Medications. o Aspirin 100mg daily Risedronate 35mg weekly. o Clopidogrel 75mg daily Calcium/VitD 600mg/1000U

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2 Medicatins Aspirin 100mg daily Risedrnate 35mg weekly Clpidgrel 75mg daily Calcium/VitD 600mg/1000U Atrvastatin 80mg ncte Allpurinl 100mg daily Diltiazem CD 240mg daily Laxatives daily Frusemide 80mg BD Omeprazle 20mg daily Issrbide mnnitrate 60 daily Prazsin 2.5mg BD Buprenphine patch Oxazepam at night

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4 Guides fr stpping: STOPP/START Beers criteria PIM Drug Burden Index

5 Medicatins Aspirin 100mg daily Risedrnate 35mg weekly Clpidgrel 75mg daily Calcium/VitD 600mg/1000U Atrvastatin 80mg ncte Allpurinl 100mg daily Diltiazem CD 240mg daily Laxatives daily Frusemide 80mg BD Omeprazle 20mg daily Issrbide mnnitrate 60 daily Prazsin 2.5mg BD Buprenphine patch Oxazepam at night

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7 U.S. Medicare Statistics 20% f Medicare Beneficiaries have 5 r mre chrnic cnditins Of these patients, 50% are n 5 r mre medicatins Tinetti ME et al. N Engl J Med. 2004;351(27):2870

8 5 Gnjidic D, Hilmer S, et al. Plypharmacy cutff and utcmes: five r mre medicine were used t identify cmmunitydwelling lder men at risk f different adverse utcmes. J Clin Epidemil 2012; 65:

9 Benefits f plypharmacy: BB in CCF r ischemic heart dz ACE r ARB in CCF Spirnlactne in systlic heart failure digxin BP treatment but in the frail 87y is the evidence strng? 9

10 ACE-Inhibitrs and ARBs Wide range f indicatins: Hypertensin Secndary Preventin f strke Reductin f CVD risk Preventin f prgressin f renal disease (CKD, Diab. Nephrpathy) Systlic heart failure Mst trials excluded frail patients N chance t reach trial endpints Practically, ften lwer dsages are used (? Due t fear f adverse effects?)

11 Trial utcme NPS-Radar March 2010

12 Trial cmparisn NPS-Radar March 2010

13 Ptential perils f plypharmacy in the Elderly: cnsistent assciatins Falls Cgnitive decline Adverse drug reactins Frailty Death

14 Effects f plypharmacy in the Elderly It s nt simply the risks f plypharmacy Dwindling benefits f medicatins fr single rgan prblems Diminishing chances f the patient realizing any imprvement in life

15 Tw grups f mice: yung and ld, fur week interventin, with cntrls. Given five cmmnly prescribed meds: simvastatin, metprll, meprazle, paracetaml, citalpram Old mice: plypharmacy caused significant decrease in lcmtr activity; lss f imprvement in rtard latency; and frnt paw wire hlding impulse, lwered bld pressure. Huizer-Pajks A, et al. Adverse geriatric utcmes secndary t plypharmacy in a muse mdel: the influence f aging. J Gerntl A bil Sci Med Sci May 4.

16 Suth Australia: lder (>75y) patients ging t RCF Patients discharged frm hspital t RCF have 25-70% ne year mrtality Patients discharged frm GEM t hme have 20% ne year mrtality

17 Nt every 34 year ld is the same

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20 Identifying the tipping pint R B R B

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22 Prgnstic tl applied at the tipping pint r when circumstances change

23 The rle fr a RCT:..a valid determinatin f a treatment s efficacy and safety. Plypharmacy = harm? Deprescribing = benefit?

24 Any prspective deprescribing studies s far? Garfinkel 2007 Nn-randmised, 120 interventin, 70 cntrls 12 mnth fllw up Avg 3 drugs stpped per patient 1yr mrtality: 45% in cntrl grup; 21% in study grup Referral t hspital: 30% in cntrl, 12% study Garfinkel D et al. IMAJ 2007; 9:

25 what did thse patients lk like? age: 82 +/- 8yr 95% demented MMSE=14 duble incntinence >90% 10% with CCF 25

26 which medicatins were ceased? nitrates H2 blckers antihtn diuretics irn sedatives antidepressants antipsychtics 26

27 barriers t deprescribing: Dctrs: busy (time); lack f demnstrated safety; lack f guidelines Patients: attachment t medicine regime Staff: antipsychtics and dementia 27

28 Australian effrts Australian Deprescribing Netwrk (ADeN) OptiMED, Perth Suth Australian Deprescribing Initiative

29 Suth Australian Deprescribing Initiative (SADI) In-hspital enrllment Multi-Dmain Patient-centred Expert pinin Gen.Pract. Invlvement Cmmunity pharmacy invlvement

30 Outcmes Mrtality Readmissin Patient qual.f life measures

31 reflectin n the pening stry, preventable death is allwing a persn t die frm the natural prgressin f a disease the same as slwly pisning them with medicatins t prevent death? 31

32 Ways t imprve ur practice f medicine Deliberate practice each day Feedback (360) Clinical research

33 Data cllectin in the trenches Cnsultant physician: while listening t presentatin by huse fficer, entering basic data Using checklists, data entry can be a standard part f every admissin. Each patient admitted t hspital is entered int a study prtcl. Ptential fr General Medicine patients, in city r reginal Australia

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43 End Thank yu