Disclosure and Acknowledgements

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1 Greetings from Penn Nursing SOHN 37 TH ANNUAL CONGRESS AND NURSING SYMPOSIUM POLYPHARMACY AND OLDER ADULTS: HIGH RISK MEDS, TOO MANY MEDS, AND TOO FEW MEDS Sarah H. Kagan PhD, RN University of Pennsylvania, Philadelphia PA USA Photos by Charlotte Glasspool Disclosure and Acknowledgements I have no conflicts of interest to disclose Useful New Reference Objectives At the end of this presentation, you will be able to: Describe nature and implications of polypharmacy as a geriatric syndrome Apply assessment instruments and guidelines for polypharmacy Analyze polypharmacy in clinical case studies Identify implications of dose attenuation and intentional polypharmacy Outline Define polypharmacy Discuss guidelines and assessment tools Discuss intentional polypharmacy Discuss dose attenuation Analyze case studies Consider questions and comments 1

2 Changing Practice is Difficult Defining Polypharmacy Emerging demographics Growing epidemiology Drug development Medication safety Defined: Polypharmacy is the use or administration of multiple medications than are clinically indicated, representing unnecessary drug use Hajjar and colleagues (2007) Understanding Polypharmacy Understanding Polypharmacy Higher risks for Drug-drug interactions Drug-food interactions Drug toxicity Serious adverse events Geriatric syndromes Risks potentiated by Altered body composition Altered metabolism Administration errors Multiple prescribers Physiological Highlights Physiological Highlights Use the Cockcroft-Gault formula for GFR GFR = (140-age)*(Wt in kg)*(0.85 if female)/(72*cr) Consider hepatic perfusion and metabolism changes Remember genetic variability of cytochrome system Consider decline in total body water Consider decreased total serum albumin Always adjust for Visual acuity changes Hearing loss Delayed cognitive processing 2

3 Geriatric Syndromes Triggered Falls Delirium Incontinence Deconditioning Frailty 3

4 Geriatric Syndromes From Inouye and colleagues (2007) Geriatric Syndromes From Inouye and colleagues (2007) Patient and Family Experiences The Big 3 Health literacy challenges Health numeracy challenges Health finances challenges Incomplete education and knowledge Difficult scheduling and administering Confusing acute and chronic medications Competing self-care and caregiving priorities General Approaches to Mitigate Polypharmacy Use standard therapy with well elders Use standard therapy with caution in comorbid elders Avoid standard therapy in multimorbid frail elders 4

5 STOPP Criteria STOPP Criteria STOPP Criteria PIM Criteria Evaluation Beers Criteria Classic approach Endorsed by AGS Focused on largely adverse events START/STOPP Criteria Newer criteria Focused on both under prescribing and adverse events Application trials show improvements in hospitalized elders meds 5

6 FORTA Classification PIM and FORTA Integration A drugs are trialed in elders with good evidence B drugs have good evidence but disadvantages C drugs have equivocal evidence and disadvantages D drugs should be avoided because of high risk profile Electronic health record use Decision support making tools Pharmacy rounds Interdisciplinary team approach Pharmacist-patient counseling PIM and FORTA Integration Under Prescribing and Dose Attenuation Prescriber education PIM use in practice FORTA drug criteria Team education Pharmacist centered Nurse specific Lack of prescriber adherence to EBP Lack of prescriber knowledge regarding EBP Misinterpretations of perceived frailty Misinterpretations of side effect profiles Intentional Polypharmacy Patient Safety Strategies Not really polypharmacy at all Using therapeutic drug combinations Effective in symptom management and palliative care Relies on synergistic or combined effects Reduces side effect profiles and toxicity risks Requires knowledgeable administration Medication reconciliation is only effective when done correctly Decision making support tools are only as good as the evidence Cultures of safety cannot be ageist and be effective Occurrences require close and careful analysis as learning tools Patient and family centered care must consider self-care first 6

7 Case Study: Mrs. K. has Sinusitis Case Study: Miss D. is Frail Mrs. K is an 81 year old woman who lives independently with her daughter nearby HX includes HTN, MI, OA, and anxiety Describes a splitting headache followed by a fall Presents to ED after setting off her medic alert pendant Current meds include Digoxin mg qday HCTZ 12.5 mg qam Lorazepam 0.5 mg BID as needed Rule out stroke protocol initiated MRI shows significant sinus infection Your thoughts? Guidelines and criteria? Polypharmacy? Prescribing considerations? Miss D. is 97 and lives in senior housing. She manages her own care with help from a nephew. HX includes OA, diverticulitis, HTN, A-fib, BrCa (surgical tx), s/p TA-hip Presents to MD with complaints of belly pain and spinning head Admitted for medical evaluation of abdominal pain and r/o CVA Current meds include Tylenol#3 q 6 hours as needed for pain Advil one or two po when the other does not work Pepto-Bismol 1-2 teaspoons po for nausea as needed ASA 81 mg po qam Lasix 20 mg bid Propranolol po 10 mg qam Tamoxifen po 20 mg MVI 1 tab po qam Vitamin E 800 iu po qam Fish oil 2000 mg po qam Your thoughts? Guidelines and criteria? Polypharmacy? Prescribing considerations? Questions and Comments Thank You skagan@nursing.upenn.edu 7