An Interdisciplinary Approach to Better Prescribing in the Elderly

Saturday, November 30, 2013Annual Scientific Assembly

Ontario College of Family Physicians

ǂMichelle A. Hart, MD CCFP M.Sc.C.H.ǂǂPauline Santora, BScPhm R.Ph ACPR PharmD

ǂDepartment of Family and Community MedicineǂǂDepartment of Pharmacy

Baycrest Health Sciences, Toronto, ON, Canada

Faculty/Presenter Disclosure

• Faculty: Dr. Michelle Hart• Program: 51st Annual Scientific Assembly

• Relationships with commercial interests:None

Disclosure of Commercial Support

• This program has not received financial support.• This program has not received in-kind support.• Potential for conflict(s) of interest: None

Mitigating Potential Bias

None

Faculty/Presenter Disclosure

• Faculty: Dr. Pauline Santora• Program: 51st Annual Scientific Assembly

• Relationships with commercial interests:None

Disclosure of Commercial Support

• This program has not received financial support.• This program has not received in-kind support.• Potential for conflict(s) of interest: None

Mitigating Potential Bias

None

ObjectivesBy the end of this workshop you will be able to:

1) Understand the changes which occur with aging: Physiological, Pharmacokinetic, and Pharmacodynamic

2) Prescribe more safely by understanding the key factors that affect drug utilization problems in the elderly

3) Utilize an interdisciplinary approach to safer and better prescribing in the elderly

Workshop Agenda1) Physiological Changes of Aging2) Pharmacokinetic Changes with Aging3) Pharmacodynamic Changes with Aging4) Polypharmacy and Drug Interactions5) Medication Adherence6) Adverse Drug Events & Other Challenges in the System7) Inappropriate Drug Prescribing Measurement Methods8) Quality Improvement Methods9) Cases

What are the key factors that affect drug utilization problems in the elderly?

Let’s brainstorm….

4 Categories of drug utilization problems in the elderly

1) Altered Physiology (changes with aging)2) Altered Pharmacokinetics and

Pharmacodynamics (drug sensitivity)3) Polypharmacy and Drug Interactions4) Medication Adherence

Agenda Item #1:Physiological changes with aging

• ↓ maximum heart rate (HR) -Longer for HR and BP to return to normal resting levels after exertion

• Blood vessels - thicker and stiffer - ↑ systolic BP - hypertension - ↑ risk of stroke, heart attack, renal failure

Physiological changes that occur with age: Cardiovascular system

• Heart valves thicken and become stiffer -heart murmurs common

• Pacemaker of the heart loses cells, develop fibrous tissue and fat deposits

-can lower HR and cause heart block -arrhythmias, extra heart beats common

Physiological changes that occur with age: Cardiovascular system

• Baroreceptors which monitor blood pressure become less sensitive

• Quick changes in position may cause dizziness – Orthostatic hypotension

Physiological changes that occur with age: Cardiovascular system

• Lungs stiffen• ↓ Respiratory muscle strength and endurance• ↑ Chest wall rigidity

Lung function:• ↔Total lung capacity • ↓ Vital capacity • ↑ residual volume

Physiological changes that occur with age: Respiratory system

• ↓ in alveolar surface area by up to 20 % - Alveoli collapse sooner on expiration • ↑ mucus production• ↓ in activity and number of cilia • ↓ efficiency in monitoring and controlling

breathing

Physiological changes that occur with age: Respiratory system

• ↑ prevalence of Atrophic Gastritis, Achlorhydria

• ↓ liver efficiency- drug metabolism, cell repair

• ↓ Decreased intestinal absorption of lactose, calcium, iron

• Diverticuli in the colon → pain.

• ↓ peristalsis of the colon →constipation.

Physiological changes that occur with age: Gastrointestinal system

• ↓ kidney mass by 25-30 %

• ↓ number of glomeruli by 30 to 40 % - ↓ ability to filter/concentrate urine, clear drugs

• ↓ hormonal response (vasopressin)

• Impaired ability to conserve salt -↑ risk for dehydration

Physiological changes that occur with age: Kidneys

• ↓ Bladder capacity - ↑ residual urine – urgency and frequency - ↑ chances for urinary infections, incontinence, obstruction.

Physiological changes that occur with age: Urinary system

• Pituitary gland shrinks with age

• Insulin resistance - impaired conversion of glucose into energy - diabetes

• ↓ aldosterone and cortisol - impaired immune and cardiovascular function

Physiological changes that occur with age: Endocrine system

Women: • Ovulation ceases, estrogen levels ↓ by 95%. • Vaginal walls become thinner and lose

elasticity • Most women experience a decrease in the

production of vaginal lubrication

Physiological changes that occur with age: Reproductive system

MEN: • In some men, testosterone ↓ by up to 35%• ↓ size of the testes • ↓ rate of sperm production • Erectile dysfunction (impotence) experienced

by 15% of men by the age of 65 and increases to 50% by age 80

• Prostatic Hypertrophy

Physiological changes that occur with age: Reproductive system

• Loss of height (age 80, avg ~ 2”) - vertebral compression, changes in posture, ↑ curvature of the hips and knees

• Weight - gain until age 60 – lifestyle (inactivity, poor eating habits) - fat mass can double, lean muscle mass ↓ - Loss after 60

Physiological changes that occur with age: Musculoskeletal system

• ↓ bone mass• ↓ muscle strength, endurance, size, weight -loss of ~ 23% by age 80 -inactivity, poor nutrition, chronic illness

Physiological changes that occur with age: Musculoskeletal system

Physiological changes that occur with age: Skin & Soft Tissue or Integument

Skin: wrinkling, pigmentation, thinning - loss of moisture, ↓ elastin and collagen - ↓ cell size - 20% thinning between dermis + epidermis - hair graying and hair loss - ** sun exposure

• 40% of those >65 are edentulous - mostly because of neglect

• Risk of caries increases with age as a result of gingival recession and loss of jaw bone density

- think of antibiotic coverage

• ↓ ability to taste sweetness, sourness and bitterness

Physiological changes that occur with age: Oral cavity

• ↓ Production of thymic hormones

• ↓ Levels of antibody response

• ↓ Response to antigens

***Importance of vaccination: yearly flu shot, Pneumovax in all elderly patients !

Physiological changes that occur with age: Immune system

Increased risk for infections:

• 3 x more likely to die of pneumonia or sepsis• 5 - 10 x more likely to die of urinary tract

infections• 15 - 20 x more likely to die of appendicitis • Mortality rate from infection is much higher

than in the young

Physiological changes that occur with age: Immune system

• ↑ Incidence of cognitive impairment with age - by age 85, up to 1/3 of elderly have some degree of cognitive impairment

• ↓ weight & volume of the brain

• Attention (to perform tasks) often preserved

• Semantic knowledge (word retrieval) declines

• Linguistic abilities ↔

Physiological changes that occur with age: Nervous system

Memory

Encoding (getting info into system) declines - affected by ↓ senses (vision, hearing, smell, taste, touch) - most likely the reason for age-related declines in short-term memoryStorage (retaining information) ↔Retrieval (recalling information) - recognition doesn’t decline but recall does

Physiological changes that occur with age: Nervous system

• ↓ visual-spatial ability

• ↓ conceptualization (mental flexibility and capacity for abstraction) (> age 70)

• ↓ performance scores in problem solving

• ↔ comprehension, math, vocabulary

• ↓ speed of information processing - ↓ reaction time

Physiological changes that occur with age: Nervous system

Agenda Item #2:

Pharmacokinetic Changes with age:

The action of drugs in the body over a period of time which include processes of:

1) Absorption2) Distribution3) Metabolism4) Elimination

Oral• ↑ gastric pH

• ↓ splanchnic blood flow

• Delayed gastric emptying

• ↓ intestinal transit

• ↓ GI absorptive surface

Pharmacokinetic changes that occur with age: Absorption

Pharmacokinetic changes that occur with age: Absorption

Oral• Most drugs are absorbed via passive diffusion which is

unchanged

• Possibly reduced intestinal absorption of agents requiring active transport

• Reduced first-pass metabolism– Increased absorption of some high-clearance drugs– Decreased absorption of drugs from pro-drugs

Overall: No significant changes in drug absorption in the elderly for most drugs. May be slower but extent is generally unchanged.

Subcutaneous/Intramuscular

• ↓ dermal vascularity

May see a decreased rate of absorption

Topical

• ↓ hydration and lipophilic content of aged skin

Theoretically, may ↓ absorption of hydrophilic drugs, but not seen in practice with transdermal patches.

Pharmacokinetic changes that occur with age: Absorption

Pharmacokinetic changes that occur with age: Absorption

Inhalation

• ↓ chest wall compliance, V/Q matching, alveolar surface area

• ↓ dexterity and diseases such as OA and Parkinson’s disease ↓ effective administration of devices

May see a decreased absorption

Pharmacokinetic changes that occur with age: Distribution

Dependent on:

• Protein Binding – Albumin (acidic drugs)– Alpha-1-acid glycoprotein (basic drugs)

• Volume of Distribution

• Blood Flow

Drugs significantly bound to Plasma Proteins

Plasma Protein Drug Protein Binding (%)

Albumin (acidic drugs) NaproxenPhenytoinWarfarin

999599

Alpha 1-glycoprotein (basic drugs) LidocainePropranololQuinidineImipramine

80908889

Change in body composition with age

%

Pharmacokinetic changes that occur with age - Distribution

↓ Total Body Water Hydrophilic Drugs -↓ Vd, ↑ plasma concentration, ↓ t ½ e.g. Lithium, Ethanol, Digoxin, Morphine

↓ Lean Body Mass Drugs which distribute into muscle -↓ Vd and ↑ plasma concentration, ↑ t ½ e.g. Digoxin

↑ Body Fat Lipophilic Drugs - ↑ Vd, ↓ plasma concentration, ↑ t ½ e.g. Diazepam, Amitriptyline, Chlorpromazine

↓ or ↔ Serum Albumin ↓ or ↔ binding acidic drugs, ↑ or ↔ free drug e.g. Warfarin, Phenytoin, Naproxen

↔ or ↑ alpha-acid glycoprotein

↔ or ↑ binding basic drugs, ↓ or ↔ free drug e.g. Lidocaine, Propranolol

Pharmacokinetic changes that occur with age: Metabolism

• ↓ Hepatic mass by 25-35 %– capacity limited

e.g. Theophylline, Warfarin, Diazepam, Phenytoin

• ↓ Hepatic blood flow by > 40 %– blood flow limited

e.g. Morphine, Meperidine, Lidocaine, Verapamil, Tricyclic Antidepressants, Calcium Channel Blockers

Pharmacokinetic changes that occur with age: Metabolism

• ↓ Phase I reactions (oxidative) (avoid or ↓ frequency) e.g. Alprazolam, Diazepam, Flurazepam

• ↔ Phase II reactions (conjugative) (not significantly affected)

e.g. Lorazepam, Oxazepam, Temazepam

Pharmacokinetic changes that occur with age: Metabolism

• Drug interactions due to polypharmacy may result in other drugs inhibiting or inducing their hepatic metabolism -phase I cytochrome P450 system

• Large interindividual variation – other variables more important than age

Pharmacokinetic changes that occur with age: Metabolism

Interindividual Variability• Genotypes - fast vs. slow acetylators

- rapid vs. poor oxidizers• Lifestyle - smoking, ethanol, grapefruit juice

• Cardiac Output• Gender, hormones• Age

Pharmacokinetic changes that occur with age: Renal Elimination

• ↓ RBF (Renal Blood Flow)• ↓ GFR (Glomerular Filtration Rate)• ↓ Tubular secretion• Renal mass ↓ by 30% with loss of functional nephrons and

glomerulosclerosis• Require decreased dosing: e.g. Digoxin, Fluoroquinolones,

Fluconazole, Cotrimoxazole, Cephalosporins, Enoxaparin• Avoid in renal dysfunction: e.g. Glyburide, Nitrofurantoin,

Metformin, Aminoglycosides

Pharmacokinetic changes that occur with age: Renal Elimination

• Overall: ↓ renal functioning; CrCl 30-50% from age 40 to 80 for the majority of elderly especially those with comorbid conditions e.g. hypertension, diabetes, etc.

Decline in Creatinine Clearance with Age

Pharmacokinetic changes that occur with age: Renal Elimination

• Not all healthy elderly have ↓ renal functioning

• 25-30 % of healthy elders maintain relatively good renal function with a

CrCl > 70 mL/min well into old age

• Muscle mass also declines with age • Therefore, serum creatinine levels are also expected

to decrease with age• A CrCl must be calculated to estimate renal function For example, 70 kg male with SCr 100 µmol/L

A Normal Serum Creatinine is not an indicator of normal renal function in the elderly

Age (yrs) 40 60 80 90

CrCl (mL/min)

86 69 52 43

• CrCl (mL/min) = (1.23)(140-age) (weight kg) Serum Creatinine (umol/L)

• Correction factor for females x 0.85

• Tool for Drug Dosing in Renal Dysfunction

Calculate Creatinine Clearance(Cockcroft & Gault Formula)

Agenda Item #3:

Pharmacodynamic changes that occur with age:

The relationship between the drug concentration and the receptor site and the body’s response.

Enhanced drug sensitivity in the elderly.

Pharmacodynamic changes that occur with age

4 Possible Mechanisms for changes in drug sensitivity in elderly;

1) Changes in receptor numbers2) Changes in receptor affinity3) Post-receptor alterations4) Age-related impairment of homeostatic mechanisms

Pharmacodynamic changes that occur with age

• ↓ B1 receptor density & agonist affinity → ↓ BB effectiveness

• ↓ concentration of some neurotransmitters (e.g. Dopamine) enhancing the effect of drugs that block the neurotransmitter’s activity

• Altered homeostasis - impaired regulation of temperature and electrolytes

Pharmacodynamic changes that occur with age

↑Sensitivity of receptors in brain & changes in NA, muscarinic, serotonergic systems leading to common ADRs. e.g. CNS depressants: - Benzodiazepines (diazepam 2-3x sensitivity, leads to more falls/fractures) - Barbiturates - Antipsychotics (e.g. sedation, anticholinergic, orthostatic hypotension and arrhythmias) (↓dopamine receptors/neurons, levels, ↑ risk of EPS effects) - Opioids: 2-8 x higher risk of respiratory depression but N/V decreased. Hallucinations and cognitive impairment may ↑ risk of falls/fractures - Antidepressants

Agenda Item #4:

Polypharmacy and Drug Interactions

Polypharmacy

• High prescribing rates = high rates of adverse drug reactions (ADRs)

• Risk increases with > 4 meds and rises dramatically when ≥ 9, multiple doses/day (>12)

• ADRs contribute to 11-31% of hospitalizations for the elderly

Physician is unaware of:

• 37 % of drugs elderly patients are taking• The 6 % of drugs that have been discontinued• The actual dose/frequency for 10 % of drugs

used

Frank 2001 Can Fam Physician

Prescribing Particularly in the Elderly

What else are they on? • 82 % of adults are taking at > 1 drug • 29 % are taking > 5 drugs • > 65 y.o. 19 % take > 10 diff. drugs/week• 63 % use vitamins • 22 % of adults use herbals/natural supplements

Slone Survey 2006

• A more current term is Medication Optimization (since many patients truly need the many medications for their plethora of problems)

• Its not about reducing medications- we actually want to ensure that Elderly are on the optimum number and dose of medication for their problems

Polypharmacy→Medication Optimization

Drug Interactions

Types:Prescription drug – Prescription drugPrescription drug – Over the counter drugPrescription drug – Herbal or Natural productPrescription drug – Food Drug – DiseaseDrug – Lab Test

Drug Interactions

• With: Age, # drugs, # doctors, # pharmacies, # diseases

• How do you identify them?• Do we need to avoid them all?• Which ones to avoid? • How do we communicate/assess? How to

avoid? How do we monitor?

Agenda Item #5:

Medication Adherence

We will review Common Causes of Medication Non-adherence

(and how to use a team approach to minimize)

Common Causes of Medication Non-adherence

• Doesn’t know why they need to take it; doesn’t agree with plan; doesn’t “trust” the physician

• Psychological disorder – doesn’t comprehend need to take• Memory disorder – doesn’t remember to take• Cannot afford medication; “not covered”; “no LU Code”• Drug unavailability• Cultural beliefs• Language barrier• Instructions unclear or incorrectly labelled (illegible Rx)

Common Causes of Medication Non-adherence

• Difficulty opening bottle (e.g. child resistant vials) due to impaired manual dexterity

• Physical limitations to administer (e.g. inhalers, insulin)• Impatience for response – patient increases dose/frequency• Complicated/impractical regimen• Unable to read label/visual impairment/small print/”as

directed”/forgets info

Common Causes of Medication Non-adherence

• Patient misorganizes pills (eg. Labeled lids mismatched to pill bottles, multiple meds into one pill bottle, pills moved to alternate pill bottle)

• Lack of care giver availability to administer• Lack of education on proper use, dose, administration

techniques, duration, delay in onset of response• Refills – lack of refills, forgets to refill, unable to order/pick up

refills • Adverse effects

Compliance Related to the Number of Medications

• Not specific to the elderly• Problem is that they are taking too many!• Overall compliance is 50 % in all age groups:

1 drug 80 %2 drugs 65 %3 drugs 55 %> 6 drugs 25 %

• Number of drugs and the frequency of dosing

Strategies to Increase Adherence

• Patient/Caregiver must understand the purpose/importance of each medication. Hear it from physician, pharmacist, care giver.

• Bring in all medications to every visit• Listen to patient/care giver regarding reasons for

non-adherence• Non-judgmental approach• Correct any reasons possible e.g. snap caps,

dosettes, adjust dose, change drug• Education – patient, family, caregiver • Family/Caregiver Support

Strategies to Increase Adherence

• Link medication doses with daily routines, such as meals, bedtime

• Address issues with method of administration (e.g. can’t swallow)

• Use memory aids• Pill counts/communication with pharmacist Re: refills• Use Team approach to review number and frequency of

drugs, whenever possible• Look for additional risk factors e.g. memory, vision,

manual dexterity, psychosocial factors

Agenda Item #6:

Adverse Drug Events & Other Challenges in the System

Adverse Drug Events

• 1/3 rd of hospital admissions in the elderly linked to drugs

• Non-adherence, omission or stopping medications accounted for ¼ of admissions

• Age does not effect compliance as much as the complexity of drug regimen and patient comprehension

• ADRs 7-10 x more common in 70-79 yo than 20-29 yo.

• 50 % are potentially preventable

• Risk factors include an increased number of medications

Chan 2001

• Warfarin (17.3%)

• Digoxin (13%)

• Insulin (3.2%)

33% of ADR visits related to these 3 meds!

Medication use leading to Emergency Department visits:

Budnitz DS, Shehab N, Kegler SR.Ann Intern Med 2007;147:755-765

The Prescription Cascade • A process whereby side effects

from drugs are misdiagnosed as symptoms of another problem, resulting in further prescribing and further side effects and unanticipated drug interactions.

Prescribing cascadesAn adverse reaction is misinterpreted as a new medical

condition

Rochon P, Gurwitz JH. BMJ 1997:315:1096-1099

Adverse drug effectmisinterpreted as a newmedical condition

Drug 2

Adverse drug effect

Drug 1

Author John ColePublished in the Times Tribune

Drugs in the elderlyEach medication should have a desired

therapeutic endpoint with a plan for monitoringStart low and go slow (but keep going!)Be aware of patients’ other medications:

BEWARE OF PRESCRIBING CASCADESOTC meds can have significant adverse effectsAdherence is always an issueRegularly review medications on listUsually less is better (but not always!)

Agenda Item #7:

Inappropriate Drug Prescribing (IDP) Measurement Methods

• Implicit Methods: as Evidence-based as the rater’s knowledge, but lack structure to permit good reliability and quality improvement

• Explicit methods: Beers, STOPP/START, etc. However rigid criteria makes it difficult individualize assessment/recommendations for patient

Inappropriate Drug Prescribing (IDP) Measurement Methods

• 1991 Beers et al. set criteria for determining IDP in Nursing Home Residents (NHR)

• 30 drugs which should not be prescribed in Nursing Home Residents

• 1997 and 2003 Beers updated criteria to be applicable to general population

• Scope of criteria now includes meds for adults > 65, includes community dwellers – geriatric patients in all settings

Medication Appropriateness: Explicit Method- Beers Criteria

New 2012 Beers Criteria

• Meds no longer available removed• New drugs introduced since 2003 added• Research updated• Evidence-based approach• Supported by American Geriatric Society (AGS)• Includes ratings of quality of evidence supporting

recommendations• Followed Institute of Medicine standards for

evidence and transparency

Limitations of Beers Criteria

• Should not substitute for professional judgement and individualized care

• Does not address needs for palliative or hospice care

Summary: Beers Criteria

• Role is to inform clinical decision making, research, training, policy

• Improve quality and safety of prescribing meds for older adults

Medication Appropriateness: Explicit Method- STOPP/START Criteria

• Screening Tool of Older Persons Potentially Inappropriate Prescriptions and Screening Tool to Alert Doctors to the Right Treatment

• Validity established through Delphi Consensus process – 18 experts in geriatric pharmacotherapy, Ireland and UK participated

STOPP/START Criteria

• STOPP comprises of 65 indicators pertaining to important drug-drug and drug-disease interactions (potentially leading to side effects such as cognitive decline and falls)

• START incorporates 22 evidence-based indicators of common prescribing omissions

STOPP/START Criteria

• Organized using physiological systems• Include “clinical stopping rules”• Considerable overlap with the American

Geriatric Society Beers Criteria

STOPP/START Criteria

• RCT Gallagher et al 2011• Use of START/STOPP criteria to screen clinical and

prescription data for representative sample of hospitalized older patients resulted in significant and sustained improvements in prescribing appropriateness in terms of reducing rates of overuse, misuse, and underuse of medications and measured by Medication Appropriate Index (MAI) and Assessment of Underutilization (AOU) Indices.

STOPP/START Criteria

• Intervention reduced:1) Use of unnecessary drugs2) Risk of drug-drug and drug-disease

interactions3) Prescriptions of drugs as incorrect

doses, frequency, and duration4) Underprescribing for common conditions such

as cardiovascular disease, diabetes, osteoporosis

Beers Criteria and STOPP/START criteria: the broader perspective

• Purpose to improve medication safety in older adults, increased awareness of inappropriate medication use in older adults

• Encourage health care providers to stop and consider carefully the risks, consider non-drug alternatives

• Broad application to electronic health records

Beers Criteria and STOPP/START criteria: the broader perspective

• Evidence to be used in complimentary manner with 2012 Beers Criteria to guide clinicians in making decision about safe medication use in older adults

Hanlon et al. Clin Epidemiol 1992; 45:1045-51Somers A. Amer J of Geriatric Pharmacotherapy. 10(2) April 2012: 101-109.

• Is there an indication for the drug?• Is the medication the right choice for the condition?• Is the dosage correct?• Are directions correct/practical?• Are there clinically significant drug-drug interactions (including

duplicate therapy)?• Are there clinically significant drug-disease/condition interactions?• Is duration of therapy acceptable?• Are there clinically significant adverse drug reactions?

Medication Appropriateness: Implicit Method: Medication Appropriateness Index

Authored by: Jim Unger Andrews and McNeel IncUniversal Press Syndicate

Agenda Item #8:

Quality Improvement Methods and

“The Future of Working Together” What might it look like?

Communication, Communication, Communication

• Perform a periodic medication review at least annually• Ask the patient to bring in all meds (incl. prescription, OTC,

vitamin, herbals/naturals). Bring family member/friend. • Apply Medication appropriateness criteria - Extrinsic e.g. Beers criteria, STOPP/START criteria - Intrinsic – assess appropriateness of each med given the patient context• Review meds: What are they taking? What are they not taking?

How is the patient taking them? Are they working? Any adverse effects?

• Reinforce (purpose/importance/benefit) or consider stopping. • With which patients to start?

Quality improvement in Drug Therapy

Office Visits - Routine• Bring bag of ALL medications to all office visits• Review last visit(s) in chart – reason for visit

and prescriptions written• Follow-up with patient/care giver -Did it resolve? -Did the medication make a difference? -Any adverse effects? -Are you still taking the medication and if so how?

Office Visits

• Have you had any other medical visits since I saw you last (eg. Specialists, ED visits, etc)?

• If so, who/where? For what? What medication if any was started?

• Any changes in your health, or new over the counter, vitamins, herbal products you have started?

“A healthy dose of information”

Program Funded: Province of Ontario, Ministry of Health (no charge to patient)

Criteria: OHIP Card, on at least 3 Rx medications for a chronic condition, haven’t done it in the past 12 months.

Who Can Request: Patient, Dr., RN EC or Pharmacist

Service: Once a year 1:1 pharmacist and patient/care giver consultation to review the medications. Ideally bring in all OTC, herbal, natural, Rx. Diabetics can have frequent follow-ups if there are issues.

Goals: To increase compliance and knowledge. To update the information e.g. allergies, what has stopped, reinforce how to use it, address patient’s concerns, refer to physician as required, etc.

Medication Reconciliation• Best Possible Medication History (BPMH)

• Comparison of BPMH to prescriptions at each transfer point within hospitalization (admission, transfer within the hospital units, discharge) and documentation of any discrepancies.

• Goal: Seamless care to prevent medication errors

• Facilitated by bringing lists, meds, related information, MARs, Family Physician list, ODB Profiler, knowing what is being taken, not taken and why.

• Currently: it is quite labor intensive.

• Future: Electronic Health Records accessible throughout

Agenda Item #9:

Cases – Medication Optimization

Case #1

• Mr S• 88 year old Male• PMH: Parkinson’s Disease, Mild Cognitive

Impairment, Hypertension, BPH, Hypercholesterolemia, Osteoarthritis

• Admitted to Slow Stream Rehab (SSR), post acute care stay for pneumonia – deconditioned, decreased mobility

On admission to SSR:

• Poor balance and mobility.• Complains of dizziness with positional changes. • Recovering from delirium

- Started on Seroquel 12.5 mg tid for agitation and an additional 25 mg qhs to help his sleep.

-Was tried first on amitriptyline for sleep first but this did not help him very much.

• Endorses low mood/anxiety.• Constipated

Meds

• Seroquel 12.5 mg po TID and 25 mg po qhs• Docusate sodium 100 mg po bid• Ramipril 10 mg po daily• Amlodipine 2.5 mg po daily• Hydrochlorothiazide 25 mg po daily• Tylenol #3 ii tabs po q 4-6 h PRN• Levodopa/Carbidopa 100/25 1 tab po qid• Tamsulosin 0.8 mg po daily• Zocor 80 mg po qhs• Milk of Magnesia 30 mL po PRN

Note: CrCl ~ 28 mL/min

• Pharmacist does a Meds Check annually.• You do an annual physical.• You need a medication list at least annually.• Pharmacist identifies issues on the meds

check annually: “Follow-up with your doctor.”

How can you and the pharmacist work better to prevent medication adverse events?

• Let’s discuss how you might optimize Mr. S’s medications.

• Consider how to address his dizziness, pain, constipation, mood, and insomnia.

Case #2

• Mrs. G• 89 year old female• Lives in Nursing Home• PMH: CVA 2011, Vascular Dementia, HTN, DM2,

Atrial Fibrillation, Chronic Renal Failure (CrCl ~ 20 mL/min), Osteoporosis, Hip # 2 years ago.

• Husband died 2 years ago and she has no other family.

Meds • Ramipril 10 mg po daily• Crestor 20 mg po qhs• Pantoprazole 40 mg po daily• Donepezil 10 mg po daily• Milk of Magnesia 15 mL po bid• Glyburide 5 mg po bid• Metformin 1000 mg po bid• Amitriptyline 25 mg po qhs for sleep (Rx’d years ago – GP) • Gabapentin 300 mg po TID for sciatica/neuropathic pain• M-eslon 10 mg po bid• Warfarin 3 mg po daily

CrCl ~ 20 mL/min

Nurses ask you to see this patient/address issues

• Hematuria x 2 days noted by nurses• Decreased po intake x 2 days• “Not herself” and complaining of a bit of nausea• No dysuria/frequency/urgency she is aware of –

incontinent and uses briefs • Urinalysis ordered yesterday: positive for blood,

leukocytes, nitrites• Urine culture & sensitivity pending

Questions for Case #2

• Current issue: UTI treatment options? What safe precautions need to be taken with antibiotics?

• Ongoing management: Optimize her meds• Should she be on a bisphosphonate? PPI?• Suggestions to better manage her constipation?• She is depressed and has difficulty sleeping – suggestions

for safer management in LTC patient?• Management of diabetes meds?• Pain management?• Efficacy of donepezil?

Case #3

• Mrs. A• 85 year old female• Lives in community alone, condominium

apartment• Divorced, 2 children live in Toronto area• PMH: Atrial fibrillation, chronic back pain,

HTN, Depression, Hypercholesterolemia

Her medication list as per your chart

• Atorvastatin 30 mg po qhs• Hydrochlorothiazide 25 mg po daily• Amlodipine 5 mg po daily• Sertraline 75 mg po daily• Omeprazole 30 mg po daily• Domperidone 10 mg po ACBLD and qhs• Warfarin 2.5 mg po daily• Lorazepam 1 mg po qhs for sleep (Rx’d at age 55

with divorce)

Presents to your office

• Anxiety has gotten “worse”. Sleepless nights, not feeling well. Recent argument with her daughter and they are not speaking at the moment.

• Cough x 5 days (3 days ago you sent her for CXR which shows LLL pneumonia)

• BP a little higher than usual 166/78, P 98, afebrile

• Crackles on LLL

Presents to your office

• Coughing- wet, productive• Reveals that lately she has been taking Gravol-

Ginger which has helped her with her sleep• Her back pain has also gotten worse and she is

taking Ibuprofen for this

Questions for you

• How can you better manage her anxiety and insomnia?

• What safety issues are you concerned about with her OTC and herbal remedies?

• What antibiotic are you considering prescribing and what precautions must you take?

• Any other suggestions to optimize her drugs?

Take Home Messages

• Caring for the elderly is a team sport!Health care team, patient, family, caregiver

• Medication in the elderly requires that the physician and pharmacist communicate, communicate, communicate.

• Education is important to avoid ADRs, IDP and non-adherence.

• “Start Low and Go Slow” but keep going!• Review regimen regularly• Non-specific complaints should prompt review to avoid

prescribing cascades

Some words of wisdom from our elders…

“All drugs are poisons; there is none that is not a poison. The right dose differentiates a poison from a remedy.”

~ Paracelsus 1493 – 1541~

Thank you!

Appendix 1

AGS Beers Criteria – Pocket Card

Appendix 2

START Criteria: Screening tool to alert doctors to the right (i.e. indicated, but not prescribed) treatment for older people

Barry P J et al. START (Screening tool to alert doctors to the right treatment) – an evidence-based screeening tool to detect prescribing omissions in elderly patients. Age Ageing 2007;36:632-638

Copyright © The Author 2007. Published by Oxford University Press on behalf of the British Geriatrics Society.

Appendix 3

STOPP: Screening Tool of Older People’s potentially inappropriate Prescriptions.

Gallagher P, O’Mahony D. STOPP (Screening Tool of Older Persons’ potentially inappropriate Prescriptions): application to acutely ill elderly patients and comparison to Beers’ criteria. Age and Ageing 2008; 37: 673-679.

The following drug prescriptions are potentially inappropriate in persons aged ≥ 65 years of age:

A.Cardiovascular System

1. Digoxin at a long-term dose > 125μg/day with impaired renal function∗ (increased risk of toxicity).2. Loop diuretic for dependent ankle edema only i.e. no clinical signs of heart failure (no evidence of efficacy, compression hosiery usually more appropriate).3. Loop diuretic as first-line monotherapy for hypertension (safer, more effective alternatives available).4. Thiazide diuretic with a history of gout (may exacerbate gout).

STOPP Criteria – A. Cardiovascular System cont’d

5. Beta-blocker with Chronic Obstructive Pulmonary Disease (COPD) (risk of increased bronchospasm).6. Beta-blocker in combination with Verapamil (risk of symptomatic heart block).7. Use of Diltiazem or Verapamil with NYHA Class III or IV heart failure (may worsen heart failure).8. Calcium channel blockers with chronic constipation (may exacerbate constipation).9. Use of Aspirin and Warfarin in combination without histamine H2 receptor antagonist (except Cimetidine because of interaction with warfarin) or Proton Pump Inhibitor (high risk of gastrointestinalbleeding).10. Dipyridamole as monotherapy for cardiovascular secondary prevention (no evidence for efficacy).11. Aspirin with a past history of peptic ulcer disease without histamine H2 receptor antagonist or Proton Pump Inhibitor (risk of bleeding).12.Aspirin at dose > 150mg day (increased bleeding risk, no evidence for increased efficacy).

STOPP Criteria – A. Cardiovascular System cont’d

13. Aspirin with no history of coronary, cerebral or peripheral vascular symptoms or occlusive event (not indicated).14. Aspirin to treat dizziness not clearly attributable to cerebrovascular disease (not indicated).15. Warfarin for first, uncomplicated deep venous thrombosis for longer than 6 months duration (no proven added benefit).16. Warfarin for first uncomplicated pulmonary embolus for longer than 12 months duration (no proven benefit).17. Aspirin, clopidogrel, dipyridamole or warfarin with concurrent bleeding disorder (high risk of bleeding).∗ estimated GFR <50ml/min.

B. Central Nervous System and Psychotropic Drugs.

1. Tricyclic antidepressants (TCA’s) with dementia (risk of worsening cognitive impairment).2. TCA’s with glaucoma (likely to exacerbate glaucoma).3. TCA’s with cardiac conductive abnormalities (pro-arrhythmic effects).4. TCA’s with constipation (likely to worsen constipation).

STOPP Criteria - B. Central Nervous System and Psychotropic Drugs cont’d

5. TCA’s with an opiate or calcium channel blocker (risk of severe constipation).6. TCA’s with prostatism or prior history of urinary retention (risk of urinary retention).7. Long-term (i.e. > 1 month), long-acting benzodiazepines e.g. Chlordiazepoxide, Fluazepam, Nitrazepam, Chlorazepate and benzodiazepines with long-acting metabolites e.g. Diazepam (risk of prolonged sedation, confusion, impaired balance, falls).8. Long-term (i.e. > 1 month) neuroleptics as long-term hypnotics (risk of confusion, hypotension, extra-pyramidal side effects, falls).9. Long-term neuroleptics ( > 1 month) in those with parkinsonism (likely to worsen extra-pyramidal symptoms)10. Phenothiazines in patients with epilepsy (may lower seizure threshold).11. Anticholinergics to treat extra-pyramidal side-effects of neuroleptic medications (risk of anticholinergic toxicity).12. Selective serotonin re-uptake inhibitors (SSRI’s) with a history of clinically significant hyponatraemia (non-iatrogenic hyponatraemia <130mmol/l within the previous 2 months).13. Prolonged use (> 1 week) of first generation antihistamines i.e. Diphenydramine, Chlorpheniramine, Cyclizine, Promethazine ( risk of sedation and anti-cholinergic side effects).

STOPP Criteria-C. Gastrointestinal System

1. Diphenoxylate, loperamide or codeine phosphate for treatment of diarrhoea of unknown cause (risk of delayed diagnosis, may exacerbate constipation with overflow diarrhoea, may precipitate toxic megacolon in inflammatory bowel disease, may delay recovery in unrecognised gastroenteritis).2. Diphenoxylate, Loperamide or codeine phosphate for treatment of severe infective gastroenteritis i.e. bloody diarrhoea, high fever or severe systemic toxicity (risk of exacerbation or protraction ofinfection)3. Prochlorperazine (Stemetil) or metoclopramide with Parkinsonism (risk of exacerbating Parkinsonism).4. PPI for peptic ulcer disease at full therapeutic dosage for > 8 weeks (dose reduction or earlier discontinuation indicated).5. Anticholinergic antispasmodic drugs with chronic constipation (risk of exacerbation of constipation).

STOPP Criteria-D. Respiratory System.

1. Theophylline as monotherapy for COPD. (safer, more effective alternative; risk of adverse effects due to narrow therapeutic index)2. Systemic corticosteroids instead of inhaled corticosteroids for maintenance therapy in moderate-severe COPD (unnecessary exposure to long-term side-effects of systemic steroids).3. Nebulised Ipratropium with glaucoma (may exacerbate glaucoma).

E. Musculoskeletal System

1. Non-steroidal anti-inflammatory drug (NSAID) with history of peptic ulcer disease or gastrointestinal bleeding, unless with concurrent histamine H2 receptor antagonist, PPI or Misoprostol (risk of peptic ulcer relapse).2. NSAID with moderate-severe hypertension (moderate: 160/100mmHg – 179/109mmHg; severe: ≥180/110mmHg) (risk of exacerbation of hypertension).3. NSAID with heart failure (risk of exacerbation of heart failure).4. Long-term use of NSAID (>3 months) for relief of mild joint pain in osteoarthtitis (simple analgesics preferable and usually as effective for pain relief).

STOPP Criteria-Musculoskeletal System cont’d

5. Warfarin and NSAID together (risk of gastrointestinal bleeding).6. NSAID with chronic renal failure∗ (risk of deterioration in renal function).7. Long-term corticosteroids (>3 months) as monotherapy for rheumatoid arthrtitis or osterarthritis (risk of major systemic corticosteroid side-effects).8. Long-term NSAID or Colchicine for chronic treatment of gout where there is no contraindication to Allopurinol (Allopurinol first choice prophylactic drug in gout)∗ estimated GFR 20-50ml/min

F. Urogenital System

1. Bladder antimuscarinic drugs with dementia (risk of increased confusion, agitation).2. Antimuscarinic drugs with chronic glaucoma (risk of acute exacerbation of glaucoma).3. Antimuscarinic drugs with chronic constipation (risk of exacerbation of constipation).4. Antimuscarinic drugs with chronic prostatism (risk of urinary retention).5. Alpha-blockers in males with frequent incontinence i.e. one or more episodes of incontinence daily (risk of urinary frequency and worsening of incontinence).6. Alpha-blockers with long-term urinary catheter in situ i.e. more than 2 months (drug not indicated).

STOPP Criteria- G. Endocrine System

1. Glibenclamide or Chlorpropamide with type 2 diabetes mellitus (risk of prolonged hypoglycemia).2. Beta-blockers in those with diabetes mellitus and frequent hypoglycaemic episodes i.e. ≥ 1 episode per month (risk of masking hypoglycaemic symptoms).3. Estrogens with a history of breast cancer or venous thromboembolism (increased risk of recurrence)4. Estrogens without progesterone in patients with intact uterus (risk of endometrial cancer).

H. Drugs that adversely affect those prone to falls (≥ 1 fall in past three months)

1. Benzodiazepines (sedative, may cause reduced sensorium, impair balance).2. Neuroleptic drugs (may cause gait dyspraxia, Parkinsonism).3. First generation antihistamines (sedative, may impair sensorium).4. Vasodilator drugs known to cause hypotension in those with persistent postural hypotension i.e. recurrent > 20mmHg drop in systolic blood pressure (risk of syncope, falls).5. Long-term opiates in those with recurrent falls (risk of drowsiness, postural hypotension, vertigo).

STOPP Criteria-I. Analgesic Drugs

1. Use of long-term powerful opiates e.g. morphine or fentanyl as first line therapy for mild-moderate pain (WHO analgesic ladder not observed).2. Regular opiates for more than 2 weeks in those with chronic constipation without concurrent use of laxatives (risk of severe constipation).3. Long-term opiates in those with dementia unless indicted for palliative care or management of moderate/severe chronic pain syndrome (risk of exacerbation of cognitive impairment).

J. Duplicate Drug Classes

Any duplicate drug class prescription e.g. two concurrent opiates, NSAID’s, SSRI’s, loop diuretics, ACE inhibitors (optimisation of monotherapy within a single drug class should be observed prior to considering a new class of drug).

Adverse Events: Beware of Meds which effect QT Prolongation !

• ↑ incidence in elderly• ↑ sudden cardiac death 2˚ to QT prolongation• Elderly more likely to be on multiple drugs

which ↑ the QT interval e.g. anti-infectives, antiarrhythmics, antipsychoticsand antidepressants