Polypharmacy, Discharge Planning, Frailty Flashcards
When does polypharmacy occur?
When 6 or more drugs are prescribed at one time (more than 5)
What to always check when prescribing?
- Correct agent for correct patient and correct diagnosis
- Drug allergies?
- Interactions
- Generic drug name used in CAPITALS
- No abbreviations
- Dose, freq, times, route of administration, start date and end date
- Cautious using decimal points
- Write units rather than u
- Print name and sign
- Review on daily basis, stop meds if not needed
Who works together for care pathway for older people?
- Healthcare workers
- Social care workers
- Patient themselves
- Family members
Main aims of discharge planning
- Reduce length of stay in hospital
- Prevent unplanned readmission
- Improve community services co-ordination
What is mainly involved in discharge planning?
Inter-professional team working:
* Sharing infromation
* Clear communication pathways
* Respect experience and expertise of collegues
* Agree roles and responsibilities
* Work flexibly
What should discharge arrangements maximise?
- QOL
- Independent living where possible
What is often done in terms of funding for discharge?
- Referral made to social services to assess for funding
- Eg for care home or direct payments (cash payment instead of community services to buy personal assistance) or a package of care
- Known as a home first form
When are social workers alerted about patient?
- referral is made
- Then notified when patient has been declared medically fit for discharge
- Then social worker takes decisive action towards discharge
- They incur a penalty if cause delayed discharge
What does discharge involve?
- Medications to take home (TTO’s)
- Transport
- Therapy assessment - ongoing referral to community occupational therapy or physio if needed. can have equiptment delivered to home
- Restart package of care
- Outpatient appt
- District nurse referral if required or palliative care or community lead referral if needed
- Transfer back letter for residential/nursing home
Reason for re-admissions
One or more elements have been inadequate eg:
* Obtaining suitable package of care
* Patient health complications
* Communcation breakdown between health care professionals and social services
* Family decisions
* Decisions around funding
What is frailty?
- Distinctive health state
- Multiple body systems lose their inbuilt reserves
- Most at risk of adverse health outcomes
- Determines which active treatments will benefit pt
How do we prevent admissions of chronically diseased pts from community ?
Specialist teams eg
* Chronic heart failure team
* Bronchiectasis nurses
* Community leads/matrons
Two types of polypharmacy
Appropriate (extend life expectancy and increase QOL) vs problematic
Reasons for polypharmacy
- Multiple health conditions
- Elderly - we are living longer
- Acute hospital admissions - new drigs given
- Treat side effect of drugs thinking they are new disease process
WHy are older people more at risk of the complications of polypharmacy?
- Decreased drug clearance
- Increase risk of adverse drug effects due to changes in metabolism from decreased organ function
Consequences/risks associated with polypharmacy
- Hip fracture
- Falls
- Adverse drug reactions
- Prescribing cascade
- Delirium
- Lethargy
- Depression
- Hopsital admission
- Death
- Increased financial burden
Reason for polypharmacy with multiple diseases
There is a lack of guidelines for managing multiple organ pathologies (which occurs esp in elderly)
We tend to have guidance for things individually rather than a whole
What is prescribing cascade?
Adverse drug reaction is interpreted as new disease so is treated with an additional medication
Rather than stopping offending drug
Common adverse effect of SSRI
Hyponatraemia - this can occur if add on another medication with this side effect or if person has suddenly developed an infection
Medications known to cause ankle swelling
Amlodipine
Doxazosin
What drug can cause drug induced parkinsonism which is commonly used in elderly?
Haloperidol - used in delirium management if pt is at risk to themselves or others
Test for bradykinesia
Open and close fist as fast as you can
Side effects of anticholinergic drugs
OPPOSITE OF SLUDGE
- Dry mouth
- Dry eyes/blurred vision
- Urinary retention
- Constipation
- Tachycardia
- Drowsy
- Hallucinations
- Hot and reduced sweating
Drugs with strong anti-cholingergic activity
- Anti-histamines
- Anti-emetics - eg promethiazine and prochlorperazine
- Antidepressants
- Anti-muscarinics (eg those used in incontinence oxybutynin, solifenacin
- Anti-parkinson drugs
- Anti-psychotics
- Anti-spasmodics
- Skeltal muscle relaxants
Value for anticholinergic burden being a problem
If 3 or more - at risk of strong side effects
Two criteria for finding suitable medications for elderly
- Beers criteria
- STOPP/START
Examples of drugs to try to avoid in elderly
- Pioglitazone - fluid retention
- SNRI
- SGLT2 - increase infection
- Tramadol - opioid but also alpha blocker, can cause postural hypo
- Lithium + loop diretic = increase risk toxicity
What is using STOPP START tool shown to have benefit with?
- Decreased ADRs
- Decreased cost medicines during hospital admissions
- Increased ADLs
- Decreased inappropriate medication prescriptions
Overall approach for elderly and polypharmacy
- Review and discontinue medications if suitable
- Consider ADRs if new symptom arises
- Consider non-pharmacological treatments instead
- Safer alternatives?
- Decrease dose - eg if kidney function low or dose not suitable
- Beneficial therapies when needed - sometimes drugs are needed, just minimise this as much as possible
Compliance and polypharmacy
More drugs = less compliant
