medicines and falls - gm
TRANSCRIPT
Polypharmacy and falls risk in frail elderly
Dr Sanjay Suman MD FRCP
Consultant Geriatrician
Medway NHS Foundation Trust
1. Concept of frailty
2. Risk of falls: Polypharmacy
3. Case Studies
4. Tools for reducing polypharmacy
Outline
FRAILTY
Of People Over 65 years
Robust/ Healthy Elderly
60%
Dependent Elderly
10%
30%
Frail/ Vulnerable Elderly
Adapted from Cochen 2009
*neurological, metabolic /endocrine , musculoskeletal, cardiorespiratory, renal and others
RAIL ROBUST
Frailty causes decline in Homeostatic Reserve across *multiple physiological domains
Minor Stressor Event*
FALLS DISABILITY HOSPITALISATION DEATH
FRAILTY ADVERSE OUTCOMES
FRAILTY: A High-Risk State Predictive of a Range of Adverse Health Outcomes
* Sepsis, Dehydration, Constipation, Polypharmacy
Frailty Phenotype
Slowness
Exhaustion
Fried at al., 2001
≥3 criteria = frail 1/2 criteria = pre-frail
Weakness (Sarcopenia)
Low energy expenditure
Weight loss
FRAIL ELDERLY
HEALTHY ELDERLY
disproportionately severe Many unable to regain baseline function
Adapted from Clegg 2013
Frailty = Vulnerability to a sudden change in health status after a minor illness
Health and Social Care Budget
Cost of falls in people > 60 in England is £2 billion/ year, or > £5.6 million/day
Age UK. Facts about Falls
“Frailty poses a considerable challenge to maintaining an upright position and balance”
FALLS
400,000 older people in England attend A & E following a fall annually
30% above the age of 65 and 50% above the age of 85 will fall annually
15% sustain serious injuries (5% have fragility fracture, 1% hip fracture)
Falls in Elderly: Scale of the problem
Consequences of falls
S Suman
FALL
Adverse Outcomes
No injuries
Fear of falling Fractures Soft tissues
injuries
Disability,
Death
Muscle strength, supple joints
Sensory modalities (vision, hearing, vestibular system)
Peripheral and central nervous system
Maintaining balance and gait
Intrinsic Risk factors
Environmental
Hazards
Risk factors for falls
Musculoskeletal: Arthritis, muscle weakness, spinal and foot problems
Sensory impairment: poor vision, deafness, vestibular disorders
Neurological conditions: Parkinson’s disease, stroke, peripheral neuropathy
Cognitive impairment: Vascular , Alzheimer’s dementia
Co-morbidities: COPD, Diabetes, Cardiovascular diseases, CKD, Anaemia……..
Polypharmacy
Intrinsic risk factors
Prevalence of chronic diseases rom 2003–04 to 2011–12.
Melzer D et al. Age Ageing 2014;ageing.afu113
© The Author 2014. Published by Oxford University Press on behalf of the British Geriatrics
Society.
THRESHOLD FOR FALLING IS LOWERED WITH POLYPHARMACY
Reduction in injurious falls through an individually tailored plan
Proactive search for risk factors
Multidisciplinary, multiagency approach
NSF for Older People (Standard 6) NICE Guidelines (CG 161) June 2013
NSF 2001
NICE CG 161 2013
Multi-factorial assessment will be needed in majority of elderly fallers
identification of falls history
gait, balance and mobility, and muscle weakness
cardiovascular examination including lying and standing BP
visual impairment
cognitive impairment and neurological examination
urinary incontinence
home hazards
Osteoporosis
medication review
NICE GUIDANCE ON FALLS
NICE CG 161 2013
POLYPHARMACY
“It is an art of no little importance to administer medicines properly: but, it is an art of much greater and more difficult acquisition to know when to suspend or altogether to omit them…..”
Philippe Pinel, psychiatrist (1745-1826)
Numerical
≥ 5 medications
Appropriateness
Choice of medications
Continued for longer than recommended duration
Co-prescription of drugs with known potential interaction
Cascade prescribing
Defining Polypharmacy
What leads to Polypharmacy?
PATIENT RELATED
↑ Co-morbidities with ageing
Patient / relatives’ expectation
↑ Patient awareness (Internet)
Over the counter medications
CLINICIAN RELATED
Single organ disease guidelines
Multiple prescribers
“Something needs to be done”
Lack of “formal” medication reviews / repeat prescriptions
Cascade prescribing: Treating the side effect of one drug with prescription of another
Greater number of adverse drug reactions (ADR’s)
Falls, delirium, acute kidney injury, constipation / diarrhoea, urinary incontinence
Increased frequency of drug interactions
Prescribing & dispensing errors
Poor compliance
Cost
Perils of Polypharmacy
ADRs are directly related to polypharmacy
Absorption Decreased gastric acid alters absorption of some medications (Iron,
Calcium)
Decreased gastric mobility can increase absorption
Drug distribution changes in body fat/lean ratio & protein binding (Diazepam)
increase free drug concentrations (warfarin; phenytoin)
Metabolism changes to liver mass and blood flow
decrease first pass metabolism - increase bioavailability (opiates, nitrates)
Elimination Decrease clearance of renally excreted drugs (digoxin, lithium, antibiotics)
Pharmacokinetic changes due to ageing predispose to ADRs
Polypharmacy “prescribing cascade” Treating the side effect of a medication with another
Amlodipine Ankle oedema
Furosemide
1. Sedation 2. Confusion and agitation 3. Dehydration 4. Hypotension / Postural hypotension 5. Impaired postural stability
6. Drug induced parkinsonism 7. Visual impairment 8. Hypoglycaemia 9. Vestibular damage 10. Hypothermia
Mechanisms for medication related falls
Need for Increasing emphasis on REPORTING of drug’s adverse effects on cognition / postural stability
Adverse effects of drugs on Cognition and Postural instability
Otmani, S. et al Hum Psychopharmacol Clin Exp 2012
How medicines contribute to the risk of falls: CNS side effects
Sedation/Drowsiness
• Antidepressants • Antipsychotics • Hypnotics
Impaired postural stability
• Hypnotics • Benzodiazpines • Antiepileptics
Confusion
• Anticholinergics • Antipsychotics • Sedative
antihitamines
Drug induced parkinsonism
• Antipsychotics • Metoclopramide
How medicines contribute to the risk of falls: CVS side effects
Postural hypotension / syncope
• Diuretics
• ACE-inhibitors
• Nitrates
• Alpha and Beta blockers
Bradycardia
• Beta blockers
• Digoxin
How medicines contribute to the risk of falls: other mechanisms
Vestibular damage
Tinnitus, deafness
• Aspirin • quinine, • Aminoglycosides
Hypoglycaemia
• Insulin • Sulphonylurea • Quinine
Hypothermia
• Hypnotics • Clonidine • Antipschotics • Beta Blockers
How medicines contribute to the risk of falls: other mechanisms
Anorexia and weight loss
• Muscle weakness
Diarrhoea / urinary incontinence
• Increased ambulation & urgency
Over the counter medicines that can contribute to falls: “Over the counter”
Cold and flu remedies
Pseudoehedrine, phenylepherine
Allergy
Chlorphenaramine
CASE STUDIES
Case: 1 (outpatient)
PHYSICAL FINDINGS
BP 110 / 70 (lying), 90 / 60 (standing)
HR 58 regular
Gait: unsteady
“What are the risk factors for falls?”
85 Male, 3 falls in 2 months
PMH Hypertension NSTEMI (8 months ago) Depression MEDICATIONS Bisoprolol 10mg Ramipril 10mg Furosemide 40mg Aspirin 75mg Clopidogrel 75mg Simvastatin 40mg Zopiclone 7.5 mg Mirtazipine 30 mg
Delirious Clinically dehydrated Temp 38.5 O2 Saturation 84% room air RR 30 PR 130 irregular BP 89/70 Chest: bronchial breathing right mid-upper zone
Case 2: Examination
85 F, CKD, T2 DM, Hypertension, AF
2/52 cough: Clarithromycin (allergic to penicillin)
4/7 decreased oral intake, drowsiness, off legs, SOB
Admitted having had a fall “found on the floor”
Case 2 (Inpatient)
Current medications: Simvastatin 20 mg od Enalapril 5 mg od, Metformin 1 gm bd, Co-tenidone (Atenolol 50+chlorthalidone 12.5) Digoxin 125 mcg od aspirin 75mg od
On
admission
Baseline
6 months
ago
CRP 230
Glucose 8.7 # 6.4 #
Sodium 122 K 143
Potassium 7.3 J 5.5 #
Urea 59.4
Creatinine 564 J 151 #
Est. GFR 6 28
ALT 18 25
ALP 86 71
T.Bilirubin 6 13
Albumin 38 41
CK
6000 J
ABG
Ph 7.27
PaCO2 3.7
PaO2 6.9
Lactate 9.5
HCO3 15.2
Base excess
-12.5
Case 2: Investigations
Case 2: Diagnosis and Discussion
Diagnosis Medications
Acute Kidney injury (↑K+) (background of CKD)
Enalapril 5 mg
Hypotension Enalapril 5 mg Co-tenidone (Atenolol50+chlorthal12.5)
Hyponatremia Co-tenidone (Atenolol50+chlorthal12.5)
Lactic acidosis
Metformin 1 gm bd
Rhabdomyolysis (Muscle necrosis due to “long lie”+ statin in this case)
Simvastatin 20 mg (recent use of clarithromycin )
CKD
Digoxin 125 mcg od (Caution in CKD)
What is a medication review
......“Structured review of the efficacy and continuing appropriateness of a patients medication”..
Aim: Modification / withdrawal from a drug
If neither are possible, close monitoring appropriate
In patients taking drugs known to contribute to falls:
medication review & subsequent prescribing changes have been shown to reduce further falls
Medication reviews for falls
4.2.1 Holistic Medical Review by the GP
“Medication reviews are important – many drugs are particularly associated
with adverse outcomes in frailty such as:
• Antimuscarinics in cognitive impairment
• Long acting benzodiazepines and some sulphonylureas, other sedatives
and hypnotics increase falls risk
• Some opiate based analgesics increase risk of confusion or delirium
• NSAID can cause severe symptomatic renal impairment in frailty”
BGS, June 2014
Medication review
TOOLS FOR REDUCING POLYPHARMACY
BEER’s
STOPP
Beers Criteria
American
Focus on medicines to be avoided by the elderly living in nursing homes
1991: 30 classes/meds, 2012 : 53 classes/meds
American Geriatrics Society Updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Ger Soc 2012; 60: 616-31
Beers Criteria example
Drug class or disease
Rationale Recommendation Quality of Evidence
Strength of recommendation
PIMs
Antispasmodics Highly anticholinergic, uncertain effectiveness
Avoid Moderate Strong
PIMs due to concomitant diseases/conditions
Syncope & alpha blockers
Increases risk of orthostatic hypotension or bradycardia
Avoid High Weak
PIMs to be used with caution
Aspirin for primary prevention of CVD
Lack of evidence of benefit vs. risk in ≥ 80yrs
Use with caution in adults aged ≥ 80 yrs
Low Weak
STOPP-START
UK & Ireland, 2007
Problems with Beers & IPET
Screening Tool of Older Persons Prescriptions
Screening Tool to Alert doctors to Right Treatment – first document to do this
Focus on patients aged >65 yrs
Delphi technique, 18 experts, consensus
65 STOPP, 22 START
Reliable
Comparison vs. Beers 2012
Gallagher P et al. STOPP and START. Consensus validation. Int J Clin Pharmacol Ther 2008; 46 (2): 72-83
STOPP TOOL
STOPP-START examples
STOPP
Loop diuretic for ankle oedema, no clinical signs of HF (no evidence of efficacy, compression hosiery more appropriate)
PPI for peptic ulcer disease at full therapeutic dose for > 8 wks (dose reduction or earlier discontinuation indicated)
START
ACE inhibitor following acute MI.
ACE inhibitor for chronic heart failure.
Antiplatelet therapy in diabetes mellitus if coexisting CVD risk factors present.
Polypharmacy poses a risk to frail elderly
Medication reviews can help to reduce the risk of adverse drug reactions including falls
Choose carefully
Prescribe wisely / Deprescribe if necessary
Monitor appropriately
Summary
THANKS Questions / Comments?