SAFE PRESCRIBING AND MANAGEMENT OF POLYPHARMACY IN OLDER ADULTS

Question 1

What is the definition of polypharmacy?

Answer 1

Agreed more than 4 drugs in general
No official definition

Question 2

Why is polypharmacy important?

Answer 2

DRUG ON DRUG INTERACTIONS
COMPLIANCE
ELDERLY PATIENTS ARE HIGH RISK
- under multiple specialists
- multi-comorbidity
Cost

Question 3

What are the main issues/ SE of polypharmacy/ medications?

Answer 3

Renal function
- Lots of drugs renally excreted
- DOAC use creatinine clearance not eGFR
Weight
- Fluid intake
- Fluid restriction
- Paracetamol
Administration
- Swallowing issues
- Can they take/cut the tablet
- Cognitive impairment
- MAR charts/ NOMAD​
SE
- More prone
- Known SE can have disproportional effect on this cohort
- Cumulative – anticholinergic burden
- Prescribing cascades

Question 4

What are the 7 steps for appropriate polypharmacy?

Answer 4

WHAT MATTERS TO THE PATIENT?
WHAT IS ESSENTIAL?
IS ANYTHING UNNECESSARY?
ARE THERAPEUTIC GOALS BEING ACHIEVED?
IS THE TREATMENT COST EFFECTIVE?
DO THEY HAVE ANY SIDE EFFECTS?
IS THE PATIENT WILLING/ABLE TO TAKE THE TABLETS?

Question 5

Why is the STOPP/START criteria for polypharmacy useful?

Answer 5

Simple and efficient touse​
Easy access​
Organised by drug class
Evidence based

Question 6

79 yo man
care home resident
mild cognitive impairment
IHD
Mod impaired LV systolic function
Smokes 5 cigarettes/day

BP 160/ 80 P 86
RR 26
U&E normal range
MMSE 18/30

He has become breathless whilst mobilising in the care home, the staff have requested a salbutamol inhaler for him. They have noticed his legs are more swollen than usual. He has also had several falls, usually first thing in the morning after sleeping very deeply all night.

Omeprazole 20mg od
Simvastatin 40mg on
Clopidogrel 75mg od
Bisoprolol 2.5mg od
Amlodipine 10mg od
Furosemide 40mg od
Trazodone 100mg on
Tolterodine MR 4mg on

What changes to the medication can we make

Answer 6

Prescribe inhaler
Omeprazole 20mg od
Simvastatin 40mg on
Clopidogrel 75mg od
Bisoprolol 2.5mg od
Amlodipine 10mg od
Furosemide 80mg od or 40mg bd
Trazodone 100mg on
Tolterodine MR 4mg on

Question 7

Medicines for IHD

Answer 7

FRAIL ELDERLY MORE LIKELY TO GO INTO CARE IRRESPECTIVE OF STATIN USE.

NO EVIDENCE FOR STATINS OVER THE AGE OF 90

THE MORE AGGRESSIVELY TREATED THE HIGHER RATE OF FALLS

BETA- BLOCKERS ARE GOOD

BP CONTROL DOSE REDUCE ALL CAUSE MORTALITY, STROKE RISK AND CAN IMPROVE CP AND HF SYMPTOMS

Question 8

Do sleeping tablets work?

Answer 8

THEY DON’T REALLY WORK
META-ANALYSIS SHOWS THEY WORK AS WELL AS PLACEBO
NNT FOR ZOPICLONE IS 13 FOR 25 MINUTES EXTRA SLEEP
NNH IS 6

Question 9

What to use for constipation?

Answer 9

NOT LACTULOSE
NOT EVERY LAXATIVE EITHER
TREAT THE TYPE

Question 10

Criteria/ considerations - Is there a valid and current indication? Is the dose appropriate?

Answer 10

PROCESS/GUIDANCE - Identify medicine and check that it does have a valid and current indication in this patient with reference to local formulary. Check the dose is appropriate (over/under dosing?)

Question 10

Is the medicine preventing rapid symptomatic deterioration?

Answer 10

Is the medicine important/essential in preventing rapid symptomatic deterioration? If so, it should usually be continued or only be discontinued following specialist advice.

Question 10

What is polypharmacy maybe defined as?

Answer 10

‘The administration of more medications than are clinically indicated’

Question 11

Is the medicine fulfilling an essential replacement function?

Answer 11

If the medicine is serving a vital replacement function, it should continue.

Question 12

Consider medication safety

Is the medicine causing:

Any actual or potential ADRs?
Any actual or potentially serious drug interactions?

Answer 12

Contraindicated drug or high risk drugs group? Strongly consider stopping

Poorly tolerated in frail patients? Consider stopping

Particular side effects? May need to consider stopping

Question 13

Consider drug effectiveness in this group/person?

Answer 13

For medicines not covered by steps 1 to 4 above, compare the medicine to the ‘Drug Effectiveness Summary’ which aims to estimate effectiveness.

Question 14

Are the form of medicine and the dosing schedule appropriate? Is there a more cost effective alternative with no detriment to patient care?

Answer 14

s the medicine in a form that the patient can take supplied in the most appropriate way and the least burdensome dosing strategy? Is the patient prepared to take the medication? UKMI Guidance on choosing medicines for patients unable to swallow solid oral dosage forms should be followed.

Question 15

Do you have the informed agreement of the patient/carer/welfare proxy?

Answer 15

Once all the medicines have been through steps 1 to 6, decide with the patient/carer/or welfare proxies what medicines have an effect of sufficient magnitude to consider continuation/discontinuation.

Question 16

What are some practical considerations that we need to take into account when it comes to drugs?

Answer 16

often drugs are not discontinued after the problem has resolved such as:
digoxin taken after AF has reverted to sinus rhythm
analgesics taken after an exacerbation of osteoarthosis has settled

Question 17

Renal and hepatic decline with polypharmacy

Answer 17

reduced renal and hepatic function make the elderly susceptible to interactions and side effects
creatinine clearance falls with age even in good health and despite a normal serum creatinine
metabolic or other adverse effects of treatment are so common that they form part of the differential diagnosis of any unwell elderly patient