1. Preventing Potentially Inappropriate Medication Use as We Age
(Speaker goes here)
Hello and welcome to today’s lunch and learn. My name is ______________ and I will be your presenter for a multi-incident analysis on potentially inappropriate medication use in the older patients with a focus on preventive actions.
©2018 Institute for Safe Medication Practices Canada. This video is for educational purposes only. Reproduction by any other processes is prohibited without permission from ISMP Canada in writing.

2. Acknowledgments
This presentation was adapted from work by Kelly Ng [BSc (Hons), PharmD Candidate] from 2015
Will we be adding the MIPS acknowledgement and CPhM to this page?
Rachel

3. Goals Understand the changes that happen to our bodies as we age
Define “Potentially Inappropriate Medication” (PIM)
Explore symptoms and other signs of PIM use
Discuss steps we can take to minimize medication harm by addressing PIM risk factors
Describe the importance of a comprehensive medication review and the role of patients in medication safety
After completing this presentation, you will be able to:
Understand the changes to the body that affect the use of medications (Slide 8)
Define “Potentially Inappropriate Medication” (Slide 9)
Explore some of the symptoms and other signs of a potentially inappropriate medication use
Identify steps we can take to minimize medication harm by addressing PIM risk factors
Describe the importance of a comprehensive medication review and the role of patients in medication safety

4. Outline Overview of ISMP Canada
Overview of MIPS and the College of Pharmacists of Manitoba
Changes to an aging body
Potentially Inappropriate Medications
Risks of Potentially Inappropriate Medications
Allergies/intolerance
Medical Conditions
Drug Interactions
Conclusions
This presentation was created by the Institute for Safe Medication Practice Canada, or ISMP Canada. We will learn about this organization on the next slide. We will also learn about two local organizations that have mandates for patient safety. They are the Manitoba Institute for Patient Safety and the College of Pharmacists of Manitoba.
After that we will talk about some things that make us vulnerable to medication harm as we age. This will include a discussion on potentially inappropriate medication use.

5. About the Institute for Safe Medication Practices Canada (ISMP Canada)
ISMP Canada is an independent not-for-profit organization dedicated to reducing preventable harm from medications
ISMP Canada aims to heighten awareness of system vulnerabilities and facilitate system improvements
The Institute for Safe Medication Practices Canada (or ISMP Canada) is an independent, national not-for-profit organization committed to the advancement of medication safety in all healthcare settings and is dedicated to reducing preventable harm from medications. Its aim is to heighten awareness of system vulnerabilities and facilitate system improvements. For more information, please visit ISMP Canada website at

6. About the Manitoba Institute for Patient Safety (MIPS)
Supports healthcare organizations and healthcare providers to learn about leading practices to improve patient safety
Empowers patients and families to engage with their healthcare team, to ask questions, to be informed and to take part in decision-making
The Manitoba Institute for Patient Safety, or MIPS, is a Manitoba-based not-for profit organization that helps healthcare organizations and patients to address and fix patient safety problems.
MIPS provided funding for the creation of this presentation through the Dr. John Wade Patient Safety Grant. You can find our more about MIPS and Dr. John Wade at their website (

7. About the College of Pharmacists of Manitoba (CPhM)
Regulates pharmacy practice in Manitoba by licensing pharmacists, setting standards for pharmacy practice, and ensuring continued education of pharmacists
Has a mandate to protect patient and the public in a context of pharmacy practice
The College of Pharmacists of Manitoba exists to protect the public by licensing pharmacists, setting standards for pharmacy practice, and ensuring the continued education of pharmacists in the province. The College also oversees the complaint process when something goes wrong in a pharmacy.

8. Now, lets begin brief introduction to the topic.
*In Canada, the older adults represent one of the fastest growing segments of the nation’s population.
*While some of us continue to be fit and active as we age, many of us will develop chronic conditions, often resulting in more medications being prescribed to us.
*In 2012, 66% of adults aged over 65 were using five or more drug classes – also known as polypharmacy. Although the use of multiple medications may be appropriate, half of the older adults taking five or more medications experienced a side effect requiring medical attention.
*We also develop age-related physiologic changes which can change the metabolism and response to medications in our bodies. For example, a patient with reduced kidney function will prevent certain drugs from being eliminated from the body, which can lead to toxicities, or other adverse side effects. As we age, our body changes in the way medications are metabolized or broken down and therefore we may need a lower dose of some medications.

9. Potentially Inappropriate Medication
As we age, our bodies go through many changes. Because of this, some medications become more likely to cause side effects that may:
decrease quality of life;
introduce new symptoms; or
lead to death
A medication that fits the above criteria is a Potentially Inappropriate Medication (PIM)
As we age, our bodies change. Because of some of the changes we go through in the aging process, medication can become more likely to cause side effects that can decrease quality of life, cause new symptoms, or even lead to death.
A medication where side effects are more likely when taken by an older person is called a Potentially Inappropriate medication or PIM.
PIM definition: Holt, Stefanie, Sven Schmiedl, and Petra A. Thürmann. "Potentially inappropriate medications in the elderly: the PRISCUS list." Deutsches Ärzteblatt International  (2010): 543. (

10. Examples of PIMs Disease/Condition PIM that may be used
Side Effects of Concern
Urinary Incontinence
Oxybutynin
Fesoterodine
Solifenacin
Blurry vision, drowsiness, constipation
Depression
Amitriptyline
Clomipramine
Antipsychotics
Drowsiness, risk of falls, orthostatic hypotension
Risk of stroke
Pain
Ibuprofen
Naproxen
Meloxicam
Increased cardiovascular risk, stomach bleed
Sleep
Lorazepam
Alprazolam
Zolpidem
Risk of falls, delirium, fractures
Here are some examples of potentially inappropriate medication. The disease or condition these medications are used to treat is also listed along with some of the possible dangers associated with these medications. This is not a complete list, so there are other potentially inappropriate medications not listed here. If you have questions about PIM, ask your pharmacist. (To Presenter: Have the Beers Criteria handy in case of questions, but no need to provide this to the audience.)
Urinary incontinence, for example, may be treated with oxybutynin, fesoterodine, solifenacin but these drugs may cause blurry vision, drowsiness, constipation.
Depression may be treated with amitriptyline or clomipramine. These two medications may cause drowsiness, a risk of falls, and orthostatic hypotension (low blood pressure when standing up can make you dizzy and cause you to fall)
Some antipsychotics may increase your risk for stroke.
When treating pain, for example in osteoarthritis or other generalized pain, use of medications such as ibuprofen, naproxen, or meloxicam may increase your risk for a cardiovascular event or stomach bleed.
Finally, treatment for sleeping disorders with benzodiazepines, such as lorazepam and alprazolam, have been linked to increased risk of falls and delirium. This also applies to zolpidem.
These medications are generally avoided where possible as we age.
Reference:
Beer’s criteria: Fick, Donna M., et al. "Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts." Archives of internal medicine  (2003):

11. Potentially Inappropriate Medication Risk-Factors
Patient Specific Risk-Factors:
Intolerance or Allergies
Medical Conditions
Drug Interaction Risk-Factors:
Antibiotic Medications Combined with Long-term Medications
Interactions between Multiple Long-term medications
Medication Duplications
As we learned earlier, part of ISMP Canada’s job is to heighten awareness about medication safety. Part of the way they do this is by analyzing the reports they receive from healthcare organizations about medication errors. Through this process, ISMP Canada found that there are two main categories that show the risk-factors of potentially inappropriate medications:
Patient-Specific Risk-Factors and Drug Interaction Risk-Factors. (Pause for a few minutes to allow the audience to read the slide).
Let’s go into a bit more detail on these.
*NB inappropriate dosing was omitted from this presentation due to it’s non-relevance to audience, but would fit under patient specific factors

12. Patient Specific Risk-Factors
Medication harm can happen when a drug is not suitable for a patient based on their medical history or current health. Risk-factors include:
Intolerance or allergies; and/or
Medical conditions
Patients are at risk for medication harm when a drug is not suited for the patient based on their specific health needs or history. In some situations a patient’s intolerance or allergies and/or their current medical condition can put them at risk for a potentially inappropriate medication harm.
Let’s look at a couple of examples.

13. Patient Specific Risk Factors Intolerance or Allergies
Sample Allergy Case: A patient was switched from one high blood pressure medication to another. The new drug contained a sulfa drug but the patient had a documented sulfa allergy. At pick-up, the patient said she knew all about the medication and the pharmacist was not called over to discuss the new drug. The patient later experienced an allergic reaction to the medication.
This sample case is taken from real medication error report made to ISMP Canada. It highlights how allergies may contribute to use of a potentially inappropriate medication that results in harm. *read sample case aloud
NB. Original version of this case:
““The patient had previously been taking AccuprilTM 20mg, and was getting a new prescription for AccureticTM 20mg/12.5mg. When entering the prescription into the computer, the pharmacy assistant just copied the AccuprilTM over to AccureticTM instead of inactivating it and creating a whole new prescription from scratch. The patient had a documented sulfa allergy. When picking the prescription up it was noted that it was now a combo drug, but he said "oh yeah, I know all about it" so the pharmacist was not called over to speak to him about the addition, along with his allergy. He ended up having a slight adverse reaction, and slight lip swelling. We sent him to the doctor, and will now discontinue taking the AccureticTM”

14. Patient Specific Risk-Factors Intolerance or Allergies
Lessons Learned:
Make sure you understand the changes to your medications
Always speak to your pharmacist at pick-up to discuss changes
Report any new allergies (food or drug) to your pharmacist
The previous example highlights the importance of understanding the changes to your medications, double-checking with the pharmacist to discuss changes and report all allergies, including food and drug, to all your pharmacies.
Now let’s look at Medical Condition Risk-Factors.

15. Patient Specific Risk-Factors Medical Conditions
Sample Case (Kidney Condition): A pharmacist checking a [prescription] knew that the patient’s kidney function was reduced and that this medication may cause harm. Sample Case (Heart Condition): A doctor didn't realize that the patient had a heart condition and prescribed an antibiotic that can affect the heart. It is not recommended that the patient take this antibiotic, so the pharmacist sent a fax to the doctor. The doctor agreed that it should not be filled and switched the prescription to another antibiotic.
These examples highlight how an existing medical condition can lead to the use of a potentially inappropriate medication. *read the cases
(These cases have been paraphrased for simplicity)
Reduced kidney function  lead to heightened concentrations and toxicity of medication
Heart conditions  QT prolongation + atrial fibrillation = worsens the condition, can lead to cardiac death
NB. Original version:
Sample Case (Renal Failure):
“Pharmacist checking the [prescription] knew that her CrCl was very low and that this medication was contraindicated with CrCl<30ml/min”
Sample Case (Heart Conditions):
“The doctor didn't realize that the [patient has atrial fibrillation] and prescribed Avelox® 400mg. This is contraindicated so the pharmacist sent off a fax to the doctor, and the doctor agreed that it should not be filled and switched it to doxycycline instead.”

16. Patient Specific Risk-Factors: Medical Conditions
Lessons Learned:
Make sure you have an understanding of your current medical conditions
Talk to your pharmacist or family doctor
Ask your pharmacy to include such information in your profile
Report all medical conditions when you visit an unfamiliar doctor, pharmacist, or other health care practitioners
If you are an older patient:
Make sure you have an understanding of your own medical conditions by talking to your pharmacist or family doctor
Ask your pharmacy to include such information in your profile, and
When seeing a doctor or using a pharmacy you aren’t familiar with, report all medical conditions to them
Now let’s look at how drug interactions can put you at risk for potentially inappropriate medication use.

17. Drug Interaction Risk-Factors
Medication harm can happen when two drugs conflict with one another, leading to side effects or reduced benefit. These cases can include:
Antibiotic medications combined with long-term medications
Interactions between multiple long-term medications
Medication duplications
Medication harm can happen when two drugs that conflict with one another are taken by a patient. These types of drug interactions can lead to toxicities or reduced benefit.
Risk factors for drug interactions can happen when antibiotics are combined with long-term medications, when two long-term medications are combined, and when medications are duplicated.

18. Drug Interaction Risk-Factors Antibiotics + Long-Term Medications
Sample Case: A patient was prescribed an antibiotic, but he was also taking a blood-thinner called Warfarin. A significant interaction between these two medications was caught when the patient asked the pharmacist if the antibiotic would interact with his Warfarin medication.
In the example we see here, an antibiotic could interact with a long term medication to potentially cause significant harm: *read case.
Now let’s talk about interactions between long-term medications.
(FYI – This interaction may cause increased risk of bleeding)
NB, original version:
Sample Case:
“Significant interaction between [sulfamethoxazole/trimethoprim] and Warfarin was not caught until [patient] was being counseled and he asked if it interacted with his Warfarin. [Prescription] went through without flashing as a [drug interaction] and interaction note at bottom of [prescription] was not seen during checking. Important to always check interactions listed on hardcopy as they do not always flash as a [drug interaction] (not sure how threshold is determined in [the dispensing system])”

19. Drug Interaction Risk-Factors Interactions between Long-Term Medications
Sample Case: A patient in a care home is on an anti-coagulant drug called Eliquis© and ASA 81mg. A short-term course of Naproxen was prescribed. When these three medications interacted they caused an unstoppable nosebleed and the patient was admitted to hospital subsequently.
For this example, it involves an interaction between chronic medications: *read case
Now we will move to the medication duplication risk-factor for drug interactions.
(FYI:
Eliquis – anticoagulant
ASA – antiplatelet, prevent clot formation
Naproxen – NSAID (anti-inflammatory)
This case was not adapted)

20. Drug Interaction Risk-Factors Medication Duplication
Sample Case: A care home patient was on a high dose vitamin D supplement once daily in addition to a multivitamin. The home started a Vitamin D/Calcium program, so another dose of Vitamin D was added daily. This patient developed Vitamin D toxicity. A physician, a pharmacist, and the nursing staff all missed the multiple sources of vitamin D.
Drug duplication happens when a patient is prescribed the same medication, but different dosages – or when they are prescribed different brands of the same drug.
We can see from this example that patients can be given the same drug at different dosages or different brands; and this can lead to harm.

21. Drug Interaction Risk-Factors
Lessons Learned:
Report all medications you are taking to unfamiliar doctors, nurses, or pharmacists;
Carry a list of your current medications to share with your health care providers; and
Ask your pharmacist to double-check drug interactions
You are the gate-keeper of safe medication use. You should:
- Report all medications you are taking to unfamiliar doctors, nurses, or pharmacists;
- Carry a list of your current medications to share with your health care providers; and
- Ask your pharmacist to double-check drug interactions

22. Comprehensive Medication Reviews
Comprehensive medication reviews are an opportunity to discuss your medical conditions and medications with your pharmacist. A pharmacist can help you:
Prepare a complete list of your medications to carry with you at all times
Review your medications to make sure you aren’t taking Potentially Inappropriate Medications
One of the most effective ways to prevent a lot of what was mentioned is to participate in a comprehensive medication review.
It provides a focused opportunity to discuss your medical conditions and medications with your pharmacist.
You may then leave the review with a complete list of your medications to carry with you at all times, that is accurate and up-to-date.
This review can also allow the pharmacist to brief your medications to make sure you aren’t taking Potentially Inappropriate Medications and to work collaboratively with your doctor to make adjustments accordingly.

23. One Simple Solution for Medication Safety
The video we are about the watch is call One Simple Solution for Medication Safety and it was produced by Reframe Health Films Inc., in collaboration with ISMP Canada. It outlines how to create a medication list and the importance of a comprehensive medication review in advancing medication safety.
The image is hyperlinked.

24. When in doubt about your medications, ask your pharmacist
When in doubt about your medications, ask your pharmacist. It’s safe to ask – Consider these 5 questions to ask about your medications.
This image is hyperlinked to

25. Conclusion
With age, we develop more health conditions, and thus we take more medications.
Body changes associated with aging can increase the risk of medication harm.
Remember the risk factors for a Potentially Inappropriate Medication
Consider participating in a Comprehensive Medication Review and carry an up-to-date medication list with you
Don’t forget the 5 questions to ask about your medications
To summarize what we’ve learned so far:
As we age, we are more vulnerable to medication harm, because we have multiple health conditions and take multiple medications. Advancing age also changes how medications are used by the body. All of these factors can increase the risk of medication harm.
Remember the potential risk factors for potentially inappropriate medications including:
(1) Patient Specific Risk-Factors such as:
Intolerance or Allergies
Medical Conditions
(2) Drug Interaction Risk-Factors such as:
Antibiotic Medications Combined with Long-term Medications
Interactions between Multiple Long-term medications
Medication Duplications
Finally, talk to your pharmacist about doing a Comprehensive Medication Review at least annually and carry an up-to-date medication list with you. And, don’t forget the 5 questions to ask about your medications.

26. To optimize health outcomes and reduce medication harm requires two pieces of the puzzle.
On the patient’s side, we need to be involved in our health management (i.e. taking initiative to ask questions and ask for Comprehensive Medication Review appointments).
On the health system side, we must implement system-based safeguards, and embrace positive patient safety culture.
And together, we can reduce medication harm, and specifically, reduce inappropriate medication use in the aging population.
Thank you!

27. info@ismp-canada.org | www.ismp-canada.org
ISMP Canada is a key partner in the Canadian Medication Incident Reporting and Prevention System (CMIRPS)
(416) or (866)
4711 Yonge Street
Suite 501
Toronto, Ontario
Canada M2N 6K8 |

28. Questions?

29. References
Kwan D. Polypharmacy: optimizing medication use in elderly patients. CGS Journal of CME. 2014; 4(1): Available from:
Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases. JAMA. 2005;294(6): doi: /jama
Canadian Institute for Health Information. Drug use among seniors on public drug programs in Canada, 2012 [Internet]. Ottawa, ON: 2014 [cited 2015 Mar 31].71p. Available from:
Drug-related problems in the elderly [Internet]. New Jersey (USA): Merck Sharp & Dohme Corporation; 2014 [cited 2015 Mar 31]. Available from:
Campanelli CM. American geriatrics society updated beers criteria for potentially inappropriate medication use in older adults: the American geriatrics society 2012 beers criteria update expert panel. Am Geriatr Soc April; 60(4): 616–631. Available from:
Gallagher P, O’Mahoney D. STOPP (Screening tool of older persons’ potentially inappropriate prescriptions): application to acutely ill elderly patients and comparison with Beers’ criteria. Age and Ageing 2008; 37: 673–679. Available from:
Anon. ABC Anticholinergic Burden Scale. Helping physicians do no harm. Available from:
Dibbern Jr DA, Montanaro A. Allergies to sulfonamide antibiotics and sulfur-containing drugs. ANN Allergy Asthma Immunol. 2008;100:
Yoo L, Ho C. Enhancing Medscheck, improving outcomes. Pharmacy Connection. [Internet] Mar. [cited 2015 Mar 31]. Available from:
Ontario Ministry of Health and Long Term Care. The MedsCheck program guidebook [Internet]. ON: Queen’s Printer for Ontario; 2008 [updated 2011 Sept 13; cited 2015 Mar 30]. Available from:
These may be useful for further reading and directly taken from Kelly Ng’s presentation

30. References
ISMP Canada. Concerned reporting: mix-ups between bisoprolol and bisacodyl. ISMP Can Saf Bull [Internet] Aug 30 [cited 2015 Apr 3];12(9):1-6. Available at:
ISMP Canada. Medication safety self-assessment for community/ambulatory pharmacy. Canadian Edition. Toronto: ISMP Canada; 2006.
ISMP. High-alert medication modeling and error-reduction scorecards [Internet]. Horsam: ISMP; 2012 [cited 2015 Apr 23] Available from:
ISMP Canada. Lowering the risk of medication errors: Independent double checks. ISMP Can Saf Bull [Internet] Jan [cited 2015 Mar 30];5(1):1-2. Available from:
Hanna J. Real-world application of MedsCheck opportunities: the Costco pharmacists intervention trial for reduction of cardiovascular risk. CPJ/RPC [Internet] [cited 2015 Mar 30];146(6): doi: /
Dolovich L, Gagnon A, McAiney CA, Sparrow L, Burns S. Initial pharmacist experience with the Ontario-based MedsCheck program. CPJ/RPC [Internet] Nov [cited 2015 Mar 30];141(6): doi: / X
Medscope. MedsCheck management system [Internet] [cited 2015 Apr 8]. Available from:
ISMP Canada. Transdermal fentanyl: a misunderstood dosage form. ISMP Can Saf Bull [Internet] Aug 14 [cited 2015 Apr 3];6(5):1-3. Available at:
ISMP Canada. Preventable death highlights the need for improved management of known drug interactions. ISMP Can Saf Bull [Internet] May [cited 2015 Mar 31];14(5):1-7. Available from:
National Association of Pharmacy Regulatory Affairs. Pharmacy care plans [Internet]. Ottawa (ON): National Association of Pharmacy Regulatory Affairs; 2006 [cited 2015 April 3]. Available from:
These may be useful for further reading and directly taken from Kelly Ng’s presentation