maju sekaran agar pitar yukyukyukyukyug.pptx

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1. Resume Kasus

2. Definition While there is no consensus definition for polypharmacy, most studies have used a numerical threshold of 5 or more medications per day Approximately 40% of older adults take 5-9 medications 1 Approximately 18% of older adults take 10 or more medications 2

3. Approximately 40% of older adults take 5-9 medications 1 Approximately 18% of older adults take 10 or more medications 2

4. Appropriate versus problematic polypharmacy Medication optimization ensures benefits outweigh risks Takes into consideration impact on outcomes important to the older adult, such as Improving the duration and quality of life Symptom control Prevention It is evidence-based Appropriate Polypharmacy

5. Appropriate versus problematic polypharmacy Risk of harm exceeds the potential benefits or coexists with the benefits Problematic Polypharmacy

6. Impact of polypharmacy on the older adult  adverse drug reactions  drug interactions  cost  risk of non adherence  risk of medication errors Precipitate or exacerbate geriatric syndromes

7. Falls Functional impairment Cognitive impairment Urinary incontinence Impaired nutrition Dehydration Constipation Geriatric syndromes

8. Risk factors for problematic polypharmacy

9. Risk factors for problematic polypharmacy Multiple medical problems/multiple medications Treatment guideline-based prescribing Promotes multiple medications Conditions for deprescribing uncertain ADRs and prescribing cascade An adverse reaction to one drug may go unrecognized/ misinterpreted Healthcare provider inappropriately prescribes a second drug to treat signs/symptoms Infrequent medication review There is a lack of incentive to deprescribe Unnecessary drugs or doses not adjusted

10. Reduced Homeostatic Mechanisms & Organ Dysfunction A decline in physiologic reserves associated with aging causes the older adult to become less resilient to various causes of stress such as acute illness or injury, or the effects that medications have on the body. The combination of increased stressors and a decrease in physiologic reserve can lead to adverse outcomes such as hospitalization or death. Risk factors for problematic polypharmacy

11. Risk factors for problematic polypharmacy Reduced Homeostatic Mechanisms & Organ Dysfunction

12. Risk factors for problematic polypharmacy Characteristics of frailty Unintended weight loss due to inadequate nutrition Slow walking speed Impaired grip strength Exhaustion Self reported decline in activity levels Frailty

13. Older age Multiple medical problems (or geriatric syndromes) Taking multiple medications Multiple psychosocial problems One or more sensory impairments (vision, hearing) New onset urinary or fecal incontinence Decrease in functional status Change in mental status- cognition/affect Disruptive behavior or personality changes Frequent falls Frailty (cont.) Several factors are known to be associated with frailty: Risk factors for problematic polypharmacy

14. With acute illness, usual medications can cause unanticipated harm With any change in medications or change in dose, adverse effects can result Acute illness or changes to medication can lead to problematic polypharmacy Risk factors for problematic polypharmacy

15. Challenges in detecting polypharmacy Problems due to medications may occur Without any changes to the medication Advancing age Coincident with acute illness or symptoms ADRs masquerade as age-related changes Atypical presentation of adverse effects Side effects difficult to interpret, may go unreported Prescribing cascade Infrequent Medication Review There is a lack of incentive to deprescribe

16. Detecting problematic polypharmacy Exaggerated medication effects Loss of medication’s effect Problems with taking medication New or worsening symptoms or conditions Decline in functional and self-care abilities Decline in mobility Problematic polypharmacy can present in atypical ways, such as …

17. Addressing polypharmacy Assess medication list with an available tool Explicit criteria – list of potentially inappropriate medications Implicit criteria or comprehensive assessment Medication assessment framework

18. Addressing polypharmacy Explicit criteria – lists of potentially inappropriate medications (PIM), for example

19. Addressing polypharmacy

20. Addressing polypharmacy Health status Prognosis and goals of care Benefit – risk assessment of each medication and overall combination of medications Implicit criteria or comprehensive assessment

21. Addressing polypharmacy Assess risk for polypharmacy Annual review of medications in all older adults Inform caregivers of medication changes to increase the chance of detecting problems as soon as possible Chose medications with the fewest side effects Stop unnecessary medications Consider the impact of medications on quality of life Consider the person’s ability to take medications and remember to take them Limiting potential harms

22. P ractical guide to stopping medication

23. Summary Medication problems can occur without a change in medications Tools are available to structure the medication assessment process Each patient is unique, medication decisions require clinical judgement All care providers can contribute to medication problem identification and reporting Recognizing problematic polypharmacy is difficult Benefit/harm ratio can change in an instant or gradually over time. Regular medication review provides an opportunity to detect problems, adjust doses based on changing physiology and consider medication deprescribing.

24. Summary Assess polypharmacy risk Annual review of medications in all older adults Inform caregivers of medication changes to increase the chance of detecting problems as soon as possible Chose medications with the fewest side effects Stop unnecessary medications Consider the impact of medications on quality of life Consider the person’s ability to take medications and remember to take them Strategies to limit the potential harms due to polypharmacy