Polypharmacy

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

16. 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

17. Adverse Drug Reactions

18. 5.6% 3-5%

19. 70%

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

21. Pharmacodynamics • Pharmacokinetics

22. 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

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

24. Top tip 1medication mapping

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

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

27. Top tip 2prescribing in the current clinical context

28. BP 100/40 Amlodipine Doxazocin Ramipril

29. Top tip 3confirm the evidence of the diagnosis

31. Top tip 4remember some ethics

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

33. Benefit vs Risk

34. Top tip 5review the evidence in context

35. Think about the Evidence Is Earl different?

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

37. 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

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

39. Top tip 6prescribing in mulitmorbidity

40. Condition A = Treatment A

41. Condition A Treatment A + + Condition B Treatment B + + Condition C Treatment C

42. Top tip 7think side effects & interactions

43. Think Side Effects

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

45. Top tip 8symptom control versus prognostic benefit

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

48. Top tip 9individualise

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

50. Top tip 10monitoring