suboptimal drug use in long term care facility patients joseph t. hanlon pharmd, ms professor,...
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Suboptimal Drug Use in Long Term Care Facility Patients
Joseph T. Hanlon PharmD, MSProfessor, 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
0
10
20
30
40
50
60
70
80
National VA
Pe
rce
nt o
f NH
R
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 VA % National %
Diuretics 29.8 34.0
Antidepressants 43.0 48.4
Antipsychotics 25.9 24.9
Antianxiety agents 9.6 12.8
Hypnotics 3.8 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 National % VA%Antipsychotic Use w/o Psychosis 22.0 19.9Sxs of Depression w/o antidepressant 4.8 3.9Hypnotic use > 2x in previous week 4.2 4.1
CMS Recommended Antianxiety and Sedative/Hypnotic
Maximum Daily Dosage
Generic Name Dosage (mg)
Alprazolam 0.75
Clonazepam 7.5
Lorazepam 1-2
Oxazepam 15-30
Temazepam 7.5-15
Zaleplon 5
Zolpidem 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 4wks 8wks 12wks 1/4ly Yrly
BMI x x x x x
Waist Circ. x x
BP x x x
FG x x x
Lipids x x
CMS Recommended Selected Antipsychotic Maximum Daily Dosage Name Dosage (mg)
Fluphenazine 4
Haloperidol 2
Perphenazine 8
Quetiapine 150
Risperidone 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®)
• ANALGESICSNSAIDs, Propoxyphene , Pentazocine, long acting opioids (fentanyl patch, methadone, SR products)
• ORAL HYPOGLYCEMICSChlorpropamide, 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 Daily Dosage (mg)
APAP 4000
Digoxin 0.125 (unless Afib)
H2 blockers based on renal function
Iron qd
Metformin based on renal function
CMS Guidelines For Drugs with Maximum Duration Limits
Drug Class Duration (days)
ACHEI ? Revaluate as dx progresses
Analgesics ? acute use
Anti-infectives ?
Antiemetics ?
Cough/Cold 14
H2 blocker/PPI 84 (unless GERD/NSAID use)
Iron 56
CMS Guidelines for Monitoring Medication Use
Drug MonitoringACE-I K+AEDS (older) levelsAminoglycosides Scr, levelsAntidiabetics Blood sugarAntipsychotics EPS, TDAPAP (>4gm/d) LFTSAppetite stimulants weight, appetiteDigoxin Scr, levelDiuretic K+Erythropoiesis stimulants BP, iron, ferritin, CBCFibrates LFTS, CBCIron iron, ferritin, CBCLithium levelNiacin blood sugar, LFTs Statins LFTsTheophylline levelsThyroid replacement TFTsWarfarin INR
CMS Drug-Drug Interactions
Drug Effected Precipitant Drug (s) ASA NSAIDsACE-I K supplements, K sparing diureticsAnticholinergic AnticholinergicAntihypertensives levodopa, nitratesAntiplatelet NSAIDCNS med CNS medDigoxin amiodarone, verapamilLithium ACEI, thiazide diuretics, NSAIDsMeperidine MAOIPhenytoin imidazoles Quinolones Type IA,C, II antiarrhythmicsSSRI tramadol, st john wortSulfonylureas imidazolesTheophylline imidazoles, quinolones, barbituratesWarfarin amiodarone, NSAIDs, sulfonamides,
macrolides, quinolones, phenytoin, imidazoles
Clinically Important Drug-Disease Interactions Determined by Expert Panel
ConsensusDrug Disease
– Alpha blockers Syncope– Anticholinergics BPH, constipation, dementia,
glaucoma (narrow angle)
– Aspirin PUD– Barbiturates Dementia– Benzodiazepines Dementia, falls– Bupropion Seizures– CCB 1st generation CHF (systolic dysfunction)– Corticosteroids DM– Digoxin Heart block
Lindblad C, Hanlon J et al. Clin Ther 2006;28:1133-43.28:1133-43.
Clinically Important Drug-Disease Interactions Determined by Expert Panel
ConsensusDrug Disease
– Metoclopramide Parkinson’s disease– Non-aspirin NSAIDs CRF, PUD– Opioid analgesics Constipation– Sedative/hypnotics Falls– Thioridazine Postural hypotension– Tricyclic antidepressants BPH, constipation
dementia, falls, heart block
postural hypotension– Typical antipsychotics Falls
Lindblad C, Hanlon J et al. Clin Ther 2006;28:1133-43.28:1133-43.
Medications with Anticholinergic Activity
• 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 Adj Hazard Ratio 95% CIOlanzapine 1.74 (1.04–2.90)Risperidone 1.32 (0.57–3.06)Typ. antipsychotics 1.35 (0.87–2.09)Antidepressants 1.45 (1.09–1.93)Sed/anxiolytics 1.19 (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 Adj. OR 95% CIAtypicals 1.37 1.11-1.69Olanzapine 1.34 0.87–2.07Risperidone 1.42 1.12–1.80Conv. antipsychotics 1.35 1.06–1.71Haloperidol 1.53 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
Holmes HM, et al. Arch Intern Med 2006;166:605-609.
A Model for Appropriate Prescribing for Patients Late in Life
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 Admission Closeout P Value Scheduled meds (mean ± sd)
7.4 ± 2.8 7.3 ± 3.53 0.16
Unnecessary meds (mean ± sd)
1.6 ± 1.5 0.3 ± 0.7 <0.001
Inappropriate meds (Beers Criteria) %
17 0 -------
MAI Score/Person (mean ± sd)
16.7 + 10.6 7.9 + 5.1 <0.001
Undertreated conditions (mean ± sd)
0.5 + 0.7 0.2 + 0.4 0.03
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
To Register for this Program and get CE Credit
• Non-VA listeners go to: https://www.ees-learning.net
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Administrator.)2) On the upper right, where it says “Search Catalog” type in
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Patients”4) Click on “Link to Evaluation and Certificate”
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