geriatric polypharmacy: a pill for every ill
DESCRIPTION
Geriatric Polypharmacy: A Pill for Every ill. Amelie Hollier, DNP, FNP-BC, FAANP President, APEA. Geriatric Patients. US Life E xpectancy. Women: 80 years Men: 75 years. Natl Vital Stat Rep. 2010;58:1-136. Geriatric Patients. 2011. The “Baby Boomers” turned 65 years old in 2011 - PowerPoint PPT PresentationTRANSCRIPT
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Geriatric Polypharmacy:
A Pill for Every ill
Amelie Hollier, DNP, FNP-BC, FAANPPresident, APEA
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Geriatric Patients
• Women: 80 years• Men: 75 years
US Life Expectancy
Natl Vital Stat Rep. 2010;58:1-136
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Geriatric Patients
• The “Baby Boomers” turned 65 years old in 2011• Elderly population increases
by 30% each year from now until 2050!!!
2011
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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.
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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
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• Inter-individual variability• Polypharmacy• Concomitant diseases• Physiological changes
associated with aging (renal, hepatic dysfunction)• Multiple Prescribers!
It is MORE difficult to prescribe medications in Elderly Patients
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A Reasonable Approach: Always answers these 3 Questions before Prescribing
• First: What is the Diagnosis? • Second: What drug?• Third: What dose?
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What Diagnosis?What Disease?
First Question?
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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
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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
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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.
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How does an older adult with anemia present?
In older adults we see:• Shortness of breath• Chest pain (angina)• Fatigue (“I’m getting older”)
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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.
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Diagnosis in Elderly
Elderly Adults have “atypical presentation” of diseases
Disease Elderly Presentation Non-Elderly Presentation
Anemia SOB, Angina, Fatigue Fatigue
Hypothyroidism Cardiac conduction defects, cognitive
changes, looks depressed
Menstrual changes, constipation,
changes in hair and skin
UTI Confusion, anorexia Burning, frequency, urgency
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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
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What Diagnosis?What Disease?
First Question?
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What Drug? (or do we even need a drug?)
Second Question?
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Example: Pain in Older Adults
Nonpharmacologic Management• Ice• Heat• Massage• Relaxation• Biofeedback• PT interventions: exercise, splints, braces
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What Drug?
Second Question?
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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
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Beers Criteria• Goal is to improve care of older
adults by reducing exposure to PIMs
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Inappropriate MedicationsAnti-cholinergic Side Effects
Memory impairment, confusion, hallucinations, dry mouth, blurred vision, urinary retention, constipation, tachycardia, acute angle glaucoma
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“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 peeI can’t spitI can’t (**it) (“defecate”)
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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.
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Mrs. Thomas
Is this harmful if she uses this only three times weekly?
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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 PanelJ AM Geriatr Soc. 2012;60(4):616-631
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Anti-HistaminesWhat’s the Problem with these?• They are highly anti-cholinergic• Clearance reduced with advanced
age• Tolerance develops when used as
hypnotic2012 Beers Criteria Update Expert PanelJ AM Geriatr Soc. 2012;60(4):616-631
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High Risk MedicationsDiphenhydramine: impaired cognition, urinary retention (next day sedation, impaired driving)
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Good Rule: “Avoid First Generation Anti-histamines”
Suppose Mrs. Thomas had an acute allergic reaction after eating boiled
crawfish in South Louisiana?
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Anti-Histamines
2nd Gen Anti-Histamine Sedative Effect
Cetirizine ++Loratadine +
Fexofenadine 0Levocetirizine ++Desloratadine +
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Good Rule of ThumbChoose an agent from a different generation; or the least potent in the medication class
“Hay Fever”: Consider a topical nasal anti-histamine {Asteline (Azelastine)}
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Good Rule of Thumb• Consider a different class of medication• What about a topical nasal steroid?
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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?1. Sulfa drug2. Ciprofloxacin3. Amoxicillin4. Nitrofurantoin2012 Beers Criteria Update Expert PanelJ AM Geriatr Soc. 2012;60(4):616-631
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Mrs. Jones is 75 years old. She is diagnosed with a UTI. Her CrCl is 50 mL/min.
Beers Criteria recommends nitrofurantion avoidance:• CrCl < 60 mL/min• For long-term suppression
2012 Beers Criteria Update Expert PanelJ AM Geriatr Soc. 2012;60(4):616-631
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What about drugs that need dose adjustment due to
renal insufficiency?
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Excretion• Age related changes in kidney function• Decreases in renal mass• Decreases in renal blood flow (1-2%
decline/year after age 40)
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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
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What Affects Creatinine Levels?
• What you look like• What you eat• Who you are
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What affects serum Cr?Muscle Mass
More Less
More muscle mass, more serum creatinineLess muscle mass, less serum creatinine
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What affects serum Cr?Diet
Meat Eater Vegetarian Diet
Creatinine Increasesbut may be temporary Creatinine Decreases
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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
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How does obesity affect serum creatinine?
a. Increases Crb. Decreases Crc. Has no effect
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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!)
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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. Coresh J, Astor BC, Greene T, Eknoyan G, Levey AS. Am J Kidney Dis. 2003;41(1):1.
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Excretion• Decrease in GFR (50% decline
between 50 and 90 years)• Decrease in Creatinine Clearance
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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?1. Sulfa drug (none as long as CrCl > 30 mL/min)2. Ciprofloxacin (none as long as CrCl > 30
mL/min)3. Amoxicillin (none as long as CrCl > 30 mL/min)4. Nitrofurantoin (AVOID!)
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Known Decreased Renal Clearance in Elderly
• Acetaminophen• Anti-arrhythmics• Anti-convulsants• Anti-depressants• Anti-psychotics• Benzos, beta blockers, theophylline• Warfarin• Many, many others!
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Excretion
• Many drugs with dosage adjustments: allopurinol, many antibiotics, digoxin, lithium, gabapentin, H2 blockers, anti-arrhythmics
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Good Rule of ThumbBe familiar with the medications you prescribe!
Remember: Some drugs require renal dosing and hepatic dosing
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What patient is most likely to present with benign prostatic hyperplasia?
a. 20 year oldb. 40 year oldc. 60 year oldd. 80 year old
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Benign Prostatic Hyperplasia• What medication class do we prescribe
to improve urinary flow?• What’s the most common side effect?
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Beers Criteria Recommends “Avoid” alpha blockers for routine treatment of hypertension
OK to use alpha blockers for BPH with education and precautions
2012 Beers Criteria Update Expert PanelJ AM Geriatr Soc. 2012;60(4):616-631
Non-selective Alpha Blocker
Medications
Doxazosin CarduraPrazosin MinipressTerazosin Hytrin
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Alpha Blockers for treatment of BPH or Urinary outflow problems
Uro-specific Alpha Blockers Comments
*Uroxatral Alfuzosin (needs renal and hepatic dose adjustments)
*Flomax (generic)
Tamsulosin (no renal or hepatic precautions); sulfa allergy precaution
*Rapaflo Silodosin (needs renal and hepatic dose adjustments)
*Possible intraoperative floppy iris syndrome (IFIS) during cataract surgery
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Good Rule of ThumbChoose an agent that is most specific in the medication class for the problem you are treating.
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“Mrs. Dash”73 year old female who has osteoarthritis in both knees. She is still mobile but complains of daily pain in her knees. She is not a surgical candidate at this time. She self-medicates with ibuprofen and she reports good pain control using 400 mg ibuprofen 2-3 times daily.
Is this a Problem?
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Beers Criteria “Avoid”: NSAIDs
Non-COX selective NSAIDs, oral• Aspirin > 325 mg daily• Ibuprofen• Diclofenac, Etodolac• Meloxicam• Naproxen• Ketorolac, Indomethacin (most adverse GI
effects)2012 Beers Criteria Update Expert PanelJ AM Geriatr Soc. 2012;60(4):616-631
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Gastrointestinal Risk
• Treated 3-6 months: 1% risk of Upper GI ulcers, bleeding or perforation• Treated 1 year: 2-4%
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Proton Pump Inhibitors• Very effective at preventing ulcers• Once daily• Usually better tolerated than
misoprostol; slightly less effective
Hooper L, Brown TJ, Elliott R, et al. The effectiveness of five strategies for the prevention of gastrointestinal toxicity induced by non-steroidal anti-inflammatory drugs: systematic review. BMJ 2004; 329:948.
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PPI OTC and RxOmeprazole and Na bicarb
(Zegerid)• Na bicarb = baking soda• Allows omeprazole to be absorbed a little bit
faster • Each cap contains 300 mg Na• Avoid in HTN, HF, or other patients in whom Na
should be restricted
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PPI plus clopidogrel• Absolutely not omeprazole (inh 2C19
activity)! Reduces conversion of clopidogrelantiplatelet activity
• Do not use esomeprazole (Nexium)• Use dexlansoprazole, lansoprazole,
pantoprazole, or HD famotidine
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PPI Use
Increases pH• Alters the absorption of many drugs• Calcium, Fe, Vitamin B12
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PPI Harms• Fracture Risk in patients > 50 years, high
doses, or use > 1 year• 25% increase in all fractures• 47% increase in spinal fractures• FDA requires fracture risk info added to
labeling in OTC and Rx PPIs
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PPI Harms• Fracture Risk in patients > 50 years, high
doses, or use > 1 year
WHY???
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PPI Harms• Possible decreased calcium absorption
caused by PPIs• Inconclusive relationship between PPIs and
bone density
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PPI HarmsInfection• Pneumonia/C. difficile: R/T gastric acid
suppression may allow bacterial growth• Care in use with patients with COPD, asthma,
increased age, immunosuppression
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What about Vitamin B12 Deficient Patients on PPIs?
• Consider using a different mucus membrane• Sublingual,
intranasal
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…Back to “Mrs. Dash”73 year old female who has osteoarthritis in both knees. She self-medicates with ibuprofen and she reports good pain control using 400 mg ibuprofen 2-3 times daily.
IF GI risks high: consider PPIIF CV risks high….
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AHA Recommends for Pain
1. Acetaminophen2. Aspirin3. Tramadol4. Opioids5. Nonacetylated salicylates (Diflunisal)6. NSAIDs with low COX-2 selectivity7. NSAIDs with some COX-2 selectivity8. COX-2 selective agents
CV disease or risk factors for ischemic heart disease
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Beers: Aspirin for Primary Prevention of cardiac events
Lack of evidence of benefit versus risk in individuals aged > 80 years
FYI: Strength of recommendation is “weak”Quality of Evidence is Low
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Beers: “Avoid” Drug-Disease or Drug Syndrome Interactions
• Heart Failure• Syncope• Dementia and Cognitive Impairment• Falls and Fractures• Insomnia• Constipation
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Beers Criteria “Avoid”: Heart Failure
Digoxin > 0.125 mg dailyHigher doses associated with no additional
benefit and may increase toxicity
2012 Beers Criteria Update Expert PanelJ AM Geriatr Soc. 2012;60(4):616-631
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Age Related Change in Pharmacokinetics
As aging occurs, there is a DECREASE in total body water (10-15%)
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DistributionDecrease in total body water (10-15%)
So, smaller distribution of water soluble drugs
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Increased Drug Concentration!
Serum levels increase due to decreased volume of distribution
Examples: Digoxin
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Mrs. Boudreaux78 year old female who is very active and enjoys playing cards with her friends one evening per week. During the card game she has dinner and a couple of glasses of wine. She states that this has been her habit for several years but now she becomes dizzy before finishing her second glass of wine. She has had no change in weight, medications (or wine).
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What is going on with Mrs. Boudreaux?
a. The wine glasses are getting bigger.
b. She just can’t hold her liquor anymore.
c. This is an age related change with EtOH metabolism.
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DistributionDecrease in total body water (10-15%)
So, smaller distribution of water soluble (EtOH) drugs
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1. Increased EtOH Concentration!
Serum levels increase due to decreased volume of distribution
Examples: EtOH (Mrs. Boudreaux’ wine)
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2. Changes in EtOH Metabolism
• Liver mass decreases• Hepatic blood flow decreases• First pass metabolism decreases
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3. Decreased Production of CYP 450 enzymes
Can decrease up to 30% in elderly!
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What is going on with Mrs. Boudreaux?
a. The wine glasses are getting bigger.
b. She just can’t hold her liquor anymore.
c. This is an age related change with EtOH metabolism.
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Beers: “Avoid” Drug-Disease or Drug Syndrome Interactions
• Heart Failure• Syncope• Dementia and Cognitive Impairment• Falls and Fractures
• Insomnia• Constipation
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Sleep Complaints in Older Adults• 50% of older adults complain of at least
one sleep complaint• Impairs functional ability• Increases risk of accidents and falls• 1/3 of elderly patients in North America
receive a benzo hypnotic for insomnia (or non-benzo)
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Beers Criteria “Avoid”: Benzos Hypnotics
Benzodiazepines: • Avoid for insomnia, agitation, or delirium• Avoid in dementia (worsens symptoms)• Increased sensitivity to these and slower
metabolism• Increased risk of falls, cognitive impairment• A short acting agent can behave like an
intermediate or long acting agent2012 Beers Criteria Update Expert PanelJ AM Geriatr Soc. 2012;60(4):616-631
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BenzodiazepinesAgent Brand Duration
Alprazolam Xanax Short/intermediate
Lorazepam Ativan Short/Intermediate
Oxazepam Serax Short/Intermediate
Clonazepam Klonopin LongDiazepam Valium Long
Flurazepam Dalman Long
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But if you just have to use one for anxiety…
Generally speaking, consider 1/3 to ½ adult dose for elderly, titrate• Lorazepam (Ativan): Pharmacokinetics are
not significantly affected by age• Avoid doses over 3 mg
Potentially harmful drugs in the elderly: Beers list and more. Pharmacist's Letter/Prescriber's Letter 2007;23(9):230907.
Ottawa (ON): Canadian Pharmacists Association; c2011. Benzodiazepine monograph [October 2009]. http://www.e-therapeutics.ca. (Accessed February 8, 2013).
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Sleep Changes in Older Adults
• Take longer to fall asleep• Have less total nighttime sleep• Increased nighttime wakefulness• Daytime sleepiness• Awaken early
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Sleep Changes in Older Adults
Common Causes• Arthritic pain• Depression• Shortness of breath (HF, COPD, angina)• Parkinson’s (nightmares, night terrors, levodopa)• Medications: SSRIs, SNRIs, theophylline,
cimetidine, phenytoin, steroids, bronchodilators• Dementia: nighttime wandering
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First StepsNon-Pharmacologic• Avoidance of nicotine, alcohol, and caffeine• Increasing daytime exercise and light
exposure• Limit or eliminate daytime napping• Reduce light and noise• Comfortable room temperature• Meals > 2-3 hours before bedtime
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Beers Criteria “Avoid”: Non-benzo Hypnotics (aka: Z-drugs)
Benzodiazepine Receptor Agonists:• Less rebound insomnia, tolerance, and
dependence than benzos• Eszopiclone (Lunesta), Zolpidem (Ambien),
Zaleplon (Sonata)• Elderly patients have same side effects as
with benzos (delirium, falls, fractures) 2012 Beers Criteria Update Expert PanelJ AM Geriatr Soc. 2012;60(4):616-631
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Sleep Changes in Older Adults
Pharmacologic• Melatonin• No serious adverse events• Interacts with warfarin, ASA,
clopidogrel, ticlopidine, antidiabetic agents (decreased glucose tolerance and insulin sensitivity)
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High Risk Medications• Insulin and SUs: Aggressive glycemic control
often yields more harm than good
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Target A1C• A1C: goal is <7% in most patients (but
not all elderly!)• >7% for some patients with many
co-morbids or too abbreviated a lifespan to benefit from intensive therapy
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What do these drugs all have in common?
• Macrolides, quinolones, telithromycin, sulfonamides• Amitriptyline, citalopram, paroxetine,
sertraline, venlafaxine, fluoxetine• Albuterol, levalbuterol, salmeterol• Phenylephrine, pseudoephedrine• Cocaine
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QT Prolongation• Long QT Syndrome (LQTS)• Increased risk of ventricular
tachycardia
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Torsades de Pointes• Polymorphic V-tach• Many drugs are culprits, but often
it is combo of drugs
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What increases the risk?• Low potassium, magnesium• Bradycardia• Anything that prolongs myocardial
repolarization
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What DRUGS increase the risk?
• Quinolones• Risk is additive with other
drugs or conditions that increase risk
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WHO is at risk?• Elderly• Psychiatric patients• Patients with eating disorders
(electrolyte imbalances)
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Osteoporosis
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Bisphosphonates• Osteoporosis• Efficacy wanes with time• What’s optimal duration?• New labeling from FDA (no
consensus what it should say!)
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BisphosphonatesFLEX Trial• Compared bisphos with stopping
after 5 years of continuous use• Alendronate > 5 years did not
provide much additional protection against fractures
Black DM, Schwartz AV, Ensrud KE, et al. Effects of continuing or stopping alendronate after 5 years of treatment. The Fracture Intervention Trial Long-term Extension (FLEX): a randomized trial. JAMA 2006;296:2927-38
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What dose?Most drug studies do not include geriatric patients in clinical trials
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Underprescribing• “Unintended underutilization”• Example: Patient with MI: BB, ACE, ASA,
statin plus other meds• Don’t underprescribe to improve compliance
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Take Home Points!Consider ADEs for ANY NEW
symptom in an elderly patient!!!
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Take Home Points!Follow the Beers list to keep elders from
unintended harm! And PIMs!
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Final Take Home Points!Do we really need a drug? Can a safer drug be used instead?