Evaluating Medication Regimens

in the Elderly

Yesenia MartinezNova Southeastern UniversityCollege of Pharmacy

Purpose and Objectives

1) What medication-related problems (MRPs) are specific to the geriatric population and what puts these patients at a higher risk for experiencing adverse drug reactions (ADRs) and MRPs?

2) What actions are taken by the pharmacist in order to identify, correct, and prevent MRPs?

MRPs - Definition

“Undesirable event experienced by a patient that involves, or is suspected to involve, drug therapy, and actually or potentially interferes with a desired patient outcome”

MRPs – Statistics & Significance

28% of hospital admissions among older patients can be attributed to MRPs

MRPs in nursing facilities cost an estimated $4 billion

For about every dollar spent on drugs in nursing facilities, about $2.00 is spent on health care resources for treatment of MRPs

MRPs - Presentation

MRPs are often mistaken for normal consequences of aging

or progression of disease

Examples: Falls and/or movement and gait disorders Confusion or changes in mental status Electrolyte imbalance

MRPs – Eight Categories

1) Disease with no treatment2) Treatment for no apparent disease3) Wrong drug4) Drug that is not the most appropriate5) Too little OR too much of correct drug6) ADR7) Drug interaction8) Improper drug administration

Elderly at Risk - PolypharmacyDrug Use Among the Elderly: 3 to 4 medications (community) 3.5 to 8 medications (hospital – acute

care) ~6 medications on average (nursing

facility)

Illness Among the Elderly: 48% of Medicare beneficiaries over 65

years old have at least 3 chronic conditions

Elderly at Risk - CPGs

Clinical Practice Guidelines: Are based on clinical evidence and

expert consensus Define standards of care Focus on improving quality of care Address single diseases

Elderly at Risk – Other Reasons

Increased Risk for MRPs Due To: Age (especially over 75 years) Underrepresentation in clinical trials Shortage of health care professionals

trained in geriatric pharmacotherapy

Risk Factors for ADRs Among Elderly1) Polypharmacy2) Multiple illnesses3) Use of high-risk medications4) Factors related to hospitalizations5) History of alcohol abuse or prior ADRs6) Living with confusion or dementia7) Certain patient characteristics (i.e.

weight, age, and renal function)

High Frequency of ADRs Among Elderly

Reasons:1) Multiple physicians prescribing

independently2) Patient nonadherence3) Inappropriate self-medication4) Inadequate patient education5) Age-related physiological changes

Medication Nonadherence

Reasons for Intentional Nonadherence:1) Feeling of being overmedicated2) Limited income

Other Reasons for Nonadherence:3) Poor communication4) Declining cognitive function5) Complicated drug regimens

Medication Nonadherence

Risk Factors:1) Chronic conditions (≥ 3); Medications (≥ 5);

Daily dosages (≥ 12); Prescribers (≥3); Medication regimen changes in previous 12 months (≥ 4)

2) Living alone in community3) Significant cognitive/physical impairment4) Recent discharge from hospital5) Relying on caregiver6) Low literacy level7) History of poor medication adherence

Inappropriate Prescribing

Beers Criteria: Medications to be avoided Maximum doses for certain medications About 7.5% to 27% of elderly patients

use a Beers list drug Most common: propoxyphene,

diphenhydramine, doxepin, amitriptylline

Inappropriate Prescribing

Medication Appropriateness Index:1) Indication?2) Is it effective?3) Correct dose and directions?4) Practical directions?5) Clinically significant interactions?6) Unnecessary duplications of therapy?7) Acceptable duration of therapy?8) Is it the least expensive alternative?

Medication Regimen Review

Step 1: Create a patient database Step 2: Review each medication Step 3: Create a problem list Step 4: Create a plan Step 5: Execute the plan Step 6: Follow up

Medication Regimen Review

M – Minimize number of drugs used A – Alternatives should be considered S – Start low and go slow T – Titrate therapy E – Educate the patient R – Review regularly

Geriatric Assessment

A multi-dimensional, diagnostic process designed to quantify an elderly person’s medical, psychosocial, and functional capabilities

Components: Mental, Functional, Social, Economic, and

Physical status Values Health maintenance

Final Thoughts

Pharmacists should be asking… Is each medication necessary? Are nonpharmacological alternatives

available? Is the lowest effective dose being used? Any unaddressed medical or medication-

related problems? Communication among pharmacist,

physician, nurse, patient, and patient’s caregiver is of utmost importance

Questions?

Miller, SW. Evaluating Medication Regimens in the Elderly. Consult Pharm. 2008 July; 23(7):538-47