1. UMMS CRIT Module II: Drug Therapy in the Elderly Jerry H. Gurwitz, MD Chief, Division of Geriatric Medicine University of Massachusetts Medical School UMass Memorial Medical Center

2. UMMS CRIT 2010 Module II: Drug Therapy in the Elderly Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation It is much easier to write upon a disease than upon a remedy. The former is in the hands of nature and a faithful observer with an eye of tolerable judgement cannot fail to delineate a likeness. The latter will ever be subject to the whim, the inaccuracies and the blunder of mankind. William Withering (1741-1799)

3. UMMS CRIT 2010 Module II: Drug Therapy in the Elderly Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation A desire to take medicine is, perhaps, the great feature which distinguishes man from other animals. Sir William Osler, 1891

4. UMMS CRIT 2010 Module II: Drug Therapy in the Elderly Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation “I know of no way to end an office visit as satisfactorily and as efficiently as by writing a prescription. The patient knows that the visit is over and is expected to leave. He has something in his hand that he thinks will help him and obtaining it required an office visit.” Marcus Reidenberg, MD Editor Emeritus, CP&T

5. UMMS CRIT 2010 Module II: Drug Therapy in the Elderly Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Drug Use in the Elderly 57% of all elderly use > 5 drugs per week 19% of elderly use > 10 drugs per week Slone Survey, 2006

6. UMMS CRIT 2010 Module II: Drug Therapy in the Elderly Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Overuse Inappropriate prescribing Underuse Suboptimal Medication Use Hanlon JT et al. JAGS. 2001;49: 200-9. Fisk D et al. Arch Intern Med. 2003;163: 2716-2724.

7. UMMS CRIT 2010 Module II: Drug Therapy in the Elderly Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Polypharmacy is not necessarily bad! Polypharmacy

8. UMMS CRIT 2010 Module II: Drug Therapy in the Elderly Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Any transition - hospitalizations, discharges, ER visits, subacute care stays New meds, different doses… Changes from generic to brand- nomenclature, color and/or shape Drug Regimen Changes ~They are very common!

9. UMMS CRIT 2010 Module II: Drug Therapy in the Elderly Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation The more providers and visits, the more medications are prescribed 2/3 of all physician visits end with a prescription Expectations of the patient to receive a prescription Lack of communication between prescribers Self-treatment: unbeknownst to the physician Why so many changes?

10. UMMS CRIT 2010 Module II: Drug Therapy in the Elderly Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Increased risk of adverse drug events and near-misses Noncompliance or nonadherence leading to poor outcomes Increased costs Impact on the Patient

11. UMMS CRIT 2010 Module II: Drug Therapy in the Elderly Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Multiple co-existing illnesses Polypharmacy: redundant effects and drug-drug interactions Adverse drug effects nonspecific Pharmacologic changes with aging Medical error Factors Influencing Drug Effects and Risk of Adverse Effects in the Elderly

12. UMMS CRIT 2010 Module II: Drug Therapy in the Elderly Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Absorption Distribution Metabolism Excretion Pharmacokinetics: Changes with Aging

13. UMMS CRIT 2010 Module II: Drug Therapy in the Elderly Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Body Composition Changes in Adult Men with Aging Age Group Body Weight (kg) Body Fat (kg) Muscle Mass (kg) 20-29801524 30-49811920 60-69792317 70-79802513 Data adapted from Cohn et al, 1980

14. UMMS CRIT 2010 Module II: Drug Therapy in the Elderly Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation

15. UMMS CRIT 2010 Module II: Drug Therapy in the Elderly Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Phase I reactions- primarily oxidative reactions –Decline in efficiency with aging Phase II reactions- conjugation reactions –No decline in efficiency with aging Hepatic Metabolism of Drugs Changes with Aging

16. UMMS CRIT 2010 Module II: Drug Therapy in the Elderly Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Renal Function: Changes with Aging Age C REATININE C LEARANCE

17. UMMS CRIT 2010 Module II: Drug Therapy in the Elderly Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation t 1/2 ~ Vd/Clearance

18. UMMS CRIT 2010 Module II: Drug Therapy in the Elderly Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Pharmacodynamics: Changes with Aging

19. UMMS CRIT 2010 Module II: Drug Therapy in the Elderly Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Clinical Pearl Any new symptom in an elderly patient should be considered a drug side effect until proven otherwise. Jerry Avorn, MD

20. UMMS CRIT 2010 Module II: Drug Therapy in the Elderly Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation The Prescribing Cascade Drug 1 ADE Drug 2

21. UMMS CRIT 2010 Module II: Drug Therapy in the Elderly Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation The Prescribing Cascade Metoclopramide Extrapyramidal Effects Levodopa Rx

22. UMMS CRIT 2010 Module II: Drug Therapy in the Elderly Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Case-Control Study Design Metoclopramide: Yes or No? Metoclopramide: Yes or No? BEGIN L-dopa Rx Controls CLASSIFY/COMPARE

23. UMMS CRIT 2010 Module II: Drug Therapy in the Elderly Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Results Metoclopramide users were over three times more likely to begin use of L-dopa therapy compared with non-users (OR=3.09; 95% CI 2.25 to 4.26).

24. UMMS CRIT 2010 Module II: Drug Therapy in the Elderly Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Likelihood of L-dopa Treatment by Metoclopramide Dose

25. UMMS CRIT 2010 Module II: Drug Therapy in the Elderly Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Conclusion Metoclopramide confers an increased risk for the initiation of treatment generally reserved for the managment of idiopathic Parkinson’s disease. Avorn et al, JAMA, 1995

26. UMMS CRIT 2010 Module II: Drug Therapy in the Elderly Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Medication reconciliation – at time of transitions Anticipate errors – prescribing & monitoring Watch out for prescribing cascades Simplify the medication regimen Identify obstacles (costs, cognitive impairment) Enlist family/nursing/PCP support & involvement Make sure there is good follow-up Improving the Quality of Prescribing to Older Adults

27. UMMS CRIT 2010 Module II: Drug Therapy in the Elderly Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Lessons from the Case