Course Content - #3. Geriatric Polypharmacy. The elderly population of the United States is projected to grow substantially over the coming decades, comprising 2. The population of those 8. As a result, the number of older adults with multiple chronic illnesses requiring drug therapy will also increase significantly. The presence of chronic illness is a predictor of greater utilization of healthcare services, including nursing facility residence, and greater number of medications. Older patients and residents of nursing facilities may have more than 2. ![]() Hazards of polypharmacy include lack of adherence, overtreatment, adverse drug reactions, and incorrect dosage and administration regimens. Older patients may receive health care from a diverse set of providers, specialists, and consultants—often, one for each disease process. Each provider may prescribe additional medication(s), and as the number of medications increases, so does the risk of adverse drug reactions. In some cases, there is confusion regarding the proprietary (brand) and generic names of medications, with some patients taking a generic and brand version of the same drug. The increasing complexity of medication regimens leaves patients vulnerable to the hazards of polypharmacy and adverse drug reactions. There is an increased demand for healthcare providers who are knowledgeable in geriatric prescribing practices. Internet Explorer 8 Beta 1 Adrenergic Receptors ActsSupported browsers for Windows include Microsoft Internet Explorer 9.0 and up, Mozilla Firefox 3.0 and up, Opera 9.0 and up, and Google Chrome. Specialized prescribing practices, geared toward managing multimorbidity in elders, are mandated by best practices and standards for geriatric care. Confusion about medication regimens, duplicate medications, non- adherence, and errors in self- administration make older adults at high risk for problems. In many cases, the "brown bag" approach is used to assess all the prescription and non- prescription medications the patient takes. This involves the patient bringing all prescription and over- the- counter medications he or she takes to each office visit. The patient/caregiver can then describe how the medications are taken/given and any reminder system or assistive device used (such as a medicine box/planner) to ensure compliance. Patient education and communication with primary care providers are key components of comprehensive care. Patients should understand that over- the- counter drugs, supplements, and home remedies are not inherently "safe" and have the potential for serious adverse effects or interactions. Prescribers should also be aware of financial constraints experienced by many older adults, some of whom may be faced with the decision to buy either food or medications. In an effort to cut costs, these patients may decide to take a daily medication every other day or cut pills in half. Some may choose to take one medication over another based on their personal priorities (e. Geriatric practitioners should have a comprehensive understanding of the physiologic changes of aging that occur, particularly in the liver and kidneys. Physiologic changes of aging cause differences in the absorption, distribution, metabolism, and excretion of medications. This increases the risk for adverse drug reactions or interactions due to excess drug accumulation and/or reduced clearance. Today, older healthcare consumers or their representatives are often informed and savvy and may request every treatment available. They may demand a treatment a neighbor or relative was prescribed, or one that was advertised on television. Some patients may fall prey to online scams to purchase fraudulent products or supplements. A formal drug re- evaluation should be performed regularly for all elderly patients. Providers should continuously assess prescribed drug therapies for necessity and appropriateness according to the patient's goals of care and best evidence- based geriatric practices. Multiple medications may be necessary to treat comorbid conditions, but vigilance is required to monitor for adverse reactions or interactions. Healthcare costs associated with the improper and unnecessary use of medications exceeded $2. IMS Institute for Healthcare Informatics [2]. These costs are related to adverse drug reactions or interactions, hospital admissions, emergency department visits, and outpatient care. Reducing the number of medications older patients take is associated with reduction in mortality rates, improved quality of life, and reduced costs [3]. Medication regimen simplification is a priority to improve patient outcomes and reduce errors. The term polypharmacy is often used but not well defined. There. are varied definitions in medical literature, but in general, polypharmacy has been defined as. Polypharmacy may be used to describe excessive or unnecessary. There has been a call to redefine polypharmacy beyond an arbitrary number of. In some cases of. However, even. when the prescription of multiple medications is warranted, it raises the risks of drug. Generally, the term polypharmacy has a. IDENTIFICATION OF PROBLEMATIC MEDICATIONS IN THE ELDERLYA retrospective study examined the use of potentially inappropriate medication use in older inpatients, and researchers found that 4. Care by a geriatrician and clinical pharmacist intervention have been found to decrease potentially inappropriate prescribing practices for these patients [6]. Several tools have also been developed to help prescribers make the best selection of agents and minimize the risks of problematic polypharmacy in older patients. In older adults, certain drugs are considered inappropriate. In 1. 99. 1, Mark H. Beers, MD, and his colleagues established. Known as the American Geriatrics Society (AGS) Beers criteria (Table. Prescribers should review the. The. Beers criteria list continues to be updated (most recently in 2. Notable new inclusions to the 2. EXAMPLES FROM THE 2. AMERICAN GERIATRICS SOCIETY BEERS CRITERIA FOR POTENTIALLY. INAPPROPRIATE MEDICATION USE IN OLDER ADULTSTherapeutic Category (Drugs)Rationale. Recommendation. Quality of Evidence. Strength of Recommendation. First- generation antihistamines (brompheniramine, carbinoxamine. Highly anticholinergic; clearance reduced with advanced age, and tolerance. Use of diphenhydramine in situations such as acute treatment of severe. Avoid. Moderate. Strong. Anti- infective (nitrofurantoin)Potential for pulmonary toxicity, hepatoxicity, and peripheral neuropathy. Avoid in individuals with creatinine clearance < 3. L/min or for long- term. Low. Strong. Antiarrhythmic (digoxin)Use in atrial fibrillation: Should not be used as a first- line agent in atrial. Avoid as first- line therapy for atrial fibrillation. Moderate. Strong. Use in heart failure: Questionable effects on risk of hospitalization and may. Avoid as first- line therapy for heart failure. Low. Strong. Decreased renal clearance of digoxin may lead to increased risk of toxic. If used for atrial fibrillation or heart failure, avoid dosages > 0. Moderate. Strong. Antipsychotics (first- [conventional] and second- [atypical]. Increased risk of cerebrovascular accident (stroke) and greater rate of. Avoid antipsychotics for. Avoid, except for schizophrenia, bipolar disorder, or short- term use as. Moderate. Strong. Antidepressants, alone or in combination (amitriptyline, amoxapine. Highly anticholinergic, sedating, and cause orthostatic hypotension; safety. Avoid. High. Strong. Insulin, sliding scale. Higher risk of hypoglycemia without improvement in hyperglycemia management. Avoid. Moderate. Strong. Proton- pump inhibitors. Risk of Clostridium difficile infection and. Avoid scheduled use for > 8 weeks unless for high- risk patients (e. NSAID use), erosive esophagitis, Barrett esophagitis. H2. blockers)High. Strong. The Beers list separates potentially inappropriate medications into several categories according to the strength of the recommendation and the potential adverse event. The first category includes drugs that are "potentially inappropriate" due to a higher risk of adverse effects and/or reduced efficacy in older patients; the AGS recommends that prescribers consider avoiding these agents [4]. The second category is for medications used in the treatment of common health problems (e. The third category is for potentially inappropriate medications that should be used with caution (and perhaps increased monitoring) in elderly patients [4]. Finally, the AGS provides a list of medications with potentially clinically important non- anti- infective drug- drug interactions that should be avoided in older adults or should be decreased in dose in those with impaired kidney function.
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