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Polypharmacy

Polypharmacy

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Polypharmacy

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  1. Polypharmacy Adrian Blundell Consultant Geriatrician Hon Assoc Prof University of Nottingham adrian.blundell@nuh.nhs.uk Sep 2015

  2. Recipe • Discuss frailty • Propose/describe top tips for more appropriate medication prescribing in older adults • Discuss some practical application of the tips

  3. Context – The > 65 years • 2004 • 461 million people • 2050 • 2 billion people

  4. http://www.goldstandardsframework.org.uk/cd-content/uploads/files/General%20Files/http://www.goldstandardsframework.org.uk/cd-content/uploads/files/General%20Files/ Prognostic%20Indicator%20Guidance%20October%202011.pdf

  5. Complexity versus Simplicity

  6. Guthrie et al. Adapting clinical guidelines to take account of Multimorbidity. BMJ 2012;345:e6341 doi: 10.1136/bmj.e6341

  7. Boyd CM et al. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA 2005; 294: 716–24.

  8. Telephoto

  9. Telephoto Panoramic

  10. Polypharmacy Multimorbidity

  11. Frailty

  12. Clegg et al. Frailty in elderly people. Lancet 2013; 381: 752–62

  13. Polypharmacy & Frailty • Polypharmacy is common (30-40% of > 65 year olds)

  14. A treatment paradox • Drugs are needed to treat LTCs • Older people with frailty have more LTCs • “Lots of drugs” is a risk factor for frailty • A new drug can precipitate a decline in a frail individual (ADR) • “Lots of drugs” is a risk factor for ADRs

  15. A treatment paradox • Frail older people need drugs to treat their long term conditions • Frail older people don’t need drugs as it can worsen their frailty

  16. Adverse Drug Reactions

  17. 5.6% 3-5%

  18. 70%

  19. Adverse Drug Reactions • Older adults more susceptible to ADRs

  20. Pharmacodynamics • Pharmacokinetics

  21. Why are older people at high risk of ADRs? Some determinants of preventable medication-related hospital admissions • Impaired cognition (OR 11.9) • Four or more co-morbidities (OR 8.1) • Dependent living situation (OR 3.0) • Impaired renal function (OR 2.6) • Non-adherence to medication regimen (OR 2.3) • Polypharmacy (OR 2.7) HARM Study: ARCH INTERN MED/VOL 168 (NO. 17), SEP 22, 2008

  22. EFFECTIVE SAFE COST Barbers Goals of Good Prescribing PATIENT FACTORS

  23. Top tip 1medication mapping

  24. Exercise 1 • Digoxin • Aspirin • Donepezil • Metformin • Ramipril • Tamsulosin • Amlodipine

  25. Exercise 2 MEDICATION Aspirin Digoxin Latanoprost Movicol Paracetamol PAST MEDICAL HISTORY Hypertension Dementia CKD 3 OA SAH 2002

  26. Top tip 2prescribing in the current clinical context

  27. BP 100/40 Amlodipine Doxazocin Ramipril

  28. Top tip 3confirm the evidence of the diagnosis

  29. Top tip 4remember some ethics

  30. Remember some Ethics • Autonomy • Beneficence • Non-maleficence • Justice

  31. Benefit vs Risk

  32. Top tip 5review the evidence in context

  33. Think about the Evidence Is Earl different?

  34. Think about the Evidence • Numbers needed to treat...

  35. Think about the evidence • Frail, older adults often not in the trial • Outcomes are not usually frailty specific e.g. falls, fractures • Trials are rarely about stopping drugs • S/Es may not be highlighted • The effects of drugs will be different in multimorbidity

  36. Health vs Function • We have a better idea of the benefits drugs have to health outcomes vs functional outcomes

  37. Top tip 6prescribing in mulitmorbidity

  38. Condition A = Treatment A

  39. Condition A Treatment A + + Condition B Treatment B + + Condition C Treatment C

  40. Top tip 7think side effects & interactions

  41. Think Side Effects

  42. Interactions • Drug – disease • Drug – drug • Drug – food • Drug – metabolism • Never say Never

  43. Top tip 8symptom control versus prognostic benefit

  44. Holmes HM et al. Arch Intern Med 2006;166:605-9

  45. Top tip 9individualise

  46. Individualise • Recognise the clinical situation i.e. frailty • Personalised medication review • Appropriate prescribing (not deprescribing) • Blister packs • Preparations • Timings

  47. Top tip 10monitoring