Medications in Older Persons Kenneth Brummel-Smith, M.D. Professor and Chair, Department of Geriatrics FSU College of Medicine Geriatric Workforce Enhancement Program Healthcare Network of SW Florida

Objectives Describe warning signs that nurses can observe that could indicate a medication problem Describe 3 common problems in geriatric medication usage Describe two techniques that can be used to assess an older patient’s understanding of the goal of treatment Describe four steps that nurses can use to educate older patients on safe medication usage

One person’s drugs

Problems in Geriatrics Medication Older patients take twice as many drugs as younger ones 28% of acute geriatric hospital admissions due to adverse drug events (ADE) 35% of community-dwelling elderly persons experience an ADE In nursing homes, $1.33 spent on ADE for every $1.00 spent on medications

ADE Cascade DRUG 1 given (e.g., donepezil) - Adverse drug effect (e.g. – dizziness) misinterpreted as a new medical condition DRUG 2 given (e.g., meclizine) Adverse drug effect- (e.g., constipation) misinterpreted as a new medical condition

Risk of ADE Age >85 Decreased BMI > 6 diagnoses Creatine clearance < 50ml/min 9 or more meds 12 or more doses a day Prior ADE

Changes in Aging Absorption Distribution Slower, so drugs may take longer to reach peak effect Distribution Less water, more fat Water-soluble drugs – need a lower dose (digoxin) Fat-soluble drugs can build up – diazepam Protein-binding Always look at the albumin level

Changes in Aging Metabolism Elimination Liver – often decreased function Alcohol – metabolized in liver, same dose gives greater effect Other common diseases can affect metabolism Heart failure Elimination Kidney is most common method of elimination Serum creatinine is NOT a good indication of kidney function

Polypharmacy Old way of thinking - # of drugs 4 10 New way of thinking – taking more drugs than is clinically indicated Goals and Targets Symptoms and Prevention

Goals and Targets Goals – patient-generated desired outcomes Avoid a stroke or heart attack Not having bad side effects Targets– prescriber-generated measurements that are proxies for the goal BP, A1C level The best outcomes happen when these are in alignment – collaborative approach

Symptoms and Prevention Symptom goals To FEEL better (less pain, less sadness, easier breathing) Expect to results of treatment today Prevention goals To NOT have something bad happen (stroke, heart attack, die) Takes time to achieve (usually) Time-to-benefit

Time To Benefit Most prevention treatments only start to show differences after years of treatment Statins – 1-3 years Blood pressure – 5-7 years Some start showing benefits pretty quickly Fewer asthma attacks with beta-agonists Sometimes prevention and symptom treatments are simultaneous Asthma

Prescribing & Deprescribing Indications to treat Example – hypertension after patient has tried to lower BP through life style changes and not be able to change behavior or no effect on BP even with changed behavior Goal? Indications to discontinue treatment Example – patient with dementia has entered later stages and donepezil is not working Goals?

Risky & Dangerous Situations Greater than 4 medications Physical frailty Dangerous 10 or more medications 2 or more psychotropics 2 or more CNS drugs Any new Sx that starts soon after a new drug

Beer’s Drugs (High Severity) amitriptylene barbituates chlordiazepoxide chlorpropamide diazepam doxepin flurazepan hysocyamine meperidine methyldopa pentazocine ticlopidine American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, JAGS, 2015

Overprescribed Drugs Anticholinergics - Antivert NSAIDs – Motrin, Aleve Antispasmodics – Bentyl, Levsin PPIs – Nexium, Prilosec Antipsychotics – Haldol, Zyprexa Sedative antihistamines - Benadryl Benzodiazepines – Valium, Tranxene Muscle relaxants – Flexeril, Soma H2 blockers – Tagamet, Zantac Tricyclic antidepressants - Elavil Insulin, sliding scale Vitamins & minerals Meclizine, dicyclomine, hyoscyamine, haloperidol, olanzepine, diazepam, clorazepate, cimetadine, ranitidine, ibuprofen, naproxen, esomeprazole, omeprazole, diphenhydramine, cyclobenzaprine, carisoprodol, amitriptylene

Underprescribed Drugs ACE inhibitors for patients with diabetes and proteinuria Bronchodilators Angiotensin-receptor blockers Proton-pump inhibitors or misoprostol for GI protection from NSAIDs Anticoagulants Statins in secondary prevention Antihypertensives and diuretics in uncontrolled hypertension Vitamin D and calcium for patients with osteoporosis β-blockers after myocardial infarction or with heart failure

Common Geriatric Problems Dementia and incontinence Do NOT prescribe an cholinesterase inhibitor if the patient is on an anticholinergic drug E.g., donepezil with tolteradine Effectively negate one another

Common Geriatric Problems Long term PPI use 2/3 of scrips probably inappropriate Increased risk of hip, spine and wrist fractures Increased risk of C. defficile infections Increased risk of pneumonia Magnesium deficiency (cardiac risk) No evidence for routine use for stress ulcer prevention in hospitalized patients Must taper off it (weeks)

Common Geriatric Problems Hypertension treatment Always consider NSAIDs as the cause of hypertension before starting treatment Atypical presentations - even when orthostatics are normal – e.g., lethargy, memory problems, depression Adjust targets No one below 130/85 Better target: below 150/90

Common Geriatric Problems Type 2 Diabetes No clear evidence that tight control reduces macrovascular events No evidence that daily BS measurement is beneficial Good evidence of risk of hypoglycemia Better targets A1C greater than 7% for all, above 7.5 for complex, and 8 to 9 for frail AGS, Choosing Wisely, www.choosingwisely.org

Harder Problems Stopping drugs in someone “trained” to watch the numbers Higher A1C level in older diabetic having metformin side effects Low BP readings in someone with a fear of strokes Stopping drugs in people near the end-of-life New goal – a death that “could be prevented”

Idealized Prescribing There is evidence that the patient’s problem is responsive to a drug The patient agrees to a drug-approach The patient is motivated to take the drug The drug causes no side effects The drug is affordable and available The drug works in this patient

Teach Your Patients Bring in all your medicines to every visit Keep a list of your drugs in your wallet or purse Use only one pharmacy Don’t ask for any drug that is advertised on TV or in magazines If a new drug is started: 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

Why Bring in Drugs? Prescription written: Diltiazem 24hr ER 30 mg Take one capsule every day

References Geriatric Nursing Review Syllabus, American Geriatric Society American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2015;63(11):616–631. Brandt N. Optimizing medication use through deprescribing: tactics for this approach. J Gerontol Nurs. 2016;42(1):10–14. O’Mahoney D, O’Sullivan D, Byrne S, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2014;44(2):213–218.