Читать книгу Pathy's Principles and Practice of Geriatric Medicine - Группа авторов - Страница 283

The physician must be able to tell the antecedents, know the present, and foretell the future — must mediate these things, and have two special objects in view with regard to disease, namely, to do good or to do no harm.

—Hippocrates

L.H. is an 88‐year‐old female with a diagnosis of hypertension, type 2 diabetes mellitus, chronic venous insufficiency, chronic depression, osteoporosis, osteoarthritis of the knees, recurrent dizziness, and mild Alzheimer’s dementia. Two weeks ago, she experienced one fall, without loss of consciousness, when she felt weak while standing in line at her local pharmacy. Subsequently, she was in hospital observation for two days and had a negative workup for acute vascular or infectious etiologies. While her sitting blood pressure was 168/90, her standing blood pressure was 132/72 and her pulse was 58. Her medications are (all taken orally) nadolol 40 mg daily, lisinopril 5 mg daily, furosemide 20 mg twice a day, spironolactone 25 mg daily, nifedipine 10 mg three times a day, metformin 1000 mg three times a day, glimepiride 4 mg twice a day, aspirin 325 mg daily, simvastatin 40 mg at bedtime, cilostazol 100 mg twice a day, omeprazole 40 mg once a day, famotidine 20 mg twice a day, sertraline 150 mg daily, trazodone 100 mg at bedtime, tramadol 50 mg three times a day, meclizine 12.5 mg every morning, oxybutynin 5 mg twice a day, donepezil 10 mg at bedtime, a multivitamin daily, ferrous sulfate 325 mg twice a day, and calcium carbonate 1000 mg three times a day. Her daughter, who is her healthcare durable power of attorney, is concerned that a medication side effect might have played a role in the fall.

Mythology introduced us to the memorable symbol of abundance known as the cornucopia, which is ubiquitously pictured as an overflowing horn‐shaped basin, typically filled with fruits and vegetables and with a positive connotation toward plenitude. On the other hand, the same idea of a cornucopia filled beyond capacity with capsules and tablets is rather ominous. Abundance, in this regard, is not necessarily a good thing. The Hippocratic maxim ‘Do no harm’ is sometimes a trying goal when it pertains to medication prescribing, and harm related to pharmacotherapy is common, pervasive, and costly. It is well known that one of the most common causes of avoidable hospital admissions in the elderly is adverse drug reactions, which, in turn, are directly correlated to the number of medications being taken.^1,2

The concepts of polypharmacy and deprescribing are relatively new, gaining traction in the mid‐1990s and becoming a more prominent and complex problem over the past two decades, as indicated by an increasing body of literature. A study in Scotland demonstrated that from 1995 to 2010, the use of five or more medications in the elderly increased from about 11% to 20%, while for 10 or more medications, it rose from a little over 1.5% to almost 6%. Along with this, an increased risk for drug interactions causing serious harm was demonstrated in 13% of older patients in 2010.³ From another study in Sweden, the use of five or more medications increased from 18% to 42% in 1992 and 2002, respectively.⁴ This same trend was observed in yet another study in Italy, in which an increase from 43% to 53% was detected in 2000 and 2010.⁵

The definition of polypharmacy is broad and sometimes puzzling. It has been defined in about 24 ways,⁶ many times inconsistently. This has led to confusion about what truly is inappropriate prescribing, resulting in challenges to identifying and measuring it. Without a standard cut‐off point for the number of prescriptions or non‐prescription drugs used, the most precise definition pertains to the use of multiple medications and more than what is deemed medically necessary.⁷ The Omnibus Budget Reconciliation Act of 1987, responsible for setting standards for care in United States nursing homes, describes unnecessary medications as those prescribed without indication or evidence of ongoing therapeutic benefit, used in excessive dose or duration, and in the presence of adverse consequences.^8,9

There is good evidence that the concomitant use of five or more medications is related to adverse reactions, most notably related to frailty, disability, mortality, and falls.¹⁰ A study conducted by the Department of Veterans Affairs (VA) healthcare system found that problems related to drug interactions or inappropriate dosing were up to 12 times higher in patients taking eight or more medications.¹¹ Adverse drug events are common in geriatric patients, with evidence that 1 in 20 older adults seeks medical care due to this problem.¹² Taking this into account, polypharmacy itself should really be considered a geriatric syndrome, since, not uncommonly, it may have consequences far more concerning than the maladies for which the medications were initially intended.¹³

Appropriate medication management in older adults can be challenging, and multiple factors need to be considered for potential benefits to outweigh possible risks. Prescribing problems such as drug interactions, unsuitable medications, wrong doses, and costly options are very common. At least one prescribing problem can be found in 50% of patients with a mean age of 75 and prescribed a median of five medications, with drug–drug interactions being problematic in 30% of those patients.¹¹ In patients on 5 to 9 medications, a 50% probability of drug‐drug interaction was detected, and this rate surged to 100% for those on at least 20 medications.¹⁴

The application of ‘evidence‐based’ guidelines to the geriatric population must be done with extreme thoughtfulness, because it is imperative for patients (and, by extent, families or care proxies) to fully understand the indications and potential risks of their pharmacotherapies. Cohesiveness in informed and shared decision‐making is paramount, and a detailed review of medications with watchful prescribing practices should be taken as one of the top priorities in the healthcare of older adults.

In this chapter, we aim to provide a greater understanding of pharmacotherapy in the ageing patient and a set of prescribing tools that will help improve medication management for older adults. Special attention will be paid to the newer concept of deprescribing with a focus on improving clinical outcomes in a standardized and individualized patient‐centred manner.