Safe Prescribing in Dementia

Transcription

1 Safe Prescribing in Dementia Dr Daniel Harwood Consultant Psychiatrist and Clinical Director, London Strategic Clinical Network Gurdeep Kaur Major Rapid Access Team Senior Pharmacist, Camden CNWL NHS Trust

2 This talk Polypharmacy in brief Safe prescribing of physical health medications in dementia 3 key clinical messages Use of cognitive enhancing drugs- when to stop, and cardiac effects

3 Polypharmacy A term that refers to either the prescribing or taking many medicines. Previously defined further as: medicines/day(ref) Currently: Prescribing or taking more medicines than clinically required. King s Fund further divides into appropriate and problematic polypharmacy 1. Appropriate polypharmacy: Prescribing for an individual for complex conditions or for multiple conditions in circumstances where medicines use has been optimised and where the medicines are prescribed according to best evidence. Problematic polypharmacy: the prescribing of multiple [medicines] inappropriately, or where the intended benefit of the [medicines are] not realised.

4 Why managing polypharmacy matters Polypharmacy is frequent - average of 8 drugs per resident in UK care homes (Shah et al 2012) is dangerous -the more drugs people with dementia take the higher their mortality SHELTER study (2013) Is not necessary -20% of drugs potentially inappropriate in care home residents (Shah et al 2012)

5 Drugs and falls Odds ratios for fall risk in older people (Woolcott et al 2009) Antidepressants 1.68 Antipsychotics 1.59 Hypnotics 1.47 Antihypertensives 1.24 NSAIDs 1.21 Diuretics 1.07 Opiates 0.96

6 Medicines Optimisation Outcome focused approach to safe and effective use of medicines, that takes into account the patient s values, perception and experience of taking their medicines 2,3 Important Outcomes for adults Improved quality of life Making a positive contribution Improved health and emotional wellbeing Personal Dignity Control and choice Economic wellbeing Freedom from discrimination

7 Deprescribing is the complex process required for the safe and effective cessation (withdrawal) of inappropriate medication, recognising that much of the evidence to support stopping medicines is empirical and based on the patient s physical functioning, co-morbidities, preferences and lifestyle4, 5.

8 Medication Review: a structured, critical examination of a person s medicines with the objective of reaching an agreement with the person about treatment, optimising the impact of medicines, minimising the number of medicines-related problems and reducing waste.

9 Neurotransmitter systems important in cognitive functioning Opioid GABA Histamine Acetylcholine

10 Acetylcholine

11 Acetylcholine Reducing brain cholinergic activity would be expected to have an effect on brain function Many drugs have some effect on anti-cholinergic activity

12 Does this matter? Yes Anticholinergic drugs cause confusion, sedation, cognitive impairment, delirium and falls (Bishara et al, 2014) may increase the risk of dementia and affect the clinical course of AD (Carriere et al 2009; Jessen et al 2010; Lu & Tune 2003) are a risk factor for onset of psychosis in AD (Cancelli et al 2009) interact negatively with AChEIs

13 Anticholinergic Effect on Cognition Scores Bishara D et al. Int J Geriatr Psychiatr; 2017: 32(6): (scoring system available via Medichec.com) Up to date and accurate estimation of cholinergic burden of medication traffic light system Green (score 0)= safe Light amber (score 1) Dark amber (score 2) Red (score 3)

14 Updated table July 2017

15 Medichec.com Enables quick checking of AEC score and contains all drugs in BNF Website enabled for easy use on smartphone

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17 Clinical implications 1 Bladder drugs Some anticholinergic drugs for urinary incontinence will counteract effects of cholinesterase inhibitors Being on an ACEI increases your risk of being on a bladder anticholinergic ie they are used to treat side effects of ACEI

18 Anticholinergic drugs Whether a drug worsens cognition does not just depend on its anticholinergic activity - other factors are: Which receptors it acts on- M1 and M2 receptors (brain)or M3 receptors (bladder)- Darifenacin is selective to M3 bladder receptors How well it crosses the blood brain barrier small, lipid soluble, unpolarized molecules cross better- Trospium- poor penetration through BBB How well it is recognised by the Permeability-glycoprotein (P-gp), (an active CNS efflux transporter which actively pumps agents back into circulation) Only darifenacin, trospium and fesoterodine are reported to be P-gp substrates oxybutynin and tolterodine are non specific and cross the BBB easily Chancellor MB et al. Drugs Aging 2012; 29(4):

19 Anticholinergic Drugs for the bladder

20 Clinical implications 2 Hyoscine Hyoscine hydrobromide (Kwells) Centrally acting anticholinergic used as antiemetic and for hypersalivation Impairs memory, speed of processing, disrupts attention Elderly more vulnerable, even at lower doses Confusion, hallucinations Effect on cognition so significant that used in trials to produce memory deficits DOT USE FOR PEOPLE WITH DEMENTIA

21 Clinical implications 3 Antihistamines 1 st generation H1 blockers (chlorpheniramine, clemastine, promethazine, cyclizine, cyproheptadine, hydroxyzine cause reduced alertness; so don t use these in dementia 2 nd generation ones (cetirizine, loratadine, fexofenadine) don t (Tannenbaum et al 2012)

22 Cognitive enhancing drugs (AcHEIs) There are many clear prescribing protocols which go through the basics. Commonly asked questions are: When to stop them? Cardiac effects when to do an ECG?

23 AcHEIs Cholinesterase inhibitors have modest effects for individuals but benefits clearer when large sample reviewed Perera et al 2014

24 When should you stop them? (Parsons 2016) Evidence base for discontinuation limited Some evidence for worsening cognition and BPSD after donepezil stopped (DOMINO-AD trial (Howard et al 2015), Holmes et al 2004) So keep on them unless Issues with adherence which cannot be resolved Intolerable side effects Risk with physical co-morbidity eg unstable cardiac status Terminal illness Patient/advocate choice

25 Cardiac effects and ECG ACEIs can cause Sinus bradycardia Sino-atrial block Aggravate sinus node disease These can lead to pauses - blackouts and falls

26 Cardiac effects and ECG 2 Frequency of severe side effects is low 1-10% dizziness % severe bradycardias, angina Routine one off ECG not much use, only do if Heart rate less than 50 Syncope Irregular heart rate

27 Cardiac assessment before starting ACEI (thanks to Dr Ceri Davies) Ask about syncope/dizziness Check pulse Do ECG if Heart rate less than 50 Syncope/dizziness Irregular heart rate If any of these things found investigate If QT interval prolonged or LBBB- discuss with cardiologist

28 Cardiac monitoring Once on an ACEI check pulse after one month, then 3 months then 6 monthly- more frequently if pulse less than 60 There are more complicated guidelines if you like! (Yorkshire and Humberside ones available free on internet)

29 Thank You

30 Safe Prescribing references Bishara et al (2014) Safe prescribing of physical health medication in patients with dementia Int J Geriatr Psychiatr; 29: Bishara et al (2016) Anticholinergic effect of cognition (AEC) of drugs commonly used in older people Int J Geriatr Psychiatr De Jong et al (2013) Drug-related falls in older patients: implicated drugs, consequences and possible prevention strategies Ther Adv Drug Saf 4: Medichec.com

31 Polypharmacy references 1) The King s Fund: Polypharmacy and Medicines Optimisation making it safe and sound. Duerdan, M, Avery, T & Payne, R Accessed online on 4 th June Accessed via: 2) Medicines Optimisation: the safe and effective use of medicines to enable the best possible outcomes. NICE guidance, accessed online on 4 th June Access via: 3) UKMI NICE Bites, April Accessed online on 4 th June Access via: on.pdf 4) A Themed Journal Issue on Deprescribing. Barnett, N & Jubraj, B. European Journal of Hospital Pharmacy: Science and Practice 2016; Published Online First: 20 Dec doi: /ejhpharm ) Deprescribing: Is the law on your side? Barnett, N & Orla, K. Eur J Hosp Pharm 2017;24: Accessed online on 4th June, via: 6) Mental Health First Aid, launched 16th June Accessed on 16th June via: