1. Challenges with Polypharmacy
Gerrie Bleifuss MSN, RN
Assistant Professor- Henry Predolin School of Nursing
Edgewood College

2. Polypharmacy What is it? How do patients end up on so many drugs?
What are some problems associated with polypharmacy?
What can be done about it?

3. Polypharmacy
Is the patient’s medication regimen in line with current disease specific guidelines?
Overprescribed medications.
What medications potentially increase patient’s risk for falls, cognitive impairment?
Most important predictor of inappropriate prescribing = number of prescribed drugs
Inappropriate prescribing imposes a burden
Ill-health, disability, hospitalization, death
*JAMA Intern Med 2015; 175(5)

4. Other factors contributing…
Is the patient actually taking the drug?
Does the drug fit with life circumstances?
i.e. Metastatic cancer patient taking statin
Biology of Aging- kidney function changes, consequences of protein bound meds, lipid solubility property
Does likely benefit outweigh risk of harm?
Increased harm for elderly patients taking
Opioids, NSAIDs
Benzodiazepines, Anti-cholinergics
PPI’s
Statins

5. To prescribe or deprescribe?
High-risk drugs –When are these safe for use?
Benzodiazepines
Opioids
PPI’s
Statins
Anti-psychotics
Anti-cholinergics

6. cont.
Goal:
Reduce risk for falls & change in cognitive & psychomotor function
Preventable ADRs
Withdrawal associated with improvements in all deficit areas

7. Deprescribing Benzodiazepines
Commonly overprescribed
Inappropriate used medication
Dementia may increase and increases anti-cholinergic activity
Increase is distribution, lipophilic drug
Metabolized faster in in older men than older women
Cause more sedation and poor psychomotor performance in older adults due to reduced clearance of the drug, resulting in higher plasma levels

8. Risks of Benzdiazepines
Poor evidence for improvement of insomnia
Cognitive impairment
Delirium
Falls and related injuries (hip fracture)
MVA
Harm of therapy occurs at a dose much loser than the dose needed to treat anxiety
Does not matter whether short term or chronic use

10. Key Points
Older patients should be warned that their use is not the best practice.
Education, education, education.
Decrease use of this one medication improves quality of life, safety and cognitive health in the elderly.
Having psychiatrists office along with primary physician office has potential of reducing the use of inappropriate meds esp benzo’s
Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial
2.Billottide Gage etalBMJ2014;349:g5205.

11. Indications for Benzo’s in Elderly
ETOH withdrawal
Terminal delirium or hospice patients at the end of life care
Resistant anxiety disorder, last resort

12. Opioids: where are we now?
Opioids cause nearly three out of four prescription drug overdoses1
A 200 percent rise in the death rate related to opioid overuse (including opioid pain relievers and heroin) since 20002
Medicare Part D3
spending on commonly abused opioids (such as hydrocodone and oxycodone) increased 165 percent from 2006–2015.
Multiple Black Box Warnings:
2013: Long-acting, extended release formulations
2016: Immediate release opioids
2016: Opioids and benzodiazepines

14. Cont. Multiple Black Box Warnings:
2013: Long-acting, extended release formulations
2016: Immediate release opioids
2016: Opioids and benzodiazepines

15. Guidelines to improve opioid use
CDC Guideline Recommendations
Non-opioids preferred, use opioids only when expected benefits (pain, function) likely to outweigh substantial risks. Encourage Non-Pharmacologic therapies
Use IR Opioids when Starting-lowest effective dose/shortest duration
Evaluate Benefits and Harms frequently
Avoid Concurrent Use of Opioid & Benzodiazepine
Centers for Disease Control and Prevention (CDC) “CDC Guideline for Prescribing Opioids for Chronic Pain —United States, 2016.”

16. PPI’s - Proton-pump Inhibitors
Initially, considered to have excellent risk benefit profile
Now, increasing appreciation of risk:
Pneumonia, C. diff, CKD, dementia, fracture risk, renal failure, unpublished CVD risk?
Often used for questionable indications:
Intended for short-term prophylaxis(4-8 weeks) or treatment, but continued long-term

17. What is wrong with STATINS
Muscle pain
Muscle weakness and fatigue
Diabetes
Cognitive impairment
FDA has added diabetes, memory loss warnings to statins.

18. Polypharmacy Associated Issues
• Adverse drug events
• Falls/Fall outcomes/Fall risk factors
• Hospitalizations
• Mortality
• Declines in Function
• Declines in Cognition
Fried TR, et al.,JAGS, 2014

19. Polypharmacy
It is much easier to add a medication than to take one away
Patients or facility staff report symptoms
The result is often a new prescription or an increased dose

20. Situations calling for deprescribing
New symptom or syndrome suggesting ADR
Manifesting advanced or end-stage disease, terminal illness, dementia, extreme frailty, or full dependence

21. Barriers to deprescribing:

22. Deprescribing- Focus on NH
The need for “deprescribing” is greatest in LTC
Often medications prescribed per patient
Regulatory environment: goal of stopping unnecessary medications

23. Strategies to facilitate deprescribing
System level:
Position statements on appropriate prescribing
Training / professional development
Clinical guidelines for complex older patients with multiple conditions

24. Shared Role in deprescribing
Instruct patients & caregivers how to recognize drug- induced harm
Ask pt what is important, what problems they are having
Review medication lists and highlight those amenable to deprescribing. Medication Reconciliation
Reduce dose of inappropriate med, slowly withdraw
Pharmacists are underutilized
Regulatory Initiatives: more dollars for research, HIT issues

25. Role of the nurse in deprescribing
Collaborative team approach; prescriber, pharmacist and nurse
Detects adverse effects, changes in patient’s behavior
Communication
Awareness of BEERS criteria

26. Deprescribing Review
Systematic process of identifying/discontinuing drugs
May lower dose or slowly wean down
Where existing or potential harms outweigh existing or potential benefits

27. Physician signing monthly orders:
Theoretically this would be a chance to review medical therapy
In practice, signing orders is usually reflexive and routine
The orders for a given facility all come at once
All facility orders are stacked at the first of the month

28. Deprescribing Summary
Process of tapering, stopping, discontinuing, or withdrawing drugs
Deliberate effort to manage polypharmacy and improve outcomes

29. Drug Withdrawal Trials
Scott, et al:
Review of 31 trials (15 randomized, 16 observational)
“With appropriate selection and education, coupled with careful withdrawal and close monitoring, antihypertensives, psychotropics and benzodiazepines could be discontinued without harm in % of patients.”

30. Scenario #1
Frail 90 y/o LTC resident nearing end-of-life, currently taking:
Atorvastatin
Memantine
Amlodipine
Diphenhydramine
Which are candidates for deprescribing?

31. Scenario #2
Patient with agitated dementia and multiple falls is taking:
Quetiapine
Memantine
Lorazepam
Hydralazine
Which are candidates for deprescribing?

32. Polypharmacy Assignment
Case Study: Group Geriatric Polypharmacy Instructions:
Carl is a 78 y/o who lives alone. After viewing the video about Carl, you are now assigned to make a home visit. When you arrive at Carl’s home, he gives you a list of the following medications he has at home.
Your group has been assigned one of the following list of medications. Analyze the case study in terms of the problematic nature of the patient’s pharmacological management. Please follow APA format. The paper should not exceed 5 pages. I encourage you to collaborate with a community pharmacist on this assignment.
Your answer should include the following:
Discuss the problem of polypharmacy in the elderly and the impact of this on drug compliance.
Consider the age-related changes of the geriatric patient and the aging effect on drug metabolism.
Identify 3 potential adverse reactions based on the combination of drugs prescribed in the case study chosen.
What additional assessments and lab values would be useful in further identifying the patient’s risks? Why?
Include educational strategies which could be implemented to improve the outcomes of this patient.

33. BEERS Criteria Update
AGS -American Geriatrics Society –2015 updated BEERS criteria. Next update 2018.
BEERS - based on consensus not evidenced based. Panel reviewed 6,700 research studies. 40 medications or classes of drugs identified as potentially inappropriate for older adults.
2 Criteria:
Medications that should generally be avoided > 65
Medications to avoid with specific medical conditions

34. BEERS 2015 Updates 3 new drugs added
2 new classes of medications added
10 new medications older adults should avoid
Suggested alternative medications and no prescription treatment options. @ HealthinAging.org

35. BEERS Changes 2015 cont.

36. BEERS Changes cont.

37. Thank you! Questions??

38. References
Scott I, Hilmer, S. (2015). The Process of Deprescribing - Reducing Inappropriate Polypharmacy. JAMA Internal Medicine 175(5),