Lecture 14 - deprescribing

Question 1

what is involved in the management of complex patients?

Answer 1

multi morbidity, frailty and polypharmacy

Question 2

what is multi morbidity ?

Answer 2

multi morbidity is the coexistence of two or more diseases or illnesses in the same individual simultaneously accompanied by physical and functional decline

Question 3

what is frailty ?

Answer 3

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

Question 4

what is frailty syndrome?

Answer 4

falls, functional decline, immobile, delirium, cognitive decline, incontinence, susceptibility to side effects of medication

Question 5

what is the definition of polypharmacy?

Answer 5

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

Question 6

what can polypharmcy increase the risk of ?

Answer 6

drug interactions and side effects, trouble taking medication s directed, body not moving as well as it should, mind not working as well as it should, falling/ fractures, hospital admission

Question 7

what are triggers for deprescribing?

Answer 7

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

Question 8

what are benefits for desprescribing?

Answer 8

fewer false and fractures, reduced referral for acute services, improved condition, better quality of life, fewer medication errors and improved adherence

Question 9

what are common drug for deprescribing ?

Answer 9

PPI, BENZOS, antimuscarinics, antipsychotics for patients with dementia, cholinesterase inhibitors, NSAIDs, opioids, antihyperglycemias

Question 10

what are PPIs potential for deprescribing ?

Answer 10

increased risk fo fractures, C diff, pneumonia, interstitial nephritis. often started without a clear indication and often continued despite symptom resolution. intitla trail 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

Question 11

Benzes and z drugs

Answer 11

high risk of psychomotor impairment, falls and cognitive impairment. not first line for anxiety or insomnia. KEY is patient education and slo taper to avoid withdrawal: 5-10% every 2 weeks. alternatives are SSRI, SNRI, CBT, sleep hygiene and melatonin

Question 12

antimuscarinics

Answer 12

highly anticholinergic, often continued despite limited or no benefit, non-pharmacological interventions are 1st line: behavioural toileting interventiosn

Question 13

antipsychotics for patients with dementia

Answer 13

no clear evidence for benefit and incased risk of mortality, eps AND FALLS. Unlikely to benefit “agitated” behaviors
Taper: slow reduction (25%) – review after a week
Behavioral and environmental interventions are first-line
Alternatives: cholinesterase inhibitors, SSRIs
Reserve for patients with problematic psychosis

Question 14

cholinesterase inhibitors

Answer 14

eg rivastigamine, pyridostigmine

only indicated fro 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

Question 15

NSAIDs

Answer 15

increased BP, peripheral oedema, CHF exacerbation, GI bleed in high risk patients >75 years or concomitant use of steroids, antipaltelet agents and anticoagulants. risk o fAKI or progression of CKD. alternatives: topical NSAIDs, TENS, physio, weight loss, steroids

Question 16

opioids

Answer 16

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

Question 17

antihyperglycemias

Answer 17

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.