Improve your prescribing practices with tips from The Curbsiders as Matt, Stuart and Paul “Pwilliams” discuss safe prescribing in frail, older adults with diabetes, chronic kidney disease, hypertension, and/or dementia in this part two episode on polypharmacy and deprescribing.
Full show notes available at http://thecurbsiders.com/podcast
- Diabetes: A1C goal 7-7.5% for healthy older adults, 7.5-8% if moderate comorbidity and < 10 years life expectancy, and 8-9% if limited life expectancy (from AGS Choosing Wisely). An A1C <7 (or 6.5%) in the elderly is okay if done safely.
- Hypertension = Check standing blood pressure to assess for orthostatic hypotension. One minute is probably sufficient to determine risk (NEJM Journal Watch 2017). Use more lenient goal <150/90 in frail elderly.
- Chronic kidney disease: Utilizing the same equation used in phase 3 clinical trial for a given medication is probably too complicated. For now, we recommend picking an equation, then assuming eGFR (or CrCl) is +/- 5 points from calculated value.
- Dementia: Donepezil improves Mini Mental Status examination score by about 1.5 points. Clinical significance/benefit is questionable, but a 3 month trial with close monitoring for side effects of nausea, urinary incontinence, bradycardia, and weight loss is recommended (from AGS Choosing Wisely).
Goal: Listeners will define, and recognize polypharmacy; recognize steps required for deprescribing; identify culprit medications, and avoid adverse events.
After listening to this episode listeners will…
- Define polypharmacy, deprescribing, and prescribing cascade
- Develop better medication lists
- Evaluate a patient’s medication list and recognize inappropriate prescribing
- Counsel patients on polypharmacy and deprescribing
- Identify common drug-drug and drug-disease interactions
- Become familiar with tools for safe prescribing
- Safely dose medications in chronic kidney disease
The Curbsiders report no relevant financial disclosures, but hope to have a long list of disclosures in the future ; )
Links from the show:
- American Geriatrics Society Ten Things Clinicians and Patients Should Question – Choosing Wisely 2013
- No Need to Wait 3 Minutes After Standing to Assess Orthostatic Hypotension. NEJM Journal Watch 2017
- J Am Geriatr Soc. 2015 Nov;63(11):2227-46. doi: 10.1111/jgs.13702. Epub 2015 Oct 8. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. By the American Geriatrics Society 2015 Beers Criteria Update Expert Panel.
- JAMA Intern Med. 2016 Apr;176(4):482-3. doi: 10.1001/jamainternmed.2015.8597. Polypharmacy-Time to Get Beyond Numbers. Steinmain, MA.
- JAMA Intern Med. 2016 Apr;176(4):473-82. doi: 10.1001/jamainternmed.2015.8581. Changes in Prescription and Over-the-Counter Medication and Dietary Supplement Use Among Older Adults in the United States, 2005 vs 2011. Cato DM, et al.
- Estimating Creatinine Clearance in the Elderly: To Round or Not to Round? by Michael J. Postelnick, BSPharm on Medscape
- JAMA. 2016 Mar 8;315(10):1034-45. doi: 10.1001/jama.2016.0299. Polypharmacy in the Aging Patient: A Review of Glycemic Control in Older Adults With Type 2 Diabetes. Lips KJ, et al.
- JAMA. 2015 Jul 14;314(2):170-80. doi: 10.1001/jama.2015.7517. Polypharmacy in the Aging Patient: Management of Hypertension in Octogenarians. Bents A , et al.
- South Med J. 2015 Feb;108(2):97-104. doi: 10.14423/SMJ.0000000000000243. Rules for improving pharmacotherapy in older adult patients: part 1 (rules 1-5). Wooten JM.
- South Med J. 2015 Mar;108(3):145-50. doi: 10.14423/SMJ.0000000000000257. Rules for improving pharmacotherapy in older adult patients: part 2 (rules 6-10). Wooten JM.
- Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med 2015
- Donepezil and memantine for moderate-to-severe Alzheimer’s disease. NEJM 2012