Appropriate Prescribing The Challenging Patient: Older Patient with Multiple Co- Morbidities

What is an ADR? What is an ADE?  Adverse Drug Reaction (ADR) any undesirable or noxious drug effect at standard drug treatment doses WHO;1996 Technical Report Series No. 425  Adverse Drug Event (ADE) ADRs + errors in drug administration  Adverse Drug Reaction (ADR) any undesirable or noxious drug effect at standard drug treatment doses WHO;1996 Technical Report Series No. 425  Adverse Drug Event (ADE) ADRs + errors in drug administration

Adverse Drug Reactions ADRs Amplified drug effects Drug-nutrient interaction Drug-drug interaction Drug-disease interaction Side-effects *not therapeutic failures *not ADWEs

ADR Risk Factors ? prior ADRs high risk drugs # of drugs # medical problems ? aging pharm ? fragmented care Adverse Drug Reaction

 risk geri syndromes Cost of Polypharmacy Polypharmacy  health care costs  risk inappropriate Rx  risk drug interactions  functional status

Taxonomy of drug-related problems ● Needed drug not given ● Improper drug selection - “best” drug not used ● Too little or too much ● Failure to take ordered drug (non-adherence) ● Adverse drug reactions ● Drug-drug and drug-disease interaction ● Drug use only for symptoms (other than palliation) or without indication ● Needed drug not given ● Improper drug selection - “best” drug not used ● Too little or too much ● Failure to take ordered drug (non-adherence) ● Adverse drug reactions ● Drug-drug and drug-disease interaction ● Drug use only for symptoms (other than palliation) or without indication Hepler & Strand. Am J Hosp Pharm. 1990;47:533.

CHAMP  Cost, Compliance  Hazardous interactions  Drug-drug; drug-disease; drug-aging  Aging pharmacology  Pharmacokinetics  Pharmacodynamics  Medications to avoid  Polypharmacy  >5 drugs, 50% chance of interaction  More meds than are required  Meds w/o clear indication  Cost, Compliance  Hazardous interactions  Drug-drug; drug-disease; drug-aging  Aging pharmacology  Pharmacokinetics  Pharmacodynamics  Medications to avoid  Polypharmacy  >5 drugs, 50% chance of interaction  More meds than are required  Meds w/o clear indication

CHAMP: Drugs and Aging Bibliography 1.Bates DW, et al: The cost of adverse drug events in hospitalized patients. JAMA 1997;277: Bates DW, et al: Incidence of adverse drug events and potential adverse drug events: implications for prevention. JAMA 1995;274: Beers, MH, Ouslander JG, Rollingher I, Reuben DB, Brooks, J, Beck JC.: Explicit criteria for determining inappropriate medication use in nursing home residents. Arch Intern Med 1991; 151: Beers MH: Explicit criteria for determining potentially inappropriate medication use by the elderly: an update Arch Intern Med 1997;157(14): Beers MH. :Inappropriate medication prescribing in skilled-nursing facilities. Ann Intern Med Oct15; 117(8): Buetow SA, Sibbald B, Cantrill JA, Halliwell S.: Appropriateness in health care: application to prescribing. Soc Sci Med 1997; 45(2): Beyth RJ, et al: Principles of drug therapy in older adults:rational drug prescribing. Clin Ger med 2002;18: Bates DW, et al: The cost of adverse drug events in hospitalized patients. JAMA 1997;277: Bates DW, et al: Incidence of adverse drug events and potential adverse drug events: implications for prevention. JAMA 1995;274: Beers, MH, Ouslander JG, Rollingher I, Reuben DB, Brooks, J, Beck JC.: Explicit criteria for determining inappropriate medication use in nursing home residents. Arch Intern Med 1991; 151: Beers MH: Explicit criteria for determining potentially inappropriate medication use by the elderly: an update Arch Intern Med 1997;157(14): Beers MH. :Inappropriate medication prescribing in skilled-nursing facilities. Ann Intern Med Oct15; 117(8): Buetow SA, Sibbald B, Cantrill JA, Halliwell S.: Appropriateness in health care: application to prescribing. Soc Sci Med 1997; 45(2): Beyth RJ, et al: Principles of drug therapy in older adults:rational drug prescribing. Clin Ger med 2002;18:

CHAMP: Drugs and Aging Bibliography 8. Chrischilles EA, et al: Use of medications by persons 65 and over: data from the established populations for the epidemiologic studies of the elderly. J Gerontol 1992; M137- M Chin MH, Wang LC, Jin L, Mulliken R, Walter J, Hayley DC, Karrison TG, Nerney MP, Miller A, Friedmann PD.: Appropriateness of medication selection for older persons in an urban academic emergency department. Academic Emergency Medicine 1999; 6: Classen DC, et al: Adverse drug events in hospitalized patients: excess length of stay, extra costs, and attributable mortality. JAMA 1997;277: Doucet J, et al: Drug-drug interactions related to hospital admissions in older adults: a prospective study of 1000 patients. J Am Geriatr Soc 1996;44: Chrischilles EA, et al: Use of medications by persons 65 and over: data from the established populations for the epidemiologic studies of the elderly. J Gerontol 1992; M137- M Chin MH, Wang LC, Jin L, Mulliken R, Walter J, Hayley DC, Karrison TG, Nerney MP, Miller A, Friedmann PD.: Appropriateness of medication selection for older persons in an urban academic emergency department. Academic Emergency Medicine 1999; 6: Classen DC, et al: Adverse drug events in hospitalized patients: excess length of stay, extra costs, and attributable mortality. JAMA 1997;277: Doucet J, et al: Drug-drug interactions related to hospital admissions in older adults: a prospective study of 1000 patients. J Am Geriatr Soc 1996;44:

CHAMP: Drugs and Aging Bibliography 12. Fick DM, Cooper JW, Wade WE, Waller JL, Maclean R, Beers MH. Updating the Beers Criteria for potentially inappropriate medication use in older adults. Arch Int Med 2003; 163: Gurwitz JH, Field TS, Avorn J, McCormick D, Jain S, Eckler M, Benser M, Edmondson AC, Bates DW. Incidence and preventability of adverse drug events in nursing homes. Am J Med 2000; 109: Hanlon JT, et al: A method for assssing drug therapy appropriateness. J Clin Epidemiol 1992; 45: Hanlon JT, Artz MB, Pieper CF, et al. Inappropriate medication use among frail elderly inpatients. Ann Pharmacother 2004; 38: Inouye SK, et al: Precipitating factors for delirium in hospitalized elderly persons: predictive model and interrelationship with baseline vulnerability. JAMA 1996;275: Kroenke K: Polypharmacy : causes, consequences, and cure. Am J Med 1985;79: Fick DM, Cooper JW, Wade WE, Waller JL, Maclean R, Beers MH. Updating the Beers Criteria for potentially inappropriate medication use in older adults. Arch Int Med 2003; 163: Gurwitz JH, Field TS, Avorn J, McCormick D, Jain S, Eckler M, Benser M, Edmondson AC, Bates DW. Incidence and preventability of adverse drug events in nursing homes. Am J Med 2000; 109: Hanlon JT, et al: A method for assssing drug therapy appropriateness. J Clin Epidemiol 1992; 45: Hanlon JT, Artz MB, Pieper CF, et al. Inappropriate medication use among frail elderly inpatients. Ann Pharmacother 2004; 38: Inouye SK, et al: Precipitating factors for delirium in hospitalized elderly persons: predictive model and interrelationship with baseline vulnerability. JAMA 1996;275: Kroenke K: Polypharmacy : causes, consequences, and cure. Am J Med 1985;79:

CHAMP: Drugs and Aging Bibliography 18. Kaiser Family Foundation. Views of the new Medicare drug law: a survey of people on Medicare. August Lazarou J, et al: Incidence of adverse drug reactions inhospitalized patients: a meta-analysis of prospective studies. JAMA 1998; 279: Leape L: Reporting of adverse events. NEJM 2002;347: Lipton HL, et al: The impact of clinical pharmacists’ consultations on physicians geriatric drug prescribing: a randomized controlled trial. Med Care 1992; 30: Ryan AA. Medication compliance and older people: a review of the literature. Int’l J Nursing Studies 1999; 36: Samsa GP, Hanlon JT, Schmader KE, Weinberger M, Clipp EC, Uttech KM, Lewis IK, Landsman PB, Cohen HJ. A summated score for the medication appropriateness index: development and assessment of clinimetric properties including content validity. J Clin Epidemiol 1994; 47(8): Schmader K, et al: Appropriateness of medication prescribing in ambulatory elderly patients. J Am Geriatr Soc 1994; 42: Kaiser Family Foundation. Views of the new Medicare drug law: a survey of people on Medicare. August Lazarou J, et al: Incidence of adverse drug reactions inhospitalized patients: a meta-analysis of prospective studies. JAMA 1998; 279: Leape L: Reporting of adverse events. NEJM 2002;347: Lipton HL, et al: The impact of clinical pharmacists’ consultations on physicians geriatric drug prescribing: a randomized controlled trial. Med Care 1992; 30: Ryan AA. Medication compliance and older people: a review of the literature. Int’l J Nursing Studies 1999; 36: Samsa GP, Hanlon JT, Schmader KE, Weinberger M, Clipp EC, Uttech KM, Lewis IK, Landsman PB, Cohen HJ. A summated score for the medication appropriateness index: development and assessment of clinimetric properties including content validity. J Clin Epidemiol 1994; 47(8): Schmader K, et al: Appropriateness of medication prescribing in ambulatory elderly patients. J Am Geriatr Soc 1994; 42:

CHAMP: Drugs and Aging Bibliography 25. Stuck AE, Beers MH, Steiner A, Aronow HU, Rubenstein LZ, Beck JC. Inappropriate medication use in community-residing older persons. Arch Intern Med 1994; 154: Van Eijken M, Tsang S, Wensing M, de Smet PAGM, Grol RPTM. Interventions to improve medication compliance in older patients living in the community: a systematic review of the literature. Drugs & Aging 2003; 20: Stuck AE, Beers MH, Steiner A, Aronow HU, Rubenstein LZ, Beck JC. Inappropriate medication use in community-residing older persons. Arch Intern Med 1994; 154: Van Eijken M, Tsang S, Wensing M, de Smet PAGM, Grol RPTM. Interventions to improve medication compliance in older patients living in the community: a systematic review of the literature. Drugs & Aging 2003; 20: