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Polypharmacy in Older Adults - It is in the eye of the beholder PowerPoint Presentation

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Description : Check out this medical presentation on Adverse Drug Events, which is titled "Polypharmacy in Older Adults - It’s in the eye of the beholder", to know about the impact of polypharmacy on older adults (harms, risk factors, high alert drugs) and some strategies to address the problem.

Tags : Adverse Drug Events, Polypharmacy, Older Adults

Published on : Jul 20, 2021 | Views : 1900 | Downloads : 13

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Polypharmacy in Older AdultsIt’s in the eye of the beholdersfCARE Conference May 24, 2018 Lawrence Jackson, RPh, BScPhm, CTDP Pharmacy Clinical Coordinator, Sunnybrook Health Sciences Centre Adjunct Professor, Leslie Dan Faculty of Pharmacy, University of Toronto
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Learning Objectives Describe the impact of polypharmacy on older adults harms, risk factors, high alert drugs Describe some strategies to address the problem recognition….. medication review….. deprescribing roles for the health care team resources
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Elderly Statistics From 2016 to 2040 15% 25% of population 66% increase in those living with dementia Increases in number of persons living with cancer & mental illness 3/10 Canadians now care for an elderly relative seniors needing help is expected to double
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What is Polypharmacy? At least 24 distinct definitions1 Taking multiple medications* Potential or actual negative consequences* Falls, confusion, functional impairments, loss of independence polypharmacy— bad vs multimodal— air of goodness A scenario created by the use of several concurrent medications in the setting of progressive decline in the functional reserves of multiple organs 2 (ie, frailty, or acute illness) Bushardt et al. Clinical Interventions in Aging 2008;3(2):383-89 Leading Age. Medication Management Technologies for Long-Term and Post-Acute Care: A Primer and Provider Selection Guide. http://www.leadingage.org/
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Polypharmacy is Common Geriatric population (≥65 years) 40% take 5-9 medications1 18% take ≥102 Risk of adverse drug event (ADE) increases with # taken3 2 medications: 13% >7 medications: 82% Inappropriate drugs have been identified in: 20% of drugs commonly used by those in the community 30-40% of drugs used by those in aged care facilities5 10% of hospital admissions ≥ 65 yr old attributed to an ADE4 , 2/3 were preventable 1. Bushardt et al. Clinical Interven in Aging 2008;3(2):383-89 2. Budnitz et al. N. Engl. J. Med 2011;365,2002–2012 3. Johansson et al. Br. J. Clin. Pharmacol. 2016;82,532–548 4. Hohl CM et al. Ann Emerg Med 2001;38:666-71 5. Scott et al. JAMA Int Med 2015;175,827–834
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Detecting Polypharmacy (CSI meets the Mentalist)
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Recognizing Polypharmacy Key Parameters: Many drugs (≥6) or “more than are medically necessary” Not indicated safer or more effective option exists changes in physiology, function or goals of care prescribing cascade medications with a high toxicity profile- sedative or anticholinergic properties or causing organ damage Duplicates/ drug interactions/ excessive dose or duration Medication taking problems (adherence issues, dysphagia or side effects) Bushardt et al. Clinical Interventions in Aging 2008;3(2):383-89
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Recognizing Polypharmacy Key Parameters: Context of: Recent changes to medications with subsequent decline in health or functioning Gradual or sudden decline in health, but maintenance medications are unchanged: Often in the setting of acute illness or worsening organ function or dehydration Manifested as: Cognitive impairment, confusion or delirium, falls, functional decline, impaired mobility, social withdrawal Bushardt et al. Clinical Interventions in Aging 2008;3(2):383-89
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Do either of these med lists represent a polypharmacy situation? Ms. B has CrCl= 30 mL/min Spironolactone 25mg daily Ramipril 2.5mg daily Metoprolol 25mg bid Oxybutynin 5mg bid Ranitidine 150mg bid Nortriptyline 50mg qhs Naproxen 250mg bid Trazodone 25mg qhs Hydroxyzine 25mg qhs Meds look OK to me Yeh, now that you mention it Maybe Both are definitely polypharmacy I’d have to see how each patient is doing No. These are all maintenance medications Ms. A Ms. B 80 years old, similar health issues They are commonly used for the conditions these patients have
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Which person has polypharmacy? Ms. A & Ms. B 80 yr-old ♀ with similar support networks. Health issues: stable CHF, OAB, GERD, Depression, OA, insomnia, itchy skin. Ms. A 9 meds Ms. B 9 meds B presents with: dry mouth, constipation, urine retention, confusion, blurred vision “I’m feeling good for my age” “I’m forgetful. I have dizziness and a fear of falling” CrCl = 60 mL/min CrCl = 30 mL/min
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Two 80 yr-old females, Ms. A & Ms. B similar support networks, stable CHF, OAB, GERD, Depression, OA, insomnia, itchy skin, forgetfulness Ms. A has CrCl 60 mL/min Spironolactone 25mg daily Ramipril 2.5mg daily Metoprolol 25mg bid Mirabegron 25mg daily Pantoprazole 20mg daily Escitalopram 20mg daily Acetaminophen 500mg qid Melatonin 5mg qhs Cetirizine 10mg daily Ms. B has CrCl= 30 mL/min Spironolactone 25mg daily Ramipril 2.5mg daily Metoprolol 25mg bid Oxybutynin 5mg bid Ranitidine 150mg bid Nortriptyline 50mg qhs Naproxen 250mg bid Trazodone 25mg qhs Hydroxyzine 25mg qhs Anticholinergic Burden Scale A= 1 B= 11 3 3 1 3 1 1 Anticholinergic effects: dry mouth, constipation, urine retention, confusion, blurred vision
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Analogy: 6 blind men and the elephant Assume medications are continuously appropriate; failure to consider impact of meds on functional status Recognizing polypharmacy is difficult to do
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Polypharmacy can have negative consequences Cost and pill burden Drug interactions (↓ efficacy, ↑ S/E) Adverse drug events (hypoglycemia, hypotension, bradycardia, electrolyte disturbances, dizziness, drowsiness, dry mouth) Medication nonadherence, dysphagia, misadventure Functional impairment Geriatric syndromes falls cognitive impairment urinary incontinence impaired nutrition (eg., dry mouth affecting ability to eat) dehydration, constipation
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Polypharmacy can have negative consequences on health and independent living Loss of independence Increased health care utilization Emergency Room care Hospitalization Institutionalization Death Maher RL et al. Expert Opinion Drug Safety 2014;13(1):57-65
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Key Points Polypharmacy is common ≥ 65 yrs due to multiple conditions requiring medications Risk of harm increases with # meds & frailty inconvenience ……hospitalization………..death Medication appropriateness may change over time decline in functional reserves of organs (frailty) medication changes result in new drug-interactions Recognizing polypharmacy is difficult to do all care providers can contribute to identification
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Prescribers do their best Use medicines that are familiar Use the lowest effective dose Anticipate medication interactions Be alert to ADRs Monitor therapy Avoid prescribing cascades Seek patient engagement in therapy Involve care givers as necessary
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What could possibly go wrong?
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What could possibly go wrong? Multiple medical problems/Multiple medications + = weakness, fatigue, weight loss, impaired mobility, reduced strength compromised homeostatic mechanisms acute illness changes to medications Frailty Increased risk of altered or harmful medication effects
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Age-Related Changes in the Elderly Changes in physiology with aging: ↑body fat, ↓ body water , ↓ albumin, ↓ liver metabolism, ↓ renal func’n ∆ Pharmacokinetics ∆ Pharmacodynamics Absorption Distribution Metabolism (liver) Excretion (kidney) ∆ in receptor binding ↓ # of receptors & activity → Δ Drug efficacy → Δ Toxicity / ADRs Changes how the body acts on the drug Changes how the drug acts on the body altered physiology unaltered by age alone CYP450 CrCl
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What could go wrong? Guideline-based prescribing Multi-system illness or frailty are not considered Focus is on starting... not stopping or reducing Safety ratio changes with age & multiple meds Benefit/Harm Benefit/ HARM Changing goals of care or ↓ life expectancy ADRs masquerade as normal aging Atypical presentation of disease or ADRs AGE
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Atypical or misleading presentation of disease
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Atypical Presentation of Disease/ADR *Typical symptoms may be present
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Medications Life stress Electrolyte disturbances Relocation stress Common cold Having a bad day (declines participation in activities) Determining the cause of a change in health status Acute illness: UTI, pneumonia Deconditioning polypharmacy Day-to-day variation in cognition Gradual cognitive decline New onset pain Not hungry or thirsty today Weakness, fatigue Recovering from acute illness Fall Confused today Dehydration
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Key Points Prescribing medication in the elderly is complex Elderly are at high risk of adverse drug reactions Identifying ADRs requires vigilance Appreciating the impact of drugs on physiology Factoring in decline in physiologic reserves Benefit/Harm ratio can flip in an instant or gradually over time
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△ in health status (acute or gradual) acute illness functional decline (acute or gradual) new or worsening symptoms at medication review Opportunities to identify polypharmacy Critical incident (falls, confusion) Routine re-evaluation of medications Detecting Subtle changes
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Benefits Harms What help is available to identify polypharmacy? Less Toxic More Toxic Explicit Criteria (PIM): Beers, STOPP, McLeod Implicit Criteria: individualized assessment & clinical judgment, MAI, ARMOR, No TEARS Multiple conditions requiring multiple meds Assessment Tools:
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Potentially Inappropriate Medications (PIM)Explicit Criteria 26 published PIM lists1 Beers, STOPP, McLeod Drugs to avoid categorically or based on disease, D-D interactions High alert medications Anticholinergic activity, benzodiazepines, TCAs, warfarin, NSAIDs, fluoxetine, digoxin, oxybutynin High alert patients Impairments of renal function, cognition or the senses; falls, hypotension, diabetes, PD, or poor nutrition Eur J Clin Pharmacol 2018;74:679-700
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Avoid in most 1st generation antihistamines Antispasmodics Peripheral alpha-1 blockers (prazosin) Digoxin TCAs (amitriptyline) Antipsychotics for BPSD Benzodiazepines PPI long term NSAIDs in CHF, renal failure Avoid in those with renal failure Spironolactone Gabapentin Ranitidine Important Drug-Drug interactions to avoid Warfarin –amiodarone Opioids- other CNS acting drugs Steroids- NSAIDs Benzodiazepines- other CNS acting drugs Avoid drugs with strong anticholinergic effects Dimenhydrinate Diphenyhdramine Amitriptyline Oxybutynin
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High Risk Medications to Avoid
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High Risk Medications to Avoid
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Medications to Avoid Based on Conditions
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Chief Question Officer (CQO) Assessment Tools Could medications be causing the problem? ARMOR tool Assess- PIMs list, high alert drugs, ✓the indication Review- D-D, D-Dis interactions, ADRs Minimize- nonessential meds Optimize- fine tuning of doses, frequency, duplicates? Reassess- functional/cognitive status routinely and after any medication change, ✓adherence Haque R. Ann Long-Term Care 2009;17:26-30
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Medication Appropriateness Index (MAI) Is there an indication for the drug? Is the medication effective for the condition Is the dose correct? Are the directions correct? Are the directions practical? Are there clinically significant drug-drug interactions Are there clinically significant drug-disease interactions Is there unnecessary duplication with other drugs? Is the duration of therapy acceptable? Is the drug the least expensive compared to others of equal utility? Chief Question Officer (CQO) Hanlon JT, et al. MAI J Clin Epidemiol. 1992;45:1045–51.
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Recognition of drug related problems by home healthcare employees J Nursing Educ and Practice 2013;3(8):41-49 107 staff RN, LPN & NA Awareness Side effect Questionnaire 10 most common meds GI- N/V, diarrhea CNS- confusion, drowsiness Dizziness RN LPN Nursing Assistant (NA) 63% 20% 83% 26% 33% Patients report to me Gaps in awareness & recognition at all levels of training Patients reported symptoms more often to the NA Staff were poorly informed of recent medication changes I Recognize 60% 92% 76% 45%
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Author’s Recommendations Patients, families, homecare workers could receive training on: medication side effects correlation between health status changes and medications patient-friendly health information materials Inform homecare workers about medication changes and empower them to report potential medication-related problems J Nursing Educ and Practice 2013;3(8):41-49
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Recognize the need to stop a medicine Reduce or stop one medicine at a time Taper medicine when appropriate Check for benefit or harm after each medicine has been stopped Source: All Wales Medicines Strategy Group; Polypharmacy: Guidance for Prescribing Drugs that generally require a cautious stepwise withdrawal and/or specialist advice: Opioids/antidepressants/antipsychotics/anticonvulsants/centrally acting antihypertensives/ corticosteroids/hypnotics and tranquilizers Practical Guide to Stopping Medication in the Elderly
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Deprescribing Guidelines All Wales Medicines Strategy Group Antihypertensives Benzodiazepines Oral corticosteroids Antidepressants Bisphosphonates Acid suppressants Statins Transdermal opioid patches OPEN Research Group PPIs Benzodiazepines & Zs Antipsychotics http://www.open-pharmacy-research.ca/ http://www.awmsg.org/
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Barriers to deprescribing, New Zealand Family Physicians Issues Patient expectations, damage to relationship Culture of prescribing Uncertainty Accountability for adverse outcomes Insufficient research, education, training and collaboration Meds prescribed by specialists Potential Incentives Targeted funding Computer prompts Information flow Access to expert advice, decision support Communicate risk to patients Access to non-pharm Get the patient involved Do the right thing Ann Fam Medicine 2017;15(4):341-46.
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Resources MedsCheck- Ontario pharmacists, public access 3 chronic meds, yearly or on request by MD, NP Choosing Wisely- lists of dos and don’ts SharedCare-BC Physicians, med decision support tools http://www.sharedcarebc.ca/ “ You Decide” SADMANS- meds to hold on sick days Telehealth Ontario- patients OPA- Drug Information Service- for pharmacists GeriMedRisk- high level consult service for HCP, McMaster U https://www.gerimedrisk.com/partners/
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Summary Polypharmacy is inevitable, but can be managed Risk of harm is variably and intermittently present It’s in the eye of the beholder Risk is highest: high risk meds + a frail/ ill person A medication’s Benefit/Harm ratio can change It’s important to identify harms ASAP Regular medication review “ounce of prevention…..” An educated patient & caregivers is good insurance