Polypharmacy and Deprescribing

Polypharmacy and Deprescribing

POLYPHARMACY AND DEPRESCRIBING PRINCIPLES OF APPROPRIATE PRESCRIBING ACROSS THE AGE SPECTRUM MILTA OYOLA LITTLE, DO, CMD OBJECTIVES BY THE END OF THE SESSION, PARTICIPANTS WILL BE ABLE TO: DISCUSS STRATEGIES TO REDUCE MEDICATION BURDEN IN COMPLEX PATIENTS WITH ADVANCED AGE OR LIMITED LIFE EXPECTANCY. DESCRIBE INTERPROFESSIONAL STRATEGIES TO REDUCE OR PREVENT POLYPHARMACY AND INAPPROPRIATE MEDICATION USE. UTILIZE DRUG-SPECIFIC TOOLS AND PROTOCOLS TO REDUCE POLYPHARMACY AND MEDICATION ERRORS IDENTIFY COMMON CHRONIC DISEASE CONDITIONS ASSOCIATED WITH INAPPROPRIATE

PRESCRIBING AND MEDICATION ERRORS IN OLDER ADULTS. WHAT IS POLYPHARMACY? MORE THAN 24 DISTINCT DEFINITIONS EXTRAORDINARY PRESCRIBING A PATIENT IS TAKING MORE MEDICATIONS THAN NECESSARY INAPPROPRIATE PRESCRIBING This Photo by Unknown Author is licensed under CC BY-SA-NC MEDICATIONS ARE PRESCRIBED FOR AN INAPPROPRIATE INDICATION Bushardt RL, et al. Clin Interv Aging 2008;3(2):383 389.

Gillette C, et al. Res Social and Admin Pharm CONSEQUENCES OF POLYPHARMACY This Photo by Unknown Author is licensed under CC BY-NC-ND REDUCTION IN FUNCTION HOSPITALIZATIONS HIGHER INCIDENCE OF FRAILTY REHOSPITALIZATIONS WORSENS QUALITY OF LIFE

ADVERSE DRUG EVENTS ED VISITS SEDATION DRUG-DRUG INTERACTIONS DEPRESSION DRUG-DISEASE INTERACTIONS DELIRIUM COSTS

WEIGHT LOSS OR GAIN COGNITIVE DECLINE ORTHOSTATIC HYPOTENSION INCREASED FRACTURE RISK FALLS UNINTENTIONAL OVERDOSES This Photo by Unknown Author is licensed under CC BY-SA INCREASED ANTICHOLINERGIC BURDEN DEATH

CONSUMER REPORTS! POLYPHARMACY AND AGING This Photo by Unknown Author is licensed under CC BY OLDER PATIENTS ARE TWO TO THREE TIMES MORE LIKELY TO EXPERIENCE ADVERSE EFFECTS OF DRUGS THAN YOUNGER PATIENTS > 6 MEDS ASSOCIATED WITH FRAILTY > 4 MEDS ASSOCIATED WITH FALLS Zia A, et al. Postgrad Med, 2015; 127(3): 330337 Moulis F, et al. JAMDA 16 (2015) 258e261

> 10 MEDS ASSOCIATED WITH INCREASED MORTALITY Chiu MH et al. Geriatr Gerontol Int 2015; 15: 856863 Jyrkk J, et al. Drugs Aging. 2009;26(12):1039-48 Beer C, et al. Br J Clin Pharmacol. 2011 Apr;71(4):592 Gomez C, et al. Gerontology 2015;61:301309 DEPRESCRIBING DEPRESCRIBING THE ACT OF SYSTEMATICALLY IDENTIFYING AND TAPERING, REDUCING OR STOPPING MEDICATIONS THAT ARE NOT INDICATED (EITHER BECAUSE OF PREVIOUS MISDIAGNOSIS OR EVIDENCE OF NO BENEFIT OR HARM FOR A TRUE DIAGNOSIS), OR ARE CAUSING, OR HAVE CONSIDERABLE POTENTIAL TO CAUSE, ADVERSE EFFECTS.

I. A. Scott1,2 and D. G. Le Couteur3,4 Internal Medicine Journal 45 (2015) Scott IA, et al. JAMA Intern Med. 2015;175(5):827-834 Scott IA, et al. JAMA Intern Med. 2015;175(5):827-834 GOOD OUTCOMES OF DEPRESCRIBING SYSTEMATIC DEPRESCRIBING ASSOCIATED WITH FALL REDUCTION IMPROVED COGNITIVE AND PSYCHOMOTOR FUNCTION REDUCED MORTALITY REDUCTION IN HEALTHCARE UTILIZATION (ED VISITS AND READMISSIONS) WITHOUT INCREASED RISK OF ADVERSE OUTCOME

Potter K, et al. PLoS ONE. 2016;11(3):e0149984 Scott IA, et al. JAMA Intern Med. 2015;175(5):827-834 Zia A, et al. Postgrad Med, 2015; 127(3): 330337 van der Cammen TJ, et al. Age Ageing 2014;43:205. Salonoja M, et al. Arch Gerontol Geriatr 2012;54:1607. van der Velde N, et al. Br J Clin Pharmacol 2007;63:2327. Roberts, et al. Br J Clin Pharmacol 2001; 51: 257-65 DEPRESCRIBING IN PALTC MULTIPLE NH STUDIES TO REDUCE POLYPHARMACY HAVE BEEN DONE WITH MANY POSITIVE BUT ALSO MIXED RESULTS NO ONE INTERVENTION HAS CONSISTENTLY PROVEN EFFECTIVE A MULTI-FACETED APPROACH IS LIKELY MORE EFFECTIVE NEED MORE RESEARCH ON CLINICAL DECISION SUPPORT SYSTEMS

Lavan AH and Gallagher P. Ther Adv Drug Saf. 2016 Feb; 7(1): 112 Molokhia and Majeed BMC Family Practice (2017) 18:70 ROLE OF THE INTERPROFESSIONAL TEAM IDENTIFY A DIAGNOSIS FOR EVERY MEDICATION BE MINDFUL OF THE PRESCRIBING CASCADE PARTNER WITH CLINICAL PHARMACISTS CONSIDER COMPUTERIZED DECISION AIDS USE A SPECIFIC TOOL TO MONITOR AND RECONCILE MEDICATIONS This Photo by Unknown Author is licensed under CC BY-SA

Scott IA. Am J Med 2012; 125(6): 529-537 Planton J. J Gerontol Nurs 2012; 36(1): 8-12 Meyer, T.J. J Gen Int Med 1991; 6, 133-136 Kripalani S. Journal of Hospital Medicine 2007;2:314323 Haque, R. Ann Long-Term Care 2009;17(6): 2630 Meulendijk MC, et al. Drugs Aging (2015) WHEN TO DEPRESCRIBE? LIMITED LIFE EXPECTANCY, FUNCTIONAL DEPENDENCY, SEVERITY OF COGNITIVE IMPAIRMENT Chrinn DN, et al. Age and Ageing 2015; 44: 704708 Farrell B, PLoS ONE 2015 10(4): HIGH-RISK MEDICATION CLASSES e0122246

NEW SYMPTOM OR SYNDROME SUGGESTIVE OF ADR Scott IA, et al. JAMA Intern Med. 2015;175(5):827-834 PREVENTIVE DRUGS WHEN BENEFIT MAXIMIZED STOP TO CONSIDER DEPRESCRIBING IN PALTC MEDICATION RECONCILIATION INITIAL PATIENT CONTACT YEARLY REVIEW CHANGE IN CONDITION FALL REVIEW HOSPICE ENROLLMENT WHEN THE PHARMACIST TELLS YOU TO

ANYTIME YOU FEEL LIKE HELPING YOUR PATIENT This Photo by Unknown Author is licensed under CC BY-SA GENERAL PRINCIPLES TO REDUCING POLYPHARMACY THE HAPPY MEDIUM LIFE EXPECTANCY QUALITY OF LIFE This Photo by Unknown Author is licensed under CC BY-SA-NC DRUG-DRUG AND DRUG-DISEASE INTERACTIONS UP TO 82% OF PATIENTS ON 6 OR MORE MEDICINES EXPERIENCE A DRUG INTERACTION Amery A, et al. Lancet 1985; 1:

MULTIMORBIDITY AND PATIENT-CENTERED CARE: WHAT PATIENTS WANT SOCIAL RELATIONSHIPS A POSITIVE FRAME OF MIND OR RESILIENCE ENJOYMENT OF LIFE MAINTAINING INDEPENDENCE. Leijten FRM, et al. BMJ Open 2018;8:e021072. CASE: FRAIL OLDER ADULT

97 YEAR OLD MAN. A MEDICATION REVIEW WAS REQUESTED DUE TO MULTIPLE FALLS. ORTHOSTATIC BLOOD PRESSURE MONITORING IS INCOMPLETE. HIS SYSTOLIC BP RANGES FROM UNDER 100 TO 140. HE IS RECEIVING 12 ROUTINE MEDICATIONS. HIS DAUGHTER DOESNT WANT ANY MEDICATION STOPPED. SEE CASE INCLUDED IN FOLDER DRUG-SPECIFIC TOOLS BEERS CRITERIA STOPP/START ARMOR

MEDICATION DISCREPANCY TOOL MEDICATION APPROPRIATENESS INDEX American Geriatrics Society 2012 Beers Criteria Update Expert Panel. BEERS CRITERIA 2019 UPDATE BEERS CRITERIA 2019 UPDATE American Geriatrics Society 2019 Beers Criteria Update Expert Panel. This Photo by Unknown Author is licensed under CC BY-SA-NC

This Photo by Unknown Author is licensed under CC BY-SA STOPP SCREENING TOOL OF OLDER PERSONS PRESCRIPTIONS THE FOLLOWING PRESCRIPTIONS ARE POTENTIALLY INAPPROPRIATE IN PERSONS AGED > 65 YEARS OF AGE BY SYSTEM: CV, CNS/PSYCHOTROPIC, GI, RESP, MSK, GU, ENDO, FALLS, ANALGESIC, DUPLICATE DRUG CLASSES SCREENING TOOL TO ALERT TO RIGHT TREATMENT START THESE MEDICATIONS SHOULD BE CONSIDERED FOR PEOPLE > 65 YEARS OF AGE WITH

THE FOLLOWING CONDITIONS, WHERE NO CONTRA-INDICATIONS TO PRESCRIPTION EXISTS BY SYSTEM: CV, RESP, CNS, GI, MSK, ENDO OMahony D, et al. European Geriatr Med 2010; This Photo by Unknown Author is licensed under CC BY-SA ARMOR: NURSING HOME MED REC 1. # Meds 2. Specific drug classes

MEDICATION APPROPRIATENESS INDEX Hanlon JT, et al. J Clin Epidemiol 1992; WHAT IS THE OPTIMAL COMBINATION OF DRUGS IN A MULTI-MORBIDITY CONTEXT? SIROIS, C., RESEARCH IN SOCIAL AND ADMINISTRATIVE PHARMACY, HTTPS://DOI.ORG/10.1016/J.SAPHARM.2018.09.008 BREAK-OUT EXERCISE FOR A PERSON AGED 65-75 WITH TYPE 2 DIABETES, HEART FAILURE, AND CHRONIC OBSTRUCTIVE PULMONARY DISEASE, WHICH DRUGS WOULD YOU RECOMMEND AS THE OPTIMAL BASIC THERAPY?

THE DELICATE CHOICE OF OPTIMAL BASIC THERAPY FOR MULTIMORBID OLDER ADULTS CROSS-SECTIONAL STUDY MOSTLY PHARMACISTS RESPONDED 10% GERIATRICIANS LITTLE CONSENSUS MEDIAN NUMBER OF RECOMMENDED DRUGS: 10 (6-13) 21.6% >2 MEDICATIONS OR CLASSES WITH A CONTRAINDICATED INTERACTION (BUT NONE OF THE GERIATRICIANS DID) WHAT IS APPROPRIATE POLYPHARMACY?? Sirois, C., Research in Social and Administrative Pharmacy,

https://doi.org/10.1016/j.sapharm.2018.09.008 POLYPHARMACY IN MULTIMORBIDITY DISEASE CLUSTERS LEADING TO HIGHEST POLYPHARMACY RATES CHF WITH OSTEOPOROSIS CKD WITH COPD CKD WITH OSTEOPOROSIS Feng X, et al. Population Health Management. 2018; 21(2):123-129 PHYSICAL ACTIVITY INVERSELY ASSOCIATED WITH POLYPHARMACY IN OLDER MULTIMORBID ADULTS Volaklis KA, et al. Scand J Med Sci Sports. 2018;28:604612.

TARGETING SPECIFIC DRUG CLASSES APPLYING THE PRINCIPLES TO REDUCING POLYPHARMACY DIABETES MELLITUS 2 ADA/AGS GLYCEMIC TARGETS IN AGE >65 HEALTHY PATIENT: FEW COEXISTING CHRONIC ILLNESSES; COGNITIVE, FUNCTIONAL STATUS INTACT RATIONALE FOR RECOMMENDATIONS: LONGER LIFE EXPECTANCY A1C GOAL: <7.5%* COMPLEX/INTERMEDIATE PATIENT: MULTIPLE COEXISTING CHRONIC ILLNESSES OR 2+ INSTRUMENTAL ADL IMPAIRMENTS OR MILD-TO-MODERATE COGNITIVE IMPAIRMENT RATIONALE FOR RECOMMENDATIONS: INTERMEDIATE LIFE EXPECTANCY; HIGH

TREATMENT BURDEN; VULNERABLE TO HYPOGLYCEMIA AND FALLS A1C GOAL: <8.0%* VERY COMPLEX/PATIENT IN POOR HEALTH: LTC OR END-STAGE CHRONIC ILLNESSES OR MODERATE-TO-SEVERE COGNITIVE IMPAIRMENT OR 2+ ADL DEPENDENCIES RATIONALE FOR RECOMMENDATIONS: LIMITED LIFE EXPECTANCY; BENEFIT UNCERTAIN A1C GOAL: <8.5% Happy Medium 2018 American College of Physicians Clinical Guidelines Guidance Statement 2:Clinicians should aim to

achieve an HbA1c level between 7% and 8% in most patients with type 2 diabetes. Guidance Statement 3:Clinicians should consider deintensifying pharmacologic therapy in MR. SWEETS: 89 Y/O MALE ADMITTED FROM HOME FOR LONG TERM CARE, AMBULATES WITH A WALKER, A1C 6.6 ASPIRIN 81 MG DAILY GLYBURIDE 10 MG DAILY

CLOPIDOGREL 75 MG DAILY METFORMIN 1000 MG BID SIMVASTATIN 80 MG DAILY AMLODIPINE 10 MG DAILY CARVEDILOL 6.25 MG BID DONEPEZIL 10 MG HS OTC: DOCUSATE 100 MG BID MULTIVITAMIN 1 TAB DAILY

FINASTERIDE 5 MG DAILY TIMOLOL OPTH DAILY AM BS 80S-120S PM BS 200S-300S ANTI-DIABETIC AGENTS Met plus Sulfonlyurea Insulin Currie CJ, et al. Lancet 2010;375:481 ANTI-DIABETIC AGENTS EVIDENCE FROM RCTS SHOWS THAT A1C <7

DOES NOT REDUCE MAJOR CARDIOVASCULAR EVENTS IN OLDER ADULTS DOES NOT REDUCE MICROVASCULAR OUTCOMES IMPORTANT TO PATIENTS CONSISTENTLY INCREASES THE RISK OF HYPOGLYCEMIA BY 1.5- TO 3-FOLD. NET HARM IN MAJORITY OF OLDER ADULTS BENEFIT HARMS OF HBA1C <7.5% LIKELY OUTWEIGH THE BENEFITS. RISK Drug-Disease

Interactions Lipska KJ, et al. JAMA. 2016;315(10):1034-1045 WHAT I DO AVOID AND STOP USE INSTEAD SULFONYLUREAS $ METFORMIN $ LONG-TERM SSI $$

DPP-4 INHIBITORS $$ GLP-1 INHIBITORS $$$ NPH OR 70/30 INSULIN $ LOW DOSE BASAL INSULIN $$ PROTON PUMP INHIBITORS (PPI) WHEN TO STOP? WHEN TO CONTINUE? THE NUMBERS PPI USE INCREASED FROM 3.9% TO 7.8% FROM 1999-2000 TO 2011 -2012 ~25-70% OF PPI RX ARE FOR INAPPROPRIATE

INDICATIONS DURATION OF USE FREQUENTLY EXTENDS BEYOND RECOMMENDATIONS OVERPRESCRIBED, RARELY DEPRESCRIBED PRESCRIBING RECOMMENDATIONS FIRST LINE TREATMENT ESOPHAGITIS (8 WEEKS, HIGH DOSE, NNT = 7) NONEROSIVE REFLUX DISEASE (4 WEEKS) PEPTIC ULCER DISEASE (PUD) PREVENTION OF NSAID ASSOCIATED ULCERS ZOLLINGER-ELLISON SYNDROME (ZES)

FUNCTIONAL DYSPEPSIA HELICOBACTER PYLORI ERADICATION OTHER RECOMMENDATIONS Quali ty of Life GASTROESOPHAGEAL REFLUX DISEASE (GERD)

SHORT-TERM HEALING, MAINTENANCE OF HEALING, LONG-TERM SYMPTOM CONTROL AFTER INITIAL TRIAL, AN ATTEMPT SHOULD BE MADE TO STOP OR REDUCE TREATMENT REFRACTORY SYMPTOMS: CONSIDER ESOPHAGEAL PH/IMPEDANCE MONITORING BEFORE RECOMMENDING LONG-TERM USE BARRETT'S ESOPHAGUS SYMPTOMATIC GERD: LONG-TERM PPI CHRONIC PPI USE COMPLICATIONS

MALABSORPTION OF KEY MINERALS / VITAMINS CALCIUM Drug-Drug Interactions MAGNESIUM B12 AND IRON ANEMIA Gray SL, et al. Arch Intern Med 2010; 170: 765-71. OSTEOPOROSIS AND FRACTURES De Jager CP, et al. (2012) Aliment PNEUMONIA Pharmacol Ther. 2012;36:941-949.

Linsky A, et al Arch Intern Med 2010; 170: 772-78. Lazarus, B, et al. JAMA Intern CKD Med 2016 Shah NH, et al. PLoS ONE 2015;10(6): MI e0124653. +/- DEMENTIA Gomm W, et al. JAMA Neurol 2016 MORTALITY . Xie Y, et al. BMJ Open

2017;7:e015735. C. DIFF BENEFIT RIS K THE RIGHT IDEA FOR THE WRONG PATIENT: RESULTS OF A NATIONAL SURVEY ON STOPPING PPI (1) GERD, well controlled for years Low Risk with normal EGD 32%

stopped RIS K BENE FIT (2) Prevention of UGIB while on low Moderate dose ASA and warfarin, otherwise Risk asymptomatic 47% stopped (3) Prevention of UGIB while on low High Risk 62% dose ASA alone with a history of

NSAID related PUD 10 years prior, stopped otherwise asymptomatic RISK BENE FIT Kurlander J et al, "The right idea in the wrong patient: a national survey of internists' attitudes towards stopping WHAT I DO COMPLETE 6-8 WEEK COURSE OF HIGH-DOSE PPI FOR HEALING OF ESOPHAGITIS, PUD, H. PYLORI SWITCH ALL PATIENTS ON PPI FOR REMOTE PUD AND CHRONIC NSAID

USE TO LOWEST DOSE OF CHEAPEST MED FOR PATIENTS WITH GERD OR ASX BARRETTS ON HIGH-DOSE PPI, CHANGE TO LOWEST DOSE OF CHEAPEST MED ON LOW-DOSE PPI, SWITCH TO H2 BLOCKER RE-ASSESS AFTER 2-4 WKS AND CONTINUE TAPER IF NO SX RECURRENCE CHOLESTEROL AND HYPERTENSION This Photo by Unknown Author is licensed under CC BY-NC-ND CLINICAL VIGNETTE: MR. CASINO 86 Y/O MALE ADMITTED TO SNF S/P PARIETO-OCCIPITAL CVA

AORTIC ANEURISM HTN PRE-DM 14 5 CAD 3.5 11 0 28

PVD RENAL ARTERY STENOSIS CVA DEMENTIA GERD WEIGHT LOSS A-FIB/SSS S/P PACER 9.6 12. 3 35. 7

1 4 11 7 0. 9 8. 7 9 6

MR. CASINO ESOMEPRAZOLE 40 MG DAILY DOXAZOSIN 1 MG DAILY DICYCLOMINE 10 MG BID LISINOPRIL 20 MG DAILY SUCRALFATE 1 GM QID FAMOTIDINE 20 MG BID METOPROLOL TARTRATE 25 MG BID

WARFARIN 5 MG DAILY CLONIDINE 0.1 MG BID ASPIRIN 81 MG DAILY LEVETIRACETAM 500 MG BID PRN: ZOPIDEM 5 MG AT HS HYDROCODONE/APAP 5/324 MG Q 8HRS ATORVASTATIN 80 MG DAILY VS: 125/68 68 20 123# NITROFURANTOIN 100 MG BID FOR

7D CHOLESTEROL STATINS MOST RECENT GUIDELINES PRIMARY PREVENTION AGES 40-75 SECONDARY PREVENTION UP TO AGE 80 This Photo by Unknown Author is licensed under CC BY MAY BE REASONABLE TO STOP STATINS(WITH) COGNITIVE DECLINE OR REDUCED LIFE EXPECTANCY THAT MAY LIMIT BENEFITS OTHER CLASSES NO EVIDENCE TO RECOMMEND USE IN ELDERLY POPULATION FOR EITHER PRIMARY OR

SECONDARY PREVENTION Stone NJ, et al. 2013 ACC/AHA Blood Cholesterol Guidelin STATINS IN > 75 YR OLDS WITHOUT DIABETES, NO REDUCED CVD RISK OR ALL-CAUSE MORTALITY IN DIABETES, EFFECT DECREASED AFTER 85 AND DISAPPEARED AFTER 90 STOPPING STATINS <1 YEAR LIFE EXPECTANCY NO CHANGE IN MORTALITY IMPROVED QOL SUBSTANTIAL COST SAVING BENEFITS MAY NOT OUTWEIGH HARMS IN 70-75 Y/O MEN UNTIL 10-YR CVD RISK > 21%

MULTIPLE DRUG-DRUG INTERACTIONS Ramos R, et al. BMJ. 2018 Sep 5;362:k3359. Kellick K, et al. Journal of Clinical Lipidology (2014) 8, S30S Abernethy AP, et al. ASCO 2014; Abstract LBA9514. Stone NJ, et al. 2013 ACC/AHA Blood Cholesterol Guideline WHAT I DO STOP ALL CHOLESTEROL-LOWERING DRUGS USED FOR PRIMARY PREVENTION EXCEPTION: DM THROUGH 80S This Photo by Unknown Author is licensed under CC BY-SA USE LOWEST DOSE, DONT TITRATE, DONT CHECK LIPID LEVELS

CONSIDER STATIN WITH NO CYP ACTIVITY SIMVASTATIN, ATORVASTATIN AND LOVASTATIN ARE METABOLIZED BY CYP3A4 PRAVASTATIN AND ROSUVASTATIN ARE NOT Kellick K, et al. Journal of Clinical Lipidology (2014) 8, S30S HYPERTENSION QUANDARIES MOST STUDIES THAT SHOWED BENEFIT IN OLDER ADULTS DO NOT APPLY TO PALTC HYVET 4,071 AMBULATORY ONLY, < 80 Y/O, EXCLUDED NURSING HOME PATIENTS SPRINT 50+ YEAR OLD, EXCLUDED DM, NH RESIDENT, DEMENTIA, CVA, ESRD, CHF, CVD 5 OUT OF 6 PATIENTS CURRENTLY TREATED FOR HTN DONT MEET STUDY CRITERIA. AGGRESSIVE TREATMENT HAD SERIOUS HARM IN 2.5 TO 4.7%, ABSOLUTE BENEFIT 1.6%

JNC 8 LUMPS 60 YEARS AND OLDER IN ONE CATEGORY, NO NH PATIENTS GENERALLY GOAL HAS BEEN TREAT IF BP > 150/90 Denardo SJ, et al. Blood pressure and outcomes in very old hypertensive coronary artery disease patients: an INVEST substudy. Am J Med 2010;123:725 HTN TRIALS RELEVANT TO FRAIL ELDERLY PARTAGE NURSING HOME STUDY SBP < 130 ON > 2 ANTIHYPERTENSIVES HAD TWOFOLD GREATER RISK OF 2-YEAR MORTALITY LOW BP IN THOSE NOT ON ANTI-HTN NOT

WITH HIGHER MORTALITY BenetosWAS A, et al. ASSOCIATED JAMA Inter Med 2015;175:989 995 -BLOCKERS POST ACUTE MI IN NH DECREASED 90-DAY MORTALITY INCREASED FUNCTIONAL DECLINE Steinman MA, et al. JAMA Intern Med 2017;177:254262 MORE QUANDARIES IN HTN

SYSTOLIC ORTHOSTASIS >20 MM HG = >30% DEATH 6 MONTHS LATE ONSET HTN (>80 YEAR OLD) IS ASSOCIATED WITH A LOWER RISK OF DEMENTIA MORE PRONOUNCED WHEN >90 TREATMENT OF HTN ASSOCIATED WITH FALL RISK IN FRAIL PERSONS SPEED WALKING ASSOCIATED WITH MORTALITY FROM BP FAST WALKERS: 3X MORTALITY WITH HIGH BP This Photo by Unknown Author is licensed under CC BY SLOW WALKERS: NO CORRELATION OF BP WITH DEATH This Photo by Unknown Author is licensed under

CC BY UNABLE TO WALK: ELEVATED BP WAS STRONGLY AND INDEPENDENTLY ASSOCIATED WITH A LOWER RISK OF DEATH This Photo by Unknown Author is licensed under WHAT I DO TREAT THE MOBILE DO NOT LOWER BP SYSTOLIC TO LESS 130 (CHF EXCEPTION) CHECK ORTHOSTATICS AND TREAT THE LOWER NUMBER GOAL 140S-160S (SOMETIMES HIGHER) FIRST LINE: ACEI CCB THIAZIDE CONSIDER NOT TREATING (DONT CHECK!)

> 90 YEAR OLDS SIGNIFICANT FRAILTY AND DISABILITY LATE ONSET HYPERTENSION This Photo by Unknown Author is licensed under CC BY-NC RESERVE HOLDING PARAMETER ORDERS FOR TITRATION PERIOD MR. CASINO: 86 Y/O MALE ADMITTED TO SNF S/P PARIETO-OCCIPITAL CVA ESOMEPRAZOLE 40 MG DAILY DOXAZOSIN 1 MG DAILY

DICYCLOMINE 10 MG BID LISINOPRIL 20 MG DAILY SUCRALFATE 1 GM QID FAMOTIDINE 20 MG BID METOPROLOL TARTRATE 25 MG BID WARFARIN 5 MG DAILY CLONIDINE 0.1 MG BID ASPIRIN 81 MG DAILY

LEVETIRACETAM 500 MG BID PRN: ZOPIDEM 5 MG AT HS HYDROCODONE/APAP 5/324 MG Q 8HRS ATORVASTATIN 80 MG DAILY VS: 125/68 68 20 123# NITROFURANTOIN 100 MG BID FOR 7D CHRONIC OBSTRUCTIVE PULMONARY DISEASE Normal

Volume, liters 5 4 3 FEV1 = 1.8L 2 FVC = 3.2L Obstructive FEV1/FVC = 0.56

1 1 2 3 4 5 6

Time, seconds 2015 Global Initiative for Chronic Obstructive Lung Disease Albertson TE, et al. Drugs & aging. 2013;30(7):479-502. FOLLOW GOLD GUIDELINES FOR MANAGEMENT OF COPD GUIDELINES DONT DIFFER FOR ELDERLY OR PA/LTC SAFE TO USE CARDIOSELECTIVE SS -BLOCKERS (USUALLY

Corsonello A, et al. Current pharmaceutical design. 2015;21(13):1672-89 CHALLENGES WITH INHALED THERAPY Taffet GE, et al. Clinical interventions in aging. 2014;9:23-30 Challenges Pressurized MDIs Dry Powder Inhalers Nebulizers

The most complex dosage form in medicine Low force of inspiration drug in the lung, drug in mouth or pharynx. Can contribute to systemic adverse events. 1. Need daily cleaning

2. Longer time to admin 3. LAMA (tiotropium) not avail as neb Do not require coordination of inhalation with activation hand strength Only require normal tidal respiration

Spacers +/- Advantages Cost Optimizing use Use breath-actuated Education goes a Use for physical and/ MDI ifwith strength long way Nursing home residents mild to moderate dementia can or

becognitive educated on limitation disabilities the proper use of DPI KEY POINTS ON PHARMACOLOGIC MANAGEMENT AGE-RELATED CHANGES POTENTIALLY DECREASE RESPONSIVENESS TO DRUGS INCREASE SUSCEPTIBILITY TO ADVERSE DRUG REACTIONS DATA IN PA/LTC AND ELDERLY POPULATIONS MOSTLY EXTRAPOLATED OVERALL, SIMILAR EFFICACY WITHIN DRUG CLASSES SO USE CHEAPEST,

EASIEST TO ADMINISTER DRUG DELIVERY AND # OF ADMINISTRATIONS/DAY IMPORTANT CONSIDERATIONS Matera MG, et a;. Current pharmaceutical design. WHAT I DO WATCH A PATIENT USE INHALER AND IF UNABLE TO USE PROPERLY EDUCATE NURSE AND PATIENT ON USE (EDUCATE YOURSELF FIRST!!) IF STILL UNABLE TO USE PROPERLY, CHANGE TO SCHEDULED NUBULIZERS IF NOT USING PRN INHALERS/NEBS AFTER 2 MONTHS, WILL D/C FROM MAR CASE: FRAIL OLDER ADULT 97 YEAR OLD MAN. A MEDICATION REVIEW WAS REQUESTED DUE TO MULTIPLE FALLS.

ORTHOSTATIC BLOOD PRESSURE MONITORING IS INCOMPLETE. HIS SYSTOLIC BP RANGES FROM UNDER 100 TO 140. HE IS RECEIVING 12 ROUTINE MEDICATIONS. HIS DAUGHTER DOESNT WANT ANY MEDICATION STOPPED. SEE CASE INCLUDED IN FOLDER THE DIFFICULT CASE: WHEN HE WANTS THEM ALL THINK BEYOND DRUGS This Photo by Unknown Author is licensed under CC BY-NC-ND PRACTICE MORE STRATEGIC PRESCRIBING MAINTAIN HEIGHTENED VIGILANCE REGARDING ADVERSE

EFFECTS EXERCISE CAUTION AND SKEPTICISM REGARDING NEW DRUGS WORK WITH PATIENTS FOR A SHARED AGENDA CONSIDER LONG-TERM, BROADER IMPACTS Schiff GD, et al. Arch Int Med 2011; 171:1433-1440 SAIL AND TIDE SAIL: KEEP MEDS AS SIMPLE AS POSSIBLE, REMEMBER ADVERSE EFFECTS, IDENTIFY THE INDICATION FOR EACH MEDICATION, LIST EACH DRUG AND DOSE TIDE: SCHEDULE TIME DURING EACH VISIT TO DISCUSS MEDICATIONS, HAVE AWARENESS OF

INDIVIDUAL RESPONSE TO MEDICATIONS, AVOID POTENTIAL DRUG/DRUG/DISEASE INTERACTIONS, EDUCATE THE PATIENT THANK YOU

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