Lecture 14 - deprescribing Flashcards
what is involved in the management of complex patients?
multi morbidity, frailty and polypharmacy
what is multi morbidity ?
multi morbidity is the coexistence of two or more diseases or illnesses in the same individual simultaneously accompanied by physical and functional decline
what is frailty ?
frailty can be defined as age-related state of weakness and fragility that causes the patients physical and mental condition to deteriorate. it negatively affects body systems which eventually impair the daily activities and affect the quality of life
what is frailty syndrome?
falls, functional decline, immobile, delirium, cognitive decline, incontinence, susceptibility to side effects of medication
what is the definition of polypharmacy?
the use of more medications that are needed or for which harm outweighs benefit. particular risk for older people because they respond to drugs differently, are often frail, and are not typically represented in research
what can polypharmcy increase the risk of ?
drug interactions and side effects,
trouble taking medication as directed,
body not moving as well as it should,
mind not working as well as it should,
falling/ fractures,
hospital admission
what are triggers for deprescribing?
no indication,
no longer aligns with goals of care or life expectancy, inappropriate medications for geriatric patients, adverse drug events,
prescribing cascades,
non-adherence,
patient preference,
palliative care/ end of life
what are benefits for desprescribing?
fewer false and fractures,
fewer medication related cooers and improved adherence
reduced referral to acute services
improved condition
better quality of life
what are common drug for deprescribing ?
PPI,
BENZOS,
antimuscarinics,
antipsychotics for patients with dementia, cholinesterase inhibitors,
NSAIDs,
opioids,
antihyperglycemias
why are PPIs potential for deprescribing ?
increased risk of fractures,
C diff,
pneumonia,
interstitial nephritis.
often started without a clear indication and often continued despite symptom resolution.
initial trial should be 8 weeks for most common indications,
taper higher doses,
abrupt d/c without management of rebound symptoms increases risk of failure.
continued if used for NSAID induced peptic ulcer risk
why are Benzes and z drugs potentials for deprescribing?
high risk of psychomotor impairment,
falls and cognitive impairment.
not first line for anxiety or insomnia.
KEY is patient education and slow taper to avoid withdrawal: 5-10% every 2 weeks.
Alternatives are SSRI, SNRI, CBT, sleep hygiene and melatonin
why are antimuscarinics potentials for deprescribing?
highly anticholinergic, often continued despite limited or no benefit, non-pharmacological interventions are 1st line: behavioural toileting interventiosn
why are antipsychotics for patients with dementia common for deprescribing?
no clear evidence for benefit and increased risk of mortality, EPS and falls.
Unlikely to benefit “agitated” behaviours
Taper: slow reduction (25%) – review after a week
Behavioural and environmental interventions are first-line
Alternatives: cholinesterase inhibitors, SSRIs
Reserve for patients with problematic psychosis
why are cholinesterase inhibitors potential for deprescribing?
eg rivastigamine, pyridostigmine
only indicated for dementia, very modest benefit for cognition and functional status,
adr: bradycardia, diarrhoea, anorexia/ weightless, urinary incontinence, nightmares.
deprescribe: if significant decline while on treatment, severe/ end-stage dementia, ADRs
why are NSAIDs potentials for deprescribing?
increased BP,
peripheral oedema,
CHF exacerbation,
GI bleed in high risk patients >75 years or
concomitant use of steroids, antipaltelet agents and anticoagulants.
risk of AKI or progression of CKD.
alternatives: topical NSAIDs, TENS, physio, weight loss, steroids
why are opioids potentials for deprescribing?
little evidence to support use in OA or chronic low back pain. risk of csntiaption, delirium, sedation, falls unintentional overdose. desprescribe if no improvement in pain or function, of if ADRs. decrease by 10% per week. alternatives are topical NDSAIDs, TENS, physio, weight loss and steroids
why are antihyperglycemias potentials for deprescribing?
higher HBA1C targets in older adults: 7-8% or higher. consider time to benefit for tight control and risk of hypoglycaemia. desprescribe starting with drug most likely to cause hypoglycaemia and drugs with lowest HbA1c lowering potential.
