Wiser Meds: Deprescribing for Older People. Dr. Rita McCracken, MD, PhD(c) Declaration of Conflicts of Interest

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1 Wiser Meds: Deprescribing for Older People Dr. Rita McCracken, MD, PhD(c) Declaration of Conflicts of Interest Faculty: Dr. Rita McCracken Relationships with commercial interests: NONE Grants/Research Support: St. Paul s Foundation, VCH/PHC Innovation Fund, BCCFP Research Fund Speakers Bureau/Honoraria: BC College of Family Physicians Consulting Fees: none Other: Family Physician, paid via BC s PMA, Associate Head, Dept. of Family and Community Medicine paid by Providence Health Care Site Faculty for Resident Research, Family Practice Residents, paid by UBC Disclosure of Commercial Support This program has NOT received financial support from anyone. This program has NOT received in kind support from anyone. Potential for conflict(s) of interest: n/a 1

2 Mitigating Potential Bias I deprescribe, a lot, but I still have patients with polypharmacy. I provide references for statements of fact/evidence. I welcome challenges and questions Learning objectives 1. Triage, where to start - identify which meds might cause problems, and develop a process to reduce polypharmacy 2. Worth the hassle? Describe risks and benefits of deprescribing 3. Toolbox - Increase awareness of existing tools that may aid in deprescribing 2

3 Where to Start Ref: Otis Historical Archives Nat'l Museum of Health & Medicine, Creative Commons 2.0 What is polypharmacy? 3

4 138 published definitions. Masnoon, et al, BMC Geri, 2017 PMID: Which pills are currently causing harm? Financial (e.g. advair, 150$ x12 months) Pill burden, (e.g. acetaminophen 650 QID = 8 tablets) Adverse effects (e.g. falls (& z-drugs), dry mouth (& TCA s), decreased appetite (& ACh-I s), constipation (acetaminophen/calcium), etc) No obvious indication (e.g. metoprolol 12.5mg started >5 years ago and no one remembers why) Excessive effect (e.g. A1c 5.9% and on metformin & glyburide) Used the think it was a good idea (e.g. ASA for primary prevention or vitamin D for almost anything) 4

5 Make a list 1. Drug name and dose 2. Indication 3. Goal/Target 4. Reasonable estimate of benefit, e.g. NNT 5. Reasonable estimate of harm, e.g. NNH 6. Patient s understanding/perception of value Where to start 5

6 Which pills does the patient want to stop? Reference: Creative Commons man portrait street man old / Harms and Benefits Ref: Otis Historical Archives Nat'l Museum of Health & Medicine, Creative Commons 2.0 6

7 Adverse drug reactions from good drugs Table 3: Most commonly implicated drugs What can you expect to happen when you deprescribe? 7

8 A little of this, a little of that What are you afraid of? 8

9 cardiac rescue / If you stop HTN Meds, what happens? 1) In 16 weeks, cognitive function does not improve. 2) Rates of adverse events EQUAL to if you keep them on the meds. 3) Blood pressure goes up, but maybe not as high as you would expect 9

10 Still think a bit of dizziness worth a mortality benefit?? If SBP <130 and on 2 or more HTN meds, Hazard ratio for MORTALITY = 1.78 Death is 100% unavoidable 10

11 the right questions 1. What is your understanding of where you are and of your illness? 2. Your fears or worries for the future? 3. Your goals and priorities? 4. What outcomes are unacceptable to you? 5. What are you willing to sacrifice and not? 6. What would a good day look like? Reference: Atul Gawande, Being Mortal, review and highlights: Toolkit Ref: Mark Knobil, flickr, creative commons license 11

12 for practice/about tools for practice/ PPI Antihyperglycemic Atypical Antipsychotic Benzo s 12

13 MedStopper.com 13

14 TI Letters (ti.ubc.ca) PathClinic.ca 14

15 CASE DISCUSSION Cheerful, but tired looking 83 year old just admitted to NURSING HOME her presentation to hospital: Concerned neighbour had found her on floor EHS noted home cluttered and dirty Admission BMI 17, poorly groomed, MMSE 13/25 Social Hx Single retired legal secretary with elderly brother in Nanaimo - she loves to tell stories about their happy youth together Advance Care Plan=Resuscitation status listed on 3 month old discharge summary (had 17 day stay for failure to thrive from VGH), says she is full code Multiple GP s listed on med rec, patient keeps saying that her family doctor is someone you know to be retired

16 PMHx (info from admission form and old discharge summary) Type 2 diabetes Hypertension Osteoporosis Coronary artery disease Hysterectomy age 20 A1c=7.6, GFR = 50, Hgb = Medications: Metformin 250mg BID Glyburide 2.5mg BID Sliding scale insulin Ramipril 5mg OD Amlodipine 5mg BID Vitamin D 1000IU daily Calcium Carbonate 1250mg daily Acetaminophen 650mg QID Alendronate Elder care bowel protocol Zopiclone 3.75mg prn Quetiapine 12.5mg prn 32 16

17 RN admission report BP 108/70, HR 60 Ambulating to bathroom, unsteady, sometimes with walker Asking nurses to phone her brother > 10x/day Needs cuing and assistance with toileting and dressing. Complains of nausea every morning Eating ~ 25-50% meal portions Loves bingo and hymn singing 33 BP 108/70, HR 60 Ambulating to bathroom, unsteady, sometimes with walker Asking nurses to phone her brother > 10x/day Needs cuing and assistance with toileting and dressing. Complains of nausea every morning Eating ~ 25 50% meal portions Loves bingo and hymn singing Advance Care Plan = Resuscitation status listed on 3 month old discharge summary (had 17 day stay for failure to thrive from VGH), says she is full code Case Summary 1. Try identifying an indication for each PMHx Type 2 diabetes Hypertension Osteoporosis Coronary artery disease Hysterectomy age 20 A1c=7.6, GFR = 50, Hgb = 109 Medications: Metformin 250mg BID Glyburide 2.5mg BID Sliding scale insulin Ramipril 5mg OD Amlodipine 5mg BID Vitamin D 1000IU daily Calcium Carbonate 1250mg OD Acetaminophen 650mg QID Alendronate Elder care bowel protocol Zopiclone 3.75mg prn Quetiapine 12.5mg prn medication. 2. What do you think would be reasonable targets? 3. What about frailty? Dementia? 4. What other information do you need? Want? 5. What are her baseline risks? 6. How could drugs help her? 7. Any drugs you think should be stopped today (active harm) 8. Any drugs you want to include in a deprescribing plan? 34 17

18 what makes a good day for our patient? 1. Good enough mobility 2. Regular bowel movements and a manageable bladder habit. 3. Clarity of thought (minimal daytime drowsiness, can have a conversation, go to Bingo, read the paper, etc) 4. Enjoyment of foods and drinks that are meaningful and pleasurable for them (as opposed to adhering to a special diet ) 5. Time with loved ones (usually). 6. Days NOT consumed by doctors appointments, trips to the pharmacy and pill taking. 35 patient goals and preferences should guide de/prescribing 18

19 Make a list Drug Name & Dose Indication Goal/ Target NNT? NNH? Pt understanding /preference Care Plan, (OSCAR: other Meds) 19

20 Care Plan Goals of care: Celebrate family relationships (photo albums, phone calls, visits Enjoy favorite food/bev treats (no restrictions) Attend bingo and music therapy (as much as possible, may need encouragement) Do not prevent natural death and avoid future hospitalizations (DNAR 2) Problem List: Frailty 7/9 CFS, Dementia, 5-6/7 GDS (fxn: ambulates w walker, continent x 2, hearing and vision WNL, mood stable) Diabetes, dx date: unknown, >5 years A1c goal 8-9%, measure q 6 months Current meds: none, consider if symptoms of hyperglycemia or if A1c > 9.5 x 2. CBG s: not indicated, do only if acutely unwell Meds d/c ed dt overtreatment: May 2015 Glyburide, metformin insulin SS (ref: Evidence-Informed Guidelines for Treating Frail Older Adults With Type 2 Diabetes: From the Diabetes Care Program of Nova Scotia (DCPNS) and the Palliative and Therapeutic Harmonization (PATH) Program Mallery, Laurie Herzig et al. JAMDA, Vol 14, Iss 11, ) Hypertension, dx date >10 y SBP goal: , measure monthly, Current meds: none indicated, consider only after 2 consecutive readings above target Meds d/c ed dt overtreatment: ramipril and amlodipine (ref: Mossello E, Effects of Low Blood Pressure in Cognitively Impaired Elderly Patients Treated With Antihypertensive Drugs. JAMA Intern Med.2015;175(4): ) Bone Health Keep ambulating, attend as many PE activities as possible, keep BMI> 20 Current meds: none Meds d/c ed dt lack of applicable evidence: Ca2+, vit D, alendronate, refs: Theodoratou E, et al Vitamin D and multiple health outcomes: umbrella review of systematic reviews and meta-analyses of observational studies and randomised trials BMJ 2014; 348 :g2035 AND Insomnia Minimize daytime napping. If not asleep by 1030, melatonin 1-3mg prn Meds d/c ed: zopiclone 3.75mg prn dt adverse effect profile 20

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