Polypharmacy. Polypharmacy. Suboptimal Prescribing in Older Adults. Kenneth Schmader, MD Professor of Medicine-Geriatrics

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1 Polypharmacy Kenneth Schmader, MD Professor of Medicine-Geriatrics Polypharmacy Definition Causes Consequences Prevention/management Suboptimal Prescribing in Older Adults Overuse Polypharmacy Underuse Absence of drug to treat or prevent a disease or condition Inappropriate use Medications that pose more risk than benefit Hanlon JT et al. J Am Geriatr Soc 2001; 49: Gurwitz JH et al. JAMA 1994;272: Monane M et al. West J Med 1997;167:

2 Polypharmacy Concurrent use of multiple drugs Specific number not established Many use > 3 to 5 medications Use of more drugs than clinically indicated Excessive/unnecessary med use Medications without indications Ineffective drugs Therapeutic duplication Hanlon JT et al. J Am Geriatr Soc 2001; 49: Hanlon JT et al. Therapeutics in the Elderly, 3rd Edition Causes Multimorbidity Fragmented medical care: multiple providers and pharmacies High health service use and transitions of care Expectations to receive medication and selftreatment Gurwitz JH et al. JAMA. 2003;289(9): Boyd CM et al.. JAMA 2005; 294:716. Complications of Polypharmacy Adverse drug reactions Nonadherence Increased cost 2

3 Definitions Adverse drug event (ADEs): An injury due to the medical use of a drug, including noxious responses, drug administration errors, and any other circumstances that lead to an injury. Adverse drug reactions (ADRs): Any response to a drug that is noxious and unintended and that occurs in doses in man for prophylaxis, diagnosis or therapy. Side effects: Undesirable secondary effect of a drug World Health Organisation (1970). Drug Intell Clin Pharm 4: Nebeker JR, et al. Ann Intern Med 2004;140: Rochon P. Drug Prescribing for Older Adults. UpToDate, ADRs in Older Adults Number of drugs -- the strongest, most reproducible marker of ADR risk in older adults Exponential increase in ADRs with addition of more drugs to a regimen (2 drugs-15%, 5 drugs-50-60% ) Other risk factors Age-related change in pharmacokinetics, pharmacodynamics Inappropriate prescribing Multimorbidity, poor health status Previous history of ADRs Poor adherence Fragmented medical care Age-Related Changes in Pharmacokinetics and Pharmacodynamics Decreased creatinine clearance and GFR Decreased hepatic metabolism Increased risk of doserelated ADRs Avoid by dose reduction, careful titration, monitoring of drug levels 3

4 Appropriate Prescribing Beers Criteria updated 2012 Drugs at high risk for ADEs in older adults Provides important guidance but med choices require customizing to patient American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. The AGS 2012 Beers Criteria Update Expert Panel. JAGS. 2012; 60: Budnitz D et al. NEJM. 2011;365: Ibuprofen BP HCTZ Prescribing Cascade Urinary Incontinence Oxybutynin Confusion Falls Hip Fracture Presentation of ADRs in Older Patients ADRs may present non-specifically Symptoms and signs may be attributed (by patient or clinician) to a pre-existing disease, a new disease, or normal aging Adverse drug reactions should be in the differential diagnosis of any geriatric symptom or syndrome (e.g. delirium, falls, incontinence) 4

5 Polypharmacy Leads to Serious ADRs ADR Drug Class Bleeding NSAIDs, anticoagulants Hypoglycemia Insulin, oral hypoglycemics Delirium Opioids, anticholinergics, benzodiazepines, antipsychotics Acute Kidney Injury/ Diuretics, ACE inhibitors, NSAIDs Electrolyte abnl Hypotension/syncope Cardiovascular, CNS Falls/injury CNS, cardiovascular C. difficile colitis Antibiotics Schmader KE, et al., Am J Med 2004;116: ; Juurlink DN et al. JAMA 2003;289:1652 8; Gurwitz JH et al. Am J Med 2000;109:87 94 Nonadherence To Medications As Prescribed Correlates more strongly with number of meds and doses than age Number med or doses = Nonadherence Osterberg L, Blaschke T. NEJM. 2005; 353: Factors Leading to Nonadherence Intentional and unintentional factors: Cognitive impairment/psych issues Lack of insight into illness Illiteracy, language/cultural issues Misunderstanding verbal instructions Lack of follow up Cost and other social barriers Complexity of med regimen Side effects/adrs 5

6 Medication Reconciliation Multiple steps in medication use are potential sources of error and ADEs Joint Commission standard to reduce ADEs- addresses errors in med use during transitions of care Gurwitz JH et al. JAMA. 2003;289(9): Prescribing Dispensing Administering Adherence Monitoring Solutions to Polypharmacy Is the Drug Truly Necessary? Many medical problems in the elderly do not require a pharmacological solution Is the Drug Harmful or Useless? Discontinue drugs that are not indicated, harmful, or ineffective Solutions to Polypharmacy Review need for all medications Simplify drug regimen Discontinue medications that are not indicated, ineffective or intolerable Understand obstacles (cost, memory loss ) Enlist caregivers Give verbal and written instructions Collaborate with nursing/pcp/specialists Make sure there is good follow up 6

7 Always Remember Prescribing cascade - a drug added to treat (mistakenly) the ADR of another drug Clinical Pearl- Any symptom in an elderly person should be evaluated as a potential ADR until proven otherwise Many geriatric syndromes can occur as a consequence of medications: delirium, falls and fractures, incontinence Take Home Message Polypharmacy is a reality of prescribing when patients have multiple comorbidities. We must all anticipate and guard against the potential complications of polypharmacy. Optimal prescribing is key! Kenneth Schmader, MD Professor of Medicine-Geriatrics 7