Be a ‘star’: Get older patients off high-risk meds

Issue Focus: Geriatrics

“Tom” had tried several pain medications for his severe headaches. When they didn’t help, he was hospitalized for a costly workup that led nowhere. The older man still didn’t know the cause of his symptoms later when he attended a talk on getting the most out of your medications, given by Jeffrey Delafuente, BSPharm, MS, at a local senior center. During the presentation, Delafuente mentioned that adverse reactions to drugs are often mistakenly treated as a separate condition. That night, Tom and his wife researched his medications online and found that two of them—heart medications—have the rare adverse effect of headaches in people older than 65 years.

Two days after Tom’s cardiologist switched his medications, Tom’s headaches stopped.

Approximately 20% of Medicare Advantage enrollees received at least one drug to avoid in the elderly (DAE) in 2009, according to an April 2013 article in the Journal of General Internal Medicine. Almost 5% of enrollees received two such drugs. The Medicare Star Rating for High-Risk Medications reports on the percentage of Medicare beneficiaries who have received at least two fills of any DAE. Community pharmacists are uniquely positioned to help Medicare Part D plans improve on this measure.

What are DAEs?

DAEs are a list of drugs, derived from Beers Criteria that was updated in 2012, considered unsafe for people older than 65 years regardless of dose, frequency, or the patient’s condition. The drugs on this list most commonly prescribed to people over 65 are estrogens, propoxyphene, muscle relaxants, anticholinergics, antihistamines, and nitrofurantoin, according to an article in the February 2009 issue of the American Journal of Geriatric Pharmacotherapy. These agents accounted for 87.5% of prescribed DAEs during a 1-month period in 2007.

A full list of DAEs is online at (readers can use this APhA Three tables list high-risk medications to avoid (Table DAE-A), high-risk medications with days’ supply criteria (Table DAE-B), and high-risk medications with average daily dose criteria (Table DAE-C).

Why are DAEs still prescribed to seniors?

While Beers Criteria have been around for more than 20 years, providers continue to prescribe DAEs to their patients older than 65 years. Why?

“We’re still seeing from 20% to 35% of older adults on one or more of the drugs that are potentially inappropriate in older adults,” said Delafuente, who is the just-installed President of American Society of Consultant Pharmacists and Associate Dean for Academic Affairs at Virginia Commonwealth University School of Pharmacy in Richmond. “They just haven’t made any impact.”

Health care providers continue to prescribe these drugs, and Medicare continues to cover them for a number of reasons.

Cheap alternative to safer drugs. Many DAEs are inexpensive, older drugs, and newer, safer alternatives cost more.

“It would be in the plan’s best interest to use a very cheap drug on their formulary, and if people use them, it will increase their profits, but it’ll harm the patients,” Delafuente said.

Member satisfaction. Because Medicare star ratings consider member experience, satisfaction, and complaints, Part D plans may be reticent to completely remove DAEs from their formulary.

“One Part D plan that got very restrictive with access to high-risk meds then wound up with very high complaint rates. So it can’t get too restrictive, but they’ve got to do something,” said David Nau, PhD, BSPharm, FAPhA, President of Pharmacy Quality Solutions.

Clinical inertia. Because patients may have started taking the high-risk medication before they turned 65 years old, physicians may simply choose not to confront patients about stopping or switching the drug later.

“Glyburide, for example, is an older diabetes medication,” Nau said. “There are newer, safer medications, but if the patient’s been on this for 30 years, a physician may say, ‘I don’t want to irritate that patient and tell him we should change.’”

Lack of awareness. Oftentimes, physicians think patients are doing well on a high-risk medication because they don’t recognize the adverse effects.

Delafuente recalls the advice of geriatrician Jerry Gurwitz: “‘Any symptom in an elderly patient should be considered a drug side effect until proven otherwise.’ That’s our mantra in geriatric pharmacotherapy.”

But too often, physicians see drug adverse effects as a new condition altogether and prescribe a workup and additional drugs to treat the symptoms.

Physicians may not assume the symptom is a adverse effect or they may not realize the drug is a DAE and has the potential for these adverse effects.

“Patients and physicians often don’t think it can be the drug because you’ve been on it for a decade,” Delafuente said. “They think it must be something else, not realizing that the changes that take place with normal aging change how that drug will manifest a side effect.”

This is where pharmacists can help.

Strategies for community pharmacists

To begin any type of intervention for DAE performance, Nau suggests that pharmacists familiarize themselves both with the drugs on the list and their pharmacy’s performance on the measure.

Pharmacy Quality Solutions’ EQuiPP portal allows pharmacies to compare their performance on Medicare star ratings to state and national performance and provides education on how they can improve. EQuiPP is in place at almost every national drugstore chain and counts a number of national payers, including Humana and Coventry, among its participants.

“We’re trying to help pharmacists understand what the meds and risks are, how often their patients get those meds, and how that compares to their peers,” Nau said.

Once pharmacies understand their relative performance, they can partner with Part D plans to improve those measures through a number of strategies—some strategies are already under way, while other innovations are still to be created through pharmacy–payer collaborations.

Mailing information about DAEs to providers who prescribe them has yielded mixed results. A study in the American Journal of Geriatric Pharmacotherapy found that an informational mailer sent to physicians who prescribed DAEs helped to reduce DAE use by almost 50%. According to Nau, however, these efforts are not always successful.

Nau supports a more direct approach. He recommends that community pharmacists identify providers in their area who are prone to prescribing DAEs and go out and talk to them.

In collaboration with the Jefferson School of Population Health, pharmacist–researchers in Parma, Italy, found that direct educational interventions with physicians reduced prescriptions for potentially inappropriate medications by nearly 10% citywide. The findings were published in Drugs and Aging in January 2013.

Communicating directly with physicians can reduce DAE use among all older patients, not just those for whom the communication is directed. But when personal visits are not feasible, Delafuente recommends that pharmacists be vigilant with their patients on a case-by-case basis.

“My responsibility as the pharmacist is to monitor this patient as closely as I can,” Delafuente said. “We know why the drug’s on the list, what the side effects and risks are. Let’s monitor if they’re occurring. At least ask questions. Are you having this issue? I’ve found that to be a good approach.”

Nau recommends that pharmacies work with their software developers to create prompts that provide warnings and alternatives for DAEs.

The need for patient-by-patient monitoring makes a good case for medication therapy management (MTM) services, Delafuente said. While regulatory issues, such as lack of provider status, create barriers to patients’ broad access to MTM, Delafuente believes that patients who understand the value of the service are willing to pay for it whether or not their insurance covers it.

“We don’t always have all the information that we need. There may be a reason the physician prescribed the drug,” he said. “That’s where medication therapy management comes in because you have carved out time to sit down with the patient, learn about the patient’s needs, and do the follow-up documentation. That’s where we really need to get pharmacy going, to do more of that.”