Appropriate Medication Use in the Elderly

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Appropriate Medication Use in the Elderly

• Mary T. Roth, PharmD, MHS
• Assistant Professor, School of Pharmacy
• and Division of Geriatric Medicine
• mroth_at_unc.edu

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Objective

• Identify common drug-related problems in the
  elderly
• Recognize medications that are considered
  potentially inappropriate in older adults
• Recognize medications that are appropriate for
  older adults, but often underused or used
  inappropriately

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Medication Use in the Elderly

• 33 of all prescription drugs are consumed by the
  elderly
• 90 of elderly take gt 1 medication regularly
• Average older person uses 4.5 prescription
  medications concurrently and an additional 2 OTC
  medications
• Elderly consume 50 of all OTC medications
• 50 (likely even higher) of all elderly Americans
  use herbal products
• Mean number of prescriptions/pt./year13-17
• Nonadherence rates hover around 50
• Nearly 1/3 of Medicare recipients lack
  prescription drug coverage and must pay
  out-of-pocket

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Drug-Related Problemsin the Elderly

• Polypharmacy (too many drugs or use of drugs with
  no indication)
• Undertreatment/Underuse
• Inappropriate prescribing (wrong drug)
• Nonadherence (failure to receive or take
  medications)
• Inappropriate regimen (dose too high or too low)
• Adverse drug events

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Beers Criteria Arch Intern Med
20031632716-2724

• A list of potentially inappropriate medications
  in the elderly
• Updated periodically
• Used in research, teaching, and practice

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Pain ManagementThe biggest problem with pain
management is inadequate management

• AVOID propoxyphene products or combinations
  (e.g., Darvon, Darvocet-N)
• Offers few analgesic advantages over Tylenol and
  is often poorly tolerated in the elderly
• Higher incidence of CNS adverse effects
• Prescribing directions often wrong
• AVOID ketorolac (Toradol) GI adverse effects
• AVOID meperidine (Demerol) not effective in
  normal doses when given orally may cause
  confusion, eliminated renally

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Pain Management

• NSAIDS
• AVOID Indomethacin, has the most CNS adverse
  effects
• AVOID chronic use of full dose long-half life
  agents naproxen, oxaprozin, piroxicam can lead
  to GI bleeding, kidney failure, uncontrolled
  blood pressure, and heart failure
• NSAIDs and COX-IIs monitor BP, serum creatinine,
  GI
• OA most common chronic disease in elderly
• Tylenol, NSAIDs, COX-II inhibitors, Glucosamine,
  Opiods, Corticosteroids

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Glucosamine

• Glucosamine for osteoarthritis...1500 mg per day
• Glucosamine takes 4 to 8 weeks to relieve pain
• Continue Tylenol or an NSAID for the first month
  or two if needed
• Advise patients its NOT necessary to take a
  supplement that also contains chondroitin
• Combo products usually cost more...and theres no
  evidence they work better than glucosamine alone

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Hypertension (primarily ISH)

• Hydrochlorothiazide
• Preferred agent in elderly for treatment HTN
• Dosing is 12.5 to 25 mg QD
• No additional BP lowering benefit from 50 mg QD
• Increase in adverse effects hypokalemia,
  hyponatremia, hyperuricemia, hyperglycemia
• Ineffective at Srcr lt 30 ml/mindo NOT use.
• Use with caution in gout and significant
  hyponatremia

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Hypertension

• Beta blockers
• Reduced effectiveness in the elderly due to
  changes in beta receptor sensitivity (primarily
  reserved for use in treatment of heart failure,
  post-MI)
• Propranolol penetrates blood brain barrier,
  highly lipophilicCNS adverse effects
• Metoprolol moderate lipophilicity, extensive
  metabolism in liver
• Atenolol low lipid solubility, eliminated
  primarily by kidney (adjust dose in renal
  impairment)
• Generally avoid beta blockers in asthma,
  restrictive airway disease, second or third
  degree heart block

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Hypertension

• ACE Inhibitors/Angiotensin Receptor Blockers
• GREAT drugs, but monitor serum creatinine and
  potassium!
• Dihydropyridine Calcium Channel blockers great
  for ISH
• Amlodipine, felodipine, long-acting nifedipine
• Nondihydropyridines not effective for ISH and
  increase adverse effects
• Diltiazem
• Verapamil constipation

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Hypertension

• Alpha blockers
• Fallen out of favor since ALLHAT trial (increase
  in heart failure in doxazosin arm)
• Often poorly tolerated (e.g., syncope, dizziness,
  lightheadedness)
• May be used in men with BPH if can tolerate
• AVOID pseudoephedrine

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Other Cardiovascular Drugs

• Digoxin
• Dose rarely should exceed 0.125 mg po QD, unless
  treating atrial arrhythmias
• Elderly may not manifest signs/symptoms of
  digoxin toxicity therefore, monitor serum cr
  regularly
• Statins
• Lasix
• Not an effective antihypertensive due to short
  half life

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Hypertension Guidelines

• HTN occurs in more than 2/3 of all individuals
  over the age of 65 AND this is the population
  with the LOWEST rates of blood pressure control!
• Pre-hypertension 120/80-139/89
• Lifestyle modifications should be initiated in
  all patients (90 will go on to develop HTN)
• For patients with HTN (BP 140/90 or higher) start
  treatment with drugs immediately regardless of
  stage
• Important to treat SBP, especially in the elderly
• May need to start with lower doses, but will
  likely require more than one drug to reach goal
  BP
• Watch for orthostatic hypotension (change in SPB
  of 10 mm Hg)

http//www.nhlbi.nih.gov/guidelines/hypertension/
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Hypertension Guidelines

• With the exception of persons who are post-MI or
  have chronic renal insufficiency, diuretics
  (HCTZ, chlorthalidone) are recommended and
  preferred.
• A two-drug combination, which should include a
  diuretic, is recommended for those with a BP over
  160/100.
• DBP should not be reduced to less than 65 mmHg in
  elderly patients (J-curve phenomenon).

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Typically avoid use of alpha blockers
(hypotension, dizziness) and clonidine (CNS
adverse effects) JNC 7 Report, JAMA
20032892560-2572
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Hypertension Guidelines

• Goal Blood Pressures
• 140/90 for most people
• 130/80 for anyone with diabetes, chronic renal
  insufficiency, or nephropathy, which is defined
  as a creatinine clearance of less than 60 ml/min.
• Same goals in elderly UNLESS signs/symptoms of
  hypotension are present, then control BP to the
  goal possible in the individual

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An Aspirin A Day Primary Prevention

• The third United States Preventive Services Task
  Force "strongly recommends" that clinicians
  discuss aspirin chemoprevention in adults who are
  at increased risk for CVD, defined as a 10 year
  risk of 6 percent or greater
• The American Heart Association guidelines for
  primary prevention recommend aspirin prophylaxis
  in all individuals with a ten-year risk of
  cardiovascular disease of 10 percent or more

• http//www.nhlbi.nih.gov/guidelines/cholesterol/
  profmats.htm

Circulation 2002 106388
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An Aspirin A Day Primary Prevention

• The Sixth American College of Chest Physicians
  (ACCP) Consensus Conference on Antithrombotic
  Therapy concluded that routine aspirin therapy
  was not recommended for primary prevention in
  people free of a history of MI, stroke, or TIA
  who are less than 50 years of age
• Aspirin should be considered for men or women
  more than 50 years of age who have at least one
  risk factor for coronary heart disease (eg,
  cigarette smoking, hypertension, diabetes, high
  cholesterol level, and family history of MI) and
  have no contraindication to aspirin.

Benefits of aspirin use must always be weighed
against the potential harm, the most concerning
of which is hemorrhagic stroke.
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An Aspirin A Day Diabetes

• Use aspirin therapy therapy (75162 mg/day) as a
  primary prevention strategy in men and women with
  type 1 and type 2 diabetes at increased
  cardiovascular risk, including those over 40
  years of age or who have additional risk factors
  (family history of CVD, hypertension, smoking,
  dyslipidemia, albuminuria).
• Use aspirin therapy (75162 mg/day) as a
  secondary prevention strategy in diabetic men and
  women with a history of MI, vascular bypass
  procedure, stroke or TIA, PVD, claudication,
  and/or angina.

http//care.diabetesjournals.org/content/vol27/sup
pl_1/
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Stroke Prevention

• Primary Prevention
• Lack of data
• Secondary Prevention
• Aspirin 50-325 mg po QD
• Plavix 75 mg po QD (recent MI, stroke, PVD, ACS)
• Aggrenox (ASA 25 mg/ER dipyridamole 200 mg) po
  BID
• Warfarin (PREFERRED in pts. with afib)
• Combination therapy Aggrenox more effective than
  aspirin alone for prevention of stroke
• AVOID Ticlid

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Clinical Pearl

• In using ASA for cardioprotection and an NSAID
  for analgesic effects, administer the ASA first,
  making sure that the NSAID had not been given for
  at least the past 6 hours. Do not administer the
  NSAID until 2 hours after the ASA is taken.
• NO NSAID within 6 hours prior to ASA dose
• GIVE ASA
• GIVE NSAID 2 hours later

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Sedatives and Hypnotics

• Anxiolytics (e.g., Benzodiazepines)
• AVOID long-acting agents (e.g., Librium,
  Valium)
• If benzo required, short- or intermediate acting
  agent preferred (e.g., Ativan, Xanax, Serax)
• With short-acting agents, doses should be limited
  (e.g., Ativan 3 mg po QD see Beers criteria).
• Sedative Hypnotics
• AVOID long-acting agents (e.g., flurazepam,
  Dalmane)
• If needed, use shorter-acting agents (e.g.,
  temazepam, Restoril)

AVOID may lead to prolonged sedation, increase
in falls, confusion, dizziness, etc.
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Sedatives and Hypnotics

• AVOID diphenhydramine-containing products (e.g.,
  Benadryl, Tylenol PM) due to anticholinergic and
  antihistaminic adverse effects dry mouth, dry
  eyes, urinary retention, constipation, confusion,
  sedation, dizziness
• DO NOT USE diphenhydramine for sleep!
• OTHER OPTIONS
• Zaleplon (Sonata) onset 10-20 minutes lasts
  2-4 hours
• Zolpidem (Ambien) onset 30 minutes lasts 6-8
  hours, sometimes longer
• Do USE Trazodone (Desyrel) preferred sleep
  agent in the elderly very sedating, but very
  little anticholinergic adverse effects

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Depression

• Tricyclics
• AVOID amitriptylline strong anticholinergic
  properties
• In general, TCAs no longer preferred
  antidepressants
• SSRIs
• AVOID fluoxetine (Prozac) long half-life causes
  increased CNS stimulation, sleep disturbances,
  and agitation
• Bupropion (Wellbutrin, Wellbutrin XL, )
• Can be used in the elderly. Should give in AM,
  since drug is very stimulating and may cause
  insomnia
• Venlafaxine (Effexor)
• Effective antidepressant and antianxiety agent
• Monitor BP when using higher doses

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Depression

• Trazodone
• Rarely used as an antidepressant (preferred sleep
  agent!)
• Mirtazapine (Remeron)
• Effective, but can cause sedation, increased
  appetite, weight gain
• Nefazodone (Serzone)
• AVOID new black box warning in 2003 linked to
  liver failure, live transplants, and death
• LFT monitoring does not seem to prevent cases of
  hepatotoxicity
• Doxepin (Sinequan)
• AVOID strong anticholinergic properties

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Paxil, Paxil, and more Paxil

• Paxil (paroxetine hydrochloride) - 77.99 for
  30 day supply
• Generic paxil, 2 products available (less than
  10 savings)
• Paroxetine HCl 70.99 for 30-day supply
• Paxil CR not longer acting. Is enteric coated
  and controlled release. Claim to fame reduces
  incidence of nausea.
• Pexeva (paroxetine mesylate) - costs 30-40
  less than Paxil BUT not equivalentno
  head-to-head trials to date.

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Dementia

• Donepezil (Aricept)
• QD
• More selective, so fewer side effects. Mostly
  diarrhea and nausea. Start at 5 mg once daily for
  4-6 weeks, then increase to 10 mg once daily
• Rivastigmine (Exelon)
• BID
• Causes the most GI problems (nausea, severe
  vomiting)
• Galantamine (Reminyl)
• BID
• Falls in the middle of Aricept and Exelon
• AVOID Tacrine (Cognex) hepatotoxicity
• Memantine (Namenda)

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Psychoses

• Atypical antipsychotics
• Risperidone (Risperdal)
• Olanzapine (Zyprexa)
• Ziprasidone (Geodon)
• Quetiapine (Seroquel) less EPS compared to
  risperidone and olanzapine
• These drugs may contribute to orthostatic
  hypotension
• An Increase Risk of Stroke (and increase in
  mortality) in Elderly Patients with Dementia?!!!
• Reported with risperidone and olanzapine
• If antipsychotic needed, may be best to use
  quetiapine

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Medications that Increase Fall Risk

• Benzodiazepines (short and long-acting agents)
• Antidepressants (tricyclics and SSRIs)
• Use caution with other agents as well
• Opiods
• Anticholinergics
• Anticonvulsants
• Others

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Other Drugs Making the Beers List

• Muscle relaxants and antispasmodics
• Short-acting oxybutynin (Ditropan)
• Cyclobenzaprine (Flexeril)
• Carisoprodol (Soma)
• Methocarbamol (Robaxin)
• Ferrous sulfate
• Doses greater than 325 mg po QD do not
  significantly increase absorption, but do
  significantly increase constipation
• Long-term stimulants may worsen bowel
  dysfunction
• OK to use long-term in the presence of opiate
  analgesic use
• Cimetidine (Tagamet)
• Amiodarone (Cordarone)
• Nitrofurantoin (Macrodantin) possible renal
  impairment
• ORAL estrogen replacement therapy increased risk
  of breast and endometrial cancer, thrombotic
  events, etc. Risks do not outweigh benefits.
• Otherssee Beers list

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Recommended Resources

• Lexi-Comps Geriatric Dosage Handbook
• Lexi-Comp
• Micromedex
• The Beers criteria
• UpToDate