity = NO
Of all available nonsteroidal, antiinflammatory drugs, indomethacin produces the most central nervous system side effects and should, therefore, be avoided in the elderly Severity = NO
What the panel said:
Phenylbutazone may produce serious hematological side effects and should not be used in the elderly. Severity = NO
Pentazocine is a narcotic analgesic that causes more central nervous system side effects, including confusion and hallucinations, more commonly than other narcotic drugs. Additionally, it is a mixed agonist and antagonist. For both reasons, it should be avoide in the elderly. Severity = YES
What the panel said:
Trimethobenzamide is one of the least effective antiemetic drugs, yet it can cause extrapyramidal side effects. When possible, it should be avoided in the elderly. Severity = NO
Most muscle relaxants and antispasmodic drugs are poorly tolerated by the elderly, leading to antichlinergic side effects, sedation and weakness. Additionally, their effectiveness at doses tolerated by the elderly is questionable. Whenever possible, they should not be used in the elderly. Severity = NO Drugs: methocarbamol, carisoprodol, oxybutynin, metaxalone, chlorzoxazone, cyclobenzaprine
What the panel said:
Benzodiazepine hypnotic has an extremely long half-life in the elderly (often days), producing prolonged sedation and increasing the incidence of falls and fractures. Medium or short acting benzodiazepines are preferable. Severity = YES Drug: Flurazepam
Because of its strong anticholinergic and sedting properties, amitriptyline is rarely the antidepressant of choice for the elderly. Severity = YES Drugs: amitriptyline, chlordiazepoxideamitripyline, and perphenazineamitriptyline
What the panel said:
Because of its strong anticholinergic and sedating properties, doxepin is rarely the antidepessant of choice for the elderly. Severity = YES
Meprobamate is a highly addictive and sedating anxiolytic. Avoid in elderly patients. Those using meprobamate for prolonged periods may be addicted and may need to be withdrawn slowly. Severity = YES if recently started
What the panel said:
Because of increased sensitivity to benzodiazepines in the elderly, smaller doses may be effective as well as safer. Total daily doses should rarely exceed the following suggested maximums. Severity = NO
Drugs and Doses: Lorazepam 3mg Oxazepam 60mg Alprazolam 2mg Temazepam 15mg Zolpidem 5mg Triazolam 0.25mg
What the panel said:
Chlordiazepoxide and diazepam have a long half-life in the elderly (often several days), producing polonged sedation and increasing the risk of falls and fractures. Short and intermediate acting benzodiazepines are preferred if a benzodiazepine is required. Severity = YES
Disopyramide, of all antiarrhythmic drugs, is the most potent negative inotrope and therefore may induce heart failure in the elderly. It is also strongly anticholinergic. When appropritate, other antiarrhythmic drugs should be used. Severity = YES
What the panel said:
Because of decreased renal clearance of digoxin,doses in the elderly should rarely exceed 0.125mg daily, except when treating atrial arrhythmias. Severity = Yes, if recently started
Dipyridamole frequently causes orthostatic hypotension in the elderly. It has been proven beneficial only in patients with artificial heart valves. Whenever possible, its use in the elderly should be avoided. Severity = NO
What the panel said:
Methyldopa may cause bradycardia and exacerbate depression in the elderly. Alternate treatments for hypertension are generally preferred. Severity = YES if recently started.
Reserpine imposes unnecessary risk in the elderly, inducing depression, impotence, sedation, and orthostatic hypotension. Safer alternatives exist. Severity = NO
What the panel said:
Chlorpropamide has a prolonged half-life in the elderly and can cause prolonged and serious hypoglycemia. Additionally, it is the only oral hypoglycemic agent that causes SIADH. Avoid in the elderly. Severity = YES
Diphenhydramine is potently anticholinergic and usually should not be used as a hypnotic in the elderly. When used to treat or prevent allergic reactions, it should be used in the smallest possible dose and with great caution. Severity = NO
What the panel said:
Gastrointestinal antispasmodic drugs are highly anticholinergic and generally produce substantial toxic effects in the elderly. Additionally, their effectiveness at doses tolerated by the elderly is questionable. All these drugs are best avoided in the elderly, especially for long-term use.
Severity = YES Drugs: dicyclomine, hyoscyamine, propantheline, belladonna alkaloids, and clidiniumchlordiazepoxide.
What the panel said:
All non-prescription and many prescription antihistamines have potent anticholinergic properties. Many cough and cold preparations are available without antihistamines, and these are safer substitutes for the elderly. Severity = NO
Chlorpheniramine, diphenhydramine, hydroxyzine, cyproheptadine, promethazine, tripelennamine, and dexchlorpheniramine
What the panel said:
Hydergine (ergot mesyloids) and the cerebral vasodilators have not been shown to be effective, in the doses studied, for the treatment of dementia or any other condition. Severity = NO Drugs: Ergot mesyloids (Hydergine) and cyclospasmol
Iron supplements rarely need to be given in doses exceeding 325mg of ferrous sulfate daily. When doses are higher, total absorption is not substantially increased, but constipation is more likely to occur. Severity = NO Drug: Iron supplements in doses > 325mg /day.
What the panel said:
Barbiturates cause more side effects than most other sedative or hypnotic drugs in the elderly and are highly addictive. They should not be started as new therapy in the elderly except when used to control seizures. Severity = YES, if recently started. Drugs: Barbiturates except phenobarbital
Meperidine is not an effective oral analgesic and has many disadvantages to other narcotic drugs. Avoid in the elderly. Severity = YES Ticlopidine has been shown to be no better than aspirin in preventing clotting and is considerably more toxic. Avoid in the elderly. Severity = YES
OBRA laws
HCFA drug use review was started in 1974 for patients in skilled nursing facilities. OBRA 1987
• “The resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the residents’ medical symptoms.” • Unnecessary Drugs: Any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above.”
OBRA laws
OBRA 87 also defines:
• • • • • What anti-psychotics may be used for What anti-psychotics can not be used for Use of long-acting benzodiazepines Use of short-acting and other anxiolytic drugs Gradual dose reductions for benzodiazepines
OBRA 90 expands to prospective as well as retrospective drug use review.
• Review is for all Medicaid recipients
Applying Drug Regimen Review to your practice
HCFA has adapted the criteria by Beers Local Consultant pharmacies are now reviewing charts using interpretations of the Beers criteria How does this affect you?
• May receive more letters from the facilities or from the pharmacist • Getting a letter does not mean you are wrong and have to change the drug therapy • May be asking for more info • May be reminding to order appropriate labs at appropriate intervals
Applying Drug Regimen Review to your practice
How does this affect you? If finding a criteria not being met, you may need to provide more info or an explanation that justifies the drug therapy Keep a copy of the letter and your response Be willing to change the therapy if it does in fact need to be changed If you become a Medical Director: you will need to help shape the drug regimen review for your facility
THE END