CHECK YOUR MEDICINES Wednesday 10 June

Transcription

1 CHECK YOUR MEDICINES Wednesday 10 June

2 Acknowledgment of Country I would like to show my respect and acknowledge the traditional custodians of this land, of elders past and present, on which this event takes place.

3 Welcome Emily Anderson Senior Coordinator Sector Development, Stay On Your Feet Check Your Medicines Campaign Know your medicines Manage your medicines Sleep problems and medicines Check your medicines

4 Welcome Emily Anderson Senior Coordinator Sector Development, Stay On Your Feet 9.00am Forum Open 9.15am Deirdre Criddle CoNeCT Care Coordinator/Pharmacist, SCGH 10.00am Kate Ingram Geriatrician, SCGH 10.45am Morning Tea 11.00am Pradeep Jayasuriya General Practitioner, Private Practice 11.30am John McLachlan Respiratory & Sleep Physician, FSH 12.00pm Workshop Activity 12.30pm Forum Conclusion Photo consent

5 Deirdre Criddle CoNecT Complex Care Coordinator and Pharmacist, SCGH One of the first NPS Medicinewise facilitators (1999) Lecturer & tutor of postgraduate Pharmacy students, UWA 2012 Awarded Eric Kirk award for Most Outstanding Contribution to Pharmacy in WA & WA PSA s Pharmacist of the Year 2013 Awarded Australian Association of Consulting Pharmacist s Consultant Pharmacist of the Year

6 Check Your Medicines Deirdre Criddle CoNeCT Complex Care Coordinator Pharmacist

7 Check Your Medicines People taking multiple medicines are at greater risk of falls Everyone should have an Up To Date Medicines List - agreed by consumer, doctor and pharmacist Sleeping tablets increase the risk of falls. Gradually reducing or withdrawing sleeping tablets under medical guidance can reduce this risk. Having a Home Medicines Review or a Medscheck is a great way to check for medicines which increase the risk of falls. Ask a GP or Pharmacist

8 What is a fall? WHO definition: html 8

9 Australian falls data 1998 Falls by the elderly in Australia: Trends and data for 1998 AIHW

10 Preventative medicine ~ ACE inhibitors - Reduce BP, improve heart failure, prevent kidney disease, reduce stroke ~ Beta-blockers Reduce mortality post MI, reduce risk IHD, improve heart failure ~ Aspirin, clopidogrel, ticagrelor - improve mortality post MI, post stent, reduce risk CHD, reduce risk stroke ~Clopidogrel or ticagrelor - improve mortality post stent, where aspirin is not tolerated ~ Warfarin, dabigatran, rivaroxaban, apixaban prevent stroke (AF) ~ Statins reduce mortality post MI, reduce MI ~ Enhanced BP lowering requiring multiple medications. ~ Improved diabetes control requiring multiple medications.metformin+gliptin+sulphonylurea ~ Antiosteoporotic medication reduce risk of fracture requiring multiple medications Vit D +Ca?+?bisphosphonate or strontium or 10

11 We re stayin alive 11

12 At what point in a person s life does the magic pill become a burden? 12

13 Falls Risk Factors Age >65 years Previous falls Polypharmacy especially with Falls Risk Increasing Drugs Cognitive impairment or depression Impaired vision and hearing Gait deficit Use of assistive device orr impairment in ADL function Arthritis and mechanical foot problems Impaired balance Muscle weakness Incontinence Unfavourable environment Change in functional status 13

14 ACSQHC 3 falls prevention guidelines Collectively referred to as The Falls Guidelines Based on current and relevant literature Identify principles of care and special considerations for culturally and linguistically diverse, Indigenous, and rural and remote groups 14

15 Key messages of the guidelines Many falls can be prevented. Address injury and falls prevention at point of care & from a multidisciplinary perspective. Manage falls risk factors Engage older people themselves Implement falls prevention strategies Do not neglect the consequences of falls even if no injury Fear of falling and reduced activity can profoundly affect function and QOL, and increase the risk of seriously harmful falls. There will be a time lag between investment in falls prevention programs and improvement in outcomes. 15

16 What is an intervention? 16

17 Show me the evidence!! 17

18 Single interventions - best evidence Encourage exercise to prevent falls. Balance training works! Remove cataracts. Modify home environment in the high-risk. Supervise the gradual withdrawal of psychoactive medications. Vit D and calcium supplementation in at risk Level 1 evidence

19 Single interventions - good evidence Home safety assessment for people with severe visual impairment and modification. Cardiac pacing in older people with carotid sinus hypersensitivity and a history of syncope or falls. Collaborative review and modification of medication by GPs and pharmacists, with patients. Level II evidence 19

20 Multiple & multifactorial interventions Multiple interventions with good evidence The combination of exercise targeting strength and balance, education and home safety intervention (the Stepping On Program) is recommended to reduce the rate of falls in older people who live in the community. (Level I) Multifactorial interventions In older people at risk of falls, individualised assessment leading directly to tailored interventions is recommended. (Level I) Falls Specialist Clinics in WA ) 20

21 The Doctor s role Review medications. Assess and manage bone health Check lying and standing BP Encourage exercise.. Refer older people with severe visual impairment to an occupational therapist for a home safety assessment. Ensure that high-risk fallers receive a multidisciplinary assessment with tailored interventions. Preventing Falls and Harm From Falls in Older People: Best Practice Guidelines for Australian Community Care

22 The Nurses role Exercise (particularly exercise programs that include balance training) Vitamin D supplementation (although only in people with low vitamin D levels) Home safety interventions (again, only in high-risk subgroups of older people). Preventing Falls and Harm From Falls in Older People: Best Practice Guidelines for Australian Community Care

23 The AHP role Single interventions effective in reducing falls exercise (particularly exercise programs that include balance training) vitamin D with calcium supplementation home safety interventions. Multiple interventions effective in reducing rate and risk of falls exercise participant education home safety exercise and home safety exercise and vision assessment exercise, vision assessment and home safety. Preventing Falls and Harm From Falls in Older People: Best Practice Guidelines for Australian Community Care

24 Who can help? If you've had a fall, or you often feel like you're at risk of falling, don't just dismiss it as part of getting older, lack of concentration or clumsiness. Talk to a health professional and ask about different options that may help you. Doctors Nurses Physiotherapists Podiatrists Occupational therapists Optometrists Pharmacists Continence nurse Dietician 24

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26 Factors that contribute to the risk of falls in the elderly population A = Patient with an accidental fall and no intrinsic or extrinsic risk factors B = Pt with acute illness C = Pt with moderate illness, loss mobility, some medications falls due to extrinsic factor D = Severely ill pt with many medications who falls even without extrinsic factors E = Elderly pt with numerous age-related changes who falls because of an extrinsic factor Adapted with permission from Steinweg KK. AAFP April

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28 Medicines are not my business! What do I do if I m NOT a pharmacist or doctor? How can I help? What should I do? See the problem? Flag the solution.

29 Why check medicines? Challenging facts: 230,000 hospital admissions each year (ACQSHC Medication Safety Review, 2013) 900 deaths (Macklin 1992) 32 69% avoidable All related to medication misadventure 29

30 Medication use In any 2 week period, 7 out of 10 Australians (and 9 in 10 older persons) will have taken at least one medicine (Prof Bruce Barraclough, Chair of Safety and Quality Council July 19, 2002) 30

31 A Medscheck Medication check provided to patients in their pharmacy Ensure medicine use is optimal and fully understood. Involves the patient and their usual pharmacist Provides an opportunity to assess medication management for patients reluctant to have a HMR Excellent way to engage customers who see more than one GP or don t want an HMR 31

32 Home Medicines Review Structured, collaborative health care service provided with GP, pharmacist and pharmacy Interview & assessment of medication management is in the home Ensures medicine use is optimal and fully understood. Involves the patient and carer(s), GP, pharmacist and other members of the health care team 32

33 The HMR Process General Practitioner Conduct Clinical Assessment Communication clarification Submit written report Community Pharmacist Identify HMR need Patient consent HMR referral Accept referral Arrange Home Interview Source Accredited pharmacist Medication Management Plan Patient 33

34 Medicines check 1. Dose/drug-related issues confusing dose or schedule change; incomplete or missing directions; duplication; disposal of unwanted and expired medications; storage of medications which may affect safety or efficacy; and problems with brands, dose form or timing of dose. 34

35 Medicines check 2. Medication-related issues actual or potential drug-drug interaction; possible adverse effect. 3. Condition-specific issues medication treating a medication side effect; and unexpected or inadequate response, despite compliance and correct administration. 35

36 Medicines check 4. Consumer management issues continuing ceased medication; misuse, overuse or underuse of medication; signs of non compliance; and misunderstanding, confusion or problems with purpose or use. 36

37 37 Falls Risk Increasing Drugs Medicines used in patients with epilepsy Medicines used in patients with depression or anxiety~ sedating and non-sedating Medicines used for people in pain acute, or acute on chronic pain Medicines used for patients with schizophrenia, bipolar disorder, dementia with behavioural symptoms Heart medicines Fluid tablets Sleeping tablets Antihistamines Hypoglycaemics oral or sc

38 Medical Conditions contributing to falls Alzheimer s disease, other dementias Arthritis, other pain syndromes Cardiovascular/cerebrovascular diseases Depression/neurosis/psychosis Diabetes mellitus Osteoporosis Parkinson s disease Seizure disorder 38

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41 re/maintaining/falls_dev/downloads/ B1E8_3(5)%20and%20B2F5%20F alls%20related%20medication%20s ide%20effects.pdf Falls Risk Increasing Drugs Diuretics or fluid medicines Medicines for Parkinsons Medicines for dizziness Medicines for nausea Medicines for epilepsy Medicines for anxiety Medicines to assist with sleep Medicines for blood pressure Medicines for heart rhythm Medicines for angina Medicines for depression Medicines for hallucinations Medicines for distressing behaviours in elderly with dementia Medicines for bipolar disorder or schizophrenia

42 re/maintaining/falls_dev/downloads/ B1E8_3(5)%20and%20B2F5%20F alls%20related%20medication%20s ide%20effects.pdf

43 Ignoring the evidence ~ or not that simple? It is worrying to observe that prescribing habits for psychotropic drugs do not seem to have changed between the separate studies, looking at the different intervals between and Huang et al Medication-Related Falls in the Elderly Causative Factors and Preventive Strategies Drugs Aging 2012; 29 (5):

44 Supporting sustainable change ~ a benzodiazepine reduction plan 44

45 The challenge of benzodiazepine withdrawal Gradual withdrawal of psychoactive medications resulted in a large falls reduction in a trial of 93 people >65 yr At the end 44 week trial 66% reduction in falls in medication withdrawal group One month after the trial 47% intervention group resumed taking their medicines! The power behind the prescribers pen? Campbell AJ, Robertson MC, Gardner MM, et al. Psychotropic medication withdrawal and a home-based exercise program to prevent falls: a randomized, controlled trial. J Am Geriatr Soc 1999; 47 (7):

46 Drugs and the risk benefit assessment Perhaps the most complicated component of a strategy to prevent falls involves reduction in the use of medications. Medications may be appropriately recommended for the treatment of a disease, but they also have adverse effects; falling is one of the most common adverse events related to drugs. Mary Tinetti NEJM ;

47 Dealing with medicines for sleep Sleep diary Sleep Hygiene Reducing your sleeping tablets data/a ssets/pdf_file/0020/84341/fact sheet Sleep_Right_Sleep_Ti ght.pdf data/assets/ pdf_file/0016/72160/a-reduction-planfor-your-sleeping-tablets.pdf

48 Making sure you have a Medicines List Paper E-List SmartPhone App pics/how-to-bemedicinewise/managing -yourmedicines/medicineslist/medicines-list-paper w-to-bemedicinewise/managing-yourmedicines/medicineslist/medicines-elist s.org.au/topic s/how-to-bemedicinewise/ managingyourmedicines/me dicineslist/medicineli stsmartphoneapp

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52 Further information and resources NPS - NPS Radar Strontium Ranalate, Teriparatide, and Zoledronic Acid NPS Prescribing Practice Review 39:Preventing Osteoporosis and reducing fracture risk Noeline Brown on Staying Active and Preventing Falls and Fractures Osteoporosis Australia Calcium supplementation; The bare bones Aust Prescr 2003;26: Fracture Risk Assessment WHO Falls Risk Assessment Tool 52

53 Further information and resources National standards Australian Commission on Quality and Safety In Healthcare HOSP1.pdf Guidebook1.pdf Leipzig, R. M., Cumming, R. G., & Tinetti, M. E. (1999). Drugs and falls in older people: a systematic review and meta-analysis: I. psychotropic drugs. Journal of the American Geriatrics Society, 47(1), Stay on Your Feet Website

54 Kate Ingram Geriatrician & Clinical Lead Falls Clinic, SCGH Runs 14 bed Geriatric Evaluation and Management Interested in Falls and Vitamin D Medical Lead in SCGH Falls Prevention Committee, Geriatrician representative on Statewide Falls Prevention Network & medical representative on WA Falls Specialist Coordinator Group Immediate past President of Australian and NZ Society for Geriatric Medicine (WA Branch) Actively involved in research and audit to both inpatient and outpatient falls

55 Don t Let Your Medications Trip You Up Dr Kate Ingram Geriatrician SCGH Falls Clinic, SCGH Falls Prevention Committee, State Falls Network

56 Outline How medications increase the risk of falling Evidence that modifying medications decreases falls risk Good medications Discharge from hospital Cases

57 Balance Control OUTPUTS Gaze Stability Postural Stability Microsoft Office Online Clipart Gallery

58 Medications that Decrease Sensory inputs Peripheral Sensation -chemotherapy eg cisplatin, bortezomib -antibiotics eg isoniazid, chloroquine, HIV meds -amiodarone (heart) -meds for autoimmune disease eg leflunamide, infliximab Vestibular- gentamicin

59 Visual -worsen glaucomaanticholinergics eg oxybutinin, antihistamines, prednisolone -Cardiac meds eg digoxin, amiodarone -retinal toxicity eg antimalarials, tamoxifen -tamsulosin -TB meds -erectile dysfunction meds

60 Medications that Impair Your Motor Function Proximal myopathy- prednisolone, colchicine Myositis- statins (painful) Arthritis Tendon damage- ciprofloxacin

61 Medications that impair central (brain) processing **Most Important!** Benzodiazepines- diazepam (valium), oxazepam (serepax), temazepam, alprazalam Major tranquillizers/ anti psychotics- haloperidol, respiradone, olanzepine, maxalon, quetiapine Antidepressants- tricyclics (dothiepin, amitryptline), SSRIs (sertraline, citalopram), mirtazepine (avanza)

62 Parkinsonism- stemetil, haloperidol, respiradone Ataxia/ unsteadiness -phenytoin

63 Antipsychotics Increased risk of death in patients with dementia (meta-analysis: death rate 2.3% Vs 3.5%) JAMA 2005 Increased risk of stroke- 4% Vs 2% CMAJ 2002, 2004 Increased risk of falls Has a FDA Black box warning in USA NNT: 9 patients, Vs NNH (fatal stroke) 14

64 Medications causing dizziness/ presyncope/ syncope Heart block/ bradycardia b blockers Digoxin verapamil Postural hypotension Diuretics any BP meds Anticholinergics Parkinson s meds tricyclic ADPs

65 Other Mechanisms Urinary/ Bowel urgencyfrusemide, laxatives

66 MEDICATION Polypharmacy > 4 medications 11 June 2015 Slide 66

67 Increasing the Risk of Injury Anticoagulants- Warfarin, rivaroxaban, apixaban, dabigatran, heparin, clexane Anti-platelets- aspirin, clopidegral, ticegrelor, asasantin Osteoporosis inducingprednisolone

68 Good Medicines Vitamin D deficiency screening is suggested by ACSQH 2009 Falls Guidelines Treat levels < 50 Drugs to treat Postural hypotension Fludrocortisone Midodrine Drugs to treat Osteoporosis

69 Meta-analysis -Woolcott et al, JAMA 2009 Medication Antihypertensives Sedative/ hypnotics Antipsychotics Antidepressants Benzodiazepines Anti- inflammatories Diuretics Odds ratio of falls

70 Guideline Care (AGS, BGS 2011)

71 ACSQH 2009 Falls Guidelines- Hospital Footwear- ensure it is well fitting, non- slip Assessment and management of postural hypotension, medication review Vestibular dysfunction- needs to be identified, investigated & managed Medications- on admission should be reviewed and modified, and psychoactive medications reduced or stopped if possible Vision- provide adequate lighting, identify & manage new visual problems, make patients glasses available, avoid bifocals when walking Surveillance- use as appropriate, falls risk alert cards/ symbols, consider volunteer sitter program, high risk patients near nursing station

72 Medication Management is Multidisciplinary Doctors Nurses Laxatives Non medical management of dementia, delirium, insomnia Pharmacists- home reviews, Webster packs OTs- sleep hiegiene, distraction Social workers- compliance strategies Physios/ Falls specialists

73 Can we change medications and reduce falls? Is a core component of multi factorial interventions that reduce falls in hospitals (Cochrane RRa0.69, RR0.71) Haumschild M et al Am J Health Sys Pharm 2003 Small hospital study of medication review RR falls 0.53 ( )

74 Nursing Homes Zermansky Age and Ageing 2006 Pharmacist review of medications with recommended medications changes Reduced falls (Controls 1.3 falls, Cases 0.8 falls)

75 What is the Evidence? -Community Campbell et al JAGS x 2 RCT of psychotropic medication withdrawal and home based exercise program 66% reduction in falls in medication withdrawal group BUT at 1 month post study- 47 % had restarted them

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77 Methods to Improve Compliance Form alliance with patient Negotiate the goals Help patients find their own solutions

78 Discharge from Hospital Beware discharging on new sleeping tablets Pifalls: Hospital audit (general medical ward): 38% benzodiazepines (>1/2 were new prescriptions) -patients may still have resolving delirium (decreased capacity to understand instructions) and are deconditioned -marrying new provided meds with cupboard of old medications at home -Brand names Vs generic names Strategies: -written and verbal effective communication -Webster pack -Once daily dosing if possible

79 A Typical Falls Clinic Case: 82 yo lady, lives with husband, help with cleaning and meals Poor mobility for years. Falls for last 3 years? Onset related to starting antidepressant 4 falls in last month Trips or LOB, indoors, often at night Sometimes trips over shower hob Some postural dizziness (no LOC) Gluteal muscle rupture with recent fall

80 Further History Short term memory and concentration have declined over the last few years, but especially in the last 6 months. Disorientated to time. 4 kg weight loss, poor appetite Husband now feels that he cannot leave her at home alone. Urinary incontinence on standing. Nocturia x 2 Uses trifocals

81 Past Medical History Osteoarthritis -Back- spinal fusion 1998, lumbar laminectory hands and feet IHD- stents 2009, CCF Depression- commenced on treatment past 3-4 years Asthma

82 Medications Aspirin Clopidogrel Carvedilol 3.25 bd Fosinopril/ hydrochlorthiazide 20/12.5 mg Spironolactone 25mg mane Nortriptyline 50mg nocte Dothiepin 150 mg nocte Oxazepam Oestrone mg nocte Atorvastatin Meloxicam 15 mg nocte

83 Examination Lethargic and slow BP 90/40 lying, 70/40 standing Gait: very unsteady with tendancy to fall backwards. Too dizzy on standing to complete a TUG. MMSE 23/30

84 Investigations CT cerebral atrophy, small vessel ischaemic changes Sodium low (120) Vitamin D very low (13)

85 Risk Factors for Falls? Postural hypotension secondary to medications (fosinopril/hydrochlorthiazide, spironolactone, carvedilol, dothiepin, nortriplyline) Polypharmacy Centrally acting medications- oxazepam, dothiepin, nortriptyline Poor cognition- secondary to medications and hyponatremia +/- underlying emerging dementia Poor gait, exacerbated by gluteal rupture causing Trendelenberg pattern Vitamin D deficiency Urinary incontinence Environmental

86 Management? Medical Reduced fosinopril 20/ Hydrochlothiazide 12.5 to fosinopril 10 mg Wean oxazepam Stop meloxicam, start panadol osteo Loaded with vitamin D In liaison with psychiatrist and GP, both antidepressants were slowly withdrawn

87 Physiotherapy Gait aids- single elbow crutch inside, 4WW outside Upon resolution of postural hypotension to start hydrotherapy based strength and balance program Avoid trifocals when walking Occupational therapy Remove shower hob Bedside commode Grabrail along route to ensuite Offered HACC services but couple refused

88 Follow up Today Mrs M looked like a completely different person No falls, continues to use 4WW, no postural dizziness Mood and cognition significantly improved Urinary incontinence resolved although continues to have nocturia Couple planning a holiday

89 Case 2 53 year old, lives with her husband Referred to clinic- 12 falls in 12 months -Declining mobility over last 5 years, due to shortness of breath and declining balance more recently. Now has very unsteady gait using 4 wheel walker. Veers to side. -falls inside, getting out of bed or overbalancing -no dizziness or blackouts, quick recovery -sustained fractured rib

90 Medical history: -Severe asthma- regular admissions and use of prednisolone -Osteoporosis- vertebral (vertebroplasty) and rib fractures -Chronic back pain- Medications initiated by a Pain Clinic -Depression

91 Medications Paracetamol Calcium 1200mg/d Vitamin D 1000iu/d Diazepam 5mg bd Montelukast 10 mg/d Omeprazole 20 mg bd Targine 40/20mg bd Pregabalin 150 mg bd Quetiapine 100 mg mane, 200mg nocte Tramadol 200mg SR bd Ventolin/ tiotropium/ seretide inhalers

92 Falls Risk Factors Cognition: Declining memory in last 12 months. Disorientated, doesn t read or pursue hobbies. Can be drowsy, vague and have slurred speech. Stopped driving 6 months ago. Sleeps a lot. Continence: nocturia x 2 Feet/ Footwear good Vision good Alcohol little

93 Further Multidisciplinary Assessment No postural drop in BP MMSE 21/30, Clock drawing impaired, ACE-R 77/100 Timed Up and Go 45 secs Gait: slow, shuffled, reduced foot clearance, trunkal sway Rhombergs test positive Proximal leg weakness

94 What do you think? Contributors to Falls Risk Medications- tramadol, targine, quetiapine, diazepam, pregabalin Proximal weakness- deconditioning and prednisalone Crush fractures spine, chronic back pain Osteoporosis Increased risk of fracture when she falls Due to prednisolone use Not on adequate treatment at present

95 Plan Slowly reduce medications- tramadol, quetiapine, targine. Liaise with GP and pharmacist Osteoporosis: dental review then denosumab Refer to SCGH pain clinic for consideration of the SCAMP Program Falls specialist physio: Attend SCGH for pool based strength and balance program Teach patient and husband how to get up off floor OT: pressure care cushion

96 Follow up Medications now pregabalin 25 mane, 50 nocte Targin 20/10mg bd Quetiapine 12.5mg nocte Tramadol and diazepam ceased No further falls! Improved proximal strength, improved sit to stand No walking aids, driving, doing housework Husband and patient delighted

97 Case- Mrs KC 95 year old, living alone, supportive daughter, frail ++ Seeing Falls Specialist at home for falls and poor mobility Referred in for urgent medical assessment for subacute decline- fatigue, worsening mobility, poor appetite & wt loss, incontinence

98 PMH -Polymyalgia Rheumatica- quiescent -OA- TKRs -Urge urinary incontinence- KEMH -Macular degeneration -TIA and? Seizure x 1 10 years ago

99 Medications prednisolone 5 mg solifenacin 5 mg vitamin D 2 tabs phenytoin 200mg thyroxine 125 mcg nexium 20mg perindopril plus 5/125mg actonel

100 Examination BP 130 systolic lying- 80 mmhg standing, dizzy ++ Hypovolaemic Investigations B (Low) Vitamin D 117 ESR and CRP normal TSH 0.22 (low) Sodium 124 (Low)

101 Management -stop vesicare, phenytion, perindopril plus -load with B12 -reduce thyroxine -stop actonel, continue with calcium & vit D -wean prednisolone

102 Review at 4 months No further falls Mobility improving with Falls Specialist- TUG improved secs No return of PMR symptoms Sodium normalised

103 Take Home Messages Try non medical management of insomnia, agitation and delirium first Minimise the use of sleeping tablets and other sedatives Measure patients lying and standing BPs if falling or on any BP lowering meds Recognition that patients on centrally acting meds or with polypharmacy are at risk of falling

104 BREAK

105 Pradeep Jayasuriya General Practitioner, Private Practice Interest in primary health care and chronic complex disease Previously worked for National Prescribing Service and Department of Veterans Affairs Worked on projects related to medicines and chronic disease Previously Royal Australian College of General Pracitioners - Director of Research in WA

106 Managing Medicines to Prevent Falls - The General Practitioners Perspective Dr Pradeep Jayasuriya June,

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108 Scale of the Problem % in community over 65 will fall each year 50 % over 80 yrs At risk population to escalate with ageing population and increasing chronic complex disease and polypharmacy 108

109 Falling is not just for older women: support for pre-emptive prevention intervention before 60. Nitz JC 1, Choy NL. Climacteric. 2008;11(6):461-6 Objective This study aimed to report falls and identify factors that might predict a fall in women aged between 40 and 80 years and thus provide evidence of earlier falls and need for morbidity preventive intervention. Design and participants A prospective cohort study design over 5 years. Results. Over the 5-year study period 463 women enrolled, 21% of women in their forties and fifties, 31% of women in their sixties and 47% in their seventies had fallen. Multiple fallers mostly comprised women in their sixties and seventies. Parametric modeling and the classification tree approach revealed age and number of co-morbidities to be most predictive of a fall. Women < 60 years old had an increased risk of a fall by 8% and women > 60 years an increased risk of a fall by 35% with every additional co-morbidity. Stability and other demographics were not predictive of falling. Conclusions For women over 40 years old, the number of co-morbidities increased the risk of a fall. The falls risk escalated with additional comorbidities if they were over 60 years. Preventive program participation to maintain good health beginning by the forties appears vital to prevent falls. 109

110 Chronic complex disease Caughey et al % of persons older than 65 have 2 or more chronic conditions; 50% have more than 4 40 % of older persons take more than 4 medicine Evidence for management lacking >3 chronic disease associated with 25% higher mortality, poorer qol, functional decline, psychological distress and higher 110 hospitalisation

111 Consequences of Falling 5-10 % of falls in elderly will lead to major injury (fracture, head trauma or laceration) Veterans Mates, 2009 Loss of independence Chronic disability Lower quality of life Premature admission to residential care facilities Cost to health care system 111

112 Primary Care Approach in Preventing Falls Relationships Access Continuity Co-ordination Patient Centred Cost 112

113 General Practioner Role Early identification recognise those at risk Evaluation Investigations and appropriate referral Education Prescribe/de-prescribe Regular review Monitoring 113

114 V Veterans Mates,

115 General Practioner Role Early identification recognise those at risk Evaluation Investigations and appropriate referral Education Prescribe/de-prescribe Regular review Monitoring 115

116 Waldron et al, AFP. Volume 41, No.12, December 2012 Pages

117 General Practitioner Role Early identification recognise those at risk Evaluation Investigations and appropriate referral Education Manage medicines - Prescribe/de-prescribe Regular review Monitoring 117

118 Medicines that increase falls risk. Effects of drug pharmacokinetic/pharmacodynamic properties, characteristics of medication use, and relevant pharmacological interventions on fall risk in elderly patients Ying Chen, 1 Ling-Ling Zhu, 2 and Quan Zhou Ther Clin Risk Manag. 2014; 10:

119 The high risk medications Anti-psychotics sedating, anticholinergic Benzodiazepines sedating, ataxia, ST memory disturbance. Doubling of risk of serious injury from falls for those over 80 yrs (Smith A, Drug and Ageing 2009) Anti-depressants sedation, post. hypotension, syncope? Exact mechanism Anti-hypertensives Low BMI, bed rest and dehydration can exacerbate post hypotension BUT - - Context is crucial 119

120 Interventions for preventing falls in older people living in the community (Review) Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE

121 Gradual withdrawal of psychotropic medication reduced rate of falls (RaR 0.34, 95% CI 0.16 to 0.73; 1 trial; 93 participants), but not risk of falling. A prescribing modification programme for primary care physician significantly reduced risk of falling (RR 0.61, 95% CI 0.41 to 0.91; 1 trial; 659 participants 121

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123 Polypharmacy and Falls Association with >4 medications and falls Mixed Results from studies (confounding factors) Appropriate prescribing more important Lack of evidence for medications use with comorbidities and the elderly Intervention as part of other initiatives most effective Complexity demands an independent review of medicines ideally by clinical pharmacist/pharmacologist 123

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125 In conclusion multifactorial interventions appear to be most effective in preventing falls in LTCG and hospital settings. 125

126 Principles of Medication Management Minimise use of medications that increase falls risk - use alternatives when possible Minimise the number of medications Implement strategies to minimise risk from postural hypotension Consider the impact of OTC medicines Regular medication reviews - with changes to condition, after hospitalisation and symptoms that might suggest ADR Consider dose administration aids - pros and cons 126

127 Minimise the number of medications Stepwise approach to prescribing Use the minimum dose possible, start low and increase Cease unnecessary therapy Consider non pharmacological approaches 127

128 Implement strategies to minimise risk from postural hypotension Reduce dose of anti-hypertensives risk versus benefit, look at evidence Educate patients to avoid precipitants Hydration Timing of medications optimising versus adherence Look at drug interactions OTC drugs Awareness of changing circumstances 128

129 Regular medication reviews With changes to condition or significant changes to medications After hospitalisation Symptoms that might suggest ADR Multiple medication use Declining cognitive function Role for pharmacists 129

130 Ted 76 y.o retired mechanic with frequent and recurrent falls. BP 80/60 Aspiration Pneumonia Pulmonary Hypertension Interstitial Lung Disease GORD Iron Deficiency Anaemia IHD Mitral Incompetence Heart Failure Parkinsons Disease Glaucoma Hypotension Osteoarthritis Postural Hypotension Salbutamol Puffer Symbicort puffer Aspirin Entacapone Ferrrotab Fludrocortisone Frusemide Madopar Esomeprazole Paracetamol Pramipexole (Sifrol) 130

131 What actually happens in practice Awareness of issue across all staff Early recognition (observation, regular home health assessments, information from relatives, neighbours, friends) Referral for exercise, home aids etc Collaboration with other health professionals Referral for DMMR (medication review) Ongoing follow up 131

132 John McLachlan Respiratory & Sleep Physician, Fiona Stanley Hospital Clinical Lead Pulmonary Physiology & Sleep Medicine Sleep Physician x 27 years Interest in Insomnia Management President Elect, WA Branch Thoracic Society of Australia & NZ

133 From ghoulies and ghosties And long-leggedy beasties And things that go bump in the night, Good Lord, deliver us! trad. Scottish

134 Overview Normal Sleep Sleep Disorders Falls Sleep Treatments Falls Alternative Management

135 Normal Sleep Gradual process Sleep pressure / Circadian / Alerting > 24 hour clock Entraining Cyclical Stages

136 Normal Sleep

137 Normal Sleep

138 Normal Sleep Falls due to normal sleep? Environment Inertia REM

139 Sleep Disorders Excessive Sleep Initiating & Maintaining Sleep Parasomnias

140 Sleep Disorders Excessive Sleep Sleep Apnoea Sleepy PU Narcolepsy / Cataplexy Sleep restriction

141 Sleep Disorders Initiating & Maintaining Sleep Insomnia Circadian

142 Sleep Disorders Initiating & Maintaining Sleep Insomnia Circadian Insomnia increase elderly Increased use of hypnotics in elderly Narrower therapeutic index Increased comorbidities Increased polypharmacy Often longer duration of action

143 Sleep Disorders Parasomnias Restless Legs REM behaviour Arousals Confusional Sleep walking Terrors

144 Sleep Treatments Oxygen CPAP Medications

145 Hypnotics and Falls Several studies show increased risk Elderly Institutionalised Benzos & other psychotropics J Gerontol 1989;44:M Some inconstant Community Large scale suggest increased risk N Engl J Med 1988; 319: JAMA 1989; 261:

146 Hypnotics and Falls Brassington et al Reported sleep problems Not psychotropic meds J Am Geriat Soc 2000; 48: Questionnaire study Falls related to insomnia Falls related insomnia not responding meds Not insomnia responding to meds If hypnotic works not a risk? J Am Geriat Soc 2005; 53:

147 Hypnotics and Falls Stone et al. Community living older women Actigraphy Medication list Risk of falls over 8 years Arch Intern Med. 2008;168(16):

148 Hypnotics and Falls Arch Intern Med. 2008;168(16):

149 Sleep and Falls Arch Intern Med. 2008;168(16):

150 Alternate Treatment

151 CBTi Components Behavioural component General Specific Cognitive component Educational component _McLachlan_Insomnia

152 CBTi Components Behavioural component General Specific Cognitive component Educational component _McLachlan_Insomnia

153 201503_McLachlan_Insomnia Exercise Exercise promotes both sleep onset and sleep consolidation in all groups Specific studies in the elderly have shown benefits with very minimal exercise Exercise confers additional benefits on bones, joints, balance

154 201503_McLachlan_Insomnia Bright Light Moderately bright light (1000 lux) or more improves subjective alertness, mood, and sleep quality Morning bright light promotes sleep onset

155 201503_McLachlan_Insomnia Sleep Hygiene Regular sleep-wake cycle Bed when sleepy Avoid caffeine / alcohol Exercise Careful use of naps Conducive environment Bed for sleeping and sex Worry time

156 CBTi Components Behavioural component General Specific Cognitive component Educational component _McLachlan_Insomnia

157 Two goals of behavioural component Stimulus Control Therapy Strengthen the relationship between sleep and sleep-related stimuli (i.e., bed, bedtime, bedroom surroundings). Sleep Restriction Consolidate sleep over shorter periods of time _McLachlan_Insomnia

158 201503_McLachlan_Insomnia Stimulus Control Bed Bedroom Sleep-incompatible activities (reading, watching tv) Frustration Bedtime Anxiety Worry

159 201503_McLachlan_Insomnia Stimulus Control Bed Drowsiness Bedroom Relaxation Bedtime Sleep

160 201503_McLachlan_Insomnia Conditioned Sleep Onset Insomnia Stimulus Control Therapy 1. Don t go to bed until sleepy. 2. If not asleep in minutes, get out of bed. 3. Go back to bed when sleepy again. 4. Keep repeating #2 & #3 until asleep. 5. Arise at the same early time (eg. 7am) every morning regardless of the time went to sleep. 6. Use the bed only for sleep and sex. 7. Don t nap (long nap) during the day.

161 201503_McLachlan_Insomnia Sleep Restriction Individuals with insomnia have reduced sleep efficiency

162 201503_McLachlan_Insomnia Sleep Restriction Align time in bed (TIB) Develop a regular sleep-wake rhythm.

163 Sleep is on our side Combine stimulus control & sleep restriction almost always win!

164 CBTi Components Behavioural component General Specific Cognitive component Educational component _McLachlan_Insomnia

165 201503_McLachlan_Insomnia Cognitive Component Challenging unrealistic sleep expectations Modifying beliefs about causes and consequences of insomnia

166 201503_McLachlan_Insomnia Cognitive Component BELIEF: It is essential to sleep x number of hours per day to feel refreshed and function well during the day

167 Morning sleepiness is normal _McLachlan_Insomnia

168 201503_McLachlan_Insomnia Historical Sleep Segmented Sleep 1st (deep) watch period 2nd lighter

169 CBTi Components Behavioural component General Specific Cognitive component Educational component _McLachlan_Insomnia

170 201503_McLachlan_Insomnia Educational Component Health practices Environmental influences

171 201503_McLachlan_Insomnia Alternative Approaches Relaxation Paradoxical intention

172 201503_McLachlan_Insomnia Online CBT

173 201503_McLachlan_Insomnia Sleep (is like) a dove which has landed near one s hand and stays there as long as one does not pay any attention to it; if one attempts to grab it, it quickly flies away. Victor E Frankl

174 Case Study Activity Euginie

175 Mrs Euginie Draper *Not actual patient Age: 82 years Height: 160cm Weight: 78Kg Blood Pressure: 141/77 Conditions Hypertension Depression Poly Myalgia Rheumatica Insomnia Osteoporosis PVD TIAs Reflux and ulcer disease Macular degeneration Urinary incontinence Hyperlipidaemia Nausea

176 Stroke

177 Mrs Draper Social History Ex Music Teacher, Lives alone, Widower (2 years) Unable to renew license due to Macular Degeneration Moved to Retirement Village to be close to her daughter Had previous fall in the last 6 months (in the garden) Recently diagnosed with bradycardia o Permanent pacemaker inserted o Has reduced mobility in shoulder & needs interim hospital package for post discharge support

178 Recent Changes Appointment to see the Continence Nurse in 2 months Previously avid gardener but fall made her reluctant Doesn t know GP or Pharmacist Previously independent awaiting Home & Community Services Assessment for shopping & socialization Seems withdrawn

179 Current Medicines Perindopril 4mg mane ~ Blood pressure Verapamil SR 240mg mane ~ Heart rate control & BP Venlafaxine XR 150mg mane ~ Depression Pantoprazole 40mg mane ~ For Indigestion/Reflux Macuvision 1 tablet mane ~ Supplement for Eye health Aspirin/Dipyridamole 25mg/200mg SR bd ~ Blood thinner Previous TIA Prednisolone (Panafcortelone) 3x1mg mane ~ Polymylagia rheumatica Calcium Carbonate (Caltrate) 600mg dinner ~ Supplement for strong bones Simvastatin (Lipex)10mg dinner ~ Cholesterol Oxazepam (Alepam )½ x 30mg nocte ~ Anxiety Nitrofurantoin (Macrodantin) 50mg nocte ~ recurrent UTI Diazepam (Ducene) 5mg prn ~ for nerves due to recent moving house Paracetamol 2x500mg tds ~ Pain Cholestyramine (Questran) 4g sachet each morning Frusemide (Urex) 40mg prn fluid retention

180 Other Information Daughter s perspective: Concern about multiple medicines Uncertain that her mother can manage her medicines Patient perspective: Concerned about falls dizziness and incontinence Continence nurse visit booked for 3 months Has new bifocal glasses

181 Questions Which conditions in Mrs Draper s history concern you with regards to her falls risk? Which medicines do you consider may increase her risk of falls? Why do they increase risk of falls? What test results would you be interested in? Why? What would you be keen to observe? What will you do with your information? i.e. Who will you refer to? How?

182 Thank You

183