Preventing Medication Related Falls

Transcription

1 A Team Approach to Deprescribing and Preventing Medication Related Falls Wednesday, February 13 th 2019 Pam Howell THIS WEBINAR IS BEING RECORDED. THE SLIDE DECK AND RECORDING WILL BE ED AFTER THE WEBINAR. Webinar technology managed by:

2 A Team Approach to Deprescribing and Preventing Medication Related Falls LOOP: Fall Prevention Community of Practice Webinar February 13 th 2019 Pam Howell

3 Everyone has a story

4 Objectives Highlight key points about polypharmacy that relate to increased falls risk Present current deprescribing guidelines research Encourage participants to think about their role in medication management and how it fits within the healthcare team Engage participants to reflect how deprescribing could be managed within their expertise and in their care setting by using available tools and resources 15 February 2019

5 Medications can: Treat symptoms Slow the progression of disease Reduce the risk of complications from disease

6 Polypharmacy The use of more medications than are needed or for which harm outweighs benefit Increases the risk of: Drug interactions and adverse reactions Falls, fractures Functional and cognitive decline Nonadherence Hospitalizations and higher health care costs Particular risk for elderly individuals who handle and respond to drugs differently, are often frail, and are not typically represented in research

7 How big is the problem? 2/3 Canadian seniors are prescribed at least 5 prescription medications Who takes 10 or more? 27% over 65 years 40% over 85 years 66% in long-term care homes $419 million spent on PIMs $1.4 billion in incremental health care expenditure due to PIMs (CIHI 2014;

8 Who is most at risk of harmful effects of medication? 1. People with multiple chronic conditions 2. Women 3. People over the age of 65 Each year in Canada: 1 in 200 seniors are hospitalized due to harmful effects of their medication. Seniors are hospitalized 5 times more often than people under the age of 65 because of harmful medication effects Canadian Institute for Health Information Adverse Drug Reaction Related Hospitalizations Among Seniors, 2006 to

9 As we get older The brain becomes more sensitive to drug effects Some medications stay longer in our body because we have less muscle and more body fat Our liver and kidneys do not process medications as efficiently as when we were younger Our body contains less water and medications can become more concentrated 8

10 Which medications increase the risk of falls? Of note: -medications that are associated with falls are also often associated with decreasing cognition Sources: de Jong et al Therapeutic Advances in Drug Safety. 4(4): & Huang et al Drugs & Aging 29(5):

11 Higher risk of falling 1.5 X Higher risk 2 X Higher risk 2.5 X Higher risk Number of medications Adapted from Ziere et al., 2006

12 If we know so much, why does polypharmacy still happen? More medications available than ever before People are living longer (and acquiring more diseases with more medications) Guidelines tell prescribers when to start drugs but not when to stop them Increased hospital admissions (many prescribers) Fear of rocking the boat Culture of prescribing

13 Change in prescribing culture and patient attitudes to drugs is half the battle: In the late 1970s, benzodiazepines are the most prescribed medication in the world. Women are generally more frequent consumers. 12

14 Challenges and enablers in the literature Prescribers may: Not be aware polypharmacy is a problem Lack confidence for deprescribing Not have the time Be influenced by treatment guidelines Be more likely to deprescribe if raised by a patient And: Want to find ways to examine ongoing need for medication and ways to reduce burden Patients Vast majority willing to reduce or stop a medication if suggested by a prescriber Influenced by physicians, family, friends, media, previous experience May be fearful of deprescribing Supported by knowing there is a process 15 February 2019

15 The Deprescribing Project

16 Deprescribing The planned and supervised process of dose reduction or stopping of medication that may be causing harm or no longer be of benefit. The goal of deprescribing is to reduce medication burden and harm, while maintaining or improving quality of life. Deprescribing is part of good prescribing backing off when doses are too high, or stopping medications that are no longer needed.

17 Making deprescribing decisions Frailty

18 The work of the Bruyère Evidence-Based Deprescribing Guidelines team Evidence-based guidelines and algorithms that help health care providers decide when and how to reduce certain medications Benzodiazepine receptor agonists, Antipsychotics, Proton pump inhibitors, Cholinesterase inhibitors and Anti-hyperglycemics ( Spreading the word: reaching out to community groups, engaging policy makers, working with organizations (CaDeN) New research: community engagement, feasibility work in community pharmacy and LTC

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22 That s all great, but I am not a pharmacist or doctor 15 February 2019

23 All of us have a role to play in improving medication management: Top Down Professional Bodies & Advisory Groups Policy Makers Administrators Prescribing and Deprescribing Frontline Healthcare Staff Support Staff e.g. PSW, volunteers Ground Up Patients and Caregivers Prescribers

24 The deprescribing process Steps in deprescribing 1. Compile a medication history 2. Identify potentially inappropriate medications, those with less evidence for benefit or those with harm 3. Assess each medication for eligibility for deprescribing 4. Prioritize medications for deprescribing 5. Develop a plan for tapering and monitoring 6. Monitor, support and document care With the patient Scott I et al, Reducing Inappropriate Polypharmacy The Process of Deprescribing, JAMA Int Med 2015 doi: /jamainternmed

25 Medication review identifies: Medications that might be causing problems Medications that are working well Medications that might be beneficial 15 February 2019

26 Steps in a medication review Ask: can this be caused by a drug? Ask: is this drug being used to treat the side effect of another drug? Screen for potentially inappropriate medications Ask: would a medication be useful? I E Indicated? Effective? Time to benefit Goals of care Goals of care Clinical status is the drug working? S Safe? Potential or actual adverse drug effects C Convenient? Pill burden Cost Route

27 Screening criteria Beers ces/uploads/files/pocket%20gui de%20to%202015%20beers%20c riteria.pdf STOPP /2016%20Stopp%20Start%2 0Cumbria.pdf Anticholinergic burden Examples of medications to avoid Benzodiazepines & Z drugs NSAIDs Tricyclic antidepressants (e.g. amitriptyline) First-generation antihistamines Antipsychotics Digoxin

28 1. No benefit Significant toxicity OR no indication OR obvious contraindication OR cascade prescribing? YES Algorithm for deciding order and mode in which drug use could be discontinued Scott et al NO 2. Harm outweighs benefit Adverse effects outweigh symptomatic effect or potential future benefits? YES Withdrawal symptoms or disease recurrence likely if drug therapy discontinued? YES Taper dose and monitor for adverse drug withdrawal effects NO 3. Symptom or disease drugs Symptoms stable or nonexistent? YES NO NO Symptoms stable or nonexistent? 4. Preventive drugs Potential benefit unlikely to be realized because of limited life expectancy? YES YES NO NO Continue drug therapy Discontinue drug therapy Restart drug therapy

29 So what does applying all this information look like in real life? 15 February 2019

30 Case #1: Tapering of a Benzodiazepine 77 year old woman Falls, pain, constipation, cognition, and polypharmacy PMH: CVD, CAD, hypertension, dementia, fibromyalgia, myositis, bipolar disorder, arthritis, remote duodenal ulcer, hypothyroidism Loss of independence (daily help with washing, dressing and medications) referred to LTC Wheelchair-bound, heavily sedated, interviewing and assessment difficult Near-falls attempting to self-transfer and could not stand unsupported CrCl 30 ml/min Farrell B, French Merkley V, Thompson W. Adding up the impact of medications from multiple prescribers managing polypharmacy. CMAJ 2013;185(14):

31 Her medication list Quinapril 40mg daily Amlodipine 5mg daily Diltiazem ER 360mg daily Acebutolol 200mg twice daily Nitroglycerin patch 0.6mg/h qhs Nitroglycerin 0.4mg spray prn Furosemide 40mg daily Dipyridamole/ASA 200/25 mg bid Rosuvastatin 20mg twice daily Levothyroxine 0.088mg daily Tiotropium 18mcg daily Salbutamol 100mcg, 2 puffs qid prn Galantamine ER 16mg daily Morphine 10mg qhs Acetaminophen 650mg q4-6h prn Cyclobenzaprine 5mg tid Glucosamine 500mg bid Amitriptyline 75mg qhs Oxazepam 15mg qhs Lactulose 15mL daily prn Mg hydroxide 311 mg 1-2 tablets qhs Fibre in water Carter s liver pill 2 pills prn Suppository Cranberry 500mg tid Carbamazepine 200mg bid Omeprazole 20mg daily

32 Interplay between the medications of a 77-year-old woman referred to a geriatric day hospital and their possible effects on sedation, cognition, constipation and risk of falls. Barbara Farrell et al. CMAJ 2013;185: by Canadian Medical Association

33 Making recommendations Identify the problem the patient is having Ask about drugs that might be contributing to that problem Suggest approaches to reducing or stopping the drug Include what you will do to monitor and follow-up on the patient 15 February 2019

34 What would you do? A. Leave everything as is (don t rock the boat) B. Taper the oxazepam C. Stop the amitriptyline D. Choose a different drug to deprescribe

35 Thinking about goals in the elderly and engaging them in the conversation can help prioritize Maintain and improve Physical functioning (e.g. activities of daily living) Psychological functioning (e.g. cognition, depression) Social functioning (e.g. social activities, support systems) Overall health and well-being (e.g. general health perception)

36 What we know about BZRAs BZRA use is common in adults and expensive: In 2012 over 30% of Canadian seniors in LTC and over 15% living in the community used BZRAs ~100 million spent on BZRAs annually in Canada Guidance for use varies: Existing guidelines suggest BZRAs should be used short-term for treatment of insomnia (up to 4 weeks) Some groups recommend avoiding BZRAs all together in older persons, or as last resort for as short a duration as possible Studies detect loss of effect in 7 to 28 days although many stay on agent indefinitely BZRAs are not harmless Chronic BZRA may lead to physical and psychological dependence Associated with increased risk of: falls, motor vehicle accidents, memory problems and daytime sedation, risks that may be increased in the elderly Pottie K, Thompson W, Davies SJC, Grenier J, Sadowski CA, Welch V, Holbrook A, Boyd CM, Swenson JR, Ma A, Farrell B (2016). Evidencebased clinical practice guidelines for deprescribing benzodiazepine receptor agonists. CAN FAM Physician 2018,64:339-51

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40 Which healthcare provider would not need to consider medication side effects in their assessment of this patient? 1) Physiotherapist 2) Occupational Therapist 3) Speech Language Pathologist 4) None of the above 15 February 2019

41 Back to our patient Taking oxazepam for anxiety and sleep (plus amitriptyline) Before tapering oxazepam, need better approach to manage anxiety (Referrals? What is your expertise?) What non-drug options can you offer?

42 Monitoring when deprescribing It s a collaborative process with the patient, family and all healthcare staff involved with their care Know what should be monitored and when who can help? Communicate why the drug is being stopped Involve your colleagues who could offer nonpharmacological alternatives Document plan and progress for the patient and the care team members 15 February 2019

43 Patient outcome Reduced # from 27 to 17 Berg Balance Score from 18 to 31/56 Wheelchair walker cane No falls from 4th week onward No worsening of pain self-confidence and independence Constipation resolved Resumed old hobbies Improved social interaction Nightime sleeping improved; daytime napping eliminated Cognitive findings in keeping with stroke, not dementia

44 Case #2 87 year old, living independently at home is referred to your community falls program PMHx: HTN, OA, B12 deficiency She has no idea why she is meeting you Her daughter (who has come with her to the appointment) is more concerned about all the falls her mom has been having over the last 4 months 15 February 2019

45 Case #2 Upon further discussion about the falls, Mrs. PH tries to downplay them, but you were able to get the following history: First fall was about 4 months ago after she tripped on a rug At that time, she started having more pain, but reports that any X-ray done by her family doctor was normal Since then, she has had about 2 falls a month, usually in the morning or when she changes positions quickly; with the last one a week ago More and more she feels dizzy and foggy in her mind; her legs are also more swollen and feel very heavy when she moves 15 February 2019

46 Her medication list Amlodipine 5mg daily Lorazepam 2 mg at bedtime as needed Ibuprofen 200mg 3 times a day regularly (OTC) ASA 81mg daily (OTC) Omeprazole 20mg daily (OTC) Vitamin B mcg daily 15 February 2019

47 The trickle effect Decreased B12 absorption Vitamin B12 Increased fracture risk if use chronic ASA Amlodipine Lorazepam Fall Increased pain Ibuprofen Stomach upset BP increases Omeprazole Amlodipine increased Postural hypotension and falls risk Increased leg swelling 15 February 2019

48 Which drug would you think about starting a deprescribing conversation about first? 1) Lorazepam 2) Ibuprofen (switch to Acetaminophen instead) 3) Nothing as I am not a pharmacist

49 You are thinking that deprescribing her lorazepam is a good idea 15 February 2019

50 You are so excited to talk to her about stopping her lorazepam 15 February 2019

51 Collaborative Care: the Client and Caregiver experience We know stuff. Patient Lived Experience Professionals Illness Experts I know me.

52 Patient barriers Poor understanding of rationale and when appropriate Not being involved in planning Not knowing options if symptoms return Help patient/family understand why deprescribing is being considered and involve in planning Drugs Aging 2013;DOI /s

53 Examples of How to Discuss Deprescribing with Patients Barbara Farrell, Dee Mangin. Am Fam Physician Jan 1;99(1):7-9, Table February 2019

54 Advocating for clients: You know your patients in their home environment and know how to navigate the healthcare system Educate where you can to empower them or their caregivers about medication side effects Reach out where possible to the family physician identifying the concerns Involve your healthcare team where possible (e.g. pharmacist MedsCheck at Home for complex cases, involving OT, PT, SW to help with non-pharm options for pain) February 2019

55 Food for thought Know what motivates your patient Plant the seed -offer patient information sheets -rebook another appointment to revisit the issue Engage others to have the same message -family or caregivers -your clinic staff and colleagues -community healthcare providers that you make referrals to (RPh, PT, OT, CCAC) 15 February 2019

56 Food for thought Be transparent about the process -trial and error -offer alternatives Build on successes -pick the lowest hanging fruit first 15 February 2019

57 Food for thought Try to prevent the problem in the future: -set expectations with drug therapy initiation -ensure other HCPs in the circle of care are kept up to date -encourage patients to ask questions about their medications 15 February 2019

58 Further helpful resources Deprescribing Guidelines Research Website: Canadian Deprescribing Network Website: Choosing Wisely Canada Website: Institute of Safe Medication Practices Canada Website: 15 February 2019

59 So what is your story?

60 Acknowledgments Deprescribing guidelines developed with funding from the Government of Ontario*, the Ontario Pharmacy Research Collaboration and Canadian Institutes of Health Research *The views expressed in this presentation are the views of the author(s)/presenter(s) and do not necessarily reflect those of the Province.

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63 Questions? Type your questions into the chat box. OR Dial *7 on your telephone to unmute. Dial *6 when you are finished speaking to re-mute. THIS WEBINAR IS BEING RECORDED. THE SLIDE DECK AND RECORDING WILL BE ED AFTER THE WEBINAR. THIS WEBINAR IS BEING RECORDED. Webinar technology managed by: