1. Recognizing and Responding to high risk medications in older adults
Noll Campbell, PharmD, MS
Scientist, IU Center for Aging Research
Regenstrief Institute
Assistant Professor, College of Pharmacy
Purdue University

2. Disclosure No financial conflicts of interest
Funded by a Career Development Award K23AG from the National Institute of Health

3. Objectives
1.       Identify alternative medications or treatments to consider as replacements for potentially inappropriate medications in frail older adults.
2.       Discuss approaches to de-prescribing potentially inappropriate medications in older adults.

4. STOPP/START

5. STOPP/START
Criteria informed by 19 geriatric experts from 13 European countries
Screening tool of older people's prescriptions (STOPP)
87 originally proposed criteria
80 opinion/evidence-based recommendations
Screening tool to alert to right treatment (START)
37 originally proposed criteria
34 opinion/evidence-based recommendations
O’Mahony D, et al. Age Aging 2015; 44(2):

6. STOPP/START Analgesics Drug Indication Criteria CV System
Coagulation System
CNS System
Renal System
Anticholinergic Burden
GI System
Respiratory System
Musculoskeletal
Urogenital System
Endocrine System
Falls Risks
O’Mahony D, et al. Age Aging 2015; 44(2):

7. STOPP/START CV System CNS + Ophtho Musculoskeletal Urogenital System
Vaccines
Respiratory System
GI System
Endocrine System
Analgesics
O’Mahony D, et al. Age Aging 2015; 44(2):

8. Comparison STOPP/START Beers Criteria PIM Recommendations
Excludes medications irrelevant for EU formularies
Considers each potentially serious
Shown to reduce ADE
PIM Recommendations
Prioritizes based on perceived severity
O’Mahony D, et al. Age Aging 2015; 44(2):

9. Case 1:
HPI: 86 year old man with worsening comorbidities and worsening lung cancer.
Recently treated for Stage IB left lung cancer with definitive radiation; now in RUL stage IIIB planning tx+rx
Possible cognitive impairment (MoCA 19/30)
Severe depressive symptoms (GDS 15/15)
Intact ADLs/IADLs, normal physical performance
Now being seen at one-year interval.

10. Case 1
Reports severe fatigue, anxiety, depression, significant daytime somnolence, and is confused about his medications. He has a cardiologist, nephrologist, oncologist, psychiatrist, and endocrinologist
Goals are to live as long as possible, and he is willing to accept side effects of his treatment even if they impair his quality of life, as long as there is a chance he’ll live longer. He thinks he takes too many medications.

11. Case 1
PMH: Diabetes mellitus, COPD, CAD, hypertension, chronic kidney disease, hearing loss, depression, bradycardia.
Social History: Previously lived with his wife who helped with IADLs (including finances and meds). His wife died 6 months ago after a sudden illness. His daughter moved in to help about 2 months ago.

12. Case 1 Pertinent Subjective and Objective Data:
BP 138/82 sitting and 112/65 standing. Pulse 48.
Lungs are clear. There is a systolic murmur. No lower extremity edema. Gait is unsteady, Timed Up and Go 14 seconds
Labs show worsening renal function (SCr 1.8), HbA1c 6.5%. Echo 3 months ago showed EF 60%, mild diastolic dysfunction. Bradycardia with several episodes in the 30s.

13. Case 1

14. What Can You Address?
Does every medication match a known medical problem or chronic condition?
Any deficiencies? Any duplications?
Are there red flags for potential drug-drug or drug- disease interactions or medication complications?
What are the patient’s current complaints or presenting problems, including onset and duration?

15. Case 1
Interval Update
You create a monitoring plan with him and his family. He misses his next visit, which was to follow up the changes.
He returns 6 months later, having progressed on third line therapy. He’s been hospitalized 3 times, for pneumonia, sepsis, and fluid overload with worsening kidney failure.
He is still profoundly fatigued, depressed and tearful.

16. Case 1
2 falls in the last 3 months. He is unsure about his medications. His fatigue is much worse than 6 months ago. He has persistent diarrhea, and a severe rash with very dry skin.
He is still very adamant about pursuing therapy until he can no longer take it. His oncologist has said things like “not much more we can offer” but has not discussed hospice care.

17. Case 1: Current medications: Aspirin 81 mg daily Atorvastatin 20 mg HS
Calcium 500 mg BID
Erlotinib 150 mg daily
Lorazepam 1 mg TID
Tamsulosin 0.4 mg HS
Quetiapine 50 mg HS
Gabapentin 300 mg TID
Atorvastatin 20 mg HS
Multivitamin
Amlodipine 10 mg daily
Potassium 10 mEq daily
B mcg daily
Vitamin D 1000 IU daily
Mirtazapine 15 mg HS

18. START/STOPP Triggers Erlotinib: drug-induced skin reaction;
Erlotinib: drug-induced CV events
Duplicate therapy: midodrine + HTN
Tamsulosin leading to ortho HoTN
IP delirium:
Lorazepam
Quetiapine
Use of Preventive Tx
Statins
CA treatment
Aspirin
B12/CA/vitamin D/MVI

19. Case 2: Mrs. SJ

20. Case 2 Demographics & Social HPI 63 yowf
14 years education, career = sales, management
Husband performs IADLs
HPI
24 month decline in cognitive abilities
Difficulty remembering current events, social withdraw
Repetitive speech, with word-finding difficulty
Functional decline
Flat affect

21. Case 2
Medical
Hyperlipidemia, HTN, Diabetes, osteoarthritis, depression, stroke, insomnia
Surgical
10 surgeries (abdominal and nasal passage) 1990’s
2007: acoustic neuroma removal
2009: laparoscopic cholecystectomy
2010: uvulopalatopharyngoplasty
2012: adrenalectomy
2012: add’l sinus
2016: dental extraction
2017: meniscus repair

22. Case 2 Medication Regimen Highlights 28 medications
Medications with adverse cognitive effects: 6
Total anticholinergic burden score: 15
Strong anticholinergics: meclizine, oxybutynin, promethazine, diphenhydramine
Benzodiazepines: lorazepam (QID), Zolpidem
Other: gabapentin

23. Case 2 Language Executive Function Depress-ion Memory
Visual organization
Attention/Mental Flexibility
Verbal fluency
Short-term memory
Problem solving
Memory
Depress-ion
New learning
Somatization of psychologic stress
Working memory

24. Approach to De-prescribing
Determine actual vs. expected drug benefit
Schedule of sequential tapers/discontinuation
Collaboration with primary care, specialty care
Gradual dose reduction with rescue plan
Taper up alternatives as needed
Social work for behavioral therapy
Weekly scheduled phone calls for adherence, tolerability assessment, stepwise guidance
Cell phone for rescue/distress phone calls

25. Case 2 Immediate reduction (1 Week):
Oxybutynin
Diphenhydramine
Tapered reduction or discontinuation (2-4 wks):
Gabapentin
Zolpidem (50%)
Meclizine
Promethazine
Ongoing reduction:
Lorazepam (delayed start, currently 38% reduction)

26. SJ Report Card Baseline 4/2/16 12 months 4/3/2017 Change # all Meds 28
↓ 28%
ACB score 15 3
↓ 80%
# Strong ACB 4 2
↓ 100%
# ACE meds 6
↓ 75%
# Benzodiazepines
No change
MMSE 16 29
↑ 81%
Summary Cog Test
< 7th %
WNL ↑↑
Depression 1
HABC-SR
DNF -- ↓

27. - Comment from SJ 6 weeks following initial visit
“I’m slowly taking back my life…
…and it feels great!”
- Comment from SJ 6 weeks following initial visit

28. Alternative Suggestions
Hanlon JT, et al. J Am Geriatr Soc 2015;63(12):e8-e18.

29. Alternatives Drug/Class Indication Alternative TCA Depression
SSRI (not paroxetine)
SNRI, bupropion
Neuropathic pain
SNRI, gabapentin, lidocaine, capsaicin, pregabalin
Skeletal muscle relaxants
Mild-mod pain
Acetaminophen, ibuprofen, naproxen*
First-gen antihistamines
Allergy
Intranasal saline, second-gen antihistamine, intranasal steroid
Benzodiazepines
Sleep
Cognitive behavioral therapy
Anxiety
SNRI, buspirone
*Assumes other contraindications not met

30. Approach to De-prescribing
Determine actual vs. expected drug benefit
Schedule of sequential tapers/discontinuation
Collaboration with providers
Gradual dose reduction with rescue plan
Taper up alternatives as needed
Social work for behavioral therapy
Weekly scheduled phone calls for adherence, tolerability assessment, stepwise guidance
Cell phone for rescue/distress phone calls

31. Barriers to De-Prescribing
Patient perception that care is being withheld
Social expression of care/concern between patient and provider
Discomfort discontinuing medications prescribed by specialists
Ethical concerns of stopping medications for chronic disease
Lack of RCT for medication discontinuation

32. Recognizing and Responding to high risk medications in older adults
Noll Campbell, PharmD, MS
Scientist, IU Center for Aging Research
Regenstrief Institute
Assistant Professor, College of Pharmacy
Purdue University

33. Anticholinergic Scales
Anticholinergic Cognitive Burden scale
Boustani, et al. Aging Health 2008; 4(3):
Anticholinergic Drug Scale
Carnahan, et al. J Clin Pharmacol 2006;46(12):
Drug Burden Index
Hilmer, et al. Arch Intern Med 2007;167: