Polypharmacy Flashcards
Define Polypharmacy
4 or more medications
What increases the chance of having an adverse drug event?
The more medications the patient takes
Adverse Drug Reaction Events
Falls Orthostatic hypotension Heart failure Delirium GI bleeding Intracranial bleeding Renal failure
Most Common Causes of Death from Adverse Drug Reactions
GI bleeding
Intracranial bleeding
Renal failure
Problem with Polypharmacy
New prescriptions
Failure to discontinue old prescriptions
Most Common Drugs Associated with Adverse Events
Antithrombotics
Antidiabetics
Diuretics
NSAIDs
Common Symptoms Secondary to an Adverse Drug Reaction
Falls
Orthostatic hypotension
Heart Failure
Delirium
Drug Metabolism & Older Adults: Liver
Hepatic blood flow decreases by 40%
Decreased 1st pass metabolism
Drug Metabolism & Older Adults: Kidneys
Renal blood flow decreases by about 1/2 at 80 years old
Drug Metabolism & Older Adults
Hepatic Renal Decreased lean body weight to fat ratio Decreased serum protein Substance abuse
Decreased Lean Body Weight to Body Fat Ratio & Drug Metabolism
Alters the distribution of drugs in body compartments
Decreased Serum Protein & Drug Metabolism
Protein bound drugs are free to roam around
Substance Abuse & Drug Metabolism
10% are problem drinkers
Prevention of Hospitalization Due to Drug Reactions
Medication review & reconciliation
Be familiar with Beers criteria
What does STOPP stand for?
Screening Tool of Older Persons’ potentially inappropriate Prescriptions
What does START stand for?
Screening Tool to Alert prescribers to Right Treatment
Beers Criteria
2 lists of medication to be avoided in older adults
1 list of medications that should be used with caution
Examples of Potentially Inappropriate Medication Use
Nitrofurantoin (Macrobind) Digoxin in doses >0.125 mcg Sliding scale insulin Sulfonylureas Non-Cox-selective NSAIDs
Reasons not to Use Nitrofurantoin in the Elderly
Potential for pulmonary toxicity
Lack of efficacy with CrCl less than 30
Reasons not to Use Digoxin in the Elderly
Increased risk of toxicity
Decreased renal clearance
Decreased protein binding
Reasons not to Use the Insulin Sliding Scale in the Elderly
High risk of hypoglycemia without improvement of hyperglycemia management
Reason not to Use Sulfonylureas in the Elderly
Prolonged hypoglycemia
Reasons not to Use Non-Cox-Selective NSAIDs
Increased risk of GI bleeding, PUD
Use of PPI or misoprostol decreases risk
Drugs That May Worsen Constipation
Antimuscarinics for urinary incontinence
Non-dihydropyridine CCBs
First generation antihistamines
Medications to Use Cautiously in Older Adults Because it can cause SIADH or Exacerbate SIADH
SNRIs
SSRIs
Antipsychotics
Inappropriate Drugs in the Elderly
Diphenhydramine (Benadryl) Amitriptyline (Elavil) Alprazolam (Xanax) Diazepam (Valium) Chlorpropamide & Glyburide Digoxin in doses >0.125 GI antispasmodics Merperidine (Demerol) Methyldopa (Aldomet)
Reasons Diphenhydramine is Inappropriate in the Elderly
Dry mouth Confusion Urinary retention Constipation Source of in-hospital mobility/delirium In many OTC products
Reasons Digoxin is Inappropriate in the Elderly
Anorexia
Confusion
Renal excretion changes over time
START Most Common Omissions
Statins
Warfarin
Anti-platelet therapy
Calcium/Vit. D
“Choose Wisely” Criteria
Don’t use antipsychotics as a 1st choice treatment for dementia
Avoid meds to achieve A1C of less than 7.5%
Don’t use benzos or other sedative hypnotics as 1st choice for insomnia, agitation, or delirium
Don’t use antimicrobials to treat bacteriuria unless symptoms present
Don’t prescribe cholinesterase inhibitors for dementia without assessment for cognitive benefits & adverse GI effects
Avoid using appetite stimulants or high-calorie supplements for anorexia or cachexia
Don’t prescribe meds without a med review
Reduce Adverse Drug Reactions
Look for meds started at young age that may need to be adjusted
Check dose for chronic therapy after a hospitalization
Avoid adding meds to treat AE’s of another med
Capture all herbal & OTC meds
Verify compliance prior to increasing dose
Avoid long term treatment for pain, behavior, & cognition
Start low & go slow
Regular follow up
Avoid starting 2 meds at one time
Incorporate a standardized method for medication review
