Disclosures. Outline. Epidemiology. Medication Management in the Elderly. In 2008 pts age 65 and older represented 40% of all hospitalized adults

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1 Medication Management in the Elderly Disclosures Melissa Stevens MD Atlanta VA Medical Center Assistant Professor Emory University Department of Medicine I have no significant financial interest or other disclosures. I have no relationship with the manufacturer of any of the products discussed in this presentation. Outline Epidemiology Age related changes in pharmacokinetics and pharmacodynamics Adverse Drug Events Potentially Inappropriate Medications safe prescribing System issues that affect prescribing Epidemiology In 2008 pts age 65 and older represented 40% of all hospitalized adults... and accounted for nearly half of all healthcare dollars spend on hospitalization Adults age 85 and older accounted for 8% of admissions Healthcare Cost and Utilization Project Facts and Figures Statistics on Hospital-Based Care in the United States. Agency for Healthcare Research and Quality (AHRQ Wier L, Pfuntner A, Steiner C. Hospital Utilization among Oldest Adults, 2008: Statistical Brief #103. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs; Agency for Health Care Policy and Research, Rockville, MD

2 Epidemiology Epidemiology Health, United States 2013; Health, United States 2013; Epidemiology Epidemiology Cross sectional national sample 50% use OTC meds 1/25 use a regimen with potential drug/drug interaction Half of this involve OTC meds Health, United States 2013; Qato.JAMA 2008; 300(24):

3 What happens as we age? Age related changes in pharmacokinetics and pharmacodynamics Definitions Pharmacokinetics How the body deals with a drug Pharmacodynamics How a drug affects the body Pharmacokinetics Pharmacokinetics Absorption Distribution Metabolism Excretion Parameter Age Effect Implication Absorption variable Drug-Drug and Drug-Food interaction more likely to alter absorption Distribution Increase fat/water ratio Decrease albumin Metabolism Decreased liver mass Decreased liver blood flow Fat soluble drugs have larger volume of distribution Protein bound drugs have greater active concentration Decreased drug clearance Lower doses may be therapeutic Excretion Decreased GFR Cr is not good estimate of CrCl Renally dose meds 3

4 Pharmacodynamics Other Effects Less predictable Changes in numbers and sensitivity of receptors sensitivity to warfarin, benzos, anticholinergics, narcotics sensitivity to beta adrenergic agonists and antagonists (isoproterenol, propranolol) Drug induced changes in cardiac conduction Increased sensitivity to drug induced conduction disorders (bradycardia or tachyarrhymias) QTc prolongation exacerbated by some drugs Decreased Oral intake or appetite Alter taste of food Decrease saliva Reuben: Geriatrics at your Fingertips, 2013 Reuben: Geriatrics at your Fingertips, 2013 Adverse Drug Events Relationship Among Medication Misadventures ADEs Medication Errors B C ADRs D E A American Society of Health-System Pharmacists. Suggested definitions and relationships among medication misadventures, medication errors, adverse drug events, and adverse drug reactions. Am J Health-Syst Pharm. 1998; 55: slide courtesy of Dr. Anna Mirk. 4

5 ADEs in the inpatient setting AHRQ reports over 770,000 people are injured or die each years from ADEs Incidence of 2-7/100 admissions Estimated national cost of $ Billion annually Patients who experience ADEs stay 8-12 days longer and cost $16-24K more Not Modifiable Age >85 Multiple comorbidities Socioeconomic status Low body weight Reduced CrCl Compliance Risk Factors for Adverse Drug Events Modifiable Polypharmacy Poor quality of prescribing Compliance What not to do Defining potentially inappropriate medications Potentially Inappropriate Medications (PIMs) BEERS List HEDIS High risk medications in the elderly STOPP & START 5

6 Potentially Inappropriate Medications (PIMs) Beers List Originally developed in 1991 for nursing home use Expanded and revised to include all geriatric care settings Most recent revision 2011 Systematic review Multidisciplinary consensus panel PIMS: BEERS List Medications or medication classes that should generally be avoided because they are either ineffective or the risk outweighs the benefit Not absolute contraindication J Am Geriatr Soc, 2012 J Am Geriatr Soc, 2012 PIMS: Beers List PIMS: Beers List 53 Drugs and Drug classes to avoid in pts 65 and older 3 categories Potentially inappropriate in all settings of geriatric care Potentially inappropriate due to Drug-Disease or Drug-Syndrome interaction Medications to be used with caution Table 2 Avoid Drug or Class Rationale Recommendation Quality of Evidence First generation antihistamines Examples: -Diphenhydramine -Hydroxyzine -Promethazine Highly anticholinergic; clearance reduced with advanced age..greater risk of confusion, dry mouth, constipation, etc (urinary retention) Avoid Hydroxyzine and promethazine: high; all others, moderate Strength of Recommendation Strong J Am Geriatr Soc, 2012 J Am Geriatr Soc, 2012 courtesy S. Nicole Hastings MD VHA 6

7 PIMs: Beers List Common BEERS List Drugs Pain medications Non Cox selective NSAIDS Ketorolac Skeletal muscle relaxants Amitriptyline/TCAs Meperidine J Am Geriatr Soc, 2012 PIMs: BEERS LIST Anticholinergics Anticholinergics/Antihistamines Hydroxyzine Meclizine Promethazine Prochlorperazine Oxybutynin Scopolamine Cyclobenzaprine J Am Geriatr Soc, 2012 PIMs: BEERS LIST Other Notable Drugs Benzodiazepines Antibiotics - Nitrofurantoin Alpha 1 blockers for blood pressure Antihypertensives Clonidine, Nifedipine IR Antiarrythmics for afib - Rate over rhythm Other cardiac stuff - Digoxin >0.125mg, spironolactone > 25mg PIMs: BEERS LIST Other Notable Drugs Nonbenzo hypnotics - Zolpidem Sliding Scale Insulin Glyburide GI - Metoclopramide J Am Geriatr Soc, 2012 J Am Geriatr Soc,

8 PIMs: BEERS List Drug/Disease Interactions Heart Failure NSAIDS Seizures Tramadol Delirium/Dementia all TCAs, corticosteroids, H2 receptor antagonists Syncope Olanzapine, alpha blockers Falls TCAs, SSRIs, anticonvulsants PIMs: Beers List Intended for use by clinicians Not intended to be punitive Adopted by Centers for Medicare and Medicaid Services in 1999 for nursing home regulation Adopted by Medicare part D and National Committee for Quality Assurance as a quality measure for outpatient care J Am Geriatr Soc, 2012 PIMS: HEDIS Measure HEDIS Quality Measures The use of high risk medications in the elderly the percentage of Medicare members who received at least one drug to be avoided in the elderly the percentage of Medicare members who received at least two different drugs to be avoided in the elderly 8

9 PIMs: STOPP & START STOPP Screening Tool of Older People s potentially inappropriate Prescriptions PIMS: STOPP & START STOPP 65 clinically significant criteria Each criterion is accompanied by a concise explanation START - Screening Tool to Alert doctors to the Right Treatment START 22 evidence-based prescribing indicators for commonly encountered diseases A method of systematically identifying appropriate omitted medicines Gallagher et al. Age and Ageing 2008; 37: PIMs: Other criteria What now? safe prescribing Chang, Chan. Drugs Aging 2010;27(12):

10 Acute Delirium/Agitation Acute Pain Insomnia/Sleep disturbance Delirium/Agitation Preventive measures Orientation protocol Ensure sleep Mobilize Get vision and hearing assist devices Recognize and treat dehydration Identify and treat medical conditions including infection and pain Non-pharmacologic Interventions Ensure safety Use family or sitter as 1 st line Use restraints as a last resort to maintain safety (prevent pulling lines and catheters) For acute agitation or aggression that impairs care or safety Haloperidol most often recommended and studied PO is best or IM (not IV due to risk of QTc prolongation) Obtain EKG before 1 st dose Initial dose 0.5mg-1mg PO (IM is twice as potent) Re-evaluate 1-2H for PO; 30-60min for IM Double dose if initial dose is not effective 10

11 Haloperidol Calculate total dose administered to control symptoms Give the equivalent oral dose the next day divided Q12; hold for sedation Maintain effective dose for 2-3 days Slowly taper and DC over 3-5 days EPS will develop with prolonged use switch to 2 nd generation if >1 week Delirium/Agitation Quetiapine drug of choice for patients with LBD, PD, AIDS-related dementia or EPS Initial dose 12.5mg -25mg PO daily or q12h Max dose 100mg/d (50mg/d frail elders) Administer the dose needed to control symptoms divided BID for 2-3 days then taper Delirium/Agitation due to ETOH or benzo withdrawal Treat with benzos Management of Acute Pain Goal is find optimal balance in pain relief, functional improvement and adverse events Identify and treat cause if possible Standardized pain scale can be modified for pts with cognitive impairment Reassess regularly Mobilize early 11

12 Management of Acute pain Refer to PT for evaluation for non pharmacologic treatments Relaxation Heat/cold TENS units Joint mobilization Stabilizing exercises Assistive devices Management of Acute pain Mild to moderate (rating 1-3) consider non opiates Moderate pain (rating 4-6) consider low dose combination agents Severe pain (rating 7-10) consider potent and titratable opiates Consider adjunct agents Management of Acute pain - Non Opiates APAP 650mg Q4-6h (Q8h if CrCl<10) max 3g/d Nonacetylated Salicylates fewer GI/renal events NSAIDS avoid chronic use, use with GI protective agent, avoid in CKD and HF Selective COX-2 inhibitors avoid in HF, increase risk of MI less GI ulceration Topicals - capsaicin, lidocaine, diclofenac Joint injections Management of Acute pain mild to moderate Codeine, codeine + APAP Hydrocodone + APAP Hydrocodone + ibuprofen Oxycodone Oxycodone + APAP Oxycodone + ASA 12

13 Management of Acute pain moderate to severe pain Morphine Hydromorphone Oxymorphone Tramadol Tramadol + APAP Fentanyl PCA pumps The hand that writes the narcotic is the hand that writes the bowel regimen... or is the hand that does the disimpaction Insomnia Treat associated medical and psychiatric conditions Review medications that cause or aggravate sleep problems Maintain circadian rhythm OOB, light during day, decrease sedating meds during the day Control Stimulus vitals at night, med dose times Insomnia - medications Use lowest dose ALL INCREASE FALL RISK For pts with anxiety at bedtime consider SSRIs or buspirone Trazodone mg effective for insomnia with or without depression 13

14 Zolpidem Associated with Inpatient Falls Retrospective cohort comparing fall rate Risk Factor Adjusted OR P Value Zolpidem 6.39 <0.001 Delirium 2.62 <0.001 Insomnia Charlson index 1.33 <0.001 Hendrich s fall risk 1.30 <0.001 Age 1.04 <0.001 What else can I do? System Issues that affect prescribing Impact HM: Zolpidem appears to be a modifiable risk factor for inpatient falls Kolla BK et al., JHM 2013; 8:1-6. P < Courtesy of Dustin Smith MD System issues Medication reconciliation Geriatrify your standard order sets Make your EMR work for you System Issues Medication Reconciliation failure to appropriately reconcile medications is an important source of harm Handoffs and Transitions of Care high risk for adverse events 66% post discharge events are ADEs Foster. Annals of Int Med 2003; Coleman 2005; JACAHO 2008; Santell 2006; Liu 2008; Yip

15 System Issues: Medication Reconciliation Skilled Nursing Facility Admissions Medically complex pts Often do not see MD for >48hours DC Summary or discharge orders are often admission orders Medication Reconciliation Cross sectional study of pts admitted to SNF for sub-acute care Of 2319 medications reviewed 495 (21.3%) had discrepancies At least one discrepancy was identified in 142/199 (71.4%) admissions Tjia et al. JGIM March 2009: Medication Reconciliation Med reconciliation done by clinical pharmacists reduces errors Interview the patient if possible Get verification from secondary source Brown Bag Done within 1 st 24 hours Geriatrify your standard order sets Eliminate PIMs Add options for renal dosing Change standing orders for vitals, activity Add options for daily screens for depression, confusion, mental status Gleason KM et al. J Gen Intern Med.2010;25: Murphy EM at al., Am J Health Syst Pharm. 2009;66: Schnipper JL et al. Arch Intern Med.2006;166:

16 Make your EMR work for you Create (recreate) order sets for geriatric syndromes Falls/Hip fractures Delirium Dehydration malnutrition Add drug warnings for PIMs Create geriatric pharmacy order sets Start Low - go Slow Appropriately dose drugs for CrCl Attention to drug-drug interactions Drug-disease interactions Monitor therapy Avoid the prescribing cascade TAMMCS 16

17 Ibuprofen Hip Fracture BP HCTZ Beware the Prescribing Cascade Falls Orthostatic Hypotension Oxybutynin Urinary Retention Terazosin Courtesy: Loren Wilkerson, M.D. Prioritize goals of care Consider quality of life Sometimes it is time to stop Substitute with safer alternatives Reduce the dose when appropriate Questions? Learning Objectives Explain factors that increase risk for adverse drug events in older patients Identify potentially inappropriate medications (PIMs) in the elderly as defined by expert consensus panel List alternatives to PIMs for elderly hospitalized patients with common complaints Evaluate and modify processes that may contribute to adverse drug event in older patients 17

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