CMS: Geriatrics

Geriatric Polypharmacy
Study Guide

GOAL: Increase awareness of prescribing pitfall facing practitioners who care for older
individuals

RISK of POLYPHARMACY:
Female sex Advanced age Rural residence Lower education Availability of Rx coverage

DEFINITIONS
Geriatric Polypharmacy: the use of excessive and frequently inappropriate medications o Consequences are serious and numerous Medical Financial o Older individuals o Take disproportionate number of medications 58% fail to inform providers of over the counter OTC medications Do not perceive OTC s to be significant if available without prescription Polypharmacy: defined as concomitant ingestion of 4 or more medications o Prescription administration or use of more medications than clinically indicated in a given patient

FACTORS that AFFECT DRUG ABSORPTION:

Route of administration What is taken with the drug Comorbid illnesses Divalent cations (calcium, magnesium, iron) can affect absorption of many fluoroquinolones (eg, ciprofloxacin) Enteral feedings interfere with absorption of some drugs (eg, phenytoin) Increased gastric pH may increase or decrease absorption of some drugs Drugs that affect GI motility can affect absorption

EFFECTS of AGING on the KIDNEY:

kidney size renal blood flow number of functioning nephrons renal tubular secretion Result: Lower glomerular filtration rate

PROBLEM:
# of medications is NOT the problem Use of Medication use NOT indicated Use of Medication use not clear Use of Duplicative medication use

CONSEQUENCES:
Excessive cost Non compliance Adverse drug reactions (ADR) Medication errors

PHARMACODYNAMICS
Definition: Time course and intensity of the pharmacologic effect of a drug o May change with AGING

CAUSE of POLYPHARMACY:
Prescribing cascade (i.e. pt demanding medications, esp. as result of marketing) Pill for every ill Each clinician visit will result in at least one Rx Direct to consumer marketing

DRUG COMPANIES TARGET DEVELOPMENT of MEDS for CHRONIC ILLNESS!

Clinical trials do not include individuals over 85 Little risk vs benefit information

ADVERSE DRUG RXNs

Top 5 causes of death in US o 80% of ADRs causing admission or occurring in hospital are type A (dose-related) o predictable from the known pharmacology of the drug and therefore potentially avoidable (NEARLY 100%!!) Most common adverse rxns of D-to-D interaction: o Confusion o Cognitive impairment o Arterial hypotension o Acute renal failure

APPROACHES to POLYPHARMACY
Start low and go slow Recognize individual needs: o Id indications and avoid unnecessary meds o Evaluate all meds: Rx and OTCs o Examine all doses Communicate and EDUCATE

PRIOR to PRESCRIBING, CONSIDER

Is this medication necessary? What are the therapeutic end points? Do the benefits outweigh the risks? Is it used to treat effects of another drug? Could 1 drug be used to treat 2 conditions? Could it interact with diseases, other drugs? Does patient know what its for, how to take it, and what ADEs to look for? Is it used to treat effects of another drug?

AGING and ABSORPTION

Amount absorbed (bioavailability) is not changed Peak serum concentrations may be higher or lower, and delayed Exceptions: drugs with extensive first-pass effect (bioavailability may increase because less drug is extracted by the liver, which is smaller with reduced blood flow)

PREVENTION
Determine which medications pt is taking REDUCE and ELIMINATE redundant medication Pts should bring in all meds including OTCs for evaluation Document ADRs Assess medication administration records Decrease the number of dose and if possible SIMPLIFY REGIMENS o Use medications with simplest schedule and instructions Provide info on alternative and nonpharmacologic options Id and mobilize internal & external resources Take a critical look during transition times