Polypharmacy in the Elderly

Transcription

1 Polypharmacy in the Elderly

2 Or How Scotland invented the Modern World

3 Sir William Ferguson Anderson

4 Became the first Professor of Geriatrics in the world when he was appointed to the David Cargill Chair of Geriatric Medicine at the University of Glasgow

5 In 1970 he wrote in his book, Practical Management of the Elderly No person in Residential Care should be taking more than 5 medications.

6 The physician more often does more good for the Patient by stopping medications than by starting them

7 So why has Polypharmacy become an issue?

8 What exactly is Polypharmacy?

9 Multiple Medications One Inappropriate Medication More than 5 medications More than 5 inappropriate medications More than 10 appropriate medications

10 Our working definition When the theoretical benefits of multiple medications are outweighed by the negative effect of the sheer number of medications, regardless of class of medication or appropriateness thereof.

11 What are the risks of Polypharmacy?.

12 Decreased: Cognitive function, ADL s,quality of Life Increased: ADE s, Falls, Transfers to Acute Care Which leads to: Hospitalisation Associated Disability

13 Hospital Associated Disability

14 Hospitalisation-Associated Disability Hospitalization is a sentinel event that often precipitates disability. This results in the subsequent inability to live independently and complete basic activities of daily living (ADLs). This hospitalizationassociated disability occurs in approximately one-third of patients older than 70 years of age and may be triggered even when the illness that necessitated the hospitalization is successfully treated.

15 Adverse Drug Reactions The most consistent risk factor for adverse drug reactions is: number of drugs being taken Risk rises exponentially as the number of drugs increases.

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17 What are the causal factors leading to Polypharmacy?

18 Clinical Practice Guidelines Chronic Disease Management Treating surrogate markers Clinical uncertainty ADE or new symptom? Treating S/E with another pill Multiple prescribers Lack of history Uncertain treatment goals Lack of communication 1 8

19 We treat multiple individual diseases and as a result we give the person an illness: POLYPHARMACY

20 What are the barriers to effective Medication Reviews?

21 Consensus on clinical/pharmacological knowledge Perceived Medico-legal Risks Process and communication issues Other care priorities, time, remuneration. Family and Residents Absentee MRPs.

22 What Else Do We Know? Studies show 50% of meds can be stopped with resultant improvement in global health and cognitive function Only 2% of meds need to be restarted due to recurrence of indication Physicians, pharmacists, nursing, and family need a solid platform from which to make decisions

23 LESS IS MORE ORIGINAL INVESTIGATION Feasibility Study of a Systematic Approach for Discontinuation of Multiple Medications in Older Adults Addressing Polypharmacy Doron Garfinkel, MD; Derelie Mangin, MBChB

24 The investigators of this study have put the theory of less is more into practice. They used an established tool to discontinue medications taken by communitydwelling older persons. Remarkably, they discontinued 311 medications in 64 patients with no significant adverse reactions; 84% of patients reported an improvement in health. Clearly, outpatient medication use among older persons is a case where less is more.

25 What Is The Right Balance? Level of intervention updates important Hidden Costs to Nursing/LPN resources Important to ask family What would (resident) want? rather than What do you want? Must consider benefit to harm concept NNT vs NNH ( Garfinkel algorithm

26 RC Med Reviews Opportunities Occasions for Full RC Medication Reviews Scheduled Med Reviews regular, but effective? When first admitted or during admissions process Transitions e.g. from Acute/ED, Special Care Unit Review of Level of Intervention or equivalent Review of standing orders e.g. Gravol 50mg Occasions for Focused RC Medication Reviews Episode of decline symptom-directed, e.g. fall, delirium Request by staff e.g. behaviour, med concerns, etc Request by resident/family education opportunity Addressing Polypharmacy in the Elderly

27 Tools Algorithm Priority Drug List DAS...Drug Advisory Sheets CAS...Condition Advisory Sheets

28 Drug Decision Algorithm Adapts Garfinkel (2010) evidence, risks, indications, etc, Addressing Polypharmacy in the Elderly

29 Priority Drug List Drugs associated with Confusional States antipsychotics, antidepressants, opioid analgesics, hypnotics Adverse Drug Event-related Falls antipsychotics, antidepressants (tricyclics), hypnotics, antihypertensives, hypoglycemics, anticonvulsants, antiparkinson meds, antihistamines Significant Anticholinergic Effects antidepressants (tricyclics), antihistamines, bladder meds Bleeding warfarin, antiplatelet meds Indications Not Present (or no longer present) statins, PPIs, analgesics, antihypertensives, antianginals, antipsychotics, antidepressants, osteoporosis meds Addressing Polypharmacy in the Elderly

30 Plan B-Top 10 Drugs Furosemide Levothyroxine Quetiapine Citalopram Ramipril Risperidone Warfarin Metoprolol Hydrochlorthiazide Rabeprazole Addressing Polypharmacy in the Elderly

31 3 1 Statins-You Decide

32 3 2

33 Statins- You Decide HARM Most RCTs report the incidence of adverse effects is no different between statins and placebo but there is uncertainty regarding patients with multiple conditions who are frail and on multiple medications. Harms- Minor side effects Nausea, gas, diarrhea or constipation 3 3

34 3 4 PPIs-You Decide

35 3 5

36 PPIs- You Decide They do reduce event rates so why stop? Only a few indications for ongoing Tx: complex peptic ulcer disease, erosive esophagitis/barrett s The indication wasn t there: Stress ulcer prevention in acute care; dyspepsia The indication is questionable: NSAIDs The indication usually doesn t warrant ongoing Tx if address precipitants- GERD- 4-8 weeks Intermittent Rx-antacids, H2 Blockers 3 6

37 QUESTIONS? One of the first duties of the physician is to educate the masses not to take medicine. Sir William Osler

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