Transcript Aging Demographics and Psychiatric Diagnoses in the Elderly

Symposium #: 445
THE WAR AGAINST POLYPHARMACY RETHINKING AND RE-EVALUTION NEEDED
FOR EACH AND EVERY DRUG IN THE ELDERLY
CHAIR:
DORON GARFINKEL, ISRAEL
SPEAKERS:
JOHN ELLERSHAW, LIVERPOOL, UK
THIERRY CHRISTEANCE, GHENT, BELGIUM
DEE MANGIN, CHRISTCHURCH, NEW ZEALAND
DORON GARFINKEL, PARDES-HANA, ISRAEL
Symposium #: 445
THE WAR AGAINST POLYPHARMACY RETHINKING AND RE-EVALUTION NEEDED
FOR EACH AND EVERY DRUG IN THE ELDERLY
INTRODUCTION
DORON GARFINKEL, M.D.
HEAD, GERIATRIC PALIATIVE DEPARTMENT
SHOHAM GERIATRIC MEDICAL CENTER
PARDES – HANA,
ISRAEL
THE “BAD SIDE” OF AGING:
AGE-RELATED DISEASES & DISFUNCTIONS
ATHEROSCLEROSIS – IHD. & CHF, CVA, PVD & RENAL
C A N C E R - MOST TYPES
D E M E N T I A (ALZHEIMER’S DIS.)
DEPRESSION
IMPAIRED IMMUNITY -> INFECTIONS
OSTEOPOROSIS & OSTEOARTHROSIS, F A L L S
DIABETES MELLITUS, PARKINSON’S DISEASE
CATARACT, GLAUCOMA, AMD, HEARING LOSS,
PROSTATIC HYPERTROPHY, INCONTINENCE,
PRESSURE SORES... BED RIDDEN
POLYPHARMACY
...preferably defined as :
“The administration of more
medications than are clinically indicated”
“Inappropriate Medication Use” (IMU) medication use that has more potential
risk for harming than potential benefit,
is less effective or most costly than
alternatives available... or does not
agree with accepted medical standards.
Hanlon et al . Suboptimal prescribing in older inpatients & outpatients.
J Am Geriatr Soc 2001; 49: 200-9 .
Inappropriate Medication Use (IMU)
Extent of the Problem
44000 - 98000 Americans Die Each
Year Secondary to Medical Mistakes..
Vehicle Accidents 43460
Breast Cancer 42300 Deaths/year
Institute of Medicine (IOM) Report, 1999:
To Err Is Human: Building a Safer Health Care System
EXTENT OF THE PROBLEM
THE ELDERLY
IN
...Use 3 TIMES the number of medications...
...Consume OVER ONE THIRD of the
prescription & nonprescription medications
used in the US
The RISK OF HOSPITALIZATION secondary to
IMU outcomes in elderly patients is estimated
at 17%
Almost 6 TIMES GREATER
than that for the general population
Lombardi
& Kennicutt.
Pharmacists
(1), 2001
Nananda
C et al,Medscape
Arch Int
Med 1990;2 150:
841-6.
EXTENT OF IMU
IN NURSING HOMES
The total number of prescriptions
correlates with
the increase number of IMU 1
Patients receive an average of 6
Over 20% receiving > 10
medications daily 2
1). Liu GG & Dale BC. J Am Pharm Assoc 2002; 42 (6): 847-57.
2). Bernabei R, et al. J Gerontol Series A 1999; 54: M 25-33.
percent of patients with ADR
100
DRUG DISTRIBUTION
10
1
0
2
4
6
8
10 12 14
number of drugs taken
16
18
20
PALLIATIVE CARE - WHEN TO START?
P
R
E
S
E
N
T
A
T
I
O
N
CURATIVE & LIFE PROLONGING
THERAPY
D
E
A
DISEASE
T
H
Relieve suffering (Palliative, Hospice)
B
I
R
T
H
PALLIATIVE PERCEPTION –
WHEN TO APPLY?
P
R
E
S
E
N
T
A
T
I
O
N
THE CURRENT MODEL
CURATIVE & PREVENTIVE THERAPY
HEALTH
DISEASE
THE SUGGESTED MODEL
HEALTH
ONLY
D I S E A SPALLIATIVE
E
PALLIATIVE – QOL & RELIEVING SUFFER
D
E
A
T
H
THE “REAL-LIFE” MODEL
IN MOST ELDERLY PEOPLE
HEALTH
HEALTH
DISEASE 1
DISEASE 2
ONLY
PALLIATIVE
ONLY
PALLIATIVE
HEALTH
DISEASE 3
ONLY
PALLIATIVE
HEALTH
DISEASE4
ONLY
PALLIATIVE
D
E
A
T
H
THE COMPLEX IMPACT OF CO-MORBIDITY
EXCEPT
~10%“BAD
WHO EXPERIENCE
SUDDEN
DEATHTHE
OF
AGING:
PREVENTIVE
& SIDE”
CURATIVE
MEANS
AGE-RELATED DISEASES & DISFUNCTIONS
PALLIATIVE
THERAPY
IN ALL !
IN MOST AGE RELATED
DISORDERS
ATHEROSCLEROSIS – IHD. & CHF, CVA, PVD & RENAL
CANCER - MOST TYPES
DEMENTIA (ALZHEIMER’S DIS.)
DEPRESSION
IMPAIRED IMMUNITY -> INFECTIONS
OSTEOPOROSIS & OSTEOARTHROSIS, FALLS
DIABETES MELLITUS, PARKINSON’S DISEASE
CATARACT, GLAUCOMA, AMD, HEARING LOSS,
PROSTATIC HYPERTROPHY, INCONTINENCE,
PRESSURE SORES... BED RIDDEN
William Shakespeare,
As You Like It, 2.7
“And so from hour to
hour we ripe and ripe,
GUSTAV VIGELAND
and then
GARDENS, OSLO
from hour to hour We Can
we rot and rot; Improve
the
and thereby hangs a tale
tale.“
HOW DO WE DIE ???
Nowadays, very few adults / elders
die suddenly while apparently healthy;
most experience time-related increased
number of incurable co-morbidities,
disability and suffering
for increasingly prolonged
periods of time before death.
AFTER AGING...
...”GET SICK AND DIE”,
which once covered no more than a few weeks,
Now often goes on for YEARS
The USUAL “END OF
LIFE” has
come to be
LIFE WITH SERIOUS CHRONIC ILLNESS
FOR A LONG TIME........
Lynn J & Cretin S. Editorial, J Am Ger Soc 2000; 48: 1017- 8.
HEALTH – DISEASE PERCEPTION
IN THE 21TH CENTURY
100
%
GOOD HEALTH
&
LIFE QUALITY
BAD QOL
.
WHICH ONE IS WORSE?
TIME IN LIFE
DEATH
D YDIENAGT...H
DRUG THERAPY –
THE HISTORIC 20TH CENTURY CHANGE
EBM MEANS OF PREVENTION (DRUGS & OTHER)
REPRESENT THE MOST COST EFFECTIVE
INTERVENTIONS TO PROMOTE HEALTH & QOL,
DELAY DISEASES & COMPLICATIONS,
DELAY & COMPRESS SUFFERING & DISABILITY,
INTO A SHORTER END OF LIFE PERIOD
BEFORE DEATH.
DO WE ACTUALLY ACHIEVE THIS GOAL IN MOST PEOPLE?
MEDICATION GUIDELINES –
WE KNOW WHEN TO START DRUGS
DO WE KNOW WHEN TO STOP ?
WHY DO PHYSICIANS CONTINUE TO GIVE
PREVENTIVE & CURATIVE MEDICATIONS
OCCASIONALLY UNTILL DEATH ?
WHY ARE PHYSICIANS,
BEING AWARE OF POLYPHARMACY / IMU
RELUCTANT TO DISCONTINUE MANY DRUGS ?
WHY DON’T WE STOP DRUGS ???
Drugs are often given to elders based on
Clinical Practice Guidelines (CPGs) that extrapolate
evidence of benefit in younger adults
without significant co-morbidity, who have
a life expectancy of several decades.
Physicians usually EXTRAPOLATE from these CPGs
to include all elders, Even Those with
MULTIPLE CO-MORBIDITIES, SEVERE DISABILITY,
DEMENTIA & even “TERMINAL” PATIENTS
Clinical practice guidelines (CPGs) and quality of care
for older patients with multiple comorbide diseases.
Adhering to current CPGs in elders with
several co-morbidities may have
undesirable effects; basing standards for
quality of care and pay-for-performance on
existing CPGs could lead to
inappropriate judgment of the care
provided, Create perverse incentives
that emphasize the wrong aspects of care
for this population and
diminish the quality of their care
Boyd CM, Darer J, Boult C, et al. J Am Med Ass 2008;294: 716 – 24.
PRINCIPLES OF DRUG THERAPY –
THE 21TH CENTURY ENLIGHTMENT
 DO WE HAVE TO CONTINUE ALL CURATIVE AND
PREVENTIVE MEDICATIONS UNTILL DEATH?
 ARE THEY STILL COST EFFECTIVE, HAVING
POSITIVE BENEFIT / RISK RATIO :
IN A VERY ADVANCED AGE ?
 IN THE PRESENCE OF SEVERE CO-MORBIDITY?
DISABILITY? DEMENTIA ?
 IN THE PRESENCE OF SIGNIFICANT SUFFERING ?
 IN THE PRESENCE OF LIMITED LIFE EXPECTANCY ?
THERE ARE NO GOOD EVIDENCE BASED ANSWERS !
PALLIATIVE PERCEPTION –
P
A
WHETHER / WHEN TO STOP DRUGS??
L
B
I
R
T
H
P
R
E
S
E
N
T
A
T
I
O
LD
I E
A
TA
I T
VH
E
N
HEALTH
DISEASES
O
N
L
Y
TILL WHEN??
ASPIRIN, WARFARIN, DIPIRIDAMOLE, STATINES, β BLOCKERS, ACE / ARI,
CALCIUM CHANNEL BLOCKERS, NITRATES, DIURETICS, OMEPRAZOLE,
H2 BLOCKERS, BENZODIAZEPINES, TCI & OTHER ANTIDEPRESSENTS,
IRON, SALTS AND VITAMIN SUPPLEMENTATIONS...
TILL WHEN??
... NO ONE WOULD SUGGEST
CONTINUATION OF
PREVENTIVE & CURATIVE GUIDELINES
GERIATRIC-PALLIATIVE
PERCEPTION
PALLIATIVE PERCEPTION
–
P
EXTRAPOLATION”
A
L
L
I
A
T
I
V
E
P
A
THE
“REVERSED
METHOD
WHETHER
/ WHEN TO STOP DRUGS??
L
B
I
R
T
H
P
R
E
S
E
N
T
A
T
I
O
N
HEALTH
DISEASES
ONLY
L
I
A
T
I
V
E
D
E
A
T
H
O
N
L
Y
ASPIRIN, WARFARIN, DIPIRIDAMOLE, STATINES, β BLOCKERS, ACE / ARI,
CALCIUM CHANNEL BLOCKERS, NITRATES, DIURETICS, OMEPRAZOLE,
H2 BLOCKERS, BENZODIAZEPINES, TCI & OTHER ANTIDEPRESSENTS,
IRON, SALTS AND VITAMIN SUPPLEMENTATIONS...
TILL WHEN??
SUMMARIZING
THE PROBLEM
FOR MOST CURATIVE / PREVENTIVE MEDICATIONS
1).
The Positive Benefit / Risk Ratio is
Decreasing or Non - Exsistant
In Correlation to Age, Multiple Co-Morbidities,
Disability, Dementia & Quality of Life
.
2). The extent of Drug Related Problems and IMU
is Increasing In Correlation to Age,
Co-Morbidities, Disability, Dementia and the
Number of Drugs Consumed (Polypharmacy)
being particularly disturbing in LTC departments
THE WAR AGAINST POLYPHARMACY
THE “REVERSED EXTRAPOLATION” METHOD
D
E
A
T
H
HEALTH
?
YEARS
CO-MORBIDITIES
< <<
TO GIVE ?
PALLIATIVE
OR NOT
ONLY
TO GIVE?
TIME
> > MONTHS << WEEKS >> DAYS ... HOURS... BEFORE
DEATH
REVERSED EXTRAPOLATION (TIME BEFORE DEATH...)
REVERSED EXTRAPOLATION - TYPE OF PATIENTS
INDEPENDENT ELDERS << COMMUNITY FRAIL ELDERS << DISABILITY / DEMETIA
THE WAR AGAINST POLYPHARMACY
A NEW GERIATRIC-PALLIATIVE APPROACH
IN THE COMMUNITY AND IN LONG TERM CARE FACILITIES
DORON GARFINKEL, M.D.
HEAD, GERIATRIC PALIATIVE DEPARTMENT
SHOHAM GERIATRIC MEDICAL CENTER
PARDES – HANA,
ISRAEL
THE WAR AGAINST POLYPHARMACY
THE “REVERSED EXTRAPOLATION” METHOD
IN LONG TERM CARE FACILITIES
D
E
A
T
H
HEALTH
?
YEARS
CO-MORBIDITIES
< <<
TO GIVE ?
PALLIATIVE
OR NOT
ONLY
TO GIVE?
TIME
> > MONTHS << WEEKS >> DAYS ... HOURS... BEFORE
DEATH
REVERSED EXTRAPOLATION (TIME BEFORE DEATH...)
REVERSED EXTRAPOLATION - TYPE OF PATIENTS
INDEPENDENT ELDERS << COMMUNITY FRAIL ELDERS << DISABILITY / DEMENTIA
THE WAR AGAINST POLYPHARMACY
A NEW GERIATRIC-PALLIATIVE APPROACH
IN LONG TERM CARE FACILITIES
METHODS & PATIENTS
Individualization of drug therapy
was started in 180 elderly patients who were
hospitalized in 6, out of the 10 nursing departments at
the Shoham Geriatric Center
In each patient, an attempt was made
TO STOP ALL DRUGS for which
THERE WAS NO CLEAR CUT INDICATION,
and / or REDUCE THE DOSAGE of drugs
for which the indication was still relevant
THE WAR AGAINST POLYPHARMACY
A NEW GERIATRIC-PALLIATIVE APPROACH
IN LONG TERM CARE FACILITIES
METHODS & PATIENTS
ATTEMPTS TO STOP/REDUCE DOSE WERE MADE FOR:
NITRATES
IN ALL ASYMPTOMATIC PATIENTS
DRUGS FOR HTn
GRADUALLY WITH STRICT MONITORING
DIURETICS
NO CLEAR SYMPTOMS/SIGNS OF CHF EXIST
ANTIACIDS & H2 BLOCKERS IN ALL ASYMPTOMATIC PATIENTS
SEDATIVES & TRANQUILIZERS
ANTI DEPRESSANTS, PSYCHOTROPIC DRUGS
PENTOXIFYLLINE, DIPYRIDAMOLE, NSAIDs,
MISCELLANEOUS: SLOW K, SLOW FE, ORAL HYPOGLYCEMICS
CHOLESTEROL LOWERING, ASPIRIN,
ANTI EPILEPTICS, MINERALS, VITAMINS ..
THE WAR AGAINST POLYPHARMACY
IN LONG TERM CARE FACILITIES
METHODS & PATIENTS
The control group was composed of patients of the
same 6 departments in whom discontinuation of
drugs (DD) have not been performed.
The study & control groups were treated by the
same interdisciplinary teams who regarded DD in
some patients as part of an overall clinical policy
attempting to improve drug therapy.
None of the team members was aware of our
intention to evaluate the long term outcomes of
patients in whom DD have/have not been performed.
DEMOGRAPHY and CO-MORBIDITIES
Parameter
Total Number
Female/Male
A G E (Mean ±S.D)
Dementia *
Double Incontinence
Indwelling Urinary Catheter
Hypertension
Congestive Heart Failure
Previous Myocardial Infarction
Chronic Atrial Fibrillation
Diabetes Mellitus
COPD
Previous Stroke - CVA
Hypo Albuminemia **
Recurrent Infections #
@
+
*
**
Study
Group
Control
Group
P - Value
119
71
-
32/87
81.2 ± 8.3
44/27
82 ± 8.7
NS @
NS +
112 (94%)
111 (93%)
21 (18%)
55 (46%)
12 (10%)
66 (93%)
66 (92%)
10 (14%)
29 (41%)
5 (7%)
NS
NS
NS
NS
NS
6 (5%)
16 (13%)
36 (30%)
6 (5%)
45 (38%)
29 (24%)
35 (29%)
9 (13%)
14 (20%)
17 (24%)
9 (13%)
28 (39%)
(25%) 18
13 (18%)
NS
NS
NS
NS
NS
NS
NS
Not significant. All parameters except Age, were analyzed employing the Chi square test
t - test
Mini Mental State Examination (MMSE) 14/30 or less
Serum albumin < 3.0 g/dl
Annual Success Rate According to the
No. Drugs Discontinued
In Nursing Departments
No. Drugs
Discontinued
Rate of Failure -
No.
Patients
Re administration
No. of
No. of
Patients
Drugs
7
2
2/2
3/14
6
4
2/4
5/24
5
13
5/13
13/65
4
15
5/15
5/60
3
29
4/29
5/87
2
26
1/26
1/52
1
30
2/30
2/30
TOTAL
119
21/119
33/332
PERCENT
100
18
10
Annual Success Rate According to
Types of Drugs Discontinued
DRUG
NITRATES
No. Pts.
Stopped
22
Reccurence of
Symptoms/Signs
0
% of
Success .
100
H2 BLOCKERS
35
2
94
ANTI HTn
51
9
82
DIURETICS (fusid)
27 (25)
4 (4)
85
PENTOXIFYLLINE
15
0
100
SLOW K
20
0
100
SLOW FE
19
1
95
SEDAT & TRANQUIL
16
2
88
ANTIDEPRESSANTS
19
5
74
ANTIPSYCHOTICS
13
4
69
Annual Rate of Deaths
Study
Group
Control
Group
Total No.
119
71
Deaths
25 (21%)
(45%) 32
P - Value
0.001
Annual Rate of Deaths and
Referrals to Acute Care Facilities
Study
Group
Control
Group
P - Value
Total No.
119
71
Deaths
25 (21%)
(45%) 32
0.001
Referrals to
Acute Care
Facilities
14 (11.8%)
(30%)21
0.002
The Average Daily Cost of
Drugs per Patient in US dollars
1 – 6 / 2003
Control group No 2 *
4(Wards(
**Study Departments
6(Wards(
*
**
1 – 6 / 2004
P Value
1.39
0.07
1.28
0.02
1.65
1.74
FOUR DEPARTMENTS (132 Patients) in which our new therapeutic approach was not applied.
SIX DEPARTMENTS (198 Patients) in which our new therapeutic approach was applied.
The figure represents cost of drugs of 119 patients of the study group
+
that of patients in whom no change in drugs was made .
Conclusions
Application of the
Good Palliative-Geriatric Practice (GPGP)
methodology in disabled elders enables
simultaneous discontinuation of several
medications and yields several benefits:
reduction in mortality rates & referrals to
acute care facilities, lower costs and
improved quality of living.
POLYPHARMACY
Inappropriate Medication Use (IMU)
medication use that has
more potential risk
for harming
than potential benefit...
At least in Nursing Departments, the
Sum Total of
Negative Impacts of MEDICATIONS,
OUTWEIGHS
the
Sum Total
of the Potential Beneficial Effects
of all specific drugs.
THE WAR ON POLYPHARMACY :
A New, Cost Effective, Geriatric - Palliative Approach
Improving Drug Therapy in Disabled Elderly People
for
DORON GARFINKEL, SARAH ZUR-GIL, JOSHUA BEN-ISRAEL
ISRAEL MEDICAL ASSOCIATION JOURNAL
(IMAJ) 9: 430 - 4 (June 2007)
THE WAR AGAINST POLYPHARMACY
THE “REVERSED EXTRAPOLATION” METHOD
IN LONG TERM CARE FACILITY
D
E
A
T
H
HEALTH
?
YEARS
CO-MORBIDITIES
< <<
TO GIVE ?
PALLIATIVE
OR NOT
ONLY
TO GIVE?
TIME
> > MONTHS << WEEKS >> DAYS ... HOURS... BEFORE
DEATH
REVERSED EXTRAPOLATION (TIME BEFORE DEATH...)
REVERSED EXTRAPOLATION - TYPE OF PATIENTS
INDEPENDENT ELDERS << COMMUNITY FRAIL ELDERS << DISABILITY / DEMETIA
THE “REVERSED EXTRAPOLATION” METHOD
IN COMMUNITY DWELLING ELDERS
D
E
A
T
H
HEALTH
?
MANY YEARS
DISEASES
<
TO GIVE ?
PALLIATIVE
OR NOT
ONLY
TO GIVE?
TIME
BEFORE
< YEARS> > MONTHS << WEEKS > DAYS . HOURS...
DEATH
TIME BEFORE DEATH...)
TYPE OF PATIENTS IN THE COMMUNITY
INDEPENDENT ELDERS << FRAIL ELDERS << DISABILITY / DEMETIA
THE WAR AGAINST POLYPHARMACY :
IN COMMUNITY DWELLING ELDERLY PEOPLE
PRELIMINARY RESULTS
70 elders, mean age 82.8 ± 7, 92% independent / frail.
94% suffered ≥ 3, 51% > 6 different health problems (co-morbidities).
Mean Follow Up 19.2 ± 11 months.
Elders used 7.73 ± 3.7 drugs (range 0-16).
DD recommended for 57.5% (4.4 ± 2.5 drugs/elder) of all drugs
47% (3.7±2.5 drugs/elder) actually stopped.
Only 5/256 DD had to be readministered (failure 2%)
successful DD eventually achieved in 80.7%.
No significant adverse effects
80% of Patients/Families reported medical - functional - mental cognitive improvement, defined as significant in 37%,
outstanding in 29%.
10 elders (14%) died, mean age at death 88 years, FU 13 ± 9 months.
THE WAR AGAINST POLYPHARMACY :
APPLYING THE GPGP APPROACH
IN THE COMMUNITY
Application of the GPGP methodology was
executed in several dozens of community
dwelling elders.
DRUG DISCONTINUATION could be
performed in almost all of them (1 – 9 drugs)
with no significant adverse effects.
In some, a remarkable improvement was
noticed in the quality of life: improvement in
mobility, alertness and cognitive status (e.g.
an increase in mini mental state examination
[MMSE] from 14/30 to 30/30 in two months)
THE GPGP APROACH –
WHEN/IF TO STOP MEDICATIONS
The decision is based on clinical common
sense and should be taken together with
the patient & family.
An attempt should be made to be less
aggressive in reaching rigid target goals
(Blood Pressure, serum glucose & lipid levels),
while giving more room to
QUALITY of LIFE and
PATIENT / FAMILY preferences.
Primum non
nocere
Individualization
Autonomy
Advance Directives
Patient / family
preferences
The Sum Total of all
potential beneficial
effects of all specific
drugs and Guidelines
The Sum Total of all
negative Impacts of
Polypharmacy &
combined Guidelines
COMMON
SENSE
HUMANITY – EXPERIENCE - EBM
KNOWLEDGE
“I feel a lot better since I ran out
of those pills you gave me.”
“It is an art of no little
importance to administer
medicines properly:
but, it is an art of much
greater and more difficult
acquisition to know when
to suspend or altogether
to omit them."
Philippe Pinel, 1745-1826
( 18th. Century !!! )
Improving Drug Therapy in Disabled / Frail Elderly Patients
- An algorithm
YES
An evidence-based consensus exists for using the drug
for the indication given in its current dosing rate,
in this patient’s age group and disability level, and
the benefit outweigh all possible known adverse effects
S
T
O
P
NO / NOT SURE
Indication seems valid and relevant
in this patient’s age group and disability level
NO
D
R
U
G
YES
S
H
I
F
T
YES
Do the known adverse reactions of the drug
outweigh possible benefit in old, disabled patients?
NO
Any adverse symptoms or signs
that may be related to the drug?
YES
NO
Another drug that may be superior to the one in question
NO
Can the dosing rate be reduced with no significant risk?
NO
CONTINUE WITH THE SAME DOSING RATE
YES
REDUCE DOSE
YES
TO
A
N
O
T
H
E
R
D
R
U
G