sfCare-Learning-Series-Polypharmacy-Intro-for-Clinicians.pptx

sfCare-Learning-Series-Polypharmacy-Intro-for-Clinicians.pptxsfCare-Learning-Series-Polypharmacy-Intro-for-Clinicians.pptxsfCare-Learning-Series-Polypharmacy-Intro-for-Clinicians.pptxsfCare-Learning-Series-Polypharmacy-Intro-for-Clinicians.pptx

1. Polypharmacy An introductory module for clinicians Lawrence Jackson , BScPhm, CTDP Pharmacy Clinical Coordinator, Sunnybrook Health Sciences

2. This module is part of the sfCare approach PowerPoint Presentation 8.5 x 11 Poster Patient Handout

3. Identify the factors that contribute to polypharmacy E xplain the consequences of problematic polypharmacy D escribe a structured approach to the detection of problematic polypharmacy Apply general strategies to limit problematic polypharmacy Apply a senior friendly care approach to polypharmacy Objectives Objectives What is polypharmacy ? Impact for the o lder adult Risk factors Detecting Addressing Case study Summary Senior friendly a pproach Questions

4. While there is no consensus definition for polypharmacy, most studies have used a numerical threshold of 5 or more medications per day What is polypharmacy ? 1. JAMA 2017;318(17):1728 2. Duerden M, et al. Prescriber 2014;25:44-47 Approximately 40% of older adults take 5-9 medications 1 Approximately 18% of older adults take 10 or more medications 2 Objectives What is polypharmacy? Impact for the o lder adult Risk factors Detecting Addressing Case study Summary Senior friendly a pproach Questions

5. 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 versus problematic p olypharmacy JAMA 2017;318(17):1728 Duerden M, et al. Prescriber 2014;25:44-47 Appropriate Polypharmacy Objectives What is polypharmacy? Impact for the o lder adult Risk factors Detecting Addressing Case study Summary Senior friendly a pproach Questions

6. Appropriate versus problematic p olypharmacy JAMA 2017;318(17):1728 Duerden M, et al. Prescriber 2014;25:44-47 Problematic Polypharmacy Risk of harm exceeds the potential benefits or coexists with the benefits Objectives What is polypharmacy? Impact for the o lder adult Risk factors Detecting Addressing Case study Summary Senior friendly a pproach Questions

7. 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 The following risks accompany polypharmacy: Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly a pproach Questions

8. Impact of polypharmacy on the older adult Falls Functional impairment Cognitive impairment Urinary incontinence Impaired nutrition Dehydration Constipation Geriatric syndromes Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly a pproach Questions

9. Risk factors for polypharmacy = Increased risk of p roblematic p olypharmacy OR h armful m edication effects + + Multiple medical p roblems / multiple m edications Reduced homeostatic mechanisms and organ dysfunction AND/OR Frailty Acute illness or change to medications Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly a pproach Questions

10. Risk factors for polypharmacy Multiple m edical problems/multiple m edications Treatment guideline-based prescribing Promotes multiple medications Conditions for deprescribing uncertain ADRs and p rescribing c ascade An adverse reaction to one drug may go unrecognized/ misinterpreted Healthcare provider inappropriately prescribes a second drug to treat signs/symptoms Infrequent m edication r eview There is a lack of incentive to deprescribe Unnecessary drugs or doses not adjusted Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly a pproach Questions

11. Taffet GE, Physiology of aging. In: Cassel CK, Leipzig RM, Cohen HJ, et al [eds]. Geriatric Medicine: An Evidence-Based Approach, 4 th ed. New York, Springer, 2003 Risk factors for polypharmacy Reduced Homeostatic Mechanisms & Organ Dysfunction Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly a pproach Questions 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.

12. Risk factors for polypharmacy Pharmacokinetics changes Absorption Distribution Metabolism (liver) Excretion (kidney ) Changes in how the body acts on the drug Pharmacodynamics changes Changes in receptor binding ↓ # of receptors and receptor activity ↑↓ Drug efficacy ↑ Toxicity / ADRs Changes in how the drug acts on the body Changes in physiology with aging: ↑ body fat ↓ body water ↓ albumin ↓ liver metabolism ↓ renal function Reduced homeostatic mechanisms and organ dysfunction Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly a pproach Questions

13. Risk factors for 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 Older people are vulnerable to medication-related problems associated with frailty. Robust Pre-frail Frail 1-2 ≥3 Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly a pproach Questions

14. Risk factors for polypharmacy 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: Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly a pproach Questions

15. Risk factors for polypharmacy 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 Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly a pproach Questions

16. Challenges in detecting p olypharmacy 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 Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly a pproach Questions

17. Detecting problematic polypharmacy Problematic polypharmacy can present in atypical ways, such as … 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 Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly a pproach Questions Confusion and falls are important clues that resilience is compromised in an older adult and should prompt a search for causes, including medications!

18. Addressing polypharmacy Assess medication list with an available tool Explicit criteria – list of potentially inappropriate medications Implicit criteria or comprehensive assessment Medication assessment framework Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly a pproach Questions

19. Addressing polypharmacy STOPP/START Explicit criteria – lists of potentially inappropriate medications (PIM), for example Suggests drugs to avoid and drugs to use High alert medications a nticholinergic activity Benzodiazepines Tricyclic antidepressants Warfarin NSAIDs Fluoxetine Digoxin O xybutynin Age and Aging 2015; 44(2):2013-218 J Am Geriatr Soc 2019;67(4):674-694 Suggests drugs to avoid and highlights high alert medications / patients High alert patients Impaired renal function Impaired cognition or senses Falls Hypotension Diabetes Parkinson’s disease P oor nutrition Beers Criteria List Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly a pproach Questions

20. DEBRIDE Tool D ose and frequency E ffects B enefit R isk I ndication D rug monitoring E xpectations Medication Appropriate Index (MAI) No TEARS ARMOR 7-Step Review Process… Gokula M, Homes H. Clin Geriatr Med 28 (2012) 323–341 DEBRIDE : Medication reviews in long-term care and supportive living. Alberta http ://www.cpsa.ca/medication-reviews-long-term-care-supportive-living-physicians-perspective / MAI : Hanlon JT, et al. MAI J Clin Epidemiol. 1992;45:1045–51 No TEARS : BMJ 2004;329:434 ARMOR : Haque R. Ann Long-Term Care 2009;17:26-30 Other Medication Assessment Frameworks Medication assessment frameworks Addressing polypharmacy Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly a pproach Questions

21. Addressing polypharmacy Implicit criteria or comprehensive assessment Health status Prognosis and goals of care Benefit – risk assessment of each medication and overall combination of medications Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly a pproach Questions

22. 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 Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly a pproach Questions

23. Addressing polypharmacy 1. Recognize the Need A practical guide to stopping medication… 2. Reduce or Stop to stop a medicine one medicine at a time 3. Taper Medicine when appropriate 4. Check for Benefit or Harm after each medicine has been stopped With the person’s consent, view the discontinuation process as a trial At the next scheduled visit review progress, then either: Maintain (at half dose) Continue to taper (e.g. quarter dose) Stop Time taken to taper may vary from days to weeks to months If symptoms worsen, may need to reinstate the medication At the first visit, halve the dose Frank C, Weir E. CMAJ 2014;186(18):1369-1376 Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly a pproach Questions

24. Case study : Mary Mary is 85 years old and has 4 chronic conditions that require 9 medications. N o changes to her medications for 5 years. One month ago a new medication was started. Soon after that, she began to feel unsteady when walking and has been incontinent of urine on 2 occasions because she is not able to get to the bathroom fast enough. One week ago, she fell but only sustained some bruising of her arm. She is mystified by these new problems and wonders if she is getting old and whether she can stay in her own apartment. She wonders if she should report these problems to her daughter. What’s going through your mind? Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly a pproach Questions

25. Is Mary at risk of problematic polypharmacy? Identify the risk factors in Mary’s case + + Multiple medical p roblems / multiple m edications Reduced homeostatic mechanisms and organ dysfunction AND/OR Frailty Acute illness or change to medications Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly a pproach Questions

26. Is Mary at risk of problematic polypharmacy? 4 chronic conditions that require 9 medications: Prescribing cascade and increasing polypharmacy Problematic medications left unchanged Risk of further decline in health status + Multiple medical p roblems / multiple m edications Reduced homeostatic mechanisms and organ dysfunction AND/OR Frailty Acute illness or change to medications Identify the risk factors in Mary’s case Objectives What is Polypharmacy? Impact for the Older Person Risk Factors Detecting Addressing Case Study Summary Senior Friendly Approach Questions

27. N ew acute condition may have: Compromised her homeostatic mechanisms; or  Worsened her already impaired organ function + M ultiple m edical p roblems / multiple m edications Reduced homeostatic mechanisms and organ dysfunction AND/OR Frailty Acute illness or change to medications Is Mary at risk of problematic polypharmacy? Identify the risk factors in Mary’s case Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly a pproach Questions

28. N ew health problems not attributed to medications: Urinary incontinence, via decreased mobility Fall Confusion: Mary is unsure if episodes should be reported to daughter Psychological distress: Mary is worried about ability to live independently + Multiple medical problems/ multiple medications Reduced homeostatic mechanisms and organ dysfunction AND/OR Frailty Acute illness or change to medications Is Mary at risk of problematic polypharmacy? Identify the risk factors in Mary’s case Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly a pproach Questions

29. R ecently been prescribed a new medication for a new condition/acute illness Usual medications have caused unanticipated harm Recent medications were not communicated to Mary’s daughter, leading to insufficient health monitoring and reporting No recent medication review + Multiple medical problems/ multiple medications Reduced homeostatic mechanisms and organ dysfunction AND/OR Frailty Acute illness or change to medications Is Mary at risk of problematic polypharmacy? Identify the risk factors in Mary’s case Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly a pproach Questions

30. Case study : Mary - resolution Finally, apply the Medication Review Framework (DEBRIDE) to determine if Mary can benefit from de-prescribing. D ose and frequency - Is the dose and frequency correct based on age and organ function ? E ffects - Have the known side effects been considered ? B enefit - Will Mary benefit from treatment given goals of care ? R isk - Is the medication considered a high risk medication? I ndication - Is the indication for the new medication clear and valid ? D rug monitoring - Is a monitoring plan in place to assess benefit and harm ? E xpectations - Are the expectations of benefit to be achieved realistic? Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly a pproach Questions

31. Summary Polypharmacy is common ≥ 65 years due to multiple conditions requiring medications polypharmacy can be appropriate or problematic Risk of harm increases with # medications, frailty, and illness inconvenience ……hospitalization……….. death Medication appropriateness may change over time decline in functional reserves of organs (frailty) maintenance medications may become harmful medication changes result in adverse effects or new drug-interactions Medication appropriateness may change with acute illness loss of physiologic reserve causes medications to have an enhanced effect Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly a pproach Questions

32. 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. Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly a pproach Questions

33. 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 Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly a pproach Questions

34. The senior friendly approach How all healthcare providers can address polypharmacy using a senior friendly care approach Leadership-supported medication reviews Providing staff and patient education Changes in condition prompt a medication review – regardless of patient age Medications are meeting the older adult’s goals Facilitate medication reviews Medication reminder systems to increase adherence Organizational Support Emotional & Behavioural Environment Ethics in Clinical Care and Research Physical Environment Processes of Care Organizational Support Ethics in Clinical Care and Research Processes of Care Emotional & Behavioural Environment Physical Environment Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions

35. Which of the strategies to limit the potential harms due to polypharmacy (slide 33) are you already using in your practice? What are some of the barriers to implementing strategies to limit the potential harms due to polypharmacy (slide 33 )? What is one strategy that you can implement moving forward? Discussion questions Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly a pproach Questions

36. The sfCare Learning Series received support from the Regional Geriatric Programs of Ontario, through funding provided by the Ministry of Health and Long-Term Care. V1 July 2019