An Interdisciplinary Approach to
Better Prescribing in the Elderly
Saturday, November 30, 2013
Annual Scientific Assembly
Ontario College of Family Physicians
ǂMichelle
A. Hart, MD CCFP M.Sc.C.H.
ǂǂPauline Santora, BScPhm R.Ph ACPR PharmD
ǂDepartment
of Family and Community Medicine
ǂǂDepartment of Pharmacy
Baycrest Health Sciences, Toronto, ON, Canada
Faculty/Presenter Disclosure
• Faculty: Dr. Michelle Hart
• Program: 51st Annual Scientific Assembly
• Relationships with commercial interests:
None
Disclosure of Commercial
Support
• This program has not received financial support.
• This program has not received in-kind support.
• Potential for conflict(s) of interest: None
Mitigating Potential Bias
None
Faculty/Presenter Disclosure
• Faculty: Dr. Pauline Santora
• Program: 51st Annual Scientific Assembly
• Relationships with commercial interests:
None
Disclosure of Commercial
Support
• This program has not received financial support.
• This program has not received in-kind support.
• Potential for conflict(s) of interest: None
Mitigating Potential Bias
None
Objectives
By the end of this workshop you will be able to:
1) Understand the changes which occur with aging:
Physiological, Pharmacokinetic, and
Pharmacodynamic
2) Prescribe more safely by understanding the key
factors that affect drug utilization problems in
the elderly
3) Utilize an interdisciplinary approach to safer and
better prescribing in the elderly
Workshop Agenda
1) Physiological Changes of Aging
2) Pharmacokinetic Changes with Aging
3) Pharmacodynamic Changes with Aging
4) Polypharmacy and Drug Interactions
5) Medication Adherence
6) Adverse Drug Events & Other Challenges in the
System
7) Inappropriate Drug Prescribing Measurement
Methods
8) Quality Improvement Methods
9) Cases
What are the key factors that affect
drug utilization problems in the
elderly?
Let’s brainstorm….
4 Categories of drug utilization
problems in the elderly
1) Altered Physiology (changes with aging)
2) Altered Pharmacokinetics and
Pharmacodynamics (drug sensitivity)
3) Polypharmacy and Drug Interactions
4) Medication Adherence
Agenda Item #1:
Physiological changes with aging
Physiological changes that occur with
age: Cardiovascular system
• ↓ maximum heart rate (HR)
-Longer for HR and BP to return to
normal resting levels after exertion
• Blood vessels - thicker and stiffer
- ↑ systolic BP - hypertension
- ↑ risk of stroke, heart attack, renal failure
Physiological changes that occur with
age: Cardiovascular system
• Heart valves thicken and become stiffer
-heart murmurs common
• Pacemaker of the heart loses cells, develop
fibrous tissue and fat deposits
-can lower HR and cause heart block
-arrhythmias, extra heart beats common
Physiological changes that occur with
age: Cardiovascular system
• Baroreceptors which monitor blood pressure
become less sensitive
• Quick changes in position may cause dizziness
– Orthostatic hypotension
Physiological changes that occur with
age: Respiratory system
• Lungs stiffen
• ↓ Respiratory muscle strength and endurance
• ↑ Chest wall rigidity
Lung function:
• ↔Total lung capacity
• ↓ Vital capacity
• ↑ residual volume
Physiological changes that occur with
age: Respiratory system
• ↓ in alveolar surface area by up to 20 %
- Alveoli collapse sooner on expiration
• ↑ mucus production
• ↓ in activity and number of cilia
• ↓ efficiency in monitoring and controlling
breathing
Physiological changes that occur with
age: Gastrointestinal system
• ↑ prevalence of Atrophic Gastritis, Achlorhydria
• ↓ liver efficiency- drug metabolism, cell repair
• ↓ Decreased intestinal absorption of lactose,
calcium, iron
• Diverticuli in the colon → pain.
• ↓ peristalsis of the colon →constipation.
Physiological changes that occur with
age: Kidneys
• ↓ kidney mass by 25-30 %
• ↓ number of glomeruli by 30 to 40 %
- ↓ ability to filter/concentrate urine, clear
drugs
• ↓ hormonal response (vasopressin)
• Impaired ability to conserve salt
-↑ risk for dehydration
Physiological changes that occur with
age: Urinary system
• ↓ Bladder capacity
- ↑ residual urine – urgency and frequency
- ↑ chances for urinary infections,
incontinence, obstruction.
Physiological changes that occur with
age: Endocrine system
• Pituitary gland shrinks with age
• Insulin resistance
- impaired conversion of glucose into energy
- diabetes
• ↓ aldosterone and cortisol
- impaired immune and cardiovascular
function
Physiological changes that occur with
age: Reproductive system
Women:
• Ovulation ceases, estrogen levels ↓ by 95%.
• Vaginal walls become thinner and lose
elasticity
• Most women experience a decrease in the
production of vaginal lubrication
Physiological changes that occur with
age: Reproductive system
MEN:
• In some men, testosterone ↓ by up to 35%
• ↓ size of the testes
• ↓ rate of sperm production
• Erectile dysfunction (impotence) experienced
by 15% of men by the age of 65 and increases
to 50% by age 80
• Prostatic Hypertrophy
Physiological changes that occur with
age: Musculoskeletal system
• Loss of height (age 80, avg ~ 2”)
- vertebral compression, changes in posture,
↑ curvature of the hips and knees
• Weight
- gain until age 60 – lifestyle (inactivity,
poor eating habits)
- fat mass can double, lean muscle mass ↓
- Loss after 60
Physiological changes that occur with
age: Musculoskeletal system
• ↓ bone mass
• ↓ muscle strength, endurance, size, weight
-loss of ~ 23% by age 80
-inactivity, poor nutrition, chronic illness
Physiological changes that occur with
age: Skin & Soft Tissue or Integument
Skin: wrinkling, pigmentation, thinning
- loss of moisture, ↓ elastin and collagen
- ↓ cell size
- 20% thinning between dermis + epidermis
- hair graying and hair loss
- ** sun exposure
Physiological changes that occur with
age: Oral cavity
• 40% of those >65 are edentulous
- mostly because of neglect
• Risk of caries increases with age as a result of
gingival recession and loss of jaw bone density
- think of antibiotic coverage
• ↓ ability to taste sweetness, sourness and
bitterness
Physiological changes that occur with
age: Immune system
• ↓ Production of thymic hormones
• ↓ Levels of antibody response
• ↓ Response to antigens
***Importance of vaccination: yearly flu shot,
Pneumovax in all elderly patients !
Physiological changes that occur with
age: Immune system
Increased risk for infections:
• 3 x more likely to die of pneumonia or sepsis
• 5 - 10 x more likely to die of urinary tract
infections
• 15 - 20 x more likely to die of appendicitis
• Mortality rate from infection is much higher
than in the young
Physiological changes that occur with
age: Nervous system
• ↑ Incidence of cognitive impairment with age
- by age 85, up to 1/3 of elderly have some
degree of cognitive impairment
•
↓ weight & volume of the brain
• Attention (to perform tasks) often preserved
• Semantic knowledge (word retrieval) declines
• Linguistic abilities ↔
Physiological changes that occur with
age: Nervous system
Memory
Encoding (getting info into system) declines
- affected by ↓ senses (vision, hearing, smell,
taste, touch)
- most likely the reason for age-related
declines in short-term memory
Storage (retaining information) ↔
Retrieval (recalling information)
- recognition doesn’t decline but recall does
Physiological changes that occur with
age: Nervous system
• ↓ visual-spatial ability
• ↓ conceptualization
(mental flexibility and capacity for abstraction) (> age 70)
• ↓ performance scores in problem solving
• ↔ comprehension, math, vocabulary
• ↓ speed of information processing
- ↓ reaction time
Agenda Item #2:
Pharmacokinetic Changes with age:
The action of drugs in the body over a period of time
which include processes of:
1) Absorption
2) Distribution
3) Metabolism
4) Elimination
Pharmacokinetic changes that occur
with age: Absorption
Oral
• ↑ gastric pH
• ↓ splanchnic blood flow
• Delayed gastric emptying
• ↓ intestinal transit
• ↓ GI absorptive surface
Pharmacokinetic changes that occur
with age: Absorption
Oral
• Most drugs are absorbed via passive diffusion which is
unchanged
• Possibly reduced intestinal absorption of agents requiring
active transport
• Reduced first-pass metabolism
– Increased absorption of some high-clearance drugs
– Decreased absorption of drugs from pro-drugs
Overall: No significant changes in drug absorption in the
elderly for most drugs.
May be slower but extent is generally unchanged.
Pharmacokinetic changes that occur
with age: Absorption
Subcutaneous/Intramuscular
• ↓ dermal vascularity
May see a decreased rate of absorption
Topical
• ↓ hydration and lipophilic content of aged skin
Theoretically, may ↓ absorption of hydrophilic drugs, but
not seen in practice with transdermal patches.
Pharmacokinetic changes that occur
with age: Absorption
Inhalation
• ↓ chest wall compliance, V/Q matching,
alveolar surface area
• ↓ dexterity and diseases such as OA and
Parkinson’s disease ↓ effective administration
of devices
May see a decreased absorption
Pharmacokinetic changes that occur
with age: Distribution
Dependent on:
• Protein Binding
– Albumin (acidic drugs)
– Alpha-1-acid glycoprotein (basic drugs)
• Volume of Distribution
• Blood Flow
Drugs significantly bound to Plasma
Proteins
Plasma Protein
Drug
Protein Binding (%)
Albumin (acidic drugs)
Naproxen
Phenytoin
Warfarin
99
95
99
Alpha 1-glycoprotein (basic drugs) Lidocaine
Propranolol
Quinidine
Imipramine
80
90
88
89
Change in body composition with age
%
Pharmacokinetic changes that occur
with age - Distribution
↓ Total Body Water
Hydrophilic Drugs -↓ Vd, ↑ plasma
concentration, ↓ t ½
e.g. Lithium, Ethanol, Digoxin, Morphine
↓ Lean Body Mass
Drugs which distribute into muscle -↓ Vd and
↑ plasma concentration, ↑ t ½ e.g. Digoxin
↑ Body Fat
Lipophilic Drugs - ↑ Vd, ↓ plasma
concentration, ↑ t ½
e.g. Diazepam, Amitriptyline, Chlorpromazine
↓ or ↔ Serum Albumin
↓ or ↔ binding acidic drugs, ↑ or ↔ free
drug e.g. Warfarin, Phenytoin, Naproxen
↔ or ↑ alpha-acid
glycoprotein
↔ or ↑ binding basic drugs, ↓ or ↔
free drug e.g. Lidocaine, Propranolol
Pharmacokinetic changes that occur
with age: Metabolism
• ↓ Hepatic mass by 25-35 %
– capacity limited
e.g. Theophylline, Warfarin, Diazepam, Phenytoin
• ↓ Hepatic blood flow by > 40 %
– blood flow limited
e.g. Morphine, Meperidine, Lidocaine, Verapamil,
Tricyclic Antidepressants, Calcium Channel Blockers
Pharmacokinetic changes that occur
with age: Metabolism
• ↓ Phase I reactions (oxidative)
(avoid or ↓ frequency)
e.g. Alprazolam, Diazepam, Flurazepam
• ↔ Phase II reactions (conjugative)
(not significantly affected)
e.g. Lorazepam, Oxazepam, Temazepam
Pharmacokinetic changes that occur
with age: Metabolism
• Drug interactions due to polypharmacy may
result in other drugs inhibiting or inducing
their hepatic metabolism -phase I cytochrome
P450 system
• Large interindividual variation – other
variables more important than age
Pharmacokinetic changes that occur
with age: Metabolism
Interindividual Variability
• Genotypes
- fast vs. slow acetylators
- rapid vs. poor oxidizers
• Lifestyle
- smoking, ethanol, grapefruit juice
• Cardiac Output
• Gender, hormones
• Age
Pharmacokinetic changes that occur
with age: Renal Elimination
•
•
•
•
↓ RBF (Renal Blood Flow)
↓ GFR (Glomerular Filtration Rate)
↓ Tubular secretion
Renal mass ↓ by 30% with loss of functional nephrons and
glomerulosclerosis
• Require decreased dosing: e.g. Digoxin, Fluoroquinolones,
Fluconazole, Cotrimoxazole, Cephalosporins, Enoxaparin
• Avoid in renal dysfunction: e.g. Glyburide, Nitrofurantoin,
Metformin, Aminoglycosides
Pharmacokinetic changes that occur
with age: Renal Elimination
• Overall: ↓ renal functioning; CrCl 30-50%
from age 40 to 80 for the majority of elderly
especially those with comorbid conditions e.g.
hypertension, diabetes, etc.
Decline in Creatinine Clearance with
Age
Pharmacokinetic changes that
occur with age: Renal Elimination
• Not all healthy elderly have ↓ renal
functioning
• 25-30 % of healthy elders maintain
relatively good renal function with a
CrCl > 70 mL/min well into old age
A Normal Serum Creatinine is not an indicator of
normal renal function in the elderly
• Muscle mass also declines with age
• Therefore, serum creatinine levels are also expected
to decrease with age
• A CrCl must be calculated to estimate renal function
For example, 70 kg male with SCr 100 µmol/L
Age (yrs)
40
60
80
90
CrCl
(mL/min)
86
69
52
43
Calculate Creatinine Clearance
(Cockcroft & Gault Formula)
• CrCl (mL/min) = (1.23)(140-age) (weight kg)
Serum Creatinine (umol/L)
• Correction factor for females x 0.85
• Tool for Drug Dosing in Renal Dysfunction
Agenda Item #3:
Pharmacodynamic changes that occur
with age:
The relationship between the drug concentration
and the receptor site and the body’s response.
Enhanced drug sensitivity in the elderly.
Pharmacodynamic changes that occur with age
4 Possible Mechanisms for changes in drug sensitivity in
elderly;
1)
2)
3)
4)
Changes in receptor numbers
Changes in receptor affinity
Post-receptor alterations
Age-related impairment of homeostatic mechanisms
Pharmacodynamic changes that occur with age
• ↓ B1 receptor density & agonist affinity → ↓ BB effectiveness
• ↓ concentration of some neurotransmitters (e.g. Dopamine)
enhancing the effect of drugs that block the neurotransmitter’s
activity
•
Altered homeostasis
- impaired regulation of temperature and electrolytes
Pharmacodynamic changes that occur with age
↑Sensitivity of receptors in brain & changes in NA, muscarinic, serotonergic
systems leading to common ADRs. e.g. CNS depressants:
- Benzodiazepines (diazepam 2-3x sensitivity, leads to more
falls/fractures)
- Barbiturates
- Antipsychotics (e.g. sedation, anticholinergic, orthostatic
hypotension and arrhythmias)
(↓dopamine receptors/neurons, levels, ↑ risk of EPS effects)
- Opioids: 2-8 x higher risk of respiratory depression but N/V
decreased.
Hallucinations and cognitive impairment may ↑ risk of falls/fractures
- Antidepressants
Agenda Item #4:
Polypharmacy and Drug Interactions
Polypharmacy
• High prescribing rates = high rates of adverse
drug reactions (ADRs)
• Risk increases with > 4 meds and rises
dramatically when ≥ 9, multiple doses/day
(>12)
• ADRs contribute to 11-31% of hospitalizations
for the elderly
Physician is unaware of:
• 37 % of drugs elderly patients are taking
• The 6 % of drugs that have been discontinued
• The actual dose/frequency for 10 % of drugs
used
Frank 2001 Can Fam Physician
Prescribing
Particularly in the Elderly
What else are they on?
• 82 % of adults are taking at > 1 drug
• 29 % are taking > 5 drugs
• > 65 y.o. 19 % take > 10 diff. drugs/week
• 63 % use vitamins
• 22 % of adults use herbals/natural
supplements
Slone Survey 2006
Polypharmacy→Medication
Optimization
• A more current term is Medication
Optimization (since many patients truly need
the many medications for their plethora of
problems)
• Its not about reducing medications- we
actually want to ensure that Elderly are on the
optimum number and dose of medication for
their problems
Drug Interactions
Types:
Prescription drug – Prescription drug
Prescription drug – Over the counter drug
Prescription drug – Herbal or Natural product
Prescription drug – Food
Drug – Disease
Drug – Lab Test
Drug Interactions
•  With: Age, # drugs, # doctors, #
pharmacies, # diseases
•
•
•
•
How do you identify them?
Do we need to avoid them all?
Which ones to avoid?
How do we communicate/assess? How to
avoid? How do we monitor?
Agenda Item #5:
Medication Adherence
We will review Common Causes of
Medication Non-adherence
(and how to use a team approach to minimize)
Common Causes of Medication
Non-adherence
• Doesn’t know why they need to take it; doesn’t agree with plan;
doesn’t “trust” the physician
• Psychological disorder – doesn’t comprehend need to take
• Memory disorder – doesn’t remember to take
• Cannot afford medication; “not covered”; “no LU Code”
• Drug unavailability
• Cultural beliefs
• Language barrier
• Instructions unclear or incorrectly labelled (illegible Rx)
Common Causes of Medication Non-adherence
• Difficulty opening bottle (e.g. child resistant vials) due to
impaired manual dexterity
• Physical limitations to administer (e.g. inhalers, insulin)
• Impatience for response – patient increases dose/frequency
• Complicated/impractical regimen
• Unable to read label/visual impairment/small print/”as
directed”/forgets info
Common Causes of Medication Non-adherence
• Patient misorganizes pills (eg. Labeled lids mismatched to pill
bottles, multiple meds into one pill bottle, pills moved to
alternate pill bottle)
• Lack of care giver availability to administer
• Lack of education on proper use, dose, administration
techniques, duration, delay in onset of response
• Refills – lack of refills, forgets to refill, unable to order/pick up
refills
• Adverse effects
Compliance Related to the Number of
Medications
• Not specific to the elderly
• Problem is that they are taking too many!
• Overall compliance is 50 % in all age groups:
1 drug
80 %
2 drugs
65 %
3 drugs
55 %
> 6 drugs 25 %
• Number of drugs and the frequency of dosing
Strategies to Increase Adherence
• Patient/Caregiver must understand the
purpose/importance of each medication. Hear it
from physician, pharmacist, care giver.
• Bring in all medications to every visit
• Listen to patient/care giver regarding reasons for
non-adherence
• Non-judgmental approach
• Correct any reasons possible e.g. snap caps,
dosettes, adjust dose, change drug
• Education – patient, family, caregiver
• Family/Caregiver Support
Strategies to Increase Adherence
• Link medication doses with daily routines, such as
meals, bedtime
• Address issues with method of administration
(e.g. can’t swallow)
• Use memory aids
• Pill counts/communication with pharmacist
Re: refills
• Use Team approach to review number and
frequency of drugs, whenever possible
• Look for additional risk factors e.g. memory,
vision, manual dexterity, psychosocial factors
Agenda Item #6:
Adverse Drug Events & Other
Challenges in the System
Adverse Drug Events
• 1/3 rd of hospital admissions in the elderly linked to drugs
• Non-adherence, omission or stopping medications
accounted for ¼ of admissions
• Age does not effect compliance as much as the
complexity of drug regimen and patient comprehension
• ADRs 7-10 x more common in 70-79 yo than 20-29 yo.
• 50 % are potentially preventable
• Risk factors include an increased number of medications
Chan 2001
Medication use leading to Emergency
Department visits:
• Warfarin (17.3%)
• Digoxin (13%)
• Insulin (3.2%)
33% of ADR visits related to these 3 meds!
Budnitz DS, Shehab N, Kegler SR.
Ann Intern Med 2007;147:755-765
The Prescription Cascade
• A process whereby side effects
from drugs are misdiagnosed as
symptoms of another problem,
resulting in further prescribing
and further side effects and
unanticipated drug interactions.
Prescribing cascades
 An adverse reaction is misinterpreted as a new
medical condition
Drug 1
Adverse drug effect
misinterpreted as a new
medical condition
Drug 2
Adverse drug effect
Rochon P, Gurwitz JH.
BMJ 1997:315:1096-1099
Author John Cole
Published in the Times Tribune
Drugs in the elderly
 Each medication should have a desired
therapeutic endpoint with a plan for monitoring
 Start low and go slow (but keep going!)
 Be aware of patients’ other medications:
BEWARE OF PRESCRIBING CASCADES
 OTC meds can have significant adverse effects
 Adherence is always an issue
 Regularly review medications on list
 Usually less is better (but not always!)
Agenda Item #7:
Inappropriate Drug Prescribing (IDP)
Measurement Methods
Inappropriate Drug Prescribing (IDP)
Measurement Methods
• Implicit Methods: as Evidence-based as the
rater’s knowledge, but lack structure to permit
good reliability and quality improvement
• Explicit methods: Beers, STOPP/START, etc.
However rigid criteria makes it difficult
individualize assessment/recommendations
for patient
Medication Appropriateness:
Explicit Method- Beers Criteria
• 1991 Beers et al. set criteria for determining
IDP in Nursing Home Residents (NHR)
• 30 drugs which should not be prescribed in
Nursing Home Residents
• 1997 and 2003 Beers updated criteria to be
applicable to general population
• Scope of criteria now includes meds for adults
> 65, includes community dwellers – geriatric
patients in all settings
New 2012 Beers Criteria
•
•
•
•
•
•
Meds no longer available removed
New drugs introduced since 2003 added
Research updated
Evidence-based approach
Supported by American Geriatric Society (AGS)
Includes ratings of quality of evidence supporting
recommendations
• Followed Institute of Medicine standards for
evidence and transparency
Limitations of Beers Criteria
• Should not substitute for professional
judgement and individualized care
• Does not address needs for palliative or
hospice care
Summary: Beers Criteria
• Role is to inform clinical decision making,
research, training, policy
• Improve quality and safety of prescribing
meds for older adults
Medication Appropriateness:
Explicit Method- STOPP/START Criteria
• Screening Tool of Older Persons Potentially
Inappropriate Prescriptions and Screening
Tool to Alert Doctors to the Right Treatment
• Validity established through Delphi Consensus
process – 18 experts in geriatric
pharmacotherapy, Ireland and UK participated
STOPP/START Criteria
• STOPP comprises of 65 indicators pertaining
to important drug-drug and drug-disease
interactions (potentially leading to side effects
such as cognitive decline and falls)
• START incorporates 22 evidence-based
indicators of common prescribing omissions
STOPP/START Criteria
• Organized using physiological systems
• Include “clinical stopping rules”
• Considerable overlap with the American
Geriatric Society Beers Criteria
STOPP/START Criteria
• RCT Gallagher et al 2011
• Use of START/STOPP criteria to screen clinical and
prescription data for representative sample of
hospitalized older patients resulted in significant
and sustained improvements in prescribing
appropriateness in terms of reducing rates of
overuse, misuse, and underuse of medications
and measured by Medication Appropriate Index
(MAI) and Assessment of Underutilization (AOU)
Indices.
STOPP/START Criteria
• Intervention reduced:
1) Use of unnecessary drugs
2) Risk of drug-drug and drug-disease
interactions
3) Prescriptions of drugs as incorrect
doses, frequency, and duration
4) Underprescribing for common conditions such
as cardiovascular disease, diabetes,
osteoporosis
Beers Criteria and STOPP/START
criteria: the broader perspective
• Purpose to improve medication safety in older
adults, increased awareness of inappropriate
medication use in older adults
• Encourage health care providers to stop and
consider carefully the risks, consider non-drug
alternatives
• Broad application to electronic health records
Beers Criteria and STOPP/START
criteria: the broader perspective
• Evidence to be used in complimentary manner
with 2012 Beers Criteria to guide clinicians in
making decision about safe medication use in
older adults
Medication Appropriateness:
Implicit Method: Medication
Appropriateness Index
Hanlon et al. Clin Epidemiol 1992; 45:1045-51
Somers A. Amer J of Geriatric Pharmacotherapy. 10(2) April 2012: 101-109.
•
•
•
•
•
Is there an indication for the drug?
Is the medication the right choice for the condition?
Is the dosage correct?
Are directions correct/practical?
Are there clinically significant drug-drug interactions (including
duplicate therapy)?
• Are there clinically significant drug-disease/condition
interactions?
• Is duration of therapy acceptable?
• Are there clinically significant adverse drug reactions?
Authored by: Jim Unger
Andrews and McNeel Inc
Universal Press Syndicate
Agenda Item #8:
Quality Improvement Methods
and
“The Future of Working Together”
What might it look like?
Communication, Communication, Communication
Quality improvement in Drug Therapy
• Perform a periodic medication review at least annually
• Ask the patient to bring in all meds (incl. prescription, OTC,
vitamin, herbals/naturals). Bring family member/friend.
• Apply Medication appropriateness criteria
- Extrinsic e.g. Beers criteria, STOPP/START criteria
- Intrinsic – assess appropriateness of each
med given the patient context
• Review meds: What are they taking? What are they not
taking? How is the patient taking them? Are they working?
Any adverse effects?
• Reinforce (purpose/importance/benefit) or consider
stopping.
• With which patients to start?
Office Visits - Routine
• Bring bag of ALL medications to all office visits
• Review last visit(s) in chart – reason for visit
and prescriptions written
• Follow-up with patient/care giver
-Did it resolve?
-Did the medication make a difference?
-Any adverse effects?
-Are you still taking the medication and if so
how?
Office Visits
• Have you had any other medical visits since I
saw you last (eg. Specialists, ED visits, etc)?
• If so, who/where? For what? What medication
if any was started?
• Any changes in your health, or new over the
counter, vitamins, herbal products you have
started?
“A healthy dose of information”
Program Funded: Province of Ontario, Ministry of Health (no charge to patient)
Criteria: OHIP Card, on at least 3 Rx medications for a chronic condition, haven’t
done it in the past 12 months.
Who Can Request: Patient, Dr., RN EC or Pharmacist
Service: Once a year 1:1 pharmacist and patient/care giver consultation to
review the medications. Ideally bring in all OTC, herbal, natural, Rx. Diabetics
can have frequent follow-ups if there are issues.
Goals: To increase compliance and knowledge. To update the information e.g.
allergies, what has stopped, reinforce how to use it, address patient’s concerns,
refer to physician as required, etc.
Medication Reconciliation
• Best Possible Medication History (BPMH)
• Comparison of BPMH to prescriptions at each transfer
point within hospitalization (admission, transfer within the
hospital units, discharge) and documentation of any
discrepancies.
• Goal: Seamless care to prevent medication errors
• Facilitated by bringing lists, meds, related information,
MARs, Family Physician list, ODB Profiler, knowing what is
being taken, not taken and why.
• Currently: it is quite labor intensive.
• Future: Electronic Health Records accessible throughout
Agenda Item #9:
Cases – Medication Optimization
Case #1
• Mr S
• 88 year old Male
• PMH: Parkinson’s Disease, Mild Cognitive
Impairment, Hypertension, BPH,
Hypercholesterolemia, Osteoarthritis
• Admitted to Slow Stream Rehab (SSR), post
acute care stay for pneumonia –
deconditioned, decreased mobility
On admission to SSR:
• Poor balance and mobility.
• Complains of dizziness with positional changes.
• Recovering from delirium
- Started on Seroquel 12.5 mg tid for agitation
and an additional 25 mg qhs to help his sleep.
-Was tried first on amitriptyline for sleep first
but this did not help him very much.
• Endorses low mood/anxiety.
• Constipated
Meds
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•
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•
•
Seroquel 12.5 mg po TID and 25 mg po qhs
Docusate sodium 100 mg po bid
Ramipril 10 mg po daily
Amlodipine 2.5 mg po daily
Hydrochlorothiazide 25 mg po daily
Tylenol #3 ii tabs po q 4-6 h PRN
Levodopa/Carbidopa 100/25 1 tab po qid
Tamsulosin 0.8 mg po daily
Zocor 80 mg po qhs
Milk of Magnesia 30 mL po PRN
Note: CrCl ~ 28 mL/min
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Pharmacist does a Meds Check annually.
You do an annual physical.
You need a medication list at least annually.
Pharmacist identifies issues on the meds
check annually: “Follow-up with your doctor.”
How can you and the pharmacist work better to
prevent medication adverse events?
• Let’s discuss how you might optimize Mr. S’s
medications.
• Consider how to address his dizziness, pain,
constipation, mood, and insomnia.
Case #2
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Mrs. G
89 year old female
Lives in Nursing Home
PMH: CVA 2011, Vascular Dementia, HTN,
DM2, Atrial Fibrillation, Chronic Renal Failure
(CrCl ~ 20 mL/min), Osteoporosis, Hip # 2
years ago.
• Husband died 2 years ago and she has no
other family.
Meds
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Ramipril 10 mg po daily
Crestor 20 mg po qhs
Pantoprazole 40 mg po daily
Donepezil 10 mg po daily
Milk of Magnesia 15 mL po bid
Glyburide 5 mg po bid
Metformin 1000 mg po bid
Amitriptyline 25 mg po qhs for sleep (Rx’d years ago – GP)
Gabapentin 300 mg po TID for sciatica/neuropathic pain
M-eslon 10 mg po bid
Warfarin 3 mg po daily
CrCl ~ 20 mL/min
Nurses ask you to see this
patient/address issues
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Hematuria x 2 days noted by nurses
Decreased po intake x 2 days
“Not herself” and complaining of a bit of nausea
No dysuria/frequency/urgency she is aware of –
incontinent and uses briefs
• Urinalysis ordered yesterday: positive for blood,
leukocytes, nitrites
• Urine culture & sensitivity pending
Questions for Case #2
• Current issue: UTI  treatment options? What safe
precautions need to be taken with antibiotics?
• Ongoing management: Optimize her meds
• Should she be on a bisphosphonate? PPI?
• Suggestions to better manage her constipation?
• She is depressed and has difficulty sleeping –
suggestions for safer management in LTC patient?
• Management of diabetes meds?
• Pain management?
• Efficacy of donepezil?
Case #3
• Mrs. A
• 85 year old female
• Lives in community alone, condominium
apartment
• Divorced, 2 children live in Toronto area
• PMH: Atrial fibrillation, chronic back pain,
HTN, Depression, Hypercholesterolemia
Her medication list as per your chart
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Atorvastatin 30 mg po qhs
Hydrochlorothiazide 25 mg po daily
Amlodipine 5 mg po daily
Sertraline 75 mg po daily
Omeprazole 30 mg po daily
Domperidone 10 mg po ACBLD and qhs
Warfarin 2.5 mg po daily
Lorazepam 1 mg po qhs for sleep (Rx’d at age 55
with divorce)
Presents to your office
• Anxiety has gotten “worse”. Sleepless nights,
not feeling well. Recent argument with her
daughter and they are not speaking at the
moment.
• Cough x 5 days (3 days ago you sent her for
CXR which shows LLL pneumonia)
• BP a little higher than usual 166/78, P 98,
afebrile
• Crackles on LLL
Presents to your office
• Coughing- wet, productive
• Reveals that lately she has been taking GravolGinger which has helped her with her sleep
• Her back pain has also gotten worse and she is
taking Ibuprofen for this
Questions for you
• How can you better manage her anxiety and
insomnia?
• What safety issues are you concerned about
with her OTC and herbal remedies?
• What antibiotic are you considering
prescribing and what precautions must you
take?
• Any other suggestions to optimize her drugs?
Take Home Messages
• Caring for the elderly is a team sport!
Health care team, patient, family, caregiver
• Medication in the elderly requires that the physician
and pharmacist communicate, communicate,
communicate.
• Education is important to avoid ADRs, IDP and nonadherence.
• “Start Low and Go Slow” but keep going!
• Review regimen regularly
• Non-specific complaints should prompt review to avoid
prescribing cascades
Some words of wisdom from our
elders…
“All drugs are poisons; there is none that is not a
poison. The right dose differentiates a poison
from a remedy.”
~ Paracelsus 1493 – 1541~
Thank you!
Appendix 1
AGS Beers Criteria – Pocket Card
Appendix 2
START Criteria: Screening tool to alert doctors to the right (i.e. indicated, but not prescribed) treatment for older people
Copyright © The Author 2007. Published by Oxford University
Press on behalf of the British Geriatrics Society.
Barry P J et al. START (Screening tool to alert doctors to the right
treatment) – an evidence-based screeening tool to detect prescribing
omissions in elderly patients. Age Ageing 2007;36:632-638
Appendix 3
STOPP: Screening Tool of Older People’s potentially
inappropriate Prescriptions.
Gallagher P, O’Mahony D. STOPP (Screening Tool of Older Persons’ potentially inappropriate
Prescriptions): application to acutely ill elderly patients and comparison to Beers’ criteria.
Age and Ageing 2008; 37: 673-679.
The following drug prescriptions are potentially inappropriate in persons
aged ≥ 65 years of age:
A.Cardiovascular System
1. Digoxin at a long-term dose > 125μg/day with impaired renal function∗
(increased risk of toxicity).
2. Loop diuretic for dependent ankle edema only i.e. no clinical signs of heart
failure (no evidence of efficacy, compression hosiery usually more appropriate).
3. Loop diuretic as first-line monotherapy for hypertension (safer, more effective
alternatives available).
4. Thiazide diuretic with a history of gout (may exacerbate gout).
STOPP Criteria –
A. Cardiovascular System cont’d
5. Beta-blocker with Chronic Obstructive Pulmonary Disease (COPD) (risk of
increased bronchospasm).
6. Beta-blocker in combination with Verapamil (risk of symptomatic heart
block).
7. Use of Diltiazem or Verapamil with NYHA Class III or IV heart failure (may
worsen heart failure).
8. Calcium channel blockers with chronic constipation (may exacerbate
constipation).
9. Use of Aspirin and Warfarin in combination without histamine H2 receptor
antagonist (except Cimetidine because of interaction with warfarin) or Proton
Pump Inhibitor (high risk of gastrointestinal
bleeding).
10. Dipyridamole as monotherapy for cardiovascular secondary prevention (no
evidence for efficacy).
11. Aspirin with a past history of peptic ulcer disease without histamine H2
receptor antagonist or Proton Pump Inhibitor (risk of bleeding).
12.Aspirin at dose > 150mg day (increased bleeding risk, no evidence for
increased efficacy).
STOPP Criteria –
A. Cardiovascular System cont’d
13. Aspirin with no history of coronary, cerebral or peripheral vascular
symptoms or occlusive event (not indicated).
14. Aspirin to treat dizziness not clearly attributable to cerebrovascular disease
(not indicated).
15. Warfarin for first, uncomplicated deep venous thrombosis for longer than 6
months duration (no proven added benefit).
16. Warfarin for first uncomplicated pulmonary embolus for longer than 12
months duration (no proven benefit).
17. Aspirin, clopidogrel, dipyridamole or warfarin with concurrent bleeding
disorder (high risk of bleeding).
∗ estimated GFR <50ml/min.
B. Central Nervous System and Psychotropic Drugs.
1. Tricyclic antidepressants (TCA’s) with dementia (risk of worsening cognitive
impairment).
2. TCA’s with glaucoma (likely to exacerbate glaucoma).
3. TCA’s with cardiac conductive abnormalities (pro-arrhythmic effects).
4. TCA’s with constipation (likely to worsen constipation).
STOPP Criteria B. Central Nervous System and Psychotropic Drugs cont’d
5. TCA’s with an opiate or calcium channel blocker (risk of severe constipation).
6. TCA’s with prostatism or prior history of urinary retention (risk of urinary
retention).
7. Long-term (i.e. > 1 month), long-acting benzodiazepines e.g.
Chlordiazepoxide, Fluazepam, Nitrazepam, Chlorazepate and benzodiazepines
with long-acting metabolites e.g. Diazepam (risk of prolonged sedation,
confusion, impaired balance, falls).
8. Long-term (i.e. > 1 month) neuroleptics as long-term hypnotics (risk of
confusion, hypotension, extra-pyramidal side effects, falls).
9. Long-term neuroleptics ( > 1 month) in those with parkinsonism (likely to
worsen extra-pyramidal symptoms)
10. Phenothiazines in patients with epilepsy (may lower seizure threshold).
11. Anticholinergics to treat extra-pyramidal side-effects of neuroleptic
medications (risk of anticholinergic toxicity).
12. Selective serotonin re-uptake inhibitors (SSRI’s) with a history of clinically
significant hyponatraemia (non-iatrogenic hyponatraemia <130mmol/l within
the previous 2 months).
13. Prolonged use (> 1 week) of first generation antihistamines i.e.
Diphenydramine, Chlorpheniramine, Cyclizine, Promethazine ( risk of sedation
and anti-cholinergic side effects).
STOPP CriteriaC. Gastrointestinal System
1. Diphenoxylate, loperamide or codeine phosphate for treatment of diarrhoea of
unknown cause (risk of delayed diagnosis, may exacerbate constipation with
overflow diarrhoea, may precipitate toxic megacolon in inflammatory bowel
disease, may delay recovery in unrecognised gastroenteritis).
2. Diphenoxylate, Loperamide or codeine phosphate for treatment of severe
infective gastroenteritis i.e. bloody diarrhoea, high fever or severe systemic
toxicity (risk of exacerbation or protraction of
infection)
3. Prochlorperazine (Stemetil) or metoclopramide with Parkinsonism (risk of
exacerbating Parkinsonism).
4. PPI for peptic ulcer disease at full therapeutic dosage for > 8 weeks (dose
reduction or earlier discontinuation indicated).
5. Anticholinergic antispasmodic drugs with chronic constipation (risk of
exacerbation of constipation).
STOPP CriteriaD. Respiratory System.
1. Theophylline as monotherapy for COPD. (safer, more effective alternative;
risk of adverse effects due to narrow therapeutic index)
2. Systemic corticosteroids instead of inhaled corticosteroids for maintenance
therapy in moderate-severe COPD (unnecessary exposure to long-term sideeffects of systemic steroids).
3. Nebulised Ipratropium with glaucoma (may exacerbate glaucoma).
E. Musculoskeletal System
1. Non-steroidal anti-inflammatory drug (NSAID) with history of peptic ulcer
disease or gastrointestinal bleeding, unless with concurrent histamine H2
receptor antagonist, PPI or Misoprostol (risk of peptic ulcer relapse).
2. NSAID with moderate-severe hypertension (moderate: 160/100mmHg –
179/109mmHg; severe: ≥180/110mmHg) (risk of exacerbation of
hypertension).
3. NSAID with heart failure (risk of exacerbation of heart failure).
4. Long-term use of NSAID (>3 months) for relief of mild joint pain in
osteoarthtitis (simple analgesics preferable and usually as effective for pain
relief)
.
STOPP CriteriaMusculoskeletal System cont’d
5. Warfarin and NSAID together (risk of gastrointestinal bleeding).
6. NSAID with chronic renal failure∗ (risk of deterioration in renal function).
7. Long-term corticosteroids (>3 months) as monotherapy for rheumatoid
arthrtitis or osterarthritis (risk of major systemic corticosteroid side-effects).
8. Long-term NSAID or Colchicine for chronic treatment of gout where there is no
contraindication to Allopurinol (Allopurinol first choice prophylactic drug in gout)
∗ estimated GFR 20-50ml/min
F. Urogenital System
1. Bladder antimuscarinic drugs with dementia (risk of increased confusion,
agitation).
2. Antimuscarinic drugs with chronic glaucoma (risk of acute exacerbation of
glaucoma).
3. Antimuscarinic drugs with chronic constipation (risk of exacerbation of
constipation).
4. Antimuscarinic drugs with chronic prostatism (risk of urinary retention).
5. Alpha-blockers in males with frequent incontinence i.e. one or more episodes of
incontinence daily (risk of urinary frequency and worsening of incontinence).
6. Alpha-blockers with long-term urinary catheter in situ i.e. more than 2 months
(drug not indicated).
STOPP CriteriaG. Endocrine System
1. Glibenclamide or Chlorpropamide with type 2 diabetes mellitus (risk of
prolonged hypoglycemia).
2. Beta-blockers in those with diabetes mellitus and frequent hypoglycaemic
episodes i.e. ≥ 1 episode per month (risk of masking hypoglycaemic symptoms).
3. Estrogens with a history of breast cancer or venous thromboembolism
(increased risk of recurrence)
4. Estrogens without progesterone in patients with intact uterus (risk of
endometrial cancer).
H. Drugs that adversely affect those prone to falls (≥ 1 fall in
past three months)
1. Benzodiazepines (sedative, may cause reduced sensorium, impair balance).
2. Neuroleptic drugs (may cause gait dyspraxia, Parkinsonism).
3. First generation antihistamines (sedative, may impair sensorium).
4. Vasodilator drugs known to cause hypotension in those with persistent
postural hypotension i.e. recurrent > 20mmHg drop in systolic blood pressure
(risk of syncope, falls).
5. Long-term opiates in those with recurrent falls (risk of drowsiness, postural
hypotension, vertigo).
STOPP CriteriaI. Analgesic Drugs
1. Use of long-term powerful opiates e.g. morphine or fentanyl as first line
therapy for mild-moderate pain (WHO analgesic ladder not observed).
2. Regular opiates for more than 2 weeks in those with chronic constipation
without concurrent use of laxatives (risk of severe constipation).
3. Long-term opiates in those with dementia unless indicted for palliative care or
management of moderate/severe chronic pain syndrome (risk of exacerbation of
cognitive impairment).
J. Duplicate Drug Classes
Any duplicate drug class prescription e.g. two concurrent opiates, NSAID’s,
SSRI’s, loop diuretics, ACE inhibitors (optimisation of monotherapy within a
single drug class should be observed prior to considering a new class of drug).
Adverse Events: Beware of Meds
which effect QT Prolongation !
• ↑ incidence in elderly
• ↑ sudden cardiac death 2˚ to QT prolongation
• Elderly more likely to be on multiple drugs
which ↑ the QT interval
e.g. anti-infectives, antiarrhythmics, antipsychotics
and antidepressants