avoiding inappropriate medication use in older adults jason stein, md emory reynolds faculty scholar...

Avoiding Inappropriate Avoiding Inappropriate Medication Use In Older Medication Use In Older

AdultsAdults

Jason Stein, MDEmory Reynolds Faculty ScholarEmory Hospital Medicine Service

Scope of the ProblemScope of the Problem

If medication related problems were ranked as If medication related problems were ranked as a disease by cause of death it would be the:a disease by cause of death it would be the:

55thth leading cause of death in the U.S. leading cause of death in the U.S.

Updating the Beers CriteriaUpdating the Beers Criteria

Demographic Trends:Demographic Trends: the Elderly the Elderly

DEMOGRAPHIC TRENDS DEMOGRAPHIC TRENDS 20th century20th century

– U.S. population < 65 tripledU.S. population < 65 tripled– U.S. population U.S. population >> 65 increased by 65 increased by factor of 11factor of 11

grew from 3.1 million (1900) to 33.2 million (1994) grew from 3.1 million (1900) to 33.2 million (1994) Will more than double by middle of 21Will more than double by middle of 21stst century century

– to 80 million people, with most of this growth b/t 2010-30.to 80 million people, with most of this growth b/t 2010-30.

Hobbs, FB, Damon BL. Sixty-Five Plus in America. Current Population Reports, Special Studies, P23–P190. Washington, DC: US Department of Commerce, Economics, and Statistics Administration, Bureau of the Census; 1996.

National Center for Health Statistics. Health, United States, 1999 With Health and Aging Chartbook. Hyattsville, MD: US Department of Health and Human Services, National Center for Health Statistics; 1999. DHHS Pub. No. (PHS) 99–1232.

Educational Trends:Educational Trends: the Elderly the Elderly

Educational Trends:Educational Trends:High School DiplomaHigh School Diploma 1970: 28%1970: 28% 1998: 67% 1998: 67% 2030: 83%2030: 83%

Bachelor’s DegreeBachelor’s Degree (or higher)(or higher)

1998: 15%1998: 15% 2030: 24%2030: 24%

Education = closely related to lifetime economic status

Education = associated with better health and lower risk of disability than those with low levels of educational attainment

Education ~ more activist health care consumers, more demanding of the health care system (speculation about better-educated elderly baby boomers)

American Association of Retired People (AARP) and Administration on Aging (AOA), US Department of Health and Human Services. Profile of Older Americans. 1999.


National Center for Health Statistics. Health, United States, 1999 With Health and Aging Chartbook. Hyattsville, MD: US Department of Health and

Human Services, National Center for Health Statistics; 1999. DHHS Pub. No. (PHS) 99–1232.

Health Trends:Health Trends: the Elderly the Elderly

Health Trends:Health Trends: 79% of persons 79% of persons >> 70 have at least one of the 7 70 have at least one of the 7

chronic conditions most common among elderly:chronic conditions most common among elderly:– ArthritisArthritis– HypertensionHypertension– Diabetes mellitusDiabetes mellitus– Heart diseaseHeart disease– StrokeStroke– Respiratory diseaseRespiratory disease– Cancer Cancer


National Center for Health Statistics. Health, United States, 1999 With Health and Aging Chartbook. Hyattsville, MD: US Department of Health and Human Services, National Center for Health Statistics; 1999. DHHS Pub. No. (PHS) 99–1232.

Functional StatusTrends:Functional StatusTrends:the Elderlythe Elderly

Functional Status Trends:Functional Status Trends: Functional disability increases with ageFunctional disability increases with age Functional disability is associated with chronic Functional disability is associated with chronic

disease disease majority < 85 yo have majority < 85 yo have nono difficulty in ADLs or difficulty in ADLs or

instrumental activities of daily living (iADLs)instrumental activities of daily living (iADLs)– 72% of those 65 – 74 yo72% of those 65 – 74 yo– 53% of those 75 - 84 yo53% of those 75 - 84 yo

majority majority >> 85 85 dodo report difficulty report difficulty– 78% !!78% !!




Hospital Diagnosis Trends:Hospital Diagnosis Trends:the Edlerlythe Edlerly

Discharge Diagnosis Trends:Discharge Diagnosis Trends: Heart DiseaseHeart Disease Heart Disease + StrokeHeart Disease + Stroke Malignant neoplasmsMalignant neoplasms PneumoniaPneumonia BronchitisBronchitis

Account for > 25% of all hospital discharges among men and women > 85

Leading discharge diagnosis





Prescription Medication Trends:Prescription Medication Trends:the Elderlythe Elderly

Prescription Medication Trends:Prescription Medication Trends: 80% of elderly use 80% of elderly use >> 1 prescription medication 1 prescription medication 93% of elderly with low functional status 93% of elderly with low functional status

(dependent for 3-5 ADLs) use (dependent for 3-5 ADLs) use >> 1 prescription 1 prescription medicationmedication– Medicate beneficiaries spend more out-of-pocket for prescription medications than Medicate beneficiaries spend more out-of-pocket for prescription medications than

physician care, vision services, and medical supplies combined. physician care, vision services, and medical supplies combined. – Medicare beneficiaries spend more than 5x more on prescription drugs than for Medicare beneficiaries spend more than 5x more on prescription drugs than for

outpatient and inpatient hospital care combinedoutpatient and inpatient hospital care combined





The Elderly andThe Elderly and Hospital Medicine Hospital Medicine

Differential diagnosis of every problem in a geriatric Differential diagnosis of every problem in a geriatric patient includes a drug side effectpatient includes a drug side effect

Inappropriate MedicationInappropriate Medication

definition: “definition: “inappropriateinappropriate” medication” medication

→ → greater potential to harm than benefit greater potential to harm than benefit patientpatient

May be due to:May be due to: Lack of proven effectLack of proven effect High likelihood of ADEHigh likelihood of ADE Potential for severe ADEsPotential for severe ADEs High potential for interaction with another drug or class of drugsHigh potential for interaction with another drug or class of drugs

Chutka D, Takahashi P, Hoel R. Inappropriate Medications in Elderly Patients. Mayo Clin Proc. Chutka D, Takahashi P, Hoel R. Inappropriate Medications in Elderly Patients. Mayo Clin Proc. 2004; 79:122-139.2004; 79:122-139.

Use of Inappropriate MedicationsUse of Inappropriate Medications

Evidence: physicians often prescribe medications Evidence: physicians often prescribe medications with increased potential of harm to elderly patientswith increased potential of harm to elderly patients

Evidence: physicians treat certain conditions Evidence: physicians treat certain conditions aggressively despite patient’s age and functional aggressively despite patient’s age and functional statusstatus

Evidence: adverse reactions up to 7x more Evidence: adverse reactions up to 7x more common in 70-79 yo compared with 20-29 yocommon in 70-79 yo compared with 20-29 yo

Evidence: Increasing number of meds increase Evidence: Increasing number of meds increase risk of serious drug interactionrisk of serious drug interaction

Chutka D, Takahashi P, Hoel R. Inappropriate Medications in Elderly Patients. Mayo Clin Chutka D, Takahashi P, Hoel R. Inappropriate Medications in Elderly Patients. Mayo Clin Proc. 2004; 79:122-139.Proc. 2004; 79:122-139.

Adverse Drug Events (ADEs)Adverse Drug Events (ADEs)

definition: “definition: “adverse drug eventadverse drug event””→ → when injury or illness occurs as a result of drug when injury or illness occurs as a result of drug

useuseMajority of occur in older adults – likely d/t 3 Majority of occur in older adults – likely d/t 3 primary reasons: primary reasons: increased polypharmacy (# medications = single most increased polypharmacy (# medications = single most

important factor)important factor) altered pharmacodynamics/kinetics (75% of geriatric altered pharmacodynamics/kinetics (75% of geriatric

adverse drug effects occur at manufacturer adverse drug effects occur at manufacturer recommended doses)recommended doses)

increased prevalence of disease with advancing ageincreased prevalence of disease with advancing age

PolypharmacyPolypharmacy

definition: “definition: “polypharmacypolypharmacy””

→ → >5 medications>5 medications Increases risk of drug interactions (which likely Increases risk of drug interactions (which likely

contributes to increased adverse effects in older adults)contributes to increased adverse effects in older adults) Increases complexity and cost of medication regimens Increases complexity and cost of medication regimens

Why Consider the Elderly?Why Consider the Elderly?

Quantity of the ElderlyQuantity of the Elderly– DemographicsDemographics

Quality of the ElderlyQuality of the Elderly– Age Related Physiological ChangesAge Related Physiological Changes– Other Age Related FactorsOther Age Related Factors

Multiple medical conditionsMultiple medical conditions Multiple medicationsMultiple medications

Why Consider the Elderly?Why Consider the Elderly?

ADEs, drug-drug interactions, and drug toxicities are ADEs, drug-drug interactions, and drug toxicities are more likely in elderly patients due to:more likely in elderly patients due to: Age related changes in pharmacokineticsAge related changes in pharmacokinetics Age related changes in pharmacodynamicsAge related changes in pharmacodynamics Reduced organ reserve capacity (tends to increase the Reduced organ reserve capacity (tends to increase the

severity of ADEs)severity of ADEs) Multiple medical conditionsMultiple medical conditions Number of medications takenNumber of medications taken

Chutka D, Takahashi P, Hoel R. Inappropriate Medications in Elderly Patients. Mayo Chutka D, Takahashi P, Hoel R. Inappropriate Medications in Elderly Patients. Mayo Clin Proc. 2004; 79:122-139Clin Proc. 2004; 79:122-139..

The Elderly: PharmacokineticsThe Elderly: PharmacokineticsBody composition changes: Body composition changes:

body fat (relative)body fat (relative)lean body masslean body massdecreased total body waterdecreased total body water

Changes in drug distribution, metabolism, and Changes in drug distribution, metabolism, and elimination increases susceptibility to ADEs elimination increases susceptibility to ADEs (but minimal (but minimal changes in absorption)changes in absorption)

Water soluble medicationsWater soluble medications: concentrations increased at : concentrations increased at any given dose relative to younger adultsany given dose relative to younger adults

Fat soluble medicationsFat soluble medications: half-lives prolonged: half-lives prolonged

The Elderly: PharmacodynamicsThe Elderly: Pharmacodynamics

Elderly more sensitive so greater drug effects Elderly more sensitive so greater drug effects (both beneficial and adverse)(both beneficial and adverse) may occur at a may occur at a given serum level relative to younger adults. given serum level relative to younger adults. e.g. altered pharmacodynamics with aging include opiates, e.g. altered pharmacodynamics with aging include opiates, benzodiazepines, warfarin, and theophyllinebenzodiazepines, warfarin, and theophylline

The Elderly andThe Elderly and Medication Compliance Medication Compliance

Altered ComplianceAltered Compliance Under-utilization Under-utilization (taking less than prescribed dose frequency (taking less than prescribed dose frequency

or strength)or strength)

Over-utilization Over-utilization (taking more than prescribed doses)(taking more than prescribed doses)

Enforced AdherenceEnforced Adherence


Under-utilizationUnder-utilization

(taking less than prescribed dose frequency or strength)(taking less than prescribed dose frequency or strength) Common and increases with polypharmacyCommon and increases with polypharmacy Associated with complex dosing regimensAssociated with complex dosing regimens Associated with expensive medicationsAssociated with expensive medications May be “appropriate” if due to drug side effectsMay be “appropriate” if due to drug side effects May occur if difficulty obtaining or taking drugs (e.g., May occur if difficulty obtaining or taking drugs (e.g.,

functional impairments, cognition, dexterity, vision functional impairments, cognition, dexterity, vision problems)problems)


Over-utilizationOver-utilization(taking more than prescribed doses)(taking more than prescribed doses)

Occurs often in patients with cognitive impairmentOccurs often in patients with cognitive impairment Increases the potential for adverse drug eventsIncreases the potential for adverse drug events Suspect if medication refills needed early, too frequentlySuspect if medication refills needed early, too frequently


Enforced ComplianceEnforced Compliance Occurs when administering an “assumed” outpatient Occurs when administering an “assumed” outpatient

dose (when in fact patient has dose (when in fact patient has notnot been taking that been taking that dose)dose)

Common occurrence in hospital or nursing home settingCommon occurrence in hospital or nursing home setting High potential for overdose/adverse drug effectsHigh potential for overdose/adverse drug effects

Elderly Patients and Elderly Patients and Hospital MedicineHospital Medicine

Risk FactorsRisk Factors Hospitalized patients with lower admission MMSE Hospitalized patients with lower admission MMSE

scores may have higher rates of ADEsscores may have higher rates of ADEs More newly prescribed inpatient medicationsMore newly prescribed inpatient medications

FrequencyFrequency 1 in 6 hospitalized elderly patients (>70 yo) may 1 in 6 hospitalized elderly patients (>70 yo) may

experience an ADEexperience an ADE

Inevitable?Inevitable? Over half of ADEs are potentially preventableOver half of ADEs are potentially preventable

Gray S, Sager M, Lestico M, Jalaluddin M. Adverse Drug Events in Hospitalized Elderly. Gray S, Sager M, Lestico M, Jalaluddin M. Adverse Drug Events in Hospitalized Elderly. Journ of Gerontology. 1998; 1: M59-M63.Journ of Gerontology. 1998; 1: M59-M63.


ADEs and Functional DeclineADEs and Functional Decline 50% of hospitalized patients who experience an 50% of hospitalized patients who experience an

ADE deteriorate in ADL function during the ADE deteriorate in ADL function during the hospitalization (25% of non-ADE patients)hospitalization (25% of non-ADE patients)

Gray S, Sager M, Lestico M, Jalaluddin M. Adverse Drug Events in Hospitalized Elderly. Gray S, Sager M, Lestico M, Jalaluddin M. Adverse Drug Events in Hospitalized Elderly. Journ of Gerontology. 1998; 1: M59-M63.Journ of Gerontology. 1998; 1: M59-M63.


Which Drug Can We Eliminate to Make the Which Drug Can We Eliminate to Make the Problem Go Away?Problem Go Away? No single drug accounts for a high % of ADEsNo single drug accounts for a high % of ADEs But there are high risk drug classes (those most often a/w But there are high risk drug classes (those most often a/w

preventable ADEs) → meds with CNS effects:preventable ADEs) → meds with CNS effects: narcoticsnarcotics sedativessedatives antidepressantsantidepressants

Gray S, Sager M, Lestico M, Jalaluddin M. Adverse Drug Events in Hospitalized Elderly. Journ Gray S, Sager M, Lestico M, Jalaluddin M. Adverse Drug Events in Hospitalized Elderly. Journ of Gerontology. 1998; 1: M59-M63of Gerontology. 1998; 1: M59-M63

54%54%


LOS and CostsLOS and Costs In one study 60/190 ADEs preventableIn one study 60/190 ADEs preventable Additional LOS assoc with ADE=2.2 dAdditional LOS assoc with ADE=2.2 d Additional cost assoc with ADE=$3,244Additional cost assoc with ADE=$3,244 Based on cost data and incidence of ADEs:Based on cost data and incidence of ADEs:

estimated annual attributable cost to in a 700 bed teaching hospital estimated annual attributable cost to in a 700 bed teaching hospital was…was…

$5.6 million $5.6 million (attributable to all ADEs)(attributable to all ADEs)

$2.8 million $2.8 million (attributable to (attributable to preventablepreventable ADEs) ADEs)

Bates D, Spell N, Cullen D, et al. The Costs of Adverse Drug Events in Hospitalized Patients. JAMA. Bates D, Spell N, Cullen D, et al. The Costs of Adverse Drug Events in Hospitalized Patients. JAMA. 1997; 277(4): 307-311.1997; 277(4): 307-311.


Scope of the ProblemScope of the Problem As many as 30% of hospital admissions of elderly patients are due As many as 30% of hospital admissions of elderly patients are due

to ADEsto ADEs 35% of ambulatory older adults experience an ADE (29% require health care 35% of ambulatory older adults experience an ADE (29% require health care

services: physician, ED, or hospitalization)services: physician, ED, or hospitalization)

Symptoms of ADEs in elderly can be:Symptoms of ADEs in elderly can be: non-specific, ornon-specific, or subtle subtle

Temptation is to “treat” an ADE with another drugTemptation is to “treat” an ADE with another drug

Chutka D, Takahashi P, Hoel R. Inappropriate Medications in Elderly Patients. Mayo Clin Proc. 2004; Chutka D, Takahashi P, Hoel R. Inappropriate Medications in Elderly Patients. Mayo Clin Proc. 2004; 79:122-139.79:122-139.

confusion, falls, hip fractures, functional decline, poor PO confusion, falls, hip fractures, functional decline, poor PO intake, urinary retention, or constipationintake, urinary retention, or constipation

Identifying the Medications to Avoid for Identifying the Medications to Avoid for Elderly Patients:Elderly Patients:

Beers Criteria – the WhyBeers Criteria – the Why

How do we formulate Clinical Guidelines?How do we formulate Clinical Guidelines? Controlled studiesControlled studies Systematically review the evidence-based Systematically review the evidence-based

literatureliterature

Beers Criteria – the WhyBeers Criteria – the Why

What if # of controlled studies is limited?What if # of controlled studies is limited? For “Medication Use in Elderly Patients” that’s the For “Medication Use in Elderly Patients” that’s the

problem – elderly excluded from many studiesproblem – elderly excluded from many studies One approach is to ask the opinion of those One approach is to ask the opinion of those

considered expertsconsidered experts– Consensus CriteriaConsensus Criteria– Types of Bias this introducesTypes of Bias this introduces– Recognize the Bias…and Move OnRecognize the Bias…and Move On

Consensus Criteria for Medication Consensus Criteria for Medication Use in Older Adults – 2 such setsUse in Older Adults – 2 such sets

1)1) Beers CriteriaBeers Criteria2)2) Canadian CriteriaCanadian Criteria

Beers Criteria – the WhatBeers Criteria – the What

““Criteria” = Statements: Criteria” = Statements: – Specific medications (or classes of medications)… Specific medications (or classes of medications)…

Should Should generally be avoidedgenerally be avoided in any person > 65yo in any person > 65yo Should not be used routinely > 65 yo Should not be used routinely > 65 yo with a specific medical with a specific medical

conditioncondition Risk for ADE too high when safer alternative existsRisk for ADE too high when safer alternative exists

– Problematic in excessive dosages Problematic in excessive dosages – Problematic in extended duration of use (when initially Problematic in extended duration of use (when initially

intended for limited time)intended for limited time)

Beers Criteria – the How?Beers Criteria – the How?

The process – Delphi MethodThe process – Delphi Method– Analysis Concurrent with Data CollectionAnalysis Concurrent with Data Collection

1) Literature Review -> 11) Literature Review -> 1stst Questionnaire Questionnaire 2) Experts complete 12) Experts complete 1stst Questionnaire Questionnaire 3) Analysis of 13) Analysis of 1stst Questionnaire -> 2 Questionnaire -> 2ndnd Questionnaire Questionnaire 4) Experts complete 24) Experts complete 2ndnd Questionnaire (Using Questionnaire (Using

Feedback Provided by Investigators - allowed to see Feedback Provided by Investigators - allowed to see answers from 1answers from 1stst Questionnaire plus Face-to-Face Questionnaire plus Face-to-Face discussion) discussion)

Delphi MethodDelphi Method

Set of procedures for formulating group judgment Set of procedures for formulating group judgment for subject matter where precise info is lackingfor subject matter where precise info is lacking

Procedures consist of obtaining individual answers Procedures consist of obtaining individual answers to pre-formulated questions, e.g. by questionnaireto pre-formulated questions, e.g. by questionnaire

Iterating questionnaire one or more times where Iterating questionnaire one or more times where information feedback b/t rounds is carefully information feedback b/t rounds is carefully controlled by exercise managercontrolled by exercise manager

Delphi MethodDelphi Method

Taking as the group response a statistical Taking as the group response a statistical aggregate of the final answersaggregate of the final answers

Leads to increased accuracy of group Leads to increased accuracy of group responses more often than notresponses more often than not

Who Were the Experts?Who Were the Experts?

12 of them (13 in 1991, 6 in 1997)12 of them (13 in 1991, 6 in 1997) ““nationally recognized experts in geriatric nationally recognized experts in geriatric

care, clinical pharmacology, and care, clinical pharmacology, and psychopharmacology”psychopharmacology”

What Made Them “Experts?”What Made Them “Experts?”

Published extensivelyPublished extensively Senior academic rankSenior academic rank Represented acute care, long-term care, Represented acute care, long-term care,

and community practice settingand community practice setting Geographically diverseGeographically diverse 12 of 16 invited experts completed all 12 of 16 invited experts completed all

rounds of survey rounds of survey (dropout, intention to survey)(dropout, intention to survey)

Response StandardizationResponse Standardization

Likert ScaleLikert Scale– Rate agreement or disagreement with a Rate agreement or disagreement with a

statement fromstatement from <1> <1> strongly agreestrongly agree <3><3> expresses equivocationexpresses equivocation

<5><5> strongly disagreestrongly disagree

Response Open-endedResponse Open-ended

If expert didn’t feel qualified to reply, could If expert didn’t feel qualified to reply, could opt not to answeropt not to answer

If expert wanted to add own statement If expert wanted to add own statement provision for thatprovision for that

(this is good because…)(this is good because…)

Literature ReviewLiterature Review

4 Investigators -> 14 Investigators -> 1stst questionnaire from questionnaire from systematic review of the literature:systematic review of the literature:– Identified literature published in English 1/1994-Identified literature published in English 1/1994-

12/2000 analyzing medication use in older 12/2000 analyzing medication use in older adults living in the community and living in NH’sadults living in the community and living in NH’s Note: did not include medication use in hospitalsNote: did not include medication use in hospitals


Searched MEDLINE using terms:Searched MEDLINE using terms:– Adverse drug reactionsAdverse drug reactions– Adverse drug eventsAdverse drug events– Medication problemsMedication problems– Medications and elderlyMedications and elderly


Hand searched & identified additional references Hand searched & identified additional references from bibliographies of relevant articlesfrom bibliographies of relevant articles

All panelists invited to add references to the All panelists invited to add references to the literature reviewliterature review

Literature Review-> 1Literature Review-> 1stst Questionnaire Questionnaire

Each publication was reviewed by 2 (of the 4) Each publication was reviewed by 2 (of the 4) principal investigatorsprincipal investigators

Each investigator used a table to outline:Each investigator used a table to outline:– Study designStudy design– Sample sizeSample size– Medications reviewedMedications reviewed– Summary of results and key pointsSummary of results and key points– Quality, type, and category of medication addressedQuality, type, and category of medication addressed– Severity of drug related problemSeverity of drug related problem

11stst Questionnaire Questionnaire

Experts RespondExperts Respond– Parts 1 and 2 reviewed 1997 criteriaParts 1 and 2 reviewed 1997 criteria– Parts 3 and 4 new for 2002Parts 3 and 4 new for 2002

Part 3 – Medications Independent of Disease or Part 3 – Medications Independent of Disease or ConditionCondition

Part 4 – Medications Considering Disease or Part 4 – Medications Considering Disease or ConditionCondition

– Provision for Expert to add open-ended input (44)Provision for Expert to add open-ended input (44)

11stst Questionnaire Analyzed Questionnaire Analyzed

Building the 2Building the 2ndnd Questionnaire – Trashing Questionnaire – Trashing Questions Questions – Calculated mean rating (Likert 1-5) Calculated mean rating (Likert 1-5) – Calculated corresponding 95% CI for each Calculated corresponding 95% CI for each

“statement or dosing question” “statement or dosing question” Where lower limit of the 95% CI was > 3 those Where lower limit of the 95% CI was > 3 those

statements & dosing questions were excluded statements & dosing questions were excluded Included statements & dosing questions whose upper Included statements & dosing questions whose upper

limit of 95% CI limit of 95% CI << 3 3

11stst Questionnaire Questionnaire

Building the 2Building the 2ndnd Questionnaire – Adding Questions Questionnaire – Adding Questions– Any statement added by an expert in the open-Any statement added by an expert in the open-

ended included in 2ended included in 2ndnd Questionnaire Questionnaire

22ndnd Questionnaire Questionnaire

Experts received it 10 days before meeting Experts received it 10 days before meeting face-to-face face-to-face

Opportunity to reconsider own responsesOpportunity to reconsider own responses– After given information on their previous After given information on their previous

answers plus anonymous answers of other answers plus anonymous answers of other expertsexperts

Severity RatingSeverity Rating

Potential medication problemsPotential medication problems 5 point scale 5 point scale

ResultsResults

Final CriteriaFinal Criteria– Table 1Table 1

48 individual medications (or classes) to avoid in 48 individual medications (or classes) to avoid in older adultsolder adults

– Table 2Table 2 20 diseases or conditions plus medications to avoid 20 diseases or conditions plus medications to avoid

– Table 3Table 3 Sensitivity of the Process Poor?Sensitivity of the Process Poor?

ExampleExample

1S tro ng ly A gree

3E qu ivo ca l

5S tro n g ly D isa gree

Q ue stio nn a ire #1A tiva n in do se o f 3 m g is sa fe

ExampleExample

1S tro ng ly A gree

3E qu ivo ca l

5S tro n g ly D isa gree

Q ue stio nn a ire #2A tiva n d o se o f 3 m g is e xce ss ive

(1 1 /1 2 O th e r P an e lis tsS tro n g ly D isa gree d)

Critiques of this MethodCritiques of this Method

Simplistic – misses other prescribing problems Simplistic – misses other prescribing problems such as underuse or interactions of drugs in older such as underuse or interactions of drugs in older patientspatients

Limiting – clinical judgment Limiting – clinical judgment Lack of prospective, controlled studies that show Lack of prospective, controlled studies that show

criteria make a difference in outcomes criteria make a difference in outcomes May not reflect best practice for the oldest old (sig May not reflect best practice for the oldest old (sig

> 65 yo)> 65 yo) Same limitations previously documented regarding Same limitations previously documented regarding

use of Delphi techniqueuse of Delphi technique

Beers Criteria – Valid?Beers Criteria – Valid?

Studies have shown the Beers Criteria to be useful Studies have shown the Beers Criteria to be useful in decreasing problems in older adults (15-19)in decreasing problems in older adults (15-19)

Adopted by CMS in July 1999 for NH regulationAdopted by CMS in July 1999 for NH regulation An independent review of scientific literature found An independent review of scientific literature found

evidence to support most of the Beers evidence to support most of the Beers designationsdesignations

Chutka D, Takahashi P, Hoel R. Inappropriate Medications in Elderly Patients. Mayo Clin Proc. 2004; 79:122-139.Chutka D, Takahashi P, Hoel R. Inappropriate Medications in Elderly Patients. Mayo Clin Proc. 2004; 79:122-139.

Improving the Care You Deliver to Improving the Care You Deliver to Hospitalized ElderlyHospitalized Elderly

Many challenges facing those prescribing meds to Many challenges facing those prescribing meds to elderly patients…elderly patients…

If inappropriate medication use is to be reduced…If inappropriate medication use is to be reduced…– Avoid inappropriate medications altogetherAvoid inappropriate medications altogether– Use inappropriate medications wiselyUse inappropriate medications wisely

Only for appropriate reasonsOnly for appropriate reasons Discontinue when no longer providing benefitDiscontinue when no longer providing benefit Dose appropriatelyDose appropriately Monitor closelyMonitor closely

Chutka D, Takahashi P, Hoel R. Inappropriate Medications in Elderly Patients. Mayo Clin Chutka D, Takahashi P, Hoel R. Inappropriate Medications in Elderly Patients. Mayo Clin Proc. 2004; 79:122-139.Proc. 2004; 79:122-139.

General Principles of Medication General Principles of Medication Prescribing for Older PatientsPrescribing for Older Patients

Start doses low and increase slowly as Start doses low and increase slowly as needed (“start low and go slow”)needed (“start low and go slow”)

Keep regimens to the bare minimum Keep regimens to the bare minimum number of medicationsnumber of medications

Use medications with simpler dosing Use medications with simpler dosing regimens (daily or twice-daily preferred)regimens (daily or twice-daily preferred)


Educate patients regarding drug indicationsEducate patients regarding drug indications (and routinely include this information on the prescription)(and routinely include this information on the prescription)

Be aware of all medications, prescription and Be aware of all medications, prescription and nonprescription, that patient may be taking. nonprescription, that patient may be taking.

D “brown bag” review when patient brings all medications D “brown bag” review when patient brings all medications (prescription and nonprescription) to hospital (prescription and nonprescription) to hospital


Review drugs regularlyReview drugs regularly – consider discontinuing agents of uncertain benefitconsider discontinuing agents of uncertain benefit

Be alert for potential drug–drug and drug–disease Be alert for potential drug–drug and drug–disease interactionsinteractions

Differential diagnosis of every problem in a geriatric patient Differential diagnosis of every problem in a geriatric patient includes a drug side effectincludes a drug side effect

We Don’t Communicate WellWe Don’t Communicate Well

14% of patients and physicians had complete congruence 14% of patients and physicians had complete congruence regarding medication regimenregarding medication regimen

70% of patients took 70% of patients took > > 1 med that…1 med that…– the physician was unaware of, orthe physician was unaware of, or– the physician thought the patient was taking but actually the physician thought the patient was taking but actually

was notwas not

Bikowski RM, Ripsin CM, Lorraine VL. Physician-patient congruence regarding Bikowski RM, Ripsin CM, Lorraine VL. Physician-patient congruence regarding medication regimens. J Am Geriatr Soc. 2001;49:1353-7medication regimens. J Am Geriatr Soc. 2001;49:1353-7

Case #1:Case #1:79 yo male admitted to your service in from ED with vomiting 79 yo male admitted to your service in from ED with vomiting

and altered mental status. Illness started 3 days ago with and altered mental status. Illness started 3 days ago with nausea and abdominal pain. Associated headache. nausea and abdominal pain. Associated headache.

He lives alone. It is July and he acknowledges mosquito He lives alone. It is July and he acknowledges mosquito bites while mowing his lawn recently. bites while mowing his lawn recently.

PMH:PMH: CAD, CHF CAD, CHF Meds:Meds:

1.1. Coumadin 4mg qdayCoumadin 4mg qday2.2. Lasix 60mg qd (doubled from 30mg qd)Lasix 60mg qd (doubled from 30mg qd)3.3. Digoxin 0.25mg qdayDigoxin 0.25mg qday4.4. Lisinopril 30mg qdayLisinopril 30mg qday5.5. Vitamin E 400 IU qdayVitamin E 400 IU qday6.6. MVI qdayMVI qday

Case #1:Case #1:

Medication history: regimen mostly unchanged for Medication history: regimen mostly unchanged for last 10 years. However, lasix dose increased last 10 years. However, lasix dose increased one week ago for mildly decompensated CHF.one week ago for mildly decompensated CHF.

What is most likely?What is most likely?A)A) Hepatic congestion from right HFHepatic congestion from right HFB)B) Viral gastroenteritisViral gastroenteritisC)C) West Nile Virus encephalitis West Nile Virus encephalitis D)D) Digoxin toxicityDigoxin toxicity

Case #1:Case #1:

Medication history: regimen mostly unchanged for Medication history: regimen mostly unchanged for last 10 years. However, lasix dose increased last 10 years. However, lasix dose increased one week ago for mildly decompensated CHF.one week ago for mildly decompensated CHF.

What should you suspect is going on?What should you suspect is going on?A)A) Hepatic congestion from right HFHepatic congestion from right HFB)B) Viral gastroenteritisViral gastroenteritisC)C) IleusIleusD)D) Digoxin toxicityDigoxin toxicity

Case #1Case #1

Digoxin toxicity in the elderlyDigoxin toxicity in the elderly– General: malaise, fatigueGeneral: malaise, fatigue– GI: anorexia, nausea, vomiting, diarrheaGI: anorexia, nausea, vomiting, diarrhea– Neuro: headache, dizziness, confusion, deliriumNeuro: headache, dizziness, confusion, delirium

Elderly patients frequently manifest Elderly patients frequently manifest neuropsychiatric findingsneuropsychiatric findings

Risk factors for dig toxicity: decreased renal Risk factors for dig toxicity: decreased renal function, hypoK, hypoMgfunction, hypoK, hypoMg

avoiding inappropriate medication use in older adults jason stein, md emory reynolds faculty scholar...

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