Geriatric Polypharmacy

Question 1

1. What is the definition of polypharmacy?

2. The ore medications the patient takes the more what?

Answer 1

1. Polypharmacy = 4 or more medications

2. The more medications the patient takes, the greater the chance of having an adverse drug event

Question 2

Examples of adverse drug events (most common)? 4

Most common causes of death from adverse drug reactions? 3

Answer 2

Examples

1. Falls
2. Orthostatic hypotension
3. Heart failure
4. Delirium

Most common causes of death from adverse drug reactions

1. GI bleeding,
2. intracranial bleeding and
3. renal failure

Question 3

Most common drugs associated with adverse events

4

Answer 3

1. Antithrombotics
2. Antidiabetics
3. Diuretics
4. NSAIDs

Question 4

How drug metabolism differs in the older adults

1. Liver changes? 2
2. Which drugs require smaller doses? 3
3. How do the kidneys change?

Answer 4

1. Liver
   - Hepatic blood flow decreases by 40%
   - Decreased first pass metabolism
2. • Warfarin,
   • BZDs,
   • opiates require smaller doses
3. Kidneys
   - Renal blood flow can decrease by about half at 80 years of age

Question 5

How drug metabolism differs in older adults. How do the following affect metabolism:
1. Decreased lean body weight to body fat ratio?

2. Decreased serum protein?
3. Substance abuse?

Answer 5

1. Alters the distribution of drugs in body compartments
2. Drugs that are protein bound are now free to act resulting in a small dose needed for the desired effect
3. 10% are problem drinkers
   - Can cause a change in drug metabolism

Question 6

Some examples of drugs that are protein bound?

8

Answer 6

1. clindamycin,
2. digoxin,
3. furosemide,
4. ibuprofen,
5. glyburide,
6. glipizide,
7. phenytoin,
8. diphenhydramine

Question 7

Medication review and reconciliation at each visit
Include drug reaction in your DDx for new complaints

Be familiar with what tools for this? 3

Answer 7

1. Be familiar with the Beers criteria
2. STOPP
   Screening tool of older persons’ potentially inappropriate prescriptions
3. START
   Screening tool to alert prescribers to right treatment

Question 8

Beers criteria for potentially inappropriate medication use examples
5

Answer 8

1. Nitrofurantoin (Macrobid)
2. Digoxin in doses > 125 mcg
3. Sliding scale insulin
4. Sulfonylureas
5. Non-Cox-selective NSAIDs

Question 9

Why are these potentially dangerous for the elderly:
1. Nitrofurantoin (Macrobid)? 2

2. Digoxin in doses > 125 mcg? 1
3. Sliding scale insulin? 1
4. Sulfonylureas? 1
5. Non-Cox-selective NSAIDs?
   2 (what can you use to decrease these risks? 2)

Answer 9

1. • Potential for pulmonary toxicity
   • Lack of efficacy with CrCl less than 60 ml/min due to inadequate drug concentration in the urine
2. Increased risk of toxicity, due to decreased renal clearance and decreased protein binding
3. Higher risk of hypoglycemia without improvement of hyperglycemia management
4. Glyburide – prolonged hypoglycemia
5. • Increased risk of GI bleeding,
   • PUD. (Use of PPI or misoprostol decreases risk)

Question 10

Drugs that may worsen constipation

3

Answer 10

1. Antimuscarinics for urinary incontinence (Oxybutynin, tolterodine and 4 others…)
2. Nondihydropyridine calcium channel blockers (Verapamil, Diltiazem)
3. First generation antihistamines

Question 11

Use cautiously in older adults
3

Why? 2

Answer 11

1. SNRIs
2. SSRIs
3. Antipsychotics
4. May cause SIADH or
5. exacerbate underlying syndrome

Question 12

Inappropriate Drugs in the Elderly

9

Answer 12

1. Diphenhydramine (Benadryl)
2. Amitriptyline (Elavil)
3. Alprazolam (Xanax)
4. Diazepam (Valium)
5. Chlorpropamide and Glyburide (1st gen. sulf)
6. Digoxin in doses > 0.125
7. GI antispasmodics
   (Belladonna, dicyclomine, hyoscyamine)
8. Meperidine (Demerol)
9. Methyldopa (Aldomet)

Question 13

Diphenhydramine
Why should this definitely be avoided in older adults?
3

Answer 13

1. Dry mouth, confusion, urinary retention, constipation
2. Source of in-hospital morbidity/delirium
3. Is in many OTC products for sleep/URI/allergy

Question 14

Why should Digoxin be avoided in the elderly? 2

What dosing is adequate for older adults?

Answer 14

1. can cause anorexia, confusion even at therapeutic drug levels
2. Renal excretion can change over time as age-related renal function declines.
3. 125mg/day most often adequate

Question 15

START: Most common omissions? 4

Answer 15

1. statins in atherosclerotic disease (26%)
2. warfarin in chronic atrial fibrillation (9.5%)
3. anti-platelet therapy in arterial disease (7.3%)
4. calcium/vitamin D supplementation in symptomatic osteoporosis (6%)

Question 16

1. Don’t use __________ as first choice to treat behavioral and psychological symptoms of dementia
2. Avoid using medications to achieve A1C less than ____% in most adults ≥ 65
3. Don’t use _____________ or other sedative hypnotics in older adults as first choice for insomnia, agitation or delirium

Answer 16

1. antipsychotics
2. 7.5
3. benzodiazepines

Question 17

Don’t prescribe what for dementia without periodic assessment for perceived cognitive benefits and adverse GI effects?

Answer 17

cholinesterase inhibitors

Question 18

Avoid using prescription what for treatment of anorexia or cachexia in older adults? 2

Don’t prescribe a medication without conducting a medication review

Answer 18

1. appetite stimulants or

2. high-calorie supplements

Question 19

Med rec advice?

10

Answer 19

1. Look for medications that were started at a young age that might now need to be adjusted
   Example: Atenolol
2. Medications used as an inpatient are often at higher doses than needed for chronic therapy
   Example: Diuretics
3. Avoid adding meds to treat adverse effects of another medication if possible
   - Instead decrease the dose, change or DC drug
4. Capture all herbal and OTC meds the patient is taking “brown bag”
5. If drug levels are subtherapeutic must verify compliance prior to increasing dose
6. Drugs for pain, behavior and cognition need to be regularly assessed for response and try to avoid long term treatment with these
7. Start low and go slow
8. Have the patient return for regular follow-up to monitor for ADE
9. Avoid starting 2 new meds in the same patient at one time
10. Incorporate a standardized method for medication review (Beers, START, STOPP)