Geriatric Pharmacotherapy: ACOVE Indicators Module Development by Lynne E' Kallenbach M'D'

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Geriatric PharmacotherapyACOVE
IndicatorsModule Development by Lynne E.
Kallenbach M.D.
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Objectives

• Address issues of medication use in vulnerable
  older adult population
• - Physiologic changes with aging
• - Adverse drugs effects polypharmacy
• Identify specific quality indicators for
  medication management in older adults
• ACOVE indicators

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ACOVE Indicators

• Assessing Care of Vulnerable Elders (ACOVE) from
  RAND Health/collaborators
• 236 if/then indicators in 4 domains
• 43 indicators re pharmacologic care
• Medication Quality Indicators
• - Prescribing indicated medications
• - Avoiding inappropriate medications
• - Education, continuity, and documentation
• - Medication monitoring

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What does this mean for us?

• As residents proceed through training, awareness
  of quality indicators is critical
• - Intended for betterment of patient care
• - On individual level, may be tied to
  re-imbursement
• - On institutional level, may be tied to
  accreditation /or public perception of your
  hospital

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What does this mean for us?

• Nearly all primary care and specialty physicians
  will have contact with older adults, and many
  will write prescriptions for them
• Many of these medications can have unintended
  consequences

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Why Geriatric Pharmacotherapy Is Important

• Now, people age 65 are 13 of US population, buy
  33 of prescription drugs
• By 2040, will be 25 of population, will buy 50
  of prescription drugs

Adapted from Geriatrics Review syllabus 6th
edition teaching slides
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Pharmacokinetics

• Absorption
• Distribution
• Metabolism
• Elimination
• Altered by changes in body make-up
• Decreased lean mass, relatively increased fat

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Aging and Absorption

• Actual amount absorbed not changed
• Peak concentrations may be altered
• May be affected by co-morbid conditions or other
  medications or vitamins

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Aging and Volume of Distribution

• ? body water ? lower Vd for hydrophilic drugs
• ? fat stores ? higher Vd for lipophilic drugs
• ? plasma protein (albumin) ? higher percentage of
  drug that is unbound (active)

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Aging and Metabolism

• Metabolism may be reduced because
• Decrease in liver blood flow, size, mass
• - liver is the most common site of drug
  metabolism
• But cannot easily estimate effect of these
  changes
• Phase II pathways generally preferable for older
  patient

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Aging and Elimination(or you and your kidney)

• ? kidney size
• ? renal blood flow
• ? number of functional nephrons
• ? renal tubular secretion
• Lower glomerular filtration rate

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Serum Creatinine Does Not Clearance

• ? lean body mass ? lower creatinine production
  ? glomerular filtration rate (GFR)
• Estimation for CrCl with Cockcroft Gault
  equation

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Pharmacodynamics

• Definition Intensity time course of the effect
  of a drug
• Examples
• Benzodiazepines may cause more sedation and worse
  psychomotor performance in older adults.
• Older patients may experience higher levels of
  morphine with longer pain relief

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Decreased homeostatic reserve

• Impacts ability to tolerate medications
• Postural hypotension
• Fluid and electrolyte problems
• Response to hypoglycemia
• Temperature/sweating regulation

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Medication Use Issues with Multiple
Prescriptions (and OTCsherbalsetc)
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What is polypharmacy?

• As older patients move through time, often from
  physician to physician, they are at increasing
  risk of accumulating layer upon layer of drug
  therapy, as a reef accumulates layer upon layer
  of coral.
• Jerry Avorn, MD
• From Gurwitz J. Arch Intern Med Oct 11, 2004

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General types of medication-related problems

• Unnecessary drug
• Not prescribing new needed Rx
• Contraindicated drug
• Dose too low or too high
• Adverse drug event
• Nonadherence
• From Williams CM, Am Fam Phys Nov 15, 2002

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Medications Accounting for Most ADEs in Older
Adults

• Cardiovascular medications
• Psychotropic medications
• Anticoagulants
• Antibiotics
• NSAIDS
• Anti-seizure medications

(JAGS 2004521349-1354 and NEJM 20033481556-64)
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The Extent of Injuries From Medications
JAGS 199745945-948 JAGS 199644194-197 Am
Pharm Assoc 200242847-857

• ADEs are responsible for 5 to 28 of acute
  geriatric hospital admissions
• Adapted from Geriatric Review Syllabus 6th
  edition, teaching slides

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Multiple Medications

• Complexity of regimen reduces adherence
• Drug interactions
• Adverse drug reactions contribute to
  hospitalization in 25 of persons 80 yr
• Drug-induced problems can mimic geriatric
  syndromes
• Prescribing cascade phenomenon
• Williams CM, Am Fam Phys Nov 15, 2002

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Prescribing Cascade

• Misinterpretation of an adverse drug reaction as
  a symptom of another condition? prescribing of
  another Rx
• Important to ask about ALL medications, not just
  the prescription ones
• Example
• Persons receiving a cholinesterase inhibitor had
  gt50 increase risk for subsequent anticholinergic
  drug for incontinence
• Gill et al. Arch Intern Med 2005, April 11

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Characteristics of Older Adults with
Medication-related Problems

• 85 years and older
• 6 or more active chronic conditions
• Estimated creat clearance lt 50 ml/min
• Low body weight
• Nine or more medications
• More than 12 doses of medication daily
• Previous adverse drug reaction
• From Williams CM, Am Fam Phys 2002, adapted from
  Fouts, Consult Pharm, 1997

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And now, for the rest of the story.

• Under-utilization of effective therapies in older
  adults is widespread

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Polypharmacy A New Paradigm for Quality Drug
Therapy in the Elderly

• Under-use of beneficial Rx in older adults
• ACE-I in CHF
• Anticoagulants in Afib
• Antiresorptive Rx in osteoporosis
• Disease management guidelines often favor more
  than one Rx for a condition
• Gurwitz J. Arch Intern Med 2004, Oct 11
• And an ARB makes nine polypharmacy in patients
  with heart failure
• Clev Clinic J Med Aug 2004

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Potentially Inappropriate Medication Use
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Inappropriate Medications in Older Adults
Beers List

• potentially or generally inappropriate
• suboptimal prescribing
• Overall risks outweigh potential benefits
• May be ineffective and/or poorly tolerated
• May be justified in some circumstances
• Controversial
• expert opinion
• Limited evidence-base for many drugs

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Beers List Two Groups of Drugs

• Unconditionally inappropriate
• Generally best avoided regardless of
  circumstances
• Some are considered more high risk than others
• Conditioned upon disease state or dose
• May only be inappropriate in specific context

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Beers List Selected Highlights 1997

• Propoxyphene (but not included in Rx review
  guidelines for NH)
• Indomethcin, phenylbutazone, pentazocine
• Digoxin above 0.125 mg except for atrial
  arrythmia
• Muscle relax/antispasmodics, including ditropan
• Flurazepam
• Amitriptyline combinations doxepin
• Dipyridamole
• Meperidine
• Ticlopidine
• GI antispasmodics
• Nonprescription and many Rx antihistamines
• Methyldopa
• Chlordiazepoxide, diazepam

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Updates to Beers List in 2003 (selected
additions since 1997)
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2003 selected conditionally inappropriate by
disease state
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Potentially Inappropriate Medications for Older
Persons

• High Potential for Severe ADEs
• Amitriptyline
• Chlorpropamide
• Digoxin gt 0.125 mg/day
• Disopyramide
• GI antispasmodics
• Meperidine
• Methyldopa
• Pentazocine
• Ticlopidine

• High Potential for Less Severe ADEs
• Antihistamines
• Diphenhydramine
• Dipyridamole
• Ergot mesylates
• Indomethacin
• Meperidine, oral
• Muscle relaxants

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Medication Appropriateness Index

• Another formalized assessment tool
• - based on evaluation of 10 criteria
• indication effectiveness
• dosage expense
• duration duplication
• drug-disease interaction
• drug-drug interaction
• directions correctness
• directions practicality

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Approach to the Older Patient with Multiple
Medications
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Approach to Multiple Medications

• Brown bag med review at least annually
• Including herbals and OTCs
• Determine clinical indication for each
• Motto One disease, one drug, once daily
• Avoid the prescribing cascade
• Eliminate drugs without benefit or indication
• Substitute less toxic drugs where able
• From Carlon JE, Geriatrics, 1996 5126-30

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Regulatory Scrutiny

• Mandated drug review already in LTC
• Provider profiling increasingly common
• Pay for performance models
• Patient satisfaction monitoring
• Increasing use of electronic records

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ACOVE Indicators

• Medication Quality Indicators
• - Prescribing indicated medications
• - Avoiding inappropriate medications
• - Education, continuity, and documentation
• - Medication monitoring

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Higashi, T. et. al. Ann Intern Med
2004140714-720
Medication Quality Indicators, Number of Eligible
Patients, and Pass Rates
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ACOVE Indicators

• Hospital indicators
• - All vulnerable older adults should not be
  prescribed a medication with strong
  anticholinergic side effects if alternatives are
  available
• - If a vulnerable older adult is prescribed a
  new drug, THEN the prescribed drug should have a
  clearly defined indication documented in the chart

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ACOVE Indicators

• Ambulatory indicators
• - All vulnerable older adults should not be
  prescribed a medication with strong
  anticholinergic effects if alternatives are
  available
• - If a vulnerable older adults is prescribed a
  new drug, THEN the patient (or caregiver) should
  receive education about the purpose of the new
  drug, how to take it, and the expected side
  effects or important adverse reactions

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ACOVE Indicators

• Ambulatory indicators, contd
• - If a vulnerable older adult is prescribed a
  new drug, THEN the prescribed drug should have a
  clearly defined indication documented in the
  record
• - Every new drug that is prescribed to a
  vulnerable older adult on an ongoing basis for
  chronic medical condition should have a
  documentation of response to therapy within 6
  months

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ACOVE Indicators

• Ambulatory indicators, contd
• - If a vulnerable older adult is newly started
  on a diuretic, THEN serum potassium and
  creatinine levels should be checked within 1
  month of initiation of therapy
• - If a vulnerable older adult is prescribed a
  thiazide or loop diuretic, THEN s/he should have
  electrolyte levels checked at least yearly
• - If a vulnerable older adult is newly started
  on an ACE inhibitor, THEN serum potassium and
  creatinine levels should be checked within 1
  month of the initiation of therapy

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ACOVE Indicators

• Ambulatory indicators, contd
• - If a vulnerable older adult is prescribed
  warfarin, THEN an INR should be determined within
  4 days after initiation of therapy
• - If a vulnerable older adult is prescribed
  warfarin, THEN an INR should be determined at
  least every six weeks

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Principles of Prescribing for Older Patients
the Basics

• Start low, go slow
• Avoid starting 2 drugs at the same time
• Is it necessary?
• Has the patient been educated about the drug and
  its potential side effects?
• Is the drug being appropriately monitored?

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The patient, treated on the fashionable theory,
sometimes will get well in spite of the
medicine. Thomas Jefferson 1807
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Additional References

• Barber N, Bradley C et al. Measuring the
  appropriateness of prescribing in primary care
  are current measures complete? Journal of
  Clinical Pharmacy and Therapeutics, 30 533-539.
• Blackstone K and Cobbs E, co-editors, Geriatric
  Review Syllabus 6th ed. Teaching slides
• Curtis L, Ostbye T et al. Inappropriate
  Prescribing for Elderly Americans in a Large
  Outpatient Population, Archives of Internal
  Medicine, Vol. 164 1621-1625, Aug 9, 2004.
• Fick D, Cooper J et al. Updating the Beers
  Criteria for Potentially Inappropriate Medication
  Use for older Adults, Archives of Internal
  Medicine, Vol. 16 2716-2724, Dec 8 2003.
• Field T, Gurwitz J et al. Risk Factors for
  Adverse Drug Events Among Older Adults in the
  Ambulatory Setting, Journal of the American
  Geriatrics Society, 521349-1354, Aug. 2004.
• Gandhi T, Weingart S et al. Adverse Drug Events
  in Ambulatory Care, New England Journal of
  Medicine, 346, 1556-1564 April 17, 2003.
• Higashi R, Shekelle P et al. The Quality of
  Pharmacologic Care for Vulnerable Older
  Patients, Annals of Internal Medicine, 140
  714-720, 2004.
• Hajjar E, Hanlon J et al. Unnecessary Drug Use n
  Frail Older People at Hospital Discharge,
  Journal of the American Geriatrics Society,
  5315181523, 2005.
• Steinman M,Landefeld C et al. Polypharmacy and
  Prescribing Quality in Older People, Journal of
  the American Geriatrics Society, 541516-1523,
  Oct. 2006.
• Willcox S, Himmelstein D, and Woolhandler S.
  Inappropriate Drug Prescribing for the Community
  Dwelling Elderly, JAMA, Vol. 272, No. 4
  292-296, July 27, 1994.
• Williams C, Using Medications Appropriately in
  Older Adults, American Family Physician, Vol.
  66, No. 10 1917-1924, Nov. 15, 2002.