Presentation on theme: "Polypharmacy in the Elderly"— Presentation transcript:
1Polypharmacy in the Elderly Marc Evans M. Abat, M.D., FPCP, FPSGMInternal Medicine-Geriatric Medicine
2Objectives Definition of polypharmacy Prevalence Consequences Pharmacology and AgingSpecific ExamplesInterventions
3Definitions Polypharmacy The use of more than 5 medications, some of which may be clinically inappropriateThe 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 occurrenceLeads to profound consequences in the elderly populationNot enough attention paid to pharmacodynamic principlesRegardless of semantics, polypharmacy is widely practiced,often unnecessary andyet sometimes required with the usual multiple medical conditions in the elderly!
4PrevalenceAs much as 25% of the overall population (Chumney et al., 2006)For those >65 years old, prevalence increases to 50%44% males, 56% females12% of both sexes > 10 drugs per dayPrevalence may also be dependent on comorbidityMore 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)
5Consequences Adverse Drug Reactions (ADRs) which may include: Drug-drug interactionsDrug-disease interactionsDrug-food interactionsDrug side effectsDrug toxicityMay increase from 7% in those using 2 drugs to 50% in those using 5 and 100% in those using > 10 (Lin 2003; Brazeau 2001)Drugs that interfere with warfarin and cause increases in INR and bleeding risk!Not appropriately adjusting dosing for renal dysfunctionDiet interfering with warfarin levelsDrug toxicity especially in drugs with low therapeutic indexThese are the basic mechanisms by which ADRs occur but the truth is that theyHave serious consequences to the elders’ quality of life and society’s pocketbook!
6Up to 30% of elderly hospital admissions involve ADRs Quality of LifeIn ambulatory elderly: 35% of experience ADRs and 29% require medical interventionIn nursing facilities: 2/3 of residents experience ADRs and 1in 7 of there require hospitalizationUp to 30% of elderly hospital admissions involve ADRsLinked to preventable geriatric syndromesThis is most common form of iatrogenic illness!Of course ADRs are linked to depression, constipation, falls, morbility, confusion, hip fracturesAnd therefore significantly impaired quality of life!Fick Arch Int Med.
7Annual cost of $85 billion $76.6 billion in ambulatory care EconomicIn 2000: ADRs caused 10,600 deathsAnnual cost of $85 billion$76.6 billion in ambulatory care$20 billion in hospitals$4 billion in SNFFick Arch Int Med.
8Pharmacokinetics 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 bodyAbsorptionDistributionMetabolismExcretionAbsorption:Decreased gastric acid alters absorption of some medicationsDecreased gastric mobility can increase absorptionDistribution:10-15% decrease in Total Body Water and lean body mass: water soluble drugs have poor distribution in adipose cause increasing serum concentrationsIncreased body fat: lipid soluble drugs accumulate and prolong duration of actionDecreased serum albumin: increases free serum concentrations which makes lab levels more challenging to interruptMetabolism:Reduced metabolism within the liver and diminished enzyme activity increases serum drug effectsExcretion:Diminished kidney function (GFR): calculate creatinine clearance(((140-age) x weight in kg)/72 x serum creatinine) x 0.85(for women)
9AbsorptionAge-related gastrointestinal tract and skin changes seem to be of minor clinical significance for medication usageDecrease in small intestine surface areaIncrease in gastric pHMedical conditions (e.g. achlorhydria), other medications or feedings may modify absorptionvitamin B12 in atrophic gastritisPPIs with sucralfateAmoxicillin with food
10Distribution Age-related changes Decrease in lean body weightDecrease in total body water(10-15%)Increased percentage body fat (~15-30%)Increased fat:water ratioDecreased plasma proteins, especially albuminOccurrence of heart failure, kidney disease with resulting water retention
11Increase in volume of distribution for lipophilic drugs sedatives that penetrate CNSLeads to longer half-lives (Linjakumpu 2003)Metabolic capacity of phase I reactions decreasePhase II reactions are largely unaffectedGreater, active, free concentration in highly protein-bound drugs
12Concurrent drug use may affect metabolism in both directions some overall decline in liver metabolic capacity due to decreased liver mass and hepatic blood flowHighly variable, no good estimation algorithmMinimal clinical manifestationsConcurrent drug use may affect metabolism in both directionsNo formula to estimate this effect
13Age-related decrease in renal blood flow Renal EliminationAge-related decrease in renal blood flowGFR decreases by 8 mL/min/1.73 m2/decadeDecreased lean body mass leads to decreased creatinine productionSerum creatinine not reliableNeed to estimate creatinine clearance and adjust medications accordingly (i.e. use Cockroft-Gault or MDRD)
14Pharmacodynamics and Aging Effect of the drug on the body with regard to agingGenerally, 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.
15Inappropriate Medications: Beers Criteria One of the most, if not the widely used consensus data for inappropriate medication use in the elderlyLatest revision in 2003Covers 2 statements regarding drug use in elderly:Those inappropriate for the elderly in generalThose inappropriate for the elderly with regard to specific conditionsOrganized in tables of potentially inappropriate medications both independent of diagnoses and as they are related to certain medical problems.However thinking about this as four main high risk drug categories is easier to remember!
21Vitamin and Herbal Use in Older Adults Highly prevalent among older adults77% in Johnson and Wyandotte county community dwelling elderlyGenerally not reported to the physicianserious drug interactions possible:Warfarin, gingko biloba, vitamin E
23Non-adherence to Medication Regimens related to both physician and patient factorsLarge number of medicationsExpensive medicationsComplex or frequently changing scheduleAdverse reactionsConfusion about brand name/trade nameDifficult-to-open containersRectal, vaginal, SQ modes of administrationLimited patient understanding
24Geriatric Prescribing Principles First consider non-drug therapiesMatch drugs to specific diagnosesTry to give medications that will treat more than conditionReduce meds when ever possibleAvoid using a drug to treat side effects of anotherReview meds regularly (at least q3 months)Avoid drugs with similar actions / same classClearly communicate with pt and caregiversConsider cost of medsUse these principles to initiate and re-evaluate medicationsInherent challenge: the elderly often have very complicated medical conditions which require the use of multiple medications-otherwise the provider feels they are not appropriately treating their patient…. I know hope difficult this challenge can be butIf you are aware of the problems with polypharmacy, have a high degree of suspicion for ADRs,and Consider ADRs as a possible etiology of functional decline in elderly patientsThen you will improving your pts quality of life!To start doing this, you should be aware of certain high risk medications!
25CARE: Avoiding Polypharmamcy Caution and ComplianceUnderstand side effect profilesIdentify risk factors for an ADRConsider a risk to benefit ratioKeep dosing simple- QD or BIDAsk about compliance
26CARE: Avoiding Polypharmamcy Adjust the DoseStart low and go slow- titrateConsider the pharmacokinetics and pharmacodynamics of the medication
27CARE: Avoiding Polypharmamcy Review Regimen RegularlyAvoid automatic refillsLook for other sources of medications- OTCCaution with multiple providersDon’t use medications to treat side effects of other medsChoose drugs discontinue or substitute safer medications
28CARE: Avoiding Polypharmamcy EducateAll medicines, even over-the-counter, have adverse effects-report all products usedTalk to your patient about potential ADRsWarn them for potential side effects and report symptomsEducate the family and caregiverAsk pharmacist for help identifying interactionsAssist your patient in making and updating a medication list- personal medical recordAvoid seeing multiple physiciansDo not use medications from othersThis is a simple and obvious idea which is not currently being utilized!
29Personal Health Record It will reduce polypharmacy and ADRsMultiple specialist involved in careTransitions in care from independent living, hospitals, nursing homes and assisted living facilitiesGreat aid in emergency careProvides the patient with more piece of mind…
30Personal Health Record Includes: Patient identifying informationDoctors contactsCaregiver contactsPast Medical History and AllergiesList of all medications, dose, reason they are taking it and whether it is newNow- lets review some key points …