Safe Prescribing in Dementia · Mental Health of Older Adults and Dementia Clinical Academic Group...

Mental Health of Older Adults and Dementia Clinical Academic Group


Safe Prescribing in Dementia

Dr Daniel Harwood Consultant Psychiatrist and Clinical Director, London Strategic Clinical Network

Gurdeep Kaur Major Rapid Access Team Senior Pharmacist, Camden

CNWL NHS Trust




This talk

• Polypharmacy – in brief

• Safe prescribing of physical health medications in dementia – 3 key clinical messages

• Use of cognitive enhancing drugs- when to stop, and cardiac effects


Polypharmacy • A term that refers to either the prescribing or

taking many medicines. • Previously defined further as: 4-5 + medicines/day(ref) • Currently: Prescribing or taking more medicines than clinically required.

• King’s Fund further divides into “appropriate” and “problematic” polypharmacy1.

• “Appropriate” polypharmacy: “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 best evidence.”

• “Problematic” polypharmacy: “the prescribing of multiple [medicines] inappropriately, or where the intended benefit of the [medicines are] not realised.”



Why managing polypharmacy matters

• Polypharmacy

– is frequent - average of 8 drugs per resident in UK care homes (Shah et al 2012)

– is dangerous -the more drugs people with dementia take the higher their mortality SHELTER study (2013)

– Is not necessary -20% of drugs “potentially inappropriate” in care home residents (Shah et al 2012)


Drugs and falls

Odds ratios for fall risk in older people (Woolcott et al 2009)

Antidepressants 1.68

Antipsychotics 1.59

Hypnotics 1.47

Antihypertensives 1.24

NSAIDs 1.21

Diuretics 1.07

Opiates 0.96

Medicines Optimisation Outcome focused approach to safe and effective use of medicines, that takes into account the patient’s values, perception and experience of taking their medicines 2,3

Important Outcomes for adults Improved quality of life Making a positive contribution Improved health and emotional

wellbeing Personal Dignity Control and choice Economic wellbeing Freedom from discrimination


Deprescribing

• is the complex process required for the safe and effective cessation (withdrawal) of inappropriate medication, recognising that much of the evidence to support stopping medicines is empirical and based on the patient’s physical functioning, co-morbidities, preferences and lifestyle4, 5.


Medication Review:

• ‘a structured, critical examination of a person’s medicines with the objective of reaching an agreement with the person about treatment, optimising the impact of medicines, minimising the number of medicines-related problems and reducing waste.’



Neurotransmitter systems important in cognitive functioning

• Opioid

• GABA

• Histamine

• Acetylcholine



Acetylcholine



Acetylcholine

• Reducing brain cholinergic activity would be expected to have an effect on brain function

• Many drugs have some effect on anti-cholinergic activity


Does this matter? Yes • Anticholinergic drugs

• cause confusion, sedation, cognitive impairment, delirium and falls (Bishara et al, 2014)

• may increase the risk of dementia and affect the clinical course of AD (Carriere et al 2009; Jessen et al 2010; Lu & Tune 2003)

• are a risk factor for onset of psychosis in AD (Cancelli et al 2009)

• interact negatively with AChEIs

Anticholinergic Effect on Cognition Scores

Bishara D et al. Int J Geriatr Psychiatr; 2017: 32(6): 65-656

(scoring system available via Medichec.com)

• Up to date and accurate estimation of cholinergic burden of medication

• “traffic light” system

• Green (score 0)= safe

• Light amber (score 1)

• Dark amber (score 2)

• Red (score 3)

Updated table July 2017


Mental Health of Older Adults and Dementia Clinical Academic Group Medichec.com

• Enables quick checking of AEC score and contains all drugs in BNF

• Website enabled for easy use on smartphone


Clinical implications 1 Bladder drugs • Some anticholinergic drugs

for urinary incontinence will counteract effects of cholinesterase inhibitors

• Being on an ACEI increases your risk of being on a bladder anticholinergic ie they are used to treat side effects of ACEI


Anticholinergic drugs

• Whether a drug worsens cognition does not just depend on its “anticholinergic activity”- other factors are:

• Which receptors it acts on- M1 and M2 receptors (brain)or M3 receptors

(bladder)- Darifenacin is selective to M3 bladder receptors

• How well it crosses the blood brain barrier – small, lipid soluble, unpolarized

molecules cross better- Trospium- poor penetration through BBB

• How well it is recognised by the Permeability-glycoprotein (P-gp), (an active

CNS efflux transporter which actively pumps agents back into circulation) Only darifenacin, trospium and fesoterodine are reported to be P-gp substrates

• oxybutynin and tolterodine are non specific and cross the BBB easily

Chancellor MB et al. Drugs Aging 2012; 29(4):259-273

Anticholinergic Drugs for the bladder


Clinical implications 2 Hyoscine

• Hyoscine hydrobromide (Kwells) – Centrally acting anticholinergic used as antiemetic and for

hypersalivation

– Impairs memory, speed of processing, disrupts attention

– Elderly more vulnerable, even at lower doses

• Confusion, hallucinations

– Effect on cognition so significant that used in trials to produce memory deficits

– DOT USE FOR PEOPLE WITH DEMENTIA


Clinical implications 3 Antihistamines

• 1st generation H1 blockers (chlorpheniramine, clemastine,

promethazine, cyclizine, cyproheptadine, hydroxyzine cause reduced alertness; so don’t use these in dementia

• 2nd generation ones (cetirizine, loratadine, fexofenadine) don’t

(Tannenbaum et al 2012)


Cognitive enhancing drugs (AcHEIs)

There are many clear prescribing protocols which go through the basics.

Commonly asked questions are:

• When to stop them?

• Cardiac effects – when to do an ECG?


AcHEIs

• Cholinesterase inhibitors have modest effects for individuals but benefits clearer when large sample reviewed

• Perera et al 2014


When should you stop them? (Parsons 2016)

• Evidence base for discontinuation limited

• Some evidence for worsening cognition and BPSD after donepezil stopped (DOMINO-AD trial (Howard et al 2015), Holmes et al 2004)

• So keep on them unless • Issues with adherence which cannot be resolved

• Intolerable side effects

• Risk with physical co-morbidity eg unstable cardiac status

• Terminal illness

• Patient/advocate choice


Cardiac effects and ECG

• ACEIs can cause • Sinus bradycardia

• Sino-atrial block

• Aggravate sinus node disease

• These can lead to “pauses”- blackouts and falls


Cardiac effects and ECG 2

• Frequency of severe side effects is low • 1-10% dizziness

• 0.01-1% severe bradycardias, angina

• Routine one off ECG not much use, only do if • Heart rate less than 50

• Syncope

• Irregular heart rate


Cardiac assessment before starting ACEI (thanks to Dr Ceri Davies)

• Ask about syncope/dizziness

• Check pulse

• Do ECG if • Heart rate less than 50

• Syncope/dizziness

• Irregular heart rate • If any of these things found – investigate

• If QT interval prolonged or LBBB- discuss with cardiologist


Cardiac monitoring

• Once on an ACEI check pulse after one month, then 3 months then 6 monthly- more frequently if pulse less than 60

• There are more complicated guidelines if you like! (Yorkshire and Humberside ones available free on internet)


Thank You

[email protected]

mailto:[email protected]


Safe Prescribing references

Bishara et al (2014) Safe prescribing of physical health medication in patients with dementia Int J Geriatr Psychiatr; 29:1230-1241

Bishara et al (2016) Anticholinergic effect of cognition (AEC) of drugs commonly used in older people Int J Geriatr Psychiatr

De Jong et al (2013) Drug-related falls in older patients: implicated drugs, consequences and possible prevention strategies Ther Adv Drug Saf 4: 147-154

Medichec.com


Polypharmacy references

1) The King’s Fund: Polypharmacy and Medicines Optimisation – making it safe and sound. Duerdan, M, Avery, T & Payne, R. 2013. Accessed online on 4th June 2017. Accessed via: https://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/polypharmacy-and-medicines-optimisation-kingsfund-nov13.pdf

2) Medicines Optimisation: the safe and effective use of medicines to enable the best possible outcomes. NICE guidance, accessed online on 4th June 2017. Access via: https://www.nice.org.uk/guidance/ng5

3) UKMI NICE Bites, April 2015. Accessed online on 4th June 2017. Access via: http://www.medicinesresources.nhs.uk/upload/documents/Health%20In%20Focus/NICEBitesApril2015MedsOptimisation.pdf

4) A Themed Journal Issue on Deprescribing. Barnett, N & Jubraj, B. European Journal of Hospital Pharmacy: Science and Practice 2016; 24 1- 2 Published Online First: 20 Dec 2016. doi:10.1136/ejhpharm-2016-001118

5) Deprescribing: Is the law on your side? Barnett, N & Orla, K. Eur J Hosp Pharm 2017;24:21-25. Accessed online on 4th June, via: http://ejhp.bmj.com/content/24/1/21.citation-tools

6) Mental Health First Aid, launched 16th June 2017. Accessed on 16th June via: https://mhfaengland.org/

http://www.medicinesresources.nhs.uk/upload/documents/Health In Focus/NICEBitesApril2015MedsOptimisation.pdf




http://ejhp.bmj.com/content/24/1/21.citation-tools




Safe Prescribing in Dementia · Mental Health of Older Adults and Dementia Clinical Academic Group...

Documents

Transcript of Safe Prescribing in Dementia · Mental Health of Older Adults and Dementia Clinical Academic Group...