IC1 (CFS) Flashcards
medication appropriateness index (MAI)
- indication of drug — NEEDS vs WANTS
- effectiveness —- taken before? guidelines?
- DDI/ Drug-disease interaction
- dose, directions
- unnecessary duplication
- duration of therapy
- least expensive alternative
missing from MAI
- Untreated indications
- ADR
- Failure to receive drugs
Reasons for prevalence of DRP (elderly > youths)
- Cognitive impairment
a. Short term memory loss
b. Cognitive impairment
= Poor safety awareness, poor historian, confused state
= Require hx from gamily - Presentation of medical symptoms differs in elderly
a. Infections (not febrile –> change in behaviour, confused, slower to respond, drowsy, FALL)
b. MI, stroke (not chest pain –> stomach pain, nausea, drowsy) - Prevalence of SE
a. More likely to be affected by SE, more receptor sensitive
b. Changes in PK, PD
= antiHTN: Postural hypotension
= Antidep: SIADH
Drug-related problems definition criteria
○ Drug-related
○ Affect outcomes (significant)
Pharmaceutical care checklist:
help pt achieve what matters to them most by address DRP
1) Present medications are appropriate - CURRENT MEDS
2) Appropriate medications present - CORRECT MEDS
3) Appropriate medications reach the patients - ADHERENCE
- Failure to receive drugs
□ Appropriate drug
□ Non-adherence/ poor technique
□ Storage (bisphosphonate, INHaler)
□ Inappropriate use (INH)
□ Intrinsic: Health beliefs, ignorance, cognitive impairment.
classification of DRPs
- indication related (untx, improper selection, no indication)
- dose related (over/ under)
- ADR (pt specific outcome)
- interactions (DDI, DFI, Drug-lab)
pharmaceutical care framework
(recognise DRP)
MEIS
- what maters most/ impt to pt
- explicit/ HAM
- implicit criteria (weight cost-benefit)
- successful delivery of appropriate drugs
- what maters most/ impt to pt
- Needs and wants – to patient and caregiver
- Consider inpatient vs ambulatory
(inpatient) : stabilise pt, vital signs, maintain disease state, maximal function
(ambulatory): needs and wants, QOL, prevent complications/ flares/ freq/ SE/ improve condition/ ADLs
- Explicit criteria/ HIGH alert medications
Explicit criteria: drugs that are more likely to cause harm than benefit
* guidelines (BEERS, FRIDs, STOPP, STOPPFrail, STOPPFall)
HAM: commonly associated with adverse events in patients, deemed as greater risk
* Insulin, opioids, anticoagulants, concentrated electrolytes, cytotoxic/ chemotherapeutic agents
- Implicit criteria – clinical judgement
- Items in MAI + ADR + any untreated indications
- Indications + CI + DDI + efficacy/ adr + corrrect dose/ instructions/ practical
- EVALUATION PROCESS applies to all medications
- pt specific reasoning
- Successful delivery of appropriate drugs
Barriers for appropriate medicines to reach patients
- Non-adherence
- Lack of support
- Cost
- Health belief
- Poor communication
- Poor technique
- Inappropriate storage
monitoring pt after medication reconciliation
- are goals met (important to pt, adherence, efficacy, ADR)
Any new symptom in older patient should be considered a possible DRUG SIDE EFFECT!!!!!!
why is this important?
Prevent prescribing cascade
- Using a another drug to treat the SE of another drug as belif is from new medical problem
○ Contribute to poly-pharmacy
○ Look for pseudo-indication (Opposing pharmacology, MOA)
eg of psuedo-indication
- A-blockers and alpha agonists
- Spironolactone and hydrocortisone
- Anticholinergic and acetylcholine inhibitors
- NSAID and hypertensives
- Sympathomimetics and antihypertensives
comprehensive geriatric assessment is for
Beneficial for older adults cfs4 - cfs7(based on frail scale + ADL & iADL)
- Not helpful for older patients who are very fit (CFS1-3)
- or severely frail – irreversible and life-limiting pathology (CFS8-9)
CGA comprise of 5 aspects
- functional status
- medical review
- mental cognition/ mood
- medication/ nutrition
- socioeconomic resources
similar to 4M
what matters (share with care team)
medication (HAM)
mentation (delirium, depression. hydrate. orientate TIME, PLACE, SITUATION, sleep)
mobility (any limitations, ensure early, freq, safe mobility)
what is CGA for?
Comprehensive geriatric assessment (CGA) is defined as a multidisciplinary diagnostic and treatment process that identifies medical, psychosocial, and functional limitations of a frail older person in order to develop a coordinated plan to maximize overall health with aging.
diagnostic, evaluation and management
- functional status (CGA)
- Pt QOL, preferences, values
○ Maximise pt function by ensuring other factors (below) are met.
○ Because pt function deficit may not be reversible, only maintained - ADLs, iADL
- Develop interventions to maintain or improve functional independence and enhance QOL
CFS
1-3: very fit to managing medical problems well
4-6: living with very mild/ mild/ moderate frailty
7-9: living with severe frailty. terminally ill
CFS 4-6
4: previously vulnerable. not dependent for daily help, but sx limit activities
5: need help with IADL (SHAFTTT)
6: need help with IADL, some help with ADLs
ADL (DEATH)
Dressing, Eating, Ambulating, Toileting, Hygiene
iADL (SHAFTTT)
Shopping, Housekeeping, Accounting, Food prep, Taking meds, Telephone, Take transport
- Require higher mental function to perform
- Compare from baseline to see if they have the functions to begin with (eg not everyone knows how to cook)
- medical review
- Conduct: conduct detailed ROS to identify any medical prob
- Assess and address: chronic conditions that impact pt overall health
- Identify potential geriatric syndromes (falls, incontinence, polypharmacy)
- Tailor (medical interventions to optimise overall well being and QOL)
common geriatric syndromes
impaired mobility, instability (falls)
UI
cognitive impairment (dementia, delirium)
frailty
sarcopenia
polypharm and iatrogenic disease
pressure areas
malnutrition
consideration for medication management in older persons
- altered PK, PD
- older persons atypical presentation
- higher prevalence of multimorbidity and polypharm
- incr susceptibility to ADR, DDI, DDI
- diff goals of care
- modified tx targets
- impaired functional capacity and cognitive decline
- Mental (cognition/ mood)
- If cognitive impairment present –> determine etiology
- Evaluate mood and emotional status to identify signs of depression/ anxiety
- Consider impact of cognitive and mood status on medication adherence and self-care
delirium/ dementia / depression
deirium - dementia:
* monitor longitudinally
* pt hx (baseline cognitive function, acute or chronic sx)
depression:
* try tx with antidep and MONITOR any improvement of sx
- medication/ nutrition
- Review pt medication regimen, address DDI & DFI
- Assess nutritional status and identify for deficiencies or malnourishment
- Optimise medication and nutrition plans to enhance pt outcomes and reduce ADE-
- socioeconomic resources
- Identify pt social support system and available resources
- Evaluate pt living conditions and potential safety concerns
- Address financial barrier and consider the impact on pt’s health management
- Advanced care preferences
ABCDEF framework for CGA
○ Accurate diagnosis of dementia
○ Behavioural and psychological symptoms (BPSD – progression of disease)
○ Caregiver stress (pt abuse)
○ Drug and disabilities
- What can pt do - we try to maintain function
-What drugs may affect pt function vs what drugs pt NEED
○ End of life discussion and equipment
- Equip to assist caregiver
- Equip for safety
○ Financial supports
summary of frameworks
- appropriateness of medication px (MAI)
- identify DRP (pharmaceutical care)
- geriatric CFS 4-7 (CGA)
(use PCF, MAI to achieve care goals of CGA)
(use PCF for older pt not considered primary beneficiary for CGA)
(CGA 5 components: if older person not under care of geriatrician)
(all CGA, ABCDEF: if CFS)
medication use principles for older persons
- start LOW, GO SLOW
- non-pharm tx to minimise unnecessary polypharm
- use meds with lowest risk of ADE (BEERS etc)
- least n.o. of meds
- monitor for ADE, atypical presentation
- review meds regularly
polypharm and deprescribing
not without harm
- no valid, current indication
- contribute to ADR, geriatric syndromes
- due to prescribing cascade* high risk in the pop
- ineffective
- for preventive indication in pt with LIFE-LIMITING ILLNESS (bisphosphonate at EOL)
- unaccceptable tx burden
deprescribe plan
- prioritise by greatest risk/ cocerns to pt
- develop plan (tapering if risk of adverse drug withdrawal reactions)
* BB, CS, BZP, APS, opioids, PPI, antiparkinson, antidep, antiseizure - self-monitoring (counsel) and FU
