end falls this fall pharmacy update. medications and falls risk medication reviews to identify falls...

End Falls this Fall

Pharmacy Update

Medications and Falls Risk Medication reviews to identify falls risks

Recommendations for caregivers, prescribers Managing the risks

Decreasing doses, decreasing the overall number of medications (polypharmacy), identifying side effects

Medications that have a high risk for falls Sedatives; benzodiazepines, “Z drugs” like zopiclone Antidepressants Anticholinergic agents (oxybutynin/Ditropan®) Antihypertensives, anticonvulsants (including gabapentin, pregabalin) Opioids

Increasing client safety Decrease the medication related risks for falling Decrease the risk for fracturing

Decreasing Falls & Fractures –Where could we improve?

Reducing Polypharmacy, since multiple medications contribute to risk of falls

Reducing the use of medications that are associated with a high risk for falls

Identifying men at risk for osteoporosis and fractures

Recognizing disease states that increase risk for falls and fractures

Prescribing Cascade

Develops when an adverse drug reaction or side effect is mistaken as a new medical condition and further drug therapy is added to manage this new “condition”

For example: a movement disorder develops from use of an antipsychotic medication like olanzapine (Zyprexa®) and this is misinterpreted as Parkinson’s disease and treated with levodopa

Prescribing Cascade Another example occurs when an older person is put on an

NSAID such as Naproxen for arthritis pain,

• The next visit to health care provider, blood pressure is elevated and ankle edema is present so……. antihypertensive diuretic hydrochlorothiazide started…

•Then electrolytes are low and a potassium supplement is started….

• Then heart burn develops so omeprazole is started

Avoiding Prescribing Cascades

Side effects/Adverse Drug Reactions (ADR) are most likely to be experienced soon after a new medication is started or after the dose increased

90% of patients with an ADR report it within 4 months of starting the new drug 75% of these patients have the ADR within the first month

of treatment For every new condition or symptom, first ask,

Is it an adverse effect of existing drug therapy?

Don’t just add another medication !

Consider Reducing Medications in the Elderly We are pretty good at adding medications but not so great at re-

evaluating and stopping them Avoiding certain possibly “more risky” drugs is only part of the picture eg. Beers list drugs, anticholinergic drugs

The patient on 13 non Beer’s list meds may still be at risk for harm, especially if dose/duration inappropriate

Minimizing anticholinergic medications is helpful Decreasing the use of anticholinergic agents (eg

amitriptyline, tolterodine, paroxetine) which can cause cognitive decline, confusion,hallucination, urinary retention, constipation and increased mortality is helpful but may only be part of the picture in for example, someone also on high doses of glyburide with poor renal function

Is there a need for Deprescribing? A study that looked at emergency hospital admissions related to adverse

drug reactions, for those age 65 or older found 6.6% admissions were associated with Beers List meds 67 % admissions occurred with non Beers list meds (warfarin,

insulin, oral antiplatelet drugs, oral hypoglycemic drugs) Starting to hear the term “Deprescribing”

Or related terms like discontinuation, prescription pruning, and pharmacolysis

Budnitz DS, Emergency hospitalizations for adverse drug events in older Americans N Engl J Med 2011;365:2002

Is there a need for Deprescribing ?

• Challenging to manage a complex older adult with multiple co-morbidities when each set of disease specific clinical practice guidelines recommends treatments • For example, someone with COPD, DM Type II, HTN, OP and OA

ends up on a minimum of 12 meds

• Often guidelines are based on research done in younger persons without multiple diseases • Some treatment goals may be overly aggressive in managing an

older person ie diabetes or hypertension

• A systematic approach is needed for reevaluating and streamlining a person’s medication list & making it appropriate for their needs and goals

• With the understanding that polypharmacy (≥ 4 or 5 Rx) Increases risk for drug interactions, ADRs, risk for hip fractures

The thought process for Rational Deprescribing

• Begin with a regular & thorough review of current drug therapy – have them bring all their prescription bottles, vitamins, eye drops , natural health products, Over-the-counter meds

• Tailor medication regimen according to individual’s conditions and their goals & goals for care What are the treatment goals?

• Prevention (consider time lines), optimize cognition, pain management, comfort

Has the individual changed?• Eg. decreased weight, declining renal function

Does each drug have a reason for use? • Eg match diagnosis list to drug list

Does the reason for use still exist?• Eg post op anemia 1 year ago, still getting iron tx

Rational Deprescribing

Does the dose need decreasing ?

• Eg drug is necessary but side effects experienced Does a medication need to be added?

Eg adding a bisphosphonate after a fracture Are there duplicate therapies?

2 or more drugs in the same category eg 2 NSAIDs Are there new symptoms?

*Could they be an adverse reaction to meds? Are there non pharmacologic therapies?

Eg sleep hygiene and relaxation techniques for insomnia instead of benzodiazepines

Some Tools for Deprescribing Screening Tool of Older Person’s Prescriptions (STOPP)

considers identification of drug interactions, duplicate therapies Identified significantly more patients with ER visit due to medication

related effect than the Beers list (2003)

Hamilton HJ, Gallagher PF, O’Mahony D. Inappropriate prescribing and adverse drug events in older people. BMC Geriatrics 2009; 9:5.

Screening Tool to Alert doctors to the Right Treatment (START) Helps to detect sub-optimal treatment or omissions in elderly

patients therapy

Barry PJ et al. START (Screening Tool to Alert doctors to the Right Treatment)—an evidence-based screening tool to detect prescribing omissions in elderly patients. Age Ageing. 2007;36:632-638.

One approach to Deprescribing Educate client and family about this therapy approach Identify polypharmacy, adverse drug reactions or side effects,

falls, effectiveness (or lack of), treatment goals Wean one medication at a time, gradually Begin with a medication thought to be responsible for undesired

side effect or a fall etc For beta blockers, benzodiazepines, opioids, long term systemic

corticosteroids and levodopa wean down over weeks & perhaps months

Monitor patient and reassess frequently for withdrawal syndromes, reappearance of illness,

cognition, falls, quality of life, etc *Deprescribing,LeCouteur D, Banks E, AustPrescr 2011;34:182-5

Can Medications be Withdrawn?

Many medications can be safely withdrawn slowly, gradually & with medical supervision Although not a lot of data there are both potential risks and benefits in stopping

Some medications can’t be stopped suddenly: especially : benzodiazepines (withdrawal, confusion, seizures etc) beta blockers (sudden stopping can result in rebound

hypertension and tachycardia ) clonidine (sudden stopping can cause rebound hypertension), levodopa needs to be tapered very slowly or serious withdrawal

& neuroleptic malignant syndrome can occur with muscle stiffness,decreased consciousness

Don’t abruptly stop these either:

Systemic corticosteroids if taken for several weeks need to be tapered gradually

SSRI’s eg paroxetine, should be tapered gradually to avoid discontinuation syndrome

Proton Pump inhibitors- stopping suddenly can result in hypersecretion of acid

Does Deprescribing Work?

• A similar systematic approach was developed into an *algorithm and used in a Feasibility study

• Evaluated the need to continue or discontinue meds for 70 elderly community living people with multiple co-morbidities taking a mean number of 7.7 medications

• stopped 58% of medications, only 2% required restarting due to recurrence of the original indication

• successful discontinuation achieved in 81% of those patients

Garfinkel,D;Mangin,D; Feasibility Study of a Systematic Approach for Discontinuation of Multiple Medications in Older Adults. Arch Intern Med. 2010;170(18):1648-1654

*see Resources slides

Does Deprescribing Work? 88% of those elderly patients reported global

improvement in health!!!

LESS is MORE !


Future Study The Ontario Ministry of Health and Long-Term Care recently funded Bruyère

Research Institute scientist and Universities of Ottawa and Waterloo assistant professor, Barbara Farrell, PharmD, approximately $430,000 to study the development and implementation of deprescribing guidelines aimed to minimize medications that are causing side effects or are no longer needed. “Reducing medication use can be a challenging process, but with the introduction of guidelines and attention to implementation, there will be better consistency in reducing the number of medications prescribed to older adults with the goal of improving quality-of-life,” says Dr. Farrell.

For example, a Bruyère Geriatric Day Hospital patient, says he is well on his way to restoring his active lifestyle, thanks in part to the slow tapering of some of his medications.

from The Ottawa Citizen, July 3 2013


Reducing Polypharmacy as multiple medications contribute to risk of falls




Selective Serotonin Reuptake Inhibitors (SSRIs) and Falls

Up to 10% of seniors are affected by depression and SSRIs are first-line treatment Depression itself is not associated with fractures

A large prospective study looked at daily SSRI use in adults in the community

SSRIs Increase Fracture Risk

Daily SSRI use in those 50 yrs or more can •Increase the risk for fragility fracture by 2 x

•Increase the risk for falling by 2 x •Lower BMD of the hip

May be due to changes in bone and on risk of falling, possibly increased risk for hypotension & syncope

Serotonin receptors found on cells that build and remodel bone suggesting possible decreased bone quality

SSRI and Increased Fracture Risk Similar studies have found the risk for O/P fractures associated

with corticosteroid use was 1.66 for persons 50 or older versus risk for fracture of 2.1 with SSRI use, so similar increased risk for

fracture with an SSRI as with corticosteroids Since elderly are already at increased risk for osteoporosis these

risks should be weighed against the benefits in treating depression Consider lowest effective dose, shortest duration

** Effect of selective Serotonin Reuptake Inhibitors on the Risk of Fracture, Richards,J, Papaioannou, A et al, Arch Intern Med/Vol 167, Jan 22 2007, 188-194

Other Potential effects of SSRIs

Hyponatremia increased risk with elderly usually occurs within 2 weeks of starting can present with confusion, drowsiness, fatigue, delirium

and hallucinations, urinary incontinence, hypotension or vomiting

Possibility of Serotonin syndrome symptoms can present with symptoms of tremor, agitation,

myoclonus, muscle rigidity or confusion.


Reducing Polypharmacy, since multiple medications contribute to risk of falls




2010 Osteoporosis Canada Guidelines

Women and men over age 50 should be assessed for risk factors for osteoporosis and fracture

To identify those at high risk for fracture Those who have had a fragility fracture

Fragility Fracture: DefinitionFragility Fracture: Definition

A fracture occurring spontaneously or following minor trauma such as a fall from standing height or less1,2

Excluding craniofacial, hand, ankle and foot fractures

1. Kanis JA, et al. Osteoporos Int 2001; 12(5):417-427.2. Bessette L, et al. Osteoporos Int 2008; 19:79-86.

Care Gap 90 % men with clinical fragility fracture were untreated

for osteoporosis Only 10% men with a clinical fracture reported being

diagnosed with osteoporosis About 20% women with fragility fracture receive

treatment to prevent further fractures If men are diagnosed with osteoporosis, they are more

likely to be treated 67% with osteoporosis diagnosis received

bisphosphonate and 87% were on calcium and/or Vitamin D

* The osteoporosis care gap in men with fragility fractures: the Canadian Multicentre Osteoporosis Study, Osteoporosis International April 2008, Vol 19, Issue 4, p 581-587.

Therapeutic Care Gap: Most Men Do Not Therapeutic Care Gap: Most Men Do Not Receive Treatment for Osteoporosis after Receive Treatment for Osteoporosis after Fracture Fracture

94.2% 94.0% 91.6% 92.6% 90.5%99.5%

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Papaioannou A, et al. Osteoporos Int 2008; 19(4):581-587.

Care Gap

Men have 1/3 of all hip fractures and are less likely to survive afterwards One year mortality

31 to 38% men vs 12 to 28% women

2 x more likely to be institutionalized after a hip fracture

Why did we forget them ?

Bone loss occurs later in men, after the age of 70

Women are more likely to fracture than men until age 80, then similar risk

Men have higher peak bone mass and larger bones have less risk of fracture

Men have lower rates of bone loss

W.H.O. Fracture Risk Factors in Men

Previous fragility fracture over 40 yo Especially vertebral compression #’s (height loss of ≥ 6 cm or kyphosis)

Glucocorticoid therapy equivalent to ≥ 7.5 mg prednisone/day x 3 months or more

Advanced age (> 65 yr)

More Factors that Increase Male Fracture Risk from W.H.O.

Condition associated with bone loss DM Type I, untreated hyperthyroidism, chronic malnutrition

Family history O/P, parental # High alcohol intake > 2 units/day Hypogonadism, delayed puberty Low BMI < 20 kg/m² Smoking (past or present) Anti-androgen therapy treatment for prostate cancer

(ie Casodex®/bicalutamide, flutamide)


Which men should be treated?

Deciding to give treatment should be based on preventing fractures

Those identified at high risk for a major osteoporotic fracture ( > 20% risk for a fracture over 10 years) should be offered treatment

If > 50 yo + fragility fracture (hip/vertebra) or >1 fragility fracture

= high risk for future fractures should be offered medications


State to treat male or female at high risk for future fracture

The key is identifying men at high risk for future fractures – that is where improvement is needed

Two tools integrate the key risk factors for fracture with (and without) BMD at femoral neck

CAROC and FRAX

Moderate risk(10-year fracture risk 10%-20%)

Lateral thoracolumbar radiography (T4-L4) or vertebral fracture assessment may aid in decision-making by identifying

vertebral fractures

Factors warranting consideration of pharmacologic therapy:

•Additional vertebral fracture(s) (by vertebral fracture assessment or lateral spine radiograph)

•Previous wrist fracture in individuals aged > 65 or those withT-score < -2.5

•Lumbar spine T-score much lower than femoral neck T-score•Rapid bone loss•Men undergoing androgen-deprivation therapy for prostate cancer•Women undergoing aromatase inhibitor therapy for breast cancer•Long-term or repeated use of systemic glucocorticoids (oral or

parenteral) not meeting conventional criteria for recent prolonged use•Recurrent falls (> 2 in the past 12 mo)•Other disorders strongly associated with osteoporosis, rapid bone

loss or fractures

Good evidence of

benefit from

pharmaco-therapy

Repeat BMD in 1-3 yr and

reassess risk

Integrated ApproachIntegrated Approach

Which Treatments for Men ?

Most osteoporosis meds were tested in women Some smaller trials with men & osteoporosis,

- Alendronate 10 mg daily (CaCo3 500 mg and Vit D 400 units daily) x 24 months increased BMD

- Risedronate 5 mg daily decreased vertebral fractures by 60% in men within 12 months

Risedronate and Alendronate effective in prevention and treatment of glucocorticoid induced O/P in men and women

What Osteoporosis Canada Says For men needing osteoporosis treatment Alendronate, risedronate and zoledronic acid

can be used as first line treatments in the prevention of fractures

Testosterone is not recommended for treatment of osteoporosis in men

Individuals > 50 yo on ≥ 3 months of glucocorticoids equivalent to prednisone ≥ 7.5 mg daily in the preceding yr

should start on alendronate, risedronate or zoledronic acid at outset of the glucocorticoid and continued for at least the duration of the glucocorticoid

What Osteoporosis Canada Says:

Individuals ( M or F) already at high risk for fracture who are also taking glucocorticoids (≥ 7.5 mg prednisone/day x 3 months or more should be considered for teriparatide daily

Men on anti-androgen therapy should be evaluated for fracture risk and osteoporosis therapy considered to prevent fractures

Don’t Forget Non-Prescription Treatments

Weight bearing exercise Falls risk assessment

multifactorial intervention (ie home safety, cataract sx, med review, physio

assessment) 1200 mg calcium daily from

all sources & the emphasis on dietary sources

Vitamin D 800 to 2,000 units/ day

Summary

We can reduce falls and fractures by Reducing prescribing cascades Regular review and pruning of medication lists Using medications with a high risk for falls more

cautiously Assessing men for fracture risks too!

Questions ?

References and Resources Hamilton HJ, Gallagher PF, O’Mahony D. Inappropriate prescribing and

adverse drug events in older people. BMC Geriatrics 2009; 9:5.

Barry PJ et al. START (Screening Tool to Alert doctors to the Right Treatment)—an evidence-based screening tool to detect prescribing omissions in elderly patients. Age Ageing. 2007;36:632-638.


http://www.osteoporosis.ca

Date of download: 9/18/2013Copyright © 2012 American Medical

Association. All rights reserved.

From: Feasibility Study of a Systematic Approach for Discontinuation of Multiple Medications in Older Adults: Addressing PolypharmacyArch Intern Med. 2010;170(18):1648-1654. doi:10.1001/archinternmed.2010.355

Improving drug therapy in elderly patients—the Good Palliative–Geriatric Practice algorithm. Revised from Garfinkel et al with permission from the Israel Medical Association Journal.

Figure Legend:

Arch Intern Med. 2010;170(18):1648-1654. doi:10.1001/archinternmed.2010.355

Absolute 10-year Fracture-Risk ToolsAbsolute 10-year Fracture-Risk Tools

Tools validated in Canada (choice based on personal preference and convenience) CAROC: Joint initiative of the Canadian Association of

Radiologists and Osteoporosis Canada1

FRAX: Fracture Risk Assessment Tool developed by the World Health Organization2

There are large differences in fracture rates from country to country3-5

Assessment tools need to be country specific

1. Leslie WD, Berger C, et al. Osteoporosi Int; In press..2. Leslie WD, Lix LM, et al. Osteoporosi Int; In press.

3. Kanis JA, et al. J Bone Miner Res 2002; 17(7):1237-1244.4. Melton LJ, III. Endocrinol Metab Clin North Am 2003; 32(1):1-13.

5. Leslie WD, et al. J Bone Miner Res 2010; in press.

CAROC tool Assesses 10-YEAR FRACTURE RISK for Women

and Men using age and BMD stratifies into 3 zones: low risk (< 10%), medium (10-20%), and high risk (>20%)

Fragility fracture after age 40 or recent prolonged systemic glucocorticoid use, increases CAROC base risk by one category (i.e., from low-risk to moderate or moderate risk to high)

The T-score for the femoral neck is derived from the National Health and Nutrition Education Survey III (NHANES III) reference database for white women.

Canadian Association of Radiologists and Osteoporosis Canada (CAROC) Risk Assessment Tool

10-year Risk Assessment for Men 10-year Risk Assessment for Men (CAROC Basal Risk)(CAROC Basal Risk)

Age Low Risk Moderate Risk High Risk

50 above -2.5 -2.5 to -3.9 below -3.9

55 above -2.5 -2.5 to -3.9 below -3.9

60 above -2.5 -2.5 to -3.7 below -3.7

65 above -2.4 -2.4 to -3.7 below -3.7

70 above -2.3 -2.3 to -3.7 below -3.7

75 above -2.3 -2.3 to -3.8 below -3.8

80 above -2.1 -2.1 to -3.8 below -3.8

85 above -2.0 -2.0 to -3.8 below -3.8

Papaioannou A, et al. CMAJ 2010 Oct 12. [Epub ahead of print].

Canadian Association of Radiologists and Osteoporosis Canada (CAROC) Risk Assessment Tool

Risk Assessment Using FRAXRisk Assessment Using FRAX

Uses age, sex, BMD, and clinical risk factors tocalculate 10-year fracture risk* BMD must be femoral neck FRAX also computes 10-year probability of hip fracture

alone This system has been validated for use in Canada1

There is an online FRAX calculator with detailedinstructions at: www.shef.ac.uk/FRAX

1. Leslie WD, et al. Osteoporos Int; In press.

* composite of hip, vertebra, forearm, and humerus

FRAX Tool: On-line CalculatorFRAX Tool: On-line Calculatorwww.shef.ac.uk/FRAX

www.shef.ac.uk/FRAX.

Using CAROC to decide which risk category (see chart for men)

Men ≥ 65 yo with T score < - 3.7 considered high risk

Men ≥ 50 yo & Fragility or Vertebral # & T score in moderate risk range are determined to be high risk

Men any age, on equiv of ≥ Prednisone 7.5 mg/day x 3 months & T score in moderate risk range are determined to be

high risk

Men any age with clinical hypogonadism and T score in the moderate risk range are determined to be high risk

Treatment should be offered to men considered to be at high risk for a fracture

More about Treatments for Men Although testosterone treatment in hypogonadal men increased

BMD at spine and hip, no trials showed fracture risk reduction so use is not recommended

Teriparatide reduced the risk for moderate or severe fractures in men with osteoporosis

Denosumab (Prolia™) increases bone mass in men with osteoporosis at high risk for fracture, (history of osteoporotic fracture, or multiple risk factors for fracture) or patients who have failed or are intolerant to other available osteoporosis therapy. SubQ: 60 mg as a single dose, once every 6 months However it is currently a Limited Use Benefit on ODB for women

(Teriparatide effects on vertebral fractures and BMD in men with osteoporosis, Osteoporos Int, 2005 May: 16(5): 510-6 Kaufman JM et al

end falls this fall pharmacy update. medications and falls risk medication reviews to identify falls...

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