Polypharmacy Adrian Blundell Consultant Geriatrician Hon Assoc Prof
Polypharmacy Adrian Blundell Consultant Geriatrician Hon Assoc Prof University of Nottingham adrian. blundell@nuh. nhs. uk Sep 2015
Recipe • Discuss frailty • Propose/describe top tips for more appropriate medication prescribing in older adults • Discuss some practical application of the tips
Context – The > 65 years • 2004 – 461 million people • 2050 – 2 billion people
http: //www. goldstandardsframework. org. uk/cd-content/uploads/files/General%20 Files/ Prognostic%20 Indicator%20 Guidance%20 October%202011. pdf
Complexity versus Simplicity
Guthrie et al. Adapting clinical guidelines to take account of Multimorbidity. BMJ 2012; 345: e 6341 doi: 10. 1136/bmj. e 6341
Boyd CM et al. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA 2005; 294: 716– 24.
Telephoto
Telephoto Panoramic
Multimorbidity Polypharmacy
Frailty
Clegg et al. Frailty in elderly people. Lancet 2013; 381: 752– 62
Polypharmacy & Frailty • Polypharmacy is common (30 -40% of > 65 year olds)
A treatment paradox • • Drugs are needed to treat LTCs Older people with frailty have more LTCs “Lots of drugs” is a risk factor frailty A new drug can precipitate a decline in a frail individual (ADR) • “Lots of drugs” is a risk factor for ADRs
A treatment paradox • Frail older people need drugs to treat their long term conditions • Frail older people don’t need drugs as it can worsen their frailty
Adverse Drug Reactions
5. 6% 3 -5%
70%
Adverse Drug Reactions • Older adults more susceptible to ADRs
• Pharmacodynamics • Pharmacokinetics
Why are older people at high risk of ADRs? Some determinants of preventable medication-related hospital admissions – – – Impaired cognition (OR 11. 9) Four or more co-morbidities (OR 8. 1) Dependent living situation (OR 3. 0) Impaired renal function (OR 2. 6) Non-adherence to medication regimen (OR 2. 3) Polypharmacy (OR 2. 7) HARM Study: ARCH INTERN MED/VOL 168 (NO. 17), SEP 22, 2008
Barbers Goals of Good Prescribing EFFECTIVE SAFE COST PATIENT FACTORS
TOP TIP 1 MEDICATION MAPPING
Exercise 1 • • Digoxin Aspirin Donepezil Metformin Ramipril Tamsulosin Amlodipine
Exercise 2 PAST MEDICAL HISTORY Hypertension Dementia CKD 3 OA SAH 2002 MEDICATION Aspirin Digoxin Latanoprost Movicol Paracetamol
TOP TIP 2 PRESCRIBING IN THE CURRENT CLINICAL CONTEXT
BP 100/40 Amlodipine Doxazocin Ramipril
TOP TIP 3 CONFIRM THE EVIDENCE OF THE DIAGNOSIS
TOP TIP 4 REMEMBER SOME ETHICS
Remember some Ethics • • Autonomy Beneficence Non-maleficence Justice
Benefit vs Risk
TOP TIP 5 REVIEW THE EVIDENCE IN CONTEXT
Think about the Evidence Is Earl different?
Think about the Evidence • Numbers needed to treat. . .
Think about the evidence • Frail, older adults often not in the trial • Outcomes are not usually frailty specific e. g. falls, fractures • Trials are rarely about stopping drugs • S/Es may not be highlighted • The effects of drugs will be different in multimorbidity
Health vs Function • We have a better idea of the benefits drugs have to health outcomes vs functional outcomes
TOP TIP 6 PRESCRIBING IN MULITMORBIDITY
Condition A = Treatment A
Condition A + Condition B + Condition C Treatment A + Treatment B + Treatment C
TOP TIP 7 THINK SIDE EFFECTS & INTERACTIONS
Think Side Effects
Interactions • • Drug – disease Drug – drug Drug – food Drug – metabolism • Never say Never
TOP TIP 8 SYMPTOM CONTROL VERSUS PROGNOSTIC BENEFIT
Holmes HM et al. Arch Intern Med 2006; 166: 605 -9
TOP TIP 9 INDIVIDUALISE
Individualise • Recognise the clinical situation i. e. frailty • Personalised medication review • Appropriate prescribing (not deprescribing) • Blister packs • Preparations • Timings
TOP TIP 10 MONITORING
Monitoring • Symptoms • Signs • Tests • i. e. full team approach • Map to observations / tests • Consider sick day rules
Recurring Themes • • • Diarrhoea (metformin / laxatives / PPI) Hypotensive / Falls (on BP tablets) Dehydrated (on diuretics) Bleeding (on anticoagulants) Normal Hb (on iron)
Other Considerations
Anticholinergic Burden
ACB & Frailty • • Increased vulnerability to SEs Slower metabolism & excretion Changes in BBB Changes in receptors
3 points Amitriptyline Chlorpheniramine Darifenacin Olanzapine Oxybutynin Paroxetine Quetiapine Solifenacin Tolteridone 3 points
1 point Atenolol Fentanyl Ranitidine Captopril Furosemide Trazodone Cetirizine Haloperidol Venlafaxine Cimetidine Hydrocortisone Warfarin Codeine Isosorbide Colchicine Loperamide Diazepam Morphine Digoxin Nifedipine Dipyridamole Prednisolone
SAA and MMSE
Remember 2 Objects
STOPP-START
STOPP A. B. C. D. E. F. G. H. I. J. Cardiovascular Neuro + Psychotropics GI Resp MSK Urogenital Endocrine Fallers Analgesics Duplicate Drug Classes
START A. B. C. D. E. F. Cardiovascular Resp Neuro GI MSK Endocrine
STOPP-START
Less is more? • Is reducing medication in older frail adults harmful? • Limited evidence of drug cessation
• Diuretic withdrawal maintained 51 -100% • Antihypertensive withdrawal maintained 20 -85% • Psychotropic withdrawal; reduced falls and improved cognition • “some clinical trial evidence for the short-term effectiveness and/or lack of significant harm when medication withdrawal is undertaken for antihypertensive, benzodiazepine and psychotropic agents in older people”
Good Palliative – Geriatric Practice Algorithm • Garfinkel et al. IMAJ 2007; 9: 430 -34 – 119 nursing home inpatients (71 control) – Average 2. 8 drugs stopped – Only 10% needed to be restarted – Reduced 1 year mortality and admission rates
• Focussed on 4 areas – Falls – Delirium – Cognitive impairment – End of life
Summary • Use the top tips for more appropriate prescribing • Familiarise yourself with the tools available • Evidence base is rather lacking • Consensus is developing • Communication is key • Individualised approach
Conclusion • Competent multidimensional assessment of needs and future potential • Individualised interventions • Effective teamwork and performance management
adrian. blundell@nuh. nhs. uk
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