Drug use in long term care. Graziano Onder Centro Medicina Invecchiamento Università Cattolica Sacro Cuore, Rome

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1 Drug use in long term care Graziano Onder Centro Medicina Invecchiamento Università Cattolica Sacro Cuore, Rome

2 Polypharmacy in nursing home (USA) Concurrent use of 9 medications was reported for 39.7% of residents. The mean number of medications taken was 8 and the median was 7 (n=13403) Dwyer et al. Am J Geriatr Pharmacother 2010

3 Polypharmacy in nursing home (Europe) Excessive polypharmacy ( 10 drugs) was observed in 24.3% residents mean number of drugs was 7 (n=4023) Onder et al. J Gerontol A Biol Sci Med Sci. 2012

4 Services and Health for Elderly in Long TERm care (SHELTER) 4156 residents 57 NH 7 EU + Israel Funded by FP7

5 Characteristics of residents in NH in Europe: SHELTER study Total sample (4156) Age, years 83±9 Female gender 73% ADL disability Assistance required Dependent 42% 39% Depression 32% Pain 36% Onder G et al. BMC Health Services Research 2012

6 Characteristics of residents in NH in Europe: SHELTER study CPS score Mild/Moderate impairment Severe impairment Total sample (4156) 38% 30% Behavioral symptoms 28% Falls 19% Multimorbidity 86% Urinary incontinence 74% Onder G et al. BMC Health Services Research 2012

7 Factors influencing prescribing in NH 1. Cognitive status/dementia 2. Limited life expectancy

8 Treatment of non dementia illness in patients with dementia Brauner et al. JAMA 2000

9 Holmes et al. Clin Pharmacol Ther 2009

10 Medication Use in Nursing Home Residents with Advanced Dementia Tija et al. J Am Geriatr Soc 2010

11 Mortality (%) N of Drugs (mean) N of drugs and life expectancy in dementia 60% 7 50% 40% 30% p= Mortality (%) Mortalità (%) N of drugs N di Farmaci (media) 20% 2 10% p< % < ADEPT score 0 Onder G et al. JAMDA 2013

12 Survival RESULTS Polipharmacy and survival ADEPT score < ADEPT score 13.5 (attesa di vita limitata) 0,8 0,8 0,6 0,6 0,4 0,4 0,2 Log rank=0.24 0,2 Log rank= Follow up (months) Polypharmacy Follow up (months) No polypharmacy

13 Treatment of non dementia illness in patients with dementia Brauner et al. JAMA 2000

14 Differences between SHEP and general population % Dementia Depression Disability SHEP General Population

15 Factors influencing prescribing in NH 1. Cognitive status/dementia 2. Limited life expectancy 3. Disability - Limited life expectancy - Functional limitations

16 Medication management by age Beckmen A Patient Educ Couns. 2005

17 Factors influencing prescribing in NH 1. Cognitive status/dementia 2. Limited life expectancy 3. Disability 4. Multimorbidity 5. Polypharmacy/interactions

18 Potentially Harmful Drug-Drug and Drug-Disease Combinations Drug-drug combination (%) Drug-disease combination (%) Total population Age (years) Zhan C et al. JAGS 2005

19 Antipsychotic drug interactions: SHELTER (n=604) Potential Adverse Effects caused from interactions with antipsychotics n (%) Decreased blood pressure and falls 210 (34.8%) QT prolongation 44 (7.3%) Sedation 43 (7.1%) Interactions with inhibitors of 9 (1.5%) cytochrome p450 Anticholinergic effects 2 (0.3%) All 278 (46.0%) Liperoti et al. In preparation

20 Antipsychotic drug interactions: SHELTER (n=604) No interactions Interactions Incident rate RR per person-year (95% CI) Log-Rank= 0.02 No interactions Interactions ( ) Liperoti et al. In preparation

21 Factors influencing prescribing in NH 1. Cognitive status/dementia 2. Limited life expectancy 3. Disability 4. Multimorbidity 5. Polypharmacy/interactions

22 Factors associated with polypharmacy: SHELTER Polypharmacy OR (95% CI) Age (10 years increment) 0.85 ( ) ADL Dependency 0.59 ( ) Cognitive status Mild/Moderate impairment Severe impairment 0.64 ( ) 0.39 ( ) Onder et al. J Gerontol A Biol Sci Med Sci. 2012

23 Factors associated with polypharmacy: SHELTER Polypharmacy OR (95% CI) Age (10 years increment) 0.85 ( ) ADL Dependency 0.59 ( ) Cognitive status Mild/Moderate impairment Severe impairment 0.64 ( ) 0.39 ( ) Pain 2.31 ( ) Dyspnoea 2.29 ( ) Onder et al. J Gerontol A Biol Sci Med Sci. 2012

24 Factors associated with polypharmacy: SHELTER Polypharmacy OR (95% CI) Age (10 years increment) 0.85 ( ) ADL Dependency 0.59 ( ) Cognitive status Mild/Moderate impairment Severe impairment 0.64 ( ) 0.39 ( ) Pain 2.31 ( ) Dyspnoea 2.29 ( ) Ischemic heart disease 2.93 ( ) Heart failure 2.06 ( ) Parkinson disease 2.82 ( ) Stroke 1.49 ( ) Diabetes 3.19 ( )

25 Prevalence of IHD Medication Use among Nursing Home Residents 100% 80% 60% 40% 3 or 4 1 or 2 None 20% 0% CS (347) DE (105) EN (61) FI (118) FR (60) IL (145) IT (170) NL (37) All (1,050) Country (N) Foebel et al. JAMDA 2014

26 Factors associated with CV medication use in IHD: SHELTER Odds Ratio (95% CI) ADL Disability Assistance Required 0.44 (0.24, 0.79) Dependent 0.14 (0.07, 0.31) Severe Cognitive Impairment 0.35 (0.16, 0.79) Foebel et al. JAMDA 2014

27 Factors associated with CV medication use in IHD: SHELTER Odds Ratio (95% CI) ADL Disability Assistance Required 0.44 (0.24, 0.79) Dependent 0.14 (0.07, 0.31) Severe Cognitive Impairment 0.35 (0.16, 0.79) Diabetes 2.73 (1.56, 4.79) Stroke 2.48 (1.42, 4.33) Dyspnoea 2.16 (1.14, 4.09) Foebel et al. JAMDA 2014

28 Factors associated with CV medication use in IHD: SHELTER Odds Ratio (95% CI) ADL Disability Assistance Required 0.44 (0.24, 0.79) Dependent 0.14 (0.07, 0.31) Severe Cognitive Impairment 0.35 (0.16, 0.79) Diabetes 2.73 (1.56, 4.79) Stroke 2.48 (1.42, 4.33) Dyspnoea 2.16 (1.14, 4.09) N of drugs (0.86, 2.60) (0.26, 1.29) Foebel et al. JAMDA 2014

29 RCT on pharmacists working in the GEMU Meds review + CGA Onder G et al. Age Ageing 2013

30 Inappropriate drug prescripton (Beers) Almost one out of two persons (48%) had at least one IDP and almost one out of five had two or more PIDPs (18%). Survival distribution function, (%) IDP and hospitalization in NH residents p=0.03 No IDP IDP Time to event, months Ruggiero C et al. Drugs&Aging 2010

31 Inappropriate drug prescripton (STOPP&START) STOPP identified 329 instances of PIP in 187 (59.8%) patients and START identified 199 PPOs in 132 (42.2%) patients a high proportion of patients recruited were prescribed at least one PID, or had an omission of a clinically indicated medicine. Ryan C et al. Age Ageing 2013 Using the STOPP criteria, 79% of the subjects showed at least one potentially inappropriate prescription. Omissions of potentially appropriate drugs were found by the START criteria in 74% of them. García-Gollarte F et al. JAMDA 2012

32 Inappropriate drug use in advanced dementia Homes criteria (SHELTER). All n= 1449 (%) CPS 4 n= 215 (%) CPS 5 n= 694 (%) CPS 6 n= 540 (%) INAPPROPRIATE DRUG 643 (44.4) 101 (47.0) 340 (49.0) 202 (37.4) RARELY APPROPRIATE Antispasmodics 100 (6.9) 15 (7.0) 54 (7.8) 31 (5.7) Digoxin 77 (5.3) 15 (7.0) 35 (5.0) 27 (5.0) Warfarin 71 (4.9) 8 (3.7) 37 (5.3) 26 (4.8) Heparin and Low-weight heparins 43 (3.3) 9 (4.2) 15 (2.2) 19 (3.5) NEVER APPROPRIATE Lipid-lowering Medications 143 (9.9) 25 (11.6) 78 (11.2) 40 (7.4) Antiplatelets Agents (ex. ASA) 143 (9.9) 10 (4.7) 75 (10.8) 58 (10.7) Acetylcholinesterase inhibitors 104 (7.2) 20 (9.3) 67 (9.7) 17 (3.1) Memantine 77 (5.3) 16 (7.4) 48 (6.9) 13 (2.4) Colloca G et al. Plos ONE 2012

33 Inappropriate drug use in advanced dementia Homes criteria (USA). Of 5406 residents with advanced dementia, 2911 (53.9%) received 1 medications with questionable benefit Tjia J et al JAMA Intern Med. 2014

34 Inappropriate drug use in advanced dementia Homes criteria (SHELTER). Inappropriate drug use (Never + Rarely Appropriate Drugs) Odds Ratio (95% Confidence Interval) Never Appropriate Drugs GERIATRIC CONDITIONS ADL impairment 0.82 ( ) 0.92 ( ) COMORBIDITIES Diabetes 1.39 ( ) 1.64 ( ) Heart failure 0.95 ( ) 1.48 ( ) Stroke 1.50 ( ) 1.43 ( ) Recent Hospitalization 1.08 ( ) 1.69 ( ) FACILITY FEATURES Presence of geriatrician 0.73 ( ) 0.55 ( ) Colloca G et al. Plos ONE 2012

35 Conclusions 1. Several factors should be considered when prescribing in NH residents, including cognitive status/dementia, limited life expectancy, disability, multimorbidity. 2. CGA + medication review may provide an optima approach to improve prescribing 3. Use of inappropriate drugs should be avoided