Polypharmacy and Rational Prescribing in Elderly Patients.pptx

A
Ahmed MshariMedical doctor at Ministry of health iraq à Ministry of health iraq
drahmadtemimi@gmail.com
and
Rational Prescribing
in Elderly Patients
By the end of this lecture, you should be able to:
1. Define POLYPHARMACY and its contributing
factors.
2. Describe the Prevalence of Polypharmacy and
its impact on older adults.
3. Discuss the Consequences of Polypharmacy,
including adverse drug reactions and
medication nonadherence.
4. Explore the Principles of Rational Geriatric
Prescribing and their importance in
preventing polypharmacy.
5. Explain the Deprescribing Process and its role
in reducing the risk of adverse drug reactions
and medication-related harm.
Learning Objectives
Introduction
The elderly represent one of the fastest
growing segments of the population and
their use of medication is increasing
significantly.
The primary care physician plays an
important role in addressing an array of
pharmaceutical issues and concerns for
elderly patients, including:
 Polypharmacy.
 Adverse drug reactions (ADRs).
 Medications nonadherence.
 Undertreatment of certain conditions.
Prevalence  A large survey estimated that roughly
40% of elderly people take 5 or more
medications.
 Nearly, 1 in 20 of these patients risked a
major drug–drug interaction.
 Polypharmacy is estimated to cause 10%
of hospital admissions in elderly people.
 The WHO estimates that more than half
of all medication-related hospital
admissions in elderly people are
preventable.
 Polypharmacy is more common in
women.
 The number of medications used by
older adults increases with age.
What is
polypharmacy ? Polypharmacy is typically defined as
the prescription of five or more
medications.
It also refers to the prescription of
medications that do not have a
specific current indication, that
duplicate other medications, or that
are known to be ineffective for the
condition being treated.
In other words, polypharmacy is the
use of multiple medications that are
unnecessary and have the potential
to do more harm than good.
Factors leading to
Polypharmacy in elderly
Poor patient education.
Multiple pathology.
Attending multiple specialist
clinics.
Lack of routine review of
medications.
Poor communication between
specialists.
Self-treat with over-the-counter
medications.
Prescribing
Cascade
 Elderly people can be the victim of
a harmful “Prescribing Cascade”.
 This happened when an adverse
drug effect is misinterpreted as a
new medical condition, for which
another drug is then prescribed,
and this new medication in turn
have adverse effects that result in
further prescribing.
 It adds an unnecessary burden to
the patient’s already complicated
medication regimen.
Drug 1
Adverse drug effects
misinterpreted as new
medical condition
Drug 2
Adverse
drug effect
Examples of
Frequent
Prescribing
Cascades
Age-related
Physiological Changes
Knowledge of the physiologic
changes that occur with aging is
essential when prescribing
medications to elderly patients.
The changes can affect the way the
body absorbs, distributes,
metabolizes and eliminates drugs.
These changes include increased
body fat, decreased body water,
decreased muscle mass, and
changes in renal and liver function.
These changes can cause ADRs in
older people.
Using multiple drugs at the same
time doesn't always connote
inappropriate prescribing; it can
actually be reasonable.
Often, 3 medications are needed to
manage symptoms of heart failure
or control high blood pressure to
meet national guidelines.
Patients with type 2 DM often
require at least two medications
for effective glucose control.
Polypharmacy
Consequences
Polypharmacy recently became an
important public health problem due
to its many possible negative
consequences, including:
Risk of adverse drug reactions.
Risk of medication nonadherence.
Risk of multiple geriatric
syndromes (e.g., cognitive
impairment, impaired balance and
falls).
Risk of hospitalization and nursing
home placement, and mortality.
Increased health care utilization
and costs.
Adverse Drug
Reactions
An ADR is defined as any noxious, unintended,
or undesired response to a therapeutic agent.
They are at least twice as common in elderly
patients as in younger patients.
Polypharmacy is a major risk factor for ADRs.
The probability of ADRs increases with the
number of medications being taken.
The three most common drug classes
associated with ADRs in the elderly are
cardiovascular drugs, psychotropic drugs, and
NSAIDs.
The orthostatic hypotension is potentially the
most serious drug reaction.
Always, consider an ADR as a cause of any new
patient symptom.
Types of ADRs
 Side effects
(dry mouth from tricyclic antidepressants and
hypokalemia from diuretics).
 Drug toxicity
(GIT bleeding and renal dysfunction caused by
NSAIDs, and cognitive impairment and falls
caused by CNS depressants).
 Drug-drug interaction
(The combined therapy of anticoagulants and
antiplatelet agents can increase the risk of
bleeding).
 Drug-disease interaction
(drugs with anticholinergic properties may affect
the cognitive function of patients with Alzheimer
disease).
 Drug withdrawal syndromes
(beta blocker withdrawal leads to angina or
tachycardia).
Medication
Nonadherence
Forms of nonadherence include:
Forgetting to take medication.
Taking medication at the wrong
dose.
Taking medication at the wrong
time.
Incorrectly administering
medications.
Discontinuing medications
prematurely.
Medication Nonadherence refers to
the failure of a patient to take
medications as prescribed.
Reasons for medication
nonadherence
Polypharmacy.
Cognitive Impairment.
Physical Impairment.
Cost.
Side Effects.
Lack of Understanding.
Forgetfulness.
Lack of Social Support.
Depression.
Fear of dependence.
Consequences of
Medication Nonadherence
Increased risk of
morbidity and
mortality.
Reduced quality of
life.
Increased healthcare
costs
Increased burden on
caregivers.
Interventions to improve
Medication Adherence
Simplifying medication regimens.
Use a medication that can treat
multiple indications.
Try to combine medications into single
pills to reduce pill burden.
Recommending low-cost or generic
alternatives when appropriate.
Educate the patient and caregiver.
Using medication reminders, such as
pillboxes, alarms, or smartphone apps.
Regular medication reviews.
Common geriatric
presentations
that can be
caused by drugs
Common geriatric
presentations
that can be
caused by drugs
Principles of Rational
Geriatric Prescribing
Individualization.
Simplification.
Avoidance of potentially inappropriate
medications.
Monitoring for adverse drug reactions.
Consideration of non-pharmacologic
interventions.
Reasonable therapeutic goals.
Consideration of cost and patient
preferences.
Monitoring parameters.
Involvement of caregivers.
Drug initiation in the elderly should be
done cautiously.
Avoid prescribing before a diagnosis is
made.
Review medications before adding a
new medication.
Start one medication at a time.
For each medication, start very low and
go very slow.
Know the actions, adverse effects, and
toxicity of the medications you
prescribe.
Attempt to maximize dose before
switching to another.
Guideline to initiate
new drugs
The Deprescribing
process
Review the patient’s medication:
including prescription and over-the-
counter medications, supplements, and
vitamins.
Assess the patient’s response to each
medication.
Develop a deprescribing plan: this may
involve discontinuing certain
medications, tapering the dose of certain
medications, or switching to alternative
medications.
Monitor for any new symptoms or
adverse effects that may arise, and
adjust the plan as necessary.
Involve the caregiver in the
deprescribing process to ensure that it is
safe and effective.
The patient's preferences and goals for
treatment are taken into consideration.
Review Checklist
for each medication
Is there an indication for the medication?
Is the medication effective for the condition?
Is the dosage correct?
Is the duration of therapy acceptable?
Are the directions correct and practical?
Are there clinically significant drug-drug
interactions?
Are there clinically significant drug-
disease/condition interactions?
Is there unnecessary duplication with other
medication(s)?
Is this medication the least expensive
alternative?
Rational
Prescribing Tools
A number of helpful prescribing tools
for appropriate medication review in
older adults:
The Beers criteria developed by
the American Geriatrics Society.
STOPP (Screening Tool of Older
Person's Prescriptions).
START (Screening Tool to Alert to
Right Treatment).
MAI (Medication Appropriateness
Index).
ARMOR (Assess, Review, Minimize,
Optimize, Reassess).
Beers Criteria The Beers Criteria is a valuable tool for
healthcare providers to assess and optimize
medication use in older adults.
It is developed by the American Geriatrics
Society.
It is an expert generated list of medications
that are potentially inappropriate for use in
older adults.
The list is updated periodically according to the
evidence-based recommendations.
It can be helpful in reducing the risk of adverse
drug events and improving patient outcomes.
However, it is important to note that the
criteria should not be used as a substitute for
clinical judgement and individualized patient
care.
Medications that should be
avoided in older adults.
Medications that should be used
with caution.
Medications requiring dose
adjustment in older adults with
specific medical conditions.
Medications that may need to be
replaced with safer alternatives.
Recommendations
of Beers Criteria
The Beers Criteria includes
recommendations regarding:
Polypharmacy and Rational Prescribing in Elderly Patients.pptx
Improving drug therapy in elderly patients: The Garfinkel Algorithm
 Polypharmacy is common among older
adults and can lead to adverse drug
events, increased healthcare costs, and
decreased quality of life.
 Rational prescribing and deprescribing
processes are essential for optimizing
medication use in this population.
 These processes involve evaluating
medications for appropriateness,
safety, and effectiveness, and
discontinuing or reducing unnecessary
medications.
 Incorporating these processes into
clinical practice can lead to better
health and quality of life for older
adults.
REFERENCES
 American Geriatrics Society. (2019). American Geriatrics
Society 2019 Updated AGS Beers Criteria(R) for Potentially
Inappropriate Medication Use in Older Adults. Journal of
the American Geriatrics Society, 67(4), 674-694.
 Chang, A. (2020). Current Diagnosis and Treatment:
Geriatrics, 3/e. McGraw Hill Professional.
 Endsley, S. (2018). Deprescribing Unnecessary
Medications: A Four-Part Process. Family Practice
Management, 25(3), 28–32.
 Evidence-Based Geriatric Nursing Protocols for Best
Practice. (2020). Springer Publishing.
 Fillit, H., Rockwood, K., & Young, J. (2017). Brocklehurst’s
textbook of geriatric medicine and gerontology. Elsevier.
 Fulmer, T. T., & Chernoff, B. (2019). Handbook of geriatric
assessment. Jones & Bartlett Learning.
 Ham, R. J. (2014). Ham’s primary care geriatrics: a case-
based approach. Saunders.
 Kim, L. K., Koncilja, K., & Nielsen, C. (2018). Medication
management in older adults. Cleveland Clinic Journal of
Medicine, 85(2), 129–135.
 Kwan, D., & Farrell, B. (2014). Polypharmacy:
optimizing medication use in elderly patients.
 Lee, A. G., Potter, J. F., & G. Michael Harper. (2021).
Geriatrics for Specialists. Springer Nature.
 Rakel, R. E., & Rakel, D. (2016). Textbook of family
medicine. Elsevier Saunders.
 Roller-Wirnsberger, R., Katrin Singler, & Maria
Cristina Polidori. (2018). Learning Geriatric
Medicine. Cham Springer International Publishing.
 Sinclair, A. J., Morley, J. E., & Vellas, B. (2012).
Pathy’s Principles and Practice of Geriatric
Medicine. John Wiley & Sons.
 Tallia, A. F., Scherger, J. E., & Dickey, N. (2021).
Swanson’s Family Medicine Review E-Book. Elsevier
Health Sciences.
 World Health Organization. (2015). Medication
safety in polypharmacy: Technical report.
https://apps.who.int/iris/bitstream/handle/10665/
181965/9789241509707_eng.pdf?sequence=1&isA
llowed=y
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Polypharmacy and Rational Prescribing in Elderly Patients.pptx

  • 2. By the end of this lecture, you should be able to: 1. Define POLYPHARMACY and its contributing factors. 2. Describe the Prevalence of Polypharmacy and its impact on older adults. 3. Discuss the Consequences of Polypharmacy, including adverse drug reactions and medication nonadherence. 4. Explore the Principles of Rational Geriatric Prescribing and their importance in preventing polypharmacy. 5. Explain the Deprescribing Process and its role in reducing the risk of adverse drug reactions and medication-related harm. Learning Objectives
  • 3. Introduction The elderly represent one of the fastest growing segments of the population and their use of medication is increasing significantly. The primary care physician plays an important role in addressing an array of pharmaceutical issues and concerns for elderly patients, including:  Polypharmacy.  Adverse drug reactions (ADRs).  Medications nonadherence.  Undertreatment of certain conditions.
  • 4. Prevalence  A large survey estimated that roughly 40% of elderly people take 5 or more medications.  Nearly, 1 in 20 of these patients risked a major drug–drug interaction.  Polypharmacy is estimated to cause 10% of hospital admissions in elderly people.  The WHO estimates that more than half of all medication-related hospital admissions in elderly people are preventable.  Polypharmacy is more common in women.  The number of medications used by older adults increases with age.
  • 5. What is polypharmacy ? Polypharmacy is typically defined as the prescription of five or more medications. It also refers to the prescription of medications that do not have a specific current indication, that duplicate other medications, or that are known to be ineffective for the condition being treated. In other words, polypharmacy is the use of multiple medications that are unnecessary and have the potential to do more harm than good.
  • 6. Factors leading to Polypharmacy in elderly Poor patient education. Multiple pathology. Attending multiple specialist clinics. Lack of routine review of medications. Poor communication between specialists. Self-treat with over-the-counter medications.
  • 7. Prescribing Cascade  Elderly people can be the victim of a harmful “Prescribing Cascade”.  This happened when an adverse drug effect is misinterpreted as a new medical condition, for which another drug is then prescribed, and this new medication in turn have adverse effects that result in further prescribing.  It adds an unnecessary burden to the patient’s already complicated medication regimen. Drug 1 Adverse drug effects misinterpreted as new medical condition Drug 2 Adverse drug effect
  • 9. Age-related Physiological Changes Knowledge of the physiologic changes that occur with aging is essential when prescribing medications to elderly patients. The changes can affect the way the body absorbs, distributes, metabolizes and eliminates drugs. These changes include increased body fat, decreased body water, decreased muscle mass, and changes in renal and liver function. These changes can cause ADRs in older people.
  • 10. Using multiple drugs at the same time doesn't always connote inappropriate prescribing; it can actually be reasonable. Often, 3 medications are needed to manage symptoms of heart failure or control high blood pressure to meet national guidelines. Patients with type 2 DM often require at least two medications for effective glucose control.
  • 11. Polypharmacy Consequences Polypharmacy recently became an important public health problem due to its many possible negative consequences, including: Risk of adverse drug reactions. Risk of medication nonadherence. Risk of multiple geriatric syndromes (e.g., cognitive impairment, impaired balance and falls). Risk of hospitalization and nursing home placement, and mortality. Increased health care utilization and costs.
  • 12. Adverse Drug Reactions An ADR is defined as any noxious, unintended, or undesired response to a therapeutic agent. They are at least twice as common in elderly patients as in younger patients. Polypharmacy is a major risk factor for ADRs. The probability of ADRs increases with the number of medications being taken. The three most common drug classes associated with ADRs in the elderly are cardiovascular drugs, psychotropic drugs, and NSAIDs. The orthostatic hypotension is potentially the most serious drug reaction. Always, consider an ADR as a cause of any new patient symptom.
  • 13. Types of ADRs  Side effects (dry mouth from tricyclic antidepressants and hypokalemia from diuretics).  Drug toxicity (GIT bleeding and renal dysfunction caused by NSAIDs, and cognitive impairment and falls caused by CNS depressants).  Drug-drug interaction (The combined therapy of anticoagulants and antiplatelet agents can increase the risk of bleeding).  Drug-disease interaction (drugs with anticholinergic properties may affect the cognitive function of patients with Alzheimer disease).  Drug withdrawal syndromes (beta blocker withdrawal leads to angina or tachycardia).
  • 14. Medication Nonadherence Forms of nonadherence include: Forgetting to take medication. Taking medication at the wrong dose. Taking medication at the wrong time. Incorrectly administering medications. Discontinuing medications prematurely. Medication Nonadherence refers to the failure of a patient to take medications as prescribed.
  • 15. Reasons for medication nonadherence Polypharmacy. Cognitive Impairment. Physical Impairment. Cost. Side Effects. Lack of Understanding. Forgetfulness. Lack of Social Support. Depression. Fear of dependence.
  • 16. Consequences of Medication Nonadherence Increased risk of morbidity and mortality. Reduced quality of life. Increased healthcare costs Increased burden on caregivers.
  • 17. Interventions to improve Medication Adherence Simplifying medication regimens. Use a medication that can treat multiple indications. Try to combine medications into single pills to reduce pill burden. Recommending low-cost or generic alternatives when appropriate. Educate the patient and caregiver. Using medication reminders, such as pillboxes, alarms, or smartphone apps. Regular medication reviews.
  • 18. Common geriatric presentations that can be caused by drugs Common geriatric presentations that can be caused by drugs
  • 19. Principles of Rational Geriatric Prescribing Individualization. Simplification. Avoidance of potentially inappropriate medications. Monitoring for adverse drug reactions. Consideration of non-pharmacologic interventions. Reasonable therapeutic goals. Consideration of cost and patient preferences. Monitoring parameters. Involvement of caregivers.
  • 20. Drug initiation in the elderly should be done cautiously. Avoid prescribing before a diagnosis is made. Review medications before adding a new medication. Start one medication at a time. For each medication, start very low and go very slow. Know the actions, adverse effects, and toxicity of the medications you prescribe. Attempt to maximize dose before switching to another. Guideline to initiate new drugs
  • 21. The Deprescribing process Review the patient’s medication: including prescription and over-the- counter medications, supplements, and vitamins. Assess the patient’s response to each medication. Develop a deprescribing plan: this may involve discontinuing certain medications, tapering the dose of certain medications, or switching to alternative medications. Monitor for any new symptoms or adverse effects that may arise, and adjust the plan as necessary. Involve the caregiver in the deprescribing process to ensure that it is safe and effective. The patient's preferences and goals for treatment are taken into consideration.
  • 22. Review Checklist for each medication Is there an indication for the medication? Is the medication effective for the condition? Is the dosage correct? Is the duration of therapy acceptable? Are the directions correct and practical? Are there clinically significant drug-drug interactions? Are there clinically significant drug- disease/condition interactions? Is there unnecessary duplication with other medication(s)? Is this medication the least expensive alternative?
  • 23. Rational Prescribing Tools A number of helpful prescribing tools for appropriate medication review in older adults: The Beers criteria developed by the American Geriatrics Society. STOPP (Screening Tool of Older Person's Prescriptions). START (Screening Tool to Alert to Right Treatment). MAI (Medication Appropriateness Index). ARMOR (Assess, Review, Minimize, Optimize, Reassess).
  • 24. Beers Criteria The Beers Criteria is a valuable tool for healthcare providers to assess and optimize medication use in older adults. It is developed by the American Geriatrics Society. It is an expert generated list of medications that are potentially inappropriate for use in older adults. The list is updated periodically according to the evidence-based recommendations. It can be helpful in reducing the risk of adverse drug events and improving patient outcomes. However, it is important to note that the criteria should not be used as a substitute for clinical judgement and individualized patient care.
  • 25. Medications that should be avoided in older adults. Medications that should be used with caution. Medications requiring dose adjustment in older adults with specific medical conditions. Medications that may need to be replaced with safer alternatives. Recommendations of Beers Criteria The Beers Criteria includes recommendations regarding:
  • 27. Improving drug therapy in elderly patients: The Garfinkel Algorithm
  • 28.  Polypharmacy is common among older adults and can lead to adverse drug events, increased healthcare costs, and decreased quality of life.  Rational prescribing and deprescribing processes are essential for optimizing medication use in this population.  These processes involve evaluating medications for appropriateness, safety, and effectiveness, and discontinuing or reducing unnecessary medications.  Incorporating these processes into clinical practice can lead to better health and quality of life for older adults.
  • 29. REFERENCES  American Geriatrics Society. (2019). American Geriatrics Society 2019 Updated AGS Beers Criteria(R) for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society, 67(4), 674-694.  Chang, A. (2020). Current Diagnosis and Treatment: Geriatrics, 3/e. McGraw Hill Professional.  Endsley, S. (2018). Deprescribing Unnecessary Medications: A Four-Part Process. Family Practice Management, 25(3), 28–32.  Evidence-Based Geriatric Nursing Protocols for Best Practice. (2020). Springer Publishing.  Fillit, H., Rockwood, K., & Young, J. (2017). Brocklehurst’s textbook of geriatric medicine and gerontology. Elsevier.  Fulmer, T. T., & Chernoff, B. (2019). Handbook of geriatric assessment. Jones & Bartlett Learning.  Ham, R. J. (2014). Ham’s primary care geriatrics: a case- based approach. Saunders.  Kim, L. K., Koncilja, K., & Nielsen, C. (2018). Medication management in older adults. Cleveland Clinic Journal of Medicine, 85(2), 129–135.  Kwan, D., & Farrell, B. (2014). Polypharmacy: optimizing medication use in elderly patients.  Lee, A. G., Potter, J. F., & G. Michael Harper. (2021). Geriatrics for Specialists. Springer Nature.  Rakel, R. E., & Rakel, D. (2016). Textbook of family medicine. Elsevier Saunders.  Roller-Wirnsberger, R., Katrin Singler, & Maria Cristina Polidori. (2018). Learning Geriatric Medicine. Cham Springer International Publishing.  Sinclair, A. J., Morley, J. E., & Vellas, B. (2012). Pathy’s Principles and Practice of Geriatric Medicine. John Wiley & Sons.  Tallia, A. F., Scherger, J. E., & Dickey, N. (2021). Swanson’s Family Medicine Review E-Book. Elsevier Health Sciences.  World Health Organization. (2015). Medication safety in polypharmacy: Technical report. https://apps.who.int/iris/bitstream/handle/10665/ 181965/9789241509707_eng.pdf?sequence=1&isA llowed=y