Post on 03-Jul-2022
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Medication Management in Older Adults
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4Ms Framework
u Identify unsafe medications u Report opportunities to
deprescribeu Enhance medication
adherenceu Use screening tools
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Objectives
1. Discuss impact of polypharmacy on older adults
2. Identify high risk medication classes that contribute to polypharmacy and adverse drug events
3. Review available resources to aid deprescribing efforts
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Inappropriate prescriptions pose health risks for older adults, leading to unnecessary hospitalizations and cost
u Emergency hospitalizations for adverse drug events in older Americans. NEJM 2011;365(21):2002-12
Van Gogh, St Paul Asylum
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Why does polypharmacy occur in older adults ?
u Medications started in middle ageu Multiple prescribers
uAverage 5 specialty visits and 2.4 primary care visits annually
u Multiple Chronic Conditions & guidelinesuExample: heart failure B block, ACE,
spironolactone, statinu Standing orders remain
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NHANES study: polypharmacy doubles each decade
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2000 2011
Prevalence
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Polypharmacy = 5 or more medications
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5 - 9 Rx > 10 Rx
Percent of 65 +
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Prescribing cascadeUSE ANOTHER MEDICATION TO TREAT SIDE EFFECTS OF A PREVIOUS PRECRIPTION
The Wilds of Lake SuperiorThomas Moran, 1871
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Prescribing Cascade
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Polypharmacyu OTC and supplementals
u 50% of patients do not tell their provider
u Example: ginseng lowers FBS by 21 mg / dL and HA1c by 0.5% in diabetics with potential for hypoglycemia
Jeremiah White, ColoradoJeremiah White
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Why reduce medication burden ?u Drugs may become unsafe with aging
uChange in kidney functionuDrug – drug interactionsuMetabolic changes
u Changes in priorities: What Mattersu Primary prevention is no longer a goalu Reduce costs
Diego Rivera
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Few medication studies for chronic conditions in older adults
Leonardo Da Vinci
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Opportunities for deprescribing
The Alchemist by Jacob Toorenvliet. fec 1684.
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Statins
u Good for secondary preventiono CVD: heart disease and stroke
u Uncertain for primary preventiono 23 % older adults given statin for primary prevention
u 10 year risk for 75+ does not meet guideline thresholds
u ALLHAT trial of statins found no efficacy
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Class Example
Antihistamines Diphenhydramine, hydroxyzine, meclizine
Anti parkinsons BenztropineMuscle relaxants Cyclobenzaprine,
methocarbamolAnti depressants Amitryiptyline, imipramine,
paroxetineAntipsychotics Abilify, haldolAntimuscarinics Oxybutynin, tolterodine,
trospiumAntiemetics Prochlorperzaine,
promethazineAntispasmodics Hyoscamine, scopalamine
ANTICHOLINERGICS
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High anti-cholinergic burden
ConfusionDeliriumPoor physical functionLoss of independenceBrain atrophyMemory lossImpulsivity
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Antagonistic therapy with Incontinence meds at odds with anticholinesterase dementia treatment
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The notorious benzo’s
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Benzos
u Mostly primary care prescribers
u 8% of populationu Anxiety, agitation,
insomnia
Too Many Sheep to Sleep -Hiroko Sakai, San Francisco
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List 3 bad things that happen with benzodiazepines
Jacob Peter Gowy The Flight of Icarus(1635–1637)
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List 3 bad things that can happen with benzodiazepines
u Fallsu Amnesiau Dementiau Impaired drivingu Hip fracturesu Dependency u Loss of REM sleep
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Antipsychotics
Théodore Géricault, “The Hyena of la Salpêtrière,” 1819
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Antipsychotics
u Increasing off label useu Only 11% effective in
managing dementia –related agitation
u Increase mortality risku 50% higher risk of
serious fall and non vertebral fracture
u Tardive dyskinesia
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Alternatives to anti-psychotics
Girl Before a Mirror, Pablo Picasso 1932
• Mirror imaging: Go with the flow
• Distract and Divert
• Treat empirically for pain
• Positive body language
• Do not argue or reprimand
• Do not rationalize
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PPIu Up to 70 % prescriptions with no
apparent indicationu Up to 50 % of hospitalized patients
sent out with PPIsu Long term use only for
uErosive esophagitisuBarrett’s esophagitisuGastrinoma / hypersecretionuRefractory reflux
Ghost of a Genius, Pall Klee, 1922
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Adverse effects of PPIsu C. difficile colitisu Community acquired pneumoniau Hip fracturesu Vitamin B12 deficiencyu Atrophic gastritisu CKDu Dementia
Alberto Giacometti
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Watch Out !
Drugs Rationale for avoidance
ASA, dabigatran, rivaroxaban, prasugrel
Risk of bleeding increases with older age
SSRI, SNRI, TCAs, diuretics, antipsychotics, carbamazepine, tramadol
SIADH and hyponatremia
Trimethoprim -sulfamethoxazole
Hyperkalemia with ACE or ARB and low eGFR
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Approach to polypharmacyHPI or ROS: Consider patient symptoms as drug – related
u Fatigue / Tirednessu Fallsu Poor sleepu Decreased alertnessu Constipation u Diarrhea u Incontinenceu Loss of appetite / weight loss u Confusion u Depression / interest in usual activities
John Henry Fuseli, “The Nightmare,” 1781
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Strategies to prevent polypharmacyu Medication list with diagnosisu Brown bag visitu Pharmacist consult, including ONE Rx referralu Check list: Beer’s criteriau Transition of care reconciliationu Align medication regimen to What Matters
Carol Josefiak
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Deprescribing
u90% of patients willing to stop medication if physician says it is possibleu Reeve E, et al. (2018) “Assessment of attitudes
toward deprescribing in older Medicare beneficiaries in the United States.” JAMA Internal Medicine
Chuck Close
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Tools for deprescribing
u Algorithmsu Pamphletsu Checklistsu Research
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Tools for deprescribing
https://deprescribing.org
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Beers List: framework
POTENTIALLY INAPROPRIATE MEDICATIONS
AVOID
CAUTION
DRUG-DRUG INTERACTIONS
DRUG – DISEASE INTERACTIONS
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Potentially Inappropriate Medications (PIMs)
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Drug – disease list
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Beers List: 30 drugs to avoid in general / 40 to use cautiouslyuSNRIs à fallsuMetoclopramide à antidopaminergicuSliding scale insulin à hypoglycemiauSulfonylureas à hypoglycemiauNSAIDs, especially with diuretics or HF
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Beers List: Combos to avoid
uOpioids with benzodiazepines or gabapentinoidsuMore than 3 CNS active RxsuMacrolides & Cipro with warfarin (bleeding)uSMX – TMP and phenytoin (Dilantin toxicity)uSMX – TMP with ACE / ARB and CKD (hyperkalemia)
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Beers List: medications to avoid or reduce with CKDMedication Side effect RecommendationCiprofloxacin CNS changes, tendon rupture Reduce doseNitrofurantoin Organ toxicity, neuropathy Avoid, especially long term useTMP - SMX Hyperkalemia, kidney faiure Reduce dose CrCL 15 -29 mL / min
Avoid if < 15 mL / minH2 blockers Mental status changes Reduce doseGabapentin / Pregabalin CNS changes Reduce dose
Duloxetine CNS changes Reduce dose
Colchicine GI side effects, BM toxicity, Neuromuscular effects
Reduce dose
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STOPP/START List
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Examples of STOPP / START
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STOPP / START protocol
u 41 – 67 % hospitalized patients with Potentially Inappropriate Medication (4 RCTs)
u Protocol impactuFall reductionuReduced drug costsuReduced adverse drug events from 24 to 12.5 %
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Consider
§ What Matters to the patient
§ Functional status
§ Life expectancy
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Goals
u Identify unsafe medications u Report opportunities to deprescribeu Enhance medication adherenceu Use screening tools
Image from Pixabay
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4Ms Framework
High-quality Geriatrics healthcare with 4Ms
Need to be delivered reliably with every older adult encounter across the continuum.
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