Tips to help reduce overmedication for older patients

Author: Marian Hodges, M.D., MPH, medical director, Providence Senior Health
Sharon Leigh, Pharm.D., BCPS, clinical pharmacy manager, Providence ElderPlace, Senior Health

The use of five or more medications, or prescribing medications that may no longer be medically necessary, is known as polypharmacy. Polypharmacy can lead to increased risk of adverse effects and accounts for 10-20% of hospital admissions and 11-35% of emergency department visits. 

Most medication-adverse effects are preventable. Polypharmacy has been correlated with much of what we are trying to help our seniors avoid: falls, decline in function and/or cognition, hospitalization, drug-disease interaction and earlier death. 
 

Most common types of medications that are overused
Medications that are available over the counter often are overused because they’re easily available. They include anti-inflammatory medications (ibuprofen or Advil, naproxen or Aleve), sleep medications (diphenhydramine or Benadryl, Tylenol PM, Advil PM), and stomach acid reducers (cimetidine or Tagamet, omeprazole or Prilosec). These OTC medications can have significant drug-to-drug interactions and drug-disease interactions, and they can lead to adverse effects such as bleeds, falls, sedation and confusion.

Among prescription medications, those with anticholinergic properties have the highest risk in older adults. They can even increase the risk for developing dementia. Anticholinergics include medicines in many drug classes, such as tricyclic antidepressants, urinary incontinence medicines or antimuscarinics, opioids, antipsychotics, antihistamines and cold medicines.

Prescription medications to minimize or avoid include: 

1. Benzodiazepines
2. Sedatives/hypnotics (such as zolpidem)
3. Skeletal muscle relaxants (such as cyclobenzaprine)
4. Opioids
5. Antipsychotics
6. Proton pump inhibitors
7. Oral hypoglycemics (such as glyburide)

In addition, older adults often can experience adverse effects to these high-risk medications due to pharmacokinetic and pharmacodynamic changes that occur with aging. As a result, doses of commonly used medications – e.g., anticoagulants, diabetes medications, narcotics, antibiotics and others – need to be adjusted. Selecting the medication with the most benefit and the lowest risk is critical to patient well-being.
 

Tips for primary care and other providers
Below are best practices when prescribing for your older patients:

• For any new symptom or geriatric syndrome in a patient, first rule out medication side effects as the cause of the new presentation.
• Start at a low dose of any new medication prescribed and go slowly in titrating the dose.
• Avoid prescribing medication to address side effects of another medication.
• As part of the 4Ms of age-friendly health care – Medications, Mobility, Mentation and What Matters – avoid medications that are at high risk for adverse effects.
• Have a specific threshold on the number of medications an older adult takes (e.g., more than nine routine medications) and evaluate to deprescribe medications that are no longer providing benefit or are causing harm. 
• Deprescribe safely one medication at a time with monitoring and follow-up plan.
• Collaborate with Providence clinical pharmacists in optimizing medication use. Visit www.deprescribing.org to learn more.

Case study: Adjusting medications reduced falls and confusion
A 79-year-old woman with Type 2 diabetes, hypertension, urinary incontinence, chronic kidney disease stage III and osteoarthritis who was living independently was hospitalized for generalized weakness, a fall, delirium and weight loss. She was on multiple medications for her chronic conditions, including three medications for blood pressure, two for her diabetes, one for urinary incontinence and an OTC medication that contained diphenhydramine (Tylenol PM). 

Upon discharge, the Providence Medical Group at Home clinical pharmacist, along with social work, nursing and the provider team, improved the patient’s medication regimen by deprescribing Tylenol PM and the incontinence medicine (tolterodine or Detrol), both of which were anticholinergic and likely contributed to her weakness and fall. They also reduced her blood pressure medications (discontinued furosemide and reduced her amlodipine dose to 5mg/day) and changed to a safer alternative for her diabetes regimen (discontinued glimepiride and maximized her Metformin ER dose). These changes took several months to implement and simplified her regimen to one she can manage reliably on her own.

As a result, six months later the patient has not fallen again, is able to slowly gain back weight, and experiences less confusion. Most importantly, she continues to live independently in her apartment. 
 

How Providence Senior Health helps reduce overmedication
Senior Health is training medical and pharmacy residents at Providence Portland Medical Center, Providence St. Vincent Medical Center, and Providence Milwaukie Hospital about polypharmacy and deprescribing high-risk and unnecessary medicines. 

We also are training six to seven PMG providers each year in a Geriatric Mini Fellowship that focuses on the 4 Ms (Medication, Mobility, Mentation, What Matters) of age-friendly care. With financial support from Providence St. Vincent Foundation, we will have our first Geriatric Pharmacy Residency program starting in July and will train a clinical pharmacist to specialize in geriatrics. 

We also are working with the Epic team to create best practice alerts for prescribers by offering safer alternatives in real time when certain high-risk medications are prescribed.

For more information
www.deprescribing.org
https://www.choosingwisely.org/age/geriatric/
Contact: Sharon.leigh@providence.org