Managing medicines in older people. Jane Noble and Caroline Ralph

Transcription

1 Managing medicines in older people Jane Noble and Caroline Ralph

2

3 Where? Community Hospital Care Home

4 What? Prescribing Dispensing Administering

5 Case 1 84 year old lady Admitted with reduced mobility Recurrent falls She falls on the ward and sustains a left Colles fracture Current medication: frusemide, bisoprolol, losartan, calcichew D3 forte, alendronate, paracetamol, codeine phosphate, lansoprazole, docusate, temazepam

6 10 medications.. Cardiac/hypertension medication: Frusemide Bisoprolol Losartan Bone protection: Calcichew D3 forte Alendronate Analgesia: Paracetamol, codeine phosphate Sedatives: Temazepam Gastrointestinal medication: Lansoprazole, docusate

7 Prescribing: polypharmacy Risk of Drug-Drug Interaction: 2 drugs = 13% 4 drugs = 38% >7 drugs = 82% Elderly people in residential care homes (n=2707) 51% 6 or more daily 22% 9 or more daily 12% of > 65yr old community based females take > 10 meds daily

8 Case 2 87 year old lady in hospital for one week MMSE 19/30 Becomes agitated and tells you she is seeing cats walking along the ward Medication: Aspirin, atenolol, codeine phosphate, losartan, paracetamol, simvastatin, solifenacin, tinzaparin What are some possible causes of her agitation? Which medication has just been started? What further management would you consider?

9 8 medications. Cardiac/hypertension medication: Atenolol, losartan Analgesia: Paracetamol, codeine phosphate Over-active bladder medication: Solifenacin Cholesterol lowering: Simvastatin Antiplatelet: Aspirin Antithrombotic: Tinzaparin

10 Anticholinergic burden scale

11 Case 3 92 year old man admitted with shortness of breath and green sputum He is treated for community acquired pneumonia and has an acute kidney injury. He is normally independent but is now disorientated. Medications: Betahistine, clopidogrel, digoxin, frusemide, lansoprazole, lisinopril, metoclopramide, simvastatin, trospium Which medications would you stop and why?

12 9 medications: Cardiac/hypertension medication: Digoxin, lisinopril Over-active bladder medication: Trospium Cholesterol lowering: Simvastatin Antiplatelet: Clopidogrel Vestibular suppressant: Betahistine Anti-emetic: Metoclopramide Antacid: Lansoprazole

13 Beers criteria

14 STOPP / START Screening Tool of Older Person s Prescriptions / Screening Tool to Alert doctors to Right Treatment List of 65 STOPP and 22 START criteria Using criteria can reduce potentially harmful prescribing and prescribing omissions in primary care, secondary care and nursing homes. Gallagher et al 2008 Int J Clin Pharm and Ther 46(2); 72-83

15 Case 4 79 year old lady with advanced metastatic lung cancer She has become progressively immobile, bedbound, and less responsive. Her doctor thinks that she is reaching the end of her life. Her medication is: Aspirin, folic acid, lansoprazole, paracetamol, rivastigmene, simvastatin, sinemet, vitamin D How would you change her medication?

16 Case 4 (continued) This lady is fast-tracked home What the considerations regarding her ongoing medication? What other issues do we need to consider?

17 Summary (prescribing): Situations when particularly appropriate to consider reviewing medications Falls Delirium and cognitive impairment PINCH ME Pain Infection Nutrition/Neoplasm Constipation Hydration Medication Environment Continence, constipation End of life

18 Dispensing

19 patient factors: Administration nurse factors:

20 Case 5 85 year old man with advanced dementia, living in a nursing home Medication: Paracetamol, simvastatin, fultium D3, bisoprolol, frusemide, codeine phosphate, senna, docusate, temazepam His MAR chart shows he is regularly missing medication What possible reasons are there for this? How could we improve the situation?

21 Possible causes: Wrong patient Swallow difficulties Compliance: disorientation, agitation, paranoia Staff issues: multiple attempts, familiar staff

22 Top tips Pick your time Reduce the medication as much as possible Reduce the number of medication times Some patients will manage liquids more easily Yoghurt Patience and repeated attempts Watch for hidden/dropped tablets Check for pocketing

23 Managing Medication a challenge: Prescribing the correct medication for the patient Dispensing the right tablets Remembering to take the medication Agreeing to take the medication Taking the tablets at the right time Getting into the tablet box/medibox Swallowing the tablet or liquid safely

24 Thank you Questions?