Speaker Introduction Katee Kindler, PharmD, BCACP Current Practice: Clinical Pharmacy Specialist Ambulatory Care, St. Vincent Indianapolis Assistant Professor of Pharmacy Practice, Manchester University, College of Pharmacy, Natural, and Health Sciences Email: katee.kindler@ascension.org
Conflict of Interest Disclosure This speaker has no conflict of interest to disclose. 2
High Risk Medications in the Elderly Katee Kindler, PharmD, BCACP March 16, 2018
Objectives Determine impact of high risk medications in elderly patients Identify medications that are high risk in elderly patients Develop strategies for alternative options for high risk medications 4
Why is this important? One-third of elderly patients have an adverse drug event Higher prescribing in elderly patients Multiple medications Multiple comorbidities Physiologic changes that predispose elderly patients to adverse drug events Individualize care Therapeutic goals may be different 5 Col N, et al. Arch Intern Med. 1990;150:841 5. Chrischilles EA, et al. Ann Intern Med. 1992;117:634 40. Lazarou J, et al. JAMA. 1998;279:1200 5.
What is the impact? Adverse drug events are the third or fourth leading cause of death in elderly patients that are hospitalized Analysis of adverse drug events in Medicare patients 28% of all events were preventable >40% of serious events were preventable Most errors occurred at prescribing or monitoring 6 Lazarou J, et al. JAMA. 1998; 279:1200 5. Gurwitz JH, et al. JAMA. 2003;289:1107 16.
Potential Risks with Medications Any symptom in an elderly patient should be considered a drug side effect until proved otherwise. Jerry Gurwitz, MD ALL medications, prescription & over-the-counter (OTC), have potential risks which must be weighed with the benefits Some medications are potentially unsafe for continued use in older adults American Geriatrics Society: Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, last updated 2015 7
Overview of Potentially Unsafe Medications Antihistamines Benzodiazepines Muscle Relaxants Sleep Medications Non-steroidal antiinflammatory Proton Pump Inhibitors Tricyclic Antidepressants Antipsychotics Urinary incontinence medications *Not an all-inclusive list 8 American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2015.
Antihistamines Risks associated: Confusion Falls Fatigue Dry mouth Constipation Common Medications: Diphenhydramine Chlorphineramine Doxylamine Meclizine Hydroxyzine Promethazine Possible Alternative Allergy products such as: cetirizine fexofenadine loratadine Steroid nasal sprays such as: fluticasone 9 American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2015.
Benzodiazepines Risks associated: Falls Confusion Common Medications: Alprazolam Chlordiazepoxide Clonazepam Diazepam Lorazepam Possible Alternative For anxiety: sertraline citalopram buspirone 10 American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2015.
Sleep Medications Risks associated: Falls Confusion Common Medications: Diphenhydramine Zolpidem Zaleplon Eszopiclone Possible Alternative Non-medication sleep hygiene techniques 11 American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2015.
Muscle Relaxants Risks associated: Sedation Falls Fractures Common Medications: Carisoprodol Cyclobenzaprine Methocarbamol Possible Alternative Avoid use, little evidence that they work well 12 American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2015.
Non-steroidal Anti-inflammatory Agents Risks associated: Gastrointestinal bleeding Gastric ulcers Kidneys? Common Medications: Ibuprofen Naproxen Meloxicam Possible Alternative Switch to acetaminophen May need to add a medication (proton-pump inhibitor) to protect the stomach 13 American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2015.
Proton Pump Inhibitors Risks associated: Clostridium difficile Bone loss and fractures Common Medications: Omeprazole Esomeprazole Lansoprazole Pantoprazole Possible Alternative Important to discuss why patient is taking this medication and ensure strong reason to continue daily use. 14 American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2015.
Tricyclic Antidepressants Risks associated: Highly anticholinergic Sedating Orthostatic hypotension Confusion Common Medications: Amitriptyline Clomipramine Doxepin Imipramine Nortriptyline 15 Possible Alternative For depression: SSRI (avoid paroxetine) SNRI bupropion For neuropathic pain: SNRI, gabapentin, pregabalin lidocaine patch American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2015.
Antipsychotics Risks associated: Stroke Mortality Cognitive decline Possible Alternative Non-pharmacological options such as behavioral therapy May be warranted if certain indications (schizophrenia, bipolar, etc.) or harm to self or others Common Medications: Aripiprazole Haloperidol Olanzapine Prochlorperazine Quetiapine Risperidone Ziprasidone 16 American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2015.
Urinary incontinence medications Risks associated: Anticholinergic Confusion Common Medications: Darifenacin* Fesoterodine Oxybutynin Solifenacin* Tolterodine Possible Alternative Bladder specific agents: Darifenacin Solifenacin M3 receptor agonist: mirabegron 17 American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2015.
Assessment Question Which of the following is an appropriate medications for an elderly patient? A. acetaminophen B. diphenhydramine C. omeprazole D. zolpidem 18
Conclusion Use caution when providing new medications to elderly patients Review current medication list carefully and consider safer alternatives Monitor high risk medications closely Individualize care for each elderly person 19
High Risk Medications in the Elderly Katee Kindler, PharmD, BCACP March 16, 2018
References Fick DM, Semla TP, Beizer J, et al. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2015;63(11):2227-46. O Mahony D, O Sullivan D, Byrne S, O Conner MN, Ryan C, Gallagher P. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015; 44(2): 213-8. Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med. 2011;365(21):2002-12. Steinman MA, Hanlon JT. Managing medications in clinically complex elders: "There's got to be a happy medium". JAMA. 2010; 304(14):1592-1601. Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. 2015; 175(5): 827-34. Lazarou J, Pomeranz BH, Corey PN. Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. JAMA. 1998; 279(15):1200 5. Gurwitz JH, Fields TS, Harrold LR, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA. 2003;289(9):1107 16. Col N, Fanale JE, Kronholm P. The role of medication noncompliance and adverse drug reactions in hospitalizations of the elderly. Arch Intern Med. 1990;150(4):841 5. Chrischilles EA, Seger ET, Wallace RB. Self-reported adverse drug reactions and related resource use. A study of community-dwelling persons 65 years of age and older. Ann Intern Med. 1992;117(8):634 40. 21