1. Managing Medications in Clinically Complex Elders Michael A. Steinman, MD, Joseph T. Hanlon, PharmD, MS JAMA, Oct 13, 2010, Vol 304, No 14 Payal Patel Mercer University, Doctor of Pharmacy Candidate 2012 RTR Medical Group

2. Patient Case Mr L. is an 84 year old male with dementia who presents to the clinic with initial concerns of forgetfulness, difficulty walking, and falling PMH  atrial fibrillation, diabetes mellitus, hypertension, hyperlipidemia, CKD, gastritis, GERD Medications  Glyburide, digoxin, warfarin, etodolac, docusate sodium, multivitamin, iron, memantine, metoprolol, gabapentin, essential fatty acids, acetaminophen prn, lactulose Family Hx  Unable to obtain Social Hx  Retired writer, plays tennis, lives with his wife

3. Presentation Vitals  BP: 135/60  HR: 50s  CrCl: 42 ml/min MMSE: 13/29 A1C: 5.9%

4. Multiple Medication Use  About 20% of elderly who live in the community age 65 years and older take 10 or more medications  Greater use of inappropriate medications  Adherence problems  Increased frequency of adverse events Adverse drug events affect 5 – 35% of elderly patients living in the community per year  Adverse health outcomes  Cost burden

5. Introduction This article summarizes evidence-based literature regarding improving medication use and describes a systematic approach for how healthcare professionals can improve medication regimens for the benefit of the patients

6. Information Gathering Assessing current medication use  Communication gaps are responsible for 37% of remediable adverse drug events  Discrepancy between patients’ understanding of what they should be taking, what they are taking and what is in physicians record  Little direct evidence as to which method is best for medication review  Brown bag review can be useful Review meds, how the patient takes it, assess efficacy

7. Information Gathering Assessing adherence  Approximately one-half of older patients have adherence problems to at least 1 medication  Patients often do not admit to nonadherence  Observe medication organization, pill count and refill history  Address reasons underlying adherence ex: cost, difficulty opening bottles, etc.  Contact pharmacists regarding concerns about patient adherence

8. Information Gathering Assess patients’ goals of medication use  Medications that increase longevity vs negative effect on QOL  Assess what the patient and family want to achieve  Prioritize values

9. Structured medication management 6 studies performed to assess the efficacy of medication management Overall, these programs reduce medication burden, prevented underuse/overuse of medications In a large study, medication management reduced the rate of serious adverse drug events from 0.6 to 0.4 events/1000 person-days (p=0.02) Less evidence of its effect on clinical outcomes such as QOL, major clinical events and utilizing health services

10. Changing the medication regimen However, it is recommended to structurally manage medications  Match medications to conditions  Identify overused, underused or misused drugs  Make improvements by changing the dose, frequency or substituting another drug with a better side effect profile

11. Discontinuation of unnecessary medications Studies of community based older patients have shown that they have an average of 1 unnecessary medication on their regimen A large study found that 44% of older patients were discharged with at least 1 unnecessary medication Drugs that should be avoided in older patients are used in approximately 20 to 30% of adults age 65 years and older

12. Discontinuation of Medications Look for drugs that lack clear indications and consider discontinuing them Screen for drugs that may be harmful in the elderly Look for drugs that provide limited benefit Drugs that cause troublesome symptoms / adverse effects Decisions of stopping medications should be based on case and common sense

13. Discontinuation of Medications Limited evidence about the best way to stop medications In one of the studies, 26% drug discontinuations lead to worsening of underlying disease and 4% lead to withdrawal reactions Use a stepwise approach in discontinuing medications It is important to slowly taper the drugs Educate patients and monitor patients for adverse withdrawal events

14. Underuse of Beneficial Medications Patients are often not prescribed potentially beneficial medications Symptoms such as pain and depression should be treated Primary prevention if appropriate  Vitamin D repletion in deficient patients can prevent falls and risk of fractures

15. Improving adherence Randomized controlled trials of strategies to improve compliance have shown mixed results Most data suggests that oral counseling or written instructions are often insufficient A more useful approach is simplifying medication dosing schedules Clinicians should prescribe longer acting mediations or combination drugs when possible to decrease frequency Behavioral interventions – medication organizers, packaging, cues Lower cost generics can also help patients with financial problems

16. Monitoring and Follow-up Ongoing monitoring for drug toxicity and efficacy is important in providing patient care Approximately 1/3 rd -2/3 rd patients receiving digoxin, carbamazepine and other drugs that need monitoring are not monitored regularly Patient’s medication list should be reviewed regularly Medication review should also be done when there is sudden decline in function or onset or worsening of certain syndromes

17. Conclusion Managing medications for older patients is a complex task A careful, step-wise approach should be taken to reduce the complexity and to help the patient achieve beneficial outcomes

18. Patient Case - Assessment/Plan Patient no longer had pain from his lumbar laminectomy  Tapering off etodolac and gabapentin while watching for increased reports of pain Tapering off digoxin watching for his heart rate Hemoglobin 13 g/dL  Discontinue iron Recommend yoga and gym twice weekly Low serum 1,25-dihydroxyvitamin D level  Added Vitamin D 800 IU/day to Mr L’s regimen Dr. S asked Mrs L if memantine was helping Mr L’s memory and she wasn’t sure  Dr. S tapered off memantine and Mr. L had diffculty with nouns and names so he resumed memantine

19. Outcomes Mr. L is now socially improved and feeling better His activities of daily living have been stable