Evidence-Based Methods to Reduce Medications in Older Patients

Evidence-Based Methods to
Reduce Medications in Older
Patients
Kenneth Brummel-Smith, MD
Charlotte Edwards Maguire Professor of Geriatrics
Florida State University College of Medicine
Copyright 2007, Florida State University College of Medicine. This work was supported by a grant from the Donald W.
Reynolds Foundation. All rights reserved.
Objectives
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Describe 5 factors to consider when
discontinuing a medication
Describe 3 initiatives physicians can take to
lower medications
Describe two initiatives patients can take to
lower medications
One person’s drugs
Prevalence of the Problem
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Medication errors each year:
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7000 deaths
95,000 hospital admissions
700,000 emergency visits
3,000,000 office visits
30% more money spent on treating errors
than on medications themselves
5th most common cause of death in US
IOM, To Err is Human, 2000
FM Residency Chart Review
Epocrates Medication Check
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17% - contradicted medication combination
42% - avoid use/alternative combination
78% - monitor/modify Treatment combination
64% - caution advised combination
Beer’s List
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44% of polypharmacy patients were on a Beer’s drug
Of those on a Beer’s drug, 75% of patients were on a
high risk drug
Polypharmacy – 5 or more prescription drugs
Beer’s Drugs (High Severity)
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amitriptylene
barbituates
chlordiazepoxide
chlorpropamide
diazepam
doxepin
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flurazepan
hysocyamine
meperidine
methyldopa
pentazocine
ticlopidine
Beers MH. Explicit criteria for determining potentially inappropriate medication use by the
elderly: an update. Arch Intern Med 1997;157:1531-6.
Considering Appropriateness
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Remaining life expectancy
Time until benefit
Goals of care
Treatment targets
Cost
“Indications to Discontinue”
Holmes H, Arch Int Med, 2006
Remaining Life Expectancy
Women
Men
Walter LC, JAMA, 2001
Time Until Benefit
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Short term benefits
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Long term benefits
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Analgesics for pain
Sx relief
Primary prevention
Secondary prevention
Different than number needed to treat
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More individualized
Goals of Care
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Cure illness
Prevent death
Prevent disability
Relieve suffering
Increase function
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Promote health
Prevent transmission
Increased quality of
life
Increased control
A good death
Shared decision making
Changes as person ages
Changes as disease progresses
Treatment Targets
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Related to goals
Goal = general
Target = measurable outcome
Positive targets (to reach)
Negative targets (to avoid)
Costs
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Financial
Impact on family
Risk of adverse effects
Costs:
Aricept?
Norvasc?
Celebrex?
Effexor?
Physician’s Control- Teach Your Students!
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Minimum 2 year wait on new drugs
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Do not use drugs on the Beer’s list
Use generics
Use the 4 step approach to evaluate new and current
drugs
Use an EHR with:
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7 year wait is safer
Medication decision support
Computerized entry
73% of pts are satisfied with reductions
Straand J, Fam Prac, 2001
Teach Your Patients
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Keep a list of your drugs – show it every visit
Use only one pharmacy
Don’t ask for any drug that is advertised on TV or in
magazines
Ask how long the drug has been on the market
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Don’t take any drug until it’s been out for at least 2 years
Ask if there are other things besides taking a drug
you can do
Ask if you should stop any current drugs
Helpful Sites
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Therapeutics Initiative: Evidence Based Drug
Therapy
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www.ti.ubc.ca
Univ of British Columbia
OHSU Drug Effectiveness Review Project
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www.ohsu.edu/drugeffectiveness