Polypharmacy + older adults

Question 1

Challenges in prescribing for the older adult

Answer 1

• Consideration for how the ageing process affects the body’s capacity to handle medicines
• Pharmacokinetics
• Pharmacodynamics
• Ensuring that medicines are prescribed and used effectively
• Potentially Inappropriate Medications (PIMs)
• Compliance/Adherence/Concordance
• Polypharmacy
• Medication reviews
• Deprescribing

Question 2

Polypharmacy definition

Answer 2

• Appropriate Polypharmacy - prescribing for someone with complex conditions or with multiple conditions AND the medicines have been optimised and prescribed according to best evidence. The combination of medicines maintain a good quality of life and minimise harm from drugs.
• Problematic Polypharmacy - the prescribing of multiple medicines inappropriately. The prescribing may:
• Not be evidence-based
• The risk of harm is likely to outweigh the benefit
• The drug combinations are hazardous, because of interactions
• The demands of medicine taking are not acceptable to the patient
• The demands are such that adherence cannot be achieved
• Medicines are being prescribed to treat side effects

Question 3

Mx of long term conditions

Answer 3

Question 4

Reasons for polypharmacy

Answer 4

• Poor communication between MDT
• Lack of joined up thinking
• Unrealistic expectations from patients, relative/carers. e.g. pain killers

Question 5

Health practitioner-risk factors

Answer 5

Question 6

Patient risk factors

Answer 6

• Not understanding what has been done and why
• Misunderstanding brand changes or generics
• Forgetting whether taken a dose or the plan
• Not throwing out old medicines
• Not being able to read labels or use packaging
• Financial factors

Question 7

Drug handling

Answer 7

• Little known about effects in elderly
• Drug trials often exclude elderly to minimise adverse events and poor outcomes
• Post-marketing surveillance often reveals the true picture in the “general population” - risk of ADRs
• Drug handling clearly vitally important in terms of adverse events

Question 8

Potentially inappropriate medications

Answer 8

Question 9

ADRs

Answer 9

Question 10

Drug interactions

Answer 10

• Risk increases exponentially with increasing number of medications
• Drugs with narrow therapeutic windows e.g. warfarin, lithium, digoxin are a particular problem
• Cytochrome p450 inhibitors (eg clarithromycin and omeprazole) need to be monitored

Question 11

Medications reviews

Answer 11

• Aim to improve quality, safety and appropriate use of medicines
• Only 50% taken as prescribed
• NSF for older people recommends every 6months for those >75yrs who are on >4 medications
• Predominantly undertaken by pharmacists but also Drs and NMPs

Question 12

reasons to consider deprescribing

Answer 12

• Increased risk (actual) - Patient is experiencing or has experienced a problem (e.g. side effect)
• Increased risk (potential) - Patient is likely to experience a problem (e.g. ADR)
• Lack of indication - No clear, documented & current indication for medication use
• Preventative benefit retained after stopping medication e.g. HRT
• No or limited benefit from medication
• Diminished benefit over time
• Time needed for medication benefit is shorter than patient life expectancye.g statin
• Poor medication adherence
• ADR/SE

Question 13

Factors to consider- symptomatic treatments

Answer 13

• Does the benefit outweigh harm?
• Does it improve QoL?
• Consider a short therapeutic trial – stop if no improvement

Question 14

Factors to consider- Preventative treatments

Answer 14

• Need for regular review
• Multiple/serious degenerative conditions may reduce longevity or influence QoL – may no longer be relevant
• Preventative goals should be explained and understood by the patient
• If the condition being treated can be manged without medication, then why not?

Question 15

How to deprescribe

Answer 15

Question 16

Medication appropriateness index

Answer 16

• Measure the appropriateness of prescrbing in elderly patients
  1 – Indication
  2 – Effectiveness
  3 – Dosage
  4 – Directions
  5 – Practicality
  6 – Drug/drug interactions
  7- Drug/disease interactions
  8 – Unnecessary duplication
  9 – Duration
  10 - Expensiveness

Question 17

Non-adherence

Answer 17

• Inverse relationship between number of medications taken and adherence
• Adherence for chronic therapy much less than for acute treatments
• “Direct” measures e.g. serum drug levels
• “Indirect” measures e.g. pill-counting, repeat requests or pharmacy refills