The Patient's Journey

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Presented at Optimizing Medications workshop in Vancouver by Johanna Trimble

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The Patient's Journey

  1. 1. Community • Professional Academic Detailing in GP offices Medication knowledge • Polypharmacy Medication review Patient Hospital • MedRec Best possible medication history • 48/6 Assess 6 areas w/i 48 hr • Polypharmacy Medication review Transition in Care Residential Care • MedRec Best possible medication history • CLeAR Appropriate antipsychotic use • Polypharmacy Medication review
  2. 2. Optimizing Medications: Time to bring the pieces together January 16-17, 2014 (BCPSQC) Is Your Mom on Drugs? Johanna Trimble Polypharmacy Initiative (Shared Care): Steering Committee Call for Less Anti-Psychotics in Residential Care: CLeAR Faculty Fraser Health Authority, Polypharmacy Initative
  3. 3. Let’s work together to change how we care for elders • Realize the impact of multiple medications on frequent hospitalizations, loss of function & inability to live independently • Schedule medication reviews that help lessen the burden of multiple medications and improve quality of life • Involve the family as part of your team – ask them for input and act on their concerns
  4. 4. Who was Fervid Trimble?
  5. 5. Teacher (MEd, U. of Idaho) Wife, mother, grandmother, family matriarch
  6. 6. Fervid Trimble, age 86 years, enjoying her apartment in a senior’s residence she’d carefully chosen for herself.
  7. 7. Fervid’s “family care team” Johanna, Dale, Fervid and Kathie
  8. 8. Fervid experienced a precipitous mental decline
  9. 9. Why we decided to intervene: • • • • • Her problems came on quite quickly Didn’t fit her diagnosis or her history Several new drugs had been prescribed We researched drug interactions, and then… We requested a medication review with facility staff
  10. 10. The family team • Pay attention to your loved one: watch, ask, listen, write • • • • • it down Research: identify REPUTABLE internet and other resources to research drugs, side effects and treatments Compare: symptoms with adverse effects or interactions of current, and especially new, drugs Communicate: first as a family – then with the staff Timing: delays can cost precious time in reversing adverse effects Be respectful but persistent
  11. 11. “Assume that any new symptom you develop upon starting a new drug may be caused by the drug. If you have a new symptom, psychiatric or otherwise, report it to your doctor” Public Citizen, Health Research Group www.worstpills.org
  12. 12. Do the professionals know the patient’s baseline? The family probably does… Everyone intends well, but they may not be seeing the big picture (or the frail person) in front of them0.
  13. 13. Symptoms of Serotonin Syndrome: 1. Cognitive/behavioral changes: confusion, agitation, lethargy 2. Autonomic instability: rapid heart rate, sweating 3. Neuromuscular changes: myoclonus (twitching a muscle or group of muscles) Self-limited if recognized early, it can be fatal if left unrecognized and untreated.
  14. 14. SSRI antidepressant (citalopram) + serotonergic pain medication to replace Vioxx (tramadol) = Serotonin Syndrome
  15. 15. MORE drugs had been suggested! • Donepezil (Aricept), often prescribed for Alzheimer’s, was suggested by the facility’s consulting Psychiatrist whose diagnosis was “vascular dementia”. • We declined, after reviewing the Therapeutics Initiative’s recommendations regarding the medication – and asked that no additional drugs be prescribed without family consent and without a medication review of all medications.
  16. 16. “Ask about changes in your loved one even if no one asks.” http://thisisnotmymom.ca
  17. 17. Delirium • Drugs and bugs (infections) most likely causes • Polypharmacy plus advanced age can often result in delirium. • Delirium can be mistaken for Alzheimer’s or dementia if the baseline isn’t known • A minor change (in drugs) can precipitate a crisis among vulnerable elders (ask Dr. Sloan!). • Delirium is a serious health threat -- but also largely preventable. • “After an episode of delirium, one year mortality among frail elderly can be as high as 35 to 40%” - Delirium Prevention Training program: IPPOD Sunnybrook Health Sciences Centre, Toronto ON
  18. 18. Definition of Polypharmacy When the theoretical benefits of multiple medications are outweighed by the negative effect of the sheer number of medications, regardless of class of medication or “appropriateness” thereof.
  19. 19. Much prescribing for the elderly is an “evidence-free zone”. A Bitter Pill: How the Medical Systemis Failing the Elderly by Dr. John Sloan
  20. 20. Polypharmacy is a stand- alone risk factor for morbidity
  21. 21. Polypharmacy & admissions to acute care • 5 or more drugs • 7 or more drugs • 9 or more drugs 10% 20% 30% Percentage increase in transfers to acute care per year
  22. 22. Loss of function • 1 in 3 frail elders admitted to hospital is discharged at a higher level of disability • Can lose up to 5% of functional muscle strength for every day in bed. • Delirium will keep a patient in bed and result in loss of function, even when the illness necessitating the hospitalization is successfully treated.
  23. 23. Fervid recovered cognitively from a diagnosis of “vascular dementia” after some drugs were stopped Enjoying white wine and oysters with her family at her favourite restaurant.
  24. 24. Many weeks in bed resulted in loss of function. Fervid could not return to independent living.
  25. 25. The result of Fervid’s “drugectomy” • Normal mental status (as bright as ever!) • Physical improvement • Fervid returned to “training” care aides she thought needed it • Formed close relationships with staff • Joined us for family outings • Lived 4 more years • But…she could not return to independent living
  26. 26. My Question: Is there an epidemic of Alzheimer’s and dementia? • We constantly hear of the “epidemic” of Alzheimer’s and dementia. • Is there an epidemic of over-medication (with resulting hospital admissions – often the worst place for a frail elder to be?) • How do I want it to be when I get there?
  27. 27. Alzheimer’s is often misdiagnosed "It's a real problem. If you're older and you get a label of Alzheimer's — even a hint that you have Alzheimer's — there's no more critical thinking about it. The difficulty in pinning down Alzheimer's makes misdiagnosis too easy." Peter Lichtenberg, Head of the Institute of Gerontology Wayne State University
  28. 28. Polypharmacy & c. difficile • Fervid had many antibiotic treatments for suspected UTI’s • 5 other residents had it • Cleaning & infection protocols substandard or inconsistent • Frequent transfer of staff and patients • 5 courses of vancomycin weakened Fervid
  29. 29. A picture is worth a thousand words… Over-medicated Life after the “drugectomy”
  30. 30. “It’s (about) quality of life…for my residents. I've seen dramatic differences in the quality of their life when the burden of their medication is reduced...”
  31. 31. What our family learned from Fervid
  32. 32. “Life’s too precious — we’ve enjoyed each other so much. I think [love] will grow. That’s the ticket into the next world. We will always be together, our love is always there and we will be part of the great growing field of love. …I’ll be out there watching you”. Fervid Trimble, August 2008
  33. 33. The meaning for all of us… Fervid died blessing us. If she had died 4 years earlier of her drug interaction, she would have died not even recognizing us. Let us work together to give our elders the chance for a leavetaking that has profound meaning both for their loved ones and themselves.
  34. 34. Dedicated to Fervid Trimble 1917 - 2008 A picnic in the garden with Fervid
  35. 35. Email: isyourmomondrugs@gmail.com Website: www.isyourmomondrugs.com
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