Managing Medications in Clinically Complex Elders "There's Got to Be a Happy Medium"

ArticleinJAMA The Journal of the American Medical Association 304(14):1592-601 · October 2010with17 Reads
DOI: 10.1001/jama.2010.1482 · Source: PubMed
Abstract
Multiple medication use is common in older adults and may ameliorate symptoms, improve and extend quality of life, and occasionally cure disease. Unfortunately, multiple medication use is also a major risk factor for prescribing and adherence problems, adverse drug events, and other adverse health outcomes. Using the case of an older patient taking multiple medications, this article summarizes the evidence-based literature about improving medication use and withdrawing specific drugs and drug classes. It also describes a systematic approach for how health professionals can assess and improve medication regimens to benefit patients and their caregivers and families.
    • "2. Know the actions, adverse effects, and toxicity profiles of medications prescribed; avoid and be vigilant of high-risk drugs as identified by the 2012 Beers criteria. 3. Start new medications at a low dose and titrate up based on tolerability and response; give a time-limited trial for new medications to determine if the medication is working ( " start low and go slow " ). 4. Prioritize medication prescribing – consider the patient's life expectancy/prognosis/quality of life and time to benefit, and modify treatment for the elderly according to life expectancy [33, 34]. 5. Avoid using one drug to treat the side effects of another (e.g., prescribing cascade). "
    [Show abstract] [Hide abstract] ABSTRACT: Elderly patients present a unique challenge to the family physician. They commonly present with multiple problems that are each multifactorial. A systematic approach is needed to assess and manage the common problems of the elderly. More complete reviews may be found in textbooks of geriatric medicine [1, 2].
    Chapter · Jan 2017 · Archives of gerontology and geriatrics
    • "Due to multiple concomitant diseases, medication intake usually increases in older people, so that polypharmacy, a well-known risk factor for drug-drug interactions (DDIs) and adverse drug reactions (ADR), is highly prevalent. In older people, these risks are also increased because ageing is often accompanied by physiological changes in the pharmacokinetic (PK) and pharmacodynamic processes [11, 12]. In older CML cases exposed to polypharmacy, the use of TKIs may be another risk factor for DDIs, because these drugs are extensively metabolized by cytochrome (CYP) P450. "
    [Show abstract] [Hide abstract] ABSTRACT: Background: About 40% of all patients with chronic myeloid leukemia are currently old or very old. They are effectively treated with imatinib, even though underrepresented in clinical studies. Furthermore, as it happens in the general population, they often receive multiple drugs for associated chronic illnesses. Aim of this study was to assess whether or not in imatinib-treated patients aged >75 years the exposure to polypharmacy (5 drugs or more) had an impact on cytogenetic and molecular response rates, event-free and overall survival, as well as on hematological or extra-hematological toxicity. Methods: 296 patients at 35 Italian hematological institutions were evaluated. Results: Polypharmacy was reported in 107 patients (36.1%), and drugs more frequently used were antiplatelets, diuretics, proton pump inhibitors, ACE-inhibitors, beta-blockers, calcium channel blockers, angiotensin II receptors blockers, statins, oral hypoglycemic drugs and alpha blockers. Complete cytogenetic response was obtained in 174 patients (58.8%), 78 (26.4%) within 6 month, 63 (21.3%) between 7 and 12 months. Major molecular response was obtained in 153 patients (51.7%), 64 (21.6%) within the 12 month. One hundred and twenty-eight cases (43.2%) of hematological toxicity were recorded, together with 167 cases (56.4%) of extra-hematological toxicity. Comparing patients exposed to polypharmacy to those without, no difference was observed pertaining to the dosage of imatinib, cytogenetic and molecular responses and hematological and extra-hematological toxicity. Conclusion: Notwithstanding the several interactions reported in the literature between imatinib and some of the medications considered herewith, this fact does not seem to have a clinical impact on response rate and outcome.
    Full-text · Article · Aug 2016
    • "Monitoring excessive polypharmacy and avoiding the occurrence of prescription cascades remains important (Walckiers et al., 2015). Considering these risks, a systematic approach is needed to tailor medications to particular patients (Steinman & Hanlon, 2010). This may require more exhaustive clinical guidelines that account for the characteristics of individual patients. "
    [Show abstract] [Hide abstract] ABSTRACT: Objectives: To assess and compare the prevalence of prescribing of potentially inappropriate medications (PIMs) identified using the Beers and STOPP criteria; and to determine the clinical variables related with the prescription of PIMs in older adults. Methods: An observational study of 250 patients aged 65 years or older was conducted in a large teaching hospital. Beers (2012) and STOPP (2008) criteria were utilized to identify PIMs. Data on age, sex, admission and discharge dates, diagnoses, and medications prescribed were obtained from medical records. Multivariate logistic regression was used to determine patient variables related with the prescription of PIMs. Key findings: Using Beers criteria, 375 PIMs were identified in 198 patients. 32% of these patients were prescribed one PIM, 20% were prescribed two PIMs, and 48% were prescribed more than two PIMs. Using STOPP criteria, 148 PIMs were identified in 120 patients. 41% of these patients were prescribed one PIM, 51% were prescribed two PIMs, and 8% were prescribed more than two PIMs. An association between PIM prescribing and polypharmacy was detected with both criteria. After adjusting for confounding variables, the prescription of Beers-identified PIMs was significantly associated with patients older than 80 (OR: 2.99; 95% CI: 1.13-7.89) and with length of hospital stay of more than 15days (OR: 2.78; 95% CI: 1.20-6.44). Conclusion: These two criteria showed that the prescription of PIMs is prevalent in hospitalized elderly patients. It may be beneficial to educate healthcare teams about these criteria to reduce the prescription of PIMs.
    Full-text · Article · Aug 2016
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