Polypharmacy Authors name and affiliation

ACKNOWLEDGEMENT These slides were designed by Dr. Nancy Ordonez as part of her faculty role in the HRSA sponsored Houston Geriatric Education Center. Please credit her if utilizing these slides and recognize the Health Resource Service Administration for their support of our geriatric education program. Nancy Ordonez., Pharm.D., BCPS Clinical Associate Professor Assistant Dean for Experiential Programs University of Houston College of Pharmacy Faculty Houston Geriatric Education Center

Funded By This project is funded by a grant from the Health Resources and Services Administration (HRSA) of the Department of Health and Human Services. The grant was initially funded in 2007 with renewed funding for five years beginning in 2010. (Grant #UB4HP19058). The grant ended in June, 2015.

Learning Objectives Successful students will be able to: Identify and describe age-related physiological changes that influence pharmacokinetic and pharmacodynamic aspects of pharmacotherapy. Discuss adverse drug reactions as they relate to older adults. Identify iatrogenic problems with multi-geriatric syndromes and their medication regimens. Discuss issues of medication compliance in older adults. Describe general guidelines for prescribing appropriately and avoiding polypharmacy.

Statistics Those 65 year and older represent 12.6% of the US population, approximately one in eight Americans. The elderly account for nearly 30% of the nation’s health care expenditures and 25% of drug expenditures. A survey of non-institutionalized participants found that 12% of women aged above 65 years took at least 10 medications and 23% took at least five prescription drugs. The average US nursing home resident uses seven different medications each month, and about one-third of residents have monthly drug regimens of nine or more medications. By 2030, it is estimated that one in five Americans (71.5 million) will be over the age of 65 years. Ramaswamy R, et al. J Eval Clin Pract. 2010

“Function/Dysfunction” line 20 yrs Functional Capacity 80 yrs “Function/Dysfunction” line Age …… ……Disease Process >>> Flaherty JH. Clin Geri Med 1998

Age Related Changes Pharmacokinetic Pharmacodynamic Absorption Distribution Metabolism Excretion Pharmacodynamic Changes in receptor affinity Changes in receptor number Changes in response Changes in homeostasis control

Disease States that Alter Pharmacokinetic and Pharmacodynamics Renal Failure Increases distribution Decreases elimination Alters distribution Decreases baroreceptor sensitivity Congestive Heart Failure Liver Disease

Intrinsic Properties of Medications Negative Long biological half-life Extensive oxidative metabolism (P450) Many active metabolites Highly protein bound Lipophilic Positive Short biological half-life Excreted unchanged or conjugative metabolism Minimal protein binding Hydrophilic

Definition of Polypharmacy Strictly defined as the use of multiple medications Threshold for the total number qualifying varies in the literature (2-10) Comprehensively defined as the use of medications with duplicative indications, drug-drug interactions, disease-drug interactions, in adequate attention to pharmacokinetic/ pharmacodynamic principles, and/or no indication Lee RD. J Am Board Fam Pract. 1998;11(2):140-144. Monane M, et al. West J Med. 1997;167:233-237.

Factors Contributing to Polypharmacy Increasing age Multiple symptoms Multiple medical problems Copious prescribing Multiple providers

Factors Contributing to Polypharmacy (continued) Lack of primary care provider to coordinate Use of multiple pharmacies Drug regimen changes Hoarding of medications Self-treatment

Indicators of Polypharmacy Prescribing medications with no apparent indication Use of medications in same drug category Concurrent use of interacting medications Prescribing drugs contraindicated in the elderly Ordering inappropriate dosages Using a drug to treat an ADR Clinical improvement following discontinuation of medications

The Prescribing Cascade INITIAL CONDITION THERAPY NEW SYMPTOM SUBSEQUENT RX ARTHRITIS NSAID  Blood Pressure BP Med DEPRESSION Tricyclic Antidepressant CONSTIPATION LAXITIVE USE AGITATION ANTIPSYCHOTIC Extra-Pyramidal Syndromes PARKINSONS MED Gurwitz JH. P&T. 1997

Potentially Inappropriate Prescribing (PIP) Defined as prescribing that poses more risk than benefit to the individual. Using medications either have no clear evidence-based indication, carry a substantially higher risk of ADE or are not cost-effective. The risk of adverse drug event (ADE) resulting from PIP ranges from weakness, to falls and fractures, even to life threatening events. The Beers criteria is one of the most widely cited guidelines. Other guides exist to determine appropriateness of therapy. Ramaswamy R, et al. J Eval Clin Pract. 2010

Potentially Inappropriate Prescribing (PIP) Studies show prevalence of at least one inappropriate medication being prescribed for up to 40% of nursing home residents and 21% of community-dwelling elderly. The cost of medication related problems has been estimated to be $76.6 billion to ambulatory care, $20 billion to hospitals, and $4 billion to nursing home facilities. If medication-related problems were ranked as a disease by cause of death, it would be the fifth leading cause of death in the United States. Ramaswamy R, et al. J Eval Clin Pract. 2010

Beer’s Criteria Fick DM, et al. Arch Intern Med. 2003;163:2716-24

Medication Appropriateness Index Each question is answered using a three-point Likert scale. The first two questions receive a weighting of (3), the next four a weighting of (2), and the last four a weighting of (1). Is there an indication for the drug? Is the medication effective for the condition? Is the dosage correct? Are the directions correct? Aare the directions practical? Are there clinically significant drug–drug inter-actions? Are there clinically significant drug–disease/condition interactions? Is there unnecessary duplication with other drugs? Is the duration of therapy acceptable? Is the drug the least expensive alternative compared to others of equal utility? Fitzgerald LS, et al. Ann Pharmacother. 1997;31:543-8.

Screening Tool of Older Persons' Potentially Inappropriate Prescriptions (STOPP) STOPP is comprised of 65 clinically significant criteria for potentially inappropriate prescribing in older people. It incorporates commonly encountered instances of potentially inappropriate prescribing in older people. includes drug-drug and drug-disease interactions, drugs which adversely affect older patients at risk of falls and duplicate drug class prescriptions. criteria are arranged according to relevant physiological systems. each criterion is accompanied by a concise explanation as to why the medication is potentially inappropriate. Levy HB, et al. Ann Pharmacother. 2010 ;44(12):1968-75.

Screening Tool to Alert Doctors to the Right Treatment (START) START consists of 22 evidence-based prescribing indicators for commonly encountered diseases in older people. The tool helps to identify prescribing omissions (medication indicated, but not prescribed). Cardiovascular system Warfarin in the presence of chronic atrial fibrillation, where there is no contraindication to warfarin Beta blocker in chronic stable angina, where no contraindication exists Respiratory system Inhaled steroid in moderate-to-severe asthma or COPD, where reversibility of airflow obstruction has been shown Central nervous system L-dopa in idiopathic Parkinson’s disease with definite functional impairment and resultant disability Gastrointestinal system Proton pump inhibitor in the presence of chronic severe gastro-esophageal acid reflux Locomotor system Calcium and vitamin D supplement in patients with known osteoporosis Endocrine system ACE inhibitor or Angiotensin Receptor Blocker in diabetes with nephropathy Levy HB, et al. Ann Pharmacother. 2010 ;44(12):1968-75.

Strategies to Optimize Prescribing Educational Interventions Small group workshops Three step approach – quarterly reports, biannual onsite visits, and annual meetings Computerized support systems Dispensing and Ordering Pharmacist interventions Physician and Patients Geriatric Medicine Services Multidisciplinary Teamwork Regulatory Polices Medication Therapy Management Kaur S, et al. Drugs Aging 2009;26(12):1013-28. Steinman M, Hanlon JT. JAMA 2010;304(14):1592-1601.

Medication Adherence in the Elderly Complex and there is no “one size fits all” solution Patient Specific Factors Medication Specific Factors Prescriber Specific Factors Health Plan Specific Factors Multimodal interventions that address behavioral aspects provide more benefit than education alone. Conn VS, et al. The Gerontologist 2009;49(4): 447–62.

Proposed Strategies to Increase Adherence Long-term Treatment Combinations of: Instruction/Instruction materials Simplify regimen Counseling/Reminders Cueing to daily events Reinforce/Reward Patient self monitoring Involve family/significant others Short-term Treatment < 2 weeks Counseling on importance Written instructions Reminder packaging Haynes et al. JAMA, 288:2880-83.

Healthcare Organization Multimodal Approach Patient Must engage in essential behavior Decide to control risk factors Negotiate with provider Adopt and maintain behavior Monitor progress towards goals Resolve barriers to goals Must communicate with provider Provider Must foster effective communication Provide clear and direct message Include the patient in decisions Incorporate behavioral strategies Must document and respond to progress Create evidence-based practice Assess adherence each visit Develop reminder system Healthcare Organization Healthcare organization must: Develop supportive environment Provide tracking and reporting systems Provide education/training for providers Provide adequate reimbursement for time Healthcare organization must adopt systems to rapidly and efficiently incorporate innovations into practice Circulation ;95:1085-1090

Technology and Informatics to the Rescue? E-prescribing Provide point-of-care alerts Decrease cost burden to patient Improve reimbursement to provider Optimize medication utilization for health plan Physician Order Entry Medical Home Model

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