Appropriate prescribing and deprescribing for older people getting it right Alan Davis Northland District Health Board
Unused returns
Potentially inappropriate medication use in the elderly 15% of older patients who attend their GP report ADE over the previous 6 months 10-30% of admissions for >75 yrs medication related PIMS prescribed in 35-50% of ARRC residents PIMS prescribed in 25-40% of community older patients 1 in 5 prescriptions for older patients inappropriate
Polypharmacy Risk of ADE rises with number of medications o 2 drugs 13% o 4 drugs 38% o >6 drugs 82% 85+ yr olds: o >4 medications 56% o >10 medications 9% ARRC residents average 7 drugs Hospitalised patients o 2-3 drugs ceased, 3-4 added o 6.6 drugs on admission, 7.7 on discharge (ChCh)
HQSC Atlas of Variation Polypharmacy in older people
HQSC Atlas of Variation Polypharmacy in older people
Harms of Potentially Inappropriate Medications Decreased physical functioning Increased falls, delirium, etc Increased risk of hospitalisation Increased mortality Reduced patient adherence to essential medications Increased cost
Evidence in older people Few studies enrol older people Fewer enrol frail older people or those with multiple morbidities Few guidelines cover management of comorbid conditions Clinical practice tends to extrapolate
Principles of prescribing choice Where there is good evidence o Avoid treatments where harm is known to outweigh benefit o Avoid treatments with evidence of no effect o Avoid preventive Rx where life expectancy < time to benefit o Avoid harmful combinations Where evidence is dubious o Err on the side of caution (non-use) o Low threshold for withdrawal Discuss NNT vs NNH with patient
Deprescribing frameworks - IA Scott
Appropriateness assessment tools Beers criteria STOPP/START (Screening Tool of Older People s potentially inappropriate Prescriptions/Screening Tool to Alert doctors to Right Treatment) CRIME (CRIteria to assess appropriate Medication use among Elderly complex patients) Medication Appropriateness Index
CRIME Diabetes 5 recommendations Hypertension 4 recommendations CHF 3 recommendations AF 5 recommendations IHD 2 recommendations
Hypertension Tight BP control not recommended in dementia or cognitive impairment Use of >3 drugs not recommended in cognitive impairment or functional limitation Tight BP control not recommended when life expectancy < 2 yrs Reduce BP meds in postural hypotension/falls
Medication review tool the ICARUS grid
Benefits of prevention medications MEDICATION DISEASE PERIOD Statins MI/stroke 5 yrs BENEFIT/100 TREATED Primary: 1-2 Secondary: 5-7 Metformin MI/stroke 5yrs 5 Oral hypoglycaemics MI/stroke 5 yrs 0 Warfarin in AF Stroke 1 yr 4 ACE/Beta blocker for CHF CHF/death 3 yrs 7 Bisphosphonates Fracture 2-3 yrs Antihypertensives (HYVET) Vertebra: 5 Hip: 1 Stroke 2 yrs 1
Life expectancy At age 65 men 21 yrs, women 23 yrs At age 80 men 9 yrs, women 10.6 yrs At age 90 men 4 yrs, women 5 yrs Alzheimer s disease (worse with older onset, male, more severe) o 82 yr female, mild-mod 5 yrs o 63 yr male, mild, 7 yrs CHF new diagnosis 5-7 yrs ARRC - 2 yrs Frailty - < 2yrs
Frailty Weight loss Slowing Reduced strength Tiredness/exhaustion Reduced activity 0/5 = robust, 3+/5 = frail
Summary What are they swallowing? Get the right meds (STOPP/START) If robust treat same as younger adults Life expectancy vs time until benefit Short life expectancy forget prevention Give the patient the informed choice (NNT/NNH)