The Bagful of Pills:

Polypharmacy in the
Elderly
Oana Marcu DO
Swedish Family Medicine
March 7, 2006

Objectives
Discuss

the profound medical and economic

consequences of polypharmacy
Discuss unique pharmacokinetics in the
elderly and identify high risk medications
Propose a plan for preventing ADRs and
improving quality of life!

Definitions
Polypharmacy: use of more then 5 medications
inappropriate prescribing of duplicative
medications where interactions are likely
Adverse Drug Reaction (ADR):
drug interaction that results in an
undesirable/unexpected event that requires a
change in management

Adverse Drug Reaction (ADR)

ADRs occur as a result of
1. Drug-drug interactions
2. Drug-disease interactions
3. Drug-food interactions
4. Drug side effects
5. Drug toxicity

Consequences: Quality of Life

In

ambulatory elderly: 35% of experience

ADRs and 29% require medical intervention
In nursing facilities: 2/3 of residents
experience ADRs and 1:7 require
hospitalization
Up to 30% of elderly hospital admissions
involve ADRs
*Beers MH. Arch Internal Med. 2003

Consequences:
Economic
In

2000: ADRs caused 10,600 deaths

Annual cost of $85 billion
$76.6 billion in ambulatory care
$20 billion in hospitals
$4 billion in SNF

*Beers MH. Arch Internal Med. 2003

If medication related problems

were ranked as a disease, it
would be the fifth leading cause of
death in the US!
*Beers MH. Arch Internal Med. 2003

Unique Pharmacokinetics: normal

part of the aging process

Absorption
Distribution
Metabolism
Excretion
Evaluate the pharmacokinetic characteristics of
each medication carefully
Start low, go slow!

Geriatric Rx Principles

First consider non-drug therapies

Match drugs to specific diagnoses
Reduce meds when ever possible
Avoid using a drug to treat side effects of another
Review meds regularly (at least q3 months)
Avoid drugs with similar actions / same class
Clearly communicate with pt and caregivers
Consider cost of meds!

High Risk Medications: Beers

Beers

and Canadian criteria are the most

widely used consensus data for inappropriate
medication use in the elderly
Original 1991, revised 1997, 2002, and 2003
Excellent well researched reference
Easily available to you!

High Risk Medications: Drug

Classes
Analgesics

- NSAIDs
- Narcotics
- Muscle relaxants

Narrow Therapeutic
Index
- digoxin
- phenytoin
- warfarin
- theophylline
- lithium

High Risk Medications: Drug

Classes

Cardiovascular
- Antihypertensives
- Calcium channel
blockers
- Propranolol
- Diuretics

Psychotropics
- TCAs
- Antipsychotics
- Benzodiazepines
- Sedative/Hypnotics

High Risk Medications: Other

H2

Blockers: mental confusion, disorientation

Anticholinergic Effects: dry mouth,
constipation, urinary retention, delirium
Gastrointestinal Antispasmodics
Antibiotics (aminoglycosides)
Hypoglycemics

SO
There

are profound medical and economic

consequences of polypharmacy and adverse
drug events
Elderly have unique pharmacokinetics
There are particular high risk medications
So, lets propose a plan for preventing ADRs
and improving quality of life!

CARE: Avoiding
Polypharmamcy
Caution

and Compliance

Understand side effect profiles

Identify risk factors for an ADR
Consider a risk to benefit ratio
Keep dosing simple- QD or BID
Ask about compliance!

CARE: Avoiding
Polypharmamcy
Adjust

the Dose

Start low and go slow- titrate!

Unique pharmacokinetics in elderly
Altered:

Absorption
Distribution
Metabolism
Excretion

CARE: Avoiding
Polypharmamcy
Review

Regimen Regularly

Avoid automatic refills

Look for other sources of medications- OTC
Caution with multiple providers
Dont use medications to treat side effects of other
meds
What can you discontinue or substitute for safer
med?

CARE: Avoiding
Polypharmamcy
Educate

Talk to your patient about potential ADRs

Warn them for potential side effects
Educate the family and caregiver
Ask pharmacist for help identifying interactions
Assist your patient in making and updating a
medication list- personal medical record!

Personal Health Record

It

will reduce polypharmacy and ADRs

Multiple specialist involved in care
Transitions in care from independent living,
hospitals, nursing homes and assisted living
facilities
Great aid in emergency care
Provides the patient with more piece of
mind

Personal Health Record

Developed

by Dr. Eric Coleman, UCHSC,

HCPR :
[Link]
Patient should bring this with them to every
medical visit and present it to their provider
Each provider should update list with any
changes

Personal Health Record

Includes:
Patient

identifying information
Doctors contacts
Caregiver contacts
Past Medical History and Allergies
List of all medications, dose, reason they are
taking it and whether it is new!

Questions
Which of the pharmacologic parameters may
be associated with ADRs in the elderly?
a) Altered free serum concentration of drug
b) Diminished volume of distribution
c) Altered renal drug clearance
d) Prolonged absorption due to decreased
gastric mobility
e) All of the above

Questions
Which of the following is (are) examples of
ADRs in elderly?
a) Drug side effects
b) Drug toxicity
c) Drug disease interaction
d) Drug-drug interaction
e) All of the above

Questions
Which of the following combinations are most
commonly associated with ADRs in elderly?
a)
Cardiovascular drugs, psychotropics, and
antibiotics
b)
Cardiovascular drugs, psychotropics, and
analgesics
c)
Gastrointestinal drugs, psychotropics, and
analgesics
d)
Gastrointestinal drugs, psychotropics, and
antibiotics

Case
80 yr. widow who now lives with her daughter comes to
your office to establish care and complains of being a
nervous wreck and not being able to turn off her mind for
the past 2 yrs. She brings with her a bag of all her meds.
PMHx: CHF, irritable bowel syndrome, depression, HTN,
recurrent UTIs, stress incontinence, anemia, occipital
headaches, osteoarthritis, generalized weakness
Meds: sucralfate 1gm TID, cimetidine 300mg QID, enteric
asa 325mg, atenolol 100mg, digoxin 0.25, alprazolam
0.5mg, naproxen 500mg TID, oxybutynin 5mg BID,
dicyclomine 10mg TID, lasix 40mg , Tylenol #2 prn

Medication Red Flags:

High

risk drugs: alprazolam, oxybutynin,

tylenol #2 (narcotics), dicyclomine, NSAIDS
Digoxin at a higher then recommended dose
(0.125mg)
naproxen and aspirin carry the potential drug
related adverse events of gastritis/GIB and
sucralfate and cimetidine are being used to
treat these side effects

Case
Mrs. Jones is a 72 yr living in an assisted living facility
where she has been recently complaining of
increasing confusion, lightheadedness in the am
and difficulty sleeping at night.
PMHx: CHF, NIDDM, OA, glaucoma, depression, and
stress incontinence
Meds: furosemide, timolol gtts, metformin, ibuprofen,
paroxetine, oxybutynin,
propoxyphene/actetaminophen prn pain, and
diphenhydramine prn insomnia

Medication Red Flags:

Diphenhydramine:

sedative, anticholinergic
properties which effect cognition
Oxybutynin: anticholinergic which is known to
cause confusion at higher doses
Propoxyphene- dangerous narcotic!
Watch for Digoxin toxicity- blurred vision,
CNS disturbances, anorexia

Case
Mr. Wilson is a 81 yr who had an URI and
subsequently was admitted for acute
confusion and disorientation. He then began
wandering and having hallucinations while
spiking a fever.
PMHx: CAD with MI, COPD, DJD,
Hypothyroidism, Depression/anxiety, chronic
anemia and diarrhea, aortic valve
replacement, gout, neuropathy, bilateral total
knee replacements

 Meds:

aggrenox, neurontin, theophylline,

synthroid, allopurinol, prozac, combivent,
colchicine, Imodium prn, metamucil, calcium,
iron, multivitamin, codeine
Medical workup: significant for negative head
CT, EKG with no acute changes, UA, CBC,
LP, Chem10 and CPP are wnl, CXR shows
possible RLL infiltrate

Assessment and Plan:

1. Fever with Delirium
2. Polypharmacy
Continue infectious workup and treatment.
Start simplifying the medical regimen

Medication Red Flags:

Theophylline:

low therapeutic index and

considered less effective then inhaled
therapies
Iron deficiency anemia is more rare in men,
so check levels and maybe discontinue
supplement
Chronic diarrhea: iatragenic? From
colchicine? Also Imodium is anticholinergic
Cost: estimated monthly drug bill $430

TAKE HOME POINTS!

Polypharmacy

and ADRs have profound

medical and economic consequences
Elderly have unique pharmacokinetics
High risk medications include cardiovascular,
analgesic, psychotropics, and meds with a
low therapeutic index
Use the CARE guidelines in prescribing
Advocate for the Personal Medical Record
Start improving your patients' quality of life!

References
1.
2.
3.
4.
5.
6.
7.
8.

Swansons Family Practice Review. Fourth Ed. A. Tallia, D. Cardone,

D. Howarth, K Ibsen; Mosby 2001.
Geriatrics: 20 common problems. A. Adelman, M. Daly; McGraw Hill
2001.
Primary Care Geriatrics: A Case- Based Approach. Third Ed. R. Ham,
P. Sloane; Mosby 1997.
Essentials of Clinical Geriatrics. Fourth Ed. RL Kane, JG Ouslander,
IB Abrass; McGraw Hill 1999.
Polypharmacy. Didactic at SFM by Dr. Pat Borman
Holland EG, Degruy FV. Drug- Induced Disorders. American Family
Physician Vol 56, Nov 1, 1997.
Beers MH. Updating the Beers Crieria for 003Potentially Inappropriate
Medication Use in Older Adults. Arch Internal Med. 2003: 2716-2724.
Personal Medical Record developed by Dr. Eric Coleman, UCHSC,
HCPR : [Link]