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- 1. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Grand Rounds PharmD. NP Physician Topic: Age-Friendly Health Systems: Polypharmacy and the Older Adult Feel free to chat in the chat box. Remember to change your chat to ‘Everyone’ so we may all benefit from your comments. To Unmute your line: Click on your screen and then the microphone at the top of screen. Then click Unmute Call
- 2. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Providing Age-Friendly Care The goal is for all care with older adults to be Age-Friendly care, which: • Follows an essential set of evidence-based practices; • Causes no harm; and • Aligns with What Matters to the older adult and their family caregivers. AFHS-specific Grand Rounds cases focus on the 4Ms Framework as it pertains to patients 65 years of age and older What Matters, Medication, Mentation, and Mobility will be addressed as a set and ASSESSED and ACTED ON in each case scenario. The 4Ms include: • What Matters: Know, align and act on each older adult’s specific health outcome goals and care preferences • Medication: Optimize medication use to reduce harm and burden, focusing on medications affecting mobility, mentation, and what matters; If medication is necessary, use Age-Friendly medication that does not interfere with What Matters to the older adult, Mobility, or Mentation • Mentation: Focus to prevent, identify, treat, and manage dementia, depression and delirium in older adults • Mobility: Focus to maintain mobility and function and prevent/treat complications of immobility in older adults; Ensure that older adults move safely in order to maintain function and do What Matters
- 3. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. How to Integrate 4Ms Care into the Clinic Visit What Matters: These are some guiding questions or statements to help patients discuss what matters most to them: • What is most important for you during today’s visit? • What are you looking forward to this week? • What activities do you enjoy? If applicable, can ask: What is preventing patient from accomplishing tasks or participating in activities? • During development of care plan: I would like to individualize your treatment with what matters most to you Medication • Ask about all prescriptions: prescribed, over-the-counter, laxatives, vitamins, supplements, herbal remedies • Reconcile medications with electronic health record • Cross-check for medications that may be on the AGS Beers© Criteria list Mentation • Assess patient’s ability to register, use kiosk, follow directions • Screen for depression using the PHQ-2© and, if positive, continue with the PHQ-9© • Screen for dementia using the Mini-Cog™ • Assess for delirium for any acute change in mental status using the Confusion Assessment Method Mobility • Assess mobility, gait, gait speed, balance, footwear beginning when the patient walks in using the Modified Get Up and Go test • Assess hand dexterity, fine motor movements as patient removes insurance cards from wallet or writes or signs name
- 4. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Learning Objectives At the end of this session, providers will be able to: • Identify risk factors for adverse drug events in the aging population • Learn principles of de-prescribing and tools to address polypharmacy in the aging population • Integrate Age-Friendly care using the 4Ms Framework in care of older adults 65 years of age and over
- 5. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Case Scenario: Polypharmacy (S) Situation: Harry is an 88 year old male visiting the clinic with c/o urinary incontinence. He is accompanied by a live in caretaker. Incontinence onset was approximately 4 weeks ago. He denies dysuria, hesitancy or involuntary loss of a large volume of urine. (B) Background: PMH: COPD, dementia probable Alzheimer’s type, hypertension, hyperlipidemia, gout. Medications: fluticasone/salmeterol inhaler twice a day, donepezil 10 mg PO daily, amlodipine 5 mg PO daily, Aricept 10 mg PO daily, simvastatin 20 mg PO daily, allopurinol 200 mg PO daily, omeprazole 20 mg PO daily, docusate sodium 100 mg PO twice daily, multivitamin 1 tab PO daily, and ferrous sulfate 325 mg PO daily. He lives with a full-time caregiver in his own home. He enjoys attending adult day care 5 days a week. Former smoker, denies alcohol use. Hospitalized 4 weeks ago for pneumonia. Caregiver reports several medications added during hospitalization including Aricept when already on donepezil.
- 6. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Case Scenario: Polypharmacy (Cont.) (A) Assessment: Alert and pleasant and cooperative with exam VS: BP 130/70 mmHg HR 78/min, RR 14/min, Temp 98.7F, SpO2 94% on room air Mentation: PHQ-2 = 1; Mini-Cog = 5 (negative) Mobility: Patient walks in unassisted wearing appropriate footwear. Get Up and Go test: No difficulty getting up from a chair, walking 10 feet, turning around, walking back, and sitting back in chair. Respiratory: Lungs clear bilateral all lobes, no CVA tenderness Cardiac: Regular rate and rhythm, S1, S2, no murmurs Abdomen: Soft, non-tender Prostate exam deferred in this setting Urinalysis dip results all within normal limits (R) Recommendation: Let’s discuss…
- 7. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Recommendations for Polypharmacy and De-Prescribing • Consider consultation with PCP to review continued need for omeprazole, docusate, MVI, simvastatin • Discontinue duplicate Aricept (donepezil already on medication list) as this may have lead to urinary incontinence • Review history and onset of gout and allopurinol. Explore de-prescribing • Refer to PCP for further evaluation
- 8. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Polypharmacy Definition: The use of multiple medications at the same time Exact number defining “polypharmacy” varies in literature, although ≥ 5 concurrent medications is commonly used Risks associated with polypharmacy • Increase in adverse drug events • Increase in potential for falls with the addition of each medication • Increases in pill burden • Financial hardship Appropriate prescribing considers polypharmacy and person-centered factors including life expectancy and individual considerations such as the inability to swallow medication and the probability of adherence to a prescribed regimen The 2019 American Geriatrics Society (AGS) Beers Criteria® Update Expert Panel (2019). American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society, 67(4), 674-694. doi: 10.1111/jgs.15767. Available online at https://geriatricscareonline.org/ProductAbstract/american-geriatrics-society-updated-beers-criteria/CL001
- 9. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Risk factors that lead to polypharmacy and adverse drug events Higher number of co-morbid conditions • 20% of Medicare beneficiaries have 5 or more chronic conditions • 50% of Medicare beneficiaries receive 5 or more medications Multiple medical conditions Multiple prescribers Multiple pharmacies Automatic prescription refill systems Cognitive impairment Greater number of physicians/care providers involved in care TOTAL number of medications is single biggest factor here for ADE TOTAL number of medications is single biggest factor here for adverse drug events
- 10. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Tools to Assess for Polypharmacy • AGS Beers Criteria© for Potentially Inappropriate Medication Use in Older Adults • STOPP - Screening Tool of Older Peoples Prescriptions • START - Screening Tool to Alert to Right Treatment For more information on these tools, please visit the AFHS Banner on the intranet The 2019 American Geriatrics Society (AGS) Beers Criteria® Update Expert Panel (2019). American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society, 67(4), 674-694. doi: 10.1111/jgs.15767. Available online at https://geriatricscareonline.org/ProductAbstract/american-geriatrics-society-updated-beers-criteria/CL001
- 11. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Special Considerations for Medications in Older Adults Drug trials often exclude older adults as subjects. Hence, approved dosages may not be appropriate for older adults Changes to pharmacokinetics with age: absorption, distribution, metabolism, and excretion • Increase in fat relative to muscle mass, decrease in total body water, decline in hepatic function affecting metabolism, decrease in renal function with a decrease in creatinine clearance leading to increased drug excretion time • With changes in pharmacokinetics—overall impact is usually TOO MUCH drug, prolonged half-life and drug toxicity Effects of pharmacodynamics-physiologic effect of the drug Older adults are often started on medications that are NEVER stopped. So it is important to consider if each medication is it STILL needed and if it is helping or harming. An example is a short term benzodiazepine given for work-related stress, or personal stress at 55 that is never stopped and now causing harm, at 75 and also causing more susceptibility to CNS-active drug-drug interactions.
- 12. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. The Prescribing Cascade • Knee pain from osteoarthritis NSAID • Elevated blood pressure Calcium Channel Blocker (CCB) • Lower extremity edema Diuretic • Urinary incontinence Anticholinergic An adverse effect of a medication is mistaken for a new diagnosis and treated with an additional medication
- 13. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. The Prescribing Cascade Initial Drug Therapy Adverse Drug Event Subsequent Drug Therapy Antipsychotics Extrapyramidal signs and symptoms Antiparkinsonian therapy Cholinesterase inhibitors Urinary incontinence Incontinence treatment Thiazide diuretics Hyperuricemia Gout treatment NSAIDs Increased BP Antihypertensive therapy Gill, S.S, Mamdani, M., & Naglie, G, et al. (2015). A prescribing cascade involving cholinesterase inhibitors and anticholinergic drugs. Archives of Internal Medicine, 165(7), 808-813. doi:10.1001/archinte.165.7.808
- 14. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Back to the case… Summary: ASSESS and ACT ON the 4Ms as a set What Matters: Know and act on each patient’s specific health outcome goals and care preferences • Discuss cost of medications, enjoys adult day care, embarrassed by incontinence. Tailor plan accordingly Medication: Optimize use to reduce harm and burden, focusing on medications affecting mobility, mentation, and what matters • Medication reconciliation to fewest necessary drugs, explore prescribing cascades, provide resources https://deprescribing.org Mentation: Focus on dementia and depression and delirium • Optimize socialization through adult day care attendance, monitor for adverse drug events, incontinence support group Mobility: Maintain mobility and function and prevent/treat complications of immobility • Mobility plan to maintain optimal ambulation and independence Provide 4Ms brochure with suggestions for patient/family to share with primary care provider • Don’t forget to scan into the EHR whenever individualized.
- 15. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Interprofessional Team Discussion…
- 16. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Acknowledgements Age-Friendly Health Systems is an initiative of The John A. Hartford Foundation and the Institute for Healthcare Improvement (IHI) in partnership with the American Hospital Association (AHA) and the Catholic Health Association of the United States (CHA). MinuteClinic’s commitment to be an Age-Friendly Health System is supported by a grant from The John A. Hartford Foundation to the Case Western Reserve University Frances Payne Bolton School of Nursing.
- 17. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Thank You
Editor's Notes
- Today’s Topic is: Polypharmacy and the Older Adult
- The goal is for all care with older adults to be Age-Friendly care, which follows an essential set of evidence-based practices, causes no harm, and aligns with What Matters to the older adult and their family caregivers. AFHS-specific Grand Rounds cases will focus on the 4Ms Framework as it pertains to our patients 65 years of age and older. What Matters, Medication, Mentation, and Mobility will be addressed as a set and ASSESSED and ACTED ON in each case scenario. The 4Ms include: What Matters: Know, align and act on each older adult’s specific health outcome goals and care preferences Medication: Optimize medication use to reduce harm and burden, focusing on medications affecting mobility, mentation, and what matters; If medication is necessary, use Age-Friendly medication that does not interfere with What Matters to the older adult, Mobility, or Mentation Mentation: Focus to prevent, identify, treat, and manage dementia, depression and delirium in older adults Mobility: Focus to maintain mobility and function and prevent/treat complications of immobility in older adults; Ensure that older adults move safely in order to maintain function and do What Matters
- This slide provides information to help integrate 4Ms care into the clinic visit. This is the basis of providing Age-Friendly care. You will become familiar with the Age-Friendly Health Systems 4Ms Framework logo. What Matters: These are some guiding questions or statements to help patients discuss what matters most to them: What is most important for you during today’s visit? What are you looking forward to this week? What activities do you enjoy? If applicable, can ask: What is preventing patient from accomplishing tasks or participating in activities? During development of care plan: I would like to individualize your treatment with what matters most to you Consider discussion about advance care planning if appropriate for the visit, likely not applicable for visit related to polypharmacy Medication Ask about all prescriptions: prescribed, over-the-counter, laxatives, vitamins, supplements, herbal remedies Reconcile medications with electronic health record Cross-check for medications that may be on the AGS Beers© Criteria list Mentation Assess patient’s ability to register, use kiosk, follow directions Screen for depression using the PHQ-2© and, if positive, continue with the PHQ-9© Screen for dementia using the Mini-Cog™ Assess for delirium for any acute change in mental status using the Confusion Assessment Method Mobility Assess mobility, gait, gait speed, balance, footwear beginning when the patient walks in using the Modified Get Up and Go test Assess hand dexterity, fine motor movements as patient removes insurance cards from wallet or writes or signs name
- At the end of this session, providers will be able to: Identify risk factors for adverse drug events in the aging population Learn principles of de-prescribing and tools to address polypharmacy in aging population Integrate Age-Friendly care using the 4Ms Framework in care of older adults 65 years of age and over
- S: Situation: Harry is an 88 year old male visiting the clinic with c/o urinary incontinence. He is accompanied by a live in caretaker. Incontinence onset was approximately 4 weeks ago. He denies dysuria, hesitancy or involuntary loss of a large volume of urine. B: Background: PMH: COPD, dementia probable Alzheimer’s type, hypertension, hyperlipidemia, gout. Medications: fluticasone/salmeterol inhaler twice a day, donepezil 10 mg PO daily, amlodipine 5 mg PO daily, Aricept 10 mg PO daily, simvastatin 20 mg PO daily, allopurinol 200 mg PO daily, omeprazole 20 mg PO daily, docusate sodium 100 mg PO twice daily, multivitamin 1 tab PO daily, and ferrous sulfate 325 mg PO daily. He lives with a full-time caregiver in his own home. He enjoys attending adult day care 5 days a week. Former smoker, denies alcohol use. Hospitalized 4 weeks ago for pneumonia. Caregiver reports several medications added during hospitalization including Aricept when already on donepezil.
- A: Assessment: Alert and pleasant and cooperative with exam VS: BP 130/70 mmHg HR 78/min, RR 14/min, Temp 98.7F, SpO2 94% on room air Mentation: PHQ-2 = 1 (negative). Mini-Cog = 5 (negative) Mobility: Patient walks in unassisted wearing appropriate footwear; Get Up and Go test: No difficulty getting up from a chair, walking 10 feet, turning around, walking back, and sitting back in chair Respiratory: Clear bilateral all lobes, no CVA tenderness Cardiac: Regular rate and rhythm, S1, S2, no murmurs Abdomen: Soft, non-tender Prostate exam deferred in this setting Urinalysis dip results all within normal limits
- Consider consultation with primary care provider to review continued need for omeprazole, docusate, multivitamin, simvastatin Discontinue duplicate Aricept as this may have led to urinary incontinence due to high dose of Cholinesterase Inhibitor Review history and onset of gout and Allopurinol- explore de-prescribing Refer to primary care provider for further evaluation
- The definition of polypharmacy varies depending on the source but usually refers to the use of multiple medications at the same time often more than 5. Sometimes patients actually do need medications added due to their multiple chronic conditions. The important thing is make sure every medication has a clear indication and is the right medication, appropriate for an older adult. There is increased risk of adverse drug events with polypharmacy. There is an increase in potential for falls with the addition of each medication. One study found polypharmacy to be an independent risk factor for hip fracture. Polypharmacy increases pill burden, risk of adverse events and financial hardship. Appropriate prescribing considers life expectancy and other person-centered factors including individual limitations such as the inability to swallow medication and probability of adherence to a prescribed regimen.
- Multiple medical conditions Multiple prescribers Multiple pharmacies Automatic prescription refill systems Cognitive impairment TOTAL number of medications is the single biggest factor here for adverse drug events
- AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults STOPP - Screening Tool of Older Peoples Prescriptions START - Screening Tool to Alert to Right Treatment For more information on these tools, please visit the AFHS Banner on the intranet
- Drug trials often exclude older adults as subjects so approved dosages may not be appropriate Changes to pharmacokinetics (absorption, distribution, metabolism, and excretion) with age. Increase in fat relative to muscle mass, decrease in total body water, decline in hepatic function affecting metabolism, and decrease in renal function with a decrease in creatinine clearance leading to increased drug excretion time. With changes in pharmacokinetics, the overall impact is usually TOO MUCH drug, prolonged half-life and drug toxicity. Effects of pharmacodynamics-physiologic effect of the drug Older adults are often started on medications that are NEVER stopped. So it is important to consider if each medication is it STILL needed and if it is helping or hurting. An example is a short term benzodiazepine given for work-related stress, or personal stress at 55 that is never stopped and now causing harm, at 75 and also causing more susceptibility to CNS-active drug-drug interactions.
- A Prescribing Cascade can develop when an adverse drug event is misinterpreted as a new medical condition which is then treated with additional medication. The figure on the slide shows an example of a prescribing cascade. A person with knee pain from osteoarthritis is given an NSAID for the pain. This then leads to elevated blood pressure which is then treated with a calcium channel blocker. That leads to the person having lower extremity edema subsequently treated with a diuretic which causes urinary incontinence which is then treated with an anticholinergic drug. The figure ends here, but could go on to demonstrate the adverse drug events that could occur in older adults taking anticholinergic drugs.
- As you can see on the slide an adverse drug event related to cholinesterase inhibitors (e.g. donepezil) is urinary incontinence. Let’s consider the case exemplar. Harry was discharged from the hospital on Aricept. He likely had the generic at home. So, he was likely taking both medications because they have different names. This could be the cause of the new onset of urinary incontinence. This is why it is essential to perform a medication reconciliation particularly after discharge from the hospital. Was the allopurinol started in hospital? Perhaps he was given a diuretic in the hospital leading to hyper-uricemia and thus started on treatment for gout. This is Important to explore when drugs were started and under what circumstances. Always keep in mind the possibility of adverse drug events (ADEs) when evaluating an older adult with new symptoms. Consider de-prescribing as a therapeutic intervention similar to initiating a medication. Resources will be posted in the GR Pearls on the intranet.
- Age-Friendly health care seeks to incorporate all 4Ms (What Matters, Mobility, Medication, Mentation) into your assessment and provision of care of your patients 65 years of age and over. Here are some recommendations referring back to the case. Keep in mind the need to ASSESS and ACT ON the 4Ms as a set. What Matters: Know and act on each patient’s specific health outcome goals and care preferences. Discuss cost of medications, enjoys day care, embarrassed by incontinence Medication: Optimize use to reduce harm and burden, focusing on medications affecting mobility, mentation, and what matters. Medication reconciliation to fewest necessary drugs, explore prescribing cascades, provide resources. The website for deprescribing.org is provided: https://deprescribing.org Mentation: Focus on dementia and depression and delirium. Optimize socialization through adult day care attendance, monitor for adverse drug events, incontinence support group Mobility: Maintain mobility and function and prevent/treat complications of immobility. Mobility plan to maintain optimal ambulation and independence Provide 4Ms brochure with suggestions for patient/family to share with primary care provider
- Team discussion: NP, pharmacist, physician, other