Selected Articles by Anthony Caprio, MD

Dr. Anthony Caprio, Assistant Professor, Division of Geriatric Medicine - on medication connections to falls risk

The following is quoted from the UNC-CH School of Medicine Office of Educational Development newsletter, Front Line, Vol. 12, Fall 2006, p. 2.

With permission from the editor of The Front Line, Katherine Savage

“Your third-year student is seeing an elderly patient in your office for follow-up after an emergency department visit for a fall. The patient brings a very long list of medications with her. Although you have prescribed some of these medications, many have been prescribed by other physicians, including specialists and hospital physicians. As the student frantically tries to look up all the medications on her handheld computer, she expresses frustration dealing with the complexity of medication management in older patients. She asks how you approach this challenging situation, evaluate possible interactions, consider the indications or contraindications for each medication, and assure that the patient is able to adhere to the prescribed regimen. What strategies would you suggest?”

 

W. James Stackhouse, MD, Goldsboro Medical Specialists:

Management of multiple medications and their side effects in the elderly patient can be frustrating, particularly when several physicians are involved, and sometimes the patient doesn’t really know the reason for the medication.

But the list of medications is really a medical history of the patient, if approached in the right manner.

The first step is to separate out those supplements from the pharmacy or health food store that are self prescribed. Put them aside, but don’t disparage their use in front of the patient too soon!

If the prescription bottles are available, the date of the prescription or the name of the prescribing doctor may give some clue to the circumstances of the encounter with the previous treating physicians. ER physicians, for example, rarely give refills of any medications, to encourage patients to follow up with their primary care providers. Acute and chronic medications can often be distinguished this way.

The next step is to segregate the various medications into groups based on a combination of the patient’s knowledge of what each is for, or your own suspicion of its use, or the indication on the pharmacy label, based on three categories: 1) medications for non-life-threatening problems or indications (such as antihistamines, sleeping pills, incontinence or constipation meds, calcium and Vitamin D, etc.), 2) medications for indications that are not immediately life-threatening if discontinued for a few days, or that you do not know the indication when prescribed (mild diuretics, hypertensives, antidepressants, etc.), and 3) medications for potentially life-threatening problems (cardiac dysrhythmia, seizures, diabetes.)

Focus on the third group first, and reconsider the potential drug interactions and side effects of the first two in the management of the patient. Discuss with the patient the elimination on a trial basis of medications in the first group which have the most chance of adverse reaction or outcomes.

I find that one of the best references for dealing with multiple drug prescribing in elderly patients is at the American College of Physicians web site, www.acponline.org. Student membership in the ACP is free, and the online Physicians Information and Education Resource (PIER) at that site has an excellent discussion and helpful information in the section “Drug Prescribing in the Elderly Patient,” as well as links to helpful sites and journal articles.

Anthony Caprio, MD, Assistant Professor of Medicine, Division of Geriatric Medicine, Program on Aging, UNC-CH: I would share the following strategies with the student:

1) Identify risk factors for Adverse Drug Events (ADEs). ADEs are common and often preventable health complications for elderly patients. A recent study showed that older adults are disproportionately represented in the number of visits to the emergency department for ADEs, and they are seven times more likely to be admitted to the hospital for an ADE than younger adults (JAMA 2006; 296:1858-1866).

There are normal physiologic changes associated with aging that increase an older person’s risk for an ADE, including decreased total body water, increased proportion of body fat, decreased lean muscle mass, and decreased renal excretion. In addition, at least 2/3 of older adults are prescribed routine medications. The primary risk factor for an ADE is simply the number of medications (both prescribed and over-the-counter) that a patient takes. A long medication list is also associated with lower adherence to a prescribed regimen and a decreased quality of life.

2) Attempt to shorten medication lists. Watchful waiting and non-pharmacologic approaches (like diet and exercise) can substitute for prescription medications in some cases. Stopping medications requires thoughtful consideration of the risks and benefits of each medication. This can be frustrating, because there is little evidence to guide decision-making. Elderly patients are often not included in drug trials because of age, comorbidities, and an inability to consent.

 It is important to review medication lists (including over-the-counter and herbals) before making a new diagnosis. ADEs can masquerade as common clinical conditions in the older adult population. Constipation, memory loss, falls, urinary incontinence, and Parkinsonism are common conditions in older patients, but all of these conditions could be caused by a medication. The prescribing cascade refers to the prescribing of a new drug to treat the ADE associated with another drug.

3) Use the Beers Criteria as a guide. The Beers Criteria (Arch Intern Med 2003;163:2716-2724) lists potentially dangerous medications for the elderly and should prompt a clinician to exercise extreme caution when prescribing these medications. Beers Criteria medications include drugs with anticholinergic effects, which can cause cognitive impairment, falls, urinary retention, and constipation. These include diphenhydramine, tricyclic antidepressants, and anti-spasmodics.

4) Incorporate tips for avoiding medication errors. First, write the indication for each medication on the prescription along with the dosing instructions. For example, writing “one tablet daily for high blood pressure,” is a useful way of avoiding confusion. Second, have the patient use a pill box, especially if they take multiple medications or multiple doses. Try to use once-daily medications if possible. Combination pills are now available, and some are even available as generics. Third, reconcile written medication lists at every office visit, but especially after hospital discharges. Even better, have the patient bring the prescription bottles to each office visit. Finally, don’t miss common drug interactions or prescribing errors. Handheld computers, electronic medical records, and your local pharmacist can be valuable resources to avoid dangerous drug interactions.

5) Set treatment goals based on the individual. Weighing the risks and benefits is essential to good prescribing. Making a patient orthostatic with too many antihypertensive medications will put them at risk for falls and fractures; a devastating and potentially deadly clinical event. On the other hand, under-treatment of hypertension increases a patient’s risk of having a stroke. It is important to avoid under-treating medical conditions in the elderly, but it is also important to set treatment goals based on individual circumstances.

Using therapies with proven benefits after five or more years has little relevance to a patient who prioritizes quality of life unencumbered by daily medications or bothersome side effects and has a life expectancy of less than five years. The art of medicine is incorporating the patient’s personal goals into treatment decisions. Incorporating goals is also the best way to enhance compliance.

I would encourage the student to use evidence-based practice whenever possible when making prescribing decisions, but also to realize that the evidence is limited for older adults with multiple chronic diseases taking multiple medications. We need to encourage more research and a rational approach to the development of guidelines for elderly patients, but we must always remember that older adults are a heterogeneous population, and individualized prescribing will maximize benefits and minimize risks.

Last updated 5/15/2008.