9/6/2017 DEPRESCRIBING SAFELY IN THE OLDER ADULT. What is Deprescribing??? What leads to overmedication?

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1 DEPRESCRIBING SAFELY IN THE OLDER ADULT Pennsylvania Coalition of Nurse Practitioners State Conference November 4, 2017 Cynthia Blevins, DNP CRNP General Internal Medicine of Lancaster What is Deprescribing??? a system of reducing medications providing the best benefit to the resident and reducing risk (Reeve et al., 2015). What leads to overmedication? Lack of close monitoring, gatekeeper failure Poor communication, different EHR Prescribing cascade Poor patient education Or 1

2 Patients may think medication easier than lifestyle change Untreated anxiety and depression affects perception of symptoms Other Factors Leading to Over Prescribing MULTIPLE DISEASES GENETIC PATHWAYS METABOLIC PROCESS INTOLERANCE OF BEHAVIORS BY STAFF LACK OF STAFFING FOR OTHER INTERVENTIONS FAMILIAL TENDENCIES LACK of KNOWLEDGE in PRESCRIBER PRESSURE FROM FAMILIES TREATING SIDE EFFECT OF OTHER DRUG ALTERED ABSORPTION IMPATIENCE 2

3 Why are med changes a concern? Lack of follow up Unknown renal or hepatic function Risk greater than benefit many times Polypharmacy- many definitions but rising health care costs and lack of adherence a result Higher risk of falls according to 16 studies. Many say more than 4, increase in fall stats (AGS, 2015; Freeland et al., 2012; Ramsey, Hin, Prado, & Fernandez, 2015 ) Side effects can mimic serious conditions. Ex. Mucinex story Increases hospital readmissions (Pavon, et al., 2014) POLYPHARMACY Many different definitions Most common is 7 or more, some define as 5 or more Varies with number of comorbidities Polypharmacy known to lead to Falls Adverse Drug Interactions/Reactions (ADIs, ADRs) between other meds Renal or hepatic impairment Side effects (ADRs) BALANCING ACT As patients get older they have more diseases so will of course take more medications. Monitor closely for ongoing need as patients change. Avoid prescribing cascade. Always read the specialist s notes and change the meds in the chart. 3

4 BEERS CRITERIA: Avoid if possible NSAIDS regarded as concerning Testosterone products should only be used if low levels Antithrombotics Diabetes meds other than Metformin, if glucose is well controlled Antibiotics STOPP/START CRITERIA: Avoid Duplicate meds Benzodiazepines especially long acting Neuroleptic medications First generation Antihistamines Long term opiates especially in those who have fallen in the past Vasodilators Antimuscarinics and alpha blockers, leads to constip, RF, don t need if Foley NSAIDs if CHF, PUD, RF, HTN Loop diuretic if not for CHF Estrogens esp if breast cancer history, DVT history etc. TCAs Better choices SSRI if chronic hyponatremia Anticholinergics Digoxin, especially if high dose Phenothiazines if patient has history of seizures Theophylline Nebulized ipatropium with glaucoma Medication Concerns Action Plan PPI long term use Renal HIGH impairment, RISK DRUGS C diff in this population Consider Ranitidine. Follow up GI, weight loss, diet Benzodiazepines Psychotropics Fall risk/fracture, worsening behaviors when running out of gas. Used inappropriately Falls, poor impulse control, arrhythmia Slow taper, Redirecting patient, Consider Buspar, Lexapro. Genetic testing for best choice of meds Do not stop suddenly. Consider better caregiver to resident ratio Anticholinergics Constipation, Falls, Dizziness Reduce to lowest possible dose Antihypertensives Ortho hypo, bradycardia Monitor BPs/HR closely and use lower doses, have parameters for when to hold ASA or Anticoagulants GI Bleed, SAH, ICB, Anemia Control AF by rate, use coated ASA, ranitidine Levaquin C diff, prolonged QT if combined with statin or SSRI Consider Z-pack, Augmentin Statin Myalgias, Hepatic issues Consider d/c if over 80, if actively seeing cardiology run by them 4

5 Medication Concerns Action Plan HIGH RISK DRUGS in this population Beta blockers Orthostatic hypotension Consider ACE Amiodarone Pulmonary complications If not keeping patient out of afib, d/c do rate control SSRI, SRNI Dizziness Start low dose and consider SNRI if pain present Macrodantin Renal failure Consider alternatives Bisophosphonates Increased risk of femur fracture after 5 yrs D/C for a year if patient has taken for 5 years. Vitamin D, dietary calcium Muscle relaxants Can be addictive, lead to falls Heat, massage, PT Sulfonyureas Hypoglycemia, renal impairment Metformin, diet, exercise Dementia medications Rarely effective, contribute to falls, $$$ Wean slowly and evaluate FALL RISK MEDICATIONS FALL RISK MEDICATIONS ACCORDING TO BEERS CRITERIA, STOPP/START and other Literature Anticholinergics- Bethanechol, Diphenydramine, Hyoscamine, Meclizine, Oybutynin, Tolterodine Barbiturates- Butalbital Benzodiazepines- Alprazolam, Clonazepam, Clorazepate, Diazepam, Lorazepam, Temazepam, Triazolam Muscle relaxants/antispasmodics- Baclofen, Cyclobenzaprine, Methocarbamol Psychotropics- Amitriptyline, Citalopram, Duloxetine, Escitalopram, Fluoxetine, Haloperidol, Metoclopramide, Nortriptyline, Paroxetine, Prochlorperazine, Promethazine, Quetiapine, Sertraline, Venlafaxine CR Miscellaneous- Clonidine, Digoxin, Doxazosin, Porpoyphene-acetaminophen, Zolpidem Hohmann, Hohmann, & Kruse, Deprescribing Safely Multiple studies support deprescribing (Garfinkel & Mangin, 2010; DeJong, Van der Elst, & Hartholt, 2013; Jetha, 2015; Potter et al., 2016). A study by Potter et al., (2016) with a small sample size (47 in retrospective, 48 in prospective) demonstrated that withdrawal of bisphosphonates, aspirin, iron supplements, angiotensin II antagonists, vitamins, supplements, and statins yielded no adverse effects. Antidepressants, anti-convulsants, pain medications, proton pump inhibitors and benzodiazepines were more challenging to withdraw in this study and required a slower taper. Because this population has multiple comorbidities, careful screening of which medications (Blanco Reina et al., 2015). A review of multiple tools (Skinner, 2015) utilized in the past revealed common aspects of pharmacology screens considered important when reducing medications. 5

6 Cheaper alternative? Side effects? Risk greater than benefit? Is it still needed Skinner, 2015; Liu & Campbell, (2016). A safer alternative? COMMUNICATION All members of team made aware of changes Rationale explained to patient/family Always mention changes in discharge summaries. GENETIC TESTING Determines best med and dose Can be very difficult to interpret- talk to company If on antipsychotics check folate levels, give methylfolate 7.5 mg Subtypes of testing 6

7 WE must be the advocates for our vulnerable elderly.. References American Geriatrics Society (AGS, 2015). American Geriatrics Society updated Beers criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatric Society, 63(11), doi: /jgs Blanco-Reina, E., Ariza-Zafra, G., Ocaña-Riola, R., León-Ortíz, M., & Bellido-Estévez, I. (2015). Optimizing elderly pharmacotherapy: polypharmacy vs. undertreatment. Are these two concepts related? European Journal of Clinical Pharmacology, 71(2), doi: /s DeJong, M. R., Van der Elst, M., & Hartholt, K. A. (2013). Drug-related falls in older residents: mplicated drugs, consequences, and possible prevention strategies. Therapeutic Advances in Drug Safety, 4(4), doi: / Freeland, K., Thompson, A., Zhao, Y., Leal, J., Mauldin, P., & Moran. W. (2012). Medication use and associated risk of falling in a geriatric outresident population. Annals of Pharmacotherapy, 46(9), doi:10,1345/aph.1q689 Gallagher P, O'Connor M, O'Mahony D. (2011). Prevention of potentially inappropriate prescribing for elderly residents: A randomised controlled trial using STOPP/START criteria. Clinical Pharmacology and Therapeutics, 89, doi: /clpt Garfinkel, D., & Mangin, D. (2010). Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: Addressing polypharmacy. Archives of Internal Medicine, 170(18), doi: /archinternmed Jetha, S. (2015). Polypharmacy, the Elderly, and Deprescribing. The Consultant Pharmacist: The Journal of The American Society of Consultant Pharmacists, 30(9), doi: /tcp.n Pavon, J.M, Zhao, Y., McConnell, E., & Hastings, S. N. (2014). Identifying Risk of Readmission in Hospitalized Elderly Adults Through Inpatient Medication Exposure. Journal of the American Geriatric Society, 62: doi: /jgs Potter, K., Flicker, L., Page, A., & Etherton-Beer, C. (2016). Deprescribing in frail older people: A randomised retrospective led trial. Plos ONE, 11(3), doi: /journal.pone Ramsey, R., Hin, A., Prado, C., & Fernandez, M. (2015). Understanding and preventing falls: Perspectives of first responders and older adults. Physical & Occupational Therapy in Geriatrics, 33(1) doi: / Reeve, E., Gnjidic, D., Long, J., & Hilmer, S. (2015). A systematic review of the emerging definition of deprescribing with network analysis: Implications for future research and clinical practice. British Journal of Clinical Pharmacology,80(6), doi: /bcp Skinner, M. (2015). A literature review: Polypharmacy protocol for primary care. Geriatric Nursing, 36(5), doi: /j.gerinurse Help me do what brings me joy 7