Herbal Medicines and Aging

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Sponsored by The National Council on the Aging
and CareSource
Healthy Aging Briefing Series
Medication Use and Older Adults Maximizing the
Benefits, Avoiding the Risks
WELCOME
This session will begin promptly at 130pm
ESTPlease mute your phonePersonal
introductions are not necessaryThe moderator
will be on the line shortly
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Dont Forget Your Free Copy of Aging in Stride
NCOA and Caresource are pleased to offer
first-time registrants for this Healthy Aging
Briefing Series a complimentary copy of the book,
Aging in Stride. To receive your copy, please
visit www.AgingInStride.org/NCOAoffer. Or just
email service_at_caresource.com with your name,
title, organization, mailing address, phone
number, and date of the Briefing you participated
in. One free copy per registrant, please.
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Kathleen Cameron, RPh, MPHConsultant Pharmacist

• Kathleen Cameron is currently a consultant on
  issues regarding medication use in
• the geriatric population, prescription drug
  benefits, aging, disability, and long-
• term care. Ms. Cameron was previously the
  Executive Director of the American
• Society of Consultant Pharmacists (ASCP) Research
  and Education Foundation, a
• position she has held from January 2001 to
  December 2004. 
• Prior to joining the ASCP Foundation, Ms. Cameron
  was Associate Director of
• Health Promotion at the National Council on the
  Aging and also served as Deputy
• Director for a 3 million national grants program
  funded by the Robert Wood
• Johnson Foundation to improve home and
  community-based services for older
• persons and individuals with disabilities.  Ms.
  Cameron worked as a community
• pharmacist for five years before entering
  graduate school. 
• Ms. Cameron received her Masters of Public
  Health from Yale University and her
• Bachelor of Science degree in pharmacy from the
  University of Connecticut.

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Medications are probably the single most
important health care technology in preventing
illness, disability, and death in the geriatric
population. Avorn J. Medication use and the
elderly current status and opportunities.
Health Affairs 1995, Spring
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New Medicines in Pipeline for Older Americans

• 800 drugs in development
• 123 Heart Disease and Stroke
• 395 Cancer
• 11 - Depression
• 18 - Osteoporosis
• 53 - Diabetes
• 22 - Alzheimers Disease/Other Dementias
• 14 - Parkinsons Disease

Source Selected Medicines in Development for
Older Americans, PhRMA, 2004.
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Medication Use and Seniors

• 90 of seniors take medication on a daily basis
• Nearly half (46) take five or more
• More than half (54) have more than one doctor
  who prescribes medications
• About one-third (35) use more than one pharmacy
• Among seniors with at least three chronic health
  conditions
• Nearly three of four (73) take five or more
  medications regularly
• More than half (52) do not take all their drugs
  as prescribed

Source Safran DG et al. Prescription Drug
Coverage And Seniors Findings From A 2003
National Survey. Health Affairs, 2005.
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Why are Seniors at Risk for Medication-Related
Problems?

• Multiple chronic diseases
• Multiple prescribers
• Multiple medications
• Increase use of high-risk medications
• Changes in drug metabolism and elimination
• Changes in the way the body responds to
  medications
• Shortage of trained professionals in geriatric
  pharmacotherapy
• Under representation in clinical trials

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Medication-Related Problems

• Medical condition that requires new or additional
  medication therapy
• Patient taking unnecessary medication given
  present condition
• Wrong medication for patients medical condition
• Correct medication, Dose too low
• Correct medication, Dose too high
• Patient not taking medication correctly
• Adverse drug events

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Economic Impact of Medication-Related Problems

• 76.6 billion - ambulatory care1
• 20.0 billion - acute care2
• 4.0 billion - nursing home care3
• Cost of MRPs 100.6 billion

Sources 1 - Bootman L, et al, Arch Internal Med,
1995 2 - Bates, et al, JAMA, 1995
3 - Bootman L, et al, Arch Internal
Med, 1997
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Medication-Related Problems are Preventable

• 62 of hospital admissions are due to preventable
  adverse drug reactions
• (McDonnell et al., Ann Pharmacother
  2002361331-6.)
• 46-80 of ED visits related to MRPs in 65 yo are
  preventable
• nonadherence
• inappropriate prescribing or monitoring
• lack of patient counseling
• specific medication use (NSAIDs, cardiovascular)
• (Gurwitz, JAMA 20032891107-16 McDonnell 2002
• Tafreshi 1999 Hanlon 1997 Dennehy, AJHP
  1996531422-6)

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"Any symptom in an elderly patient should be
considered a drug side effect until proved
otherwise." J Gurwitz, M Monane, S Monane, J
Avorn Brown University Long-term Care Quality
Letter 1995
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Symptoms of MRPs

• Confusion
• Depression
• Delirium
• Insomnia
• Parkinsons-like symptoms

• Incontinence
• Weakness or lethargy
• Loss of appetite
• Falls
• Changes in speech

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Potentially Inappropriate Medications in Seniors

• GI antispasmodics (Bentyl)
• Meperidine, oral (Demerol)
• Methyldopa (Aldomet)
• Pentazocine (Talwin)
• Ticlopidine (Ticlid)
• Amitriptyline (Elavil)
• Chlorpropamide (Diabenese)
• Digoxin 0.125 mg/day (unless for arrhythmia)
• Disopyramide (Norpace)
• Doxepin (Sinequan)

Source Beers et al. Arch Intern Med, 1997.
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Other High Risk Medications

• Warfarin (Coumadin)
• Cimetidine (Tagamet)
• NSAIDs
• Antihpertensives
• Antipsychotics
• Anti-anxiety agents
• Sedative/hypnotics

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Ways of Identifying the Problem Patient

• Medication history/observation
• Excessive use of medications
• Use of high risk medications
• Medication errors
• Information from family or caregivers can be very
  valuable
• Patient medication profile
• Brown bag program
• Computer assisted

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Safe Prescribing for Seniors

• Research - include older persons in clinical
  trials
• Diagnosis - is the medication really needed?
• Choice of medication considerations
• Efficacy, quality of life, drug interactions,
  cost, adverse effects, ease of administration,
  disease interactions
• Dose - start low, go slow, but dont stop too
  soon
• Clearly define therapeutic endpoints

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Streamlining Medication Therapy in Older Persons

• Evaluate for appropriate indication
• Evaluation of concurrent diagnoses
• Consider possible drug interactions
• Consider possible adverse drug reactions
• Consider the patient
• Consider risk vs. benefit
• Consider simplification of therapy
• Is monotherapy an option?
• Drugs with multiple indications
• New dosage forms
• New drugs with incremental advantages
• Consider monitoring criteria

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Important Questions to Ask About Medications

• For new therapy
• Why is this drug being prescribed?
• What is the goal of therapy with this drug?
• When should we expect the attainment of this
  goal?
• What non-drug options could we consider?

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Important Questions to Ask About Medications

• For ongoing therapy
• Is there still a need for this drug?
• Specifically, why is there still a need for this
  drug?
• What non-drug options could be considered?
• Could any of the patient's symptoms be caused by
  the drug?

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Senior Care is Interdisciplinary Care

• Complex multifaceted health problems include
  medical/psychosocial/economic issues
• Understanding of the role of each team member is
  crucial
• Members of the senior care team are skilled in
  their respective areas
• Team activities are prospective and ongoing
• Everyone plays a role in drug therapy!

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Role of Aging Network

• Aging network providers have access to older
  adults
• Frontline position
• Role in helping to prevent problems
• Identify at-risk seniors for medication concerns
• Link seniors in need with senior services, e.g.,
  senior care pharmacists
• Help seniors age in place

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Case Manager Referral Program

• 8 or more medications
• Side effects
• Poor adherence with medication regimen
• Discharge from the hospital with two or more new
  medications
• Falls
• Depression
• Decline in physical, cognitive, or behavioral
  functioning

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Pharmacist Role

• 10-20 client visits per week
• Initial visits Two 60 minute visits
• Follow-up visit within one month
• Researches clients medication regimens and
  conditions
• Documentation of findings and recommendations
• Prepares letters to physicians about needed
  modifications to regimens
• Follows client until problems have been addressed
  and client is stable
• In-service education for case managers

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Home Visits With Client and Caregiver

• Medical history
• Medication history
• Examines all medicines
• Modified Medication Appropriateness Index
• Assesses client knowledge
• Assesses dexterity and pain that can prevent
  proper use of medications
• Storage of medications
• Assesses environment for falls hazards
• Education about medications, diet, smoking
  cessation, osteoporosis

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Additional Resources

• American Society of Consultant Pharmacists
  www.ascp.com
• www.seniorcarepharmacist.com (inlcudes a natl
  directory of senior care pharmacists)
• FDA www.fda.gov/oc/seniors/
• NIHSeniorHealth.gov
• National Council on Patient Information and
  Education www.talkaboutrx.org
• Kaiser Family Foundationwww.kff.org

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QUESTIONS?
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Dont Forget Your Free Copy of Aging in Stride
NCOA and Caresource are pleased to offer
first-time registrants for this Healthy Aging
Briefing Series a complimentary copy of the book,
Aging in Stride. To receive your copy, please
visit www.AgingInStride.org/NCOAoffer. Or just
email service_at_caresource.com with your name,
title, organization, mailing address, phone
number, and date of the Briefing you participated
in. One free copy per registrant, please.