BEERs For the Elderly February 2008 Presented by:carla Ambrosini Seniors First Clinic Pharmacist 12/05/2008 1
Objectives To highlight the overall health care impact of drug related adverse reactions and events. To introduce the Beers Criteria as a tool to help identify potentially inappropriate medication use in older adults Educate about other risky drugs classes Educate on Medication that can increase Falls List Medications that can cause delirum 12/05/2008 2
Definitions Adverse Drug Reaction (ADR) Any noxious, unintended and undesired effects of a drug, which occurs at doses used in humans for prophylaxis, diagnosis or therapy. WHO Definition Adverse Drug-Related Event ADR in addition to medication errors (errors in prescribing, dispensing, patient adherence and monitoring). 12/05/2008 3
Definitions.. Polypharmacy concomitant use of multiple drugs administration of more medications that are indicated clinically THE KEY Ensure medication are clinically indicated and not necessarily the number of medications 12/05/2008 4
Drug-Related Problems Untreated Indication Improper Drug Selection Sub therapeutic Dosage Failure to Receive Drug Overuse Adverse Drug Reaction Drug Interactions Polypharmacy (drugs Prescribed without an indication) 12/05/2008 5
Drug Related Mortality:CBC Findings Seniors account for 44% of all reported adverse reactions causing death even though they make up 13% of the population 16,000 Canadian Seniors died from an adverse related events during the five years between 1999-2003 (3,300/yr) 12/05/2008 6
Drug Related Morbidity Majority of the Literature focus is on Adverse Drug Reactions and visits to the ER 28% of ER visits are drug related 27% resulted in hospital admissions 38-70% preventable Cost $576/EDV and $4834/admission (US$) 2004/2005 FHA data 403,000 ER Visits therefore 113,064 due to drug related problems, 27,135 admissions, 79,145 were preventable. 12/05/2008 7
Why are Elderly more Vulnerable to Side Effects Drugs are less well handled due to age related changes Inappropriate drugs and doses are taken Polypharmacy Multiple and Chronic Health Conditions Plus intermittent acute health conditions Decreased Vision, Hearing and cognition 12/05/2008 8
The Beers List Developed by an expert panel (geriatricians and pharmacologists) and led by Gerontologist Mark H. Beers in 1991 First Published in 1997 and updated most recently in 2003. Used as a guideline/reference for potentially inappropriate medication use in older adults Does NOT substitute for clinical judgment, still need to weigh risk vs. benefit 12/05/2008 9
The BEERs LIST Two tables were developed Table 1: List 48 individual drugs or drug classes that should be avoided in persons 65 or older because they are ineffective or pose unnecessarily high risk for older persons. Table 2: lists medication that should not be used in older persons known to have a specific medical condition, 20 disease/conditions are listed 12/05/2008 10
CBC findings 1/3 of all reported senior deaths were taking at one of the drugs on the BEERs list 1 in 20 reported seniors deaths were suspected to have been caused by BEERs drugs that had no conditions, meaning that they should not have been prescribed. 1 in 14 reported seniors deaths were suspected to have been caused by BEERs conditional list. 12/05/2008 11
Diseases and Conditions Identified by Beers Arrhythmias Tricyclic Antidepressants (imipramine, amitriptyline) not used due to proarrhythmic effects and QT changes (HIGH) Anorexia and Malnutrion CNS Stimulants:Methylphenidate (Ritalin) and Fluoxetine (Prozac) not used due to appetite suppressing effects (HIGH) 12/05/2008 12
Diseases. Bladder Outflow Obstruction Anticholinergics, antihistamines, GI antispasmodics, muscle relaxants, oxybutynin (Ditropan), Flavoxate (Urispas),TCA, decongestants and tolterodine (Detrol) not used as it may cause decrease in urinary flow and lead to urinary retention. (HIGH) 12/05/2008 13
Diseases Cognitive Impairment Barbitutuates, anticholingergics, antispasmodics, CNS Stimulants concern due CNS altering effects (HIGH) COPD Long acting BZD s (diazepam, Valium), Beta Blockers (propranolol) concern may exacerbate or cause respiratory depression (HIGH) 12/05/2008 14
Diseases Depression Long Term BDZ, Methyldopa, Propranolol concern that may produce or exacerbate depression (HIGH) Heart Failure Disopyramide (Rythmodan) potential to promote fluid retention (HIGH) 12/05/2008 15
Diseases.. Blood Clotting disorders or on AC NSAID s, ASA, Clopidogrel (Plavix), Ticlopidine (Ticlid) not used as may increase INR, prolong clotting time, inhibit platelet aggregation causing increased bleeding potential (HIGH) Chronic Constipation CA Channel Blockers (Adalat, Isoptin), Anticholingerics, TCA concern may exacerbate constipation (LOW) 12/05/2008 16
Diseases. Hypertension Pseudephedrine, diet pills, may produce increase in Blood pressure (HIGH) Gastric and Duodenal Ulcers NSAIDS and ASA (>325mg) may exacerbate existing ulcers or produce new ulcers (HIGH) 12/05/2008 17
Diseases.. Insomnia Decongestants, Theophylline, Ritalin, MAOI s may produce CNS stimulant effects (HIGH) Obesity Olanzapine (Zyprexa) increase appetite and cause further weight gain (LOW) 12/05/2008 18
Diseases.. Seizure or Epilepsy or Seizure Disorder Clozapine, Chlopromazine, Bupropion (Wellbutrin) may lower seizure thresholds (HIGH) Parkinson s Disease Metoclopramide and conventional Antipsychotics can worsen PD due to antidopaminergic/cholinergic effects (HIGH) 12/05/2008 19
Diseases. Syncope or Falls BDZ (all), TCA s may produce poor coordination, impaired motor function, syncope and additional falls (HIGH) Stress Incontinence Alpha Blockers (Prazosin, Terazosin) TCA, BDZ s (long acting) may produce polyuria and worsening of incontinence (HIGH) 12/05/2008 20
Drugs Seniors Should Avoid Benzodiazepines (high) Amiodarone: increase QT, poor efficacy TCA s (HIGH) Amphetamines (HIGH) Barbiturates (HIGH) Belladonna Alkaloids (Bentylol, Buscopan, (HIGH) 12/05/2008 21
Drugs. Bisacodyl (HIGH) Cascara (HIGH) Chlorpheniramine and Diphenydramine (Benadryl) (HIGH) Cimetidine (LOW) Clonidine (LOW) Cyclobenzaprine (HIGH) 12/05/2008 22
Drugs Methocarbamol (Robaxin etc) HIGH Methyldopa HIGH Mineral Oil (HIGH) Naproxen (HIGH) Nitrofurantoin (HIGH) Oxybutynin (HIGH) Proxyphene (Darvon) LOW Ticlopidine (HIGH) 12/05/2008 23
Other High Risk Drug Classes Antibiotics (ADR,GI effects, allergic reactions, compliance, wrong drug, Drug interactions) Anticoagulants (Warfarin) Digoxin Diuretics Hypoglycemic Agents (Insulin) NSAIDs (60-70% of all drug events) 12/05/2008 24
Drug Interactions Hospitalizations within 1 Week of Drug Initiation of ABX 10% to 20% more likely. Some Examples: Glyburide-Cotrimoxazole (hypoglycemia) Glyburide-Amoxicillin Digoxin-Clarithyromycin Digoxin-Cefuroxime ACEI-K sparing Diuretics REMEMBER INTERACTIONS WITH ABX 12/05/2008 25
Top Ten Drug Interactions in Long Term Care Warfarin & NSAIDS Warfarin & Sulfa drugs Warfarin & Macrolides Warfarin & Quinolones Warfarin & Phenytoin ACEI & Potassium supplements ACEI & Spironolactone Digoxin & Amiodarone Digoxin & Verapamil Theophylline & Quinolones 12/05/2008 26
Medication Non-Adherence Common problem (Dipiro 2005): - Meta-analysis (Sullivan): rate of hospital admissions due to non-adherence of all ages was 5.5% - Col et al: 11% of elderly patient admissions resulted from nonadherence - Gurwitz et al: 21 % of preventable ADRs in elderly outpatients were due to errors in patient adherence 12/05/2008 27
Medication Non-Adherence :Reasons Forgetfulness Hearing or visual problems Inability to understand how to take medications or side effects to watch for. actual or fear of side-effects inability to physically take medications (can t open vials or swallow large tablets). 12/05/2008 28
Delirium and Medications Can cause hospitalization or can happen during hospitalization Drug induced delirium rate = 12-39% Best treatment is PREVENTION 12/05/2008 29
Delirium Management Avoid drugs that can precipitate delirium: High risk: opioid analgesics - meperidine antiparkinsonian agents (esp. anticholingerics) Benzodiazipines Centrally-acting agents Corticosteroids Lithium Anticholinergics Diphenhydramine Dimenhydrinate Medium risk: alphablockers antiarrhymics e.g. lidocaine) Antipsychotic s Beta blockers Digoxin NSAIDs Postganglioni c sympathetic blockers Low risk: ACEI Antiasthmatics (aminophylline) antibacterials (quinolones, cepahlosporins, high dose penicillins) anticonvulsants (primidone and phenobarbital) Calcium channel blocker diuretics H2- antogonists 12/05/2008 30
Falls and Medications Medications linked to falls: Stronger evidence: Psychotropic medications Antidepressants Antipsychotics Benzodiazepines Weaker or conflicting evidence: Cardiovascular drugs Opioids and NSAIDs Hypoglycemic Number of medications 12/05/2008 31
How To Avoid Drug Related Problems In The Elderly Prescribe medications only for appropriate reasons Avoid inappropriate drugs (BEERs List) Use appropriate doses Start Low and Go Slow Monitor closely for efficacy and side effects Discontinue medications when no longer needed 12/05/2008 32
How To Avoid Drug Related Problems In The Elderly Screen for medication interactions Screen for high risk patients Screen for omission of treatment Estimate renal & hepatic function Avoid drugs with anticholinergic effects Choose drugs with a proven track record Maximize medication adherence 12/05/2008 33
Website www.archinternmed.com www.cbc.ca/news/background/seniorsd rugs/beers _table more.html 12/05/2008 34
Questions? 12/05/2008 35