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Integrated Care > Polypharmacy > Flashcards

Polypharmacy Flashcards

1
Q

What is polypharmacy defined as?

A

Being prescribed more than 4 medications

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2
Q

What proportion of older patients are affected by polypharmacy?

A

Over 1/3

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3
Q

What can polypharmacy result in?

A
  • Increased risk of side effects
  • Increased risk of drug-drug interactions
  • Therapeutic cascade
  • Increased risk of medications not being reviewed thoroughly
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4
Q

What is meant by the therapeutic cascade?

A

A drug is prescribed and causes an adverse effect. This adverse effect is misinterpreted as a new medical condition, causing the prescription of another drug, and the cycle continues

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5
Q

What things are considered to be ‘inappropriate prescribing’?

A
  • Prescribing drugs that are contraindicated
  • Prescribing a drug with an inappropriate dose or duration
  • Prescribing a drug that is likely to adversely affect prognosis
  • Failure to use a drug that could improve patient outcomes
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6
Q

Why is inappropriate prescribing more common in older adults?

A
  • Higher prevalence of chronic disease
  • Higher levels of polypharmacy leading to an increased risk of drug-drug and drug-disease interaction
  • Age related physiological changes
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7
Q

In what things are there age-related physical changes that affect drugs?

A
  • Distribution
  • Hepatic metabolism
  • Renal elimination
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8
Q

Are age-related changes in the GI tract clinically significant in relation to drugs?

A

No, because they do not affect the absorption of most drugs

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9
Q

What age-related changes cause changes in the distribution of drugs?

A
  • Total body fat increases
  • Total body water decreases
  • Serum albumin decreases
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10
Q

What is the effect of the increase in total body fat with ageing on drugs?

A

Increases the volume of distribution for fat soluble drugs

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11
Q

What is the effect of the decrease in total body water with ageing on drugs?

A

Decreases the volume of distribution of water soluble drugs

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12
Q

What is the effect of the decrease in serum albumin with ageing on drugs?

A

Increases the effects of albumin-bound drugs as levels of unbound drugs increase as a consequence

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13
Q

What happens to hepatic metabolism with age?

A

Reduces

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14
Q

Why does hepatic metabolism of many drugs reduce with age?

A

Because of reduced liver volume and enzymes activity

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15
Q

What is the potential result in the reduction of hepatic metabolism with age?

A

Can cause toxic accumulation

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16
Q

What should be done to prevent toxic accumulation of drugs due to reduction in hepatic metabolism with age?

A

Reduce dose or increase dosing interval

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17
Q

What drugs are effected by a reduction in the glomerular filtration rate?

A

Drugs that are excreted by the kidneys

18
Q

What effect do reductions in the GFR have on drugs that are excreted from the kidneys?

A

Reduces excretion

19
Q

Give an example of a renally excreted drug with a narrow therapeutic index?

A

Digoxin

20
Q

What is the result of digoxin being renally excreted and having a narrow therapeutic index?

A

It often requires dose reduction in later life to prevent drug toxicity

21
Q

How should toxic accumulation caused by reduced renal elimination with ageing be reduced?

A

Reduce dose or increase dosing interval

22
Q

What proportion of hospital admissions are drug related and preventable?

A

1 in 15

23
Q

Why are the risks of prescribing greater in older adults?

A
  • Changes in pharmacokinetics
  • Changes in pharmacodynamics
  • Polypharmacy
  • Frailty
  • Communication problems
  • Lack of evidence base
  • Guidelines being based on singe-organ disease processes
24
Q

What is pharmacodynamics?

A

Refers to how the drug interacts with the body to produce a response

25
Q

What is pharmacokinetics?

A

What the body does to the drug

26
Q

What concepts does pharmacokinetics include?

A
  • Absorption
  • Distribution across body compartments
  • Metabolism
  • Excretion
27
Q

What happens to the metabolism and excretion of many drugs with ageing?

A

It decreases

28
Q

What is the result of the decrease in metabolism and excretion of many drugs with ageing?

A

The doses need to be adjusted

29
Q

When is the adjustment of drugs due to ageing especially important?

A

For drugs with narrow therapeutic indexes

30
Q

Why is it important to adjust the doses of drugs with a narrow therapeutic index?

A

Because even a small increase in bioavailability can lead to toxic effects

31
Q

What are the consequences of inappropriate prescribing?

A
  • Increased morbidity and mortality
  • Increased hospital length of stay
  • Reduced compliance
  • Increased risk of adverse drug reactions
32
Q

What considerations should be made whilst prescribing?

A
  • The benefits of a drug should outweigh the risks
  • The drug should be cost-effective
  • The individual patient characteristics should be taken into account to aid prescribing
  • The drug should be safe
33
Q

What steps can be taken to ensure you are prescribing right?

A
  • Ensure you have gained accurate medication history
  • Map medication last to PMH to ensure known medical conditions are being treated appropriately
  • Prescribe in current clinical context
  • Ensure essential medications are not omitted
  • Review administration route if necessary
  • Use monitoring to determine effect of drug and help detect adverse effects
  • Remember to review if any medications are missing that should be prescribed
34
Q

Give an exampling of prescribing in the clinical context

A

Someone being treated for dehydration is unlikely to need their diuretic therapy

35
Q

Give some examples of essential medication that should not be omitted

A
  • Antibiotics
  • Anti-epileptics
  • Diabetic drugs
  • Parkinson’s drugs
36
Q

When might the administration route need to be reviewed?

A

If the patient is NBM, alternative route may need to be used, especially for essential drugs

37
Q

What monitoring can be done to ensure drugs are effective?

A
  • Symptoms and signs

- Investigation results

38
Q

What is meant by the prescribing paradox in frailty?

A

Frail adults often need drugs to treat their long-term conditions, however polypharmacy is implicated in frailty

39
Q

Why is polypharmacy bad in frailty?

A
  • A new drug is a challenge to the system, and a frail system is more likely to decompensate
  • Decompensation is more likely then there is polypharmacy
  • Polypharmacy is a risk factor for decline in the face of a non-pharmacological precipitant
40
Q

What is the problem with evidence-based prescribing in older people?

A

Evidence is often extrapolated from trials involving younger adults who often do not have multi-morbidity or polypharmacy

Integrated Care (17 decks)

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