Suboptimal Drug Use in Long Term Care
Facility Patients
Joseph T. Hanlon PharmD, MS
Professor, Departments of Medicine (Geriatrics)
and Pharmacy and Therapeutics,
University of Pittsburgh
and
Pittsburgh VA CHERP and GRECC
Learning Objectives
At the end of the talk the participants should be able to:
• List the different types of suboptimal drug use
• Describe the prevalence of polypharmacy (9+ drugs) in
long term care patients
• Discuss the underuse of medications in long term care
patients
• Summarize drugs that are potentially inappropriate or
unnecessary as per new CMS Guidelines for LTCF
• Discuss principles to optimize drug use in long term care
patients
Types of Suboptimal Drug Use
1. Overutilization (polypharmacy)
2. Underutilization
3. Inappropriate utilization
Hanlon JT, et al. J Am Geriatr Soc 2001;49:200-9;
Spinewine A, et al. Lancet 2007;370:173-184
% Taking 9+ Meds in LTCFs
80
70
Percent of NHR
60
50
40
30
20
10
0
National
VA
CMS data, 1st quarter, 2005, VA NHCU data FY 04-05
Top Medication Classes Used in LTCF
Medication Class
1997 MCBS
%
Analgesics/Anti-pyretics
76.5
GI agents
74.5
Electrolytes, caloric
71.0
CNS agents
65.9
Anti-infectives
62.3
Cardiovascular
55.0
Topical or other
47.1
Renal/GU Tract
44.4
Hormones/Synthetic subs
40.5
Respiratory agents
35.8
Anti-allergy agents
22.4
Blood formation/anti-coagulants
17.7
Doshi JA, et al. J Am Geriatr Soc. 2005;53:438-44.
Top Medication Classes Used
in VA NHCU FY 2005 (n=6554)
VA Medication Class
FY 05 %
Non-opioid analgesics
73.3
SSRI Antidepressants
54.3
Anti-infectives
Antipsychotics
GI, misc.
Stool Softeners
53.3
48.8
47.9
40.9
ACE-I
39.4
Beta blockers
39.3
Antiepileptics
38.0
MVI w/minerals
36.2
Stimulant Laxatives
34.6
Topical antifungals
34.4
Antilipemics
33.0
French DD, et al. J Am Med Dir 2007; 8:515-8
Daily Use of Specific Medication
Classes in LTCF Patients per MDS
Drug Class
Diuretics
Antidepressants
Antipsychotics
Antianxiety agents
Hypnotics
VA %
29.8
43.0
25.9
9.6
3.8
National %
34.0
48.4
24.9
12.8
3.7
CMS data, 2nd quarter, 2007, VA NHCU data FY 04-05
Risks Associated with Polypharmacy
•
•
•
•
•
Functional status decline
ADRs
Inappropriate drug use
Increased medication administration errors
Increased risk of geriatric syndromes
Learning Objectives
At the end of the talk the participants should be able to:
• List the different types of suboptimal drug use
• Describe the prevalence of polypharmacy (9+ drugs) in
long term care patients
• Discuss the underuse of medications in long term care
patients
• Summarize drugs that are potentially inappropriate or
unnecessary as per new CMS Guidelines for LTCF
• Discuss principles to optimize drug use in long term care
patients
Underutilization of Medication
• Undiagnosed and untreated condition
• Diagnosed condition but omitted treatment
• Underuse of preventive treatment
Examples of Medication
Under-Use in LTCFs
• Warfarin for stroke prevention
(McCormick et al, 2001)
• Hypoglycemics for diabetes
(Spooner et al, 2000)
• Calcium and other treatment for osteoporosis
(Jachna et al, 2005)
Inappropriate Prescribing
• Prescribing of medications that does not agree with
accepted medical standards
MDS Quality Indicator Report
Medication Use
Antipsychotic Use w/o
Psychosis
Sxs of Depression w/o
antidepressant
Hypnotic use > 2x
in previous week
National %
VA%
22.0
19.9
4.8
3.9
4.2
4.1
CMS Recommended Antianxiety and
Sedative/Hypnotic
Maximum Daily Dosage
Generic Name
Alprazolam
Clonazepam
Lorazepam
Oxazepam
Temazepam
Zaleplon
Zolpidem
Dosage (mg)
0.75
7.5
1-2
15-30
7.5-15
5
5
Indications for Antipsychotics
in the Elderly Nursing Home Patients
1. Disorders such as delirium, schizophrenia,
paraphrenia, dementia
With
2. Thinking and behavior disturbances such as delusions,
hallucinations, paranoia
And
3. Severe enough to be of harm to the patient and/or others
Antipsychotic Guidelines
in Nursing Home Elderly
• Residents should receive gradual dose reductions, behavior
interventions unless clinically contraindicated
• Avoid use of highly anticholinergic antipsychotics (e.g.,
olanzapine, chlorpromazine, thioridazine, clozapine)
• Specific doses recommended
• Monitor for metabolic and EPS problems
Weight Gain, Diabetes an Dyslipidemias
with Atypical Antipsychotics
Clozapine=Olanzapine>Quetiapine>
Paliperidone=Risperidone>Ziprasidone=Aripiprazole
ADA-APA Monitoring Guidelines
Measure Baseline
BMI
x
Waist Circ.
x
BP
x
FG
x
Lipids
x
4wks
x
8wks
x
12wks
x
x
x
x
1/4ly Yrly
x
x
x
x
CMS Recommended Selected
Antipsychotic Maximum Daily Dosage
Name
Dosage (mg)
Fluphenazine
Haloperidol
Perphenazine
Quetiapine
Risperidone
4
2
8
150
2
Inappropriate Medication Use Defined
by Explicit Criteria (Beers MH, et al. 1997)
•
•
•
•
•
CARDIOVASCULAR
Reserpine, Methyldopa,
Disopyramide
ANTIPLATELETS
Dipyridamole, Ticlopidine
DEMENTIA TREATMENTS
GASTROINTESTINAL
Antispasmodics (e.g., Donnatal®)
Trimethobenzamide (Tigan®)
ANALGESICS
Indomethacin , Phenylbutazone
Propoxyphene , Pentazocine,
Meperidine
•
•
•
•
•
ORAL HYPOGLYCEMICS
Chlorpropamide (Diabinese®)
PSYCHOTROPICS
Long acting benzodiazepines
Meprobamate, Barbiturates
Amitriptyline, Doxepin
Antidepressant/neuroleptic Comb.
SKELETAL MUSCLE
RELAXANTS
ANTIHISTAMINES
Diphenhydramine (Benadryl® )
GU ANTISPASMODICS
Oxybutynin
Use of Beers Criteria Drugs in Nursing Homes
J Am Geriatr Soc. 2005;53:991-6.
Predictive Validity of Inappropriate Drug Use
Author/yr
Sample
Criteria
Outcome
Lau/2005
MEPS NH
Beers (Do not use,
dose, drug-dx
interaction)
Death (OR=1.28)
Hospitalized (OR=1.27)
Perri/2005
Georgia
Medicaid
NH
Beers (do not use),
duplication, drug-dx
interaction
Death/Hospitalized
(OR=2.3)
Klarin/2005
Swedish
ALF/NH
Beers (high severity
do not use), DDI,
duplication
Death (OR=0.93)
Hospitalized (OR=2.72)
Ravio/2006
Finland NH Beers (do not use,
dose)
Death (HR=1.02)
Hospitalized (OR= 1.40)
Inappropriate Medication Use Defined
by CMS Criteria 2006
•
•
•
•
ANTIINFECTIVE
Nitrofurantoin
CARDIOVASCULAR
Amiodarone (unless VT/Fib),
Disopyramide, Methyldopa,
Nifedipine (SA), Prazosin
ANTIPLATELETS
Ticlopidine
GASTROINTESTINAL
Antispasmodics (e.g., Donnatal®),
Cimetidine, Metoclopramide,
Trimethobenzamide (Tigan®)
•
•
•
•
•
ANALGESICS
NSAIDs, Propoxyphene ,
Pentazocine, long acting opioids
(fentanyl patch, methadone, SR
products)
ORAL HYPOGLYCEMICS
Chlorpropamide, Glyburide
PSYCHOTROPICS
Barbiturates, Meprobamate, TCA’s,
MAOIs
SKELETAL MUSCLE
RELAXANTS
ANTIHISTAMINES
Chlorpheniramine,
Cyproheptadine, Diphenhydramine,
Hydroxyzine, Meclizine,
Promethazine
Unnecessary Medications
• Defined as a medication with excessive dose or duration;
inadequate monitoring or indication for use; presence of
adverse consequences which indicate the dose should be
reduced or d/ced
CMS Recommended Maximum
Daily Dosage
Generic Name
APAP
Digoxin
H2 blockers
Iron
Metformin
Daily Dosage (mg)
4000
0.125 (unless Afib)
based on renal function
qd
based on renal function
CMS Guidelines For Drugs
with Maximum Duration Limits
Drug Class
ACHEI
Analgesics
Anti-infectives
Antiemetics
Cough/Cold
H2 blocker/PPI
Iron
Duration (days)
? Revaluate as dx progresses
? acute use
?
?
14
84 (unless GERD/NSAID use)
56
CMS Guidelines for Monitoring
Medication Use
Drug
ACE-I
AEDS (older)
Aminoglycosides
Antidiabetics
Antipsychotics
APAP (>4gm/d)
Appetite stimulants
Digoxin
Diuretic
Erythropoiesis stimulants
Fibrates
Iron
Lithium
Niacin
Statins
Theophylline
Thyroid replacement
Warfarin
Monitoring
K+
levels
Scr, levels
Blood sugar
EPS, TD
LFTS
weight, appetite
Scr, level
K+
BP, iron, ferritin, CBC
LFTS, CBC
iron, ferritin, CBC
level
blood sugar, LFTs
LFTs
levels
TFTs
INR
CMS Drug-Drug Interactions
Drug Effected
ASA
ACE-I
Anticholinergic
Antihypertensives
Antiplatelet
CNS med
Digoxin
Lithium
Meperidine
Phenytoin
Quinolones
SSRI
Sulfonylureas
Theophylline
Warfarin
Precipitant Drug (s)
NSAIDs
K supplements, K sparing diuretics
Anticholinergic
levodopa, nitrates
NSAID
CNS med
amiodarone, verapamil
ACEI, thiazide diuretics, NSAIDs
MAOI
imidazoles
Type IA,C, II antiarrhythmics
tramadol, st john wort
imidazoles
imidazoles, quinolones, barbiturates
amiodarone, NSAIDs, sulfonamides,
macrolides, quinolones, phenytoin, imidazoles
Clinically Important Drug-Disease
Interactions Determined by Expert Panel
Consensus
Drug
Disease
– Alpha blockers
– Anticholinergics
–
–
–
–
–
–
–
Aspirin
Barbiturates
Benzodiazepines
Bupropion
CCB 1st generation
Corticosteroids
Digoxin
Syncope
BPH, constipation, dementia,
glaucoma (narrow angle)
PUD
Dementia
Dementia, falls
Seizures
CHF (systolic dysfunction)
DM
Heart block
Lindblad C, Hanlon J et al. Clin Ther 2006;28:1133-43.
Clinically Important Drug-Disease
Interactions Determined by Expert Panel
Consensus
Drug
–
–
–
–
–
–
Metoclopramide
Non-aspirin NSAIDs
Opioid analgesics
Sedative/hypnotics
Thioridazine
Tricyclic antidepressants
– Typical antipsychotics
Disease
Parkinson’s disease
CRF, PUD
Constipation
Falls
Postural hypotension
BPH, constipation
dementia, falls, heart block
postural hypotension
Falls
Lindblad C, Hanlon J et al. Clin Ther 2006;28:1133-43.
Medications with Anticholinergic Activity
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•
•
•
•
•
Anti-emetics/anti-vertigo - (e.g., meclizine)
Antiparkinsonians - (e.g., trihexyphenidyl)
Antispasmodics- (e.g., belladonna)
Cold and allergy drugs- (e.g., hydroxyzine)
Sleep aids- (e.g., diphenhydramine)
Skeletal muscle relaxants - (e.g., cyclobenzaprine)
Atypical Antipsychotic Medications and Risk
of Falls in Residents of Aged Care Facilities
Medication
Olanzapine
Risperidone
Typ. antipsychotics
Antidepressants
Sed/anxiolytics
Adj Hazard Ratio
1.74
1.32
1.35
1.45
1.19
95% CI
(1.04–2.90)
(0.57–3.06)
(0.87–2.09)
(1.09–1.93)
(0.94–1.50)
Hien LTT, et al. J Am Geriatr Soc 2006;53: 1290-1295.
Antipsychotic Medications and Risk of Hip
Fractures in NH Residents
Medication
Atypicals
Olanzapine
Risperidone
Conv. antipsychotics
Haloperidol
Adj. OR
1.37
1.34
1.42
1.35
1.53
95% CI
1.11-1.69
0.87–2.07
1.12–1.80
1.06–1.71
1.18–2.26
Liperoti R, et al. J Clin Psych 2007;68: 929-34.
Learning Objectives
At the end of the talk the participants should be able to:
• List the different types of suboptimal drug use
• Describe the prevalence of polypharmacy (9+ drugs) in
long term care patients
• Discuss the underuse of medications in long term care
patients
• Summarize drugs that are potentially inappropriate or
unnecessary as per new CMS Guidelines for LTCF
• Discuss principles to optimize drug use in long term care
patients
Principles for Optimizing Drug
Use in the Elderly
• Consider whether drug therapy is necessary
• Promote the use of a small number of drugs to treat
common problems
• Adjust doses and or/dosage intervals for medications
• Establish reasonable therapeutic endpoints and monitor for
desired outcome
• Monitor for adverse drug reactions
• Regularly review the need for chronic medications
A Model for Appropriate Prescribing
for Patients Late in Life
Holmes HM, et al. Arch Intern Med 2006;166:605-609.
Chronic Medication Review Steps
• Assess whether ADRs are the cause of any symptoms
• Match problem list with drug list
• If on drug but no match with problem list consider whether
drug is necessary
• If has a chronic condition and not on a medication
consider whether there is an evidence based drug to tx the
condition
• Assess the monitoring for efficacy/safety/appropriateness
of the remaining medications
Assessing Prescribing Appropriateness
Using the MAI
•
•
•
•
•
•
•
•
•
•
Is there an indication for the drug?
Is the medication effective for the condition?
Is the dosage correct?
Are the directions correct?
Are the directions practical?
Are there clinically significant drug-drug interactions?
Are there clinically significant drug-disease interactions?
Is there unnecessary duplication with other drugs?
Is the duration of therapy acceptable?
Is this drug the least expensive alternative compared to others of equal
utility?
Effect of an Interdisciplinary Team on Suboptimal
Prescribing in a VA LTCF (n=23)
Variable
Scheduled meds
(mean ± sd)
Unnecessary meds
(mean ± sd)
Inappropriate meds
(Beers Criteria) %
MAI Score/Person
(mean ± sd)
Undertreated
conditions
(mean ± sd)
Admission Closeout
7.4 ± 2.8
7.3 ± 3.53
P Value
0.16
1.6 ± 1.5
0.3 ± 0.7
<0.001
17
0
-------
16.7 + 10.6 7.9 + 5.1
<0.001
0.5 + 0.7
0.03
0.2 + 0.4
Jeffery S, et al. Consult Pharm 1999;14:1386-91.
Learning Objectives
At the end of the talk the participants should be able to:
• List the different types of suboptimal drug use
• Describe the prevalence of polypharmacy (9+ drugs) in
long term care patients
• Discuss the underuse of medications in long term care
patients
• Summarize drugs that are potentially inappropriate or
unnecessary as per new CMS Guidelines for LTCF
• Discuss principles to optimize drug use in long term care
patients
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