Response to symptoms by Community Pharmacists

1. Response to symptoms by Community Pharmacists Andrew McLachlan Faculty of Pharmacy University of Sydney Centre for Education and Research in Ageing, Concord Hospital

2. This session.. • Sentinel symptoms of concern • Frailty as a symptom • Multiple medications • Risk assessment to inform management • Importance of a comprehensive history

3. “ 90% of the diagnosis is in the history” • Look and Listen • Careful review of precipitating factors

4. Mr NL • 78 year old man • Lives alone, supportive nephew nearby • Mobilises with wheelchair • eGFR 60 ml/min/1.73 m2 • Assistance with shopping, cleaning and cooking

5. Mr NL Presents with • decreased mobility (ataxia) and confusion

7. Symptoms not to ignore Unexplained weight loss • common feature of many chronic underlying illnesses (cancers, chronic infections, depression). Persistent fever (> 37.5 oC) • chronic underlying infection, cancer or some other illness Unexplained changes in bowel habits • bowel disease like inflammatory bowel disease or cancer. • gastrointestinal disorders like ulcers, cancers and infections.

8. Symptoms not to ignore Confusion • behaviour change, disorientation, hallucinations • low blood sugar, side effects of drugs, possible head injury or a psychiatric condition. Shortness of breath • lung or heart disease. Flashing lights • retinal detachment Hot, red or swollen joints • arthritis or joint infection.

9. Symptoms not to ignore Chest pain • crushing and radiating, suspect heart disease. • Sweating and difficulty breathing. Sudden unexplained headaches • fever, stiff neck, rash, mental confusion, seizure, vision changes, weakness, numbness, or speaking difficulties. Sudden loss of function • weakness or numbness of the face, arm, or leg • loss of speech, blurring or loss of vision. • stroke or a transient ischaemic attack – urgent treatment is needed.

12. Mr NL • 78 year old man • Lives alone, supportive nephew nearby • Mobilises with wheelchair • Assistance with shopping, cleaning and cooking

13. Mr NL Admitted to Hospital with • decreased mobility (ataxia) and confusion On examination • UTI • hyperkalaemia • hyponatremia

14. Medical history from carer and GP Parkinson’s disease ischemic heart disease hypertension schizophrenia previous fall previous episode of delirium previous suspected TIA Gout Vision impairment MMSE: 25/30 eGFR 60 ml/min/1.73 m2 Mr NL

15. Medicines on Admission

16. First rule of geriatric medicine Old + sick = adverse drug reaction Prof David Le Couteur, Concord Hospital

17. Jerry Avorn

18. Adverse drug reactions Oldest old ADRs increase Repeat admission increasing Zang et al, Repeat adverse drug reactions causing hospitalization in older Australians: a population-based longitudinal study 1980–2003. Brit J Clin Pharmacol 2007

19. Adverse effects in older patients Reduction in organ function Altered pharmacokinetics Altered pharmacodynamic Reduced homeostatic function Adverse effects Multiple diseases Multiple medications Poor adherence

20. anticholinergic agents anticonvulsants (phenytoin, carbamazepine) antiparkinsonian agents (levodopa, pergolide) antipsychotics opiods (esp pethidine) benzodiazepines corticosteroids some CV medicines (digoxin, metoprolol, propranolol) NSAIDs (incl COX-2 selective agents) H2 blockers some anti-infectives (ciprofloxacin, aciclovir, cotrimoxazole) Medications which may worsen cognition or cause confusion

21. Medicines on Admission

22. First rule of geriatric medicine Old + sick = adverse drug reaction Second rule of geriatric medicine Everything is complicated: multifactorial and multiple comorbities Prof David Le Couteur, Concord Hospital

23. Frailty Drug interactions Environmental factors Renal disease Obesity pregnancy Genetic differences Age Hepatic disease Others diseases Pharmacokinetics Pharmacodynamics Variability in Drug Response Adherence Pharmacodynamic monitoring Therapeutic drug monitoring Dose individualisation

24. TDM • integral role in pharmacotherapy • (in age care) valuable tool in • optimising dose selection • medication safety • ADR identification and management

25. Chronological “age” Functional “age” Old Oldest old Frail old How old is old…..

26. Frailty Complex or phenotype………consisting of • Decreased mobility (walk time) • Reduced strength (eg grip strength) • poor nutritional status (weight loss) • Exhaustion • Declining physical activity ……………..increased number of medicines Fried et al . Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001; 56, M146-56

27. "It is not age that is at fault but rather our attitudes toward it" Cicero, Essay on Old Age, 73 B.C.

29. Clinically Significant Drug Interactions Three basic ingredients are needed • 2 drugs • 1 patient …..all of these can impact on the significance

30. Who is at risk from serious drug interactions? • Older and very young people • multiple medications • multiple prescribers • multiple disease states • chronic and serious illness • changes in organ function

31. Medications on CRGH admission n = 42

32. Clinical Significance of drug Interactions • Patient characteristics • Nature of pharmacodynamic response • Mechanism of drug interaction • Safety margin of the interacting drugs • Size of the dose • Duration of therapy • Time course of drug interaction • Order and timing of administration ……my “current” working list

33. The short answer…. • The interactions that are likely to lead to significant misadventure in your patients • This will differ from practice to practice • We can focus on the drugs….. • But it’s the people we give them to that determines the significance of a drug-drug interaction

35. Summary • Know and recognise sentinel symptoms of concern • Frailty is an important predictor of risk • Multiple medications need to be managed • Risk assessment informs management • Taking a comprehensive history is essential

36. Mr NL On discharge (1 month) Ceased • Levodopa- no clear beneficial response • Benzotropine- contributing to confusion • Aspirin - risk without clear benefit • Indapamide - ceased and restarted Dose reduction • oxazepam, olanzapine and mirtazipine UTI and electrolyte disturbance resolved