Polypharmacy - What next? (Planning for Wessex) Workshop Polypharmacy and Support (Dr John Duffy) March 2017

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‘Polypharmacy &
Support
Frailty
Dr John Duffy
Assistant Director Clinical
Transformation & Outcomes

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Frailty:- Definition
• A distinctive health state related to the ageing process
in which multiple body systems gradually lose their in-
built reserves

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Polypharmacy:- Definition King’s Fund 2013
Appropriate Polypharmacy prescribing for an
individual with complex/multiple conditions where the
use of medications has been optimized and there use is
evidenced based
Problematic Polypharmacy where multiple
medications are prescribed inappropriately or where the
intended benefit of medication is not realised (poor
evidence or risk of harm outweighs benefit)

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Polypharmacy:- Definition (continued)
Defining polypharmacy in the elderly: a systematic
review protocol (BMJ open access 2016)
• Recent decades, several scientific investigations have
studied polypharmacy using different approaches and
definitions and their results have been inconclusive.
Differences in definitions and approaches in these
studies form a barrier against reaching a conclusion
regarding the risk factors and consequences of
polypharmacy. It is therefore imperative to establish
an appropriate definition of polypharmacy.

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What is Frailty, how common is it ?

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2 major frailty models
• Phenotype model A distinct clinical syndrome with 3
or more from 5 criteria: weakness, slowness, low level
of physical activity, self-reported exhaustion, and
unintentional weight loss (Fried 2001)
• Cumulative deficits model The number of deficits
accumulated over time including the number of
diseases, the presence of physical and cognitive
impairments, psychosocial risk factors and geriatric
syndromes (falls, delirium, urinary incontinence)
(Rockwood 2005).
• .

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Longitudinal study 2014 UK (Fried criteria)
Weighted prevalence of frailty was 14%
Prevalence rose with increasing age
 6.5% in those >60 years
 30% in those >80 years
 65% in those >90 years
(Age & Ageing 2014)

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Based on UK population growth statistics
• 2030 percentage population >80 years increased by
70%
• 2037 percentage population >80 years doubled

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Frailty Recognition
When should you suspect frailty is part of the problem?

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Frailty Recognition:- Routine
All have good sensitivity but moderate specificity
A range of tests have been investigated however 3 tests
seem superior to the others:-
• Timed up and go test – Taking more than 10 sec to
stand up from a standard chair, walk a distance of 3
m, turn, walk back to the chair and sit down.
• Walking speed (gait speed) - Taking > 5 secs to walk
4m
• PRISMA 7 Questionnaire - 7 item questionnaire a
score of >3 considered to identify frailty.

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Frailty Recognition:- Prisma 7 Questions
• Are you more than 85 years?
• Male?
• In general do you have any health problems that require
you to limit your activities?
• Do you need someone to help you on a regular basis?
• In general do you have any health problems that require
you to stay at home?
• In case of need can you count on someone close to you?
• Do you regularly use a stick, walker or wheelchair to get
about?

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Frailty Recognition:- Crisis
5 Frailty Syndromes
Encountering one of these ‘syndromes’ should raise
suspicion that the person may have frailty!
• Falls
• Immobility
• Delirium
• Incontinence
• Susceptibility to side effects from medication

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Reasons why older patients are
susceptible to medication side effects
Geriatric patients are also particularly vulnerable to the
effects of polypharmacy due to
• comorbidity
• age-related functional decline of the kidney and liver
affecting metabolism and clearance of drugs
• decreased lean body mass and total body water
• relative increase in total body fat can further alter drug
kinetics.
Consequently, medications used in the elderly may have
faster onset, higher bioavailability, and longer duration of
action

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Case finding Frailty in primary care

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Identification and management of patients with
Frailty Enhanced Services GMS contract 17/18
Practices will use an appropriate tool (eFI) to identify patients aged 65 & over
living with moderate/severe frailty.
Patients with severe frailty will undergo a clinical review (medication
review/falls/other clinically relevant interventions).
Where a patient does not already have an enriched Summary Care Record
(SCR) the practice will seek informed patient consent to activate.
Practices will code appropriately and data will be collected:
• —— recorded with a diagnosis of moderate frailty
• —— with severe frailty
• —— with severe frailty with an annual medication review
• —— with severe frailty who had a fall in the preceding 12 months
• —— severely frail, who consented to activate their enriched SCR

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Once Frailty identified and then what?

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CGA
Medical Comorbidities Functional Basic ADL’s
Medication Gait/Balance
Nutrition Activity/Exercise
Problem list Instrumental ADL
Mental Health Cognition
Mood Social Informal support
Anxiety Social network
fears Eligibility to SS
support
Environment Home comfort/safety
Use telehealth
Transport access
Local resources

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Polypharmacy prevalence
• Primary care study on 300,000 patients in Scotland
showed increase in the mean number of drugs dispensed
from 3.3 (1995) to 4.4 (2010)
• PRACtICe study showed higher rates of concurrent
prescribing associated with higher rates of hazardous
prescribing with each medication increase raising the error
rate by 16%(Avery 2012)
• Secondary care study the mean number of medications in
an older hospitalised patient was 6 with increased
prescribing associated with increased error rate (Gallagher
2011)
• Care homes setting study in 256 residents taking an
average 8 medications with a 69% error rate (Barber 2009)

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Tools available to help identify inappropriate
prescribing in older people (Kings Fund 2013)
• Beer’s criteria JAGS 2012
• French consensus JCP 2007
• IPET Canadian JCP 2000
• Pincer indicators Lancet 2012
• RCGP indicators BJGP 2011
• STOPP-START Int JCP&T 2008

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BEER’s Criteria
Oldest and most well-known
Criteria consist of a list of medications to potentially avoid or
replace in patients ≥65 years of age
Simple and can be applied to large populations but has
several limitations including:
1. Inclusion of obsolete drugs
2. Requires periodic updating
3. Contains some controversial contraindications
4. Omission of drug-drug interactions or drug duplications
5. It overlooks medication omission errors
Eur.Ger.Med 2010

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STOPP-START
• Screening Tool of Older Persons Potentially Inappropriate
Prescriptions and Screening Tool to Alert Doctors to the Right
Treatment (STOPP/START) criteria were developed and
validated to address the limitations of the Beers criteria.
• STOPP/START criteria are organized by system, list drug-drug
and drug-disease interactions to avoid (e.g. thiazide diuretic with
history of gout), and address therapeutic duplication and
omission errors
• Prospective study 600 consecutive elderly inpatients found the
adjusted odds ratios for serious avoidable ADE were 1.85 (95%
CI: 1.51-2.26) and 1.28 (95% CI: 0.95-1.72) with application of
STOPP criteria and Beers criteria, respectively, suggesting that
STOPP/START may more accurately predict ADE JAMA 2011

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Medication Appropriateness Index
• MAI has some advantages because it incorporates clinical judgment. The
tool consists of 10 questions that are to be applied to each medication, for
example: “Is there an indication for the drug? Is it effective for the condition?
Is there unnecessary duplication with other drugs?”. The MAI focuses on
the patient-medication interaction rather than solely the medication
• A study found that a modified MAI scoring approach (allowing clinicians to
decide which MAI items were appropriate) significantly predicted ADE risk
(OR: 1.13; 95% CI 1.02-1.26), while Beers criteria and the original MAI
scoring approach did not Ann PharT 2010.
• The ideal measure would be simple, easy to calculate, patient-centred, and
validated in both inpatient and outpatient settings. While none of the existing
measures are perfect, the STOPP/START criteria may be more practical at
flagging high-risk prescribing in clinical practice. The MAI, although more
time-consuming, may have promise as a predictive tool for ADE when used
by well-trained clinicians.

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What patient factors impact on
medication related admissions?

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Multiple studies have identified risk factors associated
with polypharmacy and patients who develop ADE.
These patient characteristics can be classified into three
groups:
1. demographic (increasing age, white race, female
gender, higher levels of education)
2. health status (general poor health, cardiovascular
disease, hypertension, asthma, diabetes)
3. access to health care (increased number of health
care visits, multiple providers, type of insurance
(AJGPhar 2007)

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Patient related risk factors to
medication related admission WeMeRec 2015
• Impaired cognition
• Four or more diseases in patient’s medical history
• Dependent living situation
• Impaired renal function before hospital admission
• Non-‐adherence to medication regimen
• Age > 65 years (more likely to experience an ADR)

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Which medication factors are
commonly related to MRA?

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Medication related risk factors WeMeRec 2015
General
• Polypharmacy (≥ 5 medicines at the time of admission)
• New medicine started within the last 7 days
• Complex medication regimens at hospital admission
(Predictive of re- hospitalisations for ADRs) #
Specific drugs
• Anticoagulants
• Antiplatelet agents
• Diuretics
• NSAIDs
• ACE inhibitors

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When to target for medication review?
• Patients undergoing CGA
• Patients with impaired cognition/renal function
• Housebound patients
• Patients identified by eFi practice case finding as part
of the enhanced services GMS contract 17/18
• Situations involving transition of care, place patients
at higher risk ADE (hospital discharge JAGS 2005, care
home admission AJGPharT 2010)
• Situations when patients managed by multiple
providers increases ADE by 29% AJGPharT 2007

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Is there a case for altering clinical targets?
Growing body of evidence suggests that maintaining strict goals (e.g.
hemoglobin A1c <7 in diabetes or tighter blood pressure control based on
comorbidities) may in fact be harmful in the elderly Elderly Med 2013
• Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial
demonstrated no decrease in MI, stroke, or cardiovascular death with tight
glycemic control, but rather an increased risk of hypoglycemia, adverse
events, and death NEJM 2008
• Hypertension in the Very Elderly Trial (HYVET), a RCT that showed
reduction in stroke and overall mortality in very elderly patients (>80 years
old) with blood pressure management, showed benefit at a goal blood
pressure of 150/80--higher than oft-cited goal blood pressures NEJM 2008
By liberalizing our clinical targets, we may be able to minimize morbidity and
decrease usage of medications such as sulfonylureas or antihypertensives that
may have more potential to harm than help Elderly Med 2013

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Is there a role for an active de-prescribing
approach in Frailty?

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Deprescribing
Deprescribing is the process of withdrawal of an inappropriate medication, supervised by a
healthcare professional with the goal of managing polypharmacy and improving
outcomes.”
BrJClinPhar 2015
Medication review is “a structured, critical examination of a person's medicines with the
objective of reaching an agreement with the person about their treatment, optimising the
impact of medicines, minimising the number of medication-related problems and reducing
waste” by providing appropriate information about the harms, benefits and goals of
such treatment so that patients/NOK can be actively involved in the decision-making
process.
The reviews should include:
• identification of the patient's priorities,
• discussion of the acceptability of treatment and how it relates to the patient's beliefs
and expectations, and
• the option of stopping treatments.

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A systematic approach to de-prescribing in Israel
Applying similar care principles seen in palliative care to geriatric
and disabled (but non-palliative care) patients, developed and
tested the Good Palliative Geriatric Practice algorithm
1. Is there evidence for this drug in this patient’s age group?
2. If not, “Does benefit outweigh risk?
3. Would an alternative be better?
4. Would a lower dose be more appropriate?
Of 70 elderly patients reviewed, an average of 4.9 drugs were
discontinued in 64 patients; only 2% were restarted because of
recurrence of the original indication. Not only was discontinuation
not harmful, but an astounding 88% of patients also reported a
global improvement in health JAMA 2010/Isr.Med.Assoc.J 2007

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Current Guidance on De-prescribing
• All Wales Medicines Strategy Group
(http://www.awmsg.org/docs/awmsg/medman/Polypharmacy%20-
%20Guidance%20for%20Prescribing.pdf)
• Scottish Guidance (www.sign.ac.uk/pdf/polypharmacy_guidance.pdf)
• Derbyshire De-prescribing a practical guide
(http://www.derbyshiremedicinesmanagement.nhs.uk/assets/Clinical_Guidelines/clinic
al_guidelines_front_page/Deprescribing.pdf)
• Manchester de-prescribing toolkit 2016 (http://gmmmg.nhs.uk/docs/guidance/NWCSU-
Polypharmacy-guidance-2016.pdf)
• BGS CGA medication guidance (http://www.bgs.org.uk/cga-toolkit/cga-toolkit-
category/what-is-cga/cga-what?jjj=1490799028553)
• PrescQIPP NHS programme 2011 Polypharmacy and De-prescribing web kit
(IMPACT)
• Methodology for Developing Deprescribing Guidelines: Using Evidence and GRADE to
Guide Recommendations for Deprescribing PLoS ONE on-line 2016
• De-prescribing.org Canadian website developed by pharmacist/physician

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Developing Wessex approach
• How do we ensure the patients views are central to the
process (standardised output from process with high
visibility + training)
• Should we be developing structured algorithm approach to
the medication review section of proposed Wessex CGA
process (?role of local experts)
• Should we be developing a Wessex approach to all
admissions to a care home (Health check)
• How do we ensure decisions surrounding medication
review are consistently adhered to across all providers
(patient held record v Enhanced summary care record v
new IT solution)

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