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

2. Physiology  Absorption  Metabolism  Elimination  Pharmaco-Dynamics

3. 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

4. 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

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

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

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

8. 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)

9. Understand Health Risks with associated age groups to guide medication options

10. Health Risks – Age 70-80  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)

11. Health Risks – Age 80-90  Fall risk  Dementia(s) (1 in 5)  Arthritis – Treatment of pain  Heart disease/Diabetes  Downsizing, moving, relocation, care communities  Sensory decline  Insomnia

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

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

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

15. 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

16. 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

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

18. 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

19. 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)

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

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

22. Questions?

23. 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 2227-2246. 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