Iatrogenesis in the frail elderly

Transcription

1 Iatrogenesis in the frail elderly Professor Michael Dooley Director of Pharmacy Alfred Health Professor of Clinical Pharmacy Centre for Medicine Use and Safety Monash University Iatrogenesis in the frail elderly Drug related impacts Patient related impacts Care delivery impacts Admission Inpatient Inpatient Discharge

2 Iatrogenesis in the frail elderly Iatrogenesis definition. pathologic alteration caused to a patient. by the inappropriate practice of health professionals. which results in harmful consequences to a patient s health

3 90 year old female Admitted post fall and fractured elbow and pelvis for internal fixation Unwell with UTI symptoms Commenced oral ciprofloxacin Normal renal function (U&E s) creatinine clearance 51ml/min 6days later micro results pseudomonas aeruginosa sensitive to gentamicin Estimated weight 45kg 90 year old female Admitted post fall and fractured elbow and pelvis for internal fixation Unwell with UTI symptoms Commenced oral ciprofloxacin Normal renal function (U&E s) creatinine clearance 51ml/min 6days later micro results pseudomonas aeruginosa sensitive to gentamicin Estimated weight 45kg Received one dose 240mg had surgery Day 3 creatinine 290mmol/L. Day 4 post genta dose...gentamicin 2mg/L Continued worsening renal function.deceased D9 Cause of death on autopsy.. Renal failure secondary to gentamicin..weight 35kg

4 Iatrogenesis in the frail elderly Hospitals can be dangerous places for older people, problems experienced can include: Under nutrition / dehydration Pressure injuries Incontinence Falls Delirium Medication errors Depression Communication breakdown Iatrogenesis in the frail elderly Hospitals can be dangerous places for older people, problems experienced can include: Under nutrition / dehydration Pressure injuries Incontinence Falls Delirium Medication errors Depression Communication breakdown

5 Challenges in acute care Professor David Ben-Tovim Clinical Epidemiology and Redesigning Care, Flinders Medical Centre and Flinders University. Decision to prescribe medication in a patient with cancer

6 Decision to prescribe medication in a patient with cancer 1. What benefits various drug strategies hope to achieve Decision to prescribe medication in a patient with cancer 1. What benefits various drug strategies hope to achieve 2. How many patients per annum need to be treated with that drug to obtain benefit in one patient

7 Decision to prescribe medication in a patient with cancer 1. What benefits various drug strategies hope to achieve 2. How many patients per annum need to be treated with that drug to obtain benefit in one patient 3. How long does a patient need to be on a drug to show significant benefit Decision to prescribe medication in a patient with cancer 1. What benefits various drug strategies hope to achieve 2. How many patients per annum need to be treated with that drug to obtain benefit in one patient 3. How long does a patient need to be on a drug to show significant benefit 4. Consider stopping a medication when it is not reasonably expected to give a benefit within the reasonable expectation of that person s lifespan

8 Decision to prescribe medication in a patient with cancer 1. What benefits various drug strategies hope to achieve 2. How many patients per annum need to be treated with that drug to obtain benefit in one patient 3. How long does a patient need to be on a drug to show significant benefit 4. Consider stopping a medication when it is not reasonably expected to give a benefit within the reasonable expectation of that person s lifespan 5. Prioritise which medications are the most effective when major polypharmacy exists Decision to prescribe medication in a patient with cancer 1. What benefits various drug strategies hope to achieve 2. How many patients per annum need to be treated with that drug to obtain benefit in one patient 3. How long does a patient need to be on a drug to show significant benefit 4. Consider stopping a medication when it is not reasonably expected to give a benefit within the reasonable expectation of that person s lifespan 5. Prioritise which medications are the most effective when major polypharmacy exists 6. Consider stopping the medication where the risk of side effects now is considered greater than the expected benefit

9 Decision to prescribe medication in a patient with cancer Decision to prescribe medication in a patient with cancer 1. What benefits various drug strategies hope to achieve 2. How many patients per annum need to be treated with that drug to obtain benefit in one patient 3. How long does a patient need to be on a drug to show significant benefit 4. Consider stopping a medication when it is not reasonably expected to give a benefit within the reasonable expectation of that person s lifespan 5. Prioritise which medications are the most effective when major polypharmacy exists 6. Consider stopping the medication where the risk of side effects now is considered greater than the expected benefit Prescribing guidelines for frailty.. Martin W. Polypharmacy: Guidance for Prescribing in Frail adults. Scotland, NHS Highland 2013.

10 Iatrogenesis in the frail elderly Drug related impacts Patient related impacts Care delivery impacts Admission Inpatient Inpatient Discharge Drug related impacts Pathophysiology of frailty Clegg A, Young J, Iliffe S, et al. Frailty in elderly people. Lancet 2013; 381:

11 Drug related impacts Effect of frailty on the pharmacokinetics of drugs in older people is largely unknown Exclusion of patients from clinical studies Complicated by awareness of definitions of frailty Age related physiological changes Drug related impacts Klotz U. Drug Metab Rev 2009; 41: 67-76

12 Iatrogenesis in the frail elderly Drug related impacts Patient related impacts Patient related impacts Frailty factors Nutritional status Physical activity Mobility Energy Strength Cognition Mood Social support

13 Patient related impacts Frailty factors Nutritional status Physical activity Mobility Energy Strength Cognition Mood Social support Patient related impacts Frailty factors Nutritional status Physical activity Mobility Energy Strength Cognition Mood Social support Visual impairment Hearing impairment Swallowing problems Health literacy Comorbidity Motivation

14 Iatrogenesis in the frail elderly Drug related impacts Patient related impacts Care delivery impacts Admission Inpatient Inpatient Discharge Care delivery impacts

15 Care delivery impacts New medication initiated in hospitals A retrospective point prevalence audit was undertaken to identify all medications initiated after the patient was admitted to the Alfred Hospital. All inpatients with a length of stay greater than 24 hours were included (excluding patients admitted under psychiatry). 292 (97.7%) received 1medication that was initiated after admission (Ave 7.5 ; Range 0 to 29)

16 New medication initiated in hospitals On Admission On discharge Antipsychotics Benzodiazepines/Nonbenzodiazepine sedatives Antidepressants Medication lists inaccurate 4330 drugs Patient not doctor (17.6%) Both patient and doctor (57.7%) Doctor not patient (24.7%) In only 6.9% of patients there was >90% agreement between doctor and patient on all medication taken by the patient. 32.1% of significant drugs were non concordant.

17 Dose administration aids inaccurate Backing card versus history (n=100)* Contents versus history (n=120) Backing card versus contents (n=100)* Number of patients with 1 discrepancy of possible or high significance (%)** 75 (75) 48 (40) 32 (32) * Only 100 of the 120 DACs had a backing card Includes all medications, including variable dose medications and those that cannot be stored in DAC Contents Backing card Comprehensive history Medication incidents

18 Medication related MET calls in patients over 65 Drug-related problem Number of MET calls 1. Untreated medical condition 0 2. Wrong drug being used 2 3. Dose too low 1 4. Dose too high ADR-A (predictable) ADR-B (idiosyncratic) Drug interaction 5 8. Drug not received 6 9. No valid indication MET calls in 2years Alfred Hospital Over 50% potentially preventable Iatrogenesis in the frail elderly Drug related impacts Patient related impacts Care delivery impacts Admission Inpatient Inpatient Discharge

19 Which patients? By whom? Which tools?

20 Medication reconciliation rate Patients 65 years admitted through ED reconciled within 24 hours of admission Identification of patients at risk Domain Tool Medication name/ class Dose Form/ route/ frequency Indication Duration of Tx Health conditions No. meds Co-morbidiity Chronic Disease Score (CDS) Rx-Risk-V Medication-related Disease Burden Index Functional outcomes Polypharmacy Prescribing appropriateness Drug Burden Index Poly-pharmacy Medication regimen complexity index BEERS Stopp-Start Improved Prescribing in the Elderly Tool (IPET)

21 Identification of patients at risk (number of medications) All patient s 65 years admitted to the GMU for 24 hours or greater at The Alfred during the period of February June 2013 with a complete medication reconciliation form (MRF) was included Identification of patients at risk (number of medications) All patient s 65 years admitted to the GMU for 24 hours or greater at The Alfred during the period of February June 2013 with a complete medication reconciliation form (MRF) was included

22 Which list is accurate? Which tools? When? Why? Which tools?

23 Consider any new sign or symptom as a possible outcome of current medicines Identification of prescribing appropriateness

24 When? Why? Which tools? Iatrogenesis in the frail elderly Drug related impacts Patient related impacts Care delivery impacts Admission Inpatient Inpatient Discharge

25 What is needed in the acute clinical setting to reduce harm from medication in the frail elderly Anyone making a clinical decision takes the patient into account Evidence Simple valid clinical aid that identifies differences between patients That this aid is freely available at the point of decision making It is easy and intuitive to use The aid is imbedded into practice Decision to prescribe medication in a patient with frailty 1. What benefits various drug strategies hope to achieve 2. How many patients per annum need to be treated with that drug to obtain benefit in one patient 3. How long does a patient need to be on a drug to show significant benefit 4. Consider stopping a medication when it is not reasonably expected to give a benefit within the reasonable expectation of that person s lifespan 5. Prioritise which medications are the most effective when major polypharmacy exists 6. Consider stopping the medication where the risk of side effects now is considered greater than the expected benefit Martin W. Polypharmacy: Guidance for Prescribing in Frail adults. Scotland, NHS Highland 2013.

26 Medication in frail adults Iatrogenesis in the frail elderly Drug related impacts Patient related impacts Care delivery impacts Admission Inpatient Inpatient Discharge

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28 Prescribing in frail adults