Suboptimal Drug Use in Long Term Care Facility Patients

Joseph T. Hanlon PharmD, MSProfessor, Departments of Medicine (Geriatrics)

and Pharmacy and Therapeutics, University of Pittsburgh

and Pittsburgh VA CHERP and GRECC

Learning Objectives

At the end of the talk the participants should be able to:• List the different types of suboptimal drug use• Describe the prevalence of polypharmacy (9+ drugs) in

long term care patients• Discuss the underuse of medications in long term care

patients• Summarize drugs that are potentially inappropriate or

unnecessary as per new CMS Guidelines for LTCF • Discuss principles to optimize drug use in long term care

patients

Types of Suboptimal Drug Use

1. Overutilization (polypharmacy)

2. Underutilization

3. Inappropriate utilization

Hanlon JT, et al. J Am Geriatr Soc 2001;49:200-9;

Spinewine A, et al. Lancet 2007;370:173-184

% Taking 9+ Meds in LTCFs

0

10

20

30

40

50

60

70

80

National VA

Pe

rce

nt o

f NH

R

CMS data, 1st quarter, 2005, VA NHCU data FY 04-05

Top Medication Classes Used in LTCF

Medication Class 1997 MCBS

%

Analgesics/Anti-pyretics 76.5

GI agents 74.5

Electrolytes, caloric 71.0

CNS agents 65.9

Anti-infectives 62.3

Cardiovascular 55.0

Topical or other 47.1

Renal/GU Tract 44.4

Hormones/Synthetic subs 40.5

Respiratory agents 35.8

Anti-allergy agents 22.4

Blood formation/anti-coagulants 17.7

Doshi JA, et al. J Am Geriatr Soc. 2005;53:438-44.

Top Medication Classes Used in VA NHCU FY 2005 (n=6554)

VA Medication Class FY 05 %

Non-opioid analgesics 73.3

SSRI Antidepressants 54.3

Anti-infectives

Antipsychotics

GI, misc.

Stool Softeners

53.3

48.8

47.9

40.9

ACE-I 39.4

Beta blockers 39.3

Antiepileptics 38.0

MVI w/minerals 36.2

Stimulant Laxatives 34.6

Topical antifungals 34.4

Antilipemics 33.0

French DD, et al. J Am Med Dir 2007; 8:515-8

Daily Use of Specific Medication Classes in LTCF Patients per MDS

Drug Class VA % National %

Diuretics 29.8 34.0

Antidepressants 43.0 48.4

Antipsychotics 25.9 24.9

Antianxiety agents 9.6 12.8

Hypnotics 3.8 3.7

CMS data, 2nd quarter, 2007, VA NHCU data FY 04-05

Risks Associated with Polypharmacy

• Functional status decline

• ADRs

• Inappropriate drug use

• Increased medication administration errors

• Increased risk of geriatric syndromes

Learning Objectives

At the end of the talk the participants should be able to:• List the different types of suboptimal drug use• Describe the prevalence of polypharmacy (9+ drugs) in

long term care patients• Discuss the underuse of medications in long term care

patients• Summarize drugs that are potentially inappropriate or

unnecessary as per new CMS Guidelines for LTCF • Discuss principles to optimize drug use in long term care

patients

Underutilization of Medication

• Undiagnosed and untreated condition

• Diagnosed condition but omitted treatment

• Underuse of preventive treatment

Examples of Medication Under-Use in LTCFs

• Warfarin for stroke prevention (McCormick et al, 2001)

• Hypoglycemics for diabetes

(Spooner et al, 2000)

• Calcium and other treatment for osteoporosis

(Jachna et al, 2005)

Inappropriate Prescribing

• Prescribing of medications that does not agree with accepted medical standards

MDS Quality Indicator Report

Medication Use National % VA%Antipsychotic Use w/o Psychosis 22.0 19.9Sxs of Depression w/o antidepressant 4.8 3.9Hypnotic use > 2x in previous week 4.2 4.1

CMS Recommended Antianxiety and Sedative/Hypnotic

Maximum Daily Dosage

Generic Name Dosage (mg)

Alprazolam 0.75

Clonazepam 7.5

Lorazepam 1-2

Oxazepam 15-30

Temazepam 7.5-15

Zaleplon 5

Zolpidem 5

Indications for Antipsychotics in the Elderly Nursing Home Patients

 1. Disorders such as delirium, schizophrenia,

paraphrenia, dementia

With

2. Thinking and behavior disturbances such as delusions,

hallucinations, paranoia

And

3. Severe enough to be of harm to the patient and/or others

Antipsychotic Guidelines

in Nursing Home Elderly • Residents should receive gradual dose reductions, behavior

interventions unless clinically contraindicated

• Avoid use of highly anticholinergic antipsychotics (e.g., olanzapine, chlorpromazine, thioridazine, clozapine)

• Specific doses recommended

• Monitor for metabolic and EPS problems

Weight Gain, Diabetes an Dyslipidemias with Atypical Antipsychotics

Clozapine=Olanzapine>Quetiapine>

Paliperidone=Risperidone>Ziprasidone=Aripiprazole

ADA-APA Monitoring Guidelines

Measure Baseline 4wks 8wks 12wks 1/4ly Yrly

BMI x x x x x

Waist Circ. x x

BP x x x

FG x x x

Lipids x x

CMS Recommended Selected Antipsychotic Maximum Daily Dosage Name Dosage (mg) 

Fluphenazine 4

Haloperidol 2

Perphenazine 8

Quetiapine 150

Risperidone 2

Inappropriate Medication Use Defined by Explicit Criteria (Beers MH, et al. 1997)

• CARDIOVASCULAR

Reserpine, Methyldopa, Disopyramide

• ANTIPLATELETS

Dipyridamole, Ticlopidine

• DEMENTIA TREATMENTS

• GASTROINTESTINAL

Antispasmodics (e.g., Donnatal®)

Trimethobenzamide (Tigan®)

• ANALGESICS

Indomethacin , Phenylbutazone

Propoxyphene , Pentazocine, Meperidine

• ORAL HYPOGLYCEMICS

Chlorpropamide (Diabinese®)

• PSYCHOTROPICS

Long acting benzodiazepines

Meprobamate, Barbiturates

Amitriptyline, Doxepin

Antidepressant/neuroleptic Comb.

• SKELETAL MUSCLE RELAXANTS

• ANTIHISTAMINES

Diphenhydramine (Benadryl® )

• GU ANTISPASMODICS

Oxybutynin

Use of Beers Criteria Drugs in Nursing Homes

J Am Geriatr Soc. 2005;53:991-6.

Predictive Validity of Inappropriate Drug Use

Author/yr Sample Criteria Outcome

Lau/2005 MEPS NH Beers (Do not use, dose, drug-dx interaction)

Death (OR=1.28)

Hospitalized (OR=1.27)

Perri/2005 Georgia Medicaid NH

Beers (do not use), duplication, drug-dx interaction

Death/Hospitalized

(OR=2.3)

Klarin/2005 Swedish ALF/NH

Beers (high severity do not use), DDI, duplication

Death (OR=0.93)

Hospitalized (OR=2.72)

Ravio/2006 Finland NH Beers (do not use, dose)

Death (HR=1.02)

Hospitalized (OR= 1.40)

Inappropriate Medication Use Defined by CMS Criteria 2006

• ANTIINFECTIVE

Nitrofurantoin

• CARDIOVASCULAR

Amiodarone (unless VT/Fib), Disopyramide, Methyldopa, Nifedipine (SA), Prazosin

• ANTIPLATELETS

Ticlopidine

• GASTROINTESTINAL

Antispasmodics (e.g., Donnatal®), Cimetidine, Metoclopramide, Trimethobenzamide (Tigan®)

• ANALGESICSNSAIDs, Propoxyphene , Pentazocine, long acting opioids (fentanyl patch, methadone, SR products)

• ORAL HYPOGLYCEMICSChlorpropamide, Glyburide

• PSYCHOTROPICS Barbiturates, Meprobamate,

TCA’s, MAOIs • SKELETAL MUSCLE

RELAXANTS• ANTIHISTAMINES

Chlorpheniramine, Cyproheptadine, Diphenhydramine, Hydroxyzine, Meclizine, Promethazine

Unnecessary Medications

• Defined as a medication with excessive dose or duration; inadequate monitoring or indication for use; presence of adverse consequences which indicate the dose should be reduced or d/ced

CMS Recommended Maximum Daily Dosage

Generic Name Daily Dosage (mg)

APAP 4000

Digoxin 0.125 (unless Afib)

H2 blockers based on renal function

Iron qd

Metformin based on renal function

CMS Guidelines For Drugs with Maximum Duration Limits

Drug Class Duration (days)

ACHEI ? Revaluate as dx progresses

Analgesics ? acute use

Anti-infectives ?

Antiemetics ?

Cough/Cold 14

H2 blocker/PPI 84 (unless GERD/NSAID use)

Iron 56

CMS Guidelines for Monitoring Medication Use

Drug MonitoringACE-I K+AEDS (older) levelsAminoglycosides Scr, levelsAntidiabetics Blood sugarAntipsychotics EPS, TDAPAP (>4gm/d) LFTSAppetite stimulants weight, appetiteDigoxin Scr, levelDiuretic K+Erythropoiesis stimulants BP, iron, ferritin, CBCFibrates LFTS, CBCIron iron, ferritin, CBCLithium levelNiacin blood sugar, LFTs Statins LFTsTheophylline levelsThyroid replacement TFTsWarfarin INR

CMS Drug-Drug Interactions

Drug Effected Precipitant Drug (s) ASA NSAIDsACE-I K supplements, K sparing diureticsAnticholinergic AnticholinergicAntihypertensives levodopa, nitratesAntiplatelet NSAIDCNS med CNS medDigoxin amiodarone, verapamilLithium ACEI, thiazide diuretics, NSAIDsMeperidine MAOIPhenytoin imidazoles Quinolones Type IA,C, II antiarrhythmicsSSRI tramadol, st john wortSulfonylureas imidazolesTheophylline imidazoles, quinolones, barbituratesWarfarin amiodarone, NSAIDs, sulfonamides,

macrolides, quinolones, phenytoin, imidazoles

Clinically Important Drug-Disease Interactions Determined by Expert Panel

ConsensusDrug Disease

– Alpha blockers Syncope– Anticholinergics BPH, constipation, dementia,

glaucoma (narrow angle)

– Aspirin PUD– Barbiturates Dementia– Benzodiazepines Dementia, falls– Bupropion Seizures– CCB 1st generation CHF (systolic dysfunction)– Corticosteroids DM– Digoxin Heart block

Lindblad C, Hanlon J et al. Clin Ther 2006;28:1133-43.28:1133-43.

Clinically Important Drug-Disease Interactions Determined by Expert Panel

ConsensusDrug Disease

– Metoclopramide Parkinson’s disease– Non-aspirin NSAIDs CRF, PUD– Opioid analgesics Constipation– Sedative/hypnotics Falls– Thioridazine Postural hypotension– Tricyclic antidepressants BPH, constipation

dementia, falls, heart block

postural hypotension– Typical antipsychotics Falls

Lindblad C, Hanlon J et al. Clin Ther 2006;28:1133-43.28:1133-43.

Medications with Anticholinergic Activity

• Anti-emetics/anti-vertigo - (e.g., meclizine)

• Antiparkinsonians - (e.g., trihexyphenidyl)

• Antispasmodics- (e.g., belladonna)

• Cold and allergy drugs- (e.g., hydroxyzine)

• Sleep aids- (e.g., diphenhydramine)

• Skeletal muscle relaxants - (e.g., cyclobenzaprine)

Atypical Antipsychotic Medications and Risk

of Falls in Residents of Aged Care Facilities Medication Adj Hazard Ratio 95% CIOlanzapine 1.74 (1.04–2.90)Risperidone 1.32 (0.57–3.06)Typ. antipsychotics 1.35 (0.87–2.09)Antidepressants 1.45 (1.09–1.93)Sed/anxiolytics 1.19 (0.94–1.50)

Hien LTT, et al. J Am Geriatr Soc 2006;53: 1290-1295.

Antipsychotic Medications and Risk of Hip Fractures in NH Residents

Medication Adj. OR 95% CIAtypicals 1.37 1.11-1.69Olanzapine 1.34 0.87–2.07Risperidone 1.42 1.12–1.80Conv. antipsychotics 1.35 1.06–1.71Haloperidol 1.53 1.18–2.26

Liperoti R, et al. J Clin Psych 2007;68: 929-34.

Learning Objectives

At the end of the talk the participants should be able to:• List the different types of suboptimal drug use• Describe the prevalence of polypharmacy (9+ drugs) in

long term care patients• Discuss the underuse of medications in long term care

patients• Summarize drugs that are potentially inappropriate or

unnecessary as per new CMS Guidelines for LTCF • Discuss principles to optimize drug use in long term care

patients

Principles for Optimizing Drug Use in the Elderly

• Consider whether drug therapy is necessary • Promote the use of a small number of drugs to treat

common problems • Adjust doses and or/dosage intervals for medications • Establish reasonable therapeutic endpoints and monitor for

desired outcome • Monitor for adverse drug reactions • Regularly review the need for chronic medications

Holmes HM, et al. Arch Intern Med 2006;166:605-609.

A Model for Appropriate Prescribing for Patients Late in Life

Chronic Medication Review Steps

• Assess whether ADRs are the cause of any symptoms

• Match problem list with drug list

• If on drug but no match with problem list consider whether drug is necessary

• If has a chronic condition and not on a medication consider whether there is an evidence based drug to tx the condition

• Assess the monitoring for efficacy/safety/appropriateness of the remaining medications

Assessing Prescribing Appropriateness Using the MAI

• Is there an indication for the drug?

• Is the medication effective for the condition?

• Is the dosage correct?

• Are the directions correct?

• Are the directions practical?

• Are there clinically significant drug-drug interactions?

• Are there clinically significant drug-disease interactions?

• Is there unnecessary duplication with other drugs?

• Is the duration of therapy acceptable?

• Is this drug the least expensive alternative compared to others of equal

utility?

Effect of an Interdisciplinary Team on Suboptimal Prescribing in a VA LTCF (n=23)

Variable Admission Closeout P Value Scheduled meds (mean ± sd)

7.4 ± 2.8 7.3 ± 3.53 0.16

Unnecessary meds (mean ± sd)

1.6 ± 1.5 0.3 ± 0.7 <0.001

Inappropriate meds (Beers Criteria) %

17 0 -------

MAI Score/Person (mean ± sd)

16.7 + 10.6 7.9 + 5.1 <0.001

Undertreated conditions (mean ± sd)

0.5 + 0.7 0.2 + 0.4 0.03

Jeffery S, et al. Consult Pharm 1999;14:1386-91.

Learning Objectives

At the end of the talk the participants should be able to:• List the different types of suboptimal drug use• Describe the prevalence of polypharmacy (9+ drugs) in

long term care patients• Discuss the underuse of medications in long term care

patients• Summarize drugs that are potentially inappropriate or

unnecessary as per new CMS Guidelines for LTCF • Discuss principles to optimize drug use in long term care

patients

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