polypharmacy of older adults. objectives describe the demographics of medication usage identify the...
TRANSCRIPT
Objectives
• Describe the demographics of medication usage
• Identify the effects of physiologic changes on drug absorption, distribution, and clearance
• Describe adverse reactions to medications
• Identify iatrogenic problems associated with multigeriatric syndromes and their medication regimens.
Objectives
• Discuss strategies for preventing polypharmacy and enhancing medication compliance / adherence.
• Appreciate complex cost issues related to medications
• Discuss effects of tricyclic antidepressant drugs on older adults
Polypharmacy
“many drugs”…indicates the use of more medication than is clinically indicated or warranted. 5+ drugs
2000 = 200 million visits to the doctor– No prescription (30%)– Prescription of 1 - 2 drugs (30%)– Prescription of 3+ drugs (30%)
The Typical Older Adult…..
• Takes 4 to 5 prescription and 2 OTC drugs at a time; fills 12 – 17 prescriptions/year
• Is on fixed income, whose main source of income is Social Security
• Spends an average of $955 for medications
• In ambulatory: 2 – 4 prescription drugs• In long term care: 2 – 20 prescription
drugs
Physician Factors
• Presuming patient expects prescription medication and no medication review
• Prescribing without sufficient investigation of clinical situation
• Unclear, complex, incomplete instruction; not simplifying the regimen
• Ordering automatic refills
• Lack of knowledge of geriatric clinical pharmacology……inappropriate prescribing
Patient Factors
• Seeing multiple physicians and pharmacies
• Hoarding of medications
• Inaccurate reporting of ALL medicines concurrently being taken
• Assuming that when medication starts, they can continue indefinitely
• Changes in daily habits
• Changes in cognition, depression, insufficient funds, declining function, living alone
Polypharmacy leads to…
• Adverse drug reactions
• Drug-drug interactions
• Decreased medication compliance
• Poor quality of life
• Unnecessary drug expense
Effects of Physiologic Aging
• Absorption– Delayed gastric emptying;
decreased gastric acidity; decreased splanchic blood flow
• Drug Distribution– Higher percentage of fat; decreased
total body water; decreased plasma albumin concentration
Effects of Physiologic Aging
• Serum Concentration– Change in body composition
changes serum concentration of water-soluble drugs
– Change in fat mass affect concentration of fat-soluble medications
• Drug Clearance– Altered liver metabolism;
decreased renal excretion of drugs
Adverse Drug Reactions
• Simulate conventional image of ‘growing old’: unsteadiness, confusion, nervousness, fatigue, insomnia, drowsiness, falls, depression, incontinence, malaise
• Criteria for potentially inappropriate medication use in older adults (US Consensus Panel of Experts, 2003)
Adverse Drug Reactions
• Fifth leading cause of death in older adults
• Falls from orthostatic hypotension
• Confusion and disorientation
• Hepatic toxicity
• Renal toxicity
• *Creatinine clearance formula
Iatrogenic Problems
• Anticholinergics: confusion; orthostatic hypotension; dry mouth; blurred vision; urinary retention
• Tricyclics: confusion and unstable gait
• Antiemetics: confusion; orthostatic hypotension; blurred vision; falls; dry mouth; urinary retention
Iatrogenic Problems
• Digoxin: toxicity
• H2 Blockers: confusion
• Benzodiazepines: CNS toxicity
• Narcotics: constipation; “start low; go slow”
Preventing polypharmacy
• Requires social and nursing support
• Enhancing compliance:– Patient education – written
instruction– Sensitivity to lack of money to buy
medications– Counseling– Need to take medication even if
‘feeling good’
Enhancing compliance
• Improve provider-patient communication: more time with physician and pharmacist
• No pill sharing
• Assess other remedies patient uses
• Support Systems: Medication Event Monitoring systems (MEMS)
• At least yearly, ask patient to bring ALL medications for review
Cost of Medications
• 65% of noninstitutionalized Medicare beneficiaries – have some form of prescription drug coverage
– Spend less ($310/year) than those without drug coverage ($590/year)
– 60% employer-sponsored or private policy
– 20% Medicare + Choice HMO
– 20% supplemental Medicaid, other public programs
Cost of Medications
Medicare Prescription Drug, Improvement and Modernization Act of 2003 (comprehensive plan will be effective 1/2006)
The Discount Card Program– NOT a comprehensive benefit
– Voluntary and temporary
– Immediate assistance in lowering drug costs for 2004 and 2005
Cost of Medications
The Discount Card Program
• Medicare will contact private companies: 10% – 25% savings
• Choose a prescription drug plan; pay a premium $35.00
• Pay $250.00 deductible; Medicare will pay 75% of cost from $250 to $2,250
• Recipient will pay 100% from $2,250 - $3,600
• Medicare will pay 95% after recipient spends $3,600
ImposingCo-payments
Federal DrugRebate Program
DispensingLimits
FAIL FIRST
Generic Substitution
Preauthorization
FormulariesPreferred Drug List
Access toPrescription
Drugs for lowerIncome seniors
MEDICAID PRESCRIPTION DRUG COVERAGE COST STRATEGIES
Cost of Medications
• Older adults save money on prescription drugs by
– Cutting medications in half
– Borrowing money from friends
– Discontinuing certain medications because they ‘feel good’
Tricyclic antidepressants
• Cause adverse anticholinergic effects
• Caution when using in older adults with glaucoma and cardiac arrhythmias
• Hypotension, tachycardia, and arrhythmia
• Sedation, fatigue, anxiety, impaired cognitive function, seizures, extrapyramidal symptoms
Summary
• Demographics of medication usage
• Physiologic changes of aging and effects on drug absorption, distribution and clearance
• Adverse drug reactions
• Iatrogenic problems
• Preventing polypharmacy / enhancing compliance
• Cost Issues
• Effects of tricyclic antidepressants