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MedicationsinanAgingPopulation

MichelleA.Fritsch,Pharm.D.,CGP,BCACP

ObjectivesAsaresultofthisContinuingEducationActivity,readerswillbeableto:1)Asktherightquestionstodetermineallmedicationstakenbya

patientandhowtheyaretakenwithemphasisoncommonwarningsigns.

2)Describehowmedicationsimpactsenioradultsdifferentlythanyoungercounterparts.

3)Explainthecommonroleofmedicationsinfalls,negativecardiovascularevents,strokes,andotherlife-alteringevents.

4)Describewhymedicationregimensareoftensolargeandcomplicatedandwhatcanbedonetoreducerisksofcomplexregimens.

5)Usingcases,applytheinformationfromthepreviousobjectivestoriskreductionactionforpatients.

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Question

Whatisyourprimarypracticesite?a. Hospitalinpatientb. Hospitalbasedoutpatientc. Privateclinicd. Chainclinice. Schoolsystemf. Homebasedcareg. Other

Question

Whatpercentofyourpatients/clientsareoverage65?1. 0-9%2. 10-25%3. 26-50%4. 51-75%5. 76-100%

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GeriatricMedicationUse

AgingofAmerica

0

10,000,000

20,000,000

30,000,000

40,000,000

50,000,000

60,000,000

70,000,000

80,000,000

90,000,000

100,000,000

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050

Num

ber o

f Per

sons

65+

Population 65+ by Age: 1900-2050Source: U.S. Bureau of the Census

Age65-74

Age75-84

http://www.aoa.acl.gov/Aging_Statistics/future_growth/future_growth.aspx#age

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Medication Interview• Generic and brand name• Use of each medication• Prescription medications• Over-the-counter medications• Vitamins• Supplements• Herbals/nontraditional• How used vs. how prescribed

Medication Interview• Open-ended questions vs closed-ended

questions• Patience• Reminder questions• Follow-up questions• Information-drawing questions

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Sensory Senescence

VisionHearing

Olfaction/TasteTouch

• Medications can impact these• These can amplify the risks for falls,

nutrition deficiency, dizziness, and more

StartLow;GoSlow

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WhenUsedProperly

• Medicationscan– Curemedicalconditions– Improvecontrolandoutcomesofmedical

conditions– Alleviatesymptomsofmedicalconditions– Improvefunction/IADLs– Enhancequalityoflife– Enhancequantityoflife

WhenNotUsedProperly

• Medicationscan– Worsenmedicalconditions– Causesideeffects– Decreasefunction– Decreasequalityoflife– Decreasequantityoflife

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TypesofMedicationRelatedProblems

Needingpharmacotherapybutnotreceivingit.Receivingtoomuchofthecorrectdrug.Receivingtoolittleofthecorrectdrug.Receivingthewrongdrug.Experiencinganadversedrugreaction.Experiencingadrug-drugordrug-foodinteraction.Notreceivingthedrugprescribed.Takingadrugwithnovalidmedicalindication.

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Question

Mostpeopletaketheirmedicinesasprescribedbytheirdoctorsa. Absolutelyb. Withrareexceptionc. Mostofthetimed. Rarelye. Never

Drugs don’’t work in patients who don’’t take

them.

C.EveretteKoop,M.D.

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Types of Nonadherence

• Failure to fill prescriptions• Failure to refill the prescription• Omission of doses• Increase in dose or frequency• Errors of dosage• Incorrect administration• Errors in time of administration• Premature discontinuation

Detection of Nonadherence

Insufficient regimen or underprescribingThe groupimportant toidentify

Adherent

Not adherent

Therapeutic goal reached

Yes No

Idealsituation

Overprescribing- or -incorrectdiagnosis

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Incidence of Nonadherence

• As many as 66% of patient fail to take prescribed medications as directed.

• 50% on chronic regimens stop them after one year• 20-30% of prescriptions never filled• Compliance rates are worse with more frequent

dosing/complicated regimens• Noncompliance rates are higher among low income

groups and those with disabilities• The World Health Organization estimated that by 2020,

the number of Americans affected by at least one chronic condition requirement medication therapy will grow to 157 million

Nonadherence—Economic

Directcostestimatedat$100billionto$289billionannually• Costs$2000perpatientinphysicianvisitsannually• Improvedself-managementofchronicdiseases

resultsinanapproximatecost-to-savingsratioof1:10

• Cost-relatednonadherence reportedby11.4%(~543,000individuals)ofstrokesurvivors,mostlyamongtheuninsuredandyounger(45to64years)

Sources:Ho2009,Circulation;Levineetal.2013,AnnalsofNeurology

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Adherence for Selected Illnesses

National Council on Patient Information and Education

0

10

20

30

40

50

60

70

DM & CHF

TB

HTN

Schizophrenia

PCN

Prescriptioninterpretation

Youareprescribedamedicationwithinstructionstotakeitthreetimesdaily.Howwouldyoutakeit?1. Threeinthemorning2. Morning,midday,bedtime3. Withyourthreemeals4. Every8hours5. Threeatbedtime

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CaseExample

• Whitemaninhis50’sinanadherencetrial• Bloodpressuremedicineprescribedthree

timesperday• Bloodpressuremuchdifferentatmorning

clinicvisitsthanatafternoonclinicvisits

Adherence Aids

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AutomatedDispensingOptions

PharmacokineticsWhatthebodydoestothedrug

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Absorption

Body

Water

Food

Medication

Commonmedicationscanimpactthis,butagingitselfhaslittleimpact

Distribution

FAT

WATER

Whereinthebodythemedicationgoes

Withaging,totalbodywaterdecreases,totalbodyfatincreases

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MetabolismBreakdown– howthemedicationisbrokendowninthebody

LiverToamoreorlessactivemetabolite,usuallyless

Someenzymesfailtoactuntilaboutage5;somediminishwithadvancedage

Excretion

Howthemedicationiseliminatedfromthebody- Feces

- UrineRenalfunctiongraduallydeclineswithageafteraboutage40- Medicalconditions(diabetes)- Medications- Othercanfurtherdecreaserenalfunction

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PharmacodynamicsRelationshipbetweendoseandtherapeutic

responseWhatthedrugdoestothebody

CellularEffects

• Examples– antibiotics– Biologicresponsemodifyingmedications

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SystemicEffects

• Upregulation ordownregulation ofreceptors• Alterationsinthephysiologicresponseto

medications– E.g.selectiveserotoninreuptakeinhibitorsfor

depression

http://en.wikipedia.org/wiki/Reuptake#/media/File:Reuptake_both.png

Drug Related Morbidity and Mortality

1995: In the United States, drug related morbidity and mortality estimatedto cost $76.6 billion ($30.1-136.8)per year2001: $160 billionNearly 1:1 ratio – spent and treatment related M&MJohnson JA, Bootman JL. Arch Intern Med 1995;155:1949-56Ernst FR, Grizzle AJ. J Am Pharm Assoc 2001;41(2):192-99

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CaseExamples

StartingDose

• An81yearoldpatientwasexperiencingneuropathicpain

• Shewasstartedongabapentin300mg• Shetookherdoseanddrovetothemall• Acarpulledoutinfrontofherintheparkinglot• Shepushedthepedal…• Andlaunchedhercarontoanothercar

– Shereactedtooslowlytorealizeandchangepedals

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Mixingprn’s• Policeman’smother• Livedalong– usuallyfine• Onceinawhileneighborswouldcallpolice• Shewouldleaveherhousetoletherdogout,get

disoriented,gotoanotherhouse,getupsetwhencouldn’tgetinclaimingsomeonehadlockedheroutofherhome

• Oneveningswhenshedidn’tfeelgoodshewouldtakeprn painmedicine,sleepmedicine,andanxietymedicine

Alzheimer's• Advanceshavebeenmadetounderstandthe

condition• NOCURE• Bestoptionsmightbeabletostabilizeorslow

progression• Cholinergic

– Startatlowdoseandtitrateupslowly– Risksandbenefitsofsideeffectsandimpacton

disease• Morepromisingoptionsinthefuture

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donepezil

• Startat5mg• Iftoleratedafter2weeks,increaseto10mg• Perhaps60%noticeabledifferencein

progression• Considerations

– Highlyvariablerateofadvancewiththedisease– Muchdataextrapolation– Qualityvs quantityoflife– ethicalconsiderations

Osteoarthritis

• AmericanCollegeofRheumatologyguidelines2012

• Forpeopleoverage75,TOPICALnonsteroidalanti-inflammatorydrugs(NSAIDs)arerecommendedoversystemic/oralforms

• SystemicNSAIDrisks– Cardiovascular– bloodpressure,heartattack– Renal– decreasedkidneyfunction– Gastrointestinal– ulcers,irritation,bleeding

Hochberg,MC,Altman,RD,April,KT,etal.ArthritisCareRes(Hoboken).2012;64:465-474.)

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Evidence-Based Medicine (EBM)Why

DiabetesRegimen:• Metformin• Sulfonylrurea - oralmedicine(e.g.glipizide,

glimepiride)• Basalinsulin(e.g.insulinglargine,detemir)• Aspirin• Statinforcholesterol(e.g.simvastatin,

rosuvastatin)• Manyandgrowingnumberofoptions

Evidence-Based Medicine (EBM)Why

HeartFailureRegimen:• Betablocker(e.g.metoprolol succinate,carvedilol)• ACEInhibitororARB(e.g.lisinopril,ramipril)• Loopdiuretic(e.g.furosemide,torsemide)• Thiazide-typesdiuretic(e.g.metolazone)***• Statinforcholesterol(e.g.simvastatin,rosuvastatin)• Aspirin• +/- Digoxin

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Metolazone

• Thiazide-typediuretic• Unlikeothersinitsclass,stilleffectivewith

diminishedrenalfunctionCrCl <30ml/min• Potent,powerful• Whilepromotingremovalofsodiumand

water,alsoremovingpotassium• Mathteacherexample

PrescribingGuidance

• START• STOPP• Beer’sCriteria

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BeersCriteria• Developed1991todecreasepotentiallyinappropriatemedications

innursinghomeresidents– Updated1997,2003,andbyAmericanGeriatricSociety2012– Expandedtootherpracticesettings

• Explicitcriteria;validatedinmultiplestudies• Nowincorporatedintopolicies• Medicationstoavoidinolderadults• Medicationpotentiallyinappropriateinolderadultswithparticular

medicalconditions• Medicationstousewithcaution*

– *newin2012update

JAmGeriatrSoc.2012April;60(4):616–631.doi:10.1111/j.1532-5415.2012.03923.x.

STOPPCriteria• TheScreeningToolofOlderPersons’Prescriptions• Medicationstostopingeriatricpatientswith7organ

systems,fallsrisk,analgesics,andduplicativetherapies

• Examples

Int JClin Pharmacol Ther.2008Feb;46(2):72-83

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STARTCriteria• ScreeningTooltoAlertdoctorstoRight

Treatment• Evidence-basedtherapiestostartforspecific

conditions– Organizedin7organsystems– Cardiovascular– Respiratory– CNS– GI– Locomotor– Endocrine

Screening tool to alert doctors to the right (i.e. indicated, but not prescribed) treatment for older people (START).

Barry P J et al. Age Ageing 2007;36:632-638

Copyright © The Author 2007. Published by Oxford University Press on behalf of the British Geriatrics Society.

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Somanyotherfactors

EmptyNest• Formothers,oncethechildrenaregrown

– Youngerkidsas‘onlykids’foratime– Collegetransition– Attentionandcontrol– nolongertheconstantvigilanceover

thechildren– Socialchanges

• Nolongersocializeatchild-relatedevents• Pointofconnectionwithothermotherschanges

– Diet– Transportation– Householdduties– Shopping– Budget

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PersonalHealth

• Selfimage• Dealingwithhealthchanges

– Whatmightthesebe?• Exercise

– AJisa60yearoldwomanwhohasrecentlylostherhusband.Hertwochildrenareincollegeindifferentstates.Priortothistimeshepracticedsportswithandbikedwithherchildrenuntilgrown.Thenshewalkedmosteveningswithherhusband.Nowwhat?

RelationshipChanges• Growing/grownchildren

– Stories– Roleofchildrenchangesinpersonalhealth– https://www.youtube.com/watch?v=Aw2Bb7d3hSk

• Marriages– childrenin-law• Grandchildren• Agingparents

– Care,concern,loss– ‘Sandwich’stage– https://www.youtube.com/watch?NR=1&v=yMJ4ao-

Zsr8&feature=endscreen– https://www.youtube.com/watch?v=RVj888PT4L8

• Agingspouse

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RelationshipChanges

Lossofspouse• Responsibilitiesanddecisionsattimeofdeath• Matriarchoffamily– supportvs owngrieving• Surroundedbyfamilythenoftensuddenly

gone– (experiences)

Function

Laterlifefunction=selfcare+environment+genetics

Whatcanbecontrolled?Whendoesthatcontrolexist?

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ActivitiesofDailyLiving(ADLs)

• Eating• Dressing• Gettinginoroutofbed• Gettinginoroutofachair• Bathing• Usingthetoilet

InstrumentalActivitiesofDailyLiving(IADLs)

• Preparingmeals• Managingmoney• Shopping• Doinghousework• Usingatelephone

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Care/LivingEnvironments• Independentliving

– Ownhomeorapartment,sameasprioryears– Seniorcomplexorhousingarea– ContinuousCareRetirementCenter(CCRC)

• AssistedLiving– Facilitywherecleaning,food,dressing,bathing,orotherneeded

servicesareprovided– IsacomponentofaCCRC

• Homecare– ProgramofAll-inclusiveCarefortheElderly(PACE)

• Longtermcare– SkilledNursingFacilities(SNFs)– AlsoPACE– Medicaid’sProgramofAll-inclusiveCareforthe

Elderly

Over-the-CounterMedications

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Whattotakeforpain?

SleepAgents

Diphenhydramine

Melatonin

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Complimentary&AlternativeMedicines(CAM)

• ‘Natural’• Littlecriteria,oversight

– Notregulated byFDA

• Eachstillwithsideeffects• Limitedscientificevidenceforsafetyorefficacy

- glucosamine - fishoil- probiotics - soy- st. John’swort - chondroitin

AsNeeded‘prn’Medications

• Sleep• Cold• Flu• Headache• Jointpain• Nails• Hair• Vision

• Injury• Allergies• Stomachache• Indigestion• Diarrhea• Constipation• Weightcontrol• Overallhealth

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SubstanceAbuse

• Alcohol– Liver• Tobacco– Lungs,heart• Marijuana– Lungs,brain• Opiates– GI,brain• Heroin– Brain,heart,GI• Cocaine– Heart,brain

Drugabuse.govhttp://www.politicspa.com/pa-gov-wolf-vows-to-sign-medical-marijuana-bill/63312/

SomeCommonMedicalConditionsApplication

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Constipation

Bulking Osmotic Stimulant Stoolsofteners

Emollient Chloridechannelactivator

Psyllium$ Magnesiumhydroxide$$

Sennosides$$

Docusatesodium$

Mineraloil$$

Lubiprostone$$$$$$$$

Methyl-cellulose$$

Polyethyleneglycol$$

Bisacodyl$ Docusatecalcium$

Poly-carbophil$$

Lactulose$$

Sorbitol$$-

AdaptedfromEoff JC,etal.OptimalTreatmentofChronicConstipationinManagedCare.JMCP2008;14(9):S3-15

IncreasefluidintakeAddfiber

Higherprevalencewithdecreasedbodywater,decreasedexercise,decreasedfluidconsumption,slowedperistalticmovement

Parkinson’sDisease

• Prevalence:Upto1millionpeopleintheUS• Annualincidence

– 10/100,000ages50-59– 120/100,000ages80-89

• Usualageatdiagnosis55-65• Presentation- Atleasttwoofrestingtremor,

rigidity,bradykinesia withasymmetricalpresentation;posturalinstabilitylater

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Symptoms

Motor• Decreasedmanualdexterity• Difficultyarisingfromaseated

position• Diminishedarmswingwith

ambulation• Dysarthria• Dysphagia• Festinatinggait• Flexedposture• “freezing”atinitiationof

movement• Hypomimia/maskedfacies• Hypophonia• Micrographia

Autonomic&Sensory• Bladderandanalsphincter

disturbances• Constipation• Diaphoresis• Fatigue• Olfactorydisturbance• Orthostaticbloodpressurechanges• Pain• Parasthesia• Paroxysmalvascularflushing• Seborrhea• Sexualdysfunction• Sialorrhea

Treatment

• Dopamine• Carbidopa/levodopa• Dopamineagonists• COMTinhibitors• MOA-Binhibitor

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69Cartoon:http://fb.img.v4.skyrock.net/fb9/e-ide/pics/2059425594_small_1.jpg

VIDEO- https://www.youtube.com/watch?v=sf1N0Zf5IqA&feature=related

EarlyManagementFig68-4DiagnosisPD

NonRx:EducationExerciseNutrition

Psychsocial support Considerrasagiline

Needforadditionalsymptomatic

control

Tremor

Bradykinesia,rigidity,tremor

Rx

Consideranticholinergicoramantadine

Consideramantadine

Addamantadine,dopamineagonistorcarbidopa/levodopa

Addamantadine,dopamineagonist,orcarbidopa/levodopa

<65years* >65years*

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EarlyManagement,Fig68-4

Managementofmotorfluctuations:•Increasedosingfrequencyof

levodopa•AddMAO-BinhibitororCOMT

inhibitor•Addadopamineagonist

Managementofpeak-dosedyskinesia•Reducedopaminergic drugdose

•Addamantadine

Needformoresymptomaticcontrolofmotor

complications(despiteoptimizedpharmacotherapy):

Considersurgery

Frompreviousslide

Incontinence

• 200millionpeopleworldwide• Prevalenceashighas55%(dataranges20-70%)• Relationshiptoisolation• Relationshiptodepression• Relationshiptodehydration• Manyofthemedicationshaveanticholinergic

action(drying– impactsvision,drymouth,constipation,urinaryoutflow)

WoodLaurenN,AngerJenniferT.UrinaryincontinenceinwomenBMJ2014;349:g4531

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TypesofIncontinenceStress Urge Overactive

BladderOverflow Functional Mixed

Urinarysphincter

Detrusormuscleoveractivity

Detrusormuscle,ifincontinence

Urethraloveractivity&/orbladderunderactivity

Physicalorcognitivereasons

Combinationoftypes

α-adrenergicblockers;topicalestrogens;SSRIorSNRI

Antimuscarinic/anticholinergicorTCA

Sameasagentsforurge

α-adrenergicblockers;5-α reductaseinhibitors orantispas-modics;Cholino-mimetics

Removebarriers,useschedules,reviewneedforassistance

OwensNJ,EstusEL.RenalandUrologicDisorders.In:HutchisonLC,SleeperRB,eds.FundamentalsofGeriatricPharmacotherapy.Bethesda,MD:AmericanSocietyofHealth-SystemPharmacists,Inc.;2010;page202.

Vision

• Dryeyes• Uncorrectedvisionimpairment• Infection• Cataracts• Maculardegeneration• Glaucoma• Medicationsideeffects• Other

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Glaucoma– treatmentoptionsBeta-blockers Prostaglandin

analogsAlphaadrenergic

agonistsCarbonicanhydraseinhibitors

Cholinergicagents

AH production outflow AH production+outflow

AHproduction outflow

1st line Alternate1st

lineBrimonidine

alternate1st line2nd line

(systemicare3rd

line)

Lastline

MostBID At night MostBID-TID MostBID-TID MostBID-TID

Cautions:Heartfailure,bradycardia,asthma, COPD

Long-termusecanleadtomacularedema

Cautions:Cardiovascularorcerebrovasculardisease

Monitorwithage-relateddecreaseinrenalandhepatic function

Cautions:Parkinson’sdisease; longtermusemayleadtocataracts

AH– AqueousHumor

AdaptedfromJonesMD,Chapter61Glaucoma,inPharmacotherapyPrinciplesandPractice,2nd edition,2010:page1038

Osteoporosis

• Riskfactors• Calcium• VitaminD(buildingblocks)• Bisphosphonates

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OsteoporosisTreatmentForapatientwithaT-score<-2.5and/oralow-traumafracture-bone-healthylifestyle-Calcium1200mg/day-VitaminD800-1,000units/day-DrugTherapy

-1st line– bisphosphonates-2nd line– teriparatideorraloxifene-3rd line– intranasalcalcitonin

Reevaluatebonemineraldensity(BMD)in1-2years

AdaptedfromDiPiroJT,etal,eds.Pharmacotherapy:aPathophysiologicApproach,2011:figure99-3,page1567.

MetabolicSyndrome

Components• Diabetes• Hypertension• Cardiovasculardisease• Weight• Smoking• Diet• Excercise

Outcomes• Myocardialinfarction(MI)• Stroke(CVA)• Heartfailure• Neuropathy• Visiondecline• Wounds• Amputation

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Falls

Risks• Rugs• Pets• Steps• Otherenvironment• Cognition• MEDICATIONS

– Bloodpressure– Incontinence– Allergies– Mood– CNS– seizures,neuropathy,…– Manymore

Outcomes• Gaitchanges• Restrictedactivities• Surgery• Ambulationassistance

devices• Isolation• Dependence• Assistedliving• Skilledcare

MedicationsinanAgingPopulationSummary

• Thebodychangesphysiologicallywithage• Thesechangescanimpactmedicationeffect• Understandhowyourpatientactuallytakestheir

medications• Includethemedicinestheyselectforthemselves–

OTC,CAM,prn,vitamins,supplements• Considerlifestylechangesthatoftenaccompanyaging

impactingsleep,safety,isolation,nutrition,andmore• Remembertheadage,STARTLOW– GOSLOWiskeyto

medicationuseinanagingpopulation