When to Spare Some Pharmaceutical Care

1. When to Spare Some Pharmaceutical Care Jovino Hernandez PharmD Clinical Manager Winter Haven Hospital Pharmacy Services

2. Goals • Recognize the incidence of polypharmacy • Identify The Risk Associated with Polypharmacy • Classify Agents that Pose the Most Risk to the Elderly Population • Develop Strategies to Decrease Polypharmacy

3. Introduction • All drugs can be considered “poisons” • The more we ingest, the more apt we are to have issues • Clinical guidelines often call for multiple medications • Appropriate medication use beneficial to patients • Challenge is not to tip the scale toward adverse events

4. What is Polypharmacy? • Usually described numerically as five or more prescribed medications at any time • European Project AgeD in Home Care (ADHOC) uses 9 or more medications or • Administration of more medications than clinically indicated

5. Our Aging Population • Chronic Diseases are on the rise • Multiple Medications are often used to treat chronic illness • Sharp rise in aging population • 300% Rise in elderly disabled in North America by 2050 • Average North American over the age of 60 years has 2.2 chronic diseases

6. Our Aging Population

7. Statistics

8. Statistics

9. Statistics • Average elderly patient in community consumes 4 medications daily • Average elderly patient in a nursing home consumes 7 medications on average

10. Risk Factors • Advanced Age • 13% of US population • Account for 33% of prescription and 40% on nonprescription use • Female • 57% of women greater than 65 years take at least 5 medications • 12% take at least 10 • Low Education Level • Multiple Morbidities • Average adult over 60 years has 2.2 chronic conditions • Often based off of evidence based medicine • Core Measures • Depression • Multiple Prescribers • Frailty

11. Risk Factors (Prescriber) • Practice Environment • Low number of listed patients • High Workload • Low rate of admission to hospital • High practice prescribing rate • High average number of prescribed medications • Lower prevalence in female prescribers • No association with age or duration of practice

12. Risk Factors (Prescriber) • Medical Guidelines • Intended to support physicians in their drug choice • Usually focus on one disease state • Tend generate more drug therapy especially when compounded • Examples: CHF, AMI, COPD

13. Risk Factors (Prescriber) • Prescribing Habits • Dominate perception that diseases should be treated with drugs • A visit to a provider should end with a prescription • Can lead to a medical cascade of prescribing

14. Risk Factors (Prescriber) • Physician Behavior • Failure to make a proper medical review • Poor communication amongst prescribers • Mistrust of guidelines that decrease medications use (Antibiotics)

15. Risk Factors (Patient to Prescriber) • Good interaction essential • Reviews of entire medication list with provider is essential • Personnel continuity • Multiple providers and pharmacies increase the risk of polypharmacy

16. Risk • Polypharmacy Associated With • Poor Adherence • Inappropriate Prescribing • Adverse Drug Reactions • Drug Interactions • Geriatric Syndromes • Morbidity/Mortality

17. Poor Adherence • Nonfulfillment • Prescribed but never filled • Nonpersistence • Patients decides to stop taking without being advised be health professional • Nonconforming • Incorrect Dosing • Skipping Doses • Incorrect times

18. Inappropriate Prescribing • The use of medications that introduce a greater risk of adverse drug-related events where a safer, as-effective, alternative therapy is available to treat the same condition. • Includes • Use of medicines at a higher frequency • Longer then clinically necessary • Drug-Drug Interactions • Underuse of clinically relevant medications

19. Adverse Reactions • An unfavorable medical event related to medication misuse or • Noxious or unintended response t medication despite appropriate drug dosage or prophylaxis, diagnosis or therapy of medical conditions

20. Adverse Reactions • 4.3 million ADR related health care visits in 2005 • Occur in up to 35% of elderly patients in outpatient setting • Account for 10% of ER visits

21. Adverse Reactions • Higher amount of meds, higher rate of ADRS • 2 Meds 13% • 5 Meds 58% • 7 or more Meds 82%

22. Adverse Reactions • Most Common Classes • Cardiovascular • Diuretics • Anticoagulants • NSAIDs • Antibiotics • Hypoglycemic

23. Drug Interactions • Elderly at risk • Comorbidities • Nutritional Status • Number of drug interactions increase as number of morbidities and medications increase • Often more medications are added to treat these issues that further complicate problems

24. Geriatric Syndromes • Cognitive Impairments • Medications implicated in up to 39% of cases • Four or more medications added the day before a delirium episode is a risk factor • Finnish Study on Cognitive Impairment • No Polypharmacy – 22% risk • Polypharmacy – 33% Risk • Excessive Polypharmacy – 54% Risk

25. Geriatric Syndromes • Cognitive Impairments (cont) • Delerium • Opiods • Benzodiazepines • Anticholinergics • Dementia • Benzodiazepine • Anticonvulsants • Anticholinergics • Tricyclic Antidepressants

26. Geriatric Syndromes • Falls • Increase morbidity and mortality • Cardiovascular, Psychotropic • Urinary Incontinence • Diuretics • Psychotropics • Opioids • Sedatives

27. Geriatric Syndromes • Nutrition • Associated with poorer nutritional status • Decreased intake of soluble and nonsoluble fiber, fat soluble vitamins, B vitamins and minerals • Increased intake of cholesterol, glucose and sodium

28. Medications (Beers) • Updated in 2012 • Goal • The goal of the 2012 AGS Beers Criteria is to improve care of older adults by reducing their exposure to potentially inappropriate medications (PIMs) • Improving selection of drugs • Evaluating patterns of drug use within population • Educating on proper drug use • Evaluating health-outcome, quality care, cost, and use data

29. Medications (Beers) • Three Categories • Potentially inappropriate medications and classes to avoid in older patients • potentially inappropriate medications and classes to avoid in older adults with certain diseases and syndromes • medications to be used with caution in • older adults

35. Preventions • Barriers • Clinician uncomfortable with changing or discontinuing • Particularly medication prescribed by another clinician • Little evidence based support on discontinuing medications • Patients psychologically or physical dependant on medication • Discontinuing medication perceived as inadequate care

36. Prevention • Barriers (cont) • Potential harms such as adverse drug withdrawal events (ADWEs) • Clinically significant symptoms or signs likely caused by medication cessation • Cardiovascular and CNS classes most common

37. Prevention • Considerations • Duration of each medication • Is there still an indication for each medication • Are indications consistent with current guidelines • Adherence • If patient well without taking, pointless to continue prescribing

38. Prevention • Prescribing cascade • Discontinuing medication may reveal adverse effects of other therapies • Very little evidence to guide withdrawal process for polypharmacy • A gradual tapering is often recommended

39. Prevention • Clinical Controlled Trials • Medication Reviews by pharmacist • Prescriber Education Programs • Academic detailing • Comprehensive geriatric assessments • Multidisciplinary interventions engaging prescribers and pharmacists

40. Prevention • Nurses Role • Information • Instruction • Organization

41. Prevention • Information –Discuss with patients • Keep an accurate list of medications • Keep complete list of medical providers and contact information • Post the name and telephone number of local pharmacy

42. Prevention • Instruction: Teach patients about • Each medication, including name, appearance, purpose and effects • Potential adverse effects and interactions of each medication • Importance of contacting healthcare provider with concerns and questions • Potential drug –related problems that warrant emergency care

43. Prevention • Instructions (continued) • Importance of taking medications exactly as directed • Importance of using only one pharmacy to obtain drugs

44. Prevention • Organization: To help manage drugs • Avoid sharing medications • Store medication in secure dry area away from sunlight • Refrigerate if necessary • Dispose of old medications properly

45. Prevention • No single approach extensively studied • Prescribing and impact on outcomes inconsitent throughout studies • Best approach is probable a combined approach • Patient needs to be involved in the process

47. Where Are We Now? C. difficile Outbreak Causes Concern At Local Hospital Tuesday June 3, 2008 CityNews.Ca Staff No charges over C. diff outbreak No-one is to face charges in connection with an outbreak of Clostridium difficile which left 90 people dead.

48. Quebec 2004 • March 2003 a rise of severe CDAD in Montreal and regions in Quebec1 • 12 Hospitals studied over 6 months in 2004 • 1719 cases reviewed Logo LG, Porier L, Miller Ma, et al, A predominantly clonal multi-institutional outbreak of Clostridium difficile-associate diarrhea with high morbidity and mortality, N Engl J Med 2005;353:2442-9

49. Quebec 2004Age Logo LG, Porier L, Miller Ma, et al, A predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality, N Engl J Med 2005;353:2442-9

50. Quebec 2004Antibiotics Logo LG, Porier L, Miller Ma, et al, A predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality, N Engl J Med 2005;353:2442-9