Good Drugs, Old Drugs, & Bad Drugs
Partnering For a Better Future in
Medication Use in Older Adults
New Jersey Council of Teaching Hospitals
October 4, 2007
Donna Fick, PhD, RN, FGSA
The Pennsylvania State University School of Nursing and
School of Medicine, Department of Psychiatry
Gerontology Center, Faculty Affiliate
Objectives
• At the conclusion of this session, the participant will be able
to:
• 1. discuss the scope of polypharmacy and it's significance
to the health and quality of life of the geriatric population
• 2. discuss outcomes for inappropriate medication use in
older adults
• 3. identify barriers and facilitators to safe medication use
in older adults
• 4. identify strategies for interdisciplinary management and
safe use of medications in older adults using high alert
medications and other tools
Why Older Adults?
• Growing population----over 40% of
hospitalized patients 65 and older
• LARGEST CONSUMER OF MEDICATIONS
• More vulnerable to errors and drug-related
problems (chronic disease, aging changes)
# 1 KEEPING UP WITH NEW
DRUGS ON THE MARKET
 Internet Drug Sales
 Direct marketing to
consumers
 Are new $ drugs always
better?
 Long term effects versus
clinical trial results
 Media/marketing role (94%
of 3000 MDs reported
relationship with Pharm
industry)
# 2 INCREASED FOCUS ON ADVERSE
EVENTS CREATING TUG SAFETY/QUICK
DRUG APPROVAL
# 3 VALUE PLACED ON NONPHARMACOLOGICAL TREATMENTS
 Non-pharmacological
sleep protocols
 Supplemental pain
interventions
 Need-dementia based
model of care for
behavior problems in
persons with dementia
 Drugs should not always
be the first line of
treatment
# 4 AGING CHANGES
• Increase in body fat and
decrease in lean body mass
• Decrease in total body
water
• Decrease in GFR and CO
• Decrease plasma protein,
esp Albumin
• Decrease in liver mass and
blood flow may slow
metabolism
• Most changes lead to
increased toxicity
•
•
•
•
•
•
# 5 CHALLENGE OF ATYPICAL
PRESENTATIONS IN OLDER
ADULTS
Pneumonia
Congestive Heart failure
DELIRIUM
Myocardial Infarction
Urinary Track Infection
Depression
Adverse Drug reaction
# 6 MEASUREMENT
CHALLENGES
•
•
•
•
•
•
Unlikeliness of an event in a given pt or disease
Absence of prodromal signs before the drug exposure
Consistency with drug properties and injury
Recurrence of event with rechallenge of drug
Event goes away with discontinuance of drug
Known relationship with underlying mechanism of drug
action
• Related toxicity seen in vitro on animal studies
# 7 ATTITUDES &
KNOWLEDGE IN AGING
• In a study of Nurse knowledge of delirium utilizing
standardized case vignettes---41% recognized hypoactive
delirium and 32% said they would call the physician to
medicate the patient (Fick, Hodo, Lawrence, & Inouye,
2007)
• Only 21% recognized delirium superimposed on dementia
and 26% said they would call for a medication
# 8 MULTIPLE PLAYERS
# 9 GERIATRIC EDUCATION
• Shortage of geriatric trained
professionals
• Reduction in geriatric funding
• Growing population of older adults
• Earlier pre-clinical diagnoses of disease
• Costs and benefits of treatments
• Consumer knowledge and literacy
# 10 APPROPRIATE
MEDICATION USE
•
•
•
•
Overuse
Underuse
Misuse
Rights-drug,
patient, time,
way, dosage, price
Beers Criteria
Original author Mark Beers et al 1990
Explicit criteria (and list) of
medications to AVOID in older adults.
Should have a safer alternative.
Widely cited and used medication
criteria
Loved and hated all at the same time!
Expert Panel
• 16 potential participants with national
expertise in geriatric pharmacology,
geriatric medicine, psychopharmacology,
acute and longterm care
• Our response rate was 75% (12/16) and
all that responded agreed to participate
5 Parts In Survey For Experts to
Consider
1) Old Criteria medications to avoid with
and without diagnoses
2) New drugs out since criteria last
updated
3) New evidence since last update
4) Medications added by Panelists in first
and second rounds
Where To Find 2003 Beers
Medications*
• SeniorJournal
– http://www.seniorjournal.com/NEWS/Eldercare/5-01-06BeersCriteria03Tb2.htm
• Duke Center for Clinical and Genetic Economics
– http://www.dcri.duke.edu/ccge/curtis/beers.html
– * Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR,
Beers MH. Updating the Beers criteria for potentially
inappropriate medication use in older adults: results of a
US consensus panel of experts. Arch Intern Med.
2003;163:2716-2724.
– http://archinte.ama-assn.org/cgi/content/full/163/22/2716
HIGH ALERT MEDICATIONS
• anticoagulants, narcotics and opiates, insulins,
and sedatives
• Patients 65 and older more likely to be
harmed by high alert medications even when
used appropriately
•Our Data on High
Alert Medications
–Sedative Hypnotics
–CNS-active
Medication Use in Hospitalized Persons with Dementia
(N = 272)
Anticholinergics
Atypical Antipsychotics
Conventional Antipsychotics
Narcotic Analgesics
Antidepressants
Benzodiazepines
Acetylcholinsterase
Inhibitors
59.3
36.7
8.9
35.2
35.2
29.5
26.7
0
10
20
30
Percent
40
50
60
METHODS
• We examined association of DRPs with
administrative data for analyzing strength of
association, specificity, temporality, and biologic
plausability of the DRPs in N=960 older adults in MCO
• Claims data were collected for three years on all
identified cases with dementia and each included age,
gender, medical diagnosis for each claim (ICD-9 code)
and prescription drugs (NDC).
Aged 65 years or older
From managed care database
January 1, 1998
N=76, 388
ICD-9 code dementia
diagnosis
N=7,347 (10%)
Continuously enrolled
36 months with prescription drug
coverage N=960
Central nervous
system medications
No central nervous
system medications
N=766
N=194
RESULTS
– Over 79% of PWD in this sample were on a CNSactive medication during the three-year time period
(period prevalence).
– 62% were on a PIM as defined by 2003 Beers
criteria (Fick et al, 2003)
– 55.7% were on a COMBINATION of CNS drugs over
the 3 year period
Incidence of drug-related problems within 45 days of a CNS prescription,
n=766.
Prescription Type
Frequency Percent
Any CNS related Diagnosis within 45 days
Altered Consciousness
Syncope
Sleep Disturbance
Fatigue
Urine Retention
Constipation
Nervousness
Adverse Effect NEC
Bradycardia
Dry Mouth
Falls
Fractures
Bowel Hemorrhage
nCocussion
Hypoglycemia
Hypotension
Drug Induced Syndrome
Poisoning
Confusion
Delirium
Depression
429
91
159
46
133
33
61
1
10
26
2
42
45
34
3
12
11
10
0
63
92
25
56.0
11.9
20.8
6.0
17.4
4.3
8.0
0.1
1.3
3.4
0.3
5.5
5.9
4.4
0.4
1.6
1.4
1.3
0.0
8.2
12.0
3.3
Table 3: McNemar’s Test, Odd Ratio and 95% Confidence Interval for Differences in Drug Related Problems 45 days
before versus 45 days after a CNS prescription (n=766)
Drug Related Problem
Any CNS DRP
Syncope
Fatigue
Delirium
Altered Consciousness
Falls
DRP 45 days
before CNS
prescription
DRP 45 days after CNS
prescription
No
N (%)
Yes
N (%)
McNemar’s pvalue
McNemar’s OR and
95% CI
No
268 (34.99)
197 (25.72)
<0.0001
2.37 (1.81 – 3.12)
Yes
83 (10.84)
218 (28.46)
No
578 (75.46)
92 (12.01)
<0.0001
2.42 (1.61 – 3.67)
Yes
38 (4.96)
58 (7.57)
No
598 (78.07)
83 (10.84)
0.0001
2.08 (1.38 – 3.14)
Yes
40 (5.22)
45 (5.87)
No
653 (85.25)
62 (8.09)
0.0003
2.21 (1.36 – 3.65)
Yes
28 (3.66)
23 (3.00)
No
654 (85.38)
67 (8.75)
<0.0001
2.57 (1.57 – 4.28)
Yes
26 (3.39)
19 (2.48)
No
717 (93.60)
36 (4.70)
<0.0001
4.00 (1.76 – 9.76)
Yes
9 (1.17)
4 (30.77)
STUDY CITATIONS
• Fick, DM, Kolanowski, AM, Waller, JL, (2007). High
prevalence of inappropriate central nervous system
medications in community-dwelling older adults with
dementia over a three year period. Aging and Mental Health.
11 (5), 588-595.
• Penrod, J, Yu, F, Kolanowski, AM, Fick, DM, Loeb, S, Hupcey,
J. (2007). Reframing Person-Centered Nursing Care for
Persons with Dementia. Research and Theory in Nursing
Practice. Vol 21 (1), 61-76.
• Kolanowski, AM, Fick, DM, Waller, J, Ahern, F (2006).
Outcomes of Anti-psychotic Drug Use in Communitydwelling Elders with Dementia. Arch of Psych Nurs, 20, (5),
217-225.
What our data has shown so
far
1) Inappropriate medication use, CNS-active
and sedative hypnotic medications are
common in older adults and in PWD
2) Poor outcomes are associated with the use
in PWD
3) Medications are often the first line of
treatment for behavioral problems in PWD
4) Nurses and physicians often do not
recognize delirium
General Principles for Reducing Harm
from High-Alert Medications
• Hospitals and other care settings should employ
the following principles of a safe system:
• 1. Design processes to prevent errors and
harm.
• 2. Design methods to identify errors and harm
when they occur.
• 3. Design methods to mitigate the harm that
may result from the error.
Interventions for improving drug
use in older adults
• Many physician based interventions in managed
care—focus on only 1 player
• DADE project state of New York
• Challenges in addressing medication use in
acute care for older adults
• Most are based on computer alerts—must also
have culture change
Hospital Based Interventions in
Older Adults
1.
Joseph V. Agostini MD, Ying Zhang MD, MPH, Sharon K.
Inouye MD, MPH (2007)
Use of a Computer-Based Reminder to Improve SedativeHypnotic Prescribing in Older Hospitalized Patients
Journal of the American Geriatrics Society 55 (1), 43–48.
•
•
•
Use real-time computer based reminders to use non-pharm sleep
protocol
measured freq of prescribing 4 sed/hyp (diphenhydramine,
diazepam, lorazepam, trazodone)
Decreased 18%-15% post intervention
Interventions in Older Adults
1. Raebel et al. 2007 Randomized Trial to
Improve Prescribing Safety in Ambulatory
Elderly Patients, JAGS
2. Fick et al., 2004 Am J Man Care
3. Spinewine et al., 2007, JAGS
Decreasing Anti-cholinergic Drug
Use in Older Adults (DADE)
• Focus on providers AND patients
• State of New York CMS-designated quality
improvement organization
• Interdisciplinary Expert Panel
EDUCATION
•
•
•
•
•
•
NICHE
GERO-NURSE ONLINE
HARTFORD FOUNDATION
REYNOLDS FOUNDATION
ASCP
CONTINUOUS FEEDBACK
Future of Drug Use In Older
Adults?
• Broader interdisciplinary view
• Drug burden scales incorporating dosages and
cumulative affect
• Genetic targeting-personalized databases
*Gurwitz et al 2006
• Interdisciplinary approach and incentives
• IT-Electronic alerts, interventions, and
education
PATIENT CARE PEARLS
• Limit the overall number of medications
• Use of non-pharmacological approaches first
• Better use of technology to reconcile meds
• Good Communication between disciplines
• Continual assessment of Mental Status and
Function
• Special care at transitions and assess HOME
• Consider problem of underuse as well
NON-PHARMACOLOGICAL
ALTERNATIVES
• Sleep protocol (see McDowell, Mion, Inouye, 1998)
• Therapeutic Activity Program---http://www.atratr.org/dementiapractice/recommendations.htm
• Mobilize early and often
• Vision and Hearing aides
• Remove and camouflage invasive devices
• HELP--http://elderlife.med.yale.edu/public/publicmain.php
TAKE HOME PEARLS
• Appropriateness as DYNAMIC concept
• We must include more older adults in
clinical trials and develop system for
reliable post market data
• Geriatric education valued and funded
• Shared incentives and communication
among players
• Organization/SYSTEM culture change
To Our Many
Collaborative Partners
and Panel Experts
References
•
•
Judge et al Prescribers'responses to alerts during medication ordering in the long term care setting. J Am Med Inform Assoc. 2006 Jul-Aug;13(4):385-90.
Fick DM, Cooper JW, Wade WE et al. Updating the Beers criteria for potentially inappropriate medication use in older adults: Results of a US consensus panel of experts. Arch
Intern Med 2003;163:2716-2724.
•
•
Gurwitz, J, et al, Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA. 2003 Mar 5;289(9):1107-16
Gurwitz JH. Polypharmacy: a new paradigm for quality drug therapy in the elderly? Arch Intern Med. 2004 Oct 11;164(18):1957-9
•
•
Giron MS, Wang HX, Bernsten C et al. The appropriateness of drug use in an older nondemented and demented population. J Am Geriatr Soc 2001;49:277-283.
Schmader KE, Hanlon JT, Fillenbaum GG et al. Medication use patterns among demented, cognitively impaired and cognitively intact community-dwelling elderly people. Age
Ageing 1998;27:493-501.
Hajjar ER, Hanlon JT, Sloane RJ et al. Unnecessary drug use in frail older people at hospital discharge. J Am Geriatr Soc 2005;53:1518-1523.
Mamdani M, Rapoport M, Shulman KI et al. Mental health-related drug utilization among older adults: Prevalence, trends, and costs. Am J Geriatr Psychiatry 2005;13:892900.
Ballard C, Waite J. The effectiveness of atypical antipsychotics for the treatment of aggression and psychosis in Alzheimer's disease. Cochrane Database Syst Rev
2006:CD003476.
Vestergaard P, Rejnmark L, Mosekilde L. Fracture risk associated with the use of morphine and opiates. J Int Med 2006;260:76-87.
Meador KJ. Cognitive side effects of medications. Neurol Clin 1998;16:141-155.
Gill SS, Seitz D, Rochon PA. Atypical antipsychotic drugs, dementia, and risk of death. JAMA 2006;295:495-496.
American Society of Health-System Pharmacists. AHFS drug information. Bethesda, MD: American Society of Health-System Pharmacists, 2005.
Chan M, Nicklason F, Vial JH. Adverse drug events as a cause of hospital admission in the elderly. Intern Med J 2001;31:199-205.
Budnitz DS, Pollock DA, Mendelsohn AB et al. Emergency department visits for outpatient adverse drug events: Demonstration for a national surveillance system. Ann Emerg
Med 2005;45:197-206.
Hanlon JT, Schmader KE, Koronkowski MJ et al. Adverse drug events in high risk older outpatients. J Am Geriatr Soc 1997;45:945-948.
Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with icd-9-cm administrative databases. J Clin Epidemiol 1992;45:613-619.
Camargo AL, Cardoso Ferreira MB, Heineck I. Adverse drug reactions: A cohort study in internal medicine units at a university hospital. Eur J Clin Pharmacol 2006;62:143149.
Ensrud KE, Blackwell T, Mangione CM et al. Central nervous system active medications and risk for fractures in older women. Arch Intern Med 2003;163:949-957.
Hanlon JT, Pieper CF, Hajjar ER et al. Incidence and predictors of all and preventable adverse drug reactions in frail elderly persons after hospital stay. J Gerontol A Biol Sci
Med Sci 2006;61:511-515.
Naranjo CA, Busto U, Sellers EM et al. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther 1981;30:239-245.
Avorn, J Evaluating drug effects in the post-Vioxx world: there must be a better way. Circulation. 2006 May 9;113(18):2173-6.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
“Knowing is not enough;
we must apply.
Willing is not enough;
we must do.”
- Goethe