Challenges with Polypharmacy Gerrie Bleifuss MSN, RN Assistant Professor- Henry Predolin School of Nursing Edgewood College

Polypharmacy What is it? How do patients end up on so many drugs? What are some problems associated with polypharmacy? What can be done about it?

Polypharmacy Is the patient’s medication regimen in line with current disease specific guidelines? Overprescribed medications. What medications potentially increase patient’s risk for falls, cognitive impairment? Most important predictor of inappropriate prescribing = number of prescribed drugs Inappropriate prescribing imposes a burden Ill-health, disability, hospitalization, death *JAMA Intern Med 2015; 175(5) 827-834

Other factors contributing… Is the patient actually taking the drug? Does the drug fit with life circumstances? i.e. Metastatic cancer patient taking statin Biology of Aging- kidney function changes, consequences of protein bound meds, lipid solubility property Does likely benefit outweigh risk of harm? Increased harm for elderly patients taking Opioids, NSAIDs Benzodiazepines, Anti-cholinergics PPI’s Statins

To prescribe or deprescribe? High-risk drugs –When are these safe for use? Benzodiazepines Opioids PPI’s Statins Anti-psychotics Anti-cholinergics

cont. Goal: Reduce risk for falls & change in cognitive & psychomotor function Preventable ADRs Withdrawal associated with improvements in all deficit areas

Deprescribing Benzodiazepines Commonly overprescribed Inappropriate used medication Dementia may increase and increases anti-cholinergic activity Increase is distribution, lipophilic drug Metabolized faster in in older men than older women Cause more sedation and poor psychomotor performance in older adults due to reduced clearance of the drug, resulting in higher plasma levels

Risks of Benzdiazepines Poor evidence for improvement of insomnia Cognitive impairment Delirium Falls and related injuries (hip fracture) MVA Harm of therapy occurs at a dose much loser than the dose needed to treat anxiety Does not matter whether short term or chronic use

Key Points Older patients should be warned that their use is not the best practice. Education, education, education. Decrease use of this one medication improves quality of life, safety and cognitive health in the elderly. Having psychiatrists office along with primary physician office has potential of reducing the use of inappropriate meds esp benzo’s Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial. 2014. https://www.ncbi.nlm.nih.gov/pubmed/24733354 2.Billottide Gage etalBMJ2014;349:g5205.

Indications for Benzo’s in Elderly ETOH withdrawal Terminal delirium or hospice patients at the end of life care Resistant anxiety disorder, last resort

Opioids: where are we now? Opioids cause nearly three out of four prescription drug overdoses1 A 200 percent rise in the death rate related to opioid overuse (including opioid pain relievers and heroin) since 20002 Medicare Part D3 spending on commonly abused opioids (such as hydrocodone and oxycodone) increased 165 percent from 2006–2015. Multiple Black Box Warnings: 2013: Long-acting, extended release formulations 2016: Immediate release opioids 2016: Opioids and benzodiazepines

Cont. Multiple Black Box Warnings: 2013: Long-acting, extended release formulations 2016: Immediate release opioids 2016: Opioids and benzodiazepines

Guidelines to improve opioid use CDC Guideline Recommendations Non-opioids preferred, use opioids only when expected benefits (pain, function) likely to outweigh substantial risks. Encourage Non-Pharmacologic therapies Use IR Opioids when Starting-lowest effective dose/shortest duration Evaluate Benefits and Harms frequently Avoid Concurrent Use of Opioid & Benzodiazepine Centers for Disease Control and Prevention (CDC). 2016. “CDC Guideline for Prescribing Opioids for Chronic Pain —United States, 2016.” http://www.regulations.gov/#!documentDetail;D=CDC-2015-0112- 0002.

PPI’s - Proton-pump Inhibitors Initially, considered to have excellent risk benefit profile Now, increasing appreciation of risk: Pneumonia, C. diff, CKD, dementia, fracture risk, renal failure, unpublished CVD risk? Often used for questionable indications: Intended for short-term prophylaxis(4-8 weeks) or treatment, but continued long-term

What is wrong with STATINS Muscle pain Muscle weakness and fatigue Diabetes Cognitive impairment FDA has added diabetes, memory loss warnings to statins.

Polypharmacy Associated Issues • Adverse drug events • Falls/Fall outcomes/Fall risk factors • Hospitalizations • Mortality • Declines in Function • Declines in Cognition Fried TR, et al.,JAGS, 2014

Polypharmacy It is much easier to add a medication than to take one away Patients or facility staff report symptoms The result is often a new prescription or an increased dose www.deprescribing.org

Situations calling for deprescribing New symptom or syndrome suggesting ADR Manifesting advanced or end-stage disease, terminal illness, dementia, extreme frailty, or full dependence

Barriers to deprescribing:

Deprescribing- Focus on NH The need for “deprescribing” is greatest in LTC Often 10-20 medications prescribed per patient Regulatory environment: goal of stopping unnecessary medications

Strategies to facilitate deprescribing System level: Position statements on appropriate prescribing Training / professional development Clinical guidelines for complex older patients with multiple conditions

Shared Role in deprescribing Instruct patients & caregivers how to recognize drug- induced harm Ask pt what is important, what problems they are having Review medication lists and highlight those amenable to deprescribing. Medication Reconciliation Reduce dose of inappropriate med, slowly withdraw Pharmacists are underutilized Regulatory Initiatives: more dollars for research, HIT issues

Role of the nurse in deprescribing Collaborative team approach; prescriber, pharmacist and nurse Detects adverse effects, changes in patient’s behavior Communication Awareness of BEERS criteria

Deprescribing Review Systematic process of identifying/discontinuing drugs May lower dose or slowly wean down Where existing or potential harms outweigh existing or potential benefits

Physician signing monthly orders: Theoretically this would be a chance to review medical therapy In practice, signing orders is usually reflexive and routine The orders for a given facility all come at once All facility orders are stacked at the first of the month

Deprescribing Summary Process of tapering, stopping, discontinuing, or withdrawing drugs Deliberate effort to manage polypharmacy and improve outcomes

Drug Withdrawal Trials Scott, et al: Review of 31 trials (15 randomized, 16 observational) “With appropriate selection and education, coupled with careful withdrawal and close monitoring, antihypertensives, psychotropics and benzodiazepines could be discontinued without harm in 20-100% of patients.”

Scenario #1 Frail 90 y/o LTC resident nearing end-of-life, currently taking: Atorvastatin Memantine Amlodipine Diphenhydramine Which are candidates for deprescribing?

Scenario #2 Patient with agitated dementia and multiple falls is taking: Quetiapine Memantine Lorazepam Hydralazine Which are candidates for deprescribing?

Polypharmacy Assignment Case Study: Group Geriatric Polypharmacy Instructions: Carl is a 78 y/o who lives alone. After viewing the video about Carl, you are now assigned to make a home visit. When you arrive at Carl’s home, he gives you a list of the following medications he has at home. Your group has been assigned one of the following list of medications. Analyze the case study in terms of the problematic nature of the patient’s pharmacological management. Please follow APA format. The paper should not exceed 5 pages. I encourage you to collaborate with a community pharmacist on this assignment. Your answer should include the following: Discuss the problem of polypharmacy in the elderly and the impact of this on drug compliance. Consider the age-related changes of the geriatric patient and the aging effect on drug metabolism. Identify 3 potential adverse reactions based on the combination of drugs prescribed in the case study chosen. What additional assessments and lab values would be useful in further identifying the patient’s risks? Why? Include educational strategies which could be implemented to improve the outcomes of this patient.

BEERS Criteria Update AGS -American Geriatrics Society –2015 updated BEERS criteria. Next update 2018. BEERS - based on consensus not evidenced based. Panel reviewed 6,700 research studies. 40 medications or classes of drugs identified as potentially inappropriate for older adults. 2 Criteria: Medications that should generally be avoided > 65 Medications to avoid with specific medical conditions

BEERS 2015 Updates 3 new drugs added 2 new classes of medications added 10 new medications older adults should avoid Suggested alternative medications and no prescription treatment options. @ HealthinAging.org

BEERS Changes 2015 cont.

BEERS Changes 2015 cont.

Thank you! Questions??

References Scott I, Hilmer, S. (2015). The Process of Deprescribing - Reducing Inappropriate Polypharmacy. JAMA Internal Medicine 175(5), 827-834