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Avoiding Hobson’s choice in older patients: Managing multi-morbidity and multiple medications in geriatrics Marilyn N. Bulloch, PharmD, BCPS Assistant.

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Presentation on theme: "Avoiding Hobson’s choice in older patients: Managing multi-morbidity and multiple medications in geriatrics Marilyn N. Bulloch, PharmD, BCPS Assistant."— Presentation transcript:

1 Avoiding Hobson’s choice in older patients: Managing multi-morbidity and multiple medications in geriatrics Marilyn N. Bulloch, PharmD, BCPS Assistant Clinical Professor Harrison School of Pharmacy Auburn University

2 The Hobson’s Choice in Geriatric Pharmacotherapy Don’t Prescribe It Prescribe It

3 Objectives Discuss the impact of the aging population on healthcare utilization. Understand age-related pharmacokinetic and pharmacodynamics changes that may affect pharmacotherapy in older adults Describe complications of chronic medication therapy in the aging patient. Identify strategies to optimize benefit and minimize harm with chronic medication therapy in older adults.

4 Our Patients Are Aging Available: (Accessed April 2013)http://www.aoa.gov/Aging_Statistics/future_growth/future_growth.aspx#age

5 Patients Are Living Older Longer Available: (Accessed April 2013)http://www.aoa.gov/Aging_Statistics/future_growth/future_growth.aspx#age

6 Chronic Conditions in Older Adults Available: (Accessed April 2013)http://www.aoa.gov/Aging_Statistics/future_growth/future_growth.aspx#age

7 Multi-morbidity Co-occurrence of:  Index disease  Preexisting age-related health condition or diseases Impact  Affect disease progression  Decrease quality of life  Increase risk and severity of disability  Increase risk of mortality Shi et al. Eur J Clin Pharmacol 2008;64:

8 Patients with Multi-morbidity Adapted from Figure 1. Fried et al. NCHS Data Brief 2012;100:1 Adapted from Figure 2. Fried et al. NCHS Data Brief 2012;100:2

9 Multiple Medications in Older Adults Exhibit 13. IMS Institute for Healthcare Informatics. Avoidable Costs in U.S. Healthcare: The $200 Billion Opportunity from Using Medicines More Responsibly. June Available (accessed 20 June 2013)http://www.imshealth.com

10 Evidence-Based Geriatric Medicine Studies involving geriatrics  3% randomized, controlled studies  1% meta-analyses Make up 2-9% study subjects In 2000  3.45% of controlled trials  1.2% of meta-analysis Le Couteur et al. Aus Fam Phys 2004;33:

11 Applying EBM to Older Adults Does your patient resemble the studied population? How many older adults with multi-morbidity were included? What are the intended outcomes – are these applicable to older patients? Are there clinically important variation in baseline factors that affect intended outcome? Are the risks of the intervention known in older adults with multi-morbidity? What is known about the comparator intervention in older adults? What is the time until benefit or harm? Adapted from Table 1. J Am Geriatr Soc 2012;60:

12 Age-Related Physiologic Changes Adapted from Figure 1. Huang A. 28 th Annual Scientific Meeting of the Canadian Geriatric Society 2008;11(10):7

13 Absorption Changes ↓ saliva production ↓ gastric acid secretion ↓ gastrointestinal blood flow Delayed gastric emptying Intestinal atrophy Changes in body fat and lean muscle Pulmonary changes Skin changes Conjunctiva changes Hubbard et al. Eur J Clin Pharmacol 2013;69: McLean et al. Pharmacol Rev 2004;56: Corsonello et al. Cur Med Chem 2010;17:

14 Distribution Changes ↑ body fat ↓ lean muscle ↓ total body water ↓ albumin ↑ CNS penetration Hubbard et al. Eur J Clin Pharmacol 2013;69: Sitar. Expert Rev Clin Pharmacol 2012;5: McLean et al. Pharmacol Rev 2004;56: Corsonello et al. Cur Med Chem 2010;17:

15 Metabolism Changes ↓ hepatic blood flow ↓ liver volume ↓ plasma esterase quantity & activity  Associated more with health status than age Phase I pathways more impacted than Phase II McLean et al. Pharmacol Rev 2004;56:

16 Elimination Changes ↓ glomeruli causes ↓kidney mass ↓ GFR in 2/3 of patients ↑ drug elimination half-life McLean et al. Pharmacol Rev 2004;56:

17 Pharmacokinetic Questions How readily absorbed is the medication? What is the onset and duration of desired therapeutic action? What is the patient’s body composition? Is the medication excreted unchanged? What is the major route of elimination? Does the medication have an metabolite?  Is the metabolite active or toxic?  How is the metabolite eliminated? Adapted from Table 2. Lamy. J Am Ger Soc 1982;11;s11- s19

18 Pharmacodynamic Changes Receptor down regulation Change in receptor sensitivity  Increased  Decreased Impaired homeostatic mechanisms and/or physiologic reserves

19 COMPLICATIONS OF GERIATRIC MEDICATION USE

20 Polypharmacy Quantity ≥ X Medications Limiting - assumes > X is incorrect Quality More medications than is clinically indicated  No indication  Lack efficacy  Duplications Requires more thorough review of medications DeSovo et al. Prim Care Clin Office Pract 2012;39:

21 Reasons for Polypharmacy Age Ethnicity Rural residence Education level Insurance Multiple healthcare providers Poor health status Provider visits Chronic diseases  Anemia  Angina  Asthma  Depression  Diabetes  Diverticulosis  Gout  Hypertension  Osteoarthritis DeSovo et al. Prim Care Clin Office Pract 2012;39:

22 Avoidable Costs of Polypharmacy Exhibit 12. IMS Institute for Healthcare Informatics. Avoidable Costs in U.S. Healthcare: The $200 Billion Opportunity from Using Medicines More Responsibly. June Available (accessed 20 June 2013)http://www.imshealth.com

23 Adverse Drug Reactions Unwanted and/or harmful effects that can occur at standard doses Gurwitz et al  50.1 ADRs per 1000 person years 13.8 preventable ADRs per 1000 person years VA GEM Study  33% of patients experienced an ADR within 12 months of hospital discharge 38% considered preventable Boparai MK et al. Mt Sinai J Med 2011;78: Gurwitz et al. JAMA 2003;289: Steinman et al. J Gerontol A Biol Sci Med Sci 2011;66:

24 Risks for ADRs Prior ADR Polypharmacy Dementia/cognitive impairment Multi-morbidity Frailty CrCl < 50 mL/min Female Fragmented care Altered stimuli-induced adaptation capacity Recent hospital admission Age ≥ 85 years Low body weight ≥ 1 oz alcohol intake/ day Vision or hearing impairment Compliance Regimen complexity DeSovo et al. Prim Care Clin Office Pract 2012;39: Boparai MK et al. Mt Sinai J Med 2011;78:

25 Medications Causing ADRs Gurwitz JH, et al. JAMA 2003;289;

26 Types of ADRs Occurring Figure 1. Percent patients suffering selected injuries commonly studied among patients who experienced adverse drug events: Reducing and Preventing Adverse Drug Events To Decrease Hospital Costs. March Agency for Healthcare Research and Quality, Rockville, MD. (Accessed April 24, 2013)http://www.ahrq.gov/research/findings/factsheets/errors-safety/aderia/figure1.html

27 ADR Consequences Health care utilization  10% of emergency room visits  10-17% of hospitalizations $1.33 to manage medication-related morbidity and mortality for each $1 spent on older adults in nursing homes Can be fatal Symptoms should be considered ADRs until proven otherwise. Le Couteur et al. Aus Fam Phys 2004;33: Budnitz et al. N Eng J Med 2011;365” Boparai MK et al. Mt Sinai J Med 2011;78:

28 Drug Interactions Many types 15-46% patients have ≥ 1 interaction  1 in 25 community patients at risk for severe interaction Over 26% cause ADRs that require hospitalization  25% serious or life-threatening Approximately 20% occur in the hospital  Potential for drug-drug interaction in over 6% of medication orders McDonnell, et al. Ann Pharmacother 2002;36: Qato et al. JAMA 2008;300: Reimche et al. Clin Pharmacol 2011;51: Lindblad et al. Clin Therapeu 2006;28:

29 Drug Interactions Age  years – 24%  ≥ 80 years – 36% Risk increases with # medications  ≥ 2 medications – 13%  > 6 medications – 82%  ≥ 8 medications – almost 100% Boparai MK et al. Mt Sinai J Med 2011;78: Stegemann et al. Age Research Rev 2010;9:

30 Minimizing ADRs and Interactions Know allergies – including reactions Evaluate cognitive function Have a drug information source Use safest/most effective medication Match medications to indications Use fewest medications possible Use simple dosing Do not start 2 medications at the same time Screen for DDIs routinely Dose for renal & hepatic function Recognize a symptom as an ADR Give prophylaxis for known side effects when able Stop medications without benefit Stop PRN medications not used in past month Medication lists Involve caregivers Adapted from: Boparai MK et al. Mt Sinai J Med 2011;78:

31 Non-Adherence Adherence in patients with chronic conditions only 50-60% Responsible for up to 70.4% of medication-related ER visits May account for 39-69% of drug-related hospitalizations each year Costs $100 billion/year Coleman et al. J Manag Care Pharm 2012;18: Orwig et al. Gerontologist 2006;46:66

32 Cost of Non-Adherence Exhibit 3. IMS Institute for Healthcare Informatics. Avoidable Costs in U.S. Healthcare: The $200 Billion Opportunity from Using Medicines More Responsibly. June Available (accessed 20 June 2013)http://www.imshealth.com

33 Types of Non-adherence Forgetfulness Confusion over dosage schedule Intentional underuse  Primary non-adherence  Non-persistence  Nonconforming non-adherence Intentional overuse Coleman et al. J Manag Care Pharm 2012;18:

34 Risk Factors for Non-Adherence Communication Regimen complexity Patient-provider relationship Transition of care Health literacy Mental health disorders Cognition Smoking Asymptomatic chronic diseases Age Physical impairment Lack of social support Minority demographic Patient beliefs Sensory changes Product use Dysphagia

35 Dosing Influence on Adherence Coleman et al. J Manag Care Pharm 2012;18:

36 Overcoming Adherence Barriers BarrierSolution Forgetfulness Pill organizers Medication Calendar/Cues Dispensing Devices Family/caregiver involvement Internet-linked or electronic adherence aid Patient beliefs Establish shared goals of care Provide literacy appropriate materials Simplify regimen/reduce pill burden Difficulty Taking Change formulation Easy off caps Pill cutters Simplify regimen Syringe magnification Spacer CostGenerics Steinman et al. JAMA 2010;304:

37 EVALUATING MEDICATION MANAGEMENT ABILITY

38 Drug Regimen Unassisted Grading Scale (DRUGS) Adapted from Edelberg et al. J Am Geriatr Soc 1999;47:

39 MedTake Test Adapted from Appendix I. Raehl et al. Pharmacotherapy 2002;22:

40 MedTake Test Adapted from Appendix I. Raehl et al. Pharmacotherapy 2002;22:

41 Medication Regimen Complexity Index Checklist style tool to evaluate regimen Only for prescribed medications Medication Regimen Complexity = Total (A) + Total (B) + Total (C) Open index  # medications and directions vary by patient George et al. Ann Pharmacother 2004;38:

42 MRCI Section A: Dosage Forms Adapted from Appendix II. George et al. Ann Pharmacother 2004;38:

43 MRCI Section B: Dose Frequency Adapted from Appendix II. George et al. Ann Pharmacother 2004;38:

44 MRCI Section C: Directions Adapted from Appendix II. George et al. Ann Pharmacother 2004;38:

45 Medication Management Instrument for Deficiencies in the Elderly Adapted from Orwig et al. Gerontologist 2006;46:

46 Medication Management Instrument for Deficiencies in the Elderly Adapted from Orwig et al. Gerontologist 2006;46:

47 Hopkins Medications Schedule Appendix. Carlson et al. J Gerontol A Biol Sci Med Sci 2005;60;223

48 AUXILIARY LABELS & THE IMPORTANCE OF VERBAL COUNSELING

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77 In Conclusion We have a lot of older patients  Patients are staying older longer Older patients need medications  They respond differently than younger patients  There is not a lot of EBM to guide decisions or answer questions on geriatric medication use Try to optimize medication prescribing and use to minimize complications before taking the Hobson’s Choice

78 Questions “All substances are poisons; there is none which is not. The right dose differentiates a poison from a remedy” -Paracelsus ( )


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