1. Evidence-Based Methods to Reduce Medications in Older Patients
Kenneth Brummel-Smith, MD
Charlotte Edwards Maguire Professor of Geriatrics
Florida State University College of Medicine
Copyright 2007, Florida State University College of Medicine. This work was supported by a grant from the Donald W. Reynolds Foundation. All rights reserved.

2. Objectives
Describe 5 factors to consider when discontinuing a medication
Describe 3 initiatives physicians can take to lower medications
Describe two initiatives patients can take to lower medications

3. One person’s drugs

4. Prevalence of the Problem
Medication errors each year:
7000 deaths
95,000 hospital admissions
700,000 emergency visits
3,000,000 office visits
30% more money spent on treating errors than on medications themselves
5th most common cause of death in US
IOM, To Err is Human, 2000

5. FM Residency Chart Review
Epocrates Medication Check
17% - contradicted medication combination
42% - avoid use/alternative combination
78% - monitor/modify Treatment combination
64% - caution advised combination
Beer’s List
44% of polypharmacy patients were on a Beer’s drug
Of those on a Beer’s drug, 75% of patients were on a high risk drug
Polypharmacy – 5 or more prescription drugs

6. Beer’s Drugs (High Severity)
amitriptylene
barbituates
chlordiazepoxide
chlorpropamide
diazepam
doxepin
flurazepan
hysocyamine
meperidine
methyldopa
pentazocine
ticlopidine
Beers MH. Explicit criteria for determining potentially inappropriate medication use by the
elderly: an update. Arch Intern Med 1997;157:

7. Considering Appropriateness
Remaining life expectancy
Time until benefit
Goals of care
Treatment targets
Cost
“Indications to Discontinue”
Holmes H, Arch Int Med, 2006

8. Remaining Life Expectancy
Women
Men
Walter LC, JAMA, 2001

9. Time Until Benefit Short term benefits Long term benefits
Analgesics for pain
Sx relief
Long term benefits
Primary prevention
Secondary prevention
Different than number needed to treat
More individualized

10. Goals of Care Shared decision making Changes as person ages
Cure illness
Prevent death
Prevent disability
Relieve suffering
Increase function
Promote health
Prevent transmission
Increased quality of life
Increased control
A good death
Shared decision making
Changes as person ages
Changes as disease progresses

11. Treatment Targets Related to goals Goal = general
Target = measurable outcome
Positive targets (to reach)
Negative targets (to avoid)

12. Costs Financial Impact on family Risk of adverse effects Costs:
Aricept?
Norvasc?
Celebrex?
Effexor?

13. Physician’s Control- Teach Your Students!
Minimum 2 year wait on new drugs
7 year wait is safer
Do not use drugs on the Beer’s list
Use generics
Use the 4 step approach to evaluate new and current drugs
Use an EHR with:
Medication decision support
Computerized entry
73% of pts are satisfied with reductions
Straand J, Fam Prac, 2001

14. Teach Your Patients Keep a list of your drugs – show it every visit
Use only one pharmacy
Don’t ask for any drug that is advertised on TV or in magazines
Ask how long the drug has been on the market
Don’t take any drug until it’s been out for at least 2 years
Ask if there are other things besides taking a drug you can do
Ask if you should stop any current drugs

15. Helpful Sites Therapeutics Initiative: Evidence Based Drug Therapy
Univ of British Columbia
OHSU Drug Effectiveness Review Project