POLYPHARMACY IN THE ELDERLY:
When Too Many Becomes Deadly
ROY J. CUISON, M.D., MBA, MFPM, FPCGMInternational Society of Internal Medicine
Royal Colleges of Physicians of the United Kingdom
Philippine College of Geriatric Medicine
Philippine College of Physicians
46th Annual Convention – May 1, 2016
A GENTLE REMINDER
This slide set on POLYPHARMACY IN THE ELDERLY
is the intellectual property of
ROY J. CUISON, M.D., MBA, FPCPM, MFPM
Permission to use the information on these slides
is granted to selected individuals for
academic use PROVIDED
the corresponding CREDIT is acknowledged for
the AUTHOR.
F A C T S
• Over 3 billion prescriptions are filled per year
• Average prescription in 2000 was 28.5 per person per year
• Reached 38.5 per person per year in 2010
• 75% of people ages 45 or older take an average of 4
prescription medications/day
• Elderly patients account for 34% of all written prescriptions
• People over 65 take more prescription and OTC drugs than
any other age group
• Almost a ¼ million seniors are hospitalized per year due to
reactions between prescription drugs and OTC drugs
Rossoni, E. et al.
Univ. Of Rhode Island
Multiple Years
(Normal Aging)
Multiple Medical
Conditions
Multiple Physician
Contacts
Multiple Adverse
Drug Reactions
Multiple Pharmacy
Contacts
Multiple
Prescriptions
Reduced Quality
of Life
Multiple
HospitalizationsMultiple Deaths
(Iatrogenic)
THE CASCADE OF MULTIPLES
Lewandowski, Leon. 2009
OPTIMAL PHARMACOTHERAPY
• Balance between overprescribing and underprescribing
– Correct drug
– Correct dose
– Targets appropriate condition
– Is appropriate for the patient
Avoid “a pill for every ill”
Always consider non-pharmacologic therapy
Farho, Linda
RATIONAL DRUG USE
World Health Organization
Rational use of medicines requires that "patients
receive medications appropriate to their clinical
needs, in doses that meet their own individual
requirements, for an adequate period of time, and
at the lowest cost to them and their community".
Rational medication prescribing dictates that the
fewest medications be used to achieve the
therapeutic goals as determined by clinician and
patient.
Multiple medications not only add to the cost and
complexity of therapeutic regimens, but also place
patients at greater risk for adverse drug reactions
and drug- drug interactions.
Taskeen, M., et. al.
J Drug Del. & Therap 2012
Challenges of Geriatric Pharmacotherapy
• New drugs available each year
• FDA approved and off-label indications are
expanding
• Changing managed-care formularies
• Advanced understanding of drug-drug interactions
• Increasing popularity of “nutraceuticals”
• Multiple co-morbid states
• Polypharmacy
• Medication compliance
• Effects of aging physiology on drug therapy
• Medication costFarho, Linda
Univ. of Nebraska Medical Center
POLYPHARMACY DEFINED
Wide range of definitions; no consensus definition
Generally defined as “Administration of more
medications than clinically indicated, representing
unnecessary drug use.”
Five or more medications.
“The regular consumption of multiple medications
that are inappropriate for the patient, as well as the
use of high-risk medications with or without
inappropriate dosing.” (diTrapano, C., 2015)
By definition, polypharmacy is always bad.
Aging – Polypharmacy – Mortality
Copyright © 2000, 1995, 1990, 1985, 1979 by Churchill Livingstone
POLYPHARMACY IN THE MAKING…
• Drug reactions in the elderly often produce effects that simulate the conventional image of growing old:
unsteadiness drowsiness
dizziness falls
confusion depression
nervousness incontinence
fatigue malaise
insomnia
Laird, Rosemary D.
Univ. of Kansas Medical Center
Center on Aging
“If medication related problems
were ranked as a disease, it
would be the fifth leading cause of
death in the US!”
*Beers MH. Arch Internal Med. 2003
Marcu, Oana
Family Medicine, Sweden
2006
Side Effect Common Drugs Causing Side Effect
Common Drugs Treating Side Effect
Constipation-
Tricyclic antidepressants –First-generation antihistamines -Verapamil or diltiazem –Opioid analgesics - Calcium supplementation-
Psyllium - Docusate/senna -Lactulose
Insomnia-Prednisone, pseudoephedrine -Stimulants, antidepressants -Theophylline-
First-generation antihistamines -Benzodiazepines - Zolpidem, zaleplon
Somnolence-Antihistamines - Benzodiazepines - Gabapentin - Opioid analgesics-
Stimulants - Caffeine - Modafinil
Cognitiveimpairment-
Oxybutynin/tolterodine -Antihistamines - Opioid analgesics - Benzodiazepines-
Donepezil - Rivastigmine -Galantamine - Memantine
Diarrhea-Metformin - Antidepressants -Proton pump inhibitors -Antibiotics-
Loperamide - Diphenoxylate
SELECTED SIDE EFFECTS, MEDICATION CAUSE, AND TREATMENT THAT MAY LEAD TO POLYPHARMACY
Vande Griend, J.P., 2009
Drug 1
ADE interpreted as new
medical condition
Drug 2
ADE interpreted as new
medical condition
Drug 3
Rochon PA, Gurwitz JH. Optimizing drug treatment in elderly people: the prescribing cascase. BMJ 1997;315:1097.
THE PRESCRIBING CASCADE
Polypharmacy has been and always will be common
among the elderly population due to the
need to treat the various disease states that develop
as a patient ages.
Unfortunately with this increase in the use of multiple
medications comes an increased risk for negative
health outcomes such as higher healthcare costs,
ADEs, drug-interactions, medication non-adherence,
decreased functional status and geriatric syndromes.
Maher, R., et al. US-NIH, 2014
Advanced Healthcare Network
Advanced Healthcare Network
CONSEQUENCES OF POLYPHARMACY
• Increased total medical expenditure
• Increased incidence of ADRs & drug-drug
interactions
• Decreased patient compliance
• Decreased social activity
• Increased incidence of depression
• Diminished cognition
• Increased incidence of eventual nursing home
placement
• Increased prescribing errors
Rossoni, E. et al.
Univ. Of Rhode Island
ADVERSE DRUG REACTIONS
• The most consistent risk factor for adverse drug reactions is:
The NUMBER of drugs being taken
– Risk rises exponentially as the number of drugs increases.
Laird, Rosemary D.
Univ. of Kansas Medical Center
Center on Aging
Larsen and Martin, 1999
2 medications 6% 5 medications 50%8 medications 100%
PRINCIPLES
If an elderly person is started on a new
medication and 2 to 3 days later they are
taken to the emergency room, suspect a
drug reaction.
If an older patient seems very different than
at your last session, ask them if they are
taking any new medications.
James-Kracke, M.
Univ. of Missouri – Columbia Medical School
APPROPRIATE PRESCRIBING(Medication Appropriateness Index)
Aronson, J.K. et. Al.
Br. J Clin Pharmacol, 2004
Criteria Score
Is there an indication for the drug? 3
Is the medication effective for the condition? 3
Is the dosage correct? 2
Are the directions correct? 2
Are the directions practical? 2
Are there significant Drug-Drug Interactions? 2
Are there significant Drug-Disease Interactions? 1
Is there unnecessary duplication of the drugs? 1
Is the duration of therapy acceptable? 1
Is the drug the least expensive alternative? 1
18
1- Appropriate; 2 – Marginally appropriate; 3 - inappropriate
Mark H Beers, MD 1954-2009
MD, University of Vermont
First medical student to do a
geriatrics elective at Harvard„s
new Division on Aging
Geriatric Fellowship, Harvard U
Faculty, UCLA/RAND
Co-editor, Merck Manual of
Geriatrics
Editor in Chief, Merck Manuals
The American Geriatrics Society with the support of the John A. Hartford
Foundation, Retirement Research Foundation and Robert Wood Johnson
Foundation.
Louden, K, 2015
Beers Criteria Key Principles
Medications listed are potentially, not definitely, inappropriate inolder adults
The rationale and recommendation statements in the tablesprovide guidance and exceptions to the recommendations
Prescribing should be adjusted to take into account why a drug islisted
Safer pharmacologic and nonpharmacologic alternatives to the
listed drugs are available; a list of alternative medications is beingdeveloped by the AGS
The criteria should be a starting point from which to develop a
comprehensive process to improve medication appropriatenessand safety
The criteria do not apply in all countries
BEERS DRUGS CRITERIA
• Medications that should be avoided in the elderly (≥ 65
years old).
• Inclusion based on drug‟s specific risk-benefit analysis.
• 2 classifications of Beer‟s drugs
– Medications to avoid or use within specific dose and
duration
– Medications to avoid with concomitant diseases
• PIMs have been found to be associated with poor health
outcomes, including falls, confusion and mortality.
• Not a punitive list but aimed to improve care of the older
adults by reducing exposure to PIMs
Rossoni, E., et al. Univ. of Rhode Island
BEERS CRITERIA – OVER THE YEARS
2012 – revision
- 53 medications and classes of medications
- sponsored by the American Geriatrics Society (AGS)
- evidence-based using Institute of Medicine guidelines
- Three categories:
(1) 34 medications that pose high risk of side-effects or are
of limited effectiveness or alternatives are available.
(2) 14 medications inappropriate for certain diseases
because they exacerbate these disorders.
(3) 14 medications may have more risks than benefits but
may be the best choice for the particular individual
provided it is used with caution.
BEERS CRITERIA – OVER THE YEARS
2015 – latest revision
- an interdisciplinary panel of 13 experts in geriatric care and
pharmacotherapy who would do a systematic review and
grading
- incorporate new evidence on currently list PIMs and evidence
on new medications or conditions not addressed in the 2012
update.
- Incorporates two new areas of evidence on drug-drug
interactions and dose adjustments based on kidney function.
- Grade the strength and quality of each PIM statement based on
level of evidence and strength of recommendation.
- Incorporate needed exceptions in the criteria as deemed
clinically appropriate and make the criteria more individualized
to clinical practice and relevant across settings of care.
BEERS CRITERIA – TODAY
2015 – latest revision
- 20,748 citations
- 6,719 citations were selected for preliminary abstract review.
- 3,387 citations and abstracts were individually reviewed by
the expert panel.
- 1,188 unduplicated citations were selected for full panel
review.
- Evidence tables were developed for 342 studies, including
60 systematic reviews and meta-analyses, 49 RCTs and 233
observational and other types of publications.
- Recommendations were presented in 6 tables and evidence
tables are presented as appendices.
BEERS CRITERIA – TODAY
2015 – latest revision
1. Avoiding of anti-arrhythmics as first-line in atrial
fibrillation has been rescinded, except for Amiodarone
which is still to be avoided unless there is heart failure or
substantial LVH.
2. Non-benzodiazepine, benzodiapine receptor agonist
hypnotics (zolpidem) is to be avoided without
consideration for duration of use because they are
associated with harms (falls, vehicle accidents) with little
efficacy for insomnia.
3. Sole use of sliding scale insulin without a background of
basal insulin due to hypoglycemia risk with little
improvement of hyperglycemia management.
4. Avoid PPIs for more than 8 weeks due to risk of C. difficile
infection, bone loss and fracture.
SUMMARY: AGS 2015 Beers Criteria
Table 1: Designations of quality of evidence and strength of
recommendations.
Table 2: PIMs for older adults outside the palliative care and
hospice settings.
Table 3: medications for older adults with specific diseases
or syndromes to avoid.
Table 4: medications to be used with caution.
Table 5: potentially clinically important non-anti-infective
drug-drug interactions
Table 6: non-anti-infective medications to avoid or which
dosage should be adjusted based on individual kidney
function.
Table 7-10: documenting differences between 2012 and
2015.
Steinman, Micheal, 2015
University of California, San Francisco
Clinicians using the Beers Criteria are advised to:
1. ask themselves why the patient is taking a
drug and whether it is truly needed,
2. whether there are safer alternatives, and –
3. whether the patient has characteristics that
would increase or mitigate the potential risks
of the drug.
WORDS OF ADVICE . . .
PHARMACODYNAMICS AND AGING
• However in spite of the Beers criteria:
– Numerous studies in the last 15 years have found
that PIMs continue to be used in 12% to 40% of
older patients in community and nursing home
settings (Raebel, Charles, Dugan, & et al, 2007).
– Administrative data from nearly 400 hospitals across
the United States reveals that nearly half of all older
patients hospitalized for 7 common conditions were
prescribed at least 1 PIM (Rothberg et al, 2008).
Bonifas, R. P.
Univ. Arizona School of Social Work
OTHER PROTOCOLS
S – Simple
A – Adverse
I – Indication
L – List
A – Assess
R – Review
M – Minimize
O – Optimize
R – Reassess
THE BROWN BAG
REDUCING POLYPHARMACY AND
PROMOTING MEDICATION ADHERENCE
THE “BROWN BAG”
• At least yearly, and more often if indicated, review all medications the elderly patients have at home (they often bring them in a big brown grocery bag, thus the name of this intervention!)
– Prescription medications
– Over-the-counter medications
– Vitamins supplements
– Herbal preparations
• Intervention has four components - listing medications, discussing patient‟s understanding of why the medication is prescribed, discussing potential side effects, and discussing the findings with the patient
Adapted from Bonifas, R. P.
Univ. Arizona School of Social Work
• Use of vitamins and herbal remedies is highly prevalent
among older adults!
• Usage is generally not reported to the physician since older
adults may not consider them to be medications.
• Some serious drug interactions are possible with common
herbal remedies, for example:
– Ginkgo biloba interactions include bleeding when combined
with warfarin (coumadin), raised blood pressure when
combined with a thiazide diuretics and coma when combined
with trazodone (desyrel).
Bonifas, R. P.
Univ. Arizona School of Social Work
WHAT TO DO WITH THE
“BROWN-BAG-FULL” OF MEDICATIONS?
• First: List the medications and the associated dosages
and administration schedules – using the Brown Bag
Patient Education Tool.
• Second: Ask the patient to tell you what the medications
are prescribed for. If you hear, “I don’t know…my
doctors told me to…” this is cause for concern -
additional patient education is needed!
Adapted from Bonifas, R. P.
Univ. Arizona School of Social Work
WHAT TO DO WITH THE
“BROWN-BAG-FULL” OF MEDICATIONS?
• Drug reactions in the elderly often produce effects that simulate the conventional image of growing old and may thus be overlooked.
Bonifas, R. P.
Univ. Arizona School of Social Work
Third: Ask patients about the following symptoms:
Tiredness, sleepiness, or
decreased alertness
Constipation, diarrhea, or
incontinence
Loss of appetite
Confusion
Falls
Depression or lack of interest in
usual activities
Weakness
Tremors
Visual or auditory hallucinations
Anxiety or excitability
Dizziness
Decreased sexual behavior
WHAT TO DO WITH THE
“BROWN-BAG-FULL” OF MEDICATIONS?
• Fourth: Report findings
– Discuss the findings with the patient (including
nursing home, hospice, primary care, inpatient
settings)
– the pharmacist can also be helpful in nursing home
settings.
Adapted from Bonifas, R. P.
Univ. Arizona School of Social Work
WHAT TO DO WITH THE
“BROWN-BAG-FULL” OF MEDICATIONS?
• Such irrational polypharmacy can arise from several
factors:
The prescriber hesitates to discontinue medications the
patient has been taking a long time.
The prescriber may add more drugs to the patient's regimen
without removing any.
The prescriber orders medication to alleviate adverse
reactions to other medications.
The patient may be influenced by anecdotal reports touting
the benefits of certain medications.
Bonifas, R. P.
Univ. Arizona School of Social Work
PHARMACODYNAMICS AND AGING
Personal:
health maintenance
a reaction to changes in eating habits or health status that arise
from acute or chronic conditions
as a way to prevent aging, and
as a way to have more control over personal health concerns.
Social:
higher rates of education
a demand for more information about a wider variety of products
Environmental:
increases in television and internet advertising
in available transportation
Haines, P.
School of Public Health
Univ. of South Carolina
SOME REASONS FOR DIETARY SUPPLEMENT USE
IN THE ELDERLY
individuals who are unsatisfied with current
medical care
people who prefer to follow the growing
movement for health promotion and the
use of complementary and alternative
medicine
individuals treating both real and perceived
symptoms of aging
those who are dealing with chronic conditions.
Haines, P.
School of Public Health
Univ. of South Carolina
CATEGORIES OF SUPPLEMENT USERS
Overall, older adults
appear to take
supplements due to
beliefs that they will
incur some benefit,
gain some element of
control, or improve
their overall quality of
life.
Haines, P.
School of Public Health
Univ. of South Carolina
THE TEN COMMANDMENTS
IN PRESCRIBING FOR THE ELDERLY
1. Know the pharmacology of the drug to be prescribed,
its route of metabolism and excretion.
2. Use the drug for the correct and absolute indication
and only when necessary for treatment.
3. Simplify the medication regimen to improve
compliance and reduce the likelihood of
interactions.
4. Use the lowest possible effective dose.
5. Reduce the number of drugs to be prescribed.
6. Discontinue all other unnecessary drugs.
7. Inform the patient and responsible companion on
the purpose of the drug, its expected and
desired effects and important side-effects.
8. Write dosage instructions about the prescribed drug/s
in legible print and provide the patient with a
copy.
9. Have the patient demonstrate that he/she is able to
open the medication container.
THE TEN COMMANDMENTS
IN PRESCRIBING FOR THE ELDERLY
10. NEVER, EVER withhold medications for the simple
reason that the patient is old.
IN THE ELDERLY
Ronchon, P. A.
UpToDate, 2014
The process of prescribing a medication is
complex and includes:
1. deciding that a drug is indicated,
2. choosing the best drug,
3. determining a dose and schedule appropriate
for the patient's physiologic status,
4. monitoring for effectiveness and toxicity,
5. educating the patient about expected side
effects, and
6. indications for seeking consultation.
THANK YOU
FOR YOUR ATTENTION, INTEREST
AND TIME.
ROY J. CUISON, M.D., MBA, MFPM, FPCGMProfessor
UST Faculty of Medicine and Surgery
