"Align-tegrating" Medication Care for Seniors

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This was presented in session C4 at the Quality Forum 2014 by:

Keith White
Clinical Lead, Medication Reconciliation
BCPSQC
Lead, Polypharmacy Initiative
Shared Care

Doug Danforth
Manager, Long-term Care Services
West End Medicine Centre

Published in: Health & Medicine
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"Align-tegrating" Medication Care for Seniors

  1. 1.  I have had no support, funding or honoraria from any drug company.  But I do own and operate a pharmacy  I am a senior myself so I have a bias  I take drugs too!
  2. 2.  Quantity versus quality  Therapeutic benefit versus potential harm  Is life expectancy shorter than the time needed to benefit from the medication prescribed?  Can medications be reduced or stopped?
  3. 3.  Is there evidence the medication is effective, needed or clearly indicated?  If not, can the medication be tapered, withdrawn, stopped or dose reduced?  Is there evidence the medication is causing harm (low blood pressure and low blood sugars can be harmful!)  What is the risk of stopping the medication?
  4. 4. Home Number of Residents Male Female Age 90 or greater AM 62 17 45 24 CO 76 18 58 25 PP 75 27 48 33 KC 74 5 69 29 Total 287 67 (23%) 220 (77%) 111 (39%)
  5. 5. Average weight: Male 74 Kg Average weight: Female 57 Kg
  6. 6.  AVERAGE AGE OF ALL 287 RESIDENTS IS 88.2 YEARS  AVERAGE MEDICATION USE IN CARE HOMES IS BETWEEN 6 AND 8 REGULAR MEDICATIONS PER RESIDENTS  RANGE IS 0 TO 20  11 RESIDENTS ARE 99 OR OLDER AND AVE FOR THESE IS 5!! (RANGE 0 TO 8)
  7. 7. Intensive control of blood pressure and blood sugars does not necessarily improve outcomes. In fact, studies have shown the opposite. Frail elderly do better with higher blood pressures and higher blood sugars than previously thought. BUT! How high can we go? What is safe?
  8. 8.  TARGET SYSTOLIC BLOOD PRESSURE 140 mm Hg (SBP less than 140 mm does not improve outcomes and results in more side effects)  TARGET FASTING GLUCOSE 5.0 TO 12 mmol/L and HgA1c VALUES LESS THAN 8.5% (Prevention of hypoglycemia should be a priority)
  9. 9.  DO NOT CONSIDER STARTING TREATMENT UNLESS SBP IS GREATER THAN 160 mm Hg  IF SBP IS LESS THAN 140 mm Hg MEDICATIONS CAN BE TAPERED AND DISCONTINUED  IN THE VERY FRAIL WITH SHORT LIFE EXPECTANCY TARGET SBP IS 160 TO 190 mm Hg  DO NOT USE MORE THAN 2 ANTI-HYPERTENSIVES
  10. 10.  BP FEB 2013 122/76  BP MAR 2013 115/78  BP APR 2013 131/79  AMLODIPINE 10 MG DAILY D/C MAY 6/2013  BP AUG 2013 144/54  BP SEP 2013 122/68
  11. 11.  BP 122/66 MAY 7/13  BP 140/71 MAY 12/13  BP 116/76 JUN 1/13  AMLODIPINE 7.5 MG DAILY STOPPED JUN 19/13  BP 146/74 SEP 2013  BP 139/77 OCT 2013  BP 127/66 NOV 2013
  12. 12.  CALCIUM  BISPHOSPHONATES (eg. Alendronate, risidronate)  ANY ‘XL’, ‘ER’, ‘CR’ PRODUCTS (eg Biaxin XL or Ditropan XL)  POTASSIUM CHLORIDE PRODUCTS (eg K-DUR)  DABIGATRIN (PRADAX)
  13. 13. Primary Prevention (No history of stroke or ischemic heart disease) Secondary Prevention Do not start or continue statins Probably not necessary to start or continue (Prior history of stroke or satins ischemic heart disease) There may be extenuating circumstances that shift the risk/benefit ratio

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