POLYPHARMACY IN THE ELDERLY The Typical Older Adult…

OBJECTIVES • Takes 4 to 5 prescription and 2 OTC drugs at

a time; fills 12 – 17 prescriptions/year
• Definition of polypharmacy
• Is on fixed income, whose main source of
• Prevalence
income is Social Security
• Consequences
• Spends an average of 27% of budget for
• Pharmacology and Aging
medications
o Specific Examples
• In ambulatory: 2 – 4 prescription drugs
• Interventions
• In long term care: 2 – 10 prescription drugs
• Describe the demographics of medication
usage RISK FACTORS TO POLYPHARMACY
• Identify the effects of physiologic changes on
Chronic Illnesses
drug absorption, distribution, and clearance
• Describe adverse reactions to medications • Sometimes require different drugs to
• Identify iatrogenic problems associated with address each symptom
multigeriatric syndromes and their
Underutilization
medication regimens
• Discuss strategies for preventing • Underprescribing of medications
polypharmacy and enhancing medication • More medications may be used caused by
compliance / adherence under-treatment
Question: At least…how many drugs must an older Physician Factors
person take to make him at risk for polypharmacy?
• Presuming patient expects prescription
a. A couple medication and no medication review
b. 5 • Prescribing without sufficient investigation
c. 10 of clinical situation
d. A dozen • Unclear, complex, incomplete instruction;
Question: Any substance may have an interaction not simplifying the regimen
with the following EXCEPT: • Ordering automatic refills
• Lack of knowledge of geriatric clinical
a. Another drug pharmacology…inappropriate prescribing
b. Food
c. Disease SPECIALTY PHYSICIANS
d. None of the above • Different healthcare providers prescribe
DEFINITION different drugs
Polypharmacy Patient Factors
• The act of taking many medications (many • Seeing multiple physicians and pharmacies
drugs)
• Hoarding of medications
• The use of more than 5 medications, some of
• Inaccurate reporting of ALL medicines
which may be clinically inappropriate
concurrently being taken
• “concurrent use of several drugs” (ANA,
• Assuming that when medication starts, they
1990)
can continue indefinitely
PREVALENCE • Changes in daily habits
• Changes in cognition, depression,
• As much as 25% of the overall population insufficient funds, declining function, living
(Chumney et. al., 2006) alone
• For those >65 years old, prevalence increases
to 50% MEDICATION ERRORS
• Prevalence may also be dependent on
• Taking a wrong medication or the wrong
comorbidity
dose at the wrong time or for the wrong
o More drugs among diabetics than
purpose
age or sex non – diabetics (Good,
2002) IMPLICATIONS OF POLYPHARMACY
o Other predictors include number of
Polypharmacy leads to…
starting drugs, CAD, diabetes, and
use of medications without • Adverse drug reactions
indications (Veehof et. al., 2000) • Drug – drug interactions
 • Decreased medication compliance • Deemed complicated and expensive
• Poor quality of life
Increased incidence of hospitalization
• Unnecessary drug expense
• Usually a result of ADR’s and non-adherence
Adverse Drug Reactions
• May also result from complications from:
• A detrimental response to a given o Electrolyte imbalances
medication that is undesired, unintended, or o Gastrointestinal bleeding
unexpected in recommended doses o Hip fractures (associated with falls)
• A higher level of care is usually required to
EFFECTS OF PHYSIOLOGIC AGING
treat the adverse events
• Has been shown to increase the risk of Altered pharmacokinetics & pharmacodynamics
mortality & nursing home placement in the
• Suppression and exaggeration response to
geriatric population
other medications
• Fifth leading cause of death in older adults
• Falls from orthostatic hypotension Pharmacokinetics
• Confusion and disorientation
• Absorption
• Hepatic toxicity
o Delayed gastric emptying; decreased
• Renal toxicity
gastric acidity; decreased splanchic
Clinical manifestations of ADR’s blood flow
• Drug Distribution
➢
Nausea ➢ Insomnia
o Higher percentage of fat; decreased
➢
Constipation ➢ Confusion
total body water; decreased plasma
➢
GI bleeding ➢ Dizziness
➢
Urinary ➢ Orthostatic albumin concentration
incontinence hypotension Pharmacodynamics
➢ Muscle aches ➢ Falls
➢ Sexual • Serum concentration
dysfunction o Changes in body composition
Consequences of ADR’s changes serum concentration of
water-soluble drugs
• Drug – drug interactions
o Changes in fat mass affect
• Drug – disease interactions
concentration of fat-soluble
• Drug – food interactions
medications
• Drug side effects
• Drug clearance
• Drug toxicity
o Altered liver metabolism; decreased
DRUG – DRUG INTERACTION renal excretion of drugs

• Occurs when two or more drugs are taken
concurrently
• As the number of medications taken
increases, so does the risk for drug – drug
interaction
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
• Digoxin: toxicity
• H2 Blockers: confusion
• Benzodiazepines: CNS toxicity
• Narcotics: constipation; “start low; go slow”
Non-adherence
• The extent to which the patients are not
willing to follow the instruction
INTERVENTIONS AND STRATEGIES FOR CARE
1. Be knowledgeable about drug therapy and
the medications the individual patient is
taking
- A good starting point is to become familiar
with the medications that have been
identified as problematic (i.e. medications
with high potential for adverse reactions)
- “Vigilance in monitoring for adverse
reactions.”
2. Obtain a comprehensive medication profile
- Ask for the name of the drug, purpose, dose,
and administration parameters for each
medication
• Do you use OTC medications, including
vitamins, dietary supplements, or herbal
preparations?
• How many alcoholic beverages do you
drink a week?
• Do you ever borrow medications?
• How many health care providers are
involved in your care?
 • Do you request refills without seeing your
health care provider?
• Do you have prescription medications
from more than one health care provider?
• Do you have prescriptions filled at more
than one pharmacy?
• Do you have any vision or hearing
problems?
3. Monitor kidney function (serum blood urea
nitrogen (BUN) and creatinine)
- Excretion of most drugs depends on
adequately functioning kidneys
4. Monitor liver function (AST, ALT, ALP, &
Bilirubin)

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