1. Polypharmacy
Authors name and affiliation

2. ACKNOWLEDGEMENT
These slides were designed by Dr. Nancy Ordonez as part of her faculty role in the HRSA sponsored Houston Geriatric Education Center. Please credit her if utilizing these slides and recognize the Health Resource Service Administration for their support of our geriatric education program.
Nancy Ordonez., Pharm.D., BCPS
Clinical Associate Professor
Assistant Dean for Experiential Programs
University of Houston College of Pharmacy
Faculty
Houston Geriatric Education Center

3. Funded By
This project is funded by a grant from the Health Resources and Services Administration (HRSA) of the Department of Health and Human Services. The grant was initially funded in 2007 with renewed funding for five years beginning in (Grant #UB4HP19058). The grant ended in June, 2015.

4. Learning Objectives Successful students will be able to:
Identify and describe age-related physiological changes that influence pharmacokinetic and pharmacodynamic aspects of pharmacotherapy.
Discuss adverse drug reactions as they relate to older adults.
Identify iatrogenic problems with multi-geriatric syndromes and their medication regimens.
Discuss issues of medication compliance in older adults.
Describe general guidelines for prescribing appropriately and avoiding polypharmacy.

5. Statistics
Those 65 year and older represent 12.6% of the US population, approximately one in eight Americans.
The elderly account for nearly 30% of the nation’s health care expenditures and 25% of drug expenditures.
A survey of non-institutionalized participants found that 12% of women aged above 65 years took at least 10 medications and 23% took at least five prescription drugs.
The average US nursing home resident uses seven different medications each month, and about one-third of residents have monthly drug regimens of nine or more medications.
By 2030, it is estimated that one in five Americans (71.5 million) will be over the age of 65 years.
Ramaswamy R, et al. J Eval Clin Pract. 2010

6. “Function/Dysfunction” line
20 yrs
Functional
Capacity
80 yrs
“Function/Dysfunction” line
Age …… ……Disease Process >>>
Flaherty JH. Clin Geri Med 1998

7. Age Related Changes Pharmacokinetic Pharmacodynamic Absorption
Distribution
Metabolism
Excretion
Pharmacodynamic
Changes in receptor affinity
Changes in receptor number
Changes in response
Changes in homeostasis control

8. Disease States that Alter Pharmacokinetic and Pharmacodynamics
Renal Failure
Increases distribution
Decreases elimination
Alters distribution
Decreases baroreceptor sensitivity
Congestive Heart Failure
Liver Disease

9. Intrinsic Properties of Medications
Negative
Long biological half-life
Extensive oxidative metabolism (P450)
Many active metabolites
Highly protein bound
Lipophilic
Positive
Short biological half-life
Excreted unchanged or conjugative metabolism
Minimal protein binding
Hydrophilic

10. Definition of Polypharmacy
Strictly defined as the use of multiple medications
Threshold for the total number qualifying varies in the literature (2-10)
Comprehensively defined as the use of medications with duplicative indications, drug-drug interactions, disease-drug interactions, in adequate attention to pharmacokinetic/ pharmacodynamic principles, and/or no indication
Lee RD. J Am Board Fam Pract. 1998;11(2):
Monane M, et al. West J Med. 1997;167:

11. Factors Contributing to Polypharmacy
Increasing age
Multiple symptoms
Multiple medical problems
Copious prescribing
Multiple providers

12. Factors Contributing to Polypharmacy (continued)
Lack of primary care provider to coordinate
Use of multiple pharmacies
Drug regimen changes
Hoarding of medications
Self-treatment

13. Indicators of Polypharmacy
Prescribing medications with no apparent indication
Use of medications in same drug category
Concurrent use of interacting medications
Prescribing drugs contraindicated in the elderly
Ordering inappropriate dosages
Using a drug to treat an ADR
Clinical improvement following discontinuation of medications

14. The Prescribing Cascade
INITIAL CONDITION THERAPY NEW SYMPTOM SUBSEQUENT RX
ARTHRITIS
NSAID
 Blood Pressure
BP Med
DEPRESSION
Tricyclic Antidepressant
CONSTIPATION
LAXITIVE USE
AGITATION
ANTIPSYCHOTIC
Extra-Pyramidal Syndromes
PARKINSONS
MED
Gurwitz JH. P&T. 1997

15. Potentially Inappropriate Prescribing (PIP)
Defined as prescribing that poses more risk than benefit to the individual.
Using medications either have no clear evidence-based indication, carry a substantially higher risk of ADE or are not cost-effective.
The risk of adverse drug event (ADE) resulting from PIP ranges from weakness, to falls and fractures, even to life threatening events.
The Beers criteria is one of the most widely cited guidelines.
Other guides exist to determine appropriateness of therapy.
Ramaswamy R, et al. J Eval Clin Pract. 2010

16. Potentially Inappropriate Prescribing (PIP)
Studies show prevalence of at least one inappropriate medication being prescribed for up to 40% of nursing home residents and 21% of community-dwelling elderly.
The cost of medication related problems has been estimated to be $76.6 billion to ambulatory care, $20 billion to hospitals, and $4 billion to nursing home facilities.
If medication-related problems were ranked as a disease by cause of death, it would be the fifth leading cause of death in the United States.
Ramaswamy R, et al. J Eval Clin Pract. 2010

17. Beer’s Criteria
Fick DM, et al. Arch Intern Med. 2003;163:

18. Medication Appropriateness Index
Each question is answered using a three-point Likert scale. The first two questions receive a weighting of (3), the next four a weighting of (2), and the last four a weighting of (1).
Is there an indication for the drug?
Is the medication effective for the condition?
Is the dosage correct?
Are the directions correct?
Aare the directions practical?
Are there clinically significant drug–drug inter-actions?
Are there clinically significant drug–disease/condition interactions?
Is there unnecessary duplication with other drugs?
Is the duration of therapy acceptable?
Is the drug the least expensive alternative compared to others of equal utility?
Fitzgerald LS, et al. Ann Pharmacother. 1997;31:543-8.

19. Screening Tool of Older Persons' Potentially Inappropriate Prescriptions (STOPP)
STOPP is comprised of 65 clinically significant criteria for potentially inappropriate prescribing in older people. It incorporates commonly encountered instances of potentially inappropriate prescribing in older people.
includes drug-drug and drug-disease interactions, drugs which adversely affect older patients at risk of falls and duplicate drug class prescriptions.
criteria are arranged according to relevant physiological systems.
each criterion is accompanied by a concise explanation as to why the medication is potentially inappropriate.
Levy HB, et al. Ann Pharmacother ;44(12):

20. Screening Tool to Alert Doctors to the Right Treatment (START)
START consists of 22 evidence-based prescribing indicators for commonly encountered diseases in older people. The tool helps to identify prescribing omissions (medication indicated, but not prescribed).
Cardiovascular system
Warfarin in the presence of chronic atrial fibrillation, where there is no contraindication to warfarin
Beta blocker in chronic stable angina, where no contraindication exists
Respiratory system
Inhaled steroid in moderate-to-severe asthma or COPD, where reversibility of airflow obstruction has been shown
Central nervous system
L-dopa in idiopathic Parkinson’s disease with definite functional impairment and resultant disability
Gastrointestinal system
Proton pump inhibitor in the presence of chronic severe gastro-esophageal acid reflux
Locomotor system
Calcium and vitamin D supplement in patients with known osteoporosis
Endocrine system
ACE inhibitor or Angiotensin Receptor Blocker in diabetes with nephropathy
Levy HB, et al. Ann Pharmacother ;44(12):

21. Strategies to Optimize Prescribing
Educational Interventions
Small group workshops
Three step approach – quarterly reports, biannual onsite visits, and annual meetings
Computerized support systems
Dispensing and Ordering
Pharmacist interventions
Physician and Patients
Geriatric Medicine Services
Multidisciplinary Teamwork
Regulatory Polices
Medication Therapy Management
Kaur S, et al. Drugs Aging 2009;26(12):
Steinman M, Hanlon JT. JAMA 2010;304(14):

22. Medication Adherence in the Elderly
Complex and there is no “one size fits all” solution
Patient Specific Factors
Medication Specific Factors
Prescriber Specific Factors
Health Plan Specific Factors
Multimodal interventions that address behavioral aspects provide more benefit than education alone.
Conn VS, et al. The Gerontologist 2009;49(4): 447–62.

23. Proposed Strategies to Increase Adherence
Long-term Treatment
Combinations of:
Instruction/Instruction materials
Simplify regimen
Counseling/Reminders
Cueing to daily events
Reinforce/Reward
Patient self monitoring
Involve family/significant others
Short-term Treatment < 2 weeks
Counseling on importance
Written instructions
Reminder packaging
Haynes et al. JAMA, 288:

24. Healthcare Organization
Multimodal Approach
Patient
Must engage in essential behavior
Decide to control risk factors
Negotiate with provider
Adopt and maintain behavior
Monitor progress towards goals
Resolve barriers to goals
Must communicate with provider
Provider
Must foster effective communication
Provide clear and direct message
Include the patient in decisions
Incorporate behavioral strategies
Must document and respond to progress
Create evidence-based practice
Assess adherence each visit
Develop reminder system
Healthcare Organization
Healthcare organization must:
Develop supportive environment
Provide tracking and reporting systems
Provide education/training for providers
Provide adequate reimbursement for time
Healthcare organization must adopt systems to rapidly and efficiently incorporate innovations into practice
Circulation ;95:

25. Technology and Informatics to the Rescue?
E-prescribing
Provide point-of-care alerts
Decrease cost burden to patient
Improve reimbursement to provider
Optimize medication utilization for health plan
Physician Order Entry
Medical Home Model

26. Discussion