11/20/2014. Suggested Optimization of Medications for the frail Elderly (SOME) Polypharmacy. SOME* Polypharmacy. SOME Polypharmacy

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1 SOME* Polypharmacy Suggested Optimization of Medications for the frail Elderly (SOME) Polypharmacy Information for Nursing Home Stakeholders Joint Venture between Nova Scotia Department of Health and Wellness (DHW) and Palliative and Therapeutic Harmonization Program (PATH) and Nova Scotia District Health Authorities (DHA) *Suggested Optimization of Medications for the frail Elderly Education Program is informed by the Polypharmacy work of: Dalhousie Academic Detailing Service (ADS) Diabetes Care Program of Nova Scotia (DCPNS) PATH Drug Evaluation Alliance of Nova Scotia (DEANS) Drs. Brian Steeves and Cheryl Smith DNP Conflict of Interest is funded by the DHW Laurie Mallery and Paige Moorhouse are cofounders of the PATH model Overview Goals Polypharmacy Background Physiological changes with aging Frailty Polypharmacy Toolkit Medication Reviews Next Steps Goals to provide education to nursing home stakeholders to support appropriate prescribing in the frail elderly living in Nova Scotia nursing homes 1

2 Polypharmacy Polypharmacy Has been defined as: use of 5 or more medications administration of many medications together 2 or more medications treating 1 condition multiple medications prescribed by multiple providers taking 1 or more medications without clear cause use of inappropriate medication/s Polypharmacy describes the administration of more drugs than are clinically indicated (Polypharmacy.ca, 2013) Background Nova Scotia has one of the oldest populations with 18.3% seniors 65+ years of age LOS in nursing homes 2.9 years 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% Background % of LTC clients taking 5 or more medications at time of assessment for initial placement 40.0% 30.0% 20.0% 10.0% 0.0% DHA 1 DHA 2 DHA 3 DHA 4 DHA 5 DHA 6 DHA 7 DHA 8 DHA 9 NS Statistics Canada. (2014). Age and sex structure: Canada, provinces and territories, Retrieved from x/ /article/11511-eng.htm NH RCF NS DHW. ( ). SEAscape data. Unpublished Background Community Residents 2/3 of seniors take 5+ drugs most common drug class is statins nearly ¼ take a potentially inappropriate drug LTC Residents 2/3 of seniors take 10+ drugs double the number of community living Background Polypharmacy is common in LTC Risks of adverse drug effect (ADE) often outweigh the benefit The goal of care for frail elders needs to shift from prevention and cure toward QOL based on their goals of care. Canadian Institute for Health Information. (2012). Drug Use Among Seniors on Public Drug Programs in Canada, 2012 Garfinkel D & Mangin D. (2010). Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: Addressing polypharmacy. Arch Intern Med, 170(18),

3 Case 90 year old female admitted to a nursing home Dx weakness, severe stage dementia, HTN, Type 2 DM, Depression Past Medical Hx PUD, anxiety and insomnia after the loss of spouse 5 years ago (resolved) Objective data Blood Pressure 120/80, Heart Rate 80 Fasting Blood Sugar 6mmol/L; HbA1C 7.5% Case Vit D 1000iu od Physiological Changes with Aging in fat stores body water levels ratio of lean body mass albumin (protein) levels liver function renal function/ GFR Physiological Changes with Aging as liver drug metabolism s, drug effects can, which can lead to toxicity 80 yr old may have normal Cr and low BMI yet their CrCl can be abnormal - risk of ADE Old drugs can cause new ADR as residents age or develop new illness Hajjar E.R., Gray S.L., Guay D.R., Starner C.I., Handler S.M., Hanlon J.T. (2011). Chapter 11. Geriatrics. In B.G. Wells (Ed), Pharmacotherapy: A Pathophysiologic Approach, 8e. Mangoni, A.A. & Jackson, S.H.D. (2004). Age-related changes in pharmacokinetics and pharmacodynamics: basic principles and practical applications. British Journal of Clinical Pharmacology, 57(1), Ruscin, M.J. (2012). Pharmacokinetics in the elderly. Retrieved form Polypharmacy Driving Forces Frailty Clinical Practice Guidelines (CPG) frail not included in evidence for traditional CPG almost no evidence to support most drugs in LTC risk/benefit shift in frail seniors Specialization narrow focus on decision making inefficiency of care teams Frailty Identified by changes in: Memory (thinking) Ability to handle day to day tasks How one walks or stands from a chair Unmanageable symptoms (such as shortness of breath) Frailty means that: Health can be precarious The person is more likely to have poor outcomes when exposed to stressors (e.g. surgery) More at risk for medication side effects Life expectancy is shortened 3

4 How to Identify Frailty 1. Test memory (thinking) MMSE Comprehensive Geriatric Assessment (CGA) Brief Cognitive Rating Scale (BCRS) for staging 2. Watch and describe walking and ability to stand 3. Get information about the person s ability to perform day to day tasks (not by asking the resident, but by either watching or receiving collateral information) Staging Frailty Stage Memory Function Mild Moderate Severe C U R Current news/ events I IADLs US President/ Prime Minister R Rewearing clothes Relatives (1 st degree) A Very Severe E Everything N ADLs impaired,such as dressing, bathing, eating Non verbal Non ambulatory Based on Rockwood K. CMAJ 2005;173:489-95; Reisberg B. Psychopharmacol Bull 1988;24: Staging Frailty: Measure mobility and transfer Walking Independent without aid Independent with aid 1 person standby 1 person assist 2 person assist Total lift MacKnight, C. & Rockwood, K. (1995). Rev Clin Gerontol. 5, Independent Transfer Independent but slow 1 person standby 1 person minimal assistance 1 person assist 2 person assist Total lift Polypharmacy Driving Forces Frailty Clinical Practice Guidelines (CPG) frail not included in evidence for traditional CPG almost no evidence to support most drugs in LTC risk/benefit shift in frail seniors Specialization narrow focus on decision making inefficiency of care teams Polypharmacy Toolkit The Vision Simple.. To decrease inappropriate prescribing in the frail elderly Focus on seeing the whole person 4

5 Polypharmacy Toolkit Why? NOT because we do not care But because we DO! Polypharmacy Toolkit An evidence informed resource (paper and electronic) to assist in addressing polypharmacy in the frail elderly. Clinical practice guidelines specific to the target population DM, HTN, Lipids, Asymptomatic Bacteriuria Medication prescribing decision tools Beers Criteria, STOPP/START Assessment tools specific to seniors Literature to support decision making Guidelines Based on frailty is there time to benefit from the prescribed medication? What is the risk/benefit ratio? Have you considered the adverse drug effects? DM Guideline Recommendations Blood Glucose (BG) Targets Target BG may be between 10 and 20 mmol/l For BG <7.0 mmol/l stop or reduce treatment For BG between 7.0 and 9.0 mmol/l consider reduced treatment A1C Targets Target A1C is 8% and <12% If using insulin Basal Insulin is usually ed DM Guideline Recommendations Blood Glucose Monitoring Diabetics admitted to LTC twice daily alternate times x 1-2 weeks establish baseline and adjust treatment as needed If med regime (oral agents or basal insulin) and BG is stable, testing may not be required A1C Testing Diabetics admitted to LTC Oral agents or insulin 1-2 times yearly No diabetic medication 1 per year or may not need at all Full Summary of ations can be located at Polypharmacy.ca HTN Guideline Recommendations Decisions to be based on sitting BP measurements In general use no more than 2 meds STOP medications - if SBP <140mmHg consider if the medications are treating additional conditions if stroke history individualize care START medications if SBP >160mmHg relaxed target in very severely frail no changes required for DM Full Summary of ations can be located at Polypharmacy.ca Polypharmacy.ca 5

6 Lipid Guideline Recommendations In Severe Frailty Primary Prevention there is no reason to prescribe or continue statins for primary prevention. Secondary Prevention Statin treatment in severe frailty is probably not necessary (extenuating individualized circumstances may shift the risk/benefit ratio) If used, low dose is ed Full Summary of ations can be located at Polypharmacy.ca Polypharmacy.ca Bacteriuria Recommendations Asymptomatic bacteriuria is common in NH and should not be treated Screening is not required, if symptomatic then culture should always be obtained to inform treatment Symptomatic bacteriuria is difficult to identify Treatment depends on with or without indwelling catheter CVA tenderness, fever, delirium, rigors, dysuria, changes in urination pattern, hematuria, suprapubic pain Full Summary of ations located at Polypharmacy.ca Polypharmacy.ca Video for the lay public DHW continuing care and pharmaceutical web pages Q & A s to accompany Video for health providers Polypharmacy.ca 34 Next Steps Disseminate the Toolkit to stakeholders Integrate the evidence informed information into the LTC medication review process Legislated semi-annual reviews Develop local champions to work with district LTC medical director and education team Polypharmacy Nursing lead facility Polypharmacy Physician lead facility Medication Reviews Preparation Obtain current CGA and frailty score Objective data: date of birth, age, gender, sitting BP, HR, weight, bowel habits Current laboratory records required for medications (eg: TSH, Digoxin levels, Serum Cr, BG, etc.) Calculate CrCl using Cockcroft Gault as required for medication adjustment or yearly (as needed) Assemble: chart, requisitions, Pharmacy re-order forms Invite multi-disciplinary team members 6

7 Next Steps Case in review Studies reveal that up to 60% of medications can be removed from frail seniors medication regimes without undesirable effects. Often medication adjustments improve health cognition, quality of life and decrease mortality Garfinkel, D. & Mangin, D. (2010). Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: Addressing polypharmacy. Arch Intern Med, 170(18), pg year old female admitted to a nursing home Dx weakness, severe stage dementia, HTN, Type 2 DM, Depression Past Medical Hx PUD, anxiety and insomnia after the loss of spouse 5 years ago (resolved) Objective data Blood Pressure 120/80, Heart Rate 80 Fasting Blood Sugar 6mmol/L; HbA1C 7.5% Decrease to once daily with the intent to wean and discontinue Decrease to tid with intent to wean and discontinue 7

8 Review the risk/benefit of maintaining - discontinuing Humulin 30/70 8u ac supp Humulin 30/70 8u ac supper Change to basal insulin or oral hypoglycemic and wean to achieve HbA1C >8 Continue or wean to achieve HbA1C >8 Increase to 2000iu daily Re-assess; decrease if able or change to tid dosing (LA) 8

9 Wean and discontinue to achieve sitting SBP >140mmhg Wean to achieve sitting SBP >140mmhg Wean to discontinue. Consider sleep hygiene Reassess need Discontinue 9

10 Discontinue Discontinue Lorazepam? Basal insulin hs or oral hypoglycemic Metformin HbA1C >8 and <12 % Vit D Amlodipine SBP >140 sitting Sertraline? 14 to potentially 6 or less medications Take home messages Additional information and references Toolkit is a work in progress. As more guidelines are developed they will be added Frailty recognition is key Ask the question, Are medications appropriate to be continued or discontinued? PATH clinic referral can assist with health care decision making The entire health care team plays a role in minimizing Polypharmacy We have tools to improve care, so let s use them cheryl.smith@cha.nshealth.ca When you know better you do better. Maya Angelou 10

11 Questions? 11