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Polypharmacy in the Elderly Marc Evans M. Abat, M.D., FPCP, FPSGM Internal Medicine-Geriatric Medicine Marc Evans M. Abat, M.D., FPCP, FPSGM Internal Medicine-Geriatric.

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Presentation on theme: "Polypharmacy in the Elderly Marc Evans M. Abat, M.D., FPCP, FPSGM Internal Medicine-Geriatric Medicine Marc Evans M. Abat, M.D., FPCP, FPSGM Internal Medicine-Geriatric."— Presentation transcript:

1 Polypharmacy in the Elderly Marc Evans M. Abat, M.D., FPCP, FPSGM Internal Medicine-Geriatric Medicine Marc Evans M. Abat, M.D., FPCP, FPSGM Internal Medicine-Geriatric Medicine

2 Objectives Definition of polypharmacy Prevalence Consequences Pharmacology and Aging Specific Examples Interventions

3 Definitions Polypharmacy –The use of more than 5 medications, some of which may be clinically inappropriate –The number may not be as indicative of its presence-all may be appropriate; however the more drugs are taken, the higher are the chances for its occurrence –Leads to profound consequences in the elderly population

4 Prevalence As much as 25% of the overall population (Chumney et al., 2006) For those >65 years old, prevalence increases to 50% –44% males, 56% females –12% of both sexes > 10 drugs per day Prevalence may also be dependent on comorbidity –More drugs among diabetics than age or sex matched non-diabetics (Good, 2002) Other predictors include number of starting drugs, CAD, diabetes, and use of medications without indications (Veehof et al. 2000)

5 Consequences Adverse Drug Reactions (ADRs) which may include: –Drug-drug interactions –Drug-disease interactions –Drug-food interactions –Drug side effects –Drug toxicity May increase from 7% in those using 2 drugs to 50% in those using 5 and 100% in those using > 10 (Lin 2003; Brazeau 2001)

6 Quality of Life In ambulatory elderly: 35% of experience ADRs and 29% require medical intervention In nursing facilities: 2/3 of residents experience ADRs and 1in 7 of there require hospitalization Up to 30% of elderly hospital admissions involve ADRs Linked to preventable geriatric syndromes Fick Arch Int Med.

7 Economic In 2000: ADRs caused 10,600 deaths Annual cost of $85 billion $76.6 billion in ambulatory care $20 billion in hospitals $4 billion in SNF Fick Arch Int Med.

8 Pharmacokinetics and Aging characterization and mathematical description of the absorption, distribution, metabolism, and excretion of drugs, their by-products, and other substances of biologic interest as affected by the elderly body –Absorption –Distribution –Metabolism –Excretion

9 Absorption Age-relatedAge-related gastrointestinal tract and skin changes seem to be of minor clinical significance for medication usage –Decrease in small intestine surface area –Increase in gastric pH Medical conditions (e.g. achlorhydria), other medications or feedings may modify absorption –vitamin B12 in atrophic gastritis –PPIs with sucralfate –Amoxicillin with food

10 Distribution Age-related changes –Decrease in lean body weight –Decrease in total body water(10-15%) –Increased percentage body fat (~15-30%) –Increased fat:water ratio –Decreased plasma proteins, especially albumin Occurrence of heart failure, kidney disease with resulting water retention

11 Increase in volume of distribution for lipophilic drugs –sedatives that penetrate CNS –Leads to longer half-lives (Linjakumpu 2003) Metabolic capacity of phase I reactions decrease Phase II reactions are largely unaffected Greater, active, free concentration in highly protein-bound drugs

12 Metabolism some overall decline in liver metabolic capacity due to decreased liver mass and hepatic blood flow –Highly variable, no good estimation algorithm –Minimal clinical manifestations Concurrent drug use may affect metabolism in both directions No formula to estimate this effect

13 Renal Elimination Age-related decrease in renal blood flow GFR decreases by 8 mL/min/1.73 m2/decade Decreased lean body mass leads to decreased creatinine production –Serum creatinine not reliable –Need to estimate creatinine clearance and adjust medications accordingly (i.e. use Cockroft-Gault or MDRD)

14 Pharmacodynamics and Aging Effect of the drug on the body with regard to aging Generally, lower drug doses are required to achieve the same effect with advancing age. –Receptor numbers, affinity, or post-receptor cellular effects may change. –Changes in homeostatic mechanisms can increase or decrease drug sensitivity.

15 Inappropriate Medications: Beers Criteria One of the most, if not the widely used consensus data for inappropriate medication use in the elderly Latest revision in 2003 Covers 2 statements regarding drug use in elderly: –Those inappropriate for the elderly in general –Those inappropriate for the elderly with regard to specific conditions






21 Vitamin and Herbal Use in Older Adults Highly prevalent among older adults –77% in Johnson and Wyandotte county community dwelling elderly Generally not reported to the physician serious drug interactions possible: –Warfarin, gingko biloba, vitamin E


23 Non-adherence to Medication Regimens related to both physician and patient factors –Large number of medications –Expensive medications –Complex or frequently changing schedule –Adverse reactions –Confusion about brand name/trade name –Difficult-to-open containers –Rectal, vaginal, SQ modes of administration –Limited patient understanding

24 Geriatric Prescribing Principles First consider non-drug therapies Match drugs to specific diagnoses Try to give medications that will treat more than condition Reduce meds when ever possible Avoid using a drug to treat side effects of another Review meds regularly (at least q3 months) Avoid drugs with similar actions / same class Clearly communicate with pt and caregivers Consider cost of meds

25 CARE: Avoiding Polypharmamcy Caution and Compliance –Understand side effect profiles –Identify risk factors for an ADR –Consider a risk to benefit ratio –Keep dosing simple- QD or BID –Ask about compliance

26 CARE: Avoiding Polypharmamcy Adjust the Dose –Start low and go slow- titrate –Consider the pharmacokinetics and pharmacodynamics of the medication

27 CARE: Avoiding Polypharmamcy Review Regimen Regularly –Avoid automatic refills –Look for other sources of medications- OTC –Caution with multiple providers –Don’t use medications to treat side effects of other meds –Choose drugs discontinue or substitute safer medications

28 CARE: Avoiding Polypharmamcy Educate –All medicines, even over-the-counter, have adverse effects-report all products used –Talk to your patient about potential ADRs –Warn them for potential side effects and report symptoms –Educate the family and caregiver –Ask pharmacist for help identifying interactions –Assist your patient in making and updating a medication list- personal medical record –Avoid seeing multiple physicians –Do not use medications from others

29 Personal Health Record It will reduce polypharmacy and ADRs Multiple specialist involved in care Transitions in care from independent living, hospitals, nursing homes and assisted living facilities Great aid in emergency care Provides the patient with more piece of mind…

30 Personal Health Record Includes: Patient identifying information Doctors contacts Caregiver contacts Past Medical History and Allergies List of all medications, dose, reason they are taking it and whether it is new


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