A Practical Approach to a Geriatric Patient Tatyana Gurvich, Pharm.D., CGP USC School of Pharmacy UCI Sr. Health Center Queenscare Family Clinics Glendale Adventist FPRP

Medication-Related Problems in the Elderly Common, Costly and Preventable Common, Costly and Preventable Total estimated healthcare expenditure related to potentially inappropriate medications is $7.2billion Total estimated healthcare expenditure related to potentially inappropriate medications is $7.2billion 27% of adverse events in primary care settings 27% of adverse events in primary care settings 42% of adverse events in long term care 42% of adverse events in long term care 380, ,000 adverse drug events occur annually in hospitals. 380, ,000 adverse drug events occur annually in hospitals. JAGS 2012 Arch Int Med 2009

Contributing Factors Multiple Medical conditions An average of 6-7 Rx and 3-4 OTC daily 40% have used some form of dietary supplement ADR’s more common when taking 5 or more meds daily Multiple providers Time Constraints Patient driven prescribing

Prescribing challenges for older patients Is pharmacotherapy is beneficial Is pharmacotherapy is beneficial Adverse reaction/Drug interaction potential Adverse reaction/Drug interaction potential Prescribing Cascades Prescribing Cascades Age related changes which alter drug response in older adults Age related changes which alter drug response in older adults Dosing of medications Dosing of medications

Prescribing challenges for older patients (cont) Cost of medications/MediCare issues Cost of medications/MediCare issues New vs. Established Medications New vs. Established Medications Limitations of Pre-marketing Trials Limitations of Pre-marketing Trials Problem Medications Problem Medications

Geriatric Pharmacology: Pharmacokinetics Absorption Absorption Use of PPI, H2Blockers, Antacids Use of PPI, H2Blockers, Antacids Medications with anti-cholinergic profile Medications with anti-cholinergic profile Distribution Distribution Fat soluble medications: an extended t1/2 Fat soluble medications: an extended t1/2 Water soluble medications: Higher concentrations Water soluble medications: Higher concentrations Dose adjustments are necessary Dose adjustments are necessary

Metabolism: Drug Interactions Differences in metabolism/drug interaction potential within a drug class Differences in metabolism/drug interaction potential within a drug class Statins: Crestor/Pravachol fewer problems Statins: Crestor/Pravachol fewer problems SSRI’s: Celexa/ Lexapro fewer problems SSRI’s: Celexa/ Lexapro fewer problems H2blockers: Cimetidine more problems H2blockers: Cimetidine more problems Antibiotics: Mixed Antibiotics: Mixed Additive effect Additive effect Serotonin syndrome/ QT prolongation Serotonin syndrome/ QT prolongation Plavix and PPI’s/ Codeine Plavix and PPI’s/ Codeine

PK: Excretion Creatinine clearance declines with age Creatinine clearance declines with age Serum Cr is a poor indicator of indicator and can overestimate renal function Serum Cr is a poor indicator of indicator and can overestimate renal function Dosing adjustment with reduced renal function Dosing adjustment with reduced renal function Vague guidelines which lack clinical practicality Vague guidelines which lack clinical practicality Bisphosphonates Bisphosphonates Macrodantin Macrodantin

Pharmacodynamics Blood Brain Barrier Permeability Blood Brain Barrier Permeability Increased Sensitivity medications Increased Sensitivity medications CNS acting medications CNS acting medications Diabetes medications Diabetes medications Consequences of low Blood Glucose Consequences of low Blood Glucose HTN meds HTN meds Consequences of low Blood Pressure Consequences of low Blood Pressure Drugs with anti-cholinergic profile Drugs with anti-cholinergic profile

Pharmacodynamics Examples of altered response in geriatrics Examples of altered response in geriatrics Oxybutinin Oxybutinin Diphenydramine Diphenydramine Albuterol Inhaler Albuterol Inhaler Timoptic eye drops Timoptic eye drops

Polypharmacy/Polymedicine What is “polypharmacy”? What is “polypharmacy”? The use of unnecessary medications which is independent of the number of medications being taken The use of unnecessary medications which is independent of the number of medications being taken Increases the risk of: Increases the risk of: Adverse reactions Adverse reactions Drug/Drug Interactions Drug/Drug Interactions Prescribing cascades Prescribing cascades Compliance Compliance

The prescribing cascade Drug induced adverse events which mimic symptoms of other diseases or can precipitate confusion, and or falls. Drug induced adverse events which mimic symptoms of other diseases or can precipitate confusion, and or falls. Prozac TO a FALL Prozac TO a FALL Prozac for depression. Ativan for Prozac induced anxiety and insomnia. Pt became dizzy, fell and broke a hip Prozac for depression. Ativan for Prozac induced anxiety and insomnia. Pt became dizzy, fell and broke a hip Plendil TO a diagnosis of GERD and an ORTHO work up Plendil TO a diagnosis of GERD and an ORTHO work up Plendlil for HTN; ORTHO work up ordered for Plendil induced edema; PPI was added for GERD Plendlil for HTN; ORTHO work up ordered for Plendil induced edema; PPI was added for GERD Verapamil TO Haldol Verapamil TO Haldol Verapamil for HTN; Lasix for Verapamil induced CHF/Edema; Ditropan for diuretic induced incontinence; Haldol for Ditropan induced confusion and agitation due to its anti- cholinergic effects Verapamil for HTN; Lasix for Verapamil induced CHF/Edema; Ditropan for diuretic induced incontinence; Haldol for Ditropan induced confusion and agitation due to its anti- cholinergic effects

ACOVE: Assessing Care of Vulnerable Elders Document drug indication Document drug indication Provide adequate pt education Provide adequate pt education Maintain current medication list Maintain current medication list Document response to therapy Document response to therapy Review ongoing need for therapy Review ongoing need for therapy

Medication Considerations Benzodiazepines: Long and short acting Benzodiazepines: Long and short acting Risk of confusion, falling, dependence Risk of confusion, falling, dependence Non-BZD hypnotics: Avoid chronic use Non-BZD hypnotics: Avoid chronic use More focus on behavioral management More focus on behavioral management Opioids: Increased risk of falls/fractures Opioids: Increased risk of falls/fractures Tramadol Clcr 30ml/min: SE/Seizure risk Tramadol Clcr 30ml/min: SE/Seizure risk

Medication Considerations Focus on Neuropathic pain alternatives: Focus on Neuropathic pain alternatives: SNRI’s/Gapapentin/Pregabalin/Capsaicin/Lidoc aine SNRI’s/Gapapentin/Pregabalin/Capsaicin/Lidoc aine Gabapentin/Pregabalin Clcr less 60ml/min Gabapentin/Pregabalin Clcr less 60ml/min Increased risk of CNS side effects Increased risk of CNS side effects Duloxetine less Crcl 30ml/min Duloxetine less Crcl 30ml/min More nausea/diarrhea More nausea/diarrhea

Medication Considerations Mirtazapine/SNRI/ SSRI’s: SIADH; Check Na when starting/changing dose Mirtazapine/SNRI/ SSRI’s: SIADH; Check Na when starting/changing dose SSRI’s: Increased risk of falling SSRI’s: Increased risk of falling OTC Sympathomimetics: Stimulant effects OTC Sympathomimetics: Stimulant effects Insomnia, anxiety, agitation Insomnia, anxiety, agitation Antipsychotics for behavior management Antipsychotics for behavior management Risk of CVA and mortality; Risk vs. Benefit Risk of CVA and mortality; Risk vs. Benefit

Medications Considerations NSAID’s PPI/misoprostol doesn’t ELIMINATE risk Indomethacin/Toradol CHF and CKD risk Increase in blood pressure with chronic use Skeletal muscle relaxants Poorly tolerated, all on the Beer’s list Potentially habit forming

Medication Conisderations Medication Conisderations Ca channel blockers: constipation/edema Ca channel blockers: constipation/edema Verapamil/Diltiazem and CHF Verapamil/Diltiazem and CHF Beta blockers: Hypoglycemia; Fatigue Beta blockers: Hypoglycemia; Fatigue Thiazides: SE and CrCl<30ml/min Thiazides: SE and CrCl<30ml/min Clonidine: Bradycardia, orthostasis Clonidine: Bradycardia, orthostasis Alpha Blockers: Orthostasis Alpha Blockers: Orthostasis

Medicaton Considerations Miscelaneous GI medications Reglan, Tigan, Lomotil* DA antagonist; Anticholinergic side effects Mineral oil Absorption of fat soluble vitamins; risk of aspiration H2 antagonists in dementia/delirium Aniticholinergic effects Na Containing Antacids Na Containing Antacids Substantial sodium load: Edema and increase in BP Substantial sodium load: Edema and increase in BP

Medication Considerations Endocrine Sliding scale insulin, Glyburide Actos/Avandia for CHF risk Desiccated thyroid Estrogen/Megace/Testosterone Estrogen/Megace/Testosterone Lack of cardio-protective/cognitive effect Lack of cardio-protective/cognitive effect Lack of weight gain/increased thrombosis Lack of weight gain/increased thrombosis Cardiac risk/prostate cancer Cardiac risk/prostate cancer

Drugs with Strong Anti-cholinergic Properties 1 st Generation antihistamines/Loratadine* Artane/Cogentin Skeletal muscle relaxants TCA’s/Paroxetine* Old antipsychotics Compazine, Promethazine, Zyprexa Urinary and GI antispasmodics The concept of “anti-cholinergic load”

Steps to Reducing Poly-pharmacy “Brown Bag” all medications at each office visit. Keep accurate records “Brown Bag” all medications at each office visit. Keep accurate records Identify all medications by brand/generic name and drug class Identify all medications by brand/generic name and drug class All drugs prescribed should have a clinical indication All drugs prescribed should have a clinical indication Stop any drug without known benefit Stop any drug without known benefit Consider what effect drug therapy has on quality of life Consider what effect drug therapy has on quality of life

Steps to Reducing Poly- pharmacy (CONT) Steps to Reducing Poly- pharmacy (CONT) Know the side effects of the drugs prescribed and what to expect from them Know the side effects of the drugs prescribed and what to expect from them Understand the PK and pharmacodynamics of drugs prescribed Understand the PK and pharmacodynamics of drugs prescribed Substituting drugs within classes can eliminate DI’s and ADR’s Substituting drugs within classes can eliminate DI’s and ADR’s Be aware for the prescribing cascade Be aware for the prescribing cascade “ONE DISEASE, ONE DRUG, ONCE DAILY” “ONE DISEASE, ONE DRUG, ONCE DAILY” “START LOW, GO SLOW, BUT GO” “START LOW, GO SLOW, BUT GO”