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Robyn Bryson, PharmD Kerri Hagedorn, PharmD, BCPS Slide 2 Many different drugs, often duplicative Drugs in excess of that which is clinically- indicated Excessive number of inappropriate drugs Includes Rx, OTC, nutraceuticals Differs from polymedicine or polytherapy, which refers to multiple meds which are all clinically- indicated and appropriate Slide 3 In general: 5+ Rx drugs is considered clinically-relevant polypharmacy 10+ Rx drugs is considered excessive polypharmacy Pts and providers often only consider chronic tx CAM, short-term meds, topicals, and PRNs often excluded Slide 4 Comprise 13% of population but account for 34% of Rx and 30% OTC med use 90% of Medicare beneficiaries use Rx meds 29% of 57-85yo and 40% of Medicare beneficiaries take 5+ Rx drugs 46% of seniors use both Rx and OTC meds 52% use Rx meds and supplements (vitamins, herbals) Of women over age 65: 57% take 5+ meds (Rx, CAM, OTC) 12% take 10+ meds Slide 5 Due to longer life expectancy and the aging baby boomer population, by 2030, the number of Americans 65+ y.o. is expected to double to 71 million 85+ y.o. represent the fastest-growing segment of population Multimorbidity Majority of older adults have 3+ chronic conditions or diseases about 20% have 5+ chronic conditions Slide 6 12% of hospital admissions for seniors are due to ADRs ADR is the 4 th most common cause of hospital-related death Interactions: Potential for drug-drug interactions increases exponentially with the number of drugs Drug-diet: caffeine, alcohol, grapefruit, vit K Drug-herb Drug-disease w/ multimorbidity Slide 7 Inappropriate med use increases w/ more meds Per Beers study, 12% in community elderly 40% of nursing home pts Nonadherence increases with more meds Potential for underuse of appropriate meds Slide 8 Health System-related Longer life span means more elderly patients with chronic diseases More treatment options due to medical developments Primary and Secondary prevention strategies Increased use of healthcare services means more hospitalizations (known risk factor for polypharmacy) Slide 9 Patient-related Age: one of most common risk factors for excessive polypharmacy Female gender More pronounced in younger populations Evens out ~age 70 Race 84% of white Americans use meds 57% Asian descent Socioeconomicconflicting data Higher risk with good insurance coverage Less wealthy Less educated Slide 10 Patient-related Clinical conditions Cardiovascular disease (Odds Ratio 4.5) Anemia (4.1) Respiratory disease (3.6) Depression, HTN, asthma, angina, diverticulitis, osteoarthritis, gout, DM Medication therapy 5 most prevalent drug groups for patients with 5+ meds: Abx, analgesics, psycholeptics, antithrombotics, B-blockers Self-treatment 1/3 of 75yo in community use 3+ OTC drugs daily 37% take Rx drugs without PCPs knowledge Old prescription use, borrowing/sharing often unreported Slide 11 Physician-related Practice environment: lack of time and high workload results in meds remaining in pt records longer than necessary Education and competence levels However, age or time in practice is not associated Male gender Difficulty applying guidelines to patients with multiple diseases Slide 12 Physician-related Prescribing habits Patient expectation of a prescription ADRs resulting in prescribing cascade Improper medical review Lack of communication between PCPs, specialists, and hospitalists Skepticism regarding new guidelines, resulting in fall-back on older prescribing practices (improper dosing, multiple meds) Slide 13 Related to Physician-Patient Interaction Adherence depends on confidence in physician Pt failure to review entire med list with physician Lack of continuity due to multiple health providers, prescribers, and pharmacies Pt expectation of a prescription for each medical visit Pt requesting specific medications Disagreement between pt and provider regarding treatment Slide 14 Nursing homes and Care homes Academic detailing with face-to-face interaction between experts and prescribers Nursing workshops Family education Computerized clinical decision support systems Multidisciplinary team meetings Slide 15 Community and Hospital Multidisciplinary case conferences involving geriatrician Combination of following likely required: Education Regular med review, MTM Important when Rx drug plan formularies change Geriatrics consultation Multidisciplinary team meetings Computerized decision support systems Regulatory policies and procedures Improved documentation of medication indication Increased vigilance during transitions of care Slide 16 Pros Easy to use Easy to incorporate into computer systems and drug reviews Cons Includes some older drugs Harm from some drugs may be minor compared to inappropriate prescribing of meds not on the list Slide 17 START22 indicators of drugs commonly omitted STOPP--65 indicators--Focuses on drug- drug, drug-disease interactions, fall risk, and med duplication Lowers rates of polypharmacy and drug- drug interactions, improves correct dosing More sensitive than Beers Criteria (one study only) Easy to use, takes ~3 min to complete Slide 18 Used for nursing home residents Focus on clinical profiles and functional status Used for: Patients with 9+ meds Initial assessments Falls or behavioral disturbances Admission for rehab Goal is improved functional status and mobility Limited data shows reduced polypharmacy, healthcare costs and hospitalizations Slide 19 AAssess Beers criteria -blockers Pain medications Antidepressants Antipsychotics Other psychotropics Vitamins and supplements RReview Drugdisease interactions Drugdrug interactions Adverse drug reactions MMinimize Number of medications according to functional status rather than evidence-based medicine OOptimize For renal/hepatic clearance, PT/PTT, -blockers, pacemaker function, anticonvulsants, pain medications, and hypoglycemics; gradual dose reduction for antidepressants RReassess Functional/cognitive status in 1 week and as needed Clinical status and medication compliance Slide 20 Reduction in mortality, hospitalization, and cost Avg 2.8 drugs discontinued without significant adverse effects 82% discontinuation success Slide 21 Slide 22 Only 3 components are needed to detect polypharmacy: indication, effectiveness, and duplication Can be used for inpatient and ambulatory patients Takes ~10 min to complete Does not address underuse of appropriate prescribing Slide 23 ItemWeight Is there an indication for the drug?3 Is the medication effective for the condition?3 Is the dosage correct?2 Are the directions correct?2 Are the directions practical?1 Are there clinically significant drug-drug interactions?2 Are there clinically significant drug-disease/condition interactions? 2 Is there unnecessary duplication with other drug(s)?1 Is the duration of therapy acceptable?1 Is this drug the least expensive alternative compared to others of equal utility? 1 Slide 24 Specific meds in patients regimen are assigned a value based on anticholinergic properties and tallied The higher the ARS score, the lower the physical function score Easy to calculate Time consuming and impractical in clinical settings Slide 25 3 Points2 Points1 Point Amitriptyline hydrochlorideAmantadine hydrochlorideCarbidopa-levodopa Atropine productsBaclofenEntacapone Benztropine mesylateCetirizine hydrochlorideHaloperidol CarisoprodolCimetidineMethocarbamol Chlorpheniramine maleateClozapineMetoclopramide hydrochloride Chlorpromazine hydrochlorideCyclobenzaprine hydrochlorideMirtazapine Dicyclomine hydrochlorideLoperamide hydrochlorideParoxetine hydrochloride Diphenhydramine hydrochlorideLoratadinePramipexole dihydrochloride Fluphenazine hydrochlorideNortriptyline hydrochlorideQuetiapine fumarate Hydroxyzine hydrochloride and hydroxyzine pamoate OlanzapineRanitidine hydrochloride Hyoscyamine productsProchlorperazine maleateRisperidone Imipramine hydrochloride Pseudoephedrine hydrochloridetriprodlidine hydrochloride Selegiline hydrochloride Meclizine hydrochlorideTolterodine tartrateTrazodone hydrochloride Oxybutynin chlorideZiprasidone hydrochloride Perphenazine Promethazine hydrochloride Thioridazine hydrochloride Thiothixene Tizanidine hydrochloride Trifluoperazine hydrochloride Slide 26 Similar to ARSdescribes anticholinergic and sedative drug burden Higher DBI associated with reduced physical and cognitive function Potential to be incorporated into DUR software, but not readily available to most clinicians Need studies to determine if improving DBI score results in better outcomes Slide 27 medications are graded: A: indispensible, with obvious benefit B: proven efficacy but limited effects or possible safety concerns; C: questionable efficacy or safety D: avoid no significant decrease in the total number of prescribed drugs or in the number of negatively assessed drugs significant increase in positively assessed drugs as well as appropriate prescribing need further validation Slide 28 Physiologic changes Decline in Renal and Hepatic function Reduced clearance Accumulation More severe side effects if doses are not adjusted Reduced body weight, muscle mass, fluid Altered drug distributionabx, phenytoin Increased fatty tissue Prolonged half-life of lipophilic drugs, i.e. diazepam Slide 29 Physiologic changes Vision impairment40% unable to read Rx label Hearing impairment Difficult to understand counseling Loss of dexterity Cognitive Impairment Difficulty understanding and remembering medication instructions, complex regimens 67% unable to understand information given Slide 30 Medication Errors elderly are 4X as likely as those < 65 years of age to be hospitalized for a medication error Nonadherence Inadequate Monitoring/Follow-up INR, dig levels, etc Accidental Overdose 85% of elderly who present to ER with accidental overdose were taking antidiabetics, warfarin, antiepileptics, digoxin, theophylline, or lithium Insulin Pens/prefilled syringes vs. vials Simplify regimen, premixed insulins If regimen changes ensure pt knows to stop taking previously- prescribed insulin Start low and go slow Slide 31 Medication Errors Device Problems 40% errors related to product or device issues Pens Used like a vial Used as a single dose product (Forteo) Labeling (Apokyn mg vs. mL) Inhalers Dose counter malfunction (Asmanex Twisthaler) Institute of Safe Medication Practices (ismpinfo@ismp.org) FDA MedWatch (www.fda.gov/Safety/MedWatch/H owToReport/default.htm) Slide 32 Nonadherence 55% of Medicare beneficiaries are nonadherent Up to 40% who skip doses or stop drug do not tell provider Reasons: Forgetfulness Side effects Perceived inefficacy Cost76% more likely to have decline in overall health Slide 33 Goals of care Pt/family goals and values may not match clinician expectation Quality of life and functional status may be more important than maximally extending life expectancy Ex: recognition of advanced dementia as terminal illness VBP may financially penalize providers who take this into consideration Risk vs. Benefit Consider remaining life expectancy, time to achieve benefit from medication, and pt goals Slide 34 American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. American Geriatrics Society 2012 Beers Criteria Update Expert Panel. J Am Geriatr Soc. 2012 Apr;60(4):616-31. Clark, TR. Tough decisions about medications. Aging Well magazine, Winter 2010. Gokula M, Holmes HM. Tools to reduce polypharmacy. Clin Geriatr Med. 2012 May;28(2):323-41. Hovstadius B, Petersson G. Factors leading to excessive polypharmacy. Clin Geriatr Med. 2012 May;28(2):159-72. Medication Errors in Specific Situations and Populations. Pharmacists Letter. Volume 2011, Course Number 313. Patient-centered care for older adults with multiple chronic conditions: a stepwise approach from the American Geriatrics Society: American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity. J Am Geriatr Soc. 2012 Oct;60(10):1957-68. PL Detail-Document, Potentially Harmful Drugs in the Elderly: Beers List. Pharmacists Letter/Prescribers Letter. June 2012. PL Detail-Document, STARTing and STOPPing Medications in the Elderly. Pharmacists Letter/Prescribers Letter. September 2011. American Society of Consultant Pharmacists Geriatric Pharmacotherapy Practice Resource Center, available www.ascp.com/articles/geriatric-pharmacotherapy Medication Use Safety Training For Seniors, available www.mustforseniors.org Photo, www.caregivercollege.org Photo, dangersofpolypharmacy.wordpress.com Slide 35