1. Polypharmacy in the Elderly
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
Not enough attention paid to pharmacodynamic principles
Regardless of semantics, polypharmacy is widely practiced,
often unnecessary and
yet sometimes required with the usual multiple medical conditions in the elderly!

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)
Drugs that interfere with warfarin and cause increases in INR and bleeding risk!
Not appropriately adjusting dosing for renal dysfunction
Diet interfering with warfarin levels
Drug toxicity especially in drugs with low therapeutic index
These are the basic mechanisms by which ADRs occur but the truth is that they
Have serious consequences to the elders’ quality of life and society’s pocketbook!

6. Up to 30% of elderly hospital admissions involve ADRs
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
This is most common form of iatrogenic illness!
Of course ADRs are linked to depression, constipation, falls, morbility, confusion, hip fractures
And therefore significantly impaired quality of life!
Fick Arch Int Med.

7. Annual cost of $85 billion $76.6 billion in ambulatory care
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
Absorption:
Decreased gastric acid alters absorption of some medications
Decreased gastric mobility can increase absorption
Distribution:
10-15% decrease in Total Body Water and lean body mass: water soluble drugs have poor distribution in adipose cause increasing serum concentrations
Increased body fat: lipid soluble drugs accumulate and prolong duration of action
Decreased serum albumin: increases free serum concentrations which makes lab levels more challenging to interrupt
Metabolism:
Reduced metabolism within the liver and diminished enzyme activity increases serum drug effects
Excretion:
Diminished kidney function (GFR): calculate creatinine clearance
(((140-age) x weight in kg)/72 x serum creatinine) x 0.85
(for women)

9. Absorption
Age-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. Concurrent drug use may affect metabolism in both directions
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. Age-related decrease in renal blood flow
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
Organized 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!

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
Use these principles to initiate and re-evaluate medications
Inherent 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 but
If 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 patients
Then you will improving your pts quality of life!
To start doing this, you should be aware of certain high risk medications!

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
This is a simple and obvious idea which is not currently being utilized!

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
Now- lets review some key points …

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