Deprescribing

Question 1

LOs

Answer 1

• Understand the problems of polypharmacy in the elderly.
• Have an understanding of indication and side effects of commonly used medications in elderly patients to treat conditions such as Atrial Fibrillation, Heart Failure, Hypertension, Osteoarthritis, Diabetes Mellitus, Dementia, incontinence•

Question 2

What is polypharmacy?

Answer 2

The regular use of at least 5 medications

Question 3

What are the risk factors of polypharmacy?

Answer 3

Risk factors:

• Multiple co-morbidities
• Treatment managed by multiple subspecialists
• Residing in long term care
• Chronic mental health conditions
• Age related changes
• Altered pharmacokinetics and pharmacodynamics

Question 4

What are the problems associated with polypharmacy?

Answer 4

• Lower compliance and adherence due to multiple and complex drug regimens
• Increased risk of falls
• Increased emergency department attendances
• Increased hospital admissions

Question 5

What is the link of medications and adverse drug reactions?

Answer 5

• Medication guidelines usually focus on a single disease
  
  • Increased adverse drug reactions
  • Drug-drug reactions
  • Drug-disease reaction
  • Prescription cascade

Question 6

Explain deprescribing

Answer 6

The process of tapering, withdrawing, discontinuing or stopping medications

• Reduce potentially problematic polypharmacy, adverse drug effects and inappropriate or ineffective medication use
• Deprescribing is a therapeutic intervention
• Consider
  
  • Patient goals of therapy (doctor-patient relationship)
  • Views on medications and chronic conditions
  • Patients priorities

Question 7

Explain the anticholinergic burden

Answer 7

• Many commonly used medications block the effects of acetylcholine in the body
  
  • May be used for their anticholinergic effects or may be in addition to primary mode of action.
• Prescribed for a wide range of conditions:
  
  • Parkinson’s disease
  • Overactive bladder
  • COPD
  • Nausea and vomiting
  • Depression
• Effects of these medications cumulates and can be harmful

EXAMPLES OF ANTI-CHOLINERGIC medication

Some drugs, e.g. oxybutynin or hyoscine are used for their anticholinergic effects.

Others have anticholinergic activity not related to their primary mode of action, e.g. ranitidine or carbamazepine. There

Question 8

What drugs to avoid in the elderly and why?

Answer 8

Question 9

Explain the STOPP-START tool

Answer 9

• Screening Tool of Older People’s Prescriptions
• Screening Tool to Alert doctors to Right (i.e. appropriate, indicated) Treatment

STOPP

• NSAIDs (explain)
  
  • Peptic ulcer
  • Hypertension
  • Heart failure
  • Warfarin
  • Renal impairment
  • Long-term use of NSAIDs
  • Long-term use of corticosteroids

START

• DMARDs (with rheumatoid disease)
• Biphosphonates (in patients taking maintenance oral corticosteroid therapy)
• Calcium and Vitamin D (in patients known to have osteoporosis)

Question 10

Case: Tom Jones

• 79 year old man attends ED after a fall at home. He has recently been feeling more unsteady on his feet. He also complains of dry eyes and constipation.
• PMH - COPD, Parkinsons, Overactive bladder.
• DH to follow. NKDA.

What would you do?

Answer 10

• High Anticholinergic burden
• Rationalise medications
• Hold Oxybutynin

Question 11

Common drugs for heart failure and common side effects

Question 12

Common drugs for osteoarthritis and common side effects

Question 13

Common drugs for hypertension and common side effects

Question 14

Common drugs for incontinence and common side effects

Question 15

Common drugs for diabetes mellitis and common side effects

Question 16

Common drugs for dementia and common side effects

Question 17

Common drugs for atrial fibrillation and common side effects