University of Cincinnati / Health Alliance Reynolds Geriatric Education Center

1. Practical Prescribing for Vulnerable Community Living Elderly University of Cincinnati / Health Alliance Reynolds Geriatric Education Center

2. Presentation Outline • Review the challenges of prescribing for the Vulnerable seniors ; • Examine risks factors for Adverse Drug Events; • Propose strategies to improve prescribing outcomes; • Suggest resources available for continual support in managing medications in seniors.

3. Prescribing Challenges • Effective drug treatments for chronic illnesses have expanded, and many older people have multiple chronic illnesses • Adverse drug reactions (ADEs) and drug-drug/drug-disease interactions increase as the number of prescribed medications increases • Adherence to complex, multiple drug regimens is difficult: poor vision, poor memory, limited funds, etc.

4. Gaps in Our Understanding of Medication Use in the Elderly • Safety and effectiveness of any given medication is not well studied in the aged • Multiple concomitant medications adversely effect the safety and effectiveness of individual medications • Multiple medical problems can adversely effect the outcomes of pharmacotherapy

5. Adverse Drug Events (ADEs) • Use of multiple medications is the primary risk factor for experiencing an ADE • Multiple chronic medical conditions increases the risk for ADEs • Many ADEs are predictable and therefore preventable

6. Risk Factors for Adverse Drug Events in Older Patients • > 6 concurrent chronic diagnoses • >12 doses of medications/day • > 9 medications • Multiple Prescribing Physicians • A prior ADE • Low body weight • Age >85 years • Creatinine clearance <50 ml/minute

7. Adverse Drug Effect Cascade 15

8. Mrs. Janet Andrews An 86 year old patient comes to your office with her daughter. She last saw you more than a month ago when you completed a preoperative exam prior to an elective hip replacement. Mrs. Andrews was in the hospital for one week and in a nursing home for 3 weeks and is now back in her own home.

9. Pre-operative Meds-Most concern? • Digoxin • Enalapril (Vasotec) • Warfarin • Tylenol PM • Dicyclomine (Bentyl) • More than one of the above

10. Post-operative Symptom: ConfusionLeast likely contributor? • Digoxin • Tylenol PM • Amiodarone (Cordarone) • Oxycodone • Warfarin

11. Post-operative Symptom: Poor AppetiteLeast likely contributor? • Digoxin • Enalapril (Vasotec) • Valdecoxib (Bextra) • Amiodarone (Cordarone) • Oxycodone

12. Post-operative Symptom: Constipation Least likely contributor? • Digoxin • Tylenol PM • Amiodarone (Cordarone) • Oxycodone • Warfarin

13. Post-operative Sign: BradycardiaLeast likely contributor? • Digoxin • Enalapril (Vasotec) • Amiodarone (Cordarone) • Dicyclomine (Bentyl)

14. Today, would you discontinue or decrease the dose of one of these medications? • Digoxin • Enalapril (Vasotec) • Valdecoxib (Bextra) • Amiodarone (Cordarone) • None of the above

15. During future visits, would you discontinue or decrease the dose of one or more of these medications? • Dicyclomine • Ferrous sulfate • Oxycodone • Tylenol PM • Two of the above • Three of the above • All of the above

16. Benefit vs Risk • Appropriate medication use requires that benefits of therapy clearly outweigh the associated risks. • Benefit-to-risk ratio is unique to an individual; the very medication and dosage that helps one patient may harm another.

17. Prescribing Suggestions with Vulnerable Seniors: Basic Strategies • Prescribing ALL, indicated medications, may NOT be the best approach • Triage medications: • Start with most needed first, assess impact; then add second most important, etc. • Some conditions assumed to be “aging” can be ADEs – e.g., confusion, falls, incontinence

18. Helping Your Patients (I) • Encourage Use of Patient Medication Logs • Assess ability to take correctly • Take advantage of Medication Adherence Aids • Keep Costs Down

19. Helping Your Patients (II) • Use One Drug to Treat Multiple Problems (For example, use antidepressant side effects) • Avoid High Risk Medications • Drug-Drug Interactions • Drug-Disease Interactions

20. Where to get help • UC/Health Alliance Reynolds Grant ‘Email Geriatrics Consultation’: geriatrics@uc.edu • Net Wellness at http://www.netwellness.org • American Geriatrics Society at http://www.americangeriatrics.org • Medicaid Drug Benefit (AGS) at http://www.americangeriatrics.org/policy/medicare_info.shtml

21. Where to get help • National Guideline Clearing House at http://www.guideline.gov • Medscape at http://www.medscape.com • Assistance Programs for Low Income older adults from Drug Manufacturers http://needymeds.com/

22. Patient Medication Log • Prescription drugs - from all providers • Trans-dermal medications • Inhalers • OTC drugs • Vitamins and Dietary Supplements • Eye & ear drops • Topical agents

23. Medication Adherence Aids • Prefer QD or BID regimens • Pill boxes to organize and provide reminders

24. Example 4 x 7 compliance Aid

25. Example 1x7 Compliance Aid

26. Using One Drug to Treat Multiple Problems 76 y.o. patient with depressive symptoms, weight loss, and insomnia. • One drug could in theory treat all of these medical problems… Variation on this theme: Choose by the side effect you want or least desire when selecting otherwise “therapeutic equivalent” medications

27. Avoid Drug-Drug Interactions that are Associated with Hospitalization • ACE-inhibitor plus… • Potassium sparing diuretic or potassium • Benzodiazepine plus… • Antidepressant, antipsychotic, or another benzodiazepine • Warfarin and new antibiotic prescription • Diuretic plus….. • Digoxin, nitrate, or another diuretic

28. Avoid Drug-Disease Interactions • NSAIDs and History of Upper GI bleeding • Anticholinergics medications: • BPH/Bladder outlet obstruction • Alzheimer’s Disease • Chronic Constipation • Benzodiazepines/Tricyclic antidepressants and Falling/Gait Disturbances

29. Help Patients Keep Costs Down (I) • Prescribe a less expensive comparable brand or generic drug in the same drug class. • Optimize dosing. (Does taking the total amount of the drug once daily save money and is it still effective?) • Determine if cutting pills in half will reduce costs

30. Help Patients Keep Costs Down (II) • Suggest using Mail Order for chronic medications. • Use Assistance Programs for Low Income Seniors from Pharmaceutical Manufacturers http://needymeds.com/

31. Prescribing for Vulnerable Seniors Clinical Topics • Anti-cholinergic Medications • Analgesics • Sedative-Hypnotics • Oral Agents for Type II Diabetes • Dietary Supplements

32. Avoid Medications with High Anti-Cholinergic Properties (I) • Antihistamines in general and diphenhydramine (Benadryl) in particular • Omnipresent in OTC sedatives, cough and cold, sinusitis etc. • For antihistamines use loratadine (Claritin) or fexofenadine (Allegra)

33. Avoid Medications with High Anti-Cholinergic Properties (II) • Tricyclic Antidepressants, • Anti-spasmotics, • Anti-psychotics, • Anti-parkinsonian and muscle relaxants, • Incontinence medications

34. Analgesics-Choose Carefully (I) • Acetaminophen – 1st Choice for Chronic Pain • NSAIDS - COX-2 or Non-selective –Use cautiously ONLY for short term treatment, avoid for chronic pain or add PPI • Tramadol (Ultram) – Possible 2nd Choice for chronic pain

35. Analgesics-Choose Carefully (II) • Use scheduled narcotics to reduce chronic pain • Avoid: Propoxyphene, meperidine, trans-dermal agents AGS Chronic Pain Guidelines at http://www.americangeriatrics.org/education/manage_pers_pain.shtml Partners Against Pain athttp://www.partnersagainstpain.com/index-mp.aspx?sid=3

36. Sedative/hypnotics (I) • Trazodone • GABA selective agents – zolpidem (Ambien) or zaleplon (Sonata)

37. Sedative/hypnotics (II) • Non-GABA selective benzodiazepine • Lorazepam • Oxazepam • Temazepam • Choose a moderate half-life agent if need regularly • All can cause falls, memory impairment, “retrograde” amnesia, tolerance and withdrawal

38. Oral Agents for Diabetes (I) • How tight to control frail elderly? • If insulin used, do you need oral agent? • Insulin sensitizers – Actos, Avandia-use cautiously • May increase CHF symptoms, peripheral edema

39. Oral Agents for Diabetes (II) • Hypoglycemia more likely to occur with metformin and/or beta-blockers • Lactic acidosis more likely with metformin when used in seniors with renal impairment • Consult Am Assoc Clinical Endocrinologists at http://www.aace.com/clin/guidelines/

40. Dietary Supplements (I) • St. John’s Wort can increase drug metabolism (P450/CYP3A4) • “G-Team” all have antiplatelet effects • Ginkgo Biloba; Garlic; Ginger • Saw Palmetto – no reported drug interactions • Kava Kava – associated with hepatoxicity

41. Dietary Supplements (II) • Echinacea – avoid long term use; agent decreases immune response • Resources: • Natural Medicine Database -http://www.naturaldatabase.com/ • The Prescriber’s Letter at http://www.prescribersletter.com

42. Practical Prescribing for Vulnerable Community Living Older AdultsPart TwoManaging Common Clinical Problems

43. Mrs. Janet Andrews Mrs. Andrews returns for f/u one month after her last visit. A number of her medications have been discontinued or dosing was reduced. In general she is doing better. Less confused, no constipation, improving hydration and anemia. She continues to have trouble walking and sleeping. Although her appetite is better she has lost another 2 lbs to 108 lbs (10 lbs in the last 2 months). She has added several dietary supplements to improve her medical problems. New symptoms are increasing anxiety and agitation, and easy bruising.

44. Continuing Weight Loss / Poor Appetite:LEAST Likely Contributor • Digoxin • Ferrous sulfate • St John’s Wort • Kava kava • Anxiety / agitation • Depressive symptoms

45. Minor depression with anxiety and insomnia: BEST treatment choice? • St Johns Wort • Fluoxetine extended release (Prozac weekly) • Escitalopram (Lexapro) • Mirtazapine (Remeron) • Trazodone (Desyrel)

46. Potentiating Warfarin / Easy Bruising: LEAST Likely • Tylenol • Gingko Biloba • Garlic • Glucosamine/chondrotin • Limited dietary vitamin K

47. Dietary Supplements (I) • St. John’s Wort can increase drug metabolism (P450/CYP3A4) • “G-Team” all have antiplatelet effects • Ginkgo Biloba; Garlic; Ginger • Saw Palmetto – no reported drug interactions • Kava Kava – associated with hepatoxicity

48. Dietary Supplements (II) • Resources: • Natural Medicine Database -http://www.naturaldatabase.com/ • Herb Med athttp://www.herbmed.org/about.asp • The Prescriber’s Letter at http://www.prescribersletter.com

49. Insomnia: Which medication would be best to recommend?* • Trazodone 50 mg po qHS • Zolpidem (Ambien) 10 mg take ½ tablet (5 mg) po qHS PRN • Temazepam 15 mg capsule po PRN • Mirtazepine (Remeron) one-half of 30 mg tablet (15 mg) qHS • Zalepion (Sonata) 5 mg po qHS prn early awakening * Along with counseling on good sleep hygiene (avoid naps, improve sleep environment schedule daytime activity etc)

50. Persistent Pain: 5 on scale of 10MODIFY or ADD • Propoxyphene/acetaminophen (Darvocet)* • Hydrocodone/acetaminophen (Vicodin)* • Naproxen (Naprosyn) • Celecoxib (Celebrex) • Fentanyl patch (Duragesic) *These choices require discontinuation of acetominophen 1 gram four times a day.