Poly-pharmacy and Older People

Dr. Amit AroraConsultant Geriatrician and Associate Medical Director

Past Chairman, England Council, British Geriatrics Society@betterageing

Disclosure

• I have no conflict of interest or disclosure in relation to this presentation

Primum non nocere• Latin for "first, do no harm." • Equates to: Non-maleficence - one of the principal precepts of

bioethics that all healthcare students are taught. • Another way to state it is that, "given an existing problem, it may be

better not to do something, or even to do nothing, than to risk causing more harm than good.”

• Others include: Beneficence, Autonomy, Social justice, confidentiality

PolypharmacyAppropriate polypharmacy is defined as prescribing for an individual for complex conditions or for multiple conditions in circumstances where medicines use has been optimised and where the medicines are prescribed according to bestevidence.

Problematic polypharmacy is defined as the prescribing ofmultiple medications inappropriately, or where the intended benefit of the medication is not realised.

Hyperpolypharmacy: refers to the prescribing of ten ormore medicines and distinguishes it frompolypharmacy.

Oligo-pharmacy: Deliberate avoidance of polypharmacy i.e.five or less prescription drugsdaily.

The Kings Fund Polypharmacy and medicines optimisation-Making it safe and sound-Martin Duerden, Tony Avery and Rupert Payne

The Reasons for Polypharmacy• Older people often required multiple medications to treat multiple health- related

conditions. Adherence is complex. 1

• Patient withmultiple comorbid medical conditions also required numerousmedications to treat eachcondition.1

• Hospitalization also puts patients at risk of polypharmacy. Medicines are startedand stopped quite frequently during patient hospital stay.1

• Multiple doctors are prescribing medications for the same patient.Once apatient starts a medication, it is neverdiscontinued.1

• Multiplespecialists care for the same patient, each focusing on a single organ system.2

• Inadequate frequency of quality ofmedication review.• Lack of patient education is the most common reason. Doctors do not inform

patients or patients do notask questions.11. Rambhade S et al. A Survey on Polypharmacy and Use of Inappropriate Medications

Toxicol. Int. 2012 Jan-Apr; 19(1):68-732. Lai L. Drug-related problems and deprescribing in older adults. BC Medical Journal 2017 vol; 59 no.

3: 178-184

1. NHSBSA Pharmaceutical waste reduction in the NHS. June 2015. Available from: https://www.england.nhs.uk/wp-content/uploads/2015/06/pharmaceutical-waste-reduction.pdf <accessed on the 28.6.18

Prescribing cascade

Rochon P, Gurwitz J H. The prescribing cascade revisited The Lancet 2017; 389 (No. 10081): 1778–1780.

What is a prescribing cascade?

Common prescribing cascades• Ibuprofen → hypertension → antihypertensive therapy• Metoclopramide → parkinsonism → Sinemet• Amlodipine → edema → furosemide• Gabapentin → edema → furosemide• Ciprofloxacin → delirium → risperidone• Lithium → tremor → propanolol• Buproprion → insomnia → mirtazepine• Donepezil → urinary incontinence → oxytutynin• Amiodarone → tremor → lithium• Venlafaxine → tremor → diazepam

Common prescribing cascades• Meperidine → delirium → risperidone• Beta-blocker → depression → antidepressant• Amitriptyline → decreased cognition → donepezil• Narcotic → constipation → senokot• Senokot → diarrhea → imodium• Lorazepam → morning drowsiness → caffeine• Enalapril → cough → dextromethorphan• Furosemide → hypokalemia → Slow K• Omeprazole → low B12 → B12 supplement

Mrs. A• Widow, living alone• 84 years old• Severe knee pain limiting mobility• Often confused, unable to get out of bed• Has had 3 falls in the last year• Doesn’t want to go out anymore• Not always taking meds• Children think she should no longer be living alone

• ASA 81mg daily• ibuprofen 400mg bid*• dimenhydrinate 50mg qhs• lorazepam 1mg qhs*• warfarin as directed*• metoprolol 50mg bid*• amlodipine 10mg daily*• ramipril 5mg daily*• Lakota capsules qid• furosemide 40mg bi• Atorvastatin40mg• Dextromethorphan• lansoprazole 30mg daily*• Oxybutynin XL 10mg daily*• Vit. B12 1200mcg daily*• Calcium/Vit D bid*

How did Mrs. A’s prescribing cascade happen?

Why should we review medications in older people regularly

+ = ?

•Increased susceptibility to:ØPolypharmacyØDrug interactionsØAdverse drug reactionsØPrescribing cascadeØPoor complianceØPotentially inappropriate prescribing

•Increase in co-morbidities withage

•Physiological changesØpharmacokineticsØpharmacodynamics

Pharmacokinetic Changes inOlder People

• Hepatic blood flow drops by 40%• Half of elderly have some form of

CKD• Hepatic blood flow drops by 40%• Half of elderly have some form of

CKD• Heart failure patients

can further exacerbate these decreases

• First-pass clearance decreases inelderly– Warfarin, Benzodiazepines,

opiates

• Protein binding changes– Malnutrition– Dentures– Food preparation differences– Dietary restrictions

• Substance abuse affectingmetabolism– Up to 10% of elderly in Western

countries use significant alcohol

STOPP/START

• Consensus panel of 18experts• Delphi process (2rounds)• Final agreed list of STOPP criteria (n=65) and START (n=22)• Good inter-rater reliability (STOPP k=0.75; START k= 0.68)

Example: 70 Year oldmale

• Current Medicines– Digoxin 250microgramsod– Bendroflumethiazide 2.5mgod– Flurazepam 30mg od (past 3years)

• Application of STOPP– Long termflurazepam

Example: 70 Year oldmale

• CurrentMedicines– Digoxin 250microgramsod– Bendroflumethiazide 2.5mgod– Flurazepam 30mg od (past 3

years)

• CurrentDiagnoses– Hypercholesterolaemia– Chronic AtrialFibrillation– Ischaemic HeartDisease

• Medical History– Cataracts, Gout, Insomnia

•Biochemical Data• Chol: 8.8mmol/L

• eGFR30ml/min/1.73m2

LFTs within range

•Application ofSTOPP

Digoxin > 125mcg withimpaired renal functionThiazide diuretic and historyof goutLong termflurazepam

•Application ofSTART

Warfarin and atrial fibrillation Statin with elevatedcholesterol

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What are the main tools?•Beers criteria • (explicit, US)

•Medication appropriateness index (implicit)

•STOPP/START tool • (recently revised)

•Medstopper www.medstopper.com

•RxISK Polypharmacy Index https://rxisk.org/tools/polypharmacy-index/

Learning resourceshttp://www.polypharmacy.scot.nhs.ukhttps://itunes.apple.com/gb/app/polypharmacyguidance/id1072829127?mt=8https://www.youtube.com/watch?v=jXcRHxl9qWwhttps://www.uea.ac.uk/documents/3306616/10940915/Antic holinergics/088bb9e6-3ee2-4b75-b8ce-b2d59dc538c2

OtherResources• NICE guidance Multimorbidity and polypharmacyLink• Treatment effects Database (within NICE guidance NG 56) Link• PresQIPP

• Polypharmacy and Deprescribing Link• Considerations in FrailtyLink• Multimorbidity Link• A practical guide to deprescribingLink• High Risk Medicines Link

• Hypnotics, Fentanyl, Opioid Patches, Safety of long ternPPI’s

• Anticholinergic Burden Score - http://www.acbcalc.com/• MedStopper - http://medstopper.com/

www.sps.nhs.uk 22

Patient-centred polypharmacy process

© N Barnett L Oboh K Smith EJHP: 23 December 2015 http://ejhp.bmj.com/search?fulltext=barnett+oboh+smith&submit=yes&x=0&y=0

What isDeprescribing?

‘Deprescribing is the complex process needed to ensure the safeand effective withdrawal of inappropriate medicines (A patient centred approach to polypharmacy NHS Specialist Pharmacy Service2017).’

• Is the medication required for a current indication?• Is the medication harmful to thepatient?• Is the patient happy to continue taking themedicine?

www.sps.nhs.uk

The importance of language• Polypharmacy

• “too many medicines” • the right amount for you

• Deprescribing• “stopping your medicines”

• trial and review

• Multimorbidity......• ……?

• “the presence of two or more long-term health conditions”

• ? Medication optimization • ? Medication Rationalization• ?Medication reviews

Barriers to Deprescribing• Resistance from patients, families, carers, (may be the result ofcertain beliefs

and attitudes).– “don’t rock the boat”– “but she has always taken this medicine”– “the specialist said she can never come off thismedicine”– “we tried that before and it didn’t work.”– Concern about worsening of the condition(s)

• Prescribers worrying about stopping a medication ordered by another prescriber or worry about the adverse effects from stoppinga medication.

• Reviewing medication for potential deprescribing requires extra time to exploreprevious records and history, interview staff, and communicate and documentrationale to patients, carers andfamilies.

Medicines Optimisation• Reduced adverse effects, especially in the

elderly• Reduced hospital admissions• Reduction in inappropriate medicines• Patient prescribed medications in line

with local formularies or guidelines (evidence based)

• Collaboration with patient in theircare.• Regular reviews with the patient tocheck

adherence and suitability

Whatwearetryingtoachieve:

Evidence for Deprescribing• There is little guidance for the process of tapering,withdrawing, discontinuing,

or stopping medications in older adults with polypharmacy in general clinicalpractice.1

• Deprescribing appears to be a feasible intervention but maynotaffect mortality.2

• Evidence exists to guide deprescribing individual medicationsincarefully defined scenarios.2

• Deprescribing needs to be considered for older people as aroutine component of the ongoing medication reviewprocess.2

1.An Expert Interview With Ian A. Scott, MBBS, FRACP, MHA www.medscape.com/viewarticle/814861_22.Page AT. et al. The feasibility and effect of deprescribing in older adults on mortalityand health: a systematic review and meta-analysis. 2016. Br JClin Pharmacol 2016; 82:583–623

If shortened life expectancy,query....• Drugs for primary prevention-Noplace

• Drugs for secondary prevention ONLY if time tobenefit exceeds life expectancy– Lipid lowering drugs– Prevention of fragilityfractures– ACEI, ARB, BB to prevent diabetic neuropathy/HFmortality– Cholinesterase inhibitors and memantine forimproved

cognition

1.O’Mahoney D, O’Connor M.N. Pharmacotherapy at the end-of-life. Age and Ageing, Volume 40, Issue 4, 1 July 2011, Pages 419-422 https://doi.org/10.1093/ageing/afr059

Drugs More Likely to Cause Hospital Admissions Due to ADR?

1. Pirmohamed, et al. BMJ 2004. 329; 15-192. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61817-

5/fulltext

Polypharmacy in older people• Generally occurs due to following primary reasons:

Demographic FactorsHealth FactorsAccess to Healthcare

• Patient and clinical staff expectations• OTC drugs

Elderly Purchase 40% of OTCsUse of OTCs is 3-fold higher in elderly

1.Werder SF, Preskorn SH. Current Psychiatry2003;2(2):24–36.2.Kaufman DW, Kelly JP,Rosenberg L, Anderson TE, Mitchell AA. JAMA 2002;287(3):337–44.

Methods forDecreasing Polypharmacy• Professional

– Educational activities for providers or patients• Organizational

– Polypharmacy clinic• Financial

– Incentive programs– Regulatory interventions

Patterson SM et al. Cochrane Database Syst Rev 2012; 16;5:CD008165.

Top 20 drugs by cost (2017, UK)1

• Fluticasone (£272m)• Enteral nutrition (£258m)• Pregabalin (£216m)• Beclometasone (£209m)• Budesonide (£182m)• Glucose blood testing strips

(£176m)• Rivaroxaban (£161m)• Tiotropium (£161m)• Apixaban (£105m)• Foods for special diets (£105m)

• Colecalciferol (£94m)• Sitagliptin (£93m)• Metformin (£91m)• Levothyroxine (£87m)• Insulin Glargine (£82m)• Mesalazine (systemic) (£81m)• Insulin Aspart (£80m)• Quetiapine (£77m)• Solfenacin (£75m)• Influenza (£73m)

https://digital.nhs.uk/data-and-information/publications/statistical/prescriptions-dispensed-in-the-community/prescriptions-dispensed-in-the-community-england---2007---2017 Accessed 1.2.2019

What is meant bycompliance, adherence andconcordance

Compliance• The extent to which the patient’s behaviour matches theprescriber’s

recommendations.Adherence• Describes the extent to which patients’ medicine-taking behaviour matches agreed

recommendations from the prescriber.Concordance• Prescriber and patient agree therapeutic decisions that incorporate their respective

views, including patient support in medicine taking as well as prescribing communication. Concordance reflects social values but does not address medicine-taking and may not lead to improvedadherence.

Medcines Adherence CG76https://www.nice.org.uk/guidance/cg76/chapter/1-Guidance

Deprescribing in Clinical Practice: Reducing Polypharmacyin Older People

1. Ascertain all current medications.2. Identify patients at high risk for or experiencingADRs.3. Estimate life expectancy in high-riskpatients.4. Define overall care goals in the context of lifeexpectancy.5. Define and confirm current indications for ongoingtreatment.6. Determine the time until benefit for disease-modifying medications.7. Estimate the magnitude of benefit vs harm in relation toeach medication.8. Review the relative utility of differentdrugs.9. Identify drugs that may bediscontinued.10. Implement and monitor a drug minimization plan, with ongoing reappraisalof

drug utility and patient adherence by a single nominatedclinician.

An Expert Interview With Ian A. Scott, MBBS, FRACP,MHAwww.medscape.com/viewarticle/814861_2

Steps to consider in polypharmacy management• Know when to stop and when to taper slowly• Involve the patient in the decision (consider incentives)• Offer safer alternative therapies• Get the patient/family involved in the monitoring• Involve team members (nurse, pharmacist, dietician, social worker, physiotherapist,

occupational therapist etc.)• Include non-pharmacological approaches (sleep hygiene, recreational services)• Provide reinforcement• Be up front about the need to withdraw slowly and monitor for ADWE, as well as how

long ADWE can last• Keep the message clear & say it often• Follow up and document the progress• Make several attempts at withdrawal• Use a variety of educational media: Verbal, Written handouts, Medication Logs• Empower patients to avoid future problems

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Pearls for Decreasing Polypharmacy• Start low and go slow• Don’t set it and forget it• Ask about herbs, roots, nuts, berries• Alternatives to prescribing• Difference between guidelines and tramlines• Trust but verify• Avoid narrow therapeutic index meds• Review regularly- Atypical effects in older people in prescribing and deprescribing• Avoid too many changes at once• Begin with the end in mind but be prepared to change• Use a criteria/tool in early career, your own experience will guide you later

Doctor, I am feeling much better since I ran out of my tablets!