Claire Humphries

Pharmacist Northern Beaches Health Service April 2018

Frailty: a pharmacy perspective

Frailty

Clinical syndrome in which 3 or more present:

– Unintended weight loss (> 5kg/ past year)

– Self-reported exhaustion

– Weakness (grip strength)

– Slow walking speed

– Low physical strength

REVERSIBILITY

Presenting Case. MC, 93 yo lady:

Mechanical fall 4/3/18

– Got up during night to go to bathroom. When tried to

manoeuvre around door slipped over. Pain in hip and

couldn't get up, so on floor overnight (CK rise)

Impression:

– R #NOF: long gamma nail inserted 5/3/18

– Peri-op: Pneumonia (WCC 16, CRP 116, CORB 2)

ceftriaxone & doxycycline

Past Medical History

Prior falls

Haemorrhagic cerebellar stroke Jan 2016, TIA 2013

Cholecystectomy

Bowel perforation

Diverticular disease

Hypothyroid

Hypertension

1st degree AV block

Macular degeneration

Social history

Nursing home resident (93 yo)

Dresses, showers herself

Mobilises with 4WW

Has regular physio

Meals provided, medication dispensed

Pharmaceutical review (hyper-polypharmacy:13)

Medication Dose Issue

Macuvision 1 BD ? Vision impaired – falls risk

Lutein defence 1 BD

Thyroxine 100mcg m TFTs normal

Atorvastatin 20mg n CI post haemorrhagic stroke; muscle

weakness

Metoprolol 12.5mg BD Not indicated post stroke; ?CCF

Pantoprazole 40mg m Inc risk # & pneumonia

Colecalciferol 2000iu m

Perindopril 8mg n ? Postural hypotension

Prednisolone 5mg m Muscle weakness, delirium

Temazepam (A) 10mg n Falls risk ++

Paracetamol 1g BD

Celecoxib 200mg m CI post stroke

Loratidine *NEW* (A) 10mg d Falls risk; additive sedation

Pharmaceutical care plan:

93 yo, 52kg, looks frail, previous falls, broken hip

1. Analgesia

2. Pneumonia treatment

3. Frailty medication review

4. Osteoporosis treatment + vitamin D

Medication review of fall

Anti-hypertensives

– Perindopril & metoprolol

– B blockers not indicated post stroke

– Check postural BP

Counsel sit to stand slowly

Scheduled toileting; double voiding before bedtime

Statin review

93 yo, ?near end of life, CI haemorrhagic stroke

Ref: Collins et al. Interpretation of the evidence for the efficacy and

safety of statin therapy. Lancet 2016; 388: 2532-61

– 10,000 pts treated for 5 years with effective dose of

statin:

– 5 cases of myopathy (1 might progress to

rhabdomyolysis)

– 5 - 10 haemorrhagic stroke

RCT: Kutner et al. Safety & Benefit of Discontinuing Statin Therapy in the

Setting of Advanced, Life-Limiting Illness. JAMA Intern Med. 2015; 175 (5):

691-700

Steroid review

Initiated for post-tick bite urticaria

Myopathy

Osteoporosis—long-term corticosteroid use increases the

risk of osteoporotic fractures and accelerates bone loss.

Hypertension

Insomnia

PPI review

Review if taking for > 4- 8 weeks and no clear indication

Increased risk of

– Low B12 and magnesium

– Bone fractures

– Pneumonia

– Clostridium Difficile

CaDeN deprescribing algorithm

Maes et al. Ther Adv Drug Saf. 2017 Sep; 8(9): 293-97

Recommend life style

changes:

• Avoid triggers – spicy

food, coffee, chocolate

• Lose weight

• Avoid food 2-3 hr

before bed

• Elevate head of bed

Review sedative

BENZODIAZEPINE WITHDRAWAL:

– Temazepam started at NH, not on prior

– Patient unaware she was on a sleeping tablet

– Aim: wean to cease

– Add melatonin CR 2mg

- NEW LORATIDINE

- Post tick bite itch

- Additive sedation

- anticholinergic

CaDeN:

Canadian

Deprescribing

Network

Summary Review for postural hypotension

Physical decline

– Cease statin

– Wean prednisolone

– Wean PPI

Cognitive decline

– Wean temazepam

– Cautious use of loratidine (A)

– Trial melatonin

START osteoporosis medication & D

Successful, unsuccessful case!

Mrs JP, 71 yo female

Admitted 6/2/18 with cholecystitis due to gallstones

Recent prior admission 31/1/18 for falls & knee fracture.

Opal Seaside NH resident

PMH: IDDM, diabetic neuropathy- toes amputated, diabetic

retinopathy; CKD; AF – warfarin; IHD; hypercholesterol

aemia; CCF- LVEF 35%; COPD- occ smoker; PPM; HTN;

depression – suicidal ideation; OP (#) + low vit D; anaemia

CrCl 36ml/min, chol 2.8, TG 2

Medications (hyper-polypharmacy: 11) Medication Dose Issue

Warfarin 2.5mg n CHADS-VaSc 6

Diazepam (A) 2.5mg daily prn Falls risk

Olanzapine (A) 2.5mg bd CI IDDM; orthostatic hypotension

Lantus insulin 10 u mane

Novorapid 6 u tds

Duloxetine (A) 60mg m Orthostatic hypotension; bleeding risk

Spironolactone 12.5mg m Hyperkalaemia; CKD

Frusemide (A) 40mg m Dehydration; falls

Ramipril 10mg m Hyperkalaemia

Amlodipine 5mg m

Vitamin D 1000iu m Level 47 (low)

Pharmaceutical care plan

Olanzapine – anticholinergic; falls risk and CI in IDDM

– Can increase BSLs, weight gain, dyslipidaemia +

orthostatic hypotension

– Weight 66kg, pt states has put weight on but lost during

recent hospital admission

– Chol 2.8, TG 2

– Severe depression – GP STRONGLY advised not to

withdraw (calcaneal # 2017)

– Nil postural drop

Outcome

Olanzapine & not ideal in this patient BUT tolerating; on

lowest effective dose

Review in 6 months

Consider adding statin for TG

Consider OP medication & increase vitamin D

Conclusion

Patient-centred decision making of upmost importance

Apply the same energy and consideration to deprescribing

as to prescribing

……Some medicines cause HARM

Use FRAILTY as a trigger for review