Grab a BEERS list: Medication Management in Older Adults

Transcription

1 Grab a BEERS list: Medication Management in Older Adults Amy Siple, MSN, FNP-BC Associate Professor of Nursing, Newman University Nurse Practitioner, Wichita Medical Associates

2 Objectives The participant will be able to recall at least two issues that put older adults at increased risk for adverse drug events. The participant will be able to identify at least three pharmacologic risk factors that older adults face. The participant will be able to recall what the BEERS list is and how it can be used. The participant will be able to name at least three medications that are typically inappropriate for older adults.

3 Mr G. Your neighbor is an 89 year old Hispanic male who has been in excellent health. His wife knows you are a nurse practitioner and voices concern that her husband has been confused lately and sustained two falls this week. He had a fecal incontinence episode this morning and she said his stool was awful dark. You ask if he is taking any medications. She proudly responds that he is not.

4 Mr. G On further inquiry she says he only takes Motrin 400 BID for his arthritis. This manages his pain pretty well, but he still has discomfort at night, so last week she started giving him Tylenol PM to help him sleep. What do you think are contributing to Mr. G s symptoms?

5 Adverse Drug Events 35% of older adults experience ADEs About half are preventable Significant cause of morbidity and mortality Cost approximately $136 billion annually

6 Adverse Drug Reaction (ADR) In one study, 6.5% of hospital admissions were due to ADRs Medications often associated with hospitalization due to ADRs: Low dose aspirin Diuretics Warfarin NSAIDs

7 Older Adult Risk Factors Multiple Co-morbidities Frailty Drug Adherence Up to 52% of Medicare clients do not take Rx as prescribed Polypharmacy Potential drug interactions: 6% on 2 meds, 50% on 5 meds, nearly 90% on 8 meds

8 Pharmacokinetics Absorption Distribution Metabolism Excretion

9 Absorption: Age/Disease Related Changes Decreased Acidity of the Gut impacts absorption of meds Decreased Motility lengthens absorption time

10 Distribution: Age/Disease Related Changes Changes Higher proportion of adipose tissue Altered distribution of lipophilic drugs Stored in the body fat, resulting in prolonged drug effects Decreased total body water Potential for higher serum drug levels Occurs with water soluble drugs Decreased serum albumin concentration Affect distribution of drugs that bind to albumin Decreased cardiac output

11 Metabolism: Age/Disease Related Changes Aging changes cause decrease in: Liver size Hepatic blood flow Hepatic enzyme activity Increases potency and duration of some drugs Reduction in the cytochrome p-450 enzyme system

12 Elimination: Age/Disease Related Changes Clearance of medications may be slowed due to: Decline in renal function Reduced blood flow Decreased renal mass Decreased creatinine clearance Cockcroft-Gault formula

13 Morbidity and Mortality Adverse medication events are a significant cause of morbidity and mortality among older adults. Biological and social factors put them at great risk There is a gross lack of knowledge of geriatric medicine among health care professionals

14 Recent Changes in Recommendations for Older Adults US Preventative Services Task Force The USPSTF found the evidence insufficient to recommend for or against the use of aspirin for MI or stroke reduction in men and women age 80 and older. JNC 8 If >59 systolic goal of <150 and <90 >75 no guidelines for lipid management

15 Kirkman et al, Diabetes Care and JAGS Dec 2012 From Jeffrey B. Halter, MD; Presented on behalf of the American Diabetes Association and the American Geriatrics Consensus Statement Writing Panel A Framework for Considering Treatment Goals for Glycemia, Blood Pressure, and Dyslipidemia in Older Adults with Diabetes Health A1C goal Fasting BS HS Glucose B/P Lipids Healthy < <140/90 Statin Complex/I ntermediat e Very complex/ Poor Health < <140/90 Statin < <150/90 Consider benefit of Statin *Complex: 3 or more coexisting chronic illnesses requiring meds or 2 or more I ADL impairments or mild to mod cognitive impairment *Very Complex: Long term care or end stage chronic illness or mod to severe cognitive impairment or 2 or more ADL dependencies

16 2016 National Diabetes Education Initiative Recommendations More stringent target (<6.5%) Short diabetes duration Long life expectancy Type 2 diabetes treated with lifestyle or metformin only No significant CVD/vascular complications Less stringent target (<8.0%) Severe hypoglycemia history Limited life expectancy Advanced microvascular or macrovascular complications Extensive comorbidities Long-term diabetes in whom general A1C targets are difficult to attain

17 Beers List Inappropriate Medications Standard to determine inappropriate medications At least 23% of older adults take more than one medication on Beers List Linked to poor outcomes Higher risk of hospitalization or emergency department evaluation Lack of awareness high among practitioners

18 Mark H Beers, MD A ballet-dancing opera critic who hiked the Alps and took up rowing after diabetes cost him his legs MD, Univ of Vermont First med student to do a geriatrics elective at Harvard s new Division on Aging Geriatric Fellowship, Harvard Faculty, UCLA/RAND Co-editor, Merck Manual of Geriatrics Editor in Chief, Merck Manuals

19 Original Purpose 1991 Original Beers Criteria Evaluate inappropriate Rx used in NH residents in common situations, but under certain circumstances might be appropriate (e.g., using amitriptyline to treat pt with both Parkinson s disease and depression) Clinical research on use of Potentially Inappropriate medications (PIMs) QA/QI Education of students, residents

20 Designations of Quality and Strength of Evidence: ACP Guideline Grading System, GRADE Quality High Evidence Consistent results from well-designed, well-conducted studies that directly assess effects on health outcomes (2 consistent, higher-quality RCTs or multiple, consistent observational studies with no significant methodological flaws showing large effects) Moderate Evidence Sufficient to determine effects on health outcomes, but the number, quality, size, or consistency of included studies, generalizability, indirect nature of the evidence on health outcomes (1 higher-quality trial with > 100 participants; 2 higher-quality trials with some inconsistency, or 2 consistent, lower-quality trials; or multiple, consistent observational studies with no significant methodological flaws showing at least moderate effects) limits the strength of the evidence Low Evidence Insufficient to assess effects on health outcomes because of limited number or power of studies, large and unexplained inconsistency between higher-quality studies; important flaws in study design or conduct, gaps in the chain of evidence Or lack of information on important health outcomes

21 Designations of Quality and Strength of Evidence: ACP Guideline Grading System, GRADE Strong Strength of Recommendation Benefits clearly > risks and burden OR risks and burden clearly > benefits Weak Benefits finely balanced with risks and burden Insufficient Insufficient evidence to determine net benefits or risks

22 Strong Recommendation on Weak Evidence? Desiccated Thyroid Quality of Evidence Strength of Recommendation High Mod Low Strong Weak Insuff Reason X X Older drug, better alternatives Ticlopidine X X Safer alternative Pentazocine X X Safer alternative

23 Table 2. Drugs to Avoid (except if ) Organ System or TC or Drug Nitrofurantoin Rationale Recommend. Quality of Evidence Pulmonary/liver tox Peripheral neuropathy Avoid long term suppression; Or is CC <30 Moderate Strength of Recommend. Strong Antipsychotics (conventional or atypical) Insulin, sliding scale Chlorpropamide Glyburide Increase CVA and CV mortality in dementia. DM/Hlipids EPS Avoid unless danger to self/others and non pharm has failed Moderate Strong Hypoglycemia risk Avoid Moderate Strong Hypoglycemia risk Avoid High Strong

24 Table 2. Drugs to Avoid (except if ) Organ System or TC or Drug Tricyclic Antidepressents ( tyline drugs..amitriptylin e, nortriptyline..) Megestrol Rationale Recommend. Quality of Evidence Highly anticholinergic. Delerium, fall, ortho hypotension Minimal effect on weight; risk of thrombotic events and death Metclopramide EPS and TD Avoid, unless gastroparesis Non-COX NSAIDs, oral GI bleeding; Protection w/ PPIs or misoprostol Edema/Renal Risk Avoid High Strong Avoid Moderate Strong Moderate Strength of Recommend. Strong Avoid chronic use Moderate Strong

25 Table 2. Drugs to Avoid (except if ) Organ System or TC or Drug Benzodiazepines Estrogens with or w/o progestin Muscle Relaxants Rationale Recommend. Quality of Evidence Risk cognitive effects and injury (fall/mva); rare use appropriate Carcinogenic potential, lack of efficacy in dementia/cv dz prevention Ineffective at tolerated doses, antichol, falls Avoid for treatment of insomnia, agitation, or delirium Avoid oral and topical patch. Topical cream safe and effective for vaginal symptoms High High Strength of Recommend. Strong Strong Avoid Moderate Strong

26 Additional Drugs with High Risk Potential Warfarin Increases ADR and serious fall injury risk Ginkgo biloba and garlic augment its effect Multiple drug interactions! Fluoroquinolones with warfarin Sedatives and hypnotics Associated with oversedation, respiratory depression, confusion, alterations in cognitive capacity Non- Benzodiapeine and Benzodiazepines increase risk of mobility problems, ADL disability, fall risk Mood stabilizers Lithium interacts with many other drugs Requires close monitoring of levels and toxicity Depakote can cause liver toxicity

27 Antipsychotics Extrapyramidal Side Effects (EPS) Acute Dystonia spasms of tongue, face, throat, eyes, neck or back Akathisia Inability to stay still Pseudoparkinsonism tremor, rigidity, akinesia/bradykinesia, and loss of balance Tardive Dyskinesia nonrepetitive and choreiform movements of lips, jaw, tongue, legs and arms

28 Neuroleptic Malignant Syndrome Catatonic like state with EPS, B/P changes, and very high fevers; it is uncommon but can be a SE of neuroleptic treatment Life threatening condition and must be recognized early Elevated creatine kinase and leukocytosis with a left shift often noted

29 Anticholinergic Properties Drugs with Anticholinergic Properties include: Antidepressants Antipsychotics Most OTC antihistamines and sleep aids Intestinal and bladder relaxants Corticosteroids Antihypertensives Antiarrythmics and other cardiovascular drugs Common adverse reactions: Inability to concentrate, agitation, delirium, hallucinations Blurred vision Slowed GI motility and constipation Decreased secretions Urinary retention FALLS

30 Lanoxin Avoid first line for a-fib or CHF and never in dose >0.125/d Toxicity may present atypically (confusion, weak, anorexia) May cause death Symptomatic cardiac disturbance and arrhythmias common in older adults Older adults may experience toxicity even with normal plasma levels (.5-2.0) Use caution when prescribing concurrently with diuretics. Monitor for hypokalemia Correct and safe dosing is challenging

31 OTCs Most commonly implicated OTC medications in hospitalizations are: Aspirin (low dose) NSAIDs Monitor for aspiration risk w agents like mineral oil PPIs if no symptoms of PUD or GERD (inc risk of C diff and pneumonia). Avoid use > 8 weeks

32 Prescribing cascades

33 What can we do? Initiate non-drug approaches Admission and discharge teaching with family and patient about risks and alternatives Review scheduled and non-scheduled meds when the older adult has a change in function Observe and communicate and chart medication responses For behavioral issues Use pharm as a last resort T-A-DA, Tolerate, Anticipate, Don t Agitate further (Flaherty & Tumos, 2011)

34 Interventions Obtain detailed medication history and confirm accuracy on admission, discharge, and in between Assess for inappropriate medications Monitor new symptoms for ADRs Assess for medication adherence prior to discharge Medication Reconciliation Collaborate with Health Care Team (pharmacist, PCP )

35 Assess Functional status Ability to read medication label Open container Consume or self-administer as intended Cognitive and affective status Memory and depression issues Health literacy and ability to recognize generic brands Beliefs, concerns, and problems related to medication regimen The impact of costs Availability of support

36 Brown Bag Method Encourage patient, at admission, to bring all medications from home Document medication types, instructions, dates, duration of use Helps identify multiple prescribers and pharmacies Include prescription medications, OTCs, herbal remedies, supplements, alcohol and nicotine use Evaluate for duplicate medications

37 FREE Beers Criteria Apps

38 Mrs Jones Mrs Jones is an 86 y/o BF who is a new admit. She was demonstrating increased confusion and sustained 5 falls over the past 2 weeks. Her Dx include DM, OA, PD, HTN, H- Lipids, CHF, and Insomnia. From the following list of meds determine what concerns you have and what lab needs to be monitored with each specific med:

39 Current Meds ASA 325 mg qd for cardiac prophylaxis Ompeprazole 20 mg qd (pt w/o sx) Nitrofurantoin 100 mg qd for UTI prophylaxis Premarin mg qd for OP prophylaxis Amitriptyline 50 mg qhs for insomnia Ibuprofen 400 BID for OA Digoxin 0.5 mg qd for CHF Furosemide 20 mg BID for CHF Sinemet CR 25/100 TID for PD Zyprexa (olanzapine)5mg qd for psychosis Glyburide 5 mg qd for DM Diazepam 5 mg TID prn anxiety Tylenol PM at HS prn for pain/insomnia

40 Summary Geriatric nursing care requires a specific knowledge base Our patients need comprehensive assessments to determine their pharmacologic risk factors Beers is a good guide and APRNs/PAs and geri RN s need to have a working knowledge of it Be your client s educator and advocate

41 References Agency for Healthcare Research & Quality. (2014). Potentially harmful drug-disease interactions in the elderly: percentage of Medicare patients 65 years of age and older who have evidence of an underlying disease, condition or health concern and who were dispensed an ambulatory prescription for a potentially harmful medication, concurrent with or after the diagnosis. Boehringer, S. Darby, A. et al (2015). Appropriate medication use in older adults: 2015 updated Beers criteria. Prescribers Letter, 22(12). James P., Oparil S, et al (2014) Evidence-based guideline for the management of high blood pressure in adults: Report from the panel members appointed to the Eighth Joint National Committee. Journal of American Medical Association, 311(5): Kirkman et al, (2012). Diabetes care. Journal of American Geriatric Society. The National Diabetes Education Initiatives (2016). Diabetes management guidelines. The National Kidney Foundation. (2016). The Cockcroft-Gault formula. United States Department of Health and Human Services. (2014). Guide to clinical preventive services.