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Geriatrics > Polypharmacy and Deprescribing > Flashcards

Polypharmacy and Deprescribing Flashcards

1
Q

What is polypharmacy? What is it not?

A

High number of medications

AND

Medications that are not appropriate

More than just too many medications
Medications that are not appropriate

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2
Q

What is the cut off of the number of medications for polypharmacy?

A

No universally agreed-upon cutoff
Literature supports 5 or more medications as being associated with ↑ risk

More than 10 medications - hyperpolypharmacy

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3
Q

What is hyperpolypharmacy?

A

More than 10 medications

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4
Q

Describe the lack of appropriateness of medications component of polypharamcy?

A

Medications with no indication

Use of inappropriate medications –> Often no longer an indication for the medication

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5
Q

Is polypharamcy always a negative outcome?

A

No - Not always a bad outcome

Easy to be on multiple meds and be appropriate

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6
Q

Is polypharmacy the only concern in geriatrics? If not, what is also a concern

A

Under-utilization of indicated therapies is also common in older adults

Focusing too much on what is “too many” medications may discourage initiation of new medications, even when warranted

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7
Q

Which medications are not commonly prescribed in geriatrics (under-utilized)?

A

Bisphosphonates for osteoporosis (common)
Anticoagulation for atrial fibrillation
Pain medications
COPD treatment

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8
Q

What question should a pharamciwst be asking when evaluating the appropriateness of drug therapy in geriatrics?

A

Shifit to:

IS the pt taking the right medications?

More concerned about treating everything appropriately rather than the number of medications

The task for the clinician is not to determine whether too many or too few medications are being taken, but to determine if the patient is taking the right medications.”

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9
Q

Statistics regarding under-usage of medications in geriatrics

A

43% older adults taking 4+ medications under-treated vs 13.5% of those taking fewer medications

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10
Q

Describe the percentage of seniors in Canada and the number of medications via class?

A

58% age 65-74 taking 5+ medications

80% aged 85+ taking 5+ medications

85 and over age category that take the most medications

As we age, diagnosed with more conditions that requires more medications

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11
Q

How many disease states is a concern? Why?

A

3 or more current dx states is associated with adverse functional outcomes

3 or more chronic conditions, more likely to live with fragility

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12
Q

Describe the proportion of Canadians living with chronic conditions?

A

65-79 –> 42% with three or more disease

80+ –> 57% with 3 or more disease states

As we age, more conditions and more meds theoretically

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13
Q

Why should pharmacists be concerned about polypharmacy?

A

Number 1 risk factor for adverse drug reactions = number of medications taken

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14
Q

Is the number of medications the be-all end-all? How can it be useful for pharmacists?

A

Number of meds is not the be-all end-all

More meds someone takes, more likely to experience ADR’s

Number of drugs –> Still a good flag for risk, older adults taking a lot of meds are high risk group to invest time for medication reviews

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15
Q

Describe the rate of adverse drug reactions (ADRs) in geriatrics?

A

10-30% hospitalizations in older adults

65% considered preventable

Major problem in the geriatric population

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16
Q

Describe the factors that can lead to polypharmacy? Are they mutually exclusive? Issues?

A

Drug Interactions
ADR’s
Caregiver Brden
Poor Adherence
ER Visits, Hospitilizations

ALL LEAD TO INCREASED HEALTHCARE COSTS

Complex interplay of interactions

e.g. ER visits can be due to polypharmacy but may also lead to hospitalization which can lead to caregiver burden leading to poor adherence

ER vsiists and hospitalixations are a lot more likely to add meds rather than subtract meds

Poor adherence also results in more drugs being added to the regimen

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17
Q

What are the healthcare costs in Canada due to ADR’s in older adults?

A

2016 Study

Over 26,000 older Canadians

More than $35.7 million

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18
Q

Regarding ADR’s and polypharamcy, older adults are particularly vulnerable to:

A

Altered medication response

More comorbidities
–> Drug good for one condition runs the risk of worsening another

Altered homeostatic mechanisms
–> More susceptible to orthostatic hypotension but need to treat hypertension

Limited EBM (often not enrolled in clinical trials)

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19
Q

Who developed the BEER’s criteria? What was it initially used for?

A

Originally developed by Dr. Mark Beers in the early 90’s to assist clinicians with identifying Potentially Inappropriate Medications (PIMs) for LTC residents

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20
Q

What is the purpose of the BEER’s criteria? Is it a stationary document?

A

Medications generally considered to have risks > benefits

Revised and updated to include all adults > 65 years

Since 2012 it has been revised and updated by the American Geriatrics Society every 3 years

Most recent edition published in 2023

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21
Q

What are the different sections of the BEERS Criteria?

A

5 sections

1) Medications generally considered inappropriate for older adults (Table-2)

2) Medications inappropriate for older adults with certain medical conditions (Be familiar with – avoid in general public)

3) Medications to be used with caution in older adults

4) Clinically important drug-drug interactions to avoid

5) Medications to avoid or dose-adjust in renal impairment (no need to memorize)

Also includes a table on medications with strong anticholinergic effects

22
Q

Beers Criteria: Table 2 refers to? Examples?

A

Medications generally considered inappropriate for older adults (Table-2)

Unfavorable risk/benefit profile + better alternatives available

E.g. first-generation antihistamines, warfarin

23
Q

Beers Criteria: Table 3 refers to? Examples?

A

Medications inappropriate for older adults with certain medical conditions (Be familiar with – avoid in general public)

Drug-disease interactions

E.g. NSAIDs in HF, Non-DHP CCB in HF

24
Q

Beers Criteria: Table 4? Examples?

A

Medications to be used with caution in older adults

Some evidence of potential harm, or increased monitoring required in older adults

E.g. dabigatran, prasugrel, ticagrelor (anti-coags, anti-platlets, SGLT2I (orthostatic hypotension and hypovolemia risk)

Warrant further questions/increased monitoring to make sure they are used appropriately

25
Q

BEER’s Criteria: Table 5? Examples?

A

Clinically important drug-drug interactions to avoid

E.g. opioids + gabapentinoids or benzodiazepines

26
Q

BEERS criteria: TAble 6? Examples?

A

Medications to avoid or dose-adjust in renal impairment (no need to memorize)

E.g. ciprofloxacin, baclofen, gabapentin, etc.

Older adults likely to have renal impairment

27
Q

What are PIMs?

A

Potentially Inappropriate Medications

28
Q

Describe the utility of the BEER’s List

A

Useful tool to assist in identifying PIMs for older adults

–> Identify medications that may warrant reevaluation or closer monitoring

29
Q

What are some limitations of the BEER’s list?

A

Absence of a Beers medication does not mean an older adult’s medications are optimized

Most ADR-related hospitalizations in older adults are not due to Beers drugs

30
Q

What are the top 10 classes of medications commonly associated with ADR-related hospitalizations in Canada?

A

NSAID’s, Loop Diuretics (dependent edema) only on BEERs; others not on BEERs criteria

ANyone Asking ABout Orange Gummy Bears Never Likes Tasting dirty asshole

31
Q

What are the two categories of resources that can be used to adress polypharmacy in older adults?

A

Explicit Prescribing Tools

Implicit Prescribing Tools

32
Q

What are explicit prescribing tools? Pros and Cons? Examples?

A

Usually consensus criteria developed by a panel of experts

Lists of medications to either use or avoid

Pros: Easy to use and implement

Cons: Miss other types of DTPs

E.g. Beers Criteria, Stop-and-Start Criteria (Consensus in Ireland  Used in UK and Europe)

33
Q

What are implicit prescribing tools? Pros and Cons?

A

Outline a process for the clinician to follow to identify DTPs

Pros: Very comprehensive approach to identifying DTPs

Cons: Require clinician knowledge/expertise, time-consuming

34
Q

Examples of explicit prescribing tools

A

Beers Criteria
STOPP/START Criteria
STOPP FRAIL

35
Q

Implicit Prescribing Tools Examples

A

Medication Appropriateness Index

Good Palliative-Geriatric Practice Algorithm

36
Q

What is the medication appropriateness index? When is it useful?

A

Can be used as a research tool to evaluate a patient’s medication regimen

More useful in clinical practice as a series of questions to ask in:

–> As part of a comprehensive medication review to assess the appropriateness of each drug
–> Before starting a new medication

37
Q

What is the medication appropriateness index? Major Limitation?

A
38
Q

What is a concern with the medication appropriateness index?

A

Does not help identify untreated conditions!

39
Q

What is the Good Pallative-Geriatric Practice Algorithm? Why is it useful?

A

Originally developed in Israel to reduce polypharmacy in LTC residents

Over 1 year study:
Stopped an average of 2.8 medications/person in intervention group

Significant reductions in:

–> Hospitalizations (11.8% in intervention group vs. 30% in control group)
–> Mortality (21% in intervention group vs 45% in control group)

40
Q

Good Palliative-Geriatric Practice Algorithm and limitation

A
41
Q

What is a prescribing cascade?

A

Treating an adverse effect of a drug with another medication

42
Q

What are some other resources to use to asses polypharmacy in older adults?

A

Geri-RxFiles

Deprescribingnetwork.ca

MedSafer | Working Towards Safer Prescribing

43
Q

Describe Geri-Rx Files

A

Great resource for evaluating the appropriateness of drug therapy for a given condition in an older adult

Incorporates the Beers and STOPP criteria

Provides ALTERNATIVES to medications considered inappropriate

44
Q

Define Deprescribing

A

Deprescribing = the process of tapering, reducing, or stopping medications to improve clinical outcomes

45
Q

Describe the Canadian Deprescribing Network

A

Deprescribing guidelines developed for certain medications/conditions:

Developed patient information about the risks of certain medications:

Non-pharmacological measures for sleep

Also general deprescribing patient information

46
Q

Time to benefit requires knowledge of:
What resources are helpful?

A

Clinical knowledge of medication and condition (acute symptoms or illnesses)
E.g. Acetaminophen for headache
E.g. Amoxicillin for otitis media

More challenging for preventive therapies
References e.g. RxFiles, Geri-RxFiles

47
Q

Considerations for time to benefit:

A

Patient’s individual risk of event
–> Secondary prevention will have greater magnitude of benefit (lower NNT) than primary prevention

Clinical trial data
–> How long was the study?
–> When was impact of intervention seen?

48
Q

What are some strategies for sucessful deprescribing?

A

Patient/caregiver buy-in is key!

Taper/stop one medication at a time if possible
- Start with medications causing problems
- Medications with no indication
- Potentially inappropriate medications, medications with risk > benefit
- Medications not in line with goals of care

Watch for/try to break up prescribing cascades

Consider whether any drug interactions may be unmasked when stopping a medication
E.g. stopping amiodarone in a patient stabilized on warfarin
E.g. stopping furosemide in a patient stabilized on lithium

Anticipate and manage potential adverse drug withdrawal reactions

49
Q

What are adverse drug withdrawal reactions?

A

Clinically significant signs or symptoms on discontinuing a drug

Physiologic withdrawal
Recurrence of underlying condition
Discontinuation symptoms

50
Q

How to manage adverse drug withdrawal reactions?

A

When in doubt, taper a medication off slowly
Particularly if on a higher dose and/or have been taking chronically

Advise on how to manage unpleasant symptoms during the tapering process

Tapering regimens for select medications: Geri-RxFiles

51
Q

What are some drugs associated with adverse drug withdrawal reactions?

A
52
Q

What are some medications not associated with drug withdrawal reactions?

A

Bisphosphonates and denosumab
Aspirin
Anticoagulants
Statins
Vitamin and mineral supplements

Geriatrics (6 decks)

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