Transcript Geriatric Medicine category 2 - Hutt Valley District Health Board

Acute geriatric admissions
and
their medications
AVERAGE NUMBER OF
MEDICARE SERVICES/YEAR
Use of medical services increases with age
40
Males
Females
30
20
10
0
0-4
5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84
Age (years)
Source: Medicare Australia
85+
Use of public hospitals and prescribed medications
increases with age
Public hospitals
Pharmaceutical Benefits Scheme
1200
5000
Females
1000
4000
800
3000
Males
Males
600
2000
400
Females
1000
200
0
0
0
10
20
30
40
Age
50
60
70
80
0
10
20
30
40
Age
50
60
70
80
A typical week for geriatrics at Concord Hospital
Acute geriatric medicine in 5 steps
…or…
this is what I tell RMOs to make my life easier
1. Drugs
 look for adverse drug reactions, deprescribe
2. Bugs
 look for infection, give antibiotics
3. Tweak Comorbidities (but don’t get too excited)
 optimize treatments, but don’t expect too much
4. Seven deadly sins of immobility
 treat and prevent complications
5. Make a decision
 home/rehab/residential care/end of life / make a decision next week
High risk prescribing in older people
Nothing I am presenting
is new
…and…
We haven’t changed in
over 200 years
Dr Philippe Pinel, French
Physician and
Psychiatrist
1745-1826
“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.”
Hospital admissions due to ADRs in WA
Burgess et al MJA 2005
High risk prescribing in older people
• Polypharmacy
• ADRs
• Potentially
inappropriate
medications (PIMS)
• Mortality and
hospitalization
– Beers criteria
– PRISCUS
– DBI
• Interacting drug pairs
• Geriatric outcomes
• Falls
• Cognition
• Institutionalization
E factors for prescribing in Elderly
Ethics
Epistemology
Exploitation
Evidence
We are almost totally dependent on
interpreting what is published
because there are few medicines
where our personal experience has
any value
BEWARE the doc who says “in my
experience…”
Exploitation
Provider-driven versus Patient-led health care?
Doctors get paid for
prescribing and often fear
being sued for not ‘doing
everything’
NEJM 2007
Older people are the market
In older Australians, 5-10 medications with
psychotropics is the norm
• Hostel residents (Fisher et al 2003)
– ACT n=119; 87 yrs
– 5.8 ± 2.9 meds
– antihypertensives 65%, benzodiazepines 34%, digoxin 28%, SSRI 12%,
tricyclic antidepressants 12%
• Community dwelling men – CHAMP (Dnjidic et al 2012)
– Sydney n=1705; 77 yrs
– 4.0 ± 2.9 meds
– polypharmacy 37.7%, hyperpolypharmacy 4.8%
• Nursing homes and hostels - FREE (Hien et al 2005)
– Sydney n=1067, 86 yrs
– 5.1 ± 3.2 to 7.1 ± 3.6 meds
– 55% psychotropics
Polypharmacy and CHAMP
• 1705 men >70
• Concord area
• Commenced 2005
Investigators: Bob Cumming, Fiona Blyth, Vasi Naganathan, Louise Waite, Helen
Creasey, David Handelsman, Markus Seibel, Phil Sambrook, David Le Couteur
(Rafa de Cabo, Hal Kendig, Steve Simpson)
Pharmacoepidemiology: Danijela Gnjidic, Sarah Hilmer, Andrew McLachlan
• What is the relationship between polypharmacy (≥5),
hyperpolypharmacy (≥10) and Drug Burden Index (DBI)
with frailty?
• DBI is a dose-normalized measure of anti-cholinergic and
sedative medications developed by Sarah Hilmer at NIA
• Frailty defined by CHS criteria (weight loss, inactivity,
slowness, exhaustion, weakness)
Clin Pharmacol Ther 2012
Baseline association between polypharmacy and
frailty
Polypharmacy 38%, Hyperpolypharmacy 5%
Frail 9%, Intermediate/prefrail 41%, Robust 50%
The frailest people have BOTH most illnesses and most medicines
Polypharmacy and incident frailty 2 yrs
Polypharmacy and CHAMP:
risk per additional medication
* and remained highly significant with multivariate analysis
Gnjidic et al 2012
Five is a reasonable definition of polypharmacy…
and is the norm
Drug Burden Index
Dose normalised
summation of
anticholinergic and
sedative drugs
Dose normalised to
minimum registered
daily dose
Drug Burden Index
• DBI linked with
–
–
–
–
–
–
–
–
Poorer physical and cognitive function
Physical functional decline
Falls
Hospitalization
Delirium
Quality of life in residential care
Frailty and development of frailty
In many centres (Australia, USA, Europe)
Sarah Hilmer RNSH
A few examples of problematic ADRs
10% of hip fractures in Australia
are attributable to
benzodiazepines
Antipsychotics in BPSD/dementia:
death, strokes, falls, pneumonia
Lon Schneider JAMA 2005 Meta-analysis
Risk of death 1.65 (1.19-2.29) (pneumonia, stroke)
Falls:
Polypharmacy and psychotropic medicines
Deprescribing:
how, when and why?
•
•
•
•
•
All trials 1996-2007
Over 65 yrs, withdrawal of a single medicine
31 studies
N=8972 subjects
Variety of open label, observational,
randomized, placebo controlled studies
Drugs Aging 2008
Results
• Diuretics
– 4 studies, 448 subjects
– Successful 51-100% subjects (recommenced mainly if heart failure)
• Antihypertensives
– 9 studies, 7188 subjects
– 20-85% normotensive over following 6-60 mths
• Psychotropics
– 15 studies, 1184 subjects
– ↓falls ↑ cognition and/or behaviour
• Withdrawal syndromes
– None reported and medicines often weaned over weeks
DART-AD study
Lancet Neurol 2009
• Good palliative–geriatric practice (GPGP) algorithm to deprescribe
• 72 subjects aged 83±7yrs over 19 mths
• Reduced medicines by 4.4±2.5 per patient (from 7.7±3.3)
• 88% ↑global improvement in health scale
• 2% of medicines recommenced
Arch Int Med 2010
• Review of trials to reduce polypharmacy
– 8 pharmacist led, 8 physician led, 13 multidisciplinary
– Generally → reduction in medications
– Clinical outcomes less often assessed: no adverse
outcomes, reduction in ADRs, 1 study improved
cognition, 1 study improved mortality
Clin Geriatr Med 2012
• Polypharmacy
– Physical function, cognition, falls, institutionalization,
hospitalization and death
– Independent of underlying comorbidities
• Deprescribing can be considered when
– Polypharmacy
– Adverse effects
– No efficacy
– Change in treatment goals (palliative care, frailty, dementia)
Aust Presc 2011
a single cost-saving intervention that will prevent
multiple diseases in older people
All RCTs provide evidence for deprescribing and not
prescribing
General population with disease
Included
Excluded
Completers
Completers
Withdrawn
In RCTs, overall benefit is accrued by only this group being on medication
and withdrawing medications if adverse drug reactions occur
Typical geriatric patients are those who are excluded or get adverse reactions
Guidelines recommend everyone gets medication ‘mandatory’
Balancing risk and benefits
We tend to underestimate
adverse effects in older people
which are often more frequent
and severe; and overlooked
Deprescribing is a
‘positive’ intervention to
improve outcomes in
older people
We tend to focus primarily on
potential or actual benefit
extrapolated from younger
patients