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Problems of Polypharmacy

Problems of Polypharmacy. Dr Nivi Singh Elderly Care Department. Definition. Multiple drug use by patients 4 or more medications. Elderly. Medication use increases with age Over 60s - 19% of the population 57% of dispensed prescriptions Over 70s - 20% taking > 5 medications. Causes.

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Problems of Polypharmacy

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  1. Problems of Polypharmacy Dr Nivi Singh Elderly Care Department

  2. Definition • Multiple drug use by patients • 4 or more medications

  3. Elderly • Medication use increases with age • Over 60s - 19% of the population • 57% of dispensed prescriptions • Over 70s - 20% taking > 5 medications

  4. Causes • Appropriate • Inappropriate

  5. Appropriate • Multiple medical problems • New drugs for previously untreatable dx • Proof of efficacy of treatment in elderly

  6. Usually/always Inappropriate Multiple drug prescribers • Direct relationship btn the number of prescribing physicians and the incidence of ADRs • Non-medical prescribing No regular medication review Prescribing cascade Prescribing of drugs that are not indicated

  7. Patient factors • Inaccurate drug history • Underreporting of symptoms • Hoarding medications • Reluctance to discontinue medication

  8. Associations • Adverse drug reactions • Reduced compliance - > 2daily doses or >3 different drugs • Poor quality of life • High rate of symtomatology • Hospital admission • Longer length of stay

  9. Associations • Increased mortality • Readmission on discharge • Drug expense

  10. Adverse Drug Reaction A response to a drug that is: noxious and unintended occurs in doses normally used for the treatment, prophylaxis, or diagnosis of disease, or the modification of physiological function(WHO)

  11. ADRs • Increase morbidity and mortality • Underestimated • Implicated in ~17% hospital admissions • ~30% of elderly pts exposed to drugs that may interact with one another

  12. ADRs The most consistent risk factor for an ADR is: Number of drugs being taken ADR rate 1.2% with 1 drug 10% with 9 drugs 50% with 10 drugs

  13. Mechanisms of altered drug response in the elderly

  14. Changes with age Altered drug pharmacokinetics • changes in absorption, distribution, metabolism and excretion Altered drug pharmacodynamics • altered tissue sensitivity

  15. Volume of Distribution • Increased % of body fat • Reduced lean body mass • Reduced total body water (15%)

  16. Changes in protein binding Decrease in plasma proteins • reduced protein bound (inactive) drug • greater amount of free (active) drug • increased drug effect, potentially resulting in toxicity

  17. Metabolism • Reduction in hepatic blood-flow and mass • Hepatic clearance of many drugs is reduced • Care - drugs with a narrow therapeutic range that are metabolised by the liver (eg. warfarin, phenytoin, theophylline)

  18. Excretion • Fall in GFR and creatinine clearance • Reduces elimination of many drugs • Care - narrow therapeutic range drugs eliminated partially or totally by the kidney (eg. digoxin, lithium and aminoglycoside antibiotics)

  19. Pharmacodynamics • Changes occur in end-organ responsiveness to medications • Due to alterations in receptors and homeostatic mechanisms • e.g. an increased receptor response is seen for benzodiazepines, opiates, and warfarin • Increased likelihood of an ADR

  20. Drugs that commonly produce adverse effects in elderly

  21. Categories of medication

  22. Recognising ADRs • Constipation • Confusion • Dizziness • Depression • Incontinence • Nausea • Unsteadiness

  23. Falls Increased risk of falls • Polypharmacy is a marker of underlying comorbidity • High risk medications

  24. Benefits of reducing polypharmacy • Reduced ADRs • Improved compliance • Improved patient quality of life • Reduced hospital admissions • Lower risk of drug interactions • Fewer drug errors • Reduced prescribing costs

  25. NSF • Gain the max benefit from their medication to increase their quality and duration of life • Avoid excessive, inappropriate, or inadequate consumption of medicines

  26. Solutions

  27. Basic principles of good prescribing • Accurate diagnosis • Non-pharmacological agent • Start with lowest dose – Start low; Go slow • Consider potential side-effects and their impact • Review entire medication regimen

  28. Regular medication review • >4 medications 6-monthly review • < 4 medications annual review • Full drug history • Over-the-counter medication • Alternative drug therapies

  29. Alternative drug therapies • Gingko, garlic and ginseng – all interact with warfarin and possibly aspirin • Alcohol - exacerbates drug-induced hypotension or sedation • Many commonly prescribed medications have the potential to interact with alcohol

  30. Medication Review • Identify unnecessary drugs • Review dose • Once daily / once weekly formulations

  31. Medication Review • Non-pharmacological interventions • Enlist family/friends as needed • Medication organisation equipment • Variety of healthcare professionals • Information technology

  32. Patient Education • Written information • Take drugs as prescribed • Do not use medication from others • Report symptoms • Report all drugs used

  33. Conclusion • Common and growing problem • Inappropriate and appropriate prescribing • Benefits of reducing the drug burden • Regular medication review • Not always avoidable –minimise unnecessary multiple drugs

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