1 L_

f your elderly patienttakes several medica-tions at the same time,he's at high risk for

drug-related problems.'Elderly patients areparticularly susceptible

to polypharmacy issues not ionly because aging affectshow their body handles .....

medications, but becausethey take more medications than younger patients: In the UnitedStates, people over 65 make up approximately 13% of the populationbut use about 30% of all prescriptions written.2 At any given time, anelderly patient takes, on average, four or five prescription drugs andtwo over-the-counter (OTC) medications.3

An elderly patient is also more likely to betaking a medication that has been prescribedinappropriately-one that's unnecessary, inef-fective, or potentially dangerous-and to sufferan adverse drug event (ADE). In a study ofmore than 150,000 elderly patients, 29% hadreceived at least one of 33 potentially inappro-priate drugs.4 A study of approximately 27,600Medicare patients documented more than1,500 ADEs in a single year.5

Most ADEs are the result of drug inter-actions; the more drugs a patient takes, thehigher the risk of interactions.6 The estimated

JAMES WOOTEN, a member of the RH editorialboard, is an associate professor at the University ofMissouri-Kansas City School of Medicine in KansasCity, MO. JULIE GALAVIS is a staff nurse at AdvancedPain Management, Wisconsin Health Center inMilwaukee. The authors have no financial relationshipsto disclose.

•a STAFF EDITOR: JEFF BAUER

incidence of drug interactions rises from 6% inpatients taking two medications a day to ashigh as 50% in patients taking five a day.7

As the elderly population in the UnitedStates continues to grow, so will the incidenceof ADEs. You can help your elderly patientsavoid the negative consequences of polyphar-macy by understanding how aging affects thebody's reaction to medications, which drugsare the most problematic for older patients, andhow to spot a drug-related problem and inter-vene.

Why elderly patientstake so many meds

Several factors contribute to polypharmacyamong patients over age 65. Clinicians may beprescribing more drugs for their elderlypatients than they have in the past simply

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because there are more drugsavailable for treating these pa-tients. The discovery of a broadrange of pharmaceuticals for awide variety of conditions hashelped many patients. Unfortu-nately, this new development hasalso led to both overuse and inap-propriate use of prescriptionmedications.

Many drugs that were once ob-tainable only with a prescription,such as Prilosec (omeprazole)and Claritin (loratidine), are nowreadily available over thecounter, and their use is on therise. In addition, complementaryand alternative medicines, suchas herbal therapies, are becomingincreasingly popular among allpatients, including the elderly.8

Compared to the general popu-lation, a patient over 65 is morelikely to have several chronic dis-orders, each requiring at least onemedication. 9' 10 Elderly patientswith more than one health condi-tion are likely to receive care fromseveral healthcare providers, eachof whom may prescribe a differentmedication to treat the samesymptoms.

11

Additionally, patients may pur-

chase medications from morethan one pharmacy, and eachpharmacy checks for potentialproblems only on those medica-tions that its pharmacist knowsthe patient is, or is supposed tobe, taking." Drug-related prob-lems are less likely to occur whenone physician or nurse practi-tioner oversees the patient's med-ication regimen.

Another factor in the equationis what's called the prescribingcascade: An elderly patient de-velops side effects from a medica-tion he's taking; however, hishealthcare provider interprets thesymptoms not as side effects ofthe drug but as symptoms of adisease. The healthcare providerthen prescribes yet another drug,creating the potential for evenmore side effects.2"'

Aging affectsdrug sensitivity

An elderly patient is at risk forADEs because the physiologicchanges that occur with agingmake the body more sensitive tothe effects of medications.' Thesechanges affect both pharmaco-

SOn average, elderly patients takefour or five prescription drugs andtwo over-the-counter medications.

" "Brown bag" drug review-having qRpatients bring in all their meds-may be moreaccurate than relying on the medical record alone.

0- Elderly patients are particularly sensitive to certainantidepressants, muscle relaxants, antispasmodics,and antihistamines.

kinetics-what the body does toa drug-and pharmacodynam-ics-what a drug does to thebody.'

The three components of phar-macokinetics are absorption, dis-tribution, and clearance, andeach is affected by aging. Ab-sorption, particularly after oraladministration, is least affected.3

In elderly patients, absorption isgenerally slower but complete.2

(Absorption through the skinafter topical administration mayactually increase in the elderly asthe aging skin becomes thin andfrail.') The more medications apatient takes, however, the greaterthe chance that one drug willinterfere with the absorption ofanother.

Distribution of drugs through-out the body also changes withage. A medication gets distrib-uted into either fat or water,depending on its chemical char-acteristics. As a patient ages, hispercentage of body fat increases,so a drug that's lipid-soluble,such as diazepam (Valium), maystay in the body longer becausethere are more fat stores intowhich it can be distributed.1"And, because older patients haveproportionally less body waterthan younger ones, blood levelsof a drug that is water-solublemay be higher than expected.'It's difficult, though, to antici-pate the effect that changes in fatstores or body water will have ondrug distribution because otherbody functions, such as proteinbinding, can also complicatedrug distribution.

Aging significantly affects dear-ance because it produces changesin the liver, where drugs aremetabolized, and in the kidneys,through which drugs are ex-creted. As the body ages, bloodflow through the liver decreases,

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r

Last updated in December 2003, the Beers Criteria areused to identify medications that are potentially in-appropriate for elderly patients. The criteria consist oftwo lists. The first list, which appears below, includesmedications that should generally be' avoided inelderly patients because the drugs are either ineffec-tive or pose a high risk of adverse effects and a safer

alternative is available. The second, which appears onpage 49, emphasizes medications that should beavoided in patients with specific conditions. Bothboxes contain only highlights from the Beers Criteria.You can find more complete information at http://archinte.ama-assn. org/ cgi/ content/full/163 /22/2716.

DRUG CLASS CONCERN

Analgesics: meperidine (Demerol), pentazocine CNS effects: confusion, hallucinations(Talwin), propoxyphene (Darvon, Darvon-N, others)

Anticholinergics and antihistamines: Anticholinergic effects: confusion, blurred vision,chlorpheniramine (Chlor-Trimeton), diphenhydramine constipation, dry mouth, lightheadedness, and(Benadryl), hydroxyzine (Atarax, Vistaril), difficulty with urination or loss of bladder control.cyproheptadine (Periactin), promethazine Nonanticholinergic antihistamines are preferred for(Phenergan), tripelennamine (PBZ-SR, Pelamine), treating allergic reactions in elderly patients.dexchlorpheniramine (Dexchlor, Polaramine, others)

Antidepressants: amitriptyline (Amitril, Elavil, Strong anticholinergic effects. Sedationothers), chlordiazepoxide-amitriptyline (Limbitrol),perphenazine-amitriptyline (Triavil), doxepin(Sinequan)

Barbiturates: all except phenobarbital Highly addictive. They cause more adverse effectsin elderly patients than most sedatives or hypnoticsand should not be prescribed to elderly patientsexcept to control seizures.

Benzodiazepines, long-acting: chlordiazepoxide Prolonged sedation, which increases risk of falls and(Librium, Mitran), clidinium-chlordiazepoxide (Librax), fractures. Short- and intermediate-actingdiazepam (Valium), quazepam (Doral), halazepam benzodiazepines are preferred if a benzodiazepine is(Paxipam), clorazepate (Tranxene) required.

GI antispasmodics: dicyclomine (Antispas, Bentyl, Anticholinergic effects. Uncertain effectiveness inothers), hyoscyamine (Levsin, Levsinex, others), elderly patients. These drugs should be avoided,propantheline (Pro-Banthine), belladonna alkaloids especially for long-term use.(Donnatal)

Muscle relaxants and antispasmodics: Anticholinergic effects. Sedation, weaknesscarisoprodol (Rela, Soma), chlorzoxazone (Paraflex,Parafon Forte), cyclobenzaprine (Cycoflex, Flexeril),metaxalone (Skelaxin), methocarbamol (Marbaxin,Robaxin), oxybutynin (Ditropan)

Nonsteroidal anti-inflammatory drugs (NSAIDs), GI bleeding, renal failure, high blood pressure, heartnon-COX selective: naproxen (Aleve, Naprosyn, failureothers), oxaprozin (Daypro), piroxicam (Feldene)

Source: Fick, D. M., Cooper, J. W., et al. (2003). Updating the Beers Criteria for potentially inappropriate medication use in olderadults. Arch Intem Med, 163(22), 2176.

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which can reduce the clearance ofcertain drugs by 30% - 40%.3,9Also, the cytochrome P450 en-zyme system-the major enzymesystem by which the liver metab-olizes drugs-becomes easilyoverwhelmed in older patients,so certain medications are metab-olized more slowly and not aswell.2

In addition, the size of the kid-neys and renal blood flow bothdecrease with age.' Renal clear-ance of medications can be re-duced by up to 50% as a patientreaches age 75.3

Aging also affects pharmaco-dynamics. Changes to drug re-ceptors can make a patient moreor less sensitive to certain med-ications.8 Drugs that act on theCNS may have far greater im-•i•ii pact in an elderly patient than

,•in a younger one as a result

Sof changes in the blood-Sbrain barrier.3

Altered pharmacokinetics andpharmacodynamics increase anelderly patient's risk for bothdrug-drug and drug-diseaseinteractions.' Drug-drug interac-tions typically occur when anelderly patient takes two medica-tions that have different indica-tions but additive pharmacologiceffects. For example, an elderlypatient might experience prob-lems if he's prescribed a narcoticanalgesic and an antidiarrhealagent; each is used for a differentreason, but each can cause consti-pation.

Drug-disease interactions, inwhich a medication exacerbates adisease process, are also commonamong elderly patients, becauseof the prevalence of disease inthis population.9 Anticholinergicdrugs, for example, can exacer-bate glaucoma, Alzheimer's dis-ease, and benign prostatic hyper-plasia.

9

Know what to lookfor, how to help

One way to protect your elderlypatient from the potentially harm-ful consequences of polyphar-macy is by knowing which drugsfrequently cause problems in thisage group. The most commonculprits are listed, by name or byclass, in the two tables that ac-company this article. The tables.reflect the Beers Criteria, a sys-tem first developed in 1991 toidentify those medications thatare potentially harmful to theelderly.1"

Many healthcare organizationsuse the Beers Criteria to evaluatethe drug regimens of their el-derly patients."2 However, it isimportant to remember that thecriteria don't ban the use of cer-tain medications for all elderlypatients; instead, they emphasizethose that "should generally beavoided" either because they'reineffective or because they pose ahigh risk and a safer alternativeis available.'2 As always, the pre-scriber needs to rely on clinicaljudgment and knowledge of thepatient's condition.

Taking a thorough drug his-tory is especially important whencaring for an elderly patient. In-vestigate and document all med-ications the patient is taking,including OTC and herbal prod-ucts, which a patient may not listbecause he does not considerthem to be drugs.7 Confirm thateach drug's generic and brandname, drug class, and clinicalindication are correct as orderedfor your patient. Find out whatother healthcare providers thepatient is seeing and, if possible,which ories prescribed whichmedications.

One effective way to take adrug history is with what's called

the "brown bag" method. Ratherthan relying solely on the pa-tient's medical record, ask thepatient to bring all of his medi-cations with him to the hospitalor office visit. A recent studyfound that this method producesa more accurate list of the drugsan elderly patient takes.13 Be sureto tell your patient to bring in allthe medications he takes, includ-ing prescription and OTC drugs,topical preparations, herbal prod-ucts, vitamins, and other supple-ments. Also ask if he is using anymedications he gets from familyor friends.

Find out how often and inwhat doses the patient has beentaking all medications, and com-pare that with what the prescrip-tion calls for. About 40% of el-derly patients fail to take theirdrugs as instructed.9

Know the side effect profile foreach medication that your patienttakes. You should also be awareof any conditions a patient hasthat might increase the risk of cer-tain drug-drug interactions. Forexample, sildenafil (Viagra) maybe appropriate for an elderlypatient with erectile dysfunction,but if the patient has heart diseaseand is taking any form of nitrate,such as nitroglycerin (Nitrostat,Nitro-Dur, others) or isosorbide(Isordil, Sorbitrate, others), silde-nafil could cause his blood pres-sure to drop to dangerously lowlevels and is, therefore, contra-indicated. Know all of your pa-tient's diagnoses, including self-diagnoses that the patient maybemanaging with OTC or herbalmedications.

Because aging affects howdrugs are cleared by the body,closely monitor the patient's labvalues, particularly his liver func-tion tests and his creatinine level,which is an indicator of how well

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CONDITION DRUGS TO AVOID CONCERN

Anorexia/malnutrition CNS stimulants May suppress appetite

Bladder flow obstruction anticholinergics, antihistamines, May decrease urinary flowGI antispasmodics, muscle relaxants,antidepressants, decongestants, oxybutynin(Ditropan), flavoxate (Urispas), tolterodine(Detrol)

Clotting disorders aspirin, nonsteroidal anti-inflammatory drugs May prolong clotting time and(NSAIDs), dipyridamole (Persantine, increase potential for bleedinbPyridamole), ticlopidine (Ticlid), clopidogrel(Plavix)

Constipation (chronic) calcium channel blockers, tricyclic May exacerbate constipationantidepressants, anticholinergics

COPD long-acting benzodiazepines, beta-blockers May cause or exacerbaterespiratory depression

Depression long-term use of benzodiazepines, methyldopa May cause or exacerbate(Aldomet), reserpine (Serpalan, Serpasil), depressionguanethidine (Ismelin)

Dysrhythmia tricyclic antidepressants May induce or aggravatedsyrhythmia and produce QT-interval changes

Heart failure disopyramide (Norpace), drugs with high May promote fluid retentionsodium content and exacerbate heart failure

Hypertension pseudoephedrine (Sinutab, Sudafed, others), May elevate blood pressureamphetamines

Insomnia decongestants, methylphenidate (Ritalin), May stimulate the CNStheophylline (Theodur), monoamine oxidaseinhibitors, amphetamines

Obesity olanzapine (Zyprexa) May stimulate appetite

Parkinson's disease conventional antipsychotics, metoclopramide May have anticholinergic(Reglan), tacrine (Cognex) effects

Seizures/epilepsy clozapine (Clorazil), chlorpromazine May lower seizure threshold(Thorazine), thioridazine (Mellaril), thiothixene(Navene), bupropion (Wellbutrin)

Stress incontinence beta-blockers, anticholinergics, tricyclic May worsen incontinenceantidepressants, long-acting benzodiazepines

Syncope/falls Short- and intermediate-acting May cause ataxia andbenzodiazepines; tricyclic antidepressants impaired psychomotor

function and exacerbatesyncope and falls.

Source: Fick, D. M., Cooper, J. W., et al. (2003). Updating the Beers Criteria for potentially inappropriate medication use in olderadults. Arch Intern Med, 163(22), 2176.

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F-D')M

the kidneys are functioning. Beaware, however, that because cre-atinine is a byproduct of musclemetabolism and elderly patientshave less lean body mass thanyounger ones, serum creatininelevels might overestimate creati-nine clearance.7 For this reason,you should use a formula such asthe Cockcroft-Gault, which takesinto consideration the patient'sage, sex, and weight to estimatecreatinine clearance.9

Be vigilant in monitoring forADEs. Since the symptoms ofADEs vary widely and it may bedifficult to distinguish the ad-verse effects of a drug from thesymptoms of disease, it's wise toconsider any new sign or symp-tom to be drug-related untilproven otherwise. 211

New or sudden-onset GI dis-tress is often caused by medica-tion. One study found that themost common ADEs amongelderly patients were nausea,vomiting, diarrhea, constipation,and abdominal pain.5

Because an elderly patient ismore sensitive than a youngerone to drugs that affect the CNS,consider the possibility that anychange in mental status is drug-related. Long-acting benzodiaze-pines, such as diazepam, cancause drowsiness, impaired me-mory, confusion, and prolongedsedation, which increase anelderly patient's risk for falls andfractures.9,12

Many drugs used in the elderly,including some antidepressants,muscle relaxants, antispasmodics,and antihistamines, have stronganticholinergic effects and, there-fore, may cause confusion, blurredvision, dry mouth, lightheaded-ness, constipation, and difficultywith urination or loss of bladdercontrol.2"1 Elderly patients are par-ticularly susceptible to these effects.

Keeping your patient safe alsorequires that you instruct him touse only one pharmacy if possi-ble. Teach him about the poten-tial side effects of the medicationshe's taking, and tell him to notifyhis healthcare provider if hedevelops any new symptoms.

If you have prescribing author-ity, you'll need to take additionalsteps to reduce your elderly pa-tients' risk of an ADE. Heed theadage to "start low and go slow."Although requirements vary con-siderably from patient to patient,doses often must be reduced forelderly patients by one-third toone-half of the recommendedadult dose.9

Try to simplify the patient'sregimen as much as possible by,for example, prescribing a singleagent rather than multiple drugsto treat a condition or choosing adrug that can be given once ortwice, rather than three times aday. Always write the purpose ofthe drug on the order.

Review the patient's medicalrecord and eliminate duplicate

1. Lim, W. K., & Woodward, M. C. (1999).Improving medication outcomes in olderpeople. Aust J Hosp Pharm, 29(2), 103.2. Williams, C. M. (2002). Using medica-tions appropriately in older adults. AmFam Physician, 66(10), 1917.3. Beers, M. H. "Aging as a risk factor formedication-related problems." 1999.www.ascp.com/public/pubs/tcp/1 999/dec/aging.shtml (16 May 2005).4. Simon, S. R., Chan, K. A., et al. (2005).Potentially inappropriate medication useby elderly persons in U.S. health mainte-nance organizations, 2000 - 2001. J AmGeriatr Soc, 53(2), 227.5. Gurwitz, J. H., Field, T. S., et al. (2003).Incidence and preventability of adversedrug events among older persons in theambulatory care setting. JAMA, 289(9),1107.6. Corcoran, M. E. "Polypharmacy in theolder patient with cancer." 1997. www.moffitt.usf.edu/pubs/ccj/v4n5/article5.html (16 May 2005).7. Un, P. (2004). Drug interactions: Amethod to the madness. Perspectives InCardiology, 20(10), 20.

medications-those prescribed bydifferent healthcare providers forthe same problem-and drugswith no therapeutic benefit orclinical indication.' You shouldsubstitute safer medications when-ever possible. Avoid treating anadverse reaction caused by onedrug with a second drug; if possi-ble, discontinue the drug that'scausing the problem or reduce thedosage.

Drug therapy has improved thelives of many patients. Medica-tions can be used to effectivelytreat patients regardless of theirage. When drugs are used judi-ciously and thoughtfully, there'sa much better chance of avoidingADEs. You can help ensure thatyour elderly patient gets safe andeffective drug therapy by care-fully monitoring what your pa-tient is taking and being alert forsigns of trouble. RH{

Have you ever asked an elderly- - patient to "brown bag" his med-

ications and bring them in? Visitwww.mweb.com and vote in our poll.

8. Fulton, M. M., & Allen, E. R. (2005).Polypharmacy in the elderly: A literaturereview. J Am Acad Nurse Pract, 17(4),123.9. Beers, M. H. (Ed.) "The Merck manualof geriatrics (3rd ed.), Section 1, Basics ofgeriatric care, Chapter 6, Clinical pharma-cology." 2005. www.merck.com/mrkshared/mmg/secl/ch6/ch6a.jsp (16 May2005).10. Zahn, C., Sangl, J., et al. (2001).Potentially inappropriate medication use inthe community-dwelling elderly. JAMA,286(22), 2823.11. Conry, M. "Polypharmacy: Pandora'smedicine chest?" 2000. www.geriatrictimes.com/gOO1 028.html (16 May 2005).12. Fick, D. M., Cooper, J. W., et al.(2003). Updating the Beers Criteria forpotentially inappropriate medication use inolder adults. Arch Intern Med, 163(22),2716.13. Caskie, G. I., & Willis, S. L. (2004).Congruence of self-reported medicationswith pharmacy prescription records inlow-income older adults. Gerontologist,44(2), 176.

50 RN AUGUST 2005 Vol. 68, No. 8 www.rnweb.com

- I REFERENCES 1-

RN/Thomson AHC Home Study Program

Continuing Education Test #102.9"Polyphannacy: Keeping the elderly safe"OBJECTIVES After reading the article you should be able to:

1. Discuss the implications of polypharmacy in the elderly,2. Identify drugs that the elderly patient should avoid.3. Develop a teaching plan for an elderly patient taking multiple medications.

Circle the one best answer for each question below. Transfer your answers to the card that follows page 60.Save this sheet to compare your answers with the explanations you'll receive. Or, take the test online at www.rnweb.com.

1. In the United States, what percentageof all prescriptions are written forpeople over age 65?a. 20%.b, 30%.c. 40%.d. 50%.

2. An elderly patient takes, on average,how may prescription drugs?a. One or two,b. Two or three.c. Three or four.d. Four or five.

3. In a study of more than 150,000elderly patients, what percentagehad received at least one of33 inappropriate drugs?a. 12%.b. 19%.c. 29%.d. 36%.

4. The estimated incidence of druginteractions rises from 6% in patientstaking two medications a day to ashigh as what percentage in patientstaking five a day?a. 20%.b. 30%.c. 40%.d. 50%.

5. All of the following contribute topolypharmacy in the elderly EXCEPT:a. Many former prescription drugs are now

available over the counter.b. Herbal remedies are becoming

increasingly popular with the elderly.c, The elderly are more likely to receive

care from one healthcare provider.d. The elderly tend to have more than one

chronic disorder.

6. Which of the following is a concernfor an elderly patient with a historyof COPD who's prescribed beta-blockers? They may:a. Elevate blood pressure.b. Stimulate the CNS.c. Worsen incontinence.d. Cause or exacerbate respiratory

depression.

7. Which of the following is correctconcerning the Beers Criteria? It:a. Bans the use of certain drugs for all

elderly patients,b. Identifies drugs that are effective in

treating elderly patients.c. Emphasizes drugs that should generally

be avoided in elderly patients.d. Is used to evaluate drug regimens in

both children and the elderly,

8. Renal clearance of medications canbe reduced by up to what percentageas a patient reaches age 75?a. 30%,b. 40%,c. 50%.d, 60%,

9. Which of the following group of drugscan exacerbate glaucoma in elderlypatients?a. Antibiotics.b. Anticholinergics.c. Antidiabetics.d. Thrombolytics.

10. Which system was developed in 1991to identify drugs that are potentiallyharmful to the elderly?.a. Beers Criteria.b, Denver Screening Test.c. Homans' test.d. Kline's test.

11. Which of the following should thenurse monitor because it indicateshow well the kidneys are functioning?a. Blood urea nitrogen.b. Creatinine.c. Electrolytes.d. Urine specific gravity,

12. When taking a drug history on anelderly patient, the nurse should doall of the following EXCEPT:a. Document only prescription drugs that

the elderly patient is taking.b. Identify the drug's generic and brand

name.c. Find out what other healthcare

providers the patient is seeing.d. Identify the drug class and clinical

indication.

13. One study found that the mostcommon adverse drug events (ADEs)among elderly patients include:a. Abdominal pain.b. Glaucoma.c. Headache.d. Tachycardia.

14. Which of the following statementsis correct concerning pharmokineticsin the elderly?.a. Absorption of oral drugs is generally

faster and incomplete,b. Drug clearance tends to be increased

by 30% - 40%.c. Blood levels of a drug that's water

soluble may be higher than expected.d. Certain drugs are metabolized more

quickly,

15. Which of the following is ananticholinergic effect that maybe seen in the elderly?a. Blurred vision.b. Diarrhea.c, Diuresis,d. Profuse sweating.

16. Which of the following can reducean elderly patient's chancesof developing an ADE?a. Treating an adverse reaction caused

by one drug with a second drug.b. Choosing a drug that can be given

at least three times a day.c. Prescribing a single agent rather than

multiple drugs.d. Starting therapy with a higher dose

of the drug.

17. According to the Beers Criteria,an elderly patient with hypertensionshould avoid which of the following?a. Acetaminophen.b. Aspirin.c. Penicillin.d. Pseudoephedrine (Sinutab, Sudafed,

others).

18. Which of the following is a concern foran elderly patient taking nonsteroidalanti-inflammatory idrugs?a. Heart failure.b. Strong anticholinergic effects.c. Prolonged sedation.d. Weakness.

Credit will be granted for this unit through August 2007. It was prepared by Marilyn Herbert-Ashton, RN, BC, MS. Approved for ANCC credit and AACN CategoryA credit. California Board of Registered Nursing (#CEP1 0864).

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TITLE: Polypharmacy: Keeping the elderly safeSOURCE: RN 68 no8 Ag 2005

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