Better Living through Chemistry: Pharmacologic Issues in Seniors Amie Blaszczyk, Pharm.D., CGP, BCPS, FASCP Associate Professor & Division Head – Geriatrics Texas Tech University Health Sciences Center School of Pharmacy October 17, 2013

Objectives By the end of this session, the learner should be able to: Describe unique aspects of drug pharmacokinetics and pharmacodynamics for older adults Discuss current prevalence and risk of polypharmacy among older adults Discuss vulnerability of the older adult to specific adverse drug events Describe best practice strategies to improve appropriate medication use

So, why do we care?

The Senior Patient “Older Adult” is a misnomer Literature support for interventions Changes in goals of therapy Never what you think it is Pharmacokinetic (PK) and Pharmacodynamic (PD) changes

PK/PD Pharmacokinetics Pharmacodynamics “What you do to the drug” Absorption Distribution Metabolism Excretion Pharmacodynamics “What the drug does to you” More drug response

Pharmacokinetic Changes Absorption pH increased (more basic) Medications affected The wrath of the PPI! Distribution Albumin decreased Increased monitoring

Pharmacokinetic Changes Metabolism Phase I metabolism Greatly affected CYP450 interactions Medications typically affected Phase II metabolism Relatively unchanged APAP Controversy

Pharmacokinetic Changes Excretion Decreased renal function Medications affected

Pharmacodynamic Changes Body Composition Increased Changes in body fat (%) Decreased Changes in body water (%) Changes in lean body mass (%) Start low, go slow, but go!

Pharmacodynamic Changes Cardiovascular Function Resting HR decreased Medications to watch: Beta-blockers, Cholinesterase inhibitors Baroreceptor response diminished Alpha-blockers, Parkinson’s medications

Pharmacodynamic Changes CNS Function Blood supply to the brain Increased BBB permeability GI Function Increased risk for GI bleeds NSAIDs ASA SSRIs

Pharmacodynamic Changes Renal Function Difficulty maintaining appropriate volume status Diuretics ACE Inhibitors Medications which can cause diarrhea Genitourinary Function Prostate & anticholinergics

It’s not just changes with medications…

Seniors have lives too! Heterogeneity of aging Other impacting factors Environmental Economic Sociological Psychological

PolyPharmacy: Have MERCY!

Polypharmacy Definition Depends who you ask! Use of multiple medications or the use of an unnecessary medication 4? 5? 9? 12? What determines unnecessary?

Polypharmacy Incidence Depends on where they live Community 94% of 65+ take at least 1 medication/week 2/3 of older adults take 5+ medications Nursing home 67.2% take 9+ medications Qato DM, et al. JAMA. 2008;300:2867-2878. Centers for Medicare and Medicaid Services. MDS quality measure/indicator report. January-March 2008.

Polypharmacy Incidence Depends on the definition of what is a “medication” 13% of the elderly with herbal use in previous 12 months Impact of Medicare Part D Bruno JJ, et al. Ann Pharmacother. 2005;39:643-648.

Seniors and Polypharmacy Why are seniors at risk? Increasing number of comorbid diseases Increasing number of doctors Prescribing cascade Self-care OTCs Herbals

Example Prescribing Cascade 80 year old with osteoarthritis pain unresponsive to Tylenol Starts taking OTC ibuprofen 600 mg PO Q6H scheduled without MD knowledge Ibuprofen raises her blood pressure Prescribed HCTZ 12.5 mg Qday Diuretic effect leads to incontinence episodes Prescribed Ditropan (Oxybutynin) 5 mg PO TID Oxybutynin causes problems with memory Prescribed Aricept (Donepezil) 5 mg Daily

Vulnerability of the Aged Misuse of medications Using another’s medication The phantom pain med from 40 years ago Problems with Labeling/Instructions Vision Contrast Print size Vague instructions Personal favorite: 1-2 tablets PO Q4-6H PRN Twice daily

Vulnerability of the Aged Inappropriate prescriptions Prescribing cascade Somatic complaints vs. Psychological condition Beers’ List & other like-minded “Inappropriate medication” lists All leading to an increased risk of adverse drug reactions

Adverse Drug Reactions Upwards of $177 billion a year Many are preventable 27.6%-88% depending on the venue of care Top 3 classes Cardiovascular medications Analgesics Diabetes medications Ernst FR, et al. J Am Pharm Assoc. 2001;41:192-199. Gurwitz JH, et al. JAMA. 2003;289:1107-1116. Hanlon JT, et al. J Gerontol Med Sci. 2006;61A:511-515. Gurwitz JH, et al. Am J Med. 2000;109:87-94. Gurwitz JH, et al. Am J Med. 2005;118:251-258. Sleeper RB. In: Fundamental of Geriatric Pharmacotherapy: An evidence-based approach. 2010; ASHP Publishing

Adverse Drug Reactions 3 Main Causes Inappropriate drug selection Overuse Underuse Where do they come from? Prescribing Dispensing Administration & Adherence Monitoring Sleeper RB. In: Fundamental of Geriatric Pharmacotherapy: An evidence-based approach. 2010; ASHP Publishing

Adverse Drug Reactions: Prescribing Inappropriate Drug Choice Inappropriate Dose Inappropriate Regimen/Instructions Sleeper RB. In: Fundamental of Geriatric Pharmacotherapy: An evidence-based approach. 2010; ASHP Publishing

Adverse Drug Reactions: Dispensing Medication Preparation Medication Handling Pre-dispensing storage and security Dispensing Related recordkeeping Sleeper RB. In: Fundamental of Geriatric Pharmacotherapy: An evidence-based approach. 2010; ASHP Publishing

Adverse Drug Reactions: Administration & Adherence Patient receives or takes the wrong drug or dose Administered at the wrong time or wrong frequency Administered via the wrong technique Non-adherence Sleeper RB. In: Fundamental of Geriatric Pharmacotherapy: An evidence-based approach. 2010; ASHP Publishing

Adverse Drug Reactions: Administration & Adherence Most common types of error in administration Other than wrong time Administration of unauthorized drug (44.8%) Omission of prescribed drug (41.5%) Administration of wrong dose (11%) Administration via wrong route (2%) Administration of wrong form (0.4%) Sleeper RB. In: Fundamental of Geriatric Pharmacotherapy: An evidence-based approach. 2010; ASHP Publishing Aspden P, et al. IOM Quality Chasm Series: Preventing medication Errors 2006 Committee on Identifying and Preventing medication Errors.

Adverse Drug Reactions: Monitoring Important to note: Safety AND Efficacy Is it working for the condition prescribed? Mention a medication side effect… Sleeper RB. In: Fundamental of Geriatric Pharmacotherapy: An evidence-based approach. 2010; ASHP Publishing

Best Practices

A new symptom in an elderly person should always be considered a medication side effect first!

Your Role Be an advocate Be the voice of your patient The passive-aggressive last ditch route Be the voice of your patient And eyes, ears… Utilize non-pharmacologic methods first Try to avoid calling the MD for an additional medication, if you can

Best Practices to Improve Appropriate Use On intake, asking the right questions What are you taking? What are you taking it for? Who prescribed it? How do you know it’s working? What commonly aren’t perceived as “medications” Non-Rx medications

Best Practices to Improve Appropriate Use Encouraging individuals/caregivers to keep track All practitioners they see Medications Who prescribes what medications Give the list to every practitioner they see Utilize 1 pharmacy Coupons

Best Practices to Improve Appropriate Use Recognizing ADRs when they’re happening If unsure, ask your pharmacist! Recognizing when lower doses may be needed Knowing when to stop a medication is as important as knowing when to start one Utilize a patient’s loved ones/caregivers as viable, imperative sources of medication information. “What were they REALLY taking?”

Best Practices to Improve Appropriate Use Medication Class Overview Cardiovascular medications Analgesics Diabetes medications Psychotropics

Cardiovascular Medications Prescribing Dosing Right medication for the right condition Administration & Adherence Checking vitals prior to administration Crushable vs. non-crushable medications Nitrate-free Interval

Cardiovascular Medications Monitoring Side effects Bradycardia Hypotension Depression Orthostasis ED Cough/Angioedema Pedal edema Constipation Lethargy Monitoring Efficacy BP reduction Pulse reduction Anginal episode reduction Improved exercise tolerance

Analgesics Prescribing Dosing Safe medications in the elderly Remember PK and PD changes Right medication for the right condition APAP vs. NSAIDs vs. Opioids Neuropathic (nerve) pain vs. Nociceptive pain Long-acting vs. short-acting APAP-containing opioids

Analgesics Administration & Adherence Timeliness PRN vs. Scheduled The “right” PRN for the pain Do not crush

Analgesics Monitoring Monitoring Side effects Efficacy Respiratory depression Constipation Nausea/Vomiting Sedation (excessive) Occult blood Elevated blood sugars Monitoring Efficacy Pain relief (timely reassessment) Pain scales 0-10 Wong-Baker Faces Line

Diabetes Medications Prescribing Administration & Adherence Dosing Right medicine for a senior patient Administration & Adherence Timely in regards to meals

Diabetes Medications Monitoring Monitoring Side effects/Safety Hypoglycemia Nausea Edema Monitoring Efficacy Glucose control Fasting Pre-meals Decrease in pain Wound healing

Psychotropics Gradual dose reduction trials Is it working? Why? When? How? Is it working? Administration & Adherence PRN antipsychotic use

Psychotropics Monitoring Monitoring Safety/Side effects Efficacy AIMS Sedation Activation Disinterest Disinhibition Monitoring Efficacy PRN documentation Mood Agitation Sleep

Questions? Amie.blaszczyk@ttuhsc.edu