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Polypharmacy

Polypharmacy. An introductory module for clinicians. Lawrence Jackson , BScPhm, CTDP Pharmacy Clinical Coordinator, Sunnybrook Health Sciences. This module is part of the sfCare approach. Patient Handout. 8.5 x 11 Poster. PowerPoint Presentation. Objectives. Objectives

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Polypharmacy

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  1. Polypharmacy An introductory module for clinicians Lawrence Jackson, BScPhm, CTDP Pharmacy Clinical Coordinator, Sunnybrook Health Sciences

  2. This module is part of the sfCare approach Patient Handout 8.5 x 11 Poster PowerPoint Presentation

  3. Objectives Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions Identify the factors that contribute to polypharmacy Explain the consequences of problematic polypharmacy Describe a structured approach to the detection of problematic polypharmacy Apply general strategies to limit problematic polypharmacy Apply a senior friendly care approach to polypharmacy

  4. What is polypharmacy? While there is no consensus definition for polypharmacy, most studies have used a numerical threshold of 5 or more medications per day Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions • Approximately 40% of older adults take 5-9 medications1 • Approximately 18% of older adults take 10 or more medications2 1. JAMA 2017;318(17):1728 2. Duerden M, et al. Prescriber 2014;25:44-47

  5. Appropriate versus problematic polypharmacy Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions Appropriate Polypharmacy • Medication optimization ensures benefits outweigh risks • Takes into consideration impact on outcomes important to the older adult, such as • Improving the duration and quality of life • Symptom control • Prevention • It is evidence-based JAMA 2017;318(17):1728 Duerden M, et al. Prescriber 2014;25:44-47

  6. Appropriate versus problematic polypharmacy Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions Problematic Polypharmacy • Risk of harm exceeds the potential benefits or coexists with the benefits JAMA 2017;318(17):1728 Duerden M, et al. Prescriber 2014;25:44-47

  7. Impact of polypharmacy on the older adult The following risks accompany polypharmacy: Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions  adverse drug reactions  drug interactions  cost  risk of non adherence  risk of medication errors Precipitate or exacerbate geriatric syndromes

  8. Impact of polypharmacy on the older adult Geriatric syndromes Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions • Falls • Functional impairment • Cognitive impairment • Urinary incontinence • Impaired nutrition • Dehydration • Constipation

  9. Risk factors for polypharmacy Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions Multiple medical problems/ multiple medications Increased risk of problematic polypharmacy OR harmful medication effects + Reduced homeostatic mechanisms and organ dysfunction = + Acute illness or change to medications Frailty AND/OR

  10. Risk factors for polypharmacy Multiple medical problems/multiple medications Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions • Treatment guideline-based prescribing • Promotes multiple medications • Conditions for deprescribing uncertain • ADRs and prescribing cascade • An adverse reaction to one drug may go unrecognized/ misinterpreted • Healthcare provider inappropriately prescribes a second drug to treat signs/symptoms • Infrequent medication review • There is a lack of incentive to deprescribe • Unnecessary drugs or doses not adjusted

  11. Risk factors for polypharmacy Reduced Homeostatic Mechanisms & Organ Dysfunction Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions • A decline in physiologic reserves associated with aging causes the older adult to become less resilient to various causes of stress such as acute illness or injury, or the effects that medications have on the body. • The combination of increased stressors and a decrease in physiologic reserve can lead to adverse outcomes such as hospitalization or death. Taffet GE, Physiology of aging. In: Cassel CK, Leipzig RM, Cohen HJ, et al [eds]. Geriatric Medicine: An Evidence-Based Approach, 4th ed. New York, Springer, 2003

  12. Risk factors for polypharmacy Reduced homeostatic mechanisms and organ dysfunction Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions Pharmacokinetics changes Pharmacodynamics changes Changes in physiology with aging: Changes in how the body acts on the drug Changes in how the drug acts on the body • Absorption • Distribution • Metabolism (liver) • Excretion (kidney) • ↑ body fat • ↓ body water • ↓ albumin • ↓ liver metabolism • ↓ renal function • Changes in receptor binding • ↓ # of receptors and receptor activity • ↑↓ Drug efficacy • ↑ Toxicity / ADRs

  13. Risk factors for polypharmacy Frailty Older people are vulnerable to medication-related problems associated with frailty. Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions • Characteristics of frailty • Unintended weight loss due to inadequate nutrition • Slow walking speed • Impaired grip strength • Exhaustion • Self reported decline in activity levels Robust Pre-frail Frail 0 1-2 ≥3

  14. Risk factors for polypharmacy Frailty (cont.) Several factors are known to be associated with frailty: Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions • Older age • Multiple medical problems (or geriatric syndromes) • Taking multiple medications • Multiple psychosocial problems • One or more sensory impairments (vision, hearing) • New onset urinary or fecal incontinence • Decrease in functional status • Change in mental status- cognition/affect • Disruptive behavior or personality changes • Frequent falls

  15. Risk factors for polypharmacy Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions Acute illness or changes to medication can lead to problematic polypharmacy • With acute illness, usual medications can cause unanticipated harm • With any change in medications or change in dose, adverse effects can result

  16. Challenges in detecting polypharmacy Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions • Problems due to medications may occur • Without any changes to the medication • Advancing age • Coincident with acute illness or symptoms • ADRs masquerade as age-related changes • Atypical presentation of adverse effects • Side effects difficult to interpret, may go unreported • Prescribing cascade • Infrequent Medication Review • There is a lack of incentive to deprescribe

  17. Detecting problematic polypharmacy Problematic polypharmacy can present in atypical ways, such as … Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions • Exaggerated medication effects • Loss of medication’s effect • Problems with taking medication • New or worsening symptoms or conditions • Decline in functional and self-care abilities • Decline in mobility • Confusion and falls are important clues that resilience is compromised in an older adult and should prompt a search for causes, including medications!

  18. Addressing polypharmacy Assess medication list with an available tool Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions • Explicit criteria – list of potentially inappropriate medications • Implicit criteria or comprehensive assessment • Medication assessment framework

  19. Addressing polypharmacy Explicit criteria – lists of potentially inappropriate medications (PIM), for example Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions • STOPP/START • Suggests drugs to avoid and drugs to use • Beers Criteria List • Suggests drugs to avoid and highlights high alert medications / patients • High alert medications • anticholinergic activity • Benzodiazepines • Tricyclic antidepressants • Warfarin • NSAIDs • Fluoxetine • Digoxin • Oxybutynin • High alert patients • Impaired renal function • Impaired cognition or senses • Falls • Hypotension • Diabetes • Parkinson’s disease • Poor nutrition Age and Aging 2015; 44(2):2013-218 J Am Geriatr Soc 2019;67(4):674-694

  20. Addressing polypharmacy Medication assessment frameworks Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions Other Medication Assessment Frameworks 7-Step Review Process… Dose and frequencyEffectsBenefitRiskIndicationDrug monitoringExpectations • DEBRIDE Tool • Medication Appropriate Index (MAI) • No TEARS • ARMOR Gokula M, Homes H. Clin Geriatr Med 28 (2012) 323–341 DEBRIDE: Medication reviews in long-term care and supportive living. Alberta http://www.cpsa.ca/medication-reviews-long-term-care-supportive-living-physicians-perspective/ MAI: Hanlon JT, et al. MAI J Clin Epidemiol. 1992;45:1045–51 No TEARS: BMJ 2004;329:434 ARMOR: Haque R. Ann Long-Term Care 2009;17:26-30

  21. Addressing polypharmacy Implicit criteria or comprehensive assessment Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions • Health status • Prognosis and goals of care • Benefit – risk assessment of each medication and overall combination of medications

  22. Addressing polypharmacy Limiting potential harms Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions Assess risk for polypharmacy Annual review of medications in all older adults Inform caregivers of medication changes to increase the chance of detecting problems as soon as possible Chose medications with the fewest side effects Stop unnecessary medications Consider the impact of medications on quality of life Consider the person’s ability to take medications and remember to take them

  23. Addressing polypharmacy A practical guide to stopping medication… Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions • 3. Taper Medicine • 4. Check for Benefit or Harm • 2. Reduce or Stop • 1. Recognize the Need one medicine at a time to stop a medicine when appropriate after each medicine has been stopped • At the first visit, halve the dose • At the next scheduled visit review progress, then either: • Maintain (at half dose) • Continue to taper (e.g. quarter dose) • Stop • With the person’s consent, view the discontinuation process as a trial • Time taken to taper may vary from days to weeks to months • If symptoms worsen, may need to reinstate the medication Frank C, Weir E. CMAJ 2014;186(18):1369-1376

  24. Case study: Mary • Mary is 85 years old and has 4 chronic conditions that require 9 medications. No changes to her medications for 5 years. • One month ago a new medication was started. Soon after that, she began to feel unsteady when walking and has been incontinent of urine on 2 occasions because she is not able to get to the bathroom fast enough. One week ago, she fell but only sustained some bruising of her arm. • She is mystified by these new problems and wonders if she is getting old and whether she can stay in her own apartment. She wonders if she should report these problems to her daughter. Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions What’s going through your mind?

  25. Is Mary at risk of problematic polypharmacy? Identify the risk factors in Mary’s case Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions Multiple medical problems/ multiple medications + Reduced homeostatic mechanisms and organ dysfunction + Acute illness or change to medications Frailty AND/OR

  26. Is Mary at risk of problematic polypharmacy? Identify the risk factors in Mary’s case Objectives What is Polypharmacy? Impact for the Older Person Risk Factors Detecting Addressing Case Study Summary Senior Friendly Approach Questions • 4 chronic conditions that require 9 medications: • Prescribing cascade and increasing polypharmacy • Problematic medications left unchanged • Risk of further decline in health status Multiple medical problems/ multiple medications + Reduced homeostatic mechanisms and organ dysfunction Acute illness or change to medications Frailty AND/OR

  27. Is Mary at risk of problematic polypharmacy? Identify the risk factors in Mary’s case Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions • New acute condition may have: • Compromised her homeostatic mechanisms; or  • Worsened her already impaired organ function Multiple medical problems/ multiple medications + Reduced homeostatic mechanisms and organ dysfunction Acute illness or change to medications Frailty AND/OR

  28. Is Mary at risk of problematic polypharmacy? Identify the risk factors in Mary’s case • New health problems not attributed to medications: • Urinary incontinence, via decreased mobility • Fall • Confusion: Mary is unsure if episodes should be reported to daughter • Psychological distress: Mary is worried about ability to live independently Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions Multiple medical problems/ multiple medications + Reduced homeostatic mechanisms and organ dysfunction Acute illness or change to medications Frailty AND/OR

  29. Is Mary at risk of problematic polypharmacy? • Recently been prescribed a new medication for a new condition/acute illness • Usual medications have caused unanticipated harm • Recent medications were not communicated to Mary’s daughter, leading to insufficient health monitoring and reporting • No recent medication review Identify the risk factors in Mary’s case Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions Multiple medical problems/ multiple medications + Reduced homeostatic mechanisms and organ dysfunction Acute illness or change to medications Frailty AND/OR

  30. Case study: Mary - resolution Finally, apply the Medication Review Framework (DEBRIDE) to determine if Mary can benefit from de-prescribing. Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions • Dose and frequency - Is the dose and frequency correct based on age and organ function? • Effects - Have the known side effects been considered? • Benefit - Will Mary benefit from treatment given goals of care? • Risk - Is the medication considered a high risk medication? • Indication- Is the indication for the new medication clear and valid? • Drug monitoring - Is a monitoring plan in place to assess benefit and harm? • Expectations- Are the expectations of benefit to be achieved realistic?

  31. Summary • Polypharmacy is common ≥ 65 years • due to multiple conditions requiring medications • polypharmacy can be appropriate or problematic • Risk of harm increases with # medications, frailty, and illness • inconvenience ……hospitalization………..death • Medication appropriateness may change over time • decline in functional reserves of organs (frailty) • maintenance medications may become harmful • medication changes result in adverse effects or new drug-interactions • Medication appropriateness may change with acute illness • loss of physiologic reserve causes medications to have an enhanced effect Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions

  32. Summary Recognizing problematic polypharmacy is difficult Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions • medication problems can occur without a change in medications • tools are available to structure the medication assessment process • each patient is unique, medication decisions require clinical judgement • all care providers can contribute to medication problem identification and reporting • Benefit/harm ratio can change in an instant or gradually over time. • Regular medication review provides an opportunity to detect problems, adjust doses based on changing physiology and consider medication deprescribing.

  33. Summary Strategies to limit the potential harms due to polypharmacy Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions • Assess polypharmacy risk • Annual review of medications in all older adults • Inform caregivers of medication changes to increase the chance of detecting problems as soon as possible • Chose medications with the fewest side effects • Stop unnecessary medications • Consider the impact of medications on quality of life • Consider the person’s ability to take medications and remember to take them

  34. The senior friendly approach How all healthcare providers can address polypharmacy using a senior friendly care approach Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions • Leadership-supported medication reviews • Providing staff and patient education Organizational Support Organizational Support • Changes in condition prompt a medication review – regardless of patient age Emotional & Behavioural Environment Emotional & Behavioural Environment Processes of Care Processes of Care Ethics in Clinical Care and Research • Medications are meeting the older adult’s goals Ethics in Clinical Care and Research • Facilitate medication reviews • Medication reminder systems to increase adherence Physical Environment Physical Environment

  35. Discussion questions Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions • Which of the strategies to limit the potential harms due to polypharmacy (slide 33) are you already using in your practice? • What are some of the barriers to implementing strategies to limit the potential harms due to polypharmacy (slide 33)? • What is one strategy that you can implement moving forward?

  36. The sfCare Learning Series received support from the Regional Geriatric Programs of Ontario, through funding provided by the Ministry of Health and Long-Term Care. V1 July 2019

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