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