Evidence-Based Methods to Reduce Medications in Older Patients Kenneth Brummel-Smith, MD Charlotte Edwards Maguire Professor of Geriatrics Florida State University College of Medicine Copyright 2007, Florida State University College of Medicine. This work was supported by a grant from the Donald W. Reynolds Foundation. All rights reserved.

Objectives Describe 5 factors to consider when discontinuing a medication Describe 3 initiatives physicians can take to lower medications Describe two initiatives patients can take to lower medications

One person’s drugs

Prevalence of the Problem Medication errors each year: 7000 deaths 95,000 hospital admissions 700,000 emergency visits 3,000,000 office visits 30% more money spent on treating errors than on medications themselves 5th most common cause of death in US IOM, To Err is Human, 2000

FM Residency Chart Review Epocrates Medication Check 17% - contradicted medication combination 42% - avoid use/alternative combination 78% - monitor/modify Treatment combination 64% - caution advised combination Beer’s List 44% of polypharmacy patients were on a Beer’s drug Of those on a Beer’s drug, 75% of patients were on a high risk drug Polypharmacy – 5 or more prescription drugs

Beer’s Drugs (High Severity) amitriptylene barbituates chlordiazepoxide chlorpropamide diazepam doxepin flurazepan hysocyamine meperidine methyldopa pentazocine ticlopidine Beers MH. Explicit criteria for determining potentially inappropriate medication use by the elderly: an update. Arch Intern Med 1997;157:1531-6.

Considering Appropriateness Remaining life expectancy Time until benefit Goals of care Treatment targets Cost “Indications to Discontinue” Holmes H, Arch Int Med, 2006

Remaining Life Expectancy Women Men Walter LC, JAMA, 2001

Time Until Benefit Short term benefits Long term benefits Analgesics for pain Sx relief Long term benefits Primary prevention Secondary prevention Different than number needed to treat More individualized

Goals of Care Shared decision making Changes as person ages Cure illness Prevent death Prevent disability Relieve suffering Increase function Promote health Prevent transmission Increased quality of life Increased control A good death Shared decision making Changes as person ages Changes as disease progresses

Treatment Targets Related to goals Goal = general Target = measurable outcome Positive targets (to reach) Negative targets (to avoid)

Costs Financial Impact on family Risk of adverse effects Costs: Aricept? Norvasc? Celebrex? Effexor?

Physician’s Control- Teach Your Students! Minimum 2 year wait on new drugs 7 year wait is safer Do not use drugs on the Beer’s list Use generics Use the 4 step approach to evaluate new and current drugs Use an EHR with: Medication decision support Computerized entry 73% of pts are satisfied with reductions Straand J, Fam Prac, 2001

Teach Your Patients Keep a list of your drugs – show it every visit Use only one pharmacy Don’t ask for any drug that is advertised on TV or in magazines Ask how long the drug has been on the market Don’t take any drug until it’s been out for at least 2 years Ask if there are other things besides taking a drug you can do Ask if you should stop any current drugs

Helpful Sites Therapeutics Initiative: Evidence Based Drug Therapy www.ti.ubc.ca Univ of British Columbia OHSU Drug Effectiveness Review Project www.ohsu.edu/drugeffectiveness