1. Best Practices for Safe Prescribing in Older ED Patients S. Nicole Hastings, M.D., M.H.S. 1

2. Safe Prescribing in Older ED Patients Review Beers’ Criteria, tool for identifying Potentially Inappropriate Medications Discuss most frequent medication problems in ED discharge medications Review strategies for reducing use of high risk medications in the ED 2

3. ED Discharge Medications In VAMC EDs, 45-65% of older adults are prescribed at least one new medication at the time of ED discharge 59% - 1 new medication 27% - 2 new medications 14% - 3 or more Most common drug classes Anti-infectives Cardiovascular Central nervous system 3

4. The Medication Maze New medications and dosage changes Common ED discharge drugs (e.g. NSAIDs, opioid analgesics, antibiotics) are often risky for older patients Medication Reconciliation Across Transitions Different prescribers Multiple medications and chronic conditions Over the counter drugs 4

5. Potentially Inappropriate Medications Risk of adverse event outweighs clinical benefit Identifying PIMs in older adults –Beers’ Criteria –STOPP/START Criteria –HEDIS –Medication Appropriateness Index 5

6. Beers’ Criteria 2012 Update with AGS Target audience – practicing clinician Goal - Improve care by ↓ exposure to PIMS –Educational tool –Quality measure –Research tool 6

7. Beers’ Criteria Intended clinical use –Improve care of older adults by reducing exposure to PIMs –Guideline to identify medications for which risk > benefit –Not meant to supersede clinical judgment or individual patient’s values and needs –Serve as a reminder for closer monitoring American Geriatrics Society

8. Beers’ Criteria Table 2 – Avoid 8 Drug or Class RationaleRecomm endation Quality of Evidence Strength of Recommendati on First generation antihistamines Examples: -Diphenhydramine -Hydroxyzine -Promethazine Highly anticholinergic; clearance reduced with advanced age..greater risk of confusion, dry mouth, constipation, etc (urinary retention) AvoidHydroxyzine and promethazine: high; all others, moderate Strong

9. Anticholinergics Diphenhydramine Hydroxyzine Meclizine Promethazine Prochlorperazine (Compazine) Oxybutynin Scopolamine Cyclobenzaprine J Am Geriatr Soc 2012

10. Prescriber Beware….. Drug-Drug Interactions –Warfarin, digoxin –QTc prolongation Drug-Disease Interactions –NSAIDS-PUD –Anticholinergics/antihistamines and bladder outlet obstruction –Anticholinergics/antihistamines and cognitive impairment Dose adjust for renal insufficiency –Cr overestimates GFR in older adults

11. ED Discharge Medication Problems 11

12. ED Discharge Medication Problems Beers’ drug – 11.6% Drug-drug interactions – 12.6% Drug-disease interactions – 5.7% Problem with monitoring - 17.6% One or more – 31.8% 12

13. ED Discharge Medication Problems Quality ProblemExamples Drug to avoidcyclobenzaprine, diphenhydramine, indomethacin Drug-drug interactionlisinopril - naproxen Drug-disease interactionamitryptyline – benign prostatic hyperplasia Therapeutic duplicationibuprofen - naproxen Inadequate monitoringno potassium, creatinine check after new prescription for diuretic

14. Suboptimal Pharmacotherapy Time until first adverse event (repeat ED visit, hospital admission or death) among patients with: (1) no new discharge drug, (2) new discharge drug but no suboptimal pharmacotherapy and (3) new discharge drug with suboptimal pharmacotherapy.

15. Before Prescribing, Consider… Is a medication necessary? –Think drugs with any new geriatric syndrome Do the benefits outweigh the risks? Is it used to treat effects of another drug? Could it interact with a disease, other drugs? Does the patient know what it’s for, how to take it, and what ADEs to look for?

16. Free AGS Beers App

17. EQUiPPED Enhancing Quality of Prescribing in the Emergency Department 5 site QI program funded of Office of Geriatrics and Extended Care 17

18. Beers’ Meds Common in ED Pain Meds –Non-COX selective NSAIDS –Indomethacin –Ketorolac (Toradol) –Skeletal Muscle relaxants –Amitriptyline/TCAs Benzodiazepines Anticholinergics/Antihistamines www.fanpop.com Courtesy: Loren Wilkerson, M.D.

23. Safe Prescribing in Older ED Patients Is a medication necessary? Is there a safer alternative? Does the risk outweigh the benefit? AGS Beers Criteria as a guideline Reduce PIM use in your ED through education, provider feedback, CPRS tools 23

24. Thanks for your Attention! 24

25. Bibliography “Review: Emergency Department Use by Older Adults: A Literature Review on Trends, Appropriatness, and Consequences of Unmet Health Care Needs,” Anrea Gruneir, Mara J. Silver and Paula A. Rochon, Med Care Res Rev 2011 68:131 http://mcr.sagepub.com/content/682/131http://mcr.sagepub.com/content/682/131 “Older Adults in the Emergency Department: A Systematic Review of Patterns of Use, Adverse Outcomes, and Effectiveness of Interventions,” Faranak Aminzadeh, William Dalziel, Annals of Emergency Medicine, March 2002;39:3,238-247. “How Frequent Emergency Department Use by US Veterans Can Inform Good Public Policy,” Jesse Pines, Annals of Emergency Medicine, 2013, pending publication. 25

26. Bibliography Survey: Many Elderly Are in the Dark at ED Discharge, http://www.acep.org/content.aspx?id=46032 http://www.acep.org/content.aspx?id=46032 “Health Services Use of Older Veterans Treated and Released from Veterans Affairs Medical Center Emergency Departments.” Hastings SN et al. J Am Geriatr Soc 2013; 61:1515-1521. “Quality of Pharmacotherapy and Outcomes for Among Older Veterans Discharged from the Emergency Department.” Hastings et al. J Am Geriatr Soc 2008; 56 (5):875-880. “Older Veterans and Emergency Department Discharge Information.” Hastings SN et al. BMJ Qual Saf 2012 Oct;21:835-842. 26

27. Questions/Comments 27