See discussions, stats, and author profiles for this publication at: http://www.researchgate.net/publication/272511766Rules for Improving Pharmacotherapy inOlder Adult Patients: Part 2 (Rules 6-10).ARTICLE FEBRUARY 2015DOI: 10.14423/SMJ.0000000000000243 Source: PubMedDOWNLOADS56VIEWS511 AUTHOR:James M WootenUniversity of Missouri - Kansas City33 PUBLICATIONS 98 CITATIONS SEE PROFILEAvailable from: James M WootenRetrieved on: 23 July 2015Rules for Improving Pharmacotherapy in OlderAdultPatients:Part2(Rules6Y10)JamesM.Wooten, PharmDAbstract: The population of older adult patients in the United Statesis growing each year. Appropriate pharmacotherapy has allowed manyolder patients to live longer and maintain healthy lives. Unfortunately,theinappropriateutilizationofmedicationscanbeharmfultoolderadult patients. Inappropriate pharmacotherapy may lead to overusingmedications andpolypharmacy. Polypharmacycancontribute toa higherincidence of adverse effects, increase the risk of dangerous drug in-teractions, cause noncompliance with appropriate medication use, andsignicantly increase the cost of health care. The polypharmacy issuewith geriatric patients has been described as an epidemic and this issuemust be addressed. This review provides objective rules that may helpprevent polypharmacy. Consideration of these rules when prescribing,dispensing, and caring for older adult patients will improve the overallpharmacotherapy regimens instituted by healthcare providers.Key Words: Gerontology, pharmacodynamics, pharmacokinetics, phar-macology, pharmacotherapyInPart1, whichappearedintheFebruaryissue, polyphar-macywasdenedastakingmultipleunnecessarymedi-cations.1Y4Because of the variety of medications taken by thegrowing older adult population of the United States, as well asan ever-increasing armamentarium of medications to treat al-most all diseases, polypharmacy has become a major healthcareissue for older patients. Polypharmacy increases the risk of drug-relatedadverseeffectsandharmfuldruginteractions,reducescompliancetoappropriatepharmacotherapy,andsignicantlyincreasesthelevelofmorbidityandmortalityinthe geriatricpopulation.Rules/guidelines should be established and adhered to byall healthcare providers so that the polypharmacy epidemic canbe stopped and older adult patients can lead better lives. Thisarticle provides practitioners with specic rules/guidelines thatthey can use when prescribing medications for their older adultpatients. Theserules/guidelinescouldbeprintedandpostedwhere prescribers could easily and readily be reminded of theseimportant objectiveconcerns. Followingtheserules greatlyenhances the pharmacotherapy plan for all older patients, pre-vent potential adverse drug effects, reduce healthcare costs, andallow patients to lead happier and healthier, productive lives.Part 2 enumerates the nal ve, rules 6 through 10.Rule 6: Prescribe and Recommend OnlyThose Medications/Drug Classes for WhichYou Have a Thorough Understandingof the PharmacologyRule 6 appears obvious, but some medication choices arebetter than others. For instance, a patient who is hypertensiveand has systolic heart failure can be treated with an angiotensin-converting enzyme inhibitor, which treats both problems.Thoroughlyassessingthepatientsmedical issuesandjudi-ciously prescribing specic medications is an effective way toapproach this rule. Practitioners must realize that if more thanonehealthcareproviderismanagingthepatientsmedicationprole, a consultation with the other providers may be neces-sary to ensure that the proper pharmacotherapy is prescribed.2,3Important aspectsofamedicationspharmacologicpro-leincludethedrugsindicationsforuse, mechanismofac-tion, pharmacokinetics, appropriate dosage formost patients,adverse effects/contraindications; and monitoring parameters.Because of the extensive number of medications on the market,it is impossible to knoweverything about every drug; however,intimateknowledgeofmedicationscommonlyprescribedtoolder adults can assist practitioners in making safe and effectivepharmacologic decisions for these patients.Key Points& Polypharmacy in the geriatric population is an important issue.& Older adult patientsundergophysiologicchangesthat canalter a drugs pharmacokinetics and pharmacodynamics.& Practitioners must take great care when prescribing medica-tionstoolderadult patientstoensurethat everydrugpre-scribed is appropriately assessed and monitored.Review ArticleSouthernMedicalJournal & Volume 108, Number 3, March 2015 145From the Department of Internal Medicine-Clinical Pharmacology, Universityof Missouri-Kansas City School of Medicine; Kansas City.Reprint requests to Dr James M Wooten, University of Missouri-Kansas CitySchool of Medicine, 2411 Holmes St, Kansas City, MO 64108.E-mail: wootenj@umkc.eduThe author has no nancial relationships to disclose and no conicts of interestto report.Accepted September 22, 2014.Copyright * 2015 by The Southern Medical Association0038-4348/0Y2000/108-145DOI: 10.14423/SMJ.0000000000000257Copyright 2015 The Southern Medical Association. Unauthorized reproduction of this article is prohibited.DosageMost older adult patients need lower doses of medicationsthandootherpatientpopulations. Thisdosinginformationisavailable in some tertiary pharmacotherapy texts (eg, PhysiciansDesk Reference) or medical applications for various electronicdevices (Epocrates). The majorityof the datawere not discoveredduring clinical trials. (The Food and Drug Administration doesnotmandatethat aspecicnumber ofolderadultsubjects beenrolled in Phase I, II, or III trials before drug approval. Becauseolder adults have a large number of comorbidities and take manymedications, they are not ideal subjects for trials.5) In general,postmarketingsurveillanceis theprimarymethodbywhichspecic dosing recommendations in older adults is obtained.3Y8Practitioners shouldnote the followingimportant con-siderations regarding drug doses in older adults:& Assess the patients renal function, hepatic function, and nutritionalstatus (eg, weight, albumin) before any dose is prescribed. Each ofthese parameters has a signicant inuence on the precise dosagefor a patient.& Be aware that changing from one dosage form to another may in-uence the bioavailability of the drug, which may affect the dosage.& Realize that liquid preparations to be delivered via a feeding tubemay interact with various nutrients.& Understand that controlled-release preparations cannot be crushed,and the number of doses per day may need to be altered.& Contact apharmacist if thereisaquestionregardingadoseordosage form.& Start with lower doses of a drug and titrate to efcacy and toler-ability whenever possible.AdverseDrugReactionsThe older adult population experiences more adverse drugevents (ADEs) than do other patient groups because of the phys-iologic effects of aging (eg, reduced renal and hepatic function).One could describe ADEs in older patients as a perfect stormof issuesthatcometogethertomakeolderpeopleextremelysusceptible to ADEs. Because of this, a thorough understandingoftheadverseeffect proleofeachdrugprescribedandthepotential risk involved in using a particular drug in a specic pa-tient are critical. Every drug has associated ADEs. The followingprovides suggestions for reducing ADEs in older adults3,4,8Y11:& Provide proper medication counseling.& Ensure that the patient receives adequate tutelage in taking med-ications with exact/complex instructions for use (eg, inhalers, sub-cutaneous insulin injection).& Providewrittenmaterialsorbrochures(ifavailable)onthedis-ease(s) being treated and for medications.& Try to improve patient compliance.& Use correct dosage based on patients renal and/or hepatic functionand titrate doses up slowly, if possible.& Knowand anticipate the ADEs of all drugs prescribed and monitorpatient(eg,obtainbloodlevels, internationalnormalizedratioifpatient takes warfarin) for those ADEs.& Ensure that the pharmacy also counsels the patient.& AlwaysassessforpotentialdrugYdrug,drugYdisease,drugYfoodinteractionsandchoosedrugs/drugclasses withreducedinterac-tion risk (see Table 3).& Train the patients family or caregiver to monitor for ADEs.There are several tools that enumerate the most appropriateand the least appropriate/most unsafe drugs/drug classes to useand/oravoid in the geriatric population. The Beers criteria isalist ofmedicationsthat detailsthedrugs/drugclassesthathave the potential to be dangerous to older adult patients basedon pharmacology (ie, mechanism of action, pharmacokinetics,ADEs).12The Beers criteria do not preclude practitioners fromprescribing any of the drugs on the list, but it is an excellent toolto help guide practitioners in selecting the best and safest med-ications for their older adult patients.Similar to, but much more comprehensive than the Beerscriteria, is the STOPP (Screening Tool of Older Persons poten-tially inappropriate Prescriptions) criteria.13These criteria weredeveloped to reduce ADEs in older people with acute illnesses.STOPP assesses potential adverse drugYdrug interactions and/orduplicatedrugclassprescriptions.TheSTOPPandtheBeerscriteria overlap in several areas.Using various tools can improve the drug selection processfor practitioners prescribing for older adult patients. Whichevertools are used, thereis no substitute forthorough knowledgeregarding the patients history and medical issues.Rule 7: Identify, Anticipate, and MonitorPotential Drug Interactions Before TheyBecome a ProblemIt has been estimated that 90% of all individuals 65 yearsor older take at least 1 medication per week, 40% use Q5, and12% use Q10/week. Because of the sheernumber of medica-tions that someindividuals receive, theriskfor drugYdruginteractions is extremely high. DrugYdrug interactions can becategorizedas either pharmacodynamicor pharmacokineticinteractions.14,15PharmacodynamicInteractionsPharmacodynamic interactions occur when prescribingdrugs with synergistic actions. These interactions are commonandcanoccurwhenapatient hasmorethanonehealthcareprovider or the prescriber does not thoroughly understand thepharmacology of the drugs being prescribed. This can be con-fusing and dangerous, especially when drugs from completelydifferent drug classes are prescribed. The presentation in patientscan be insidious as the drugs are added one on top of the other(drug stacking), until the synergistic effects merge and thesyndromepresentsitself; thus, medicationreviewsbyphar-macology experts should be recommended for patients who aretaking several different medications. Two specic examples ofthis problem are presented in Table 1.15Y18Pharmacokinetic InteractionsBecause of the physiologic changes associated with aging,thesepatientsareat greater riskfor drugYdruginteractions.Hepatic metabolismmaybe signicantlyalteredfor somedrugs. The reasons for various drugYdrug interactions in olderWooten & Rules for Improving Pharmacotherapy in Elderly Patients146 *2015SouthernMedicalAssociationCopyright 2015 The Southern Medical Association. Unauthorized reproduction of this article is prohibited.adultpatientsincludechangesindrugabsorptionanddistri-bution, reduced hepatic clearance and reduced renal function,polypharmacy, and the high number of comorbidities in theseindividuals.15Y18DrugYdruginteractionscannotalwaysbeavoided. Prac-titioners must be able to anticipate these interactions and createamonitoringplantominimizetherisktothepatient. Waystomitigatetheseinteractions inolder adults, beyondthosementionedearlierinthearticle, includeclosemonitoringofdrugs with a narrow therapeutic range or index (Table 2) andknowledgeofthecommoninducerandinhibitor drugs(Table 3).14Y18Another type ofinteraction prevalent in the geriatric pop-ulation is drugYdisease interactions, wherein a particular drugmayworsenaspecicmedical condition(Table4). Under-standing the pharmacologic prole of each drug prescribed toan older adult patient can reduce the incidence of these types ofinteractions.14Y18Otherinteractiontypesoccurinolderpeople, includingdrugYfood interactions and drugYnutrient interactions. Practi-tionersmustbeobservantwithalldrugsprescribedtoavoidthese common interaction issues.Rule 8: Establish a Monitoring Plan forEach Medication Prescribed for BothEfcacy and ToxicityPatient monitoringfor adrugsefcacyandtoxicityiscritical. Practitioners should address the monitoring plan at thetimeadrugisprescribed.Amonitoringplanforeachmedi-cation on the patients prole should be a part of the patientsTable 1. Pharmacodynamic drugYdrug interactionsDrug-induced problem/syndrome Drugs/drug classes contributing to problem SymptomatologySerotonin syndrome SSRIs (eg, paroxetine, sertraline, uoxetine) Spontaneous clonusLevodopa, carbidopa-levodopa(indirectly causes release of serotonin)Inducible clonus and agitation or diaphoresisSNRIs (eg, desvenlafaxine, duloxetine,milnacipran, venlafaxine)Ocular clonus and agitation or diaphoresisDirect serotonin receptor agonists: tryptans(eg, sumatriptan, rizatriptan)Tremor and hyperreexiaHypertoniaFentanyl Temperature above 38-C and ocular clonusor inducible clonusTramadolBuspironeMeperidineCyclobenzaprineCocaineSt Johns wort (hypericum perforatum)Anticholinergic syndrome Antihistamines (eg, chlorpheniramine,cyproheptadine, doxylamine, hydroxyzine,diphenhydramine, meclizine, promethazine)Flushing caused by cutaneous vasodilation(red as a beet)Anhydrosis (dry as a bone)Hyperthermia caused by loss of sweat(hot as a hare)Blurry vision caused by nonreactive mydriasisand paralysis of accommodation (blind as a bat)Agitated delirium (mad as a hatter)Urinary retention (full as a ask)Decreased bowel soundsTachycardiaSNRIs, serotonin-norepinephrine reuptake inhibitors; SSRIs, selective serotonin reuptake inhibitors.Table 2. Common drugs/drug classes with a narrowtherapeutic rangeClass DrugAnticoagulants WarfarinAnticonvulsants PhenytoinAntiarrhythmics AmiodaroneImmunosuppressants CyclosporineReview ArticleSouthernMedicalJournal & Volume 108, Number 3, March 2015 147Copyright 2015 The Southern Medical Association. Unauthorized reproduction of this article is prohibited.medical record. Suggestions regarding monitoring include thefollowing19Y22:& Understand the pharmacologic prole of every drug prescribed.& Understand that monitoring for efcacy may be as simple as takingblood pressure measures (eg, for antihypertensive agents) or as com-plicated as assessing a chest x-ray for pneumonia (eg, for antibiotics).& Know which drugs have a narrowtherapeutic index; slight changesin concentration can yield ADEs.& Know the adverse effect prole for every drug prescribed so thatthe patient can be assessed for these effects.& Double-check dosesbased onrenalorhepaticfunctionusinganappropriate resource. Contact a pharmacist if necessary.& Individualize doses for each individual patientVone size does nott all.Rule 9: Properly Counsel Patients/Caregiverson All of the Patients Medications andEnsure That the Patient Understands thePharmacotherapy PlanEffective patientcounselingandinstructionis animpor-tant part of the healthcare plan. Patients who are informed andunderstandtheirownhealthcareissues willbeabletoassessand monitor their therapy and take an active role in improvingtheir health; however, this is challenging for some patients, es-pecially if there are unique barriers that limit effective counsel-ing, such as the following21Y24:& Limited cognitive function& Limited education& Literacy issues& Hearing difculties& Vision limitations& Limited nancial resources& Polypharmacy (can complicate medication instruction)& Language barriers& Limited time& Cultural differencesToovercome these barriers, the rst stepis identifyingwhichof them maylimit communicationandthen structuring an ef-fective counseling session with the patient or patients caregiver.The following provides suggestions to improve communicationwith geriatric patients:& Counsel the patient/caregiver in a quiet, well-lighted environmentwhere the patient/caregiver is comfortable.& Do not rush.& Attempt to identify any barriers that may exist with the patient thatwill limit communication. Try to correct the issues that are iden-tied (eg, if patient has limited hearing, provide written materials).& Providepatient/caregiverwithanup-to-datemedicationlist andmake sure all parties have the same list.& Assess language barriers and use interpreters if necessary.& Use language that is appropriatefor patients educational background.& Use written instruction aides whenever possible.& Identify and correct any cultural barriers that may exist.& Identify potential nancial difculties that may limit compliance.& Maintain a positive attitude and try to motivate the patient to takean active role.& Be respectful and refer to patient in an appropriate way (eg, MrsLopez, rather than Fulgenica or Dear).& Do not be judgmental.& Use any teaching aides that are available.& Answer all of the patients/caregivers/familys questions. If certainquestions cannot be answered, then help them nd someone whocan answer the questions.& Ask the patient to repeat instructions.& Ensure that the patient knows the possible limitations of treatment(eg, adverse effects, potential interactions).& Instruct patient about over-the-counter medications, vitamins, nu-tritionals, and herbal therapies.Table 3. Common inducer and inhibitor drugs forcytochrome P450 drugYdrug interactionsEnzyme Inhibitors InducersCYP1A2 Ciprooxacin, uvoxamine Phenytoin, rifampinCYP2C9 Fluconazole Carbamazepine, rifampinCYP2D6 Bupropion, uoxetine,paroxetineCYP3A Macrolides (eg, erythromycin,clarithromycin)Carbamazepine, modanil,phenytoin, phenobarbitone,rifabutin, rifampicin,St Johns wortAzole antifungals(eg, voriconazole, itraconazole,ketoconazole, uconazole)Protease inhibitors (eg, indinavir,ritonavir, saquinavir)Grapefruit juiceCimetidineCiprooxacinTable 4. DrugYdisease state interactionsDrug/drug class Disease state Pharmacologic interactionA-Adrenergic antagonists (eg, propranolol,metoprolol, carvedilol)Asthma/COPD Blocking the A-2 receptors in the lungs may induce bronchoconstriction,which may worsen asthma or COPDAminoglycosides (eg, gentamicin, tobramycin) Chronic kidney disease Aminoglycosides are nephrotoxic and may worsen renal functionNSAIDs (eg, ibuprofen, naproxen) Peptic ulcer disease NSAIDs can cause peptic ulcersNondihydropyridine calcium-channel blockers(eg, verapamil, diltiazem)Congestive heart failure Verapamil or diltiazem can reduce the inotropic action of the heartCOPD, chronic obstructive pulmonary disease; NSAIDs, nonsteroidal anti-inammatory drugs.Wooten & Rules for Improving Pharmacotherapy in Elderly Patients148 *2015SouthernMedicalAssociationCopyright 2015 The Southern Medical Association. Unauthorized reproduction of this article is prohibited.The practitioner must ensure that the patient/caregiverclearly understands that all pharmacotherapy treatment will bemonitored for both efcacy and potential toxicity (include inthe medication list if possible). Objective and specic goals forthe treatment regimens should be set, and the patient/caregivershould understandthe goalsand objectives of pharmacother-apy. Ensure that patient clearly understands the plan if a specictreatment is not successful or proves to be harmful. Follow-upappointments should be arranged and reminders (eg, telephonecalls, e-mails, texts) provided. Compliance should be assessedat every visit. All questions should be answered to the patientssatisfaction.21Y24Rule 10: Assess and AddressCompliance IssuesCompliance can be a major problem in providing effectivehealth care to older adult patients. There are several reasons fortheir poor compliance, including the following25Y29:& Lack of appropriate discharge planning& Adverse effects of medication& Lack of trust in the healthcare provider(s) and/or the treatment plan& Poor understanding ofillness(es)& Poor patientYprovider relationship& Complexity of treatment regimen& Financial difculties& Cognitive issues (eg, Alzheimer disease)& Psychological problems (eg, psychosis, depression)& PolypharmacyComplianceshouldbeaddressedwiththepatient/care-giver at the time each drug is prescribed (Table 5).ConclusionsThisarticleanditspredecessorpresent 10rulesforim-proving pharmacotherapy in older adults. Rules like these arenecessarybecauseolder patientsuseahigher percentageofmedicationsthanother patient populationsandtheyareex-tremely vulnerable to drug-related issues that could cause greatharm. Practitioners must be cognizant of the challenges that areencounteredwhenprescribingdrugs toolder patients, andtheserulesprovideaconstantremindertopromotesafeandeffective pharmacotherapy. These rules help ensure that patientsareawarethattheirhealthcareprovidersareconsideringandimplementing the most appropriate pharmacology plan that tsTable 5. Potential compliance barriers and strategies to improve complianceBarriers StrategiesPatient-related issuesForgetting to take medication Use pill boxes, medication calendars, smartphone appsDifculty taking so many medications Structure times to take medications around daily activities (eg, meals)Lack of understanding of disease Reduce number of medications, if possible; address polypharmacy issueDenial Ensure patient understands disease being treated and whyLow expectations Set specic goals for patient (eg, blood pressure goals, blood sugar goals)Depression Find devices to patient overcome physical barriers to compliance (eg, special inhaler)Physical barriers Sort out nancial barriers and attempt to help patient in whatever way possibleFinancial difculties Use translatorLanguage literacy issues Ask patient to write down all questionsMedication-related issuesComplex pharmacotherapy regimen Review pharmacotherapy plan at each visitAdverse effects Check patients medication list and make sure it is appropriateChange to drug with fewer/different adverse effect prole, if possibleAssess all medication adverse effectsReduce polypharmacy as much as possibleDiscontinue medications that are not useful to patients current regimenPrescriber-related issuesPrescriber does not explain treatment plan Use multidisciplinary team to help care for patientPrescriber does not take time with patient/patients family Provide verbal and written instructionsPrescriber does not listen to patient Use training aidesPrescriber provides information that patient/patients familydoes not understandEnsure that patient/caregiver has easy access to provider so that questions are answeredPrescriber will not answer questions Encourage patient to write down all questionsPrescriber does not follow-up with patient/family Ensure that patients medication list is identical to practitioners listReview ArticleSouthernMedicalJournal & Volume 108, Number 3, March 2015 149Copyright 2015 The Southern Medical Association. Unauthorized reproduction of this article is prohibited.withtheirage, comorbidities, andother treatment regimens.Practitioners shouldavoidthe sevendeadlysins of prescribing29:1. A drug is prescribed to treat a disease or ailment that is actuallycausedbyanadversereactiontoanotherdrug. Example: Pre-scribingadrugforapatient whohasconstipationcausedbyoverprescribing drugs with anticholinergic properties.2. Adrugisprescribedtotreat aproblemthat shouldbetreatedinitiallywithnonpharmacologictherapy. Example: Prescribingasedativeforinsomniatoapatient whoregularlyingestscaf-feinated products right before bedtime.3. Attempt to treat a medical problem that may be either self-limitedor unresponsive to pharmacologic treatment. Example: Prescribingan antibiotic to a patient who has a viral infection.4. A drug is prescribed for a problem, but instead of the safest, mosteffective treatment, the healthcare provider recommends an agentthat is inappropriate for a geriatric patient. Example: Prescribingdiazepam (long-acting benzodiazepine on the Beers list) as a sed-ative when a mild sedative (trazodone) would be more appropriate.5. Two drugs are prescribed appropriately, but they interact to causeserious injury or death, and there was no monitoring plan in placefor the interaction. Example: Prescribing warfarin (for deep veinthrombosis)alongwithtrimethoprim/sulfamethoxazole(foruri-narytractinfection).Thiscombinationslowsthemetabolismofwarfarin, which leads toover-anticoagulation and possibly a severebleeding episode.6. Two or more drugs in the same drug class are used to treat separateproblems. Thedrugsdonot improveefcacy, but rather haveadditive effects that could harm the patient. Example: Prescribingabeta-blocker(carvedilol)toslow heartrate,butthepatientisalreadytakingpropranolol (prescribedbypsychiatrist)totreatanxiety; this in turn leads to profound bradycardia.7. The correct drug is selected to treat a problem, but the dosage ismuch too high for the patient. Example: Prescribing levooxacin750 mg/day to treat a urinary tract infection in a patient with renalinsufciency. Thisoccursofteninolder adults;typicaldosagesare prescribed when older adults should be receiving a lower dosebecause of reduced renal or hepatic function.References1. AntimisiarisDE. Polypharmacy: amoderndaysilent epidemic. http://www.polypharmacyinitiative.com/education.html. Accessed August 4, 2014.2. Wooten JM. Rules for improving pharmacotherapy in older adult patients:part 1 (rules 1Y5). South Med J 2015;108:97Y104.3. WootenJM. Pharmacotherapyconsiderations inelderlyadults. SouthMed J 2012;105:437Y445.4. Wooten J, Galavis J. Polypharmacy. Keeping the elderly safe.RN 2005;68:44Y50.5. FoodandDrugAdministration. Postmarketingsurveillance programs.http://www.fda.gov/Drugs/GuidanceComplianceRegulatoryInformation/Surveillance/ucm090385.htm. Published August 19, 2014. 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