Month: August 2019

Aging.  One of life’s inevitabilities that some people embrace and others fight.  Regardless of one’s attitude, getting older is a certainty. Becoming “elderly” is someone who is at least 65 years old, by most definitions. However, many of these people do not require geriatric care until they are 70, 75 or even 80 years old.¹ EMS professionals assess and treat many patients in this age range daily, partially due to the longevity of the Baby Boomer generation – individuals born between 1946 and 1964.  Keep in mind that aging is a unique process. A 75-year-old with multiple ailments and the same-aged healthy patient metabolize drugs differently.

Several physiological changes occur with aging.  The elasticity of the lungs decreases, as does vital capacity.  Vascular peripheral resistance increases, leading to hypertension.  The kidneys atrophy, and eventually have a decrease in blood flow, filtration, secretion, and reabsorption.  Combine this with the decreased activity of certain liver enzymes and increased serum drug levels, the likelihood of adverse drug effects is high.  Decreases in lean body mass, muscle mass, total body water and an increased cellular resistance to insulin and glucose intolerance occur.  This causes a higher incidence of diabetes, dehydration, and loss of strength and balance – resulting in a higher incidence of syncope, falls and increased drug elimination time.

Polypharmacy

Polypharmacy (commonly defined as taking more than 5-10 drugs per day²) is essentially a geriatric issue. Elderly patients are generally sicker and require more medical therapy than younger patients, taking multiple medications for a myriad of medical problems.  Consider the following cases:

• 80-year-old male
  • Hx: COPD, atrial fibrillation, coronary artery disease, hypertension, and hyperlipidemia
  • Meds: warfarin 5mg daily, ipratropium/albuterol inhaler, 2 puffs 4 times daily, simvastatin 40mg daily, metoprolol 50mg twice daily, aspirin 81mg daily, amlodipine 10mg daily
• 89-year-old female
  • Hx: Alzheimer’s disease, overactive bladder, osteoporosis, glaucoma, hypertension, depression, iron deficiency anemia
  • Meds: Calcium/Vitamin D 600/200 BID, alendronate 70 mg weekly, donepezil 10 mg daily, solifenacin 7.5 mg daily, sertraline 50 mg daily, lisinopril 40 mg daily, latanoprost eye drops daily, ferrous sulfate 325 mg daily

The multiple pathologies these patients live with many times require EMS intervention and/or transportation.  As the number of medical problems increases with their age, these patients eventually are evaluated and managed by multiple specialist physicians. However, communication between these physicians is typically minimal to non-existent. This leads to multiple medications being prescribed and taken by the elderly patient – potentially resulting in dangerous drug interactions.  Multiple medical conditions alone pose diagnostic challenges. Add to the mix multiple medications with the various signs and symptoms they produce, and/or ones’ they may mask, and diagnosis and appropriate interventions become very difficult for the EMS professional.  Additionally, large numbers of prescription medications have a correlation to poor health outcomes.³

There are other negative consequences associated with polypharmacy.  These include adverse drug events, drug-drug interactions, non-adherence taking a medication, cognitive impairment, falls, and compromised nutritional status.

Adverse Drug Events

A population-based study discovered that elderly patients taking five or more medications had an 88% increased risk of experiencing an adverse drug event compared to those who were taking fewer medications.⁵

Anticoagulant drugs, antidiabetic drugs, and drugs with a narrow therapeutic index (e.g. digoxin and phenytoin) account for almost 50% of all adverse drug events in the elderly.⁴ Therapeutic index is a ratio that compares the blood concentration at which a drug becomes toxic and the concentration at which the drug is effective. If the therapeutic index is narrow (the difference between the two concentrations is very small), even though the drug dose is appropriate, the patient can easily become toxic from taking one extra dose with their normal dose.

Commonly prescribed medications cause a variety of side effects in the elderly patient. These include: aspirin (gastrointestinal bleeding), digitalis preparations (toxicity, depression), antidepressant medications (altered mental status, cardiac, seizures), loop diuretics (incontinence), over-the-counter sympathomimetics (urinary retention), medications for hypertension (dizziness, syncope), benzodiazepine sedatives (falls) and narcotic analgesics (altered mental status, constipation/impaction).⁷ Thus, EMS professionals may observe a wide variety of signs, symptoms and complaints in an elderly patient that takes multiple medications.

Drug Interactions

Drug interactions are more likely to occur as the elderly patient’s number of mediations increases.  One particular study determined that a patient taking 5-9 medications had a 50% probability of an interaction, whereas the risk increased to 100% when a patient was taking 20 or more medications.⁶

A drug interaction occurs when two medications, taken together, results in a pharmacologic change of at least one of the medications, either magnifying or reducing the affected medication’s action.  Mixing alcohol or over-the-counter medications with prescription medication may enhance its therapeutic effect and result in toxicity.

Drug interactions can also alter the rate of drug metabolism.  Many commonly prescribed medications suppress specific liver enzymes that are responsible for breaking down other ingested medications.  As more of the liver’s detoxification ability changes, drug metabolism is delayed.  This results in multiple medications remaining in the patients’ bloodstream longer, prolonging their effects.

Medication Non-adherence

Medication non-adherence is associated with potential disease progression, hospitalization, and adverse drug effects.  Non-adherence rates in community-dwelling elderly adults has been reported to be between 43-100%.⁸ Multiple medications that an elderly patient requires enhances this problem.  There are several issues associated with non-adherence, including:

• Forgetting to take their medication. Patients with Alzheimer’s and other forms of dementia, as well as the average aging patient, become forgetful.  Sometimes this results in not taking a dose at all.  A patient may forget they took a dose, but actually did, then take a second dose. If a patient is depressed, they may not be motivated to fill their prescriptions, or after getting them filled, may not want to take them.
• Inability to afford their medications. A large percentage of senior citizens live on fixed incomes. With the rising cost of medications, patients may be in a position where they have to decide between paying for food or multiple medications.  The problem that arises is that some medications need to be taken with food, otherwise, unwelcome side effects occur.  Elderly adults have also been known to cut pills in half, skip doses, or skip meals to save money.
• Failure to complete/maintain the entire course of therapy. A common scenario is a patient taking antibiotics.  He or she feels better after a few days, so they stop taking the medication.  Soon thereafter, a worse infection than the previous typically manifests.  Patients on diuretics figure out that if they stop taking their medication, they don’t have to go to the bathroom as often.  When the effects catch up, EMS is called for CHF acerbation and/or pulmonary edema.  If medications are stopped and the patient is still taking other multiple other medications, the changes in metabolite concentrations may alter or enhance their actions as well.
• Problems with the container. Childproof caps also become elderly-proof, especially with patients suffering from arthritis.  The patient can’t open the container(s), so he or she doesn’t take their medication(s).  Patients with poor eyesight and/or poor ambient lighting may not be able to read labels or small print.  They can’t distinguish what to take, so the elderly patient doesn’t take the right medication when they should, or take too much of a medication that they shouldn’t.

Cognitive Impairment

Cognitive impairment, seen with both delirium and dementia, has been associated with polypharmacy. A study in hospitalized elderly adults determined that increasing the number of medications was a risk factor for developing delirium.⁹   Another study in elderly patients with dementia reported that these patients who reported a fall had an increased prevalence of polypharmacy.¹⁰ Several drugs, particularly psychotropic medications (e.g. Xanax, Zoloft, Celexa, Prozac, Ativan, Lexapro), can cause cognitive impairment.

Falls

After aging, polypharmacy may be the most common risk factor for falls in older adults. An analysis of over 800 ED patients aged greater than 65-years-old found drugs given for GERD and peptic ulcer disease, analgesics, anti-Parkinson drugs, nasal drugs, medicated eye drops, antipsychotics, and antidepressants were significantly associated with EMS calls for recurrent falling.¹¹ In another study of elderly adults, the risk of experiencing a fall was increased by 7% for each additional medication prescribed to the patient.¹²

There are specific drug interactions that may lead to falls that deserve special attention.  Antidiabetic agents (sulfonylurea) when taken with beta-blockers or antibiotics may cause an acute hypoglycemic event and possible fall.  Any patient on antihypertensive therapy (especially calcium channel blockers) is at risk for orthostatic hypotension, which may lead to a fall.  The risk is increased if the patient is taking erythromycin or clarithromycin.¹⁵ Opioids such as codeine or tramadol, when taken with serotonin selective reuptake inhibitors (Celexa, Lexapro, Prozac, Paxil, Zoloft) can also increase the likelihood of a fall.

Nutrition

Polypharmacy has been reported to affect a patient’s nutritional status. A survey of community-dwelling elderly adults found that polypharmacy was associated with a reduced intake of fiber, fat-soluble and B vitamins and minerals, as well as an increased intake of cholesterol, glucose, and sodium.¹³ The diseases and conditions most frequently implicated in the development of malnutrition include the following patients:¹⁴

• higher age groups, particularly 80-years-old, and older
• chronic respiratory diseases
• digestive tract diseases
• tumors
• neurodegenerative diseases, chronic infections and psychiatric diseases

These patients are often managed with long-term therapy, involving multiple prescribed medications.

Nearly 50% of older adults take one or more medications that are not medically necessary and research has established a strong relationship between polypharmacy and negative clinical outcomes. Polypharmacy has been and always will be common among the elderly population due to the need to treat various disease states that develop as a person ages. Unfortunately, with this increase in the use of multiple medications comes an increased risk for negative health outcomes such as higher healthcare costs, adverse drug events, drug interactions, medication non-adherence, and potential for traumatic falls, TBI, and potentially death

References

1. Besdine, R.W. (2019, April) Introduction to Geriatrics. Retrieved from: https://www.merckmanuals.com/professional/geriatrics/approach-to-the-geriatric-patient/introduction-to-geriatrics
2. Ferner RE and Aronson JK. Communicating information about drug safety. BMJ 2006 Jul 15;333(7559):143-5.
3. Hajjar ER, Cafiero AC, Hanlon JT. Polypharmacy in elderly patients. Am J Geriatr Pharmacother. 2007;5(4):345–351.
4. Samaras N, Chevalley T, Samaras D, et al. Older patients in the emergency department: a review. Ann Emerg Med 2010;56:261-269.
5. Bourgeois FT, Shannon MW, Valim C, et al. Adverse drug events in the outpatient setting: an 11-year national analysis. Pharmacoepidemiol Drug Saf. 2010;19:901–10.
6. Doan J, Zakrewski-Jakubiak H, Roy J, et al. Prevalence and risk of potential cytochrome p450-mediated drug-drug interactions in older hospitalized patients with polypharmacy. Ann Pharmacother. 2013;47:324–32
7. Limmer, D.D., Mistovich, J.J., Krost, W.S. (2006, September 1). Beyond the Basics: Geriatric Care. Retrieved from: https://www.emsworld.com/article/10322463/beyond-basics-geriatric-care
8. Vik SA, Maxwell CJ, Hogan DB. Measurement, correlates, and health outcomes of medication adherence among seniors. Ann. Pharmacother. 2004;38:303–12.
9. Martin NJ, Stones MJ, Young JE, et al. Development of delirium: a prospective cohort study in a community hospital. International Psychogeriatrics. 2000;12:117–27.
10. Lee CY, Chen LK, Lo YK, et al. Urinary incontinence: an under-recognized risk factor for falls among elderly dementia patients. Neurourol Urodyn. 2011;30:1286–90.
11. Askari M, Eslami S, Scheffer AC, Medlock S, de Rooij SE, van der Velde N, Abu-Hanna A. Different risk-increasing drugs in recurrent versus single fallers: are recurrent fallers a distinct population? Drugs Aging 2013 Oct;30(10):845-51.
12. Damian J, Pastor-Barriuso R, Valderrama-Gama E, de Pedro-Cuesta J. Factors associated with falls among older adults living in institutions. BMC Geriatr. 2013;13:6.
13. Heuberger RA, Caudell K. Polypharmacy and nutritional status in older adults. Drugs Aging. 2011;28:315–323
14. Zadak, et.al. “Polypharmacy and malnutrition.” Current Opinion in Clinical Nutrition and Metabolic Care, vol. 16, no. 1, 2013, pp. 50–55, journals.lww.com/co-clinicalnutrition/fulltext/2013/01000/Polypharmacy_and_malnutrition.9.aspx
15. Wright AJ, Gomes T, Mamdani MM, Horn JR, Juurlink DN. The risk of hypotension following co-prescription of macrolide antibiotics and calcium-channel blockers. CMAJ 2011 Feb 22;183(3):303
16. Nixon, R.G. 2003. Geriatric Prehospital Care, 1^st Ed, pp. 97-102. New Jersey: Pearson Education.
17. Snyder, D.R., Christmas, C. 2003. Geriatric Education for Emergency Medical Services, pp. 261-274. New York, NY: American Geriatrics Society and Sudbury, MA: Jones and Bartlett.