Old Peeps and Drugs- Just Say NO Elizabeth von Wellsheim, MA, MSN, GNP Co-owner and Medical Director, ElderHealth & Living

Physiology  Absorption  Metabolism  Elimination  Pharmaco-Dynamics

Prescribing Rules of Thumb(s)  Attempt to eliminate medication(s) at every visit (De-prescribing)  Question adding medication to treat side effect  Can patient/care-partner take/give medication (time, frequency)?  Start low, go slow, keep going

Prescribing Rules of Thumb(s) (continued)  Reach therapeutic dosage before switching or adding medications  Look for duel action in a medication  Aricept – Alzheimer’s, constipation, tachycardia  Celexa – Depression, weight loss, stimulant  Remeron – Depression, weight gain, sleep aid

De-Prescribing  Opportunities  Care transition(s)  Annual/semi-annual wellness visits  When starting new medication  When identifying new problem

De-Prescribing (continued)  D/C Meds  Harm outweighs benefit  Minimal effectiveness  No diagnosis/indication  Not taking  Too old to benefit

De-Prescribing (continued)  Plan with patient  What to expect  Careful instructions  When to call if withdrawal reaction or worsening of underlying disease

Potentially Inappropriate Medications- PIM’s  Beers Criteria PIM’s – Quality of Evidence & Recommendations 1. Anticholinergics 2. Benzodiazepines (falls, delirium) 3. Antiparkinsonian Agents 4. Alpha-1 blockers 5. Digoxin – Avoid 1 st line A-fib (Quality mod., Rec. high) 6. Antipsychotics 7. Nitrofurantoin (Quality low, Rec. high)

Understand Health Risks with associated age groups to guide medication options

Health Risks – Age  Multiple co-morbidities  Complications of Heart Disease  Type II Diabetes Mellitus  Obesity  Alcoholism  Post-Retirement psycho/social depression  Dementia(s) – Major Neurocognitive Disorders (1 in 8)

Health Risks – Age  Fall risk  Dementia(s) (1 in 5)  Arthritis – Treatment of pain  Heart disease/Diabetes  Downsizing, moving, relocation, care communities  Sensory decline  Insomnia

Health Risks – Age 90+  FALLS, FALLS, FALLS  Dementia, Major Neurocognitive Disorder (1 in 3 live long enough will develop dementia)  Sensory deficits  Insomnia  Pain

Before Prescribing  Patient’s goals of care  Disease modification expectations  Life expectancy  Palliative management

Behavioral Issues with Dementia  Know type of dementia  Target specific (Reactive) Behaviors

Know Type of Dementia & Specific Behaviors  Alzheimer’s  Cholinesterase Inhibitors – Donepizil, Razydyne, Rivastigmine, Memantine  Exercise, bright lights, music  Hallucination/delusions/anxiety  Labile/mood swings - Nuedexta

Know Type of Dementia & Specific Behaviors (continued)  Lewy Body  Cholinesterase Inhibitors – Donepizil, Razydyne, Rivastigmine, Memantine  Management of hallucinations with fear/violence  Seroquel  Exercise, bright lights

Know Type of Dementia & Specific Behaviors (continued)  Vascular  Stimulating Antidepressants – SSRI, SNRI  Ritalin  Treat vascular disease – Lipids, blood pressure, diabetes mellitus  Exercise, bright lights

Know Type of Dementia & Specific Behaviors (continued)  Frontotemporal Lobe Dementia  No cholinesterase inhibitors  Labile mood – Nuedexta, Valproic acid  SSRI’s  Aggression violence  Prazosin - 1 mg qd, increase after 3 days up to 3 mg bid (check BP’s)  ? Antipsychotics  Bright lights, exercise

Rule-out Pain  Osteoarthritis (80% over age 70)  Step 1 NSAIDS/Tylenol (650 mg tid)/Aspirin (just low dose)/bed/mattress/seat height/cushion/walking/ exercise/off load weight to joint  Step 2 Step 1 plus: Lidoderm patch – everywhere! Tramadol Mod-pot-Oxycodone/hydrocodone  Step 3 Oral high-potency, long acting patches (more if skinny)

Rule-out Pain (continued)  Neuropathy  Step 1 Gabapentin Antidepressants – SNRI, SSRI’s Lidoderm patches NSAIDS (low intermittent) Tylenol Tramadol – 50 or long acting

Rule-out Insomnia  Melatonin (0.5 mg at 5 pm, 3 mg HS)  Sleep hygiene

Questions?

References Alzheimer’s Association. (2012). Alzheimer’s disease facts and figures. Alzheimer’s & Dementia, Volume 8 (Issue 2). American Geriatric Society. (2015). Updated Beers criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatric Society, Volume 63, pages Reuben, D., Herr, K., Pacala, J., Pollock, B., Potter, J., & Semla, T. (2015). Geriatrics at your fingertips (17 th ed.). New York: The American Geriatrics Society. eprognosis.ucsf.edu