Too much of a good thing: John Newman, MD, PhD Assistant Professor of Medicine Division of Geriatrics, UCSF
Disclosures No financial interests to disclose 2
Medications and you Medications save lives What is polypharmacy Principles of medications in older adults What you can do [We ll talk principles, not specific medical advice] 3
Medicines save lives 4
Treating high blood pressure saves lives HYVET: A randomized trial in adults over 85 years old Treating high blood pressure reduced deaths by 20%! NEJM 2008, 358:1887 5
Treating high blood pressure saves lives SPRINT: A randomized trials of intensive blood pressure lowering Aiming for a lower blood pressure goal reduced deaths by more than 20%! (Especially in adults over 75) NEJM 2015, 373:2103 6
Treating high blood pressure keeps us healthy HYVET: Fewer strokes, less heart failure Treating high blood pressure dramatically reduced how many people developed heart failure over time NEJM 2008, 358:1887 7
Too much of anything can harm 8
We can t survive without water But you can drown in too much of it 9
Polypharmacy Polypharmacy = Too many medications 10
Problems caused by polypharmacy Side effects Interactions with other medications Difficult to take them all as intended Prescribing cascades Expensive Medicalizing life 11
Polypharmacy is easy Easy as (following a recipe for) pie Patients have diseases Diseases have guidelines Follow the guidelines 12
Polypharmacy is easy Example: A 79-year-old woman with five common diseases: Diabetes COPD/emphysema High blood pressure Osteoporosis Osteoarthritis JAMA 2005: 294: 716 13
Polypharmacy is easy Optimal guideline-driven therapy: 12 medications 19 doses 5 times of the day 14
How many medications do we take? Community-dwelling older adults: 28% take 5 or more medications Nursing home residents: Up to 74% take 9 or more medications Jokanovic JAMDA 2015; Beloosesky Clin Interv Aging 2013 15
Many of these may not be helpful More medications often means more inappropriate medications: Potentially unsafe, ineffective, unnecessary, or duplicative Steinman et al., JAGS 2008 16
Principle: Diminishing benefits and increasing harms 17
Each medication adds a smaller benefit The first medication you take for diabetes, blood pressure, etc. has the biggest clinical benefit. Effect size Diminishing marginal benefit Each additional medication may still help, but not as much. Number of meds 18
and an increasing risk of harm Effect size Diminishing marginal benefit Increasing marginal risks Falls Cognitive decline Delirium Hospitalization Med interactions Side effects Incorrect use Etc etc Number of meds 19
Choose wisely! Effect size Diminishing marginal benefit Increasing marginal risks Falls Cognitive decline Delirium Hospitalization Med interactions Side effects Incorrect use Etc etc Where you and your doctor should be! Choose wisely! Number of meds 20
Principle: Goldilocks 21
Treatments should be just right Older adults often benefit enormously from treating diseases like high blood pressure or heart disease These diseases and their dreaded effects, like strokes or heart attacks, are more common in older adults But older adults can also be harmed by over-treatment, which at extremes can be as dangerous as the disease being treated 22
Goldilocks: U-shaped curves Risk or Outcom e (e.g. death) Not enough treatment Just right! Too much treatment Intensity of treatment 23
Goldilocks: U-shaped curves Risk or Outcom e (e.g. death) Blood pressure too high = Strokes Heart attacks Just right! Blood pressure too low = Falls Strokes Intensity of treatment 24
Example: Blood pressure and kidney disease Study of 650,000 older veterans with high blood pressure and kidney disease How did their treated blood pressure affect their risk of dying? Kovedsy et al., Annals IM 2013 25
Principle: Everyone gets side effects, but older adults get them worse 26
Why are side effects worse in older adults? Slower to metabolize/clear medications from the body Reduced kidney function Reduced liver function Change/decrease in volume of distribution More adipose tissue, less total body water More interactions Polypharmacy is common More diseases Side effects more likely to be significant Less overall physiological resilience 27
Young adult feels a bit dizzy, older adult falls Physiological changes make the elderly less able to cope with perturbations caused by drugs (or anything else) Range of OK Age This is called homeostenosis, or a narrowing (stenosis) of the ability to maintain homeostasis 28
Why are side effects worse in older adults? Vascular: Reduced arterial compliance Cardiac: Reduced maximum heart rate, sick sinus/bradycardia How does a side effect (dizziness from low blood pressure) interact with changes from age to cause a fall? Renal: Less able to concentrate urine, prone to dehydration Muscles: Reduced muscle mass and strength, unable to recover from nearfall Vascular: Immobile, blood pools in venous insufficient legs during prolonged seated period 29
Corollary: A new symptom is a medication side effect until proven otherwise 30
Watch out for the prescribing cascade High blood pressure prescribe amlodipine Next visit: leg swelling prescribe furosemide for heart failure Next visit: urinary incontinence prescribe oxybutinin Next visit: confusion dementia? Three new diagnoses, three new medications Boy, Dad is not doing so well 31
Watch out for the prescribing cascade High blood pressure prescribe amlodipine Next visit: leg swelling prescribe furosemide for heart failure Next visit: urinary incontinence prescribe oxybutinin Next visit: confusion dementia? All side effects! The first step should be to stop/change amlodipine 32
What can you do? 33
Why am I taking this? 34
Why do we take medications? Disease Risks Symptoms What is most important to you? 35
Why do we take medications? Disease Bad: I have X, therefore I must take Y Risks Good: Prevent strokes What is most important to you? Symptoms Good: Treat tremor Is it worth possible side effects? How do I weigh it against other medications? 36
Beware zombie medications No one knows where it came from No one knows what it s for Is anyone brave enough to stop it? Zombie medications are especially common after ER visits or hospitalization. Often they were never meant to be continued long-term. 37
Is this the right medicine? 38
Ask your doctor about the Beers Criteria Beers Criteria is from the American Geriatrics Society List of medications that should be used with caution specifically in older adults Updated every few years by national experts http://www.healthinaging.org/medications-older-adults/ 39
2015 Beers: Ten groups of medicines Non-steroidal anti-inflammatory drugs (NSAIDs) Digoxin (Lanoxin) Certain diabetes drugs Muscle relaxants Certain anxiety and insomnia drugs Certain anticholinergic drugs Meperidine (Demerol) Certain antihistamines like diphenhydramine Antipsychotics Estrogen pills and patches 40
Ask your doctor about the Beers Criteria 41
Most serious problems are from a few meds Blood thinners - bleeding Diabetes medicines low blood sugar Inherent in how the medicines work Sudden and serious Budnitz et al., NEJM 2011 42
With great power Powerful medicines save lives Poweful medicines carry powerful risks Know how you affect how the medicine works Diet, monitoring, timing, etc. Know how to identify serious side effects early Tell your doctor everything about these medicines Ask for help 43
Is this the right medicine for me? 44
Precision medicine: Is it right for you? Do any of my other medical problems affect this? What about my kidneys? Your medical history Your other medicines Will this interact with my warfarin? How will this work with the other medicine I take for that? Your priorities How do I weigh the expected benefit vs the possible risks? How would the common side effects affect me? Is this my most important medicine, or the 10 th most important? 45
For every new medicine, and at least once a year for all medicines: Why am I taking this? Do I still need it? Is it still the best choice? 46
Make sure all of your doctors know everything you take 47
Keep all of your doctors in the know Safe prescribing requires knowing everything you take Avoid duplication, interactions, etc. Bring your medications (or an updated list) to every appointment Tell each doctor about any recent changes Ideally, pick one doctor do all the prescribing 48
Tell you doctors about any problems! Trouble with insurance or the pharmacy Trouble with affording medications Need help organizing or taking medications? Possible side effects If for a symptom, does the medicine help? If you don t tell them, they ll never know! 49
Principles of medications for older adults Diminishing benefits and increasing harms Both under-treatment and over-treatment can cause harm Side effects are often worse in older adults A new symptom is a medication side effect until proven otherwise 50
What you can do For every new medication, and at least once a year for all medications: Why am I taking this? To prevent something bad, or to help me feel better? Do I still need to take this? Is it important enough to take? Is this the right medication? American Geriatrics Society Beers Criteria Have I changed? Make sure all of your doctors know everything you take Tell your doctors of any problems with your medications 51
Less is often more! 52
Thank you! 53 geriatrics.ucsf.edu healthinaging.org