Drug use in long term care Graziano Onder Centro Medicina Invecchiamento Università Cattolica Sacro Cuore, Rome
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
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
Services and Health for Elderly in Long TERm care (SHELTER) 4156 residents 57 NH 7 EU + Israel Funded by FP7
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
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
Factors influencing prescribing in NH 1. Cognitive status/dementia 2. Limited life expectancy
Treatment of non dementia illness in patients with dementia Brauner et al. JAMA 2000
Holmes et al. Clin Pharmacol Ther 2009
Medication Use in Nursing Home Residents with Advanced Dementia Tija et al. J Am Geriatr Soc 2010
Mortality (%) N of Drugs (mean) N of drugs and life expectancy in dementia 60% 7 50% 40% 30% p=0.41 6 5 4 3 Mortality (%) Mortalità (%) N of drugs N di Farmaci (media) 20% 2 10% p<0.001 1 0% < 4 4-5 6-7 8-9 10-11 12-13 14-15 16 ADEPT score 0 Onder G et al. JAMDA 2013
Survival RESULTS Polipharmacy and survival ADEPT score < 13.5 1 1 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=0.02 0 0 3 6 9 12 Follow up (months) Polypharmacy 0 0 3 6 9 12 Follow up (months) No polypharmacy
Treatment of non dementia illness in patients with dementia Brauner et al. JAMA 2000
Differences between SHEP and general population 25 20 % 15 10 5 0 Dementia Depression Disability SHEP General Population
Factors influencing prescribing in NH 1. Cognitive status/dementia 2. Limited life expectancy 3. Disability - Limited life expectancy - Functional limitations
Medication management by age Beckmen A Patient Educ Couns. 2005
Factors influencing prescribing in NH 1. Cognitive status/dementia 2. Limited life expectancy 3. Disability 4. Multimorbidity 5. Polypharmacy/interactions
Potentially Harmful Drug-Drug and Drug-Disease Combinations Drug-drug combination (%) Drug-disease combination (%) Total population 0.76 2.58 Age (years) 65-79 0.64 2.25 70-74 0.63 2.62 75-79 0.95 2.79 80-84 0.95 2.44 85 1.52 3.03 Zhan C et al. JAGS 2005
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
Antipsychotic drug interactions: SHELTER (n=604) No interactions Interactions Incident rate RR per person-year (95% CI) Log-Rank= 0.02 No interactions Interactions 0.17 0.26 1 1.68 (1.13-2.49) Liperoti et al. In preparation
Factors influencing prescribing in NH 1. Cognitive status/dementia 2. Limited life expectancy 3. Disability 4. Multimorbidity 5. Polypharmacy/interactions
Factors associated with polypharmacy: SHELTER Polypharmacy OR (95% CI) Age (10 years increment) 0.85 (0.74-0.96) ADL Dependency 0.59 (0.40-0.86) Cognitive status Mild/Moderate impairment Severe impairment 0.64 (0.47-0.88) 0.39 (0.26-0.57) Onder et al. J Gerontol A Biol Sci Med Sci. 2012
Factors associated with polypharmacy: SHELTER Polypharmacy OR (95% CI) Age (10 years increment) 0.85 (0.74-0.96) ADL Dependency 0.59 (0.40-0.86) Cognitive status Mild/Moderate impairment Severe impairment 0.64 (0.47-0.88) 0.39 (0.26-0.57) Pain 2.31 (1.80-2.97) Dyspnoea 2.29 (1.61-3.27) Onder et al. J Gerontol A Biol Sci Med Sci. 2012
Factors associated with polypharmacy: SHELTER Polypharmacy OR (95% CI) Age (10 years increment) 0.85 (0.74-0.96) ADL Dependency 0.59 (0.40-0.86) Cognitive status Mild/Moderate impairment Severe impairment 0.64 (0.47-0.88) 0.39 (0.26-0.57) Pain 2.31 (1.80-2.97) Dyspnoea 2.29 (1.61-3.27) Ischemic heart disease 2.93 (2.06-4.16) Heart failure 2.06 (1.43-2.99) Parkinson disease 2.82 (1.68-4.72) Stroke 1.49 (1.05-2.12) Diabetes 3.19 (2.28-4.45)
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
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
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
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 5 9 1.50 (0.86, 2.60) 10 0.58 (0.26, 1.29) Foebel et al. JAMDA 2014
RCT on pharmacists working in the GEMU Meds review + CGA Onder G et al. Age Ageing 2013
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 1.00 0.75 0.50 0.25 0.00 p=0.03 No IDP IDP 0.00 0.30 0.60 0.90 1.20 Time to event, months Ruggiero C et al. Drugs&Aging 2010
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
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
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
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 (0.71 0.94) 0.92 (0.81 1.04) COMORBIDITIES Diabetes 1.39 (0.99 1.93) 1.64 (1.21 2.24) Heart failure 0.95 (0.64 1.41) 1.48 (1.04 2.09) Stroke 1.50 (1.07 2.10) 1.43 (1.06 1.93) Recent Hospitalization 1.08 (0.73 1.60) 1.69 (1.20 2.39) FACILITY FEATURES Presence of geriatrician 0.73 (0.51 1.05) 0.55 (0.39 0.77) Colloca G et al. Plos ONE 2012
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