1. Medication Management in the Older Patient

2. Older adults are more likely to have an Adverse Drug Reaction More likely to be on 5 or more medications Hazzard, Principles of Geriatric Medicine and Gerontology

3. Older adults are more likely to have an Adverse Drug Reaction Altered pharmacokinetics – Declines in hepatic blood flow & hepatic oxidation – Declines in renal function – Changes in amount of body fat Altered pharmacodynamics – Decreased baroreceptor reflex – Decreased sensitivity to beta adrenergic effects – Increased CNS sensitivity to anticholinergics Podrazik, P. CHAMP (Curriculum for the Hospitalized Aging Medical Patient): DRUGS AND AGING. POGOe - Portal of Geriatric Online Education; 2009 Available from: http://www.pogoe.org/productid/20105

4. ADRs in older adults can be due to… Amplified drug effects Side Effects Drug-disease interaction Drug-drug interaction Drug-nutrient interaction Podrazik P. Drugs and Aging, CHAMP 2007

5. Mrs. G 78 year old woman with dementia Starts on donepezil for her dementia 6 weeks later she presents for follow up appointment complaining of urinary incontinence and anorexia She is given oxybutynin for UI and megestrol for anorexia

6. Bad stuff that happened here Side effects – Anorexia and UI are side effects of donepezil Polypharmacy – Prescribing cascade: oxybutynin and megestrol were added to treat side effects of donepezil Drug-disease interaction – Oxybutynin is anticholinergic, but dementia is already a low acetylcholine state Drug-drug interactions – Donepezil vs. oxybutynin

7. Step 1: Know what your patient is taking Multiple pharmacies often used Over the counter medications, herbals, supplements not always reported Medications belonging to others sometimes taken Best way to overcome all this is to do a “Brown Bag Review”

8. Step 2: Identify problems Match medications with the patient’s conditions Identify potentially inappropriate medications Identify prescribing omissions Ensure renal dosing if needed Look for – Drug-disease interactions – Drug-drug interactions – Drug-nutrient interactions Steinman MA & Hanlon JT. JAMA 2010

9. Matching Drug to Condition 75 year old woman with atrial fibrillation, hypertension, depression, and osteoporosis Independent with ADLs/IADLs Active social life Goal is to stay healthy and active Medication list – Digoxin 0.125mg QD – Metoprolol 50mg BID – Atorvastatin 20mg QD – Amitriptyline 50mg QHS – Alendronate 70mg Qwk

11. Beers list, STOPP criteria Developed by an expert panel These are lists of high risk/low benefit drugs – meds/classes of meds that should generally be avoided in patients over 65 ineffective high risk with a safer alternative available – meds to avoid due to specific medical condition The American Geriatrics Society 2012 Beers Criteria Update Expert Panel. J Am Geriatr Soc. 2012; Hamilton H et al. Arch Int Med 2011

12. Examples of Potentially Inappropriate Medications Top 3 drug classes resulting in ADEs – Musculoskeletal drugs NSAIDs muscle relaxants – CNS active drugs benzodiazepines anticholinergic drugs – Cardiovascular drugs antihypertensives antiarrhythmics Narrow safety margins Warfarin, insulin, digoxin

13. Academic Detailing

14. Step 3: Maximize adherence Is the regimen too complicated? Does the patient have physical problems that affect prescribing? – Low vision (large print labels) – Arthritis (no child safety bottles) – Swallowing problems (small pills, liquids) Is the cost of medications prohibitive?

15. 3 Steps for Medication Management Know what your patient is taking – Brown bag review Identify problems – Match drug to condition – Look for potentially inappropriate medications Maximize adherence

16. Useful References Steinman MA & Hanlon JT. Managing medications in clinically complex elders: “There’s got to be a happy medium.” JAMA 2010 Oct 3; 304(14):1592-1601. Hamilton H, Gallagher P, Ryan C, Byrne S, O’Mahony D. Potentially inappropriate medications defined by STOPP criteria and the risk of adverse drug events in older hospitalized patients. Archives Internal Medicine. 2011; 171(11):1013-1019. The American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012; 60(4): 616-631.