1. Medications in Older Persons
Kenneth Brummel-Smith, M.D.
Professor and Chair, Department of Geriatrics
FSU College of Medicine
Geriatric Workforce Enhancement Program
Healthcare Network of SW Florida

2. Objectives
Describe warning signs that nurses can observe that could indicate a medication problem
Describe 3 common problems in geriatric medication usage
Describe two techniques that can be used to assess an older patient’s understanding of the goal of treatment
Describe four steps that nurses can use to educate older patients on safe medication usage

3. One person’s drugs

4. Problems in Geriatrics Medication
Older patients take twice as many drugs as younger ones
28% of acute geriatric hospital admissions due to adverse drug events (ADE)
35% of community-dwelling elderly persons experience an ADE
In nursing homes, $1.33 spent on ADE for every $1.00 spent on medications

5. ADE Cascade DRUG 1 given (e.g., donepezil)-
Adverse drug effect (e.g. – dizziness)
misinterpreted as a new medical condition
DRUG 2 given (e.g., meclizine)
Adverse drug effect- (e.g., constipation)
misinterpreted as a new medical condition

6. Risk of ADE Age >85 Decreased BMI > 6 diagnoses
Creatine clearance < 50ml/min
9 or more meds
12 or more doses a day
Prior ADE

7. Changes in Aging Absorption Distribution
Slower, so drugs may take longer to reach peak effect
Distribution
Less water, more fat
Water-soluble drugs – need a lower dose (digoxin)
Fat-soluble drugs can build up – diazepam
Protein-binding
Always look at the albumin level

8. Changes in Aging Metabolism Elimination
Liver – often decreased function
Alcohol – metabolized in liver, same dose gives greater effect
Other common diseases can affect metabolism
Heart failure
Elimination
Kidney is most common method of elimination
Serum creatinine is NOT a good indication of kidney function

9. Polypharmacy Old way of thinking - # of drugs4 10
New way of thinking – taking more drugs than is clinically indicated
Goals and Targets
Symptoms and Prevention

10. Goals and Targets Goals – patient-generated desired outcomes
Avoid a stroke or heart attack
Not having bad side effects
Targets– prescriber-generated measurements that are proxies for the goal
BP, A1C level
The best outcomes happen when these are in alignment – collaborative approach

11. Symptoms and Prevention
Symptom goals
To FEEL better (less pain, less sadness, easier breathing)
Expect to results of treatment today
Prevention goals
To NOT have something bad happen (stroke, heart attack, die)
Takes time to achieve (usually)
Time-to-benefit

12. Time To Benefit
Most prevention treatments only start to show differences after years of treatment
Statins – 1-3 years
Blood pressure – 5-7 years
Some start showing benefits pretty quickly
Fewer asthma attacks with beta-agonists
Sometimes prevention and symptom treatments are simultaneous
Asthma

13. Prescribing & Deprescribing
Indications to treat
Example – hypertension after patient has tried to lower BP through life style changes and not be able to change behavior or no effect on BP even with changed behavior
Goal?
Indications to discontinue treatment
Example – patient with dementia has entered later stages and donepezil is not working
Goals?

14. Risky & Dangerous Situations
Greater than 4 medications
Physical frailty
Dangerous
10 or more medications
2 or more psychotropics
2 or more CNS drugs
Any new Sx that starts soon after a new drug

15. Beer’s Drugs (High Severity)
amitriptylene
barbituates
chlordiazepoxide
chlorpropamide
diazepam
doxepin
flurazepan
hysocyamine
meperidine
methyldopa
pentazocine
ticlopidine
American Geriatrics Society 2015 Updated Beers Criteria for
Potentially Inappropriate Medication Use in Older Adults, JAGS, 2015

16. Overprescribed Drugs Anticholinergics - Antivert
NSAIDs – Motrin, Aleve
Antispasmodics – Bentyl, Levsin
PPIs – Nexium, Prilosec
Antipsychotics – Haldol, Zyprexa
Sedative antihistamines - Benadryl
Benzodiazepines – Valium, Tranxene
Muscle relaxants – Flexeril, Soma
H2 blockers – Tagamet, Zantac
Tricyclic antidepressants - Elavil
Insulin, sliding scale
Vitamins & minerals
Meclizine, dicyclomine, hyoscyamine, haloperidol, olanzepine, diazepam, clorazepate, cimetadine, ranitidine, ibuprofen, naproxen, esomeprazole, omeprazole, diphenhydramine, cyclobenzaprine, carisoprodol, amitriptylene

17. Underprescribed Drugs
ACE inhibitors for patients with diabetes and proteinuria
Bronchodilators
Angiotensin-receptor blockers
Proton-pump inhibitors or misoprostol for GI protection from NSAIDs
Anticoagulants
Statins in secondary prevention
Antihypertensives and diuretics in uncontrolled hypertension
Vitamin D and calcium for patients with osteoporosis
β-blockers after myocardial infarction or with heart failure

18. Common Geriatric Problems
Dementia and incontinence
Do NOT prescribe an cholinesterase inhibitor if the patient is on an anticholinergic drug
E.g., donepezil with tolteradine
Effectively negate one another

19. Common Geriatric Problems
Long term PPI use
2/3 of scrips probably inappropriate
Increased risk of hip, spine and wrist fractures
Increased risk of C. defficile infections
Increased risk of pneumonia
Magnesium deficiency (cardiac risk)
No evidence for routine use for stress ulcer prevention in hospitalized patients
Must taper off it (weeks)

20. Common Geriatric Problems
Hypertension treatment
Always consider NSAIDs as the cause of hypertension before starting treatment
Atypical presentations - even when orthostatics are normal – e.g., lethargy, memory problems, depression
Adjust targets
No one below 130/85
Better target: below 150/90

21. Common Geriatric Problems
Type 2 Diabetes
No clear evidence that tight control reduces macrovascular events
No evidence that daily BS measurement is beneficial
Good evidence of risk of hypoglycemia
Better targets
A1C greater than 7% for all, above 7.5 for complex, and 8 to 9 for frail
AGS, Choosing Wisely,

22. Harder Problems
Stopping drugs in someone “trained” to watch the numbers
Higher A1C level in older diabetic having metformin side effects
Low BP readings in someone with a fear of strokes
Stopping drugs in people near the end-of-life
New goal – a death that “could be prevented”

23. Idealized Prescribing
There is evidence that the patient’s problem is responsive to a drug
The patient agrees to a drug-approach
The patient is motivated to take the drug
The drug causes no side effects
The drug is affordable and available
The drug works in this patient

24. Teach Your Patients Bring in all your medicines to every visit
Keep a list of your drugs in your wallet or purse
Use only one pharmacy
Don’t ask for any drug that is advertised on TV or in magazines
If a new drug is started:
Ask how long the drug has been on the market
Don’t take any drug until it’s been out for at least 2 years
Ask if there are other things besides taking a drug you can do
Ask if you should stop any current drugs

25. Why Bring in Drugs? Prescription written: Diltiazem 24hr ER 30 mg
Take one capsule every day

26. References
Geriatric Nursing Review Syllabus, American Geriatric Society
American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2015;63(11):616–631.
Brandt N. Optimizing medication use through deprescribing: tactics for this approach. J Gerontol Nurs. 2016;42(1):10–14.
O’Mahoney D, O’Sullivan D, Byrne S, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2014;44(2):213–218.