Check Your Medicines. Deirdre Criddle CoNeCT Complex Care Coordinator Pharmacist

Transcription

1 Check Your Medicines Deirdre Criddle CoNeCT Complex Care Coordinator Pharmacist

2 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

3 What is a fall? WHO definition: html 3

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

5 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 5

6 We re stayin alive 6

7 At what point in a person s life does the magic pill become a burden? 7

8 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 8

9 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 9

10 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. 10

11 What is an intervention? 11

12 Show me the evidence!! 12

13 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

14 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 14

15 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 ) 15

16 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

17 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

18 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

19 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 19

20 20

21 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

22 22

23 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.

24 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 24

25 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) 25

26 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 26

27 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 27

28 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 28

29 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. 29

30 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. 30

31 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. 31

32 32 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

33 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 33

34

35 35

36 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

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

38 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):

39 Supporting sustainable change ~ a benzodiazepine reduction plan 39

40 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):

41 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 ;

42 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

43 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

44 44

45 45

46 46

47 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 47

48 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