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Angus Polypharmacy Initiative

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Angus Polypharmacy Initiative

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    1. Angus Polypharmacy Initiative Douglas Lowdon Acute / Community Geriatric Consultant, Angus

    2. Is Polypharmacy a problem ??

    4. Acute Medical Unit admission 101 year old lady Lives alone with carers 4 times/day Admitted with 2 week history of reduced oral intake, nausea, weight loss, reduced mobility and twitching Past medical history MI – Dec 2010. Treated conservatively. Atrial fibrillation Hypertension Type 2 Diabetes Mellitus

    5. Drug History Candesartan 8mg od Clopidogrel 75mg od Aspirin 75mg od Rosuvastatin 10mg od Spironolactone 25mg od Furosemide 20mg od Glipizide 5mg od Metformin 500mg bd Ranitidine 300mg bd Ferrous sulphate 200mg tid Bisoprolol 5mg od Digoxin 125 micrograms od Paracetamol 1g qid Prochlorperazine 5mg bd Recent 3/7 course of trimpethoprim for ?UTI

    6. Examination findings Dehydrated Confused – MSQ 3/10 Bradycardic – 50bpm Hypothermic – temp 35.7 BP 180/40, RR 22, Sa02 100% (air) Globally reduced muscle power Examination otherwise unremarkable

    7. Initial investigations Bloods Na 141 K 8.7 Urea 31.5 Creatinine 222 Digoxin 2.2 LFTs normal CK 53 Lactate 1.0 Bic 12.3 Hb 11.1 WCC 12.9 (neutrophilia) Platelets 228 ABG – partially compensated metabolic acidosis ECG – sinus bradycardia 50bpm Deep anterior Q waves and poor R wave progression in chest leads Digoxin effect V5-6

    8. Diagnosis and Management Acute kidney injury with severe hyperkalaemia Digoxin toxicity Management Nephrotoxics stopped IV fluids IV Calcium gluconate Insulin/dextrose infusions Salbutamol Medication review

    9. Medication Review 11 medications discontinued: Nephrotoxics & diuretics stopped due to AKI/hyperkalaemia Digoxin & bisoprolol stopped to bradycardia Metformin stopped due to acidosis Rosuvastatin & Clopidogrel – no evidence in age group Ranitidine Ferrous sulphate Prochlorperazine Discharge medications – aspirin, glipizide, domperidone

    10. Medication Review 11 medications discontinued: Nephrotoxics & diuretics stopped due to AKI/hyperkalaemia Digoxin & bisoprolol stopped to bradycardia Metformin stopped due to acidosis Rosuvastatin & Clopidogrel – no evidence in age group Ranitidine Ferrous sulphate Prochlorperazine Discharge medications – aspirin, glipizide, domperidone BUT re-admission 10 days later with Cardiac Failure, so diuretic and candersartan re-introduced

    11. Why is Polypharamcy so common in the elderly?

    12. Why is Polypharamcy so common in the elderly?

    13. “Doctors are men who prescribe medicines of which they know little, to cure diseases of which they know less, in human beings of whom they know nothing” ?- Voltaire

    14. South Angus Polypharmacy Initiative

    15. Angus Polypharmacy Initiative 1. Care Home annual joint medication reviews 2. Polypharmacy reviews of patients aged older than 75 years and on 12 or more medications

    16. How to do Community Polypharmacy review Gold standard would be in conjunction with patients own Practitioner and Practise pharmacist: GP buy-in to allow optimal drug changes Helps Practise Pharmacists in future to influence GP prescribing behaviour Educational element – three way Additional information Increase patient trust and satisfaction Community / locality Geriatrics

    17. How to do Community Polypharmacy review In conjunction with patients own Practitioner and ideally Practise pharmacist: GP buy-in to allow optimal drug changes Helps Practise Pharmacists in future to influence GP prescribing behaviour Educational element – three way Additional information Increase patient trust and satisfaction Community / locality Geriatrics Patient in attendance and ideally with relative

    18. How to do Polypharmacy review In conjunction with patients own Practitioner and ideally Practise pharmacist: GP buy-in to allow optimal drug changes Helps Practise Pharmacists in future to influence GP prescribing behaviour Educational element – three way Additional information Increase patient trust and satisfaction Community / locality Geriatrics Patient in attendance and ideally with relative Secondary care notes in attendance Patient drugs in attendance too !!!!!!!!!!!!!!!!!

    19. How to do Polypharamcy review in older people STOPP (Screening Tool of Older Peoples’ Potentially In-appropriate Prescriptions) Age and Ageing 2008, Gallagher P, O Mahoney D NSAIDS, especially heart failure, renal disease and previous peptic ulcer disease Alpha blockers, especially in heart failure Anti-muscarinics Sedatives, in particular benzodiazepines Opiate analgesia Warfarin and anti-platelet combinations PPIs and C diff ?? ………………………………

    20. How to do Polypharamcy review in older people START ACE inhibitors and BBlockers in left ventricular dysfunction Warfarin in Atrial fibrillation Bisphosphonates for osteoporosis Ensure patients in Calcium and Vitamin D adjunct therapy also Clopidogrel post stroke (stop aspirin and dipyridamole) ………………………..

    21. How to do Polypharamcy review in older people Preventative medication Patients choice Side effects Drug load Compliance Life expectancy and co-morbidity

    22. How to do Polypharamcy review in older people Preventative medication Patients choice Side effects Drug load Compliance Life expectancy and co-morbidity Efficiency savings Atorvostatin change Risedronate change Tramadol MR change Lormetazepam change Ferrous sulphate change etc

    23. How to do Polypharamcy review in older people Compliance Minimal numbers medications Minimal timings of medications Assess drug administartion i.e “How do you take your weekly tablet for osteoporosis ?”

    24. South Angus Polypharmacy Initiative 1. Care Home annual joint medication reviews 2. Polypharmacy reviews of patients aged older than 75 years and on 12 or more medications Integrated review with Practise Pharmacist, General Practitioner and South Angus locality Medicine for the Elderly Geriatric Consultant

    25. 1. Outcomes of Annual Care Home medication reviews Data from 34 reviews 1. Number medications stopped = 46 (1.4 medictions per patient) Started, or changed = 11

    26. Outcomes of Annual Care Home medication reviews Data from 34 reviews 1. Number medications stopped = 46 (1.4 medictions per patient) Started, or changed = 11 i) 41 % (19/46) Preventative medications no longer appropriate Statin 8/19 7/19 Aspirin Osteoporosis treatment 4/19 ii) 22% (10/46) Antidepressants/ Antipsychotics / Sedatives iii) 15% (7/46) Analgesia, usually codeine based

    27. Outcomes of Annual Care Home medication reviews Data from 34 reviews 1. Number medications stopped = 46 (1.4 medictions per patient) Started, or changed = 11 i) 41 % (19/46) Preventative medications no longer appropriate Statin 8/19 7/19 Aspirin Osteoporosis treatment 4/19 ii) 22% (10/46) Antidepressants/ Antipsychotics / Sedatives iii) 15% (7/46) Analgesia, usually codeine based

    28. Outcomes of Annual Care Home medication reviews Data from 34 reviews 1. Number medications stopped = 46 (1.4 per patient) Started, or changed = 11 2. Nursing time saved from drug administration = 50 minutes per day (1.5 mins per day, per patient reviewed)

    29. Outcomes of Annual Care Home medication reviews Data from 34 reviews 1. Number medications stopped = 46 (1.4 per patient) Started, or changed = 11 2. Nursing time saved from drug administration = 50 minutes per day (1.5 mins per day, per patient reviewed) 3. Cost savings: Ł 3740 per annum (Ł110 per patient per year)

    30. Care Homes visited so far Joint reviews: Roughly South Angus locality Care Home >200 patients : Antiquarry house (SpringWest NH LES patients with Ledlie) x 2 years Camus House (Carnoustie MC patients with Dr Webster) Kendale, Tarriebank and Monkbarns (SpringWest patients with Dr Ledlie) Cairnie Lodge (SpringEast LES patients with Dr Meachan and Dr Veitch) Lunan Court and Cairnie Lodge (SpringWest patients with Dr Ledlie) South Grange (Monifieth HC LES patients with Dr Whyte) Cairnie Lodge (SpringEast LES patients with Dr Riaz) Lunan court (SpringEast LES patients with Dr Raitt)

    31. National and Tayside direction British Geriatric society Meet 2nd June 2011 Development of Scottish Community Geriatric Services Recommendation that Geriatrician be involved in ALL Care Home annual Polypharmacy review. Meeting about Future of Tayside Nursing HomeLES 9th June 2011 Recommendation that ALL Care Home annual medication reviews have Geriatrician input.

    32. Angus Polypharmacy Initiative 1. Care Home annual joint medication reviews 2. Polypharmacy reviews of patients aged older than 75 years and on 12 or more medications Integrated review with Practise Pharmacist, General Practitioner and South Angus locality Medicine for the Elderly Geriatric Consultant

    33. 2. Springfield West medications reviews Patients aged over 75 years 12 or more repeat medications 96 patients Weekly Clinics in practise, 8 patients per clinic (30 minute slots) GP, Geriatrician and Practise Pharmacist Patient and relative

    34. 2. Springfield West medications reviews Patients aged over 75 years 12 or more repeat medications 96 patients = 1000-1500 patients per 100,000 population !!! Weekly Clinics in practise, 8 patients per clinic (30 minute slots) GP, Geriatrician and Practise Pharmacist Patient and relative

    35. 2. Springfield West medications reviews. Outcomes: August 2010; 96 patients aged over 75 years on 12 or more medications May 2011; 56 patients over 75 years on 12 or more medications 42 % reduction 8 / 96 patients had no drug reductions (<10% patients)

    36. 2. Springfield West medications reviews. Outcomes: Outcomes from 10 Clinics: Patients reviewed jointly = 77 (7.7 per clinic) Medication stopped = 181 (2.3 per patients) Medication initiated = 33 (0.4 per patient) Dose changes = 49 (0.6 per patient) ·   

    37. 2. Springfield West medications reviews. Outcomes: Outcomes from 10 Clinics: Patients reviewed jointly = 77 (7.7 per clinic) Medication stopped = 181 (2.3 per patients) Medication initiated = 33 (0.4 per patient) Dose changes = 49 (0.6 per patient) ·    Co-codamol Atorvostatin ·     Felodipine Quinine ·     Alendronic acid Simvastatin ·     Aspirin Dipyridamole ·     Calcichew Omeprazole ·     Amlodipine ·     Lactulose ·     Clopidogrel ·     Contour biosensor strips ·     Isosorbide mononitrate

    38. 2. Springfield West medications reviews Outcomes Patient satisfaction survey 40 patients: ‘It was helpful to discuss my mother-in-laws attitude towards her medication’ ‘It was good to be able to air my health concerns’ ‘I found that an interest was being taken in my long term medication’ ‘Felt the process was very worthwhile. Changing circumstances has allowed a more streamlines approach to medication’ ‘I feel as if the doctors care’ ‘ I feel less lethargic and more energetic’ ‘I am feeling more stable with my tablets I am now on’

    39. 2. Springfield West medications reviews Outcomes Patient satisfaction survey: 40 patients: 90 % felt appointment was helpful 79% felt they understood their medications better 26 % subjectively felt better after 6 weeks

    40. 2. Springfield West medications reviews Outcomes Financial Cost per clinic (including 1 session MFE) = Ł550 Prescribing savings per patient = Ł132 x 8 patients x 6-7 years = Ł6864 Savings per clinic = Ł6314

    41. 2. Springfield West medications reviews Financial Cost per clinic (including 1 session MFE) = Ł550 Prescribing savings per patient = Ł132 x 8 patients x 6-7 years = Ł6864 Savings per clinic = Ł6314 1500 patients older than 75 years, on 12 or more medication in Angus Potential of nearly 200 such clinics ……

    42. 2. Springfield West medications reviews Additional Benefits Education - Staff learning from each other i.e. GPs being educated how to prescribe like their locality Geriatrician. Geriatrician thinking and understanding like GP Trust – staff and patients spend time together and so eases relationships for future cases Non-medication assessment – Almost every patient during consultation had additional assessment : Blood pressure, examination, MFE, Osteoporosis, diabetes, update GP registers (dementia, cancer) etc….

    43. 2. Springfield West medications reviews Additional Benefits Education - Staff learning from each other i.e. GPs being educated how to prescribe like their locality Geriatrician. Geriatrician thinking and understanding GP Trust – staff and patients spend time together and so eases relationships for future cases Non-medication assessment – Almost every patient during consultation had additional assessment : Blood pressure, examination, MFE, Osteoporosis, diabetes, update GP registers (dementia, cancer) etc…. Integration – Primary and Secondary Care staff working together in-order to deliver integrated care for complex older patient in their own home

    44. 2. Springfield West medications reviews Additional Benefits Education - Staff learning from each other i.e. GPs being educated how to prescribe like their locality Geriatrician. Geriatrician thinking and understanding GP Trust – staff and patients spend time together and so eases relationships for future cases Non-medication assessment – Almost every patient during consultation had additional assessment : Blood pressure, examination, MFE, Osteoporosis, diabetes, update GP registers (dementia, cancer) etc…. Integration – Primary and Secondary Care staff working together in-order to deliver integrated care for complex older patient in their own home COMMUNITY GERIATRICS

    45. Polypharmacy Pan-Tayside

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