the pieces of the puzzle in optimizing medications: polypharmacy in the elderly

Polypharmacy in the Elderly

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Previously lived with daughter and son-in-law. Mild dementia, hypertension from age 50, NIDDM, diet controlled from age 60. Same Family Physician for 25 years. Suffered a slight stroke, left with residual dysphasia and increased cognitive problems. Admitted to RC, 45min drive from physician’s office. LOI 2, no advanced directive. 60 bedded RC, looked after by call-group of 10 Family , 6 Residents each. Meds on admission: Aspirin, HCTZ, Altace, plus standing orders – Gravol, Tylenol, etc. Family member works in Rapid Access Stroke Unit – tells daughter Statin would prevent another stroke......Rx Lipitor 40mg daily. Six weeks later, develops pain in thighs and knees.......phone Dr. On-call.... ...Rx Tylenol 3, 1 tablet 3x daily. Twice daily, Glucostix......FBS 9.0 Postprandial......14 Started on Metformin, 2x daily.

Dorothy....age 84

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Nursing discussion with family...want her on Donepizil... 2.5mg daily ordered by Doctor On-Call 1 month later...Dorothy has had 3 syncopal episodes... 2 hospital admissions of a week each. Sustained bradycardia......Pacemaker inserted. On return from hospital, won’t get out of bed... Depression...Citalopram 10mg daily. Also has some urinary incontinence....Oxybutinin.... dipstick shows WBC’s...Cipro. Nauseated...Gravol 50mg STAT...prn...TID. Now has a rash...Benadryl 25mg TID. Now “calls out” a lot at night...Ativan 1mg STAT...prn...twice a day. Does not help...Respiridone 0.25mg STAT...prn...twice a day. Helps somewhat. Two weeks later, “calling out” again, has managed to get out of bed and is wandering into other people’s rooms. Rx Seroquel.

Dorothy....age 84

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Dorothy....age 84

Falls and breaks hip. Hospital for 3 weeks. Comes back to RC on Nexium, Fosamax, Calcium, Vitamin D, Multivitamin... Now lies in bed and stares at ceiling... Family conference...LOI 1...stop all drugs...

Multiple Medications

One Inappropriate Medication

More than 5 medications

More than 5 inappropriate medications

More than 10 appropriate medications

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Our working definition

When the theoretical benefits of multiple

medications are outweighed by the negative

effect of the sheer number of medications,

regardless of class of medication or

“appropriateness” thereof.

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What are the risks of

Polypharmacy?.

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Decreased:

Cognitive function, ADL’s,Quality of Life

Increased:

ADE’s, Falls, Transfers to Acute Care

Which leads to:

Hospitalisation Associated Disability

I

Adverse Drug Reactions

The most consistent risk factor for adverse drug reactions is:

number of drugs being taken

Risk rises exponentially as the number of drugs increases.

1

10

100

0 2 4 6 8 10 12 14 16 18 20

number of drugs taken

percen

t o

f p

ati

en

ts w

ith

AD

R

12

What are the causal factors

leading to Polypharmacy?

Clinical Practice Guidelines

Chronic Disease Management

Treating surrogate markers

Clinical uncertainty

ADE or new symptom?

Treating S/E with another pill

Multiple prescribers

Lack of history

Uncertain treatment goals

Lack of communication

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What are the barriers to effective

Medication Reviews?

Consensus on clinical/pharmacological knowledge Perceived medico-legal risks Other care priorities, time, remuneration Process and communication issues Family and residents Absentee MRP’s Cartesian practice

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Drugs of Concern

• Drugs associated with:

• Falls • Antipsychotics • antidepressants (tricyclics) • hypnotics • Antihypertensives • Hypoglycemics • Anticonvulsants • Antiparkinson meds • Antihistamines

Drugs of Concern

• Drugs associated with:

• Confusional states • Antipsychotics • Antidepressants • Opioid • Analgesics • Hypnotics

Drugs of Concern

• Drugs associated with: • Indications not or no longer present • Statins • PPIs • Analgesics • Osteoporosis meds • Antihypertensives • Antianginals • Antipsychotics • Antidepressants

Drugs of Concern

• Drugs associated with:

• Significant anticholinergic effects • Antidepressants (tricyclics) • Antihistamines

Who are the key stakeholders who will be essential for sustainability

of this Project?

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Physicans

MRP’s

Medical Directors

Specialists

Pharmacists

PSD

Nursing

DoC

RN,LPN, Care Aids

Health Authorities

Residents, families, caregivers, future residents. 21

Back to Dorothy!

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Dorothy....age 84

Falls and breaks hip. Hospital for 3 weeks. Comes back to RC on Nexium, Fosamax, Calcium, Vitamin D, Multivitamin... Now lies in bed and stares at ceiling... Family conference...LOI 1...stop all drugs...

Summary

Count the Pills!.

QUESTIONS?

“One of the first duties of the physician is to educate the masses not to take medicine.”

Sir William Osler

1849-1919