Polypharmacy Adrian Blundell Consultant Geriatrician Hon Assoc Prof University of Nottingham firstname.lastname@example.org Sep 2015
Recipe • Discuss frailty • Propose/describe top tips for more appropriate medication prescribing in older adults • Discuss some practical application of the tips
Context – The > 65 years • 2004 • 461 million people • 2050 • 2 billion people
Guthrie et al. Adapting clinical guidelines to take account of Multimorbidity. BMJ 2012;345:e6341 doi: 10.1136/bmj.e6341
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.
Polypharmacy & Frailty • Polypharmacy is common (30-40% of > 65 year olds)
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
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
Adverse Drug Reactions • Older adults more susceptible to ADRs
Pharmacodynamics • Pharmacokinetics
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
EFFECTIVE SAFE COST Barbers Goals of Good Prescribing PATIENT FACTORS
Exercise 1 • Digoxin • Aspirin • Donepezil • Metformin • Ramipril • Tamsulosin • Amlodipine
Exercise 2 MEDICATION Aspirin Digoxin Latanoprost Movicol Paracetamol PAST MEDICAL HISTORY Hypertension Dementia CKD 3 OA SAH 2002
BP 100/40 Amlodipine Doxazocin Ramipril
Remember some Ethics • Autonomy • Beneficence • Non-maleficence • Justice
Think about the Evidence Is Earl different?
Think about the Evidence • Numbers needed to treat...
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
Health vs Function • We have a better idea of the benefits drugs have to health outcomes vs functional outcomes
Condition A Treatment A + + Condition B Treatment B + + Condition C Treatment C
Interactions • Drug – disease • Drug – drug • Drug – food • Drug – metabolism • Never say Never
Individualise • Recognise the clinical situation i.e. frailty • Personalised medication review • Appropriate prescribing (not deprescribing) • Blister packs • Preparations • Timings