the american geriatrics society geriatrics health professionals
DESCRIPTION
POLYPHARMACY Wendolyn Gozansky , MD, MPH Associate Professor Division of Geriatric Medicine University of Colorado Denver. AGS. THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals. Leading change. Improving care for older adults. CONTENTS. Drugs and the elderly - PowerPoint PPT PresentationTRANSCRIPT
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POLYPHARMACY
Wendolyn Gozansky, MD, MPHAssociate Professor
Division of Geriatric MedicineUniversity of Colorado Denver
THE AMERICAN GERIATRICS SOCIETYGeriatrics Health Professionals.
Leading change. Improving care for older adults.
AGS
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CONTENTS
• Drugs and the elderly
• Pharmacodynamic and pharmacokinetic changes with aging
• Drug knowledge and compliance
• Prudent prescribing
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DRUG USE IN THE ELDERLY12% of the population is aged 65+
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DRUG USE IN THE ELDERLY12% of the population is aged 65+
30% of all prescription drug use is among those aged 65+
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DRUG USE IN THE ELDERLY12% of the population is age 65+
30% of all prescription drug use is among those aged 65+
50% of all OTC drug use is among those aged 65+
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ADVERSE DRUG REACTIONS (ADRs)
• 106,000 deaths in 1994
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ADVERSE DRUG REACTIONS (ADRs)
• 106,000 deaths in 1994• $177 billion in 2000
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ADVERSE DRUG REACTIONS (ADRs)
• 106,000 deaths in 1994• $177 billion in 2000• For every $1 spent on drugs, $1 spent on ADRs
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ADVERSE DRUG REACTIONS (ADRs)
• 106,000 deaths in 1994• $177 billion in 2000• For every $1 spent on drugs, $1 spent on ADRs• 95% of ADRs considered to be predictable
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ADVERSE DRUG REACTIONS (ADRs)
• 106,000 deaths in 1994• $177 billion in 2000• For every $1 spent on drugs, $1 spent on ADRs• 95% of ADRs considered to be predictable• 7-fold increased risk in the elderly
Related to polypharmacy Changes in pharmacodynamics/pharmacokinetics Drug-disease interactions
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EXPONENTIAL RELATION BETWEEN POLYPHARMACY AND ADRs
JAGS. 1988;36:142-149.
# of Drugs Taken
Perc
ent o
f Pat
ient
s w
ith
an A
DR
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CONTENTS
• Drugs and the elderly
• Pharmacodynamic and pharmacokinetic changes with aging
• Drug knowledge and compliance
• Prudent prescribing
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PHARMACODYNAMICS
Response that occurs when a drug interacts at its receptor
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PHARMACODYNAMIC CHANGESWITH AGING
Increased response(eg, opiates)
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PHARMACODYNAMIC CHANGESWITH AGING
Increased response(eg, opiates)
Decreased response(eg, beta-agonists)
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PHARMACOKINETICS
Drug concentration at the site of action
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PHARMACOKINETICS
• Drug concentration at the site of action
• 4 determinants: Absorption Distribution Metabolism Elimination
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PK CHANGES WITH AGING: ABSORPTION
gastric pH gastric emptying splanchnic blood flow intestinal motility
Minimal clinical importance
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PK CHANGES WITH AGING: DISTRIBUTION
fat mass muscle mass total body water albumin (binds acidic drugs) alpha-1 glycoprotein (binds basic drugs)
Clinically important
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20-year-old woman
J Nutr. 1997. 127:990-991S.
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64-year-old woman
20-year-old woman
J Nutr. 1997; 127:990-991S.
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64-year-old woman
20-year-old woman
J Nutr. 1997. 127:990-991S.
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64-year-old woman
20-year-old woman
J Nutr. 1997. 127:990-991S.
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hepatic mass hepatic blood flow first-pass metabolism
Clinically important: Longer half-life of drugs undergoing phase I metabolism (eg, diazepam vs lorazepam)
PK CHANGES WITH AGING:METABOLISM
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renal mass renal blood flow glomerular filtration rate
Most clinically important• concentration of drugs dependent on renal clearance• Serum creatinine alone does not provide adequate
information to guide dosing
PK CHANGES WITH AGING:ELIMINATION
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PHARMACOKINETIC CHANGESWITH AGING
What is the best formula for estimating GFR in older adults?• Cockcroft-Gault (CG)• Modification of Diet in Renal Disease (MDRD)
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CG VERSUS MDRD
Verhave et al Lamb et alMean age, yr 71 80
Mean measured GFR,mL/min/1.73m2
79.4 53.3
Subject characteristics Healthy – no DM, CAD, CHF, CRI
Comorbidities and CRI
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CG VERSUS MDRD
Verhave et al Lamb et alMean age, yrs 71 80
Mean measured GFR,mL/min/1.73m2
79.4 53.3
Subject characteristics Healthy – no DM, CAD, CHF, CRI
Comorbidities and CRI
CG Underestimated GFR Underestimated GFR
MDRD Underestimated GFR Overestimated GFR
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BIOLOGY OF THE PATIENT
• Limited functional reserve
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BIOLOGY OF THE PATIENT
Disease Compensatory severity mechanisms
Symptomatic Asymptomatic
Lancet. 1997;350:1157-1158.Slide 30
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BIOLOGY OF THE PATIENT
• Limited functional reserve
• Drug-disease interactions
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CONTENTS
• Drugs and the elderly
• Pharmacodynamic & pharmacokinetic changes with aging
• Drug knowledge and compliance
• Prudent prescribing
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DO YOU KNOW WHAT’S IN YOUR PATIENT’S MEDICINE CABINET?
~20% of drugs found on home inventory were not revealed by physician interview
Most frequently unreported class of drugs?
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DO YOU KNOW WHAT’S IN YOUR PATIENT’S MEDICINE CABINET?
~20% of drugs found on home inventory were not revealed by physician interview
Most frequently unreported class of drugs?
BENZODIAZEPINES!!!
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ALTERED COMPLIANCE
• Under-utilization
• Over-utilization
• Enforced compliance
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RELATION BETWEEN POLYPHARMACYAND NUMBER OF PRESCRIBERS
# of Drugs Prescribed
# of
Pre
scrib
ers
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RELATION BETWEEN POLYPHARMACYAND COMPLIANCE
# of Drugs Prescribed
% C
ompl
ianc
e
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METHODS TO IMPROVE COMPLIANCE• # of drugs, prescribers, and pharmacies• Once-daily or twice-daily dosing• Pill boxes• Medication reminder charts• frequency of clinic visits
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CONTENTS
• Drugs and the elderly
• Pharmacodynamic & pharmacokinetic changes with aging
• Drug knowledge and compliance
• Prudent prescribing
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AVOID THE PRESCRIBING CASCADE
Drug 1
BMJ. 1997;315:1096-1099.Slide 41
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AVOID THE PRESCRIBING CASCADE
Drug 1
Adverse effect misinterpreted as new medical condition
BMJ. 1997;315:1096-1099.Slide 42
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AVOID THE PRESCRIBING CASCADE
Drug 1
Adverse effect misinterpreted as new medical condition
BMJ. 1997;315:1096-1099.
Drug 2
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AVOID THE PRESCRIBING CASCADE
• HCTZ – Allopurinol
• NSAIDs – Antihypertensives
• Metoclopramide – Carbidopa/levodopa
• Cholinesterase inhibitors – Tolterodine
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BEWARE OF DRUG-DRUG INTERACTIONS (DDIs)
• 100% chance of DDIs with 8 drugs
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BEWARE OF DRUG-DRUG INTERACTIONS (DDIs)
• 100% chance of DDIs with 8 drugs
• Nearly 50% of community-dwelling geriatric patients had at least one DDI
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BEWARE OF DRUG-DRUG INTERACTIONS (DDIs)
• 100% chance of DDIs with 8 drugs
• Nearly 50% of community-dwelling geriatric patients had at least one DDI
• DDIs can result in ADRs or suboptimal dosing
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PRUDENT PRESCRIBING PRINCIPLES
• Know your patients and their drug cabinets
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PRUDENT PRESCRIBING PRINCIPLES
• Know your patients and their drug cabinets• Educate yourself and your patients
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PRUDENT PRESCRIBING PRINCIPLES
• Know your patients and their drug cabinets• Educate yourself and your patients• Understand biases in clinical trials
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PRUDENT PRESCRIBING PRINCIPLES
• Know your patients and their drug cabinets• Educate yourself and your patients• Understand biases in clinical trials• Ask about compliance
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PRUDENT PRESCRIBING PRINCIPLES
• Know your patients and their drug cabinets• Educate yourself and your patients• Understand biases in clinical trials• Ask about compliance• Always include ADRs in the differential
diagnosis of a new problem
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PRUDENT PRESCRIBING PRINCIPLES
• Know your patients and their drug cabinets• Educate yourself and your patients• Understand biases in clinical trials• Ask about compliance• Always include ADRs in the differential
diagnosis of a new problem• Try non-pharmacologic strategies
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PRUDENT PRESCRIBING PRINCIPLES
• Know your patients and their drug cabinets• Educate yourself and your patients• Understand biases in clinical trials• Ask about compliance• Always include ADRs in the differential
diagnosis of a new problem• Try non-pharmacologic strategies• Offer drug therapy when indicated
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Which of the following is an age-related change that causes clinically
significant alterations in drug pharmacokinetics?
1 2 3 4
0% 0%0%0%
A. Decreased fat massB. Increased gastric pHC. Decreased
glomerular filtration rate
D. Increased total body water
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Which of the following does not contribute to adverse drug reactions
(ADRs) in the elderly?
1 2 3 4
0% 0%0%0%
A. All prescriptions written by one provider
B. Comorbid illnessC. HospitalizationD. Increasing numbers
of medications
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Which of the following is associated with improved medication
compliance?
1 2 3 4 5
0% 0% 0%0%0%
A. Increasing numbers of medications
B. Clinic visit in the previous 48 hours
C. TID dosingD. Drug side effectsE. Expensive
medications
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Which of the following is a principle of prudent prescribing?
1 2 3 4
0% 0%0%0%
A. Only inquire about prescribed medications
B. Ask the patient, “What could possibly be so hard about taking pills every day?”
C. Do not begin treatment without a diagnosis
D. Use drugs before a trial of non-pharmacologic therapy
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Which of the following effects of aging contributes to an increased risk of
ADRs related to benzodiazepine use?
1 2 3
0% 0%0%
A. Increased body fat mass causing a greater volume of distribution and decreasing drug half-life
B. Increased hepatic volume resulting in increased production of active metabolites
C. Decreased renal function causing delayed renal excretion
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Patients who think they are taking too many medications report lower quality of life than patients who think they are
taking the right number of medications.
1 2
0%0%
1. True2. False
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A patient with a serum creatinine of 0.5 mg/dL (within the normal range) will also
have a normal creatinine clearance
1 2
0%0%
1. True2. False
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Older adults uniformly exhibit exaggerated pharmacodynamic responses compared
with younger adults.
1 2
0%0%
1. True2. False
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Which of the following drugs is/are listed as “high-severity” potentially inappropriate
medications for patients aged 65+?
A. B. C. D. E. F. G. H. I.
0% 0% 0% 0% 0%0%0%0%0%
A. Amiodarone (Cordarone)B. Amitriptyline (Elavil)C. Cyclobenzaprine (Flexeril)D. Diazepam (Valium)E. Diphenhydramine (Benadryl)F. Indomethacin (Indocin)G. Ketorolac (Toradol)H. Nitrofurantoin (Macrodantin)I. All of the above
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Mark H. Beers, MD
19542009
DM Fick et al. Arch Intern Med.
2003;163:2716-2724.
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Visit us at:
Facebook.com/AmericanGeriatricsSociety
Twitter.com/AmerGeriatrics
www.americangeriatrics.org
THANK YOU FOR YOUR TIME!
linkedin.com/company/american-geriatrics-society
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