1. Curriculum for the Hospitalized Aging Medical Patient CHAMP Drugs and Aging Paula M. Podrazik, MD Paula M. Podrazik, MD University of Chicago University of Chicago

2. Case of Mrs. T….. 85 y/o with h/o DM, CHF, lumbar spinal stenosis admitted with increasing confusion and falls. Lives alone, daughter involved. Daughter notes patient h/o anxiety but c/o insomnia and phoning her continuously throughout the night for the past 3 nights. 85 y/o with h/o DM, CHF, lumbar spinal stenosis admitted with increasing confusion and falls. Lives alone, daughter involved. Daughter notes patient h/o anxiety but c/o insomnia and phoning her continuously throughout the night for the past 3 nights. Brought to U of C ER by daughter after a witnessed fall. New patient to the U of C system. Admitted at 3AM to telemetry. Brought to U of C ER by daughter after a witnessed fall. New patient to the U of C system. Admitted at 3AM to telemetry. On exam, alternately agitated and somnolent, oriented to person only. On exam, alternately agitated and somnolent, oriented to person only. VS: T99, P54, RR20, BP110/50 lying supine wt. 100lbs. 5’1” VS: T99, P54, RR20, BP110/50 lying supine wt. 100lbs. 5’1” Cor: RRR, +S 3 Cor: RRR, +S 3 Lungs: dry crackles in bases Lungs: dry crackles in bases Abd: soft, nontender, nondistended, firm stool felt throughout colon Abd: soft, nontender, nondistended, firm stool felt throughout colon ER data:CT head neg., dirty urine, CXR with  cor, KUB FOS, BUN 48/CR 2.7, glc= 74, K + hemolyzed at 6.3 F/U pending,INR=3.0, EKG SB-rate 58, no peaked t waves. Given dose IV antibiotics in ER. ER data:CT head neg., dirty urine, CXR with  cor, KUB FOS, BUN 48/CR 2.7, glc= 74, K + hemolyzed at 6.3 F/U pending,INR=3.0, EKG SB-rate 58, no peaked t waves. Given dose IV antibiotics in ER.

3. Case of Mrs. T….. Meds: Lisinopril 40mg q daily Glipizide ER 20mg BID Lasix 40 mg q daily KCL 20 meq q daily Paxil 20 mg q daily Amiodarone 200mg q daily Digoxin 0.25 mg q daily Coumadin 5mg q daily T#3 prn Ativan 1mg prn Unsom (OTC) prn sleep Lomotil (OTC) prn Senna and colace prn

4. Questions Raised…. Why is this patient on so many meds?Why is this patient on so many meds? Could some of these meds be causing her decline?Could some of these meds be causing her decline? What is involved in medication management in the aging population?What is involved in medication management in the aging population? Why is medication management so difficult in this population?Why is medication management so difficult in this population? Are there principles help guide medication management?Are there principles help guide medication management?

5. Drugs and Aging: Topics for Review Information GapInformation Gap Aging PharmacologyAging Pharmacology PolypharmacyPolypharmacy Drugs to AvoidDrugs to Avoid Adverse Drug ReactionsAdverse Drug Reactions CostCost ComplianceCompliance Medication ReviewMedication Review

6. Drugs and Aging Information GapInformation Gap Aging PharmacologyAging Pharmacology PolypharmacyPolypharmacy Drugs to AvoidDrugs to Avoid Adverse Drug ReactionsAdverse Drug Reactions CostCost ComplianceCompliance Medication ReviewMedication Review

7. Older patients under-represented in drug trials Statins: 47 RCTsStatins: 47 RCTs –Only 1/3 reported proportion of patients >65 years –Median % of patients >65 in US trials was 21.1% Acute Coronary SyndromesAcute Coronary Syndromes –Of patients hospitalized for ACS in 1995, 37% were >75 years –Only 9% of patients in ACS trials 1991 to 2000 were >75 years Bartlett, et al. Heart 2003; 89: 327-328.

8. Adverse Drug Events, Research and Aging Elderly excluded from investigational trials small sample sizes Phase III trials exclusion criteria=vulnerable elder “in vivo” no look at drugs in combo Under-reporting of drug safety problems Schmucker DL, et al:J Clin Pharmacol 1999;39:1103-8 Avorn J: Br Med J 1997;315:1033-1034

9. Drugs and Aging Information GapInformation Gap Aging PharmacologyAging Pharmacology Adverse Drug ReactionsAdverse Drug Reactions Drugs to AvoidDrugs to Avoid PolypharmacyPolypharmacy CostCost ComplianceCompliance Medication ReviewMedication Review

10. Aging Pharmacology: Objectives DefinitionsDefinitions PharmacokineticsPharmacokinetics –Aging & drug absorption –Aging drug distribution –Aging & Drug Clearance Renal MetabolismRenal Metabolism Hepatic BiotransformationHepatic Biotransformation PharmacodynamicsPharmacodynamics

11. Drug Absorption with Normal Aging  in gastric pH, motility, absorptive surface  in gastric pH, motility, absorptive surface  gastric emptying time  gastric emptying time May see slower absorption,  time to effectMay see slower absorption,  time to effect Bottom line: No clinically sign. age-related change in drug absorption with normal aging. Bottom line: No clinically sign. age-related change in drug absorption with normal aging.

12. Drug Distribution with Aging  body fat to age 60-70   antipsychotics, TCAs  body fat to age 60-70   antipsychotics, TCAs  in lean body mass and fat after 70   digoxin conc.  in lean body mass and fat after 70   digoxin conc.  protein-binding can effect Vd  warfain + amiodarone, phenytoin, ketaconazole  protein-binding can effect Vd  warfain + amiodarone, phenytoin, ketaconazole Bottom Line: Drug dosing is a dynamic process with aging. Bottom Line: Drug dosing is a dynamic process with aging.

13. Hepatic Biotransformation and Aging Age- related declineAge- related decline –Reduction in liver blood flow High-clearance drugs affected: propanolol, labetolol, esmolol, lidocaineHigh-clearance drugs affected: propanolol, labetolol, esmolol, lidocaine –Reduction in hepatic oxidation: CYP450 No age-related changesNo age-related changes –Hepatic acetylation –Hepatic conjugation

14. Cytochrome P450 Systems CYP3ACYP3A –Metabolizes >60% of prescribed drugs including: Calcium channel blockers, certain beta-blockers, most “statins”, warfarin, amiodarone CYP2D6CYP2D6 –Metabolizes: metoprolol, propranolol, tramadol, codeine,oxycodone,TCAs, SSRIs

15. Cytochrome P450 Inhibitors CYP3A InhibitorsCYP3A Inhibitors –Amiodarone, cimetadine, cyclosporin, erythromycin, itra-/ketoconazole,grapefruit juice CYP2D6 InhibitorsCYP2D6 Inhibitors –Cimetidine, SSRIs, quinidine

16. Renal Clearance and Aging ~ age 40, renal func. declines 1% per year~ age 40, renal func. declines 1% per year Normal serum Cr  normal GFRNormal serum Cr  normal GFR Estimate using Cockcroft-Gault equationEstimate using Cockcroft-Gault equation Creatinine clearance = ( 140-age) * Wt (kg) (  0.85 in women) ( 140-age) * Wt (kg) (  0.85 in women) 72 * serum Cr Modified MDRDModified MDRD GFR estimate=  186x(Cr) -1.154 x (Age) -0.203 x (0.742, if female) x (1.21, if African American)

17. Aging Pharmacodynamics With aging: Beta-adrenergic responsiveness Beta-adrenergic responsiveness  Anticholinergic drugs   CNS effectsAnticholinergic drugs   CNS effects Baroreceptor reflex bluntedBaroreceptor reflex blunted

18. Medication use based on aging pharmacology principles Start low, go slow, dose to effectStart low, go slow, dose to effect Adjust for decrease in renal clearanceAdjust for decrease in renal clearance ID drugs w/narrow toxic/therapeutic indexID drugs w/narrow toxic/therapeutic index ID drugs that effect CPY450 system e.g., inhibitors/inducersID drugs that effect CPY450 system e.g., inhibitors/inducers Adjust for anticholinergic properties of drugsAdjust for anticholinergic properties of drugs Remember the blunted barorecepter reflexRemember the blunted barorecepter reflex

19. Drugs and Aging Information GapInformation Gap Aging PharmacologyAging Pharmacology PolypharmacyPolypharmacy Adverse Drug ReactionsAdverse Drug Reactions Drugs to AvoidDrugs to Avoid CostCost ComplianceCompliance Medication ReviewMedication Review

20. Case of Mrs. K….. 75 y o F with CAD, HTN, OP, LBP Walks 1 mile 3x per week & Tai Chi 2x per week & water aerobics class 1x per week Med list: asa 81 q day asa 81 q day lisinopril 20 q day lisinopril 20 q day atenolol 25 q day atenolol 25 q day hctz 25 q day hctz 25 q day lipitor (atorvastatin) 10 q day lipitor (atorvastatin) 10 q day fosamax (alendronate) 70 mg q week fosamax (alendronate) 70 mg q week MVI q day MVI q day tums 3 q day tums 3 q day vicodin (hydrocodone/acetaminophen) prn vicodin (hydrocodone/acetaminophen) prn

21. What is the prevalence of drug use in the elderly? Ambulatory adults > 65 surveyedAmbulatory adults > 65 surveyed –12% take > 10 meds –50% take 5 or > meds Kaufman DW, et al The Slone survey. JAMA 2002;287:337..

22. 2040 projections  > 65 =20% of population & consume 50% prescribed meds 2040 projections  > 65 = 20% of population & consume 50% prescribed meds

23. Will polypharmacy continue to escalate?

24. Factors that influence prescribing in the elderly –More chronic conditions w/advancing age –Newer Rx for diseases (e.g., Alzheimer’s) –Wider indications for CV drugs –Lower thresholds @ which diseases Rx’d (e.g., hypercholesterolemia) –Increased use of primary/secondary prevention Kaufman DW, et al. JAMA. 2002;287:337.

25. Drug Interactions  with 5 or > drugs Hazzard, Principles of Geriatric Medicine and Gerontology

26. Polypharmacy definitions? > 5 medications used> 5 medications used Concurrent use of multiple prescriptions & over-the-counter medsConcurrent use of multiple prescriptions & over-the-counter meds Definitions w/measure of "appropriateness"Definitions w/measure of "appropriateness" –Use of one med to treat adverse effects of another –Medical regimen includes > one unnecessary med –Use of more meds than clinically indicated

27. Polypharmacy & Adverse Drug Reactions Rochon PA, Gurwitz JH BMJ 1997; 315:1097

28. What is the risk of polypharmacy? Risk of drug-drug interactions increases with increasing # of medsRisk of drug-drug interactions increases with increasing # of meds Up to 73% of ADRs involved unnecessary medsUp to 73% of ADRs involved unnecessary meds 10-17% of hospital admissions due to ADEs10-17% of hospital admissions due to ADEs Bergendal L, et al. Pharm World Sci. 1995;17:152. Lindley CM. et al. Age Ageing. 1992;21:294. Beard K. Drugs Ageing. 1992;2:356.

29. Drugs and Aging Information GapInformation Gap Aging PharmacologyAging Pharmacology PolypharmacyPolypharmacy Drugs to AvoidDrugs to Avoid Adverse Drug ReactionsAdverse Drug Reactions CostCost ComplianceCompliance Medication ReviewMedication Review

30. Explicit Criteria --Beers List of medications to avoid in elderly nursing home patientsList of medications to avoid in elderly nursing home patients Developed by consensus panel in 1991Developed by consensus panel in 1991 Updated in 1997 and 2002Updated in 1997 and 2002 Beers, et al. Arch Intern Med 1991; 151: 1825-1832. Beers MH. Arch Intern Med 1997; 157(14): 1531-1536. Fick DM, et al. Arch Int Med 2003; 163: 2716-24.

31. Drugs to Avoid in the Elderly Drug Classes/Drugs Drug Classes/Drugs antihistamines antihistamines antispasmodics antispasmodics certain CV meds certain CV meds – methyldopa, (Aldomet TM ), reserpine – disopyramide (Norpace TM ) – dipyridamole (Persantine TM ) certain psychotropics certain psychotropics – amitriptyline( Elavil TM ), doxepin (Sinequan TM ) – meprobamate(Miltown TM ), diazepam, flurazepam (Dalmane TM ), barbs flurazepam (Dalmane TM ), barbs Beers MH Arch Intern Med 1997;157:1531-1536 Beers MH Arch Intern Med 1997;157:1531-1536

32. Drugs to Avoid in the Elderly Drug Classes/Drugs Drug Classes/Drugs certain analgesics certain analgesics – propoxyphene (Darvon TM ) – merperidine (Demerol TM ) – pentazocine (Talwin TM ) chlorpropamide (Diabenase TM ) chlorpropamide (Diabenase TM ) trimethobenzamide (Tigan TM ) trimethobenzamide (Tigan TM ) certain anti-inflammatory agents certain anti-inflammatory agents – indomethacin (Indocin TM ),ketorolac (Toradol TM ), piroxicam(Feldene TM ) Beers MH Arch Intern Med 1997;157:1531-1536 Beers MH Arch Intern Med 1997;157:1531-1536

33. Interactions to Beware Drug-Disease Interactions to Avoid Drug-Disease Interactions to Avoid  dementia, falls + benzodiazepines  dementia, falls + benzodiazepines  BPH, constipation + antihistamines,  BPH, constipation + antihistamines, antispasmodics, TCAs antispasmodics, TCAs  CRF, CHF, PUD + NSAIDS  CRF, CHF, PUD + NSAIDS  DM + steroids  DM + steroids  asthma, COPD, PVD, HB + beta blockers  asthma, COPD, PVD, HB + beta blockers Beers MH Arch Intern Med 1997;157:1531-1536 Beers MH Arch Intern Med 1997;157:1531-1536

34. Limitations of Explicit Criteria Clinical relevanceClinical relevance –Many medications outdated or not used –Requires update by consensus panel Validity of dataValidity of data –Criteria developed from nursing home data –Applied in many unvalidated settings Room for clinical judgement?Room for clinical judgement? Buetow SA, et al. Soc Sci Med 1997; 45(2): 261-271.

35. Drugs and Aging Information GapInformation Gap Aging PharmacologyAging Pharmacology PolypharmacyPolypharmacy Drugs to AvoidDrugs to Avoid Adverse Drug ReactionsAdverse Drug Reactions CostCost ComplianceCompliance Medication ReviewMedication Review

36. ADR/ADE--defined Adverse Drug Reaction (ADR)Adverse Drug Reaction (ADR) any undesirable or noxious drug effect at standard drug treatment doses WHO;1996 Technical Report Series No. 425 WHO;1996 Technical Report Series No. 425 Adverse Drug Event (ADE)Adverse Drug Event (ADE) ADRs + errors in drug administration

37. ADRs ADRs Amplified drug effects Drug-nutrient interaction Drug-drug interaction Drug-disease interaction Side-effects *not therapeutic failures *not ADWEs

38. ADR Risk Factors Carbonin P, et al JAGS 1991;39:1093-1099

39. ADR Risk Factors ? prior ADRs high risk drugs # of drugs # medical problems ? aging pharm ? fragmented care Adverse Drug Reaction

40. ADEs and Hospitalization Recent inhospital studies look at ADEs Recent inhospital studies look at ADEs How big a problem? How big a problem? 4th-6th leading cause of hospital death (serious ADRs 6.2%, fatal ADRs 0.32%)4th-6th leading cause of hospital death (serious ADRs 6.2%, fatal ADRs 0.32%) Increased length of stayIncreased length of stay Increased costIncreased cost Lazarou J, et al JAMA 1998; 280(20):1741-44 Lazarou J, et al JAMA 1998; 280(20):1741-44 Classen D, et al JAMA 1997; 277(4): 301-6 Classen D, et al JAMA 1997; 277(4): 301-6

41. Drugs and Aging Information GapInformation Gap Aging PharmacologyAging Pharmacology Adverse Drug ReactionsAdverse Drug Reactions Drugs to AvoidDrugs to Avoid PolypharmacyPolypharmacy CostCost ComplianceCompliance Medication ReviewMedication Review

42. Drugs and Aging: Cost Important to ask: “How do you pay for your medications?”Important to ask: “How do you pay for your medications?” Federal poverty level: $10,400 for individual, $14,000 for coupleFederal poverty level: $10,400 for individual, $14,000 for couple Potential sources of aid: Medicare Part D, Medicaid, Circuit Breaker, Illinois Care Rx, Rx buying club, manufacturer-sponsored programsPotential sources of aid: Medicare Part D, Medicaid, Circuit Breaker, Illinois Care Rx, Rx buying club, manufacturer-sponsored programs

43. Drugs and Aging Information GapInformation Gap Aging PharmacologyAging Pharmacology Adverse Drug ReactionsAdverse Drug Reactions Drugs to AvoidDrugs to Avoid PolypharmacyPolypharmacy CostCost ComplianceCompliance Medication ReviewMedication Review

44. Compliance Compliance Adherence ConcordanceCompliance Adherence Concordance Non-adherence 25 to 59% in the elderlyNon-adherence 25 to 59% in the elderly Factors associated with non-adherenceFactors associated with non-adherence –Physical impairment –Psychosocial risks –Medication related factors Higher risk of re-hospitalizationHigher risk of re-hospitalization Risk of noncompliance after dischargeRisk of noncompliance after discharge Ryan AA. Int’l J Nursing Studies 1999; 36: 153-62. Van Eijken M, et al. Drugs & Aging 2003; 20: 229-40.

45. Drugs and Aging Information GapInformation Gap Aging PharmacologyAging Pharmacology Adverse Drug ReactionsAdverse Drug Reactions Drugs to AvoidDrugs to Avoid PolypharmacyPolypharmacy CostCost ComplianceCompliance Medication ReviewMedication Review

46. Strategies for improving quality of medication use in the elderly Medication ReviewMedication Review –Implicit criteria vs. explicit criteria Enlisting the pharmacistEnlisting the pharmacist Use of the CPOEUse of the CPOE Enlisting the patientEnlisting the patient Simplifying administrationSimplifying administration –Polypill –Single daily dosing –Pill organizers

47. Medication Review Explicit criteriaExplicit criteria –Drugs/classes of drugs w/high risk/ low benefit –U.S. example: Beers drugs-to-avoid criteria Requires updating Requires updating Validity of data in other settings?Validity of data in other settings? ? Room for clinical judgment/ "patient-centered" care? Room for clinical judgment/ "patient-centered" care Implicit criteriaImplicit criteria –IDs individual elements of prescribing as inappropriate e.g., MAI –Time consuming, pharmacist driven Fick DM, et al. Arch Int Med. 2003;163:2716. Hanlon JT, et al. J Clin Epidemiol 1992;45:1045. Samsa GP, et al. J Clin Epidemiol 1994;47:891.

48. Hanlon JT, et al J Clin Epidemiology 1992;45:1045. The Medication Appropriateness Index

49. Balancing the polypharmacy tension with a view to improving quality Every drug listed …… has clinical indicationhas clinical indication is actually being takenis actually being taken has a risk/benefit analysis that is recognized/understood/acceptedhas a risk/benefit analysis that is recognized/understood/accepted is at the lowest effective doseis at the lowest effective dose is evaluated for costis evaluated for cost

50. Key to med review in the elderly is the clinical context Takes into account unique patient needs guided by goals of careTakes into account unique patient needs guided by goals of care –patient preferences –estimated remaining life expectancy (RLE) –best medical evidence including time until benefit Need a “captain of the ship” for med reviewNeed a “captain of the ship” for med review –Need to prioritize meds for patients with multiple conditions –Address new symptoms by including med review as part of the process Holmes HM, et al. Arch Intern Med 2006; 166:605.

51. Enlist the pharmacist Use in the clinical care teamUse in the clinical care team ExamplesExamples –Coumadin clinics –Multidisciplinary interventions ICUICU COPDCOPD CHFCHF Holland R, et al. Homer trial BMJ 2005;330:293. Lenaghan E, et al. Age & Ageing 2007;36:292. Chiquette E, et al. Arch Intern Med 1998;158:1641. Leape LL, et al. JAMA 1999;282:267. Strom BL, et al JAMA 2002;288:1642. Rich MW, et al N Engl J Med 1995;333:1190.

52. Use of Computerized Physician Order Entry (CPOE) Bates DW, et al JAMA 1998;1311-16. Classen DC, et al J Am Med Infromat Assoc 2006 14:48. Leapfrog CPOE Evaluation Test Clinical Decision Support Categories * Therapeutic Duplication *Single & Cumulative Dose Limits *Allergies & Cross Allergies *Contraindicated Route of Administration *Drug-Drug & Drug-Disease Interactions * Contraindications/Dose Limits Based on Patient Diagnosis *Contraindications/ Dose Limits Based in Patient Age or Weight *Contraindications/Dose Limits Based on Laboratory Studies *Contraindications/Dose Limits Based on Radiology Studies *Corollary *Cost of Care * Nuisance

53. Case of Mrs. T….. 85 y/o with h/o DM, CHF, lumbar spinal stenosis admitted with increasing confusion and falls. Lives alone, daughter involved. Daughter notes patient h/o anxiety but c/o insomnia and phoning her continuously throughout the night for the past 3 nights. 85 y/o with h/o DM, CHF, lumbar spinal stenosis admitted with increasing confusion and falls. Lives alone, daughter involved. Daughter notes patient h/o anxiety but c/o insomnia and phoning her continuously throughout the night for the past 3 nights. Brought to U of C ER by daughter after a witnessed fall. New patient to the U of C system. Admitted at 3AM to telemetry. Brought to U of C ER by daughter after a witnessed fall. New patient to the U of C system. Admitted at 3AM to telemetry. On exam, alternately agitated and somnolent, oriented to person only. On exam, alternately agitated and somnolent, oriented to person only. VS: T99, P54, RR20, BP110/50 lying supine wt. 100lbs. 5’1” VS: T99, P54, RR20, BP110/50 lying supine wt. 100lbs. 5’1” Cor: RRR, +S 3 Cor: RRR, +S 3 Lungs: dry crackles in bases Lungs: dry crackles in bases Abd: soft, nontender, nondistended, firm stool felt throughout colon Abd: soft, nontender, nondistended, firm stool felt throughout colon ER data:CT head neg., dirty urine, CXR with  cor, KUB FOS, BUN 48/CR 2.7, glc= 74, K + hemolyzed at 6.3 F/U pending,INR=3.0, EKG SB-rate 58, no peaked t waves. Given dose IV antibiotics in ER. ER data:CT head neg., dirty urine, CXR with  cor, KUB FOS, BUN 48/CR 2.7, glc= 74, K + hemolyzed at 6.3 F/U pending,INR=3.0, EKG SB-rate 58, no peaked t waves. Given dose IV antibiotics in ER.

54. Case of Mrs. T…..hospital day #5 Lisinopril 40mg q daily Glipizide ER 20mg BID Lasix 40 mg q daily KCL 20 meq q daily Paxil 20 mg q daily Amiodarone 200mg q daily Digoxin 0.25 mg q daily Coumadin 5mg q hs T#3 prn Ativan 1mg prn Unsom (OTC) prn sleep Lomotil (OTC) prn Senna and colace prn Lisinopril 20mg q daily Glipizide ER 20 mg daily Lasix 40 mg q daily Amiodarone 200mg q daily Digoxin 0.125 mg q M,W,Fri Coumadin 3mg q hs Tylenol 1000mg TID Cipro 250 mg BID

55. Medication use based on aging pharmacology principles Start low, go slow, dose to effectStart low, go slow, dose to effect Adjust for decrease in renal clearanceAdjust for decrease in renal clearance ID drugs w/narrow toxic/therapeutic indexID drugs w/narrow toxic/therapeutic index ID drugs that effect CPY450 system e.g., inhibitors/inducersID drugs that effect CPY450 system e.g., inhibitors/inducers Adjust for anticholinergic properties of drugsAdjust for anticholinergic properties of drugs Remember the blunted barorecepter reflexRemember the blunted barorecepter reflex

56. Med Review: Intersecting Safeties PCP plays key role in med review (prioritize & individualize)PCP plays key role in med review (prioritize & individualize) New symptom consider a medication in the D/DxNew symptom consider a medication in the D/Dx Meds on list guided by goals of careMeds on list guided by goals of care Review meds on list forReview meds on list for –Indication –Dose –Interactions—drug/drug & drug/disease –Duplications –Adherence –Cost Enlist the pharmacistEnlist the pharmacist Enlist a CPOE systemEnlist a CPOE system Review for medication underuseReview for medication underuse

57. Into the future…… Increase knowledge base on drugs in the elderlyIncrease knowledge base on drugs in the elderly –Clinical trials vs. post marketing surveillance Broaden testing/implementation of technologies e.g., CPOEBroaden testing/implementation of technologies e.g., CPOE Multidisciplinary monitoringMultidisciplinary monitoring Support continued affordable drug coverageSupport continued affordable drug coverage

58. Special Thanks CHAMP core facultyCHAMP core faculty Holly Holmes, MDHolly Holmes, MD Visit our website @http://champ.bsd.uchicago.eduVisit our website @http://champ.bsd.uchicago.edu

59. CHAMP: Drugs and Aging Bibliography 1.Bates DW, et al: The cost of adverse drug events in hospitalized patients. JAMA 1997;277:307-11. 2.Bates DW, et al: Incidence of adverse drug events and potential adverse drug events: implications for prevention. JAMA 1995;274:29-34. 3.Beers, MH, Ouslander JG, Rollingher I, Reuben DB, Brooks, J, Beck JC.: Explicit criteria for determining inappropriate medication use in nursing home residents. Arch Intern Med 1991; 151: 1825-1832.. 4.Beers MH: Explicit criteria for determining potentially inappropriate medication use by the elderly: an update Arch Intern Med 1997;157(14):1531-36. 5.Beers MH. :Inappropriate medication prescribing in skilled-nursing facilities. Ann Intern Med. 1992 Oct15; 117(8): 684-689. 6.Buetow SA, Sibbald B, Cantrill JA, Halliwell S.: Appropriateness in health care: application to prescribing. Soc Sci Med 1997; 45(2): 261- 271. 7. Beyth RJ, et al: Principles of drug therapy in older adults:rational drug prescribing. Clin Ger med 2002;18:577-92.

60. CHAMP: Drugs and Aging Bibliography 8. Chrischilles EA, et al: Use of medications by persons 65 and over: data from the established populations for the epidemiologic studies of the elderly. J Gerontol 1992; M137- M144. 9. Chin MH, Wang LC, Jin L, Mulliken R, Walter J, Hayley DC, Karrison TG, Nerney MP, Miller A, Friedmann PD.: Karrison TG, Nerney MP, Miller A, Friedmann PD.: Appropriateness of medication selection for older persons in an Appropriateness of medication selection for older persons in an urban academic emergency department. Academic Emergency urban academic emergency department. Academic Emergency Medicine 1999; 6: 1232-1242. Medicine 1999; 6: 1232-1242. 10. Classen DC, et al: Adverse drug events in hospitalized patients: excess length of stay, extra costs, and attributable mortality. JAMA 1997;277: 301-6. 11. Doucet J, et al: Drug-drug interactions related to hospital admissions in older adults: a prospective study of 1000 admissions in older adults: a prospective study of 1000 patients. J Am Geriatr Soc 1996;44:944-48. patients. J Am Geriatr Soc 1996;44:944-48.

61. CHAMP: Drugs and Aging Bibliography 12. Fick DM, Cooper JW, Wade WE, Waller JL, Maclean R, Beers MH. Updating the Beers Criteria for potentially inappropriate medication use in older adults. Arch Int Med 2003; 163: 2716-24. 13. Gurwitz JH, Field TS, Avorn J, McCormick D, Jain S, Eckler M, Benser M, Edmondson AC, Bates DW. Incidence and preventability of adverse drug events in nursing homes. Am J Med 2000; 109: 87-94. 14. Hanlon JT, et al: A method for assssing drug therapy appropriateness. J Clin Epidemiol 1992; 45: 1045-51. appropriateness. J Clin Epidemiol 1992; 45: 1045-51. 15. Hanlon JT, Artz MB, Pieper CF, et al. Inappropriate medication use among frail elderly inpatients. Ann Pharmacother 2004; 38: 9-14. 15. Hanlon JT, Artz MB, Pieper CF, et al. Inappropriate medication use among frail elderly inpatients. Ann Pharmacother 2004; 38: 9-14. 16. Inouye SK, et al: Precipitating factors for delirium in hospitalized elderly persons: predictive model and interrelationship with baseline vulnerability. JAMA 1996;275: 852-57. 17. Kroenke K: Polypharmacy : causes, consequences, and cure. Am J Med 1985;79:149-52. Am J Med 1985;79:149-52.

62. CHAMP: Drugs and Aging Bibliography 18. Kaiser Family Foundation. Views of the new Medicare drug law: a survey of people on Medicare. August 2004. 19. Lazarou J, et al: Incidence of adverse drug reactions inhospitalized patients: a meta-analysis of prospective studies. JAMA 1998; 279: 1200- 5. 20. Leape L: Reporting of adverse events. NEJM 2002;347: 1633-38. 21. Lipton HL, et al: The impact of clinical pharmacists’ consultations on physicians geriatric drug prescribing: a randomized controlled trial. Med Care 1992; 30: 646-58. 22. Ryan AA. Medication compliance and older people: a review of the literature. Int’l J Nursing Studies 1999; 36: 153-162. 23. Samsa GP, Hanlon JT, Schmader KE, Weinberger M, Clipp EC, Uttech KM, Lewis IK, Landsman PB, Cohen HJ. A summated score for the medication appropriateness index: development and assessment of clinimetric properties including content validity. J Clin Epidemiol 1994; 47(8):891-896. 24. Schmader K, et al: Appropriateness of medication prescribing in ambulatory elderly patients. J Am Geriatr Soc 1994; 42: 1241-47. 24. Schmader K, et al: Appropriateness of medication prescribing in ambulatory elderly patients. J Am Geriatr Soc 1994; 42: 1241-47.

63. CHAMP: Drugs and Aging Bibliography 25. Stuck AE, Beers MH, Steiner A, Aronow HU, Rubenstein LZ, Beck JC. Inappropriate medication use in community-residing older persons. Arch Intern Med 1994; 154: 2195-2200. 26. Van Eijken M, Tsang S, Wensing M, de Smet PAGM, Grol RPTM. Interventions to improve medication compliance in older patients Interventions to improve medication compliance in older patients living in the community: a systematic review of the literature. Drugs & Aging 2003; 20: 229-240. living in the community: a systematic review of the literature. Drugs & Aging 2003; 20: 229-240. 27. Illinois Department of Public Aid website, ©2004.