Geriatric Polypharmacy: A Pill for Every ill

1. Geriatric Polypharmacy:A Pill for Every ill Amelie Hollier, DNP, FNP-BC, FAANP President, APEA

2. Geriatric Patients US Life Expectancy • Women: 80 years • Men: 75 years Natl Vital Stat Rep. 2010;58:1-136

3. Geriatric Patients 2011 • The “Baby Boomers” turned 65 years old in 2011 • Elderly population increases by 30% each year from now until 2050!!!

4. Geriatric Patients • 20% of people aged > 65 years take at least 10 medications • Termed: the “P” word Patterns of medication use in the United States, 2006. A report from the Slone Survey. www.bu.edu/slone/SloneSurvey/ AnnualRpt/ SloneSurveyWebReport2006.pdf. Accessed February 1, 2013.

5. Geriatric Patients • As the number of medications increases, so does the risk of adverse drug events (ADEs) • ADEs: weight loss, falls, changes in cognition, loss of independence, hospitalization

6. It is MORE difficult to prescribe medications in Elderly Patients • Inter-individual variability • Polypharmacy • Concomitant diseases • Physiological changes associated with aging (renal, hepatic dysfunction) • Multiple Prescribers!

7. A Reasonable Approach: Always answers these 3 Questions before Prescribing • First: What is the Diagnosis? • Second: What drug? • Third: What dose?

8. What Diagnosis?What Disease? First Question?

9. Unrecognized ADEs • In older adults, drug induced symptoms are commonly mistaken for a new disease or worsening of an existing disease • Some drug induced symptoms are indistinguishable from common older adult illnesses

10. Diagnosis in the Elderly New onset of disease in an elderly patient usually affects an organ that has been weakened by a different disease process • Ex: Elderly adult develops anemia Harrison’s Principles of Internal Medicine

11. Example 1: Mr. Smith 80 year old male who is mostly independent; he has a number of chronic diseases that are stable. He has developed iron deficiency anemia over the last 3 months from a “slow bleeding” polyp in large intestine.

12. How does an older adult with anemia present? In older adults we see: • Shortness of breath • Chest pain (angina) • Fatigue (“I’m getting older”)

13. Example 2:Mrs. Jones 80 year old female who is very independent; she has several chronic diseases that are stable with medications. She has developed hypothyroidism over the last 4 months.

14. Diagnosis in Elderly Elderly Adults have “atypical presentation” of diseases

15. Diagnosis in the Elderly New onset of disease in an elderly patient usually affects an organ that has been weakened by a different disease process Harrison’s Principles of Internal Medicine

16. What Diagnosis?What Disease? First Question?

17. What Drug? (or do we even need a drug?) Second Question?

18. Example: Pain in Older Adults Nonpharmacologic Management • Ice • Heat • Massage • Relaxation • Biofeedback • PT interventions: exercise, splints, braces

19. What Drug? Second Question?

20. Beers Criteria • Most widely used criteria (since 1991) to assess inappropriate drug prescribing in elderly • AGS Updated 2012 Beers Criteria for Potentially Inappropriate Medication (PIMS) Use in Older Adults

21. Beers Criteria • Goal is to improve care of older adults by reducing exposure to PIMs

22. Inappropriate Medications Anti-cholinergic Side Effects Memory impairment, confusion, hallucinations, dry mouth, blurred vision, urinary retention, constipation, tachycardia, acute angle glaucoma

23. “An Ode to an Anticholinergic Med” Oh this drug, it makes me pink, Sometimes, I can’t think or even blink. I can’t see, I can’t pee I can’t spit I can’t (**it) (“defecate”)

24. Mrs. Thomas 80 year old female who is completely independent; she has a several chronic diseases that are stable with medications. She complains of difficulty sleeping when her arthritic knee aches. She takes an OTC medication with diphenhydramine for sleep.

25. Mrs. Thomas Is this harmful if she uses this only three times weekly?

26. Potentially Inappropriate Medications AVOID Antihistamines (First Generations) • Brompheniramine (Bromfed) • Carbinoxamine (Chlor-Trimeton) • Diphenhydramine (Benadryl) • Hydroxyzine (Atarax, Vistaril) • Promethazine (Phenergan) • Others 2012 Beers Criteria Update Expert Panel J AM Geriatr Soc. 2012;60(4):616-631

27. Anti-Histamines What’s the Problem with these? • They are highly anti-cholinergic • Clearance reduced with advanced age • Tolerance develops when used as hypnotic 2012 Beers Criteria Update Expert Panel J AM Geriatr Soc. 2012;60(4):616-631

28. High Risk Medications Diphenhydramine: impaired cognition, urinary retention (next day sedation, impaired driving)

29. Good Rule: “Avoid First Generation Anti-histamines” Suppose Mrs. Thomas had an acute allergic reaction after eating boiled crawfish in South Louisiana?

30. Anti-Histamines

31. Good Rule of Thumb Choose an agent from a different generation; or the least potent in the medication class “Hay Fever”: Consider a topical nasal anti-histamine {Asteline (Azelastine)}

32. Good Rule of Thumb • Consider a different class of medication • What about a topical nasal steroid?

33. Mrs. Jones is 75 years old. She is diagnosed with a UTI. Her CrCl is 50 mL/min. Which anti-infective should be avoided in her because of inadequate drug concentration in the urine? • Sulfa drug • Ciprofloxacin • Amoxicillin • Nitrofurantoin 2012 Beers Criteria Update Expert Panel J AM Geriatr Soc. 2012;60(4):616-631

34. Mrs. Jones is 75 years old. She is diagnosed with a UTI. Her CrCl is 50 mL/min. Beers Criteria recommends nitrofurantionavoidance: • CrCl < 60 mL/min • For long-term suppression 2012 Beers Criteria Update Expert Panel J AM Geriatr Soc. 2012;60(4):616-631

35. What about drugs that need dose adjustment due to renal insufficiency?

36. Excretion • Age related changes in kidney function • Decreases in renal mass • Decreases in renal blood flow (1-2% decline/year after age 40)

37. Measure of Kidney Function • Creatinine production is related to muscle mass • Creatinine production decreases with advancing age & loss of muscle mass. This produces decreased serum Cr levels • So…..Normal serum Cr, but impaired renal function

38. What Affects Creatinine Levels? • What you look like • What you eat • Who you are

39. What affects serum Cr?Muscle Mass More Less More muscle mass, more serum creatinine Less muscle mass, less serum creatinine

40. What affects serum Cr?Diet Meat Eater Vegetarian Diet Creatinine Increases but may be temporary Creatinine Decreases

41. What affects serum Cr?Age and Gender Creatinine decreases as you age (due to less muscle mass) Creatinine greater in males due to greater muscle mass

42. How does obesity affect serum creatinine? • Increases Cr • Decreases Cr • Has no effect

43. So…. many Factors Affect Creatinine Levels • A better measure of kidney function is CrCl (mL/min) • Most accurate CrCl is collected over a 24 hour period, but it’s a major drag to collect!! • GFR (Glomerular filtration rate = mL/min) can be used to estimate CrCl (Not Perfect, but it’s pretty good!)

44. GFR is usually estimated by Labs: eGFR • eGFR Normal Range > 60mL/min/1.73m2 • About 38% of individuals aged 70 years or older without HTN or DM, had GFRs of < 60mL/min/1.73m2 Prevalence of chronic kidney disease and decreased kidney function in the adult US population: Third National Health and Nutrition Examination Survey. CoreshJ, Astor BC, Greene T, Eknoyan G, LeveyAS. Am J Kidney Dis. 2003;41(1):1.

45. Excretion • Decrease in GFR (50% decline between 50 and 90 years) • Decrease in Creatinine Clearance

46. Mrs. Jones is 75 years old. She is diagnosed with a UTI. Her CrCl is < 50 mL/min. Which anti-infective should be avoided in her because of inadequate drug concentration in the urine? • Sulfa drug (none as long as CrCl > 30 mL/min) • Ciprofloxacin (none as long as CrCl > 30 mL/min) • Amoxicillin (none as long as CrCl > 30 mL/min) • Nitrofurantoin (AVOID!)

47. Known Decreased Renal Clearance in Elderly • Acetaminophen • Anti-arrhythmics • Anti-convulsants • Anti-depressants • Anti-psychotics • Benzos, beta blockers, theophylline • Warfarin • Many, many others!

48. Excretion • Many drugs with dosage adjustments: allopurinol, many antibiotics, digoxin, lithium, gabapentin, H2 blockers, anti-arrhythmics

49. Good Rule of Thumb Be familiar with the medications you prescribe! Remember: Some drugs require renal dosing and hepatic dosing

50. What patient is most likely to present with benign prostatic hyperplasia? • 20 year old • 40 year old • 60 year old • 80 year old