Polypharmacy in the Elderly
Dorothy....age 84
Previously lived with daughter and son-in-law.
Mild dementia, hypertension from age 50, NIDDM, diet cont...
Dorothy....age 84
Nursing discussion with family...want her on Donepizil...
2.5mg daily ordered by Doctor On-Call
1 month ...
Dorothy....age 84
Falls and breaks hip.
Hospital for 3 weeks.
Comes back to RC on Nexium, Fosamax, Calcium, Vitamin D,
Mul...
 Multiple Medications
 One Inappropriate Medication
 More than 5 medications
 More than 5 inappropriate medications
 ...
Our working definition
 When the theoretical benefits of multiple
medications are outweighed by the negative
effect of th...
What are the risks of
Polypharmacy?.

7
Decreased:
Cognitive function, ADL’s,Quality of Life
Increased:

ADE’s, Falls, Transfers to Acute Care
Which leads to:

Ho...
Adverse Drug Reactions
 The most consistent risk factor for adverse drug
reactions is:
number of drugs being taken
 Risk...
percent of patients with ADR

100

10

1
0

2

4

6
8 10 12 14
number of drugs taken

16

18

20
What are the causal factors
leading to Polypharmacy?

12
 Clinical Practice Guidelines
 Chronic Disease Management
 Treating surrogate markers
 Clinical uncertainty





...
What are the barriers to effective
Medication Reviews?

14
Consensus on clinical/pharmacological knowledge
Perceived medico-legal risks
Other care priorities, time, remuneration
Pro...
Drugs of Concern
• Drugs associated with:
• Falls
• Antipsychotics
• antidepressants (tricyclics)
• hypnotics
• Antihypert...
Drugs of Concern
• Drugs associated with:
• Confusional states
• Antipsychotics
• Antidepressants
• Opioid
• Analgesics
• ...
Drugs of Concern
• Drugs associated with:
• Indications not or no longer present
• Statins
• PPIs
• Analgesics
• Osteoporo...
Drugs of Concern
• Drugs associated with:
• Significant anticholinergic effects
• Antidepressants (tricyclics)
• Antihista...
Who are the key stakeholders who
will be essential for sustainability
of this Project?

20
 Physicans
 MRP’s
 Medical Directors
 Specialists
 Pharmacists
 PSD
Nursing
DoC
RN,LPN, Care Aids
Health Authorities...
Back to Dorothy!
Dorothy....age 84
Falls and breaks hip.
Hospital for 3 weeks.
Comes back to RC on Nexium, Fosamax, Calcium, Vitamin D,
Mul...
Summary

Count the Pills!.
QUESTIONS?

 “One of the first duties of the physician is to

educate the masses not to take medicine.”




1919

Sir W...
The Pieces of the Puzzle in Optimizing Medications: Polypharmacy in the Elderly
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The Pieces of the Puzzle in Optimizing Medications: Polypharmacy in the Elderly

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Presented at Optimizing Medications workshop by Keith White.

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The Pieces of the Puzzle in Optimizing Medications: Polypharmacy in the Elderly

  1. 1. Polypharmacy in the Elderly
  2. 2. Dorothy....age 84 Previously lived with daughter and son-in-law. Mild dementia, hypertension from age 50, NIDDM, diet controlled from age 60. Same Family Physician for 25 years. Suffered a slight stroke, left with residual dysphasia and increased cognitive problems. Admitted to RC, 45min drive from physician’s office. LOI 2, no advanced directive. 60 bedded RC, looked after by call-group of 10 Family , 6 Residents each. Meds on admission: Aspirin, HCTZ, Altace, plus standing orders – Gravol, Tylenol, etc. Family member works in Rapid Access Stroke Unit – tells daughter Statin would prevent another stroke......Rx Lipitor 40mg daily. Six weeks later, develops pain in thighs and knees.......phone Dr. On-call.... ...Rx Tylenol 3, 1 tablet 3x daily. Twice daily, Glucostix......FBS 9.0 Postprandial......14 Started on Metformin, 2x daily.
  3. 3. Dorothy....age 84 Nursing discussion with family...want her on Donepizil... 2.5mg daily ordered by Doctor On-Call 1 month later...Dorothy has had 3 syncopal episodes... 2 hospital admissions of a week each. Sustained bradycardia......Pacemaker inserted. On return from hospital, won’t get out of bed... Depression...Citalopram 10mg daily. Also has some urinary incontinence....Oxybutinin.... dipstick shows WBC’s...Cipro. Nauseated...Gravol 50mg STAT...prn...TID. Now has a rash...Benadryl 25mg TID. Now “calls out” a lot at night...Ativan 1mg STAT...prn...twice a day. Does not help...Respiridone 0.25mg STAT...prn...twice a day. Helps somewhat. Two weeks later, “calling out” again, has managed to get out of bed and is wandering into other people’s rooms. Rx Seroquel.
  4. 4. Dorothy....age 84 Falls and breaks hip. Hospital for 3 weeks. Comes back to RC on Nexium, Fosamax, Calcium, Vitamin D, Multivitamin... Now lies in bed and stares at ceiling... Family conference...LOI 1...stop all drugs...
  5. 5.  Multiple Medications  One Inappropriate Medication  More than 5 medications  More than 5 inappropriate medications  More than 10 appropriate medications 5
  6. 6. Our working definition  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. 6
  7. 7. What are the risks of Polypharmacy?. 7
  8. 8. Decreased: Cognitive function, ADL’s,Quality of Life Increased: ADE’s, Falls, Transfers to Acute Care Which leads to: Hospitalisation Associated Disability I 8
  9. 9. Adverse Drug Reactions  The most consistent risk factor for adverse drug reactions is: number of drugs being taken  Risk rises exponentially as the number of drugs increases.
  10. 10. percent of patients with ADR 100 10 1 0 2 4 6 8 10 12 14 number of drugs taken 16 18 20
  11. 11. What are the causal factors leading to Polypharmacy? 12
  12. 12.  Clinical Practice Guidelines  Chronic Disease Management  Treating surrogate markers  Clinical uncertainty       ADE or new symptom? Treating S/E with another pill Multiple prescribers Lack of history Uncertain treatment goals Lack of communication 13
  13. 13. What are the barriers to effective Medication Reviews? 14
  14. 14. Consensus on clinical/pharmacological knowledge Perceived medico-legal risks Other care priorities, time, remuneration Process and communication issues Family and residents Absentee MRP’s Cartesian practice 15
  15. 15. Drugs of Concern • Drugs associated with: • Falls • Antipsychotics • antidepressants (tricyclics) • hypnotics • Antihypertensives • Hypoglycemics • Anticonvulsants • Antiparkinson meds • Antihistamines
  16. 16. Drugs of Concern • Drugs associated with: • Confusional states • Antipsychotics • Antidepressants • Opioid • Analgesics • Hypnotics
  17. 17. Drugs of Concern • Drugs associated with: • Indications not or no longer present • Statins • PPIs • Analgesics • Osteoporosis meds • Antihypertensives • Antianginals • Antipsychotics • Antidepressants
  18. 18. Drugs of Concern • Drugs associated with: • Significant anticholinergic effects • Antidepressants (tricyclics) • Antihistamines
  19. 19. Who are the key stakeholders who will be essential for sustainability of this Project? 20
  20. 20.  Physicans  MRP’s  Medical Directors  Specialists  Pharmacists  PSD Nursing DoC RN,LPN, Care Aids Health Authorities Residents, families, caregivers, future residents. 21
  21. 21. Back to Dorothy!
  22. 22. Dorothy....age 84 Falls and breaks hip. Hospital for 3 weeks. Comes back to RC on Nexium, Fosamax, Calcium, Vitamin D, Multivitamin... Now lies in bed and stares at ceiling... Family conference...LOI 1...stop all drugs...
  23. 23. Summary Count the Pills!.
  24. 24. QUESTIONS?  “One of the first duties of the physician is to educate the masses not to take medicine.”   1919 Sir William Osler 1849-

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