Polypharmacy and the Older Adult Leslie Baker, PharmD, BCGP Umanga Sharma, MD
Objectives Identify what polypharmacy is Identify factors leading to polypharmacy Discuss consequences of polypharmacy Identify common medications which are potentially inappropriate for use in older adults with dementia Discuss why it is important to consider simplifying medication regimen as dementia progresses
What is Polypharmacy? No consensus on the definition Generally refers to multiple medications 5 or more medications Medications may not be clinically indicated Must consider OTC, herbals/supplements Medications may be considered inappropriate for older adults
How Do We Get to This? One weeks worth of medications brought in by a clinic client: o 10 prescription medications o 19 OTC supplements
Medication Use in Age > 65 Years 40.7% took 5+ prescription medications in the past 30 days (2011 to 2014) Most common therapeutic classes Anti-hyperlipidemic Anti-hypertensive PPI or H2 Blockers Anti-diabetic https://www.cdc.gov/nchs/data/hus/hus16.pdf#079
Factors Leading to Polypharmacy Multiple chronic illnesses Lack of indication Multiple providers/pharmacies Inaccurate reporting of meds Treatment duration of medication Expectation to receive medication Self treatment
Polypharmacy Leads to Increased risk of adverse drug reaction Increased risk of drug/drug and drug/disease interactions Increased risk of depression, sedation, delirium Increased risk of non-adherence Increased health care $$ Potential for under treatment Functional decline Increased risk of falls
Adverse Drug Reactions Common symptoms of ADR Confusion Nausea Falls and balance problems Sedation Change in bowel habits Manifestations in older adults may not be obvious. Can be similar to problems frequently seen.
Case Review: Mrs. J 75 y/o female presented for comprehensive geriatric evaluation, accompanied by her husband and daughter for memory loss. Lives in a single family home with husband, has 2 kids. High School Diploma; worked as a service representative for the telephone company.
More on Mrs. J Memory loss: slow and progressive over the last 3-4 years, daughter has noted significant decline. No h/o stroke, very limited physical activity Other significant comorbidities: COPD/Diabetes/Hypertension/Hyperlipidemia/Hypothyroidism/ Macular degeneration/depression/urinary incontinence No Falls in the last 3 months
Additional Information for Mrs. J. On exam: frail elderly female, in wheelchair Memory screen: Mini COG 0/5, DEMENTED Number of words successfully recalled: 0 Clock drawn appropriately and correctly shows time? : no Depression screen: PHQ-9: 18 FRAIL score: Frail, fatigued, illness more than 5, not able to climb a flight of stairs/walk a block, no significant weight loss Functional status: dependent in ADLs, IADL
Mrs. J. s Medications Metoprolol Succinate ER: Take 1 tablet by mouth 1 time daily Allopurinol 300 mg: Take 1 tablet by mouth 1 time daily Levothyroxine 125 mcg: Take 1 tablet by mouth 1 time daily Advair 250/50: Inhale 1 puff by mouth 1 times daily Aspirin 81 mg: Take 1 tablet by mouth 1 time daily Oxybutynin 5 mg: Take 1 tablet by mouth 2 times daily Glipizide ER 10 mg: Take 1/2 tablet by mouth 1 times daily if morning blood sugar >90 Metformin 500 mg: Take 1 tablet by mouth 1 time daily if morning blood sugar > 90 Lovastatin 20 mg: Take 1 tablet by mouth 1 time daily Clonidine 0.2 mg: Take 1 tablet by mouth 4 times daily Fluoxetine 20 mg: Take 1 capsule by mouth 1 time daily in the morning
Assessment 1. Labs not available for review 2. Medication identified as having anticholinergic effects: oxybutynin; Beer's list : oxybutynin, clonidine for blood pressure 3. OTC /Pain meds: not taking, had script for pain meds but doesn't take, no longer taking Lyrica 4. Diabetes: Checks blood sugar in the morning and if it is above 90 or 91, he gives meds. On average, getting meds 2 or 3 times per week. Cutting glipizide ER in half. 5. COPD: only taking Advair once daily
Medication Compliance Husband organizes and administers medicines Interventionschecking blood pressure and blood sugars Complicated patient instructions, health literacy Dementia Sometimes she resists (is receiving meds 5 times daily!) Pill burden Potentially inappropriate/side effects: Clonidine/oxybutynin Caregiver s stress Medicines aren't being given as prescribed
Addressing Polypharmacy and Dementia Things to consider: 1) Does she need to be on all these medicines? 2) How are the medications helping or NOT helping? 3) What is her life expectancy? 4) What are her goals? 5) How can we reduce caregiver s stress?
Simplifying the Regimen 1) Hypertension Consider tapering her off of clonidine and starting lisinopril ( by eliminating multiple dosing of clonidine, less side effects and caregiver burden) 2) Diabetes Consider discontinuing the glipizide ER and use only metformin. Can try metformin 500 mg ER once daily to achieve a goal A1C of 7.5 to 8% based on age and other chronic conditions. It is preferred to not have the caregiver administering oral meds based on daily blood glucoses.
Simplifying the Regimen part 2 3) Depression: non- pharmacologic strategies Consider a trial of different SSRI as Prozac not preferred due to half life and drug interactions. 4) COPD: on observing, after multiple attempts to use, she continued to have significant struggles with inhaler. Consider trying Advair HFA with a spacer or discontinue 5) Urinary incontinence: non- pharmacologic measures, no benefit from oxybutynin, is incontinent and uses diapers.
Simplifying the Regimen part 3 6) Medicines for primary prevention with advanced dementia: pill burden and life expectancy Consider discontinuation 7) Chronic pain: non-pharmacologic modalities; scheduled APAP/local treatment. 8) Frailty: Optimize nutrition; increase physical activity 9) Role of other medicines for dementia
Take Home Points Try to know all medicines your client takes including over the counter medicines and those prescribed by different providers. Maximize non-pharmacologic strategies if applicable. Each time you start a new medication, consider desired outcome, a stop date and side effects. Deprescribing.org
Special thanks to the EJC Foundation and the Nevada Aging and Disability Services Division for their support of the Sanford Center Geriatric Specialty Clinic and the Medication Therapy Management Program. Sanford Center for Aging 775-784-4774 https:med.unr.edu/aging