POLYPHARMACY in the ELDERLY. C. Frank Webber Lectureship Dale C. Moquist, MD April 13, 2018

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1 POLYPHARMACY in the ELDERLY C. Frank Webber Lectureship Dale C. Moquist, MD April 13,

2 Speaker Disclosure Dr. Moquist has disclosed that he has no actual or potential conflict of interest in relation to this topic. 2

3 Learning Objectives By the end of this activity, the participant will be better able to: 1. Describe common polypharmacy issues in the elderly. 2. Avoid the use of problematic medications in the elderly and stop certain medications even if prescribed by other physicians. 3. Compare the benefits and risks of polypharmacy and educate elderly patients and/or their caregivers on appropriate adherence to certain medications. 4. Utilize practical strategies to attempt to achieve optimal prescribing patterns for the elderly. 3

4 Outline Overview Beers START/STOPP Deprescribing Cases Summary 6

5 Overview Complexity Challenges Basics of Prescribing 7

6 Importance of Geriatric Pharmacotherapy Now, people age 65+ are 13% of US population, buy 33% of prescription drugs By 2040, will be 25% of population, will buy 50% of prescription drugs. Slide 8

7 Polypharmacy No clear definition Prevalence over age 65 13% with 2 meds 58% with 5 meds 82% with 7 or more Increased risk of adverse events The number of drugs that a patient is taking is the single most important predictor of harm 9

8 Drug Treatment More Complex 10 Acute and chronic diseases Prevention of many diseases Correct medication Correct dosage Correct disease or condition Correct patient Other diseases Other medications Functional status Adherence and beliefs

9 Challenges of Geriatric Pharmacotherapy More drugs are available each year FDA and off-label indications are expanding January Effect Formularies change frequently Knowledge of drug-drug interactions advances Drugs change from prescription to OTC Nutraceuticals are booming herbals and nutritional supplements 11

10 Realities of 2018 Polypharmacy may be indicated Heart Failure: 3-5 medications Stringent blood pressure control Diabetes Mellitus: 3-5 medications Medication reconciliation Make list of all conditions Match ALL meds to a condition Check meds after transitions of care Meds are usually added Inadvertently left out

11 Risk Factors for ADEs 6 or more concurrent chronic conditions 12 or more doses of drugs/day 9 or more medications Prior adverse drug event Low body weight or low BMI Age 85 or older Estimated CrCl< 50 ml/min 13

12 The REAL Question What is the APPROPRIATE medication for your patient? 14

13 Basics of Prescribing for The Elderly Start with a low dose Titrate upward slowly as tolerated by the patient Avoid starting 2 drugs simultaneously Ask patient to bring in ALL medications prescribed, OTC, supplements Look for duplicate therapies Eliminate unnecessary medications Simplify dosing regimens 15

14 Prescribing a New Medication 16 Is this medication necessary? What are the therapeutic endpoints? Do the benefits outweigh the risks? Is it used to treat effects of another drug? Could 1 drug be used to treat conditions? Could it interact with diseases or other drugs? Patient Education: What it s for? How to take it? What ADEs to look for?

15 Beer's Criteria Benefits and Challenges Changes Drugs to Avoid Use With Caution Drug-Disease/Syndrome Interactions Adverse Drug Interactions 17

16 ARS Question Which of the following cardiac med is on the Beers List? 1. Atenolol 2. Metoprolol 3. Lisinopril 4. Amiodarone 18

17 ARS Question Which of the following antihypertensive is on the Beers List? 1. Lisinopril 2. Metoprolol 3. Hydrochlorothiazide 4. Valsartan 5. Clonidine 19

18 ARS Question Which of the following is NOT on the Beers List? 1. Temazepam 2. Zolpidem 3. Zaleplon 4. Eszopiclone 5. Trazodone 20

19 Intent of the AGS 2015 Beers Criteria Goals: Improve care by exposure to PIMS Educational tool Quality measure Research tool 21

20 Purpose of Beer s Criteria Identify potentially inappropriate meds that should be avoided in many older adults To reduce adverse drug events and drug-related problems Improve medication selection and medication use in older adults Designed for use in any clinical setting and also for education, quality, and research 22

21 Benefits and Challenges Use of many medications has declined Increased appreciation of special considerations when prescribing for older adults Mistakenly believe Beer s Criteria judge ALL uses of the listed meds is universally inappropriate Some quality improvement programs have implicitly considered use of these meds to be problematic Some prior authorization programs have misapplied Beer s Criteria by payors/clinicians 23

22 Not Included in Beer s List Drugs with risks not unique to elderly Purpose is for PIMs specific to elderly Drug-drug interactions Not unique to elderly List of alternatives Too complex, requires patient specific judgment 24

23 Previous Drugs to Avoid Dropped from 2012 AGS Beers Criteria DRUGS Cyclandelate Off market Rationale 25 Guanethidine, guanadrel Propoxyphene Stimulant laxative, chronic FeSo4 325mg daily Amphetamines/anorexics Cimetidine and Fluoxetine Ethacrynic acid Off market Off market New safety info Not geriatric specific Risk not geriatric specific DDI risk not geri. specific Weak ototoxicity evidence

24 2015 Changes Z drugs for sleep: Avoid chronic use Testosterone: Avoid unless indicated for moderate to severe hypogonadism Topical vaginal estrogen: Acceptable low dose use for specific conditions Spironolactone: Avoid >25 mg/day in pts with heart failure or CrCl <30 Antipsychotics: Avoid unless nonpharm treatment has failed or threat to self/others PPIs Beyond 8 Weeks: Bone Loss, Fractures, C. difficile, B12 26

25 Beer s Recommendations Evidence-Based 5 Categories 1. Drugs to avoid 2. Drugs to avoid with specific diseases or syndromes 3. Drugs to use with caution 4. Selected drugs whose dose should be adjusted based on kidney function 5. Selected drug-drug interactions 27

26 Drugs to Avoid Organ System or TC or Drug Nitrofurantoin Antipsychotics (conventional or atypical) Rationale Recommend. Quality of Evidence Pulmonary tox Alternatives Lack of efficacy <60 ml/min Increase CVA and CV mortality in dementia Avoid long term suppression; avoid if CrCl <60 ml/min Avoid unless danger to self/others and non pharm has failed Moderate Moderate Strength of Recommend. Strong Strong Insulin, sliding scale Chlorpropamide Glyburide Hypoglycemia risk Avoid Moderate Strong Hypoglycemia risk Avoid High Strong 28

27 Drugs to Avoid Organ System or TC or Drug Benzodiazepines Short and long acting Megestrol Rationale Recommend. Quality of Evidence Risk cognitive effects and injury (fall/mva); rare use appropriate eg benzo withdrawal Minimal effect on weight; risk of thrombotic events and death Avoid for treatment of insomnia, agitation, or delirium Metclopramide EPS and TD Avoid, unless gastroparesis Non-COX NSAIDs, oral GI bleeding; Protection w/ PPIs or misoprostol High Strength of Recommend. Strong Avoid Moderate Strong Moderate Strong Avoid chronic use Moderate Strong 29

28 Drugs to Avoid Organ System or TC or Drug Rationale Recommend. Quality of Evidence Strength of Recommend. Non Benzodiazepines Hypnotics ( z drugs) Estrogens with or w/o progestin Muscle Relaxants Risk cognitive effects and injury (fall/mva); same ADE as benzo s Carcinogenic potential, lack of efficacy in dementia/cv dz prevention Ineffective at tolerated doses, antichol, falls Avoid chronic use, >90 days Avoid oral and topical patch. Topical cream safe and effective for vaginal symptoms Moderate High Strong Strong Avoid Moderate Strong 30

29 Drugs to Avoid 31 Organ System or TC or Drug Antidepressants, alone or with: Amitriptyline Desipramine Imipramine Doxepin > 6 mgqd Paroxetine Nortriptyline Protein-pump Inhibitors Androgens: Methyltestosterone TestosteroneAnd Rationale Recommend. Quality of Evidence Highly anticholinergic, sedating, and cause orthostatic hypotension Risk of C. difficile, bone loss, fractures, B12 Potential for Cardiac problems and do not use in prostate CA Avoid High Strong Avoid scheduled us for > 8 wks unless for high-risk Avoid unless confirmed hypogonadism High Moderate Strength of Recommend. Strong Weak

30 Drugs to Avoid Organ System or TC or Drug Peripheral alpha-1 Blockers: doxazosin, prazosin, terazosin Central alpha blockers: clonidine, methyldopa, reserpine Amiodarone Nifedipine, immediate releasend Rationale Recommend. Quality of Evidence High risk of orthostatic hypotension High risk of adverse CNS effects, Effective but is more toxic than other meds Reasonable in HF Potential for hypotension, risk of myocardial ischemia Avoid use as an antihypertensive Avoid clonidine as first-line antihypertensive Avoid as first-line unless HF or LVH Moderate Low High Strength of Recommend. Strong Strong Strong Avoid High Strong 32

31 Use with Caution Drug Rationale Recommend Quality of Evidence Dabigatran Drugs linked to SIADH/ Hyponatremia (eg SSRI, TCA, CBZ, antipsychotics) Risk of bleeding; lack of evidence if CrCl < 30mL/min May exacerbate or cause SIADH/ hyponatremia; monitor Use with caution if >75 or if CrCl < 30mL/min Moderate Strength of Recommend Weak Use with caution Moderate Strong 33

32 Drug-Disease/Syndrome Interactions Disease or Syndrome Syncope Insomnia Drug Rationale Recomm. Quality of Evidence AChEIs Peripheral α- blockers Tert. TCAs Chlorpromazine Thioridazine Olanzapine Oral decongestants Stimulants Theobromines Orthostatic hypotension or bradycardia CNS stimulant effects Avoid α- blockers: High TCAs, AChEIs, antipsych: Moderate Strength of Recomm. Avoid Moderate Strong AChEIs,TCAs: Strong α- blockers, antipsych.: Weak 34

33 Drug-Disease/Syndrome Interactions Disease or Syndrome Heart Failure Parkinson disease Drug Rationale Recomm. Quality of Evidence NSAIDs & COX-2 Diltiazem Verapamil Thiazolidinediones Cilostazol Dronedarone All antipsychotics Except aripiprazole, quetiapine, clozapine Metoclopramide Prochlorperazine Promethazine Promote Fluid Retention and exacerbate HF Dopaminereceptor antagonists with potential to worsen Parkinsonian symptoms Avoid NSAIDs: mod CCBs: mod Thiazolidinediones: High Cilostazol: Low Dronedarone: High Strength of Recomm. Strong Avoid Moderate Strong 35

34 Adverse Drug Interactions that Increase the Risk of Harm Combination ACE inhibitor + potassium-sparing diuretic Anticholinergic + anticholinergic Calcium channel blockers + erythromycin or clarithromycin Concurrent use of 3 CNS active drugs Digoxin + erythromycin, clarithromycin, or azithromycin Lithium + loop diuretics or ACE inhibitor Peripheral alpha 1 blockers + loop diuretics Phenytoin + SMX/TMP Risk Hyperkalemia Cognitive decline Hypotension and shock Falls and fractures Digoxin toxicity Lithium toxicity Urinary incontinence in women Phenytoin toxicity

35 Adverse Drug Interactions that Increase the Risk of Harm Combination Sulfonylureas + SMX/TMP, ciprofloxacin, levofloxacin, erythromycin, clarithromycin, azithromycin, and cephalexin Tamoxifen + paroxetine (other CYP2D6 inhibitors) Theophylline + ciprofloxacin Trimethoprim (alone or as SMX/TMP) + ACE inhibitor or ARB or spironolactone Warfarin + SMX/TMP, ciprofloxacin, levofloxacin, gatifloxacin, fluconazole, amoxicillin, cephalexin, and amiodarone Warfarin + NSAIDs Hypoglycemia Risk Prevention of converting tamoxifen to its active moiety, resulting in increased breast cancer-related deaths Theophylline toxicity Hyperkalemia Bleeding GI bleeding

36 38 Beers Criteria Apps

37 STOPP/START History START Criteria Commonly Underprescribed Medications STOPP Criteria Commonly Overprescribed Medications 39

38 History Version 1 released in 2010 Updated in 2014 as version 2 STOPP meds are associated with adverse drug events STOPP/START applied at a single time point during hospitalization for acute illness improved appropriateness STOPP/START as an intervention applied within 72 hours of admission reduce ADRs and average length of stay 31% increase in STOPP/START Criteria in version 2 40

39 Helpful Approaches Screening Tool to Alert doctors to Right Treatment (START) Individualize therapy Not appropriate for every patient May mot provide medical benefit Systems-based tool: Errors of omission STOPP (Screening Tool of Older People s Potentially Inappropriate Prescriptions) Similar to Beers Different approach: Drug-drug and drug-disease 41

40 42 START Criteria Cardiovascular Warfarin or NOACs for chronic atrial fibrillation Aspirin for atrial fibrillation with warfarin contraindication Antiplatelet RX for CAD, CVD, and PVD Antihypertensive RX for Systolic BP >160 and Diastolic > 90 Statins for secondary prevention (CAD, CVD, & PVD) ACE for Heart Failure or After MI Beta-Blocker for chronic stable angina Endocrine Metformin for Type 2 Diabetes ACE for Diabetes and Nephropathy Antiplatelet & Statin for Diabetes and CVD

41 START Criteria 43 Gastrointestinal PPI for severe GERD or esophageal stricture Fiber supplement for chronic symptomatic diverticular Musculoskeletal DMARD for moderate and severe RA Bisphosphonates for chronic oral steroids Calcium and Vitamin D for osteoporosis Bone anti-resorptive or anabolic RX for osteoporosis Vitamin D in housebound or experiencing falls or osteopenia Xanthine-oxidase inhibitors for recurrent gout Folic Acid supplementation in patients taking methotrexate

42 44 More on START Nervous System Levodopa for Parkinson s Disease with functional impairment Non-TCA antidepressant for persistent major depression symptoms Acetyl cholinesterase inhibitor for mild-moderate Alzheimer s SSRI or SNRI for persistent anxiety interfering with function Dopamine agonist for Restless Legs Syndrome Respiratory Daily inhaled Beta agonist or antimuscarinic for mild to moderate asthma or COPD Daily inhaled steroid for asthma or COPD with FEV 1 <50% of predicted value Continuous home Oxygen for chronic hypoxemic respiratory failure: po 2 < 60 mm Hg

43 Final START 45 Urogenital System Alpha-1 receptor blocker with symptomatic prostatism 5-alpha reductase inhibitor with symptomatic prostatism Topical vaginal estrogen for symptomatic atrophic vaginitis Analgesics High-potency opioids in moderate-severe pain Laxatives in patients receiving opioids regularly Vaccines Seasonal trivalent influenza vaccine annually Pneumococcal vaccine at least once after age 65

44 Commonly Under Prescribed Drugs ACE inhibitors for patients with diabetes and proteinuria Angiotensin-receptor blockers Anticoagulants Antihypertensives and diuretics for uncontrolled hypertension β-blockers for patients after MI or with heart failure Bronchodilators Proton-pump inhibitors or misoprostol for GI protection from NSAIDs Statins Vitamin D and calcium for patients with or at risk of osteoporosis Slide 46

45 STOPP More flexible Designed to be used with START Indication of medication Any drug without an evidence-based clinical indication Any drug prescribed beyond the recommended duration Any duplicate drug class prescription (2 NSAIDS) Highlights of some clinical situations Amiodarone may be only effective drug for arrhythmia Doxazosin in resistant HTN Nitrofurantoin may be only drug sensitive to pathogen 47

46 Cardiovascular System Digoxin for HF with normal systolic ventricular function Loop Diuretic: Ankle edema and HTN with UI Thiazide with hypokalemia and gout B-Blocker with bradycardia Verapamil/Diltiazem in Class III or IV HF Amiodarone as first-line in SVT B-Blocker with Verapamil/Diltiazem Central-acting antihypertensives unless clear intolerance with other meds ACE Inhibitors or ARBs in hyperkalemia Aldosterone antagonists with concurrent potassium-conserving drugs Phosphodiesterase Type-5 Inhibitors in HF with hypotension or concurrent use of nitrate RX 48

47 Antiplatelet/Anticoagulation 49 Long-term ASA > 160 mg ASA in PUD without PPI ASA, Clopidogrel, NOACs Dipyridamole, Vit K antagonists with significant bleeding risk ASA + Clopidogrel as secondary stroke prevention ASA with Warfarin or NOACs in chronic AF Clopidogrel with Vit K or NOACs with CAD/PVD Ticlopidine in any circumstances Vit K or NOACs for DVT w/o risk factors > 6 mos Vit K or NOACS for 1 st PE w/o risk factors > 12 mos Combination of NSAID, Vit K, & NOACs NSAID with antiplatelet w/o PPI prophylaxis

48 50 CNS and Psychotropic TCAs in dementia, glaucoma, cardiac conduction abnormalities, prostatism, and history of urinary retention TCAs for first-line antidepressant RX Long-acting Benzos >1 month Anticholinergics/Antimuscarinic in delirium, dementia, prostatism, UR ACE Inhibitors with syncope, bradycardia, diltiazem, digoxin verapamil Long-term neuroleptics in Parkinsonism Anti-Cholinergic RX EPS of neuroleptics SSRIs in HX hyponatremia First generation antihistamines Phenothiazines as first-line Neuroleptics >1 month as a hypnotic Levodopa/dopamine agonists for benign essential tremor Neuroleptic antipsychotic for dementia behavior unless severe

49 More on STOPP 51 Urogenital Antimuscarinic: Dementia Antimuscarinic: Glaucoma Antimuscarinic: Prostatism Alpha Blockers: Symptomatic Orthostatic Hypotension or Micturition Syncope Endocrine Long-acting sulfonylureas Thiazolidenediones in HF Beta-Blockers in DM & frequent Hypoglycemia Estrogens: HX of Breast Cancer or DVT Estrogens without progesterone with intact uterus Androgens in absence of primary or secondary hypogonadism

50 STOPP on Systems Gastrointestinal Drugs likely cause constipation in chronic constipation Prochlorperazine or Metclopramide in Parkinsonism Full dose PPI >8 weeks Oral elemental iron doses > 200 mg daily Respiratory Theophylline monotherapy for COPD Systemic steroids instead of inhaled steroids for maintenance in moderatesevere COPD Nebulized Ipratropium in glaucoma or bladder outflow obstruction Nonselective B-Blocker in asthma Benzos with acute respiratory failure 52

51 Musculoskeletal System NSAIDs: PUD or GI Bleed NSAIDs: Severe HTN or HF NSAIDs > 3 Months for Mild Joint Pain w/o Acetaminophen Corticosteroids for OA Cox-2 Selective NSAIDs with concurrent CV NSAIDs with Corticosteroids w/o PPI Long-term corticosteroids >3 months for monotherapy for RA Long-term NSAID / Colchicine for chronic RX of gout with NO contraindication to allopurinol Oral bisphosphonates with current or recent HX of UGI disease 53

52 Renal System Digoxin at a long-term dose > 1.25 mg Q daily if egfr < 30 ml/min Dabigatran if egfr < 30 ml/min Factor Xa Inhibitors (Rivaroxaban, Apixaban) if egfr < 15 ml/min NSAIDs if egfr < 50 ml/min Colchicine if egfr < 10 ml/min Metformin if egfr < 30 ml/min 54

53 More STOPP Conditions Prone to Falls Benzodiazepines Neuroleptic drugs Vasodilator drugs: Postural Hypotension Hypnotic Z-Drugs: Prolonged sedation and ataxia Analgesic Drugs Long-Term opiates as first-line RX in mild-moderate Regular opiates without concomitant laxative Long-acting opiates without shortacting opioids for breakthrough pain 55

54 Commonly Over Prescribed and Inappropriately Used Drugs Androgens/testosterone Anti-infective agents Anticholinergic agents Urinary & GI antispasmodics Antipsychotics Benzodiazepines Nonbenzodiazepine hypnotics Digoxin as first-line for afib or heart failure Dipyridamole H 2 receptor antagonists Insulin, sliding scale NSAIDs Proton-pump inhibitors Sedating antihistamines Skeletal muscle relaxants Tricyclic antidepressants

55 Deprescribing Systemic Process Brown Bag Test Describe 5 Step Process: Harms vs Benefits Explain and Agree With Management Plan 57

56 Definition Systemic process of identifying and discontinuing drugs in instances in which existing or potential harms outweigh existing or potential benefits within the Context of an individual patient s care goals Current level of functioning Life expectancy Values Preferences Not about denying effective treatment to eligible patients 58

57 5 Step Protocol 1. Ascertain all drugs the patient is currently taking 2. Consider overall risk of drug-induced harm 3. Assess each drug for discontinuation 4. Prioritize drugs for discontinuation 5. Implement and monitor drug discontinuation 59

58 STEP 1 Ask patient to bring ALL drugs Prescribed, complimentary, and alternative Do not forget OTC Brown Bag Test Ask about prescribed drugs not being taken Ask reason for each drug 60

59 Step 2 61 Ascertain and assess risk Number of drugs (single most important predictor) High risk drugs Past or current toxicity Patient Factors Age > 80 Cognitive impairment Multiple comorbidities Substance abuse Multiple prescribers Past or current nonadherence

60 Step 3 62 Assess each drug for its eligibility to be discontinued No valid indication Part of a prescribing cascade Potential harm of drug clearly outweighs benefit Disease/Symptom control drug is ineffective or symptoms have completely resolved Preventive drug is not beneficial over patient s lifespan Drugs are imposing unacceptable treatment burden Since you started this medicine, has it made such a difference to how you feel that you would prefer to stay on it?

61 Step 4 Deciding the order of discontinuation of drug may depend on three pragmatic criteria 1. Those with the greatest harm and least benefit 2. Those easiest to discontinue, lowest likelihood of withdrawal reactions or disease rebound 3. Those the patient is most willing to discontinue first Rank drugs from high harm/low benefit to low harm/high benefit 63

62 Step 5 Implement drug discontinuation regimen Explain and agree with patient on management plan Stop one drug at a time so that harms and benefits can be attributed to specific drugs and rectified Wean patients off drugs more likely to cause adverse withdrawal effects Communicate plan to all health professionals and family Fully document the reasons of describing 64

63 Strategies Assisting in Prescribing What are the treatment options (including nondrug options) for my condition? What are possible benefits and harms of each treatment? What might be reasonable grounds for discontinuing use of a drug? Are you experiencing any adverse effects? 65

64 66 Cases

65 Case 1 Husband of an 82 year-old woman calls because his wife s behavior has changed over the last few days. She is confused and becomes agitated when he assists with ADLs. She will not eat because she thinks she is being poisoned. History of HTN, depression, osteoarthritis, Alzheimer s, and urinary incontinence. SLUMS score was 22/30 2 months ago. Meds: Acetaminophen 325 QID, donepezil 5 mg QD, memantine ER 14 mg, HCTZ 25 mg QD, lisinopril 10 mg QD, citalopram 20 mg QD, and tolterodine 2 mg BID Tolterodine was increased 1 week ago 67

66 Case 1 Continued A visiting nurse obtains laboratory samples later that day. Lab values are: BUN = 18 Serum Creatinine = 1.1 Sodium = 138 Glucose = 81 Urinalysis: 0-5 WBCs, negative for bacteria and leukocyte esterase 68

67 ARS Question What is most appropriate at this time? 1. Discontinue Tolterodine 2. Increases Memantine ER to 28 mg QD 3. Start Lorazepam 0.5 mg BID 4. Start Risperidone 0.25 mg 69

68 Case 2 80 year-old woman fell and underwent repair of hip fracture 3 days ago. She now reports dizziness and has excessive daytime drowsiness. History: HTN, frequent falls, post-herpetic neuralgia Pre-admission Meds: HCTZ 12.5 mg QD, metoprolol 50 mg QD, amlodipine 10 mg QD, gabapentin 600 mg TID, calcium carbonate 500 mg TID Meds started after surgery: Enoxaparin 30 mg QD, docusate 250 mg BID, Senna 8.6 mg BID, oxycodone 5-15 mg every 4 hours, she has received two 10 mgm doses in last 24 hours. 70

69 Case 2 Continued Weight 45 kg (99 lb.) Blood Pressure 144/76 No orthostatic changes Estimated Creatinine clearance is 30 ml/min Two months ago estimate GFR was 60 ml/min 71

70 ARS Question What is the best next step now? 1. Discontinue Oxycodone 2. Increase Enoxaparin to 30 mgm BID 3. Reduce Gabapentin to 600 mg BID 4. Start Alendronate 70 mg once weekly 72

71 SUMMARY Warning Light Engage The Whole Patient 73

72 Warning Light Beers and STOPP is a warning light Warning light should make you stop and think Why is the patient taking the drug? Are there safer and/or more effective alternatives? Does my patient have particular characteristics that increase or mitigate risk of this medication? Keep in mind there are situations in which use of Beer s meds are justified and appropriate. 74

73 Engage Actively inquire about symptoms that could be adverse drug effects Do not automatically defer to colleagues Just because another clinician prescribed a Beers/STOPP med doesn t mean it is safe and/or effective Use the opportunity to discuss with colleagues whether that medication is right for the patient 75

74 The Whole Patient Don t let Beers/STOPP distract you from closely attending to other elements of prescribing that are not addressed by the criteria Issues Other high-risk meds Medication adherence Unnecessary medication use Underuse of medications 76

75 One Final Thought Use Clinical Common Sense 77

76 RESOURCES Pharmacotherapy. Geriatrics Review Syllabus 9 th Edition. May Pharmacotherapy. Geriatrics Review Syllabus Teaching Slides. May American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. JAGS DOI: /jgs O Mahoney. STOPP/START Criteria for Potentially Inappropriate Prescribing in Older People: Version 2. Age and Ageing 2015; 44:

77 RESORCES Pretorius. Reducing the Risk of Adverse Drug Events in Older Adults. Am Fam Phy March 1, 2013; 87: Appropriate Use of Polypharmacy for Older Patients. Cochran for Clinicians. Am Fam Phy April 1, 2013; 87:

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