Complex, Frail Elderly Presentation

Kim Jany

Primary Care Pharmacist

Surrey and Sussex CSU

Working for Guildford and Waverley CCG

April 2013

BGS Definition of Frail, Elderly

• Aged over 75, often over 85, with multiple diseases, which may include dementia

• Tend to present to hospital with symptoms such as falls, immobility and confusion

• Their functional reserve is reduced making them additionally vulnerable to developing complications while in hospital

Surrey Facts

• Surrey has a higher proportion of older people compared with England. The 2010 census data shows that Waverley has the highest % of over 85s in Surrey and 2nd highest % of over 65s.

• Life expectancy in Surrey - Guildford and Waverley is high at 84 years for women and 81 years for men, almost two years longer than the average for England.

Kings Report updated Apr 13 medicines management – a top 10

priority for commissioners

• Four out of five people aged over 75 years take a prescription medicine and 36% are taking four or more (Department of Health 2001).

• The average number of medicines prescribed for people aged 60 years and over in England almost doubled from 21.2 to 40.8 items per person per year in the ten years to 2007 (Information Centre 2007).

Age Related Pharmacokinetics

Absorption particularly important to consider the effects of any coprescribed drugs on absorption eg calcium reduces absorption of bisphosphonates, levothyroxine

Distribution reduced volume of distribution of water soluble

drugs, e.g. digoxin (which may lead to increased initial drug concentration)

increased volume of distribution of lipid soluble drugs, e.g. benzodiazepines (which may lead to increased elimination half-life and prolonged effect).

EliminationDrugs metabolised in liveroxidation, reduction and hydroxylation, largely performed by the mixed function oxidases such as cytochrome P450 are reduced as

reduced hepatic blood flow (35% reduction in hepatic blood flow in the elderly)

reduced hepatic volume (hepatic volume is reduced by 28% in men and 44% in women by the age of 91)

Drugs metabolised in the kidney

reduced glomerular function - GFR is reduced by 6 to 10% per decade after the age of 40

reduced tubular function which means that by the age of 90 there may be a 30 to 40% reduction in overall renal function

This results in reduced clearance of drugs which are mainly excreted via filtration at the kidney

Coexisting disease

• Renal failure results in reduced secretion resulting

accumulation of the drug increased length of time to reach steady state plasma

levels (takes approximately 5 half-lives)

• Congestive cardiac failure results in reduced absorption (due to mucosal oedema, reduced

epithelial blood supply and splanchnic vasoconstriction)reduced volume of distribution (due to decreased tissue

perfusion)reduced elimination (due to reduced hepatic blood flow,

reduced oxidising capacity as a result of hypoxia, reduced GFR and increased tubular reabsorption).

Adverse drug reactions

ADRs increase steadily in incidence with age due to

pharmacokinetic and pharmacodynamic changes

impairment of homeostatic mechanismso baroreceptor responseso control of body swayo thirst o volume regulation o glucose and electrolyte controlo Thermoregulation

Studies show that 10% or more of elderly patient hospital admissions are due to ADRs.

Alarm Bell Drugs• NSAIDs – increased risk of bleed, increased risk of

CV and renal complications

• Diuretics – risk of excessive diuresis leading to orthostatic hypotension, dehydration, renal and electrolyte imbalance

• ACE / ARBs - hypotension, angioedema, hyperkalaemia, renal or hepatic impairment

• SSRI – increased risk GI bleed

• Metformin – lactic acidosis – review if Egfr <45ml/min/1.73m² , stop if <30ml/min/1.73m²

Compliance

• An elderly person whose mental function is intact is no more likely to make mistakes with their medication than a younger person.

• Polypharmacy does make errors more likely

• Deliberate non-compliance failing to take prescribed medication as frequently as directed or

not at all

taking a larger dose in the mistaken belief that it will be more therapeutic or lead to a faster cure

hoarding drugs for future unauthorised use

self-prescribing with over-the-counter preparations

Improve adherence

• Explore non-intentional adherence and find solutions with patient

ability to read, swallow, open bottles, use inhaler devices or insulin pens and testing equipment

Try out devices to improve adherence, e.g. haleraids, spacers, medicine record card, large print labels

• Explore reasons for intentional non-adherence

Provide rationale and teaching behind prescriptions where appropriate

Develop plan with patient as to how to proceed e.g. alternative agent, different formulation, different packaging

Mrs EE, 90yrs old

•Lives with daughter

•Forgetful, otherwise good health

•17 medicines, daughter thinks they are too many

•Only taking 4 laxatives!

•Doesn’t like BP tabs thinks they make her drowsy

•Doesn’t remember to take afternoon dose

Discontinued • Intralgin gel • Fybogel sachets • Vitamin BPC caps • Flixonase spray • Doxazosin 2mg • Dipyridamole (b/4 NICE) • Movicol • NaCl irrigation solution

Continued • Thyroxine 50mcg • Bendroflumethiazide 2.5 • Perindopril • Senna • Lactulose • Aspirin • Digoxin • Simvastatin • Timoptol eye drops

Polypharmacy

Polypharmacy itself should be conceptually perceived as a “disease” with potentially more serious complications than those of the diseases these different drugs have been prescribed for

Doran Gafinkel 2010

Guilty or not guilty

Guilty • Discontinue • Reduce dose/frequency/prn • Substitute with a safer drug/formulation,

schedule • Wait and see, review after a period

Not Guilty • Continue

Reducing polypharmacy is everybody’s business

• Focus on patients with the highest medication related risks and morbidities

• For individual patients, focus on the drugs with the highest risks or highest benefits

• Share the workload with others e.g

dieticians/sip feed, TVN/ dressing, incontinence adviser/antiholinergics, CMHT/ antipsychotics, sleep clinics, pain clinics etc

• Patients, Relatives, carers, community pharmacists, OTs nurses etc can monitor drug effects and feedback

Establish the patient’s overall care goals

Treat the patient not just the disease!

•What outcomes are we working towards with the patient?

•Medicines optimisation goals must fit into overall goal, not work against it

Frail, elderly checklist Ensure an accurate diagnosis

Question necessity for the drug. Avoid inappropriate and over enthusiastic treatment. Consider the patient as a whole.

Can nonpharmacological alternatives be used instead?

Has the most suitable drug been chosen for the patient?

Is the dose correct? Start low and titrate carefully

Consider risk of drug interactions

Ensure a thorough drug history is taken, including OTC medication

Does the patient suffer from another disease for which the drug in question is contraindicated?

Is the treatment regimen as simple as possible?

Has the patient and any carer been counselled about the treatment and do they understand how to take the drugs and for how long?

Appropriate prescribing, Avoidable Waste?

Useful websites / resources

• http://www.cumbria.nhs.uk/ProfessionalZone/MedicinesManagement/Guidelines/StopstartToolkit2011.pdf

• http://www.nhshighland.scot.nhs.uk/Publications/Documents/Guidelines/id1214%20%20Polypharmacy%20Guidance%20for%20Prescribing%20in%20Frail%20Adults.pdf

• http://cks.nice.org.uk/

• http://www.evidence.nhs.uk/

So we know why we should reduce polypharmacy

But how?

Dr Sarah Taylor-Smith,

Frail Elderly Medication Reviews

• By definition these patients have multiple diagnosis. They will collect medications from secondary care out patients and inpatient stays.

• QOF criteria/ targets may add to their polypharmacy.

• Medication review in these patients is an important tool.

Medication Review

• Qof requirement/ GMC guidance• Opportunity to ensure problem coding correct• Can be used to have patient focused

conversation• If on a visit recording may be difficult• Probably already doing this but are we

recording and communicating?

3 C’s for medication review

• Clear

• Considered

• Compliance

Medication review: Clear

Clear: for the GP. Which medication for which diagnosiseg ACE for LVF or BP.

Linking with Emis web

Clear: for the patient, carers, out of hours clinical staff. NHS spine.

Pitfalls- Heart Failure/ Renal failure understanding of terms. Confidentiality

Medication Review: Considered

• Considered: is treatment symptomatic, secondary prevention, primary prevention? Do we need to treat?

• Considered: evidence base in this age group. Adverse affects eg Bp and postural hypotension.

• Considered: Patients wishes.eg Statin in the “world weary.” May give an opening to talk through anticipatory care plan

Medication Review: Compliance

• Compliance: Formulation, stockpiling, dosing schedule, repeat intervals, arrangement with pharmacy.

• Compliance: Care home/nursing home drug error reporting/ audit trail. Medication changes communication.

Clear, Considered, Compliant

• Patient centered approach to reduce medications for complex group of patients

• Clear communication on notes

• On NHS spine

When to review?

• On discharge from hospital

• On arrival to new GP, new care home, nursing home

• QOF yearly review

• Audit?

• Workload implications.