DRUGS!!!!

I recently had the opportunity to present about medication issues in the elderly to a group of healthcare professionals. This is always a popular topic and area of concern for folks involved in the care of an older adult- what should they take, what should they NOT take, aren't they on too many medications, can we take some medications away, is this medication causing them to...? The questions can be endless.

There are entire books and innumerable articles in the literature along with who knows how many websites dedicated to the topic of medications in the older adult. It can be an overwhelming topic. So, let's break it down to a few key "take home" points that are critical to understand and can hopefully help trigger important conversations with health care providers and patients/families.

Overview/Statistics

Older adults, often due to the numerous chronic medical conditions they have, often end up with regimens of numerous prescription medications. Additionally, many also take over-the-counter (OTC) preparations, supplements, vitamins, & perhaps even herbal/"natural" remedies for various reasons. They may think the latter are less "harmful" or more "natural," but the reality is they all act on different systems of the body and can have significant effects, side effects, or interactions.

It is estimated that about 85-90% of older community dwelling adults take at least 1 prescription medication, and that over a third are on more than 5 prescription medications. Furthermore, chronic disease management guidelines often result in older adults being on numerous prescription medications. For example, if you take an older woman with COPD, osteoporosis, osteoarthritis, diabetes, & high blood pressure, she might need to take up to TWELVE prescription medications, based on disease management guidelines. Guidelines are good- they can help make the practice of medicine more efficient for busy physicians, but many guidelines are based on studies that have excluded older adults who may have numerous chronic medical conditions, impairments in the ability to care for themselves, and issues with their cognition.

So, here are some key terms & points to bear in mind as we navigate conversations & decisions regarding medication management in older adults:

a) Polypharmacy- the definitions vary in terms of numbers, but generally it's the use of multiple medications (the minimum usually defined as 5-10). Polypharmacy increases the risk of interactions (see below), falls, medication errors, non-adherence, hospitalizations, and adverse drug events (ADEs).

b) Interactions- how drugs may impact each other or various disease conditions.

Drug-drug interactions are when one drug may increase or decrease the effect of another drug. The classic example involves taking Fluconazole (an antifungal medication) while on Warfarin (Coumadin), a blood thinner. The interaction of these two can significantly heighten the risk of bleeding events. Or, how some acid blockers (e.g. Pantoprazole- Protonix) delay or reduce the absorption of other drugs. Finally, even "herbal" or "natural" remedies can have interactions- St. John's Wart, often used for depression can reduce the effectiveness of Warfarin. It can also increase the risk of a condition called Seratonin Syndrome if the patient is also taking an SSRI for depression (e..g. Sertraline- Zoloft; Paroxetine- Paxil; Citalopram- Celexa; Escitalopram- Lexapro; Fluoxetine- Prozac).

Drug-disease interactions are the impacts of medications on certain disease states. Examples include an increase in urinary incontinence when taking Donepezil (Aricept) for memory loss/dementia. Or a worsening of blood sugar control in diabetics when taking a steroid. Or an exacerbation of heart failure due to fluid retention/electrolyte imbalances when taking an NSAID (non-steroidal antiinflammatory- e.g. Advil/Ibuprofen/Aleve/Motrin). And one of my most dreaded examples- giving a diuretic (water pill) to an older adult with impaired gait and osteoporosis--> rushing to the bathroom in the middle of the night, stumbles, falls, & ends up with a hip or other fracture/injury.

c) Adverse Drug Event (ADE)- basically a "noxious" or unwanted response to a medication. ADEs are estimated to account for up to 10% of hospitalizations in older adults, though I feel it is likely much higher. An adverse drug event can be something like a fall due to lowered blood pressure after taking blood pressure pills, or a bleeding ulcer due to taking non-steroidal anti-inflammatory agents (NSAIDs- Ibuprofen/Advil/Motrin...) or a change in mental status after taking a pain pill or antidepressant.

All of these phenomena can result in what we call a prescribing cascade which only increases risks of ADEs, interactions, and polypharmacy. Prescribing cascades happen when a medication is prescribed to manage the side effect or adverse drug event of another medication. Think about the blood pressure medication, Amlodipine (Norvasc)- one of the common side effects include swelling around the ankles. The patient then goes to his/her doctor complaining of swelling & gets put on a diuretic to manage the swelling and then perhaps a potassium supplement to manage the electrolytes problems of being on a diuretic and then an incontinence agent due to the increased urinary frequency and accidents at night...and so on, and so on, and so on...

And remember, as I noted before- over-the-counter medications, herbal preparations, supplements, & vitamins are all drugs- pharmacological agents which are meant to produce an effect in the body. The danger of this specific group of medications is that they aren't regulated nor are they studied in rigorous standardized trials to assess their effects, interactions, etc. Yet, when taken, they can have many side effects, interactions, & ADEs. I highlighted the example of St. John's Wort above. Another classic one is Gingko Biloba for memory loss- it hasn't been shown to be particularly effective and it is known to increase the risk of bleeding along with problematic interactions with medications like Warfarin/Coumadin, Aspirin, etc.

d) "Anticholinergic" effects- This term often comes up when talking about medications in older adults, especially medications that may be considered "inappropriate." Anticholinergic means that the medications interferes with the action of a chemical called acetylcholine- this is a naturally occurring agent in our bodies that plays an important role in the nervous system, muscular system, & regulation of critical body functions. Medications that are anticholinergic can result in a variety of important side effects including:

1. Decreased salivation which can lead to dry mouth

2. Decreased secretions in the airways leading to plugging of mucous

3. Decreased ability to sweat which can disrupt our body's ability to regular temperature

4. Disruption of vision, including blurriness & potentially increasing eye pressures (glaucoma)

5. Increased heart rate which can lead to palpitation, angina/chest pain,

6. Problems with urination- retaining urine & distension of the bladder (not good for those with enlarged prostates)

7. Reduced motility of the bowels leading to constipation
   

What are some of the medications that are common "anticholinergic culprits?"

1. Diphenhydramine (Benadryl, Tylenol PM)

2. Some anti-Parkinson's medications

3. Some narcotic pain medications

4. Medications we use for overactive bladder (Oxybutynin- Oxytrol/Ditropan)

5. Psychiatric medications (older antipsychotics especially & tricyclic antidepressants)
   

So- knowing the risks of medications and polypharmacy in older adults, what are some questions you should be asking?

1. What is the indication for this medication?

2. Is this medication effective for the indication?

3. Is the dose correct & does it take into account my kidney & liver function (they change with time and can effect how drugs are metabolized)?

4. What are the directions for taking the medication & are they clear? Are they practical?

5. What are some of the interactions known for this medication- with other drugs & with other diseases?

6. Is this medication being prescribed to treat or manage the side effect of another medication?

7. Is this medication duplicating the effect of another medication?

8. How long will the medication be needed?

9. Is this the least expensive option in its class?

10. Are there medications that can be "deprescribed"- discontinued or reduced in dose?

11. Are there "nonpharmacological" ways to treat the condition- that is, ways that don't involve medication?

And some tips to reduce ADEs

1. Always keep an accurate & up to date list of all your medications- prescription, oral, topical, OTC, supplements/vitamins, herbals, etc.

2. Consider "brown bagging" your medications periodically- put them in a brown bag & take them to a doctor's appointment to review & ensure which ones are appropriate and which ones are not.

3. Be as educated about your medication as possible- don't be afraid to ask questions & get information/literature from your doctor or pharmacist. Don't rely on Google...

4. Consider medication organizers

5. Get to know your community pharmacist- they are a wealth of information

6. Be very alert to "transitions" of care- that is when you are transferred between hospital wards, from hospital to a nursing home/rehab, from hospital to home or from home to hospital. These are key moments when medication errors & confusion can occur and having a clear list and strong advocate are critical.
   

There are many other issues to consider regarding medication management in older adults, and I'm more than happy to address topics in future blogs- feel free to email me thoughts/questions for future topics. But, I do hope that this gives you a bit of an overview of some key issues and serves as a start to your conversations about medication management.