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?