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POLYPHARMACY Wendolyn Gozansky, MD, MPH Associate Professor Division of Geriatric Medicine University of Colorado Denver THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals. Leading change. Improving care for older adults. AGS

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POLYPHARMACY Wendolyn Gozansky , MD, MPH Associate Professor Division of Geriatric Medicine University of Colorado Denver. AGS. THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals. Leading change. Improving care for older adults. CONTENTS. Drugs and the elderly - PowerPoint PPT Presentation

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Page 1: THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals

POLYPHARMACY

Wendolyn Gozansky, MD, MPHAssociate Professor

Division of Geriatric MedicineUniversity of Colorado Denver

THE AMERICAN GERIATRICS SOCIETY

Geriatrics Health Professionals.

Leading change. Improving care for older adults.

AGS

Page 2: THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals

CONTENTS

• Drugs and the elderly

• Pharmacodynamic and pharmacokinetic changes with aging

• Drug knowledge and compliance

• Prudent prescribing

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DRUG USE IN THE ELDERLY12% of the population is aged 65+

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DRUG USE IN THE ELDERLY12% of the population is aged 65+

30% of all prescription drug use is among those aged 65+

Slide 4

Page 5: THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals

DRUG USE IN THE ELDERLY12% of the population is age 65+

30% of all prescription drug use is among those aged 65+

50% of all OTC drug use is among those aged 65+

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ADVERSE DRUG REACTIONS (ADRs)

• 106,000 deaths in 1994

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ADVERSE DRUG REACTIONS (ADRs)

• 106,000 deaths in 1994• $177 billion in 2000

Slide 7

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ADVERSE DRUG REACTIONS (ADRs)

• 106,000 deaths in 1994• $177 billion in 2000• For every $1 spent on drugs, $1 spent on ADRs

Slide 8

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ADVERSE DRUG REACTIONS (ADRs)

• 106,000 deaths in 1994• $177 billion in 2000• For every $1 spent on drugs, $1 spent on ADRs• 95% of ADRs considered to be predictable

Slide 9

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ADVERSE DRUG REACTIONS (ADRs)

• 106,000 deaths in 1994• $177 billion in 2000• For every $1 spent on drugs, $1 spent on ADRs• 95% of ADRs considered to be predictable• 7-fold increased risk in the elderly

Related to polypharmacyChanges in pharmacodynamics/pharmacokineticsDrug-disease interactions

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EXPONENTIAL RELATION BETWEEN POLYPHARMACY AND ADRs

Nolan L. JAGS. 1988;36(2):142-149.

# of Drugs Taken

Perc

ent o

f Pat

ient

s w

ith

an A

DR

Slide 11

Page 12: THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals

CONTENTS

• Drugs and the elderly

• Pharmacodynamic and pharmacokinetic changes with aging

• Drug knowledge and compliance

• Prudent prescribing

Slide 12

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PHARMACODYNAMICS

Response that occurs when a drug interacts at its receptor

Slide 13

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PHARMACODYNAMIC CHANGESWITH AGING

Increased response(eg, opiates)

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PHARMACODYNAMIC CHANGESWITH AGING

Increased response(eg, opiates)

Decreased response(eg, beta-agonists)

Slide 15

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PHARMACOKINETICS

Drug concentration at the site of action

Slide 16

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PHARMACOKINETICS

• Drug concentration at the site of action

• 4 determinants:AbsorptionDistributionMetabolismElimination

Slide 17

Page 18: THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals

PK CHANGES WITH AGING: ABSORPTION

gastric pH gastric emptying splanchnic blood flow intestinal motility

Minimal clinical importance

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PK CHANGES WITH AGING: DISTRIBUTION

fat mass muscle mass total body water albumin (binds acidic drugs) alpha-1 glycoprotein (binds basic drugs)

Clinically important

Slide 19

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20-year-old woman

Rosenberg, I. J Nutr. 1997. 127(5):990-991S. Published with permission.

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64-year-old woman

20-year-old woman

Rosenberg, I. J Nutr. 1997. 127(5):990-991S. Published with permission.

Page 22: THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals

64-year-old woman

20-year-old woman

Rosenberg, I. J Nutr. 1997. 127(5):990-991S. Published with permission.

Page 23: THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals

64-year-old woman

20-year-old woman

Rosenberg, I. J Nutr. 1997. 127(5):990-991S. Published with permission.

Page 24: THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals

hepatic mass hepatic blood flow first-pass metabolism

Clinically important: Longer half-life of drugs undergoing phase I metabolism (eg, diazepam vs lorazepam)

PK CHANGES WITH AGING:METABOLISM

Slide 24

Page 25: THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals

renal mass renal blood flow glomerular filtration rate

Most clinically important• concentration of drugs dependent on renal clearance•Serum creatinine alone does not provide adequate information to guide dosing

PK CHANGES WITH AGING:ELIMINATION

Slide 25

Page 26: THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals

PHARMACOKINETIC CHANGESWITH AGING

What is the best formula for estimating GFR in older adults?• Cockcroft-Gault (CG)• Modification of Diet in Renal Disease (MDRD)

Slide 26

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CG VERSUS MDRD

Slide 27

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CG VERSUS MDRD

Slide 28

Page 29: THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals

BIOLOGY OF THE PATIENT

• Limited functional reserve

Slide 29

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BIOLOGY OF THE PATIENT

Disease Compensatory severity mechanisms

Symptomatic Asymptomatic

Resnick N.M, Marcantonio E.R. The Lancet. 1992;350(9085):1157-1158. Published with permission.

Slide 30

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BIOLOGY OF THE PATIENT

• Limited functional reserve

• Drug-disease interactions

Slide 31

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CONTENTS

• Drugs and the elderly

• Pharmacodynamic & pharmacokinetic changes with aging

• Drug knowledge and compliance

• Prudent prescribing

Slide 32

Page 33: THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals

DO YOU KNOW WHAT’S IN YOUR PATIENT’S MEDICINE CABINET?

~20% of drugs found on home inventory were not revealed by physician interview

Most frequently unreported class of drugs?

Slide 33

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Slide 34

Page 35: THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals

DO YOU KNOW WHAT’S IN YOUR PATIENT’S MEDICINE CABINET?

~20% of drugs found on home inventory were not revealed by physician interview

Most frequently unreported class of drugs?

BENZODIAZEPINES!!!

Slide 35

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ALTERED COMPLIANCE

• Under-utilization

• Over-utilization

• Enforced compliance

Slide 36

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RELATION BETWEEN POLYPHARMACYAND NUMBER OF PRESCRIBERS

# of Drugs Prescribed

# of

Pre

scrib

ers

Slide 37

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RELATION BETWEEN POLYPHARMACYAND COMPLIANCE

# of Drugs Prescribed

% C

ompl

ianc

e

Slide 38

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METHODS TO IMPROVE COMPLIANCE• # of drugs, prescribers, and pharmacies• Once-daily or twice-daily dosing• Pill boxes• Medication reminder charts• frequency of clinic visits

Slide 39

Page 40: THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals

CONTENTS

• Drugs and the elderly

• Pharmacodynamic & pharmacokinetic changes with aging

• Drug knowledge and compliance

• Prudent prescribing

Slide 40

Page 41: THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals

AVOID THE PRESCRIBING CASCADE

Drug 1

BMJ. 1997;315:1096-1099. Slide 41

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AVOID THE PRESCRIBING CASCADE

Drug 1

Adverse effect misinterpreted as new medical condition

Rochon, P. BMJ. 1997;315:1096-1099. Published with permission.

Slide 42

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AVOID THE PRESCRIBING CASCADE

Drug 1

Adverse effect misinterpreted as new medical condition

Drug 2

Slide 43Rochon, P. BMJ. 1997;315:1096-1099. Published with permission.

Page 44: THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals

AVOID THE PRESCRIBING CASCADE

• HCTZ – Allopurinol

• NSAIDs – Antihypertensives

• Metoclopramide – Carbidopa/levodopa

• Cholinesterase inhibitors – Tolterodine

Slide 44

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BEWARE OF DRUG-DRUG INTERACTIONS (DDIs)

• 100% chance of DDIs with 8 drugs

Slide 45

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BEWARE OF DRUG-DRUG INTERACTIONS (DDIs)

• 100% chance of DDIs with 8 drugs

• Nearly 50% of community-dwelling geriatric patients had at least one DDI

Slide 46

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BEWARE OF DRUG-DRUG INTERACTIONS (DDIs)

• 100% chance of DDIs with 8 drugs

• Nearly 50% of community-dwelling geriatric patients had at least one DDI

• DDIs can result in ADRs or suboptimal dosing

Slide 47

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PRUDENT PRESCRIBING PRINCIPLES

• Know your patients and their drug cabinets

Slide 48

Page 49: THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals

PRUDENT PRESCRIBING PRINCIPLES

• Know your patients and their drug cabinets• Educate yourself and your patients

Slide 49

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PRUDENT PRESCRIBING PRINCIPLES

• Know your patients and their drug cabinets• Educate yourself and your patients• Understand biases in clinical trials

Slide 50

Page 51: THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals

PRUDENT PRESCRIBING PRINCIPLES

• Know your patients and their drug cabinets• Educate yourself and your patients• Understand biases in clinical trials• Ask about compliance

Slide 51

Page 52: THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals

PRUDENT PRESCRIBING PRINCIPLES

• Know your patients and their drug cabinets• Educate yourself and your patients• Understand biases in clinical trials• Ask about compliance• Always include ADRs in the differential

diagnosis of a new problem

Slide 52

Page 53: THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals

PRUDENT PRESCRIBING PRINCIPLES

• Know your patients and their drug cabinets• Educate yourself and your patients• Understand biases in clinical trials• Ask about compliance• Always include ADRs in the differential

diagnosis of a new problem• Try non-pharmacologic strategies

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Page 54: THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals

PRUDENT PRESCRIBING PRINCIPLES

• Know your patients and their drug cabinets• Educate yourself and your patients• Understand biases in clinical trials• Ask about compliance• Always include ADRs in the differential

diagnosis of a new problem• Try non-pharmacologic strategies• Offer drug therapy when indicated

Slide 54

Page 55: THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals

Which of the following is an age-related change that causes clinically

significant alterations in drug pharmacokinetics?

1 2 3 4

0% 0%0%0%

A. Decreased fat massB. Increased gastric pHC. Decreased

glomerular filtration rate

D. Increased total body water

:10Fick D.M, et al. Arch Intern Med. 2003;163(22):2716-2724.

Page 56: THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals

Which of the following does not contribute to adverse drug reactions

(ADRs) in the elderly?

1 2 3 4

0% 0%0%0%

A. All prescriptions written by one provider

B. Comorbid illnessC. HospitalizationD. Increasing numbers

of medications:10

Fick D.M, et al. Arch Intern Med. 2003;163(22):2716-2724.

Page 57: THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals

Which of the following is associated with improved medication

compliance?

1 2 3 4 5

0% 0% 0%0%0%

A. Increasing numbers of medications

B. Clinic visit in the previous 48 hours

C. TID dosingD. Drug side effectsE. Expensive

medications:10

Fick D.M, et al. Arch Intern Med. 2003;163(22):2716-2724.

Page 58: THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals

Which of the following is a principle of prudent prescribing?

1 2 3 4

0% 0%0%0%

A. Only inquire about prescribed medications

B. Ask the patient, “What could possibly be so hard about taking pills every day?”

C. Do not begin treatment without a diagnosis

D. Use drugs before a trial of non-pharmacologic therapy

:10Fick D.M, et al. Arch Intern Med. 2003;163(22):2716-2724.

Page 59: THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals

Which of the following effects of aging contributes to an increased risk of

ADRs related to benzodiazepine use?

1 2 3

0% 0%0%

A. Increased body fat mass causing a greater volume of distribution and decreasing drug half-life

B. Increased hepatic volume resulting in increased production of active metabolites

C. Decreased renal function causing delayed renal excretion

:10

Fick D.M, et al. Arch Intern Med. 2003;163(22):2716-2724.

Page 60: THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals

Patients who think they are taking too many medications report lower quality of life than patients who think they are

taking the right number of medications.

1 2

0%0%

1. True2. False

:10Fick D.M, et al. Arch Intern Med. 2003;163(22):2716-2724.

Page 61: THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals

A patient with a serum creatinine of 0.5 mg/dL (within the normal range) will also

have a normal creatinine clearance

1 2

0%0%

1. True2. False

:10Fick D.M, et al. Arch Intern Med. 2003;163(22):2716-2724.

Page 62: THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals

Older adults uniformly exhibit exaggerated pharmacodynamic responses compared

with younger adults.

1 2

0%0%

1. True2. False

:10Fick D.M, et al. Arch Intern Med. 2003;163(22):2716-2724.

Page 63: THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals

Which of the following drugs is/are listed as “high-severity” potentially inappropriate

medications for patients aged 65+?

A. B. C. D. E. F. G. H. I.

0% 0% 0% 0% 0%0%0%0%0%

A. Amiodarone (Cordarone)B. Amitriptyline (Elavil)C. Cyclobenzaprine (Flexeril)D. Diazepam (Valium)E. Diphenhydramine (Benadryl)F. Indomethacin (Indocin)G. Ketorolac (Toradol)H. Nitrofurantoin (Macrodantin)I. All of the above

:10Fick D.M, et al. Arch Intern Med. 2003;163(22):2716-2724.

Page 64: THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals

Mark H. Beers, MD

19542009

Data from "Updating the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults: Results of a US Consensus Panel of Experts." Donna M. Fick, PhD, RN, et al. Arch Intern Med. 2003;163(22):2716-2724.

Page 65: THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals

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THANK YOU FOR YOUR TIME!

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