Polypharmacy

Question 1

Define Polypharmacy

Answer 1

4 or more medications

Question 2

What increases the chance of having an adverse drug event?

Answer 2

The more medications the patient takes

Question 3

Adverse Drug Reaction Events

Answer 3

Falls
Orthostatic hypotension
Heart failure
Delirium
GI bleeding
Intracranial bleeding
Renal failure

Question 4

Most Common Causes of Death from Adverse Drug Reactions

Answer 4

GI bleeding
Intracranial bleeding
Renal failure

Question 5

Problem with Polypharmacy

Answer 5

New prescriptions

Failure to discontinue old prescriptions

Question 6

Most Common Drugs Associated with Adverse Events

Answer 6

Antithrombotics
Antidiabetics
Diuretics
NSAIDs

Question 7

Common Symptoms Secondary to an Adverse Drug Reaction

Answer 7

Falls
Orthostatic hypotension
Heart Failure
Delirium

Question 8

Drug Metabolism & Older Adults: Liver

Answer 8

Hepatic blood flow decreases by 40%

Decreased 1st pass metabolism

Question 9

Drug Metabolism & Older Adults: Kidneys

Answer 9

Renal blood flow decreases by about 1/2 at 80 years old

Question 10

Drug Metabolism & Older Adults

Answer 10

Hepatic
Renal
Decreased lean body weight to fat ratio
Decreased serum protein
Substance abuse

Question 11

Decreased Lean Body Weight to Body Fat Ratio & Drug Metabolism

Answer 11

Alters the distribution of drugs in body compartments

Question 12

Decreased Serum Protein & Drug Metabolism

Answer 12

Protein bound drugs are free to roam around

Question 13

Substance Abuse & Drug Metabolism

Answer 13

10% are problem drinkers

Question 14

Prevention of Hospitalization Due to Drug Reactions

Answer 14

Medication review & reconciliation

Be familiar with Beers criteria

Question 15

What does STOPP stand for?

Answer 15

Screening Tool of Older Persons’ potentially inappropriate Prescriptions

Question 16

What does START stand for?

Answer 16

Screening Tool to Alert prescribers to Right Treatment

Question 17

Beers Criteria

Answer 17

2 lists of medication to be avoided in older adults

1 list of medications that should be used with caution

Question 18

Examples of Potentially Inappropriate Medication Use

Answer 18

Nitrofurantoin (Macrobind)
Digoxin in doses >0.125 mcg
Sliding scale insulin
Sulfonylureas
Non-Cox-selective NSAIDs

Question 19

Reasons not to Use Nitrofurantoin in the Elderly

Answer 19

Potential for pulmonary toxicity

Lack of efficacy with CrCl less than 30

Question 20

Reasons not to Use Digoxin in the Elderly

Answer 20

Increased risk of toxicity
Decreased renal clearance
Decreased protein binding

Question 21

Reasons not to Use the Insulin Sliding Scale in the Elderly

Answer 21

High risk of hypoglycemia without improvement of hyperglycemia management

Question 22

Reason not to Use Sulfonylureas in the Elderly

Answer 22

Prolonged hypoglycemia

Question 23

Reasons not to Use Non-Cox-Selective NSAIDs

Answer 23

Increased risk of GI bleeding, PUD

Use of PPI or misoprostol decreases risk

Question 24

Drugs That May Worsen Constipation

Answer 24

Antimuscarinics for urinary incontinence
Non-dihydropyridine CCBs
First generation antihistamines

Question 25

Medications to Use Cautiously in Older Adults Because it can cause SIADH or Exacerbate SIADH

Answer 25

SNRIs SSRIs Antipsychotics

Question 26

Inappropriate Drugs in the Elderly

Answer 26

``` Diphenhydramine (Benadryl) Amitriptyline (Elavil) Alprazolam (Xanax) Diazepam (Valium) Chlorpropamide & Glyburide Digoxin in doses >0.125 GI antispasmodics Merperidine (Demerol) Methyldopa (Aldomet) ```

Question 27

Reasons Diphenhydramine is Inappropriate in the Elderly

Answer 27

``` Dry mouth Confusion Urinary retention Constipation Source of in-hospital mobility/delirium In many OTC products ```

Question 28

Reasons Digoxin is Inappropriate in the Elderly

Answer 28

Anorexia Confusion Renal excretion changes over time

Question 29

START Most Common Omissions

Answer 29

Statins Warfarin Anti-platelet therapy Calcium/Vit. D

Question 30

"Choose Wisely" Criteria

Answer 30

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

Question 31

Reduce Adverse Drug Reactions

Answer 31

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