Transcript Geriatrics for GPs - Guildford GP Education

GP educational
update in geriatrics
May 2015
Agnes Toth
• Cases from the rapid response/OPDAS
clinic
• Drug therapies in older people
• STOPP/START medication reviews
• Anticholinergics and cognitive impairment
Patient examples
from rapid response
/OPDAS clinic
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82 yr old male
4/52 of SOB, significantly worse on
exertion, leg oedema
No chest pain
• PMHx:
• LVF, AF (2005)-seen privately
by local cardiologist,
• AAA repair 2005;
• intermittent claudication 2005;
• moderate, stable COPD 2010;
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Medication
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2/1
Frusemide 40mg bd
Digoxin 125mcg od
Bisoprolol 1.25mg od
Ramipril 10mg od
Rivaroxaban 15 mg od
Seretide, Tiotropium inhalers
Simvastatin 20 mg od
2/2
• Increasing Frusemide to 120 mg od –no
effect in 1/52
• Added Prednisolone 30 mg od-no effect in
1/52
• Referred to rapid response clinic
2/3
• On exam: SOB+++ on getting in and out of
chair
• pale
• Slow AF, LAD, HR 50
• BP 100/48 supine, 100/38 erect
• JVP 3 cm
• Pitting oedema to knees
2/4
• decision to admit
• HB 55, MCV 74
• OGD- chronic
duodenitis
Colonoscopy/CT
CAP: diverticular
disease
• ECHO-LVEF 73%,
mild RVF, moderate
AS
2/5
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Transfused
Fe sulphate
Stopped Rivaroxaban
Continued Bisoprolol 1.25 and Digoxin 62.5
Frusemide 40 mg bd, Ramipril 10mg od
3/1
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95 yr old lady
Seen 1st time by (this)GP
Lower back pain
CCF-oedema to mid thigh, clinical pleural effusion
• Bumetanide doubled to 2 mg/day
• Bradycardia-slow AF-refused PPM as “doesn’t
want to prolong life” HR 45
• Parotid swelling-currently being treated with CoAmoxyclav, USS arranged after call to geriatrician of
the day
• MGUS
• DNAR
3/2
• Stopped Perindopril 2/52 before due to renal
failure (RF not worse on results from 2/12
prior)
• Started Doxazosin same time
• Bisoprolol 2/12
3/3
• HR 36, AF
• Oedema to mid thigh
• Dull chest bases, CXR bilateral effusions
3/4
• Stop Bisoprolol
• Iv diuresis, fluid restriction
• Apixaban
• D/C after 8 days as inpatient on
• Perindopril 4 mg od
• Frusemide 40 mg od
• Bisacodyl 5mg od
3/5
• PPM 4 weeks later as day case
4/1
• 91 yr old lady
• PMHx
• Type II DM
• Severe LVF diagnosed on ECHO 1995-20 yrs
ago!
• AF since 1992
• Essential hypertension
• Femoral stents for arterial vascular disease
• CRF stage 3.
• Recent osteomyelitis of toe
4/2
• Medication:
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Digoxin 125mcg od
Bumetanide 1 mg od
Ramipril 5 mg od
Apixaban 2.5mg od
4/3
• Increasing SOB and oedema
• Refusing to come to hospital
4/4
• Exam:
• AF 90 bpm
• BP 140/80
• Oedema to sacrum and large bilateral pleural
effusions, swollen hands and face
Toilet/bath and bedroom upstairs
4/5
• Bloods
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HB 105
U 18 (up from 13)
Cr 180 (up from 130)
eGFR 24 (down from 30)
4/6
• Plan
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Bumetanide 1 mg bd or up to 2 mg bd
Metolazone 5 mg 2x weekly
Twice weekly bloods
Palliative care
HF nurse in community
Communication of this potentially being terminal
Door remains open
Message
• Heart failure is leading cause of admission
amongst elderly
• Complex
• Being “too good” at keeping patients out of
hospital
• Conflict
• Bleep 0818 via switch
Drug therapies
STOPP/START
ANTICHOLINERGICS
Prescribing (for the Older Patient)
• Does this agent reflect the priorities of the
patient?
• Are there better alternatives? (efficacy,
effectiveness, tolerability)
• Are the dose, frequency, formulation
appropriate?
• How does this prescription relate to the
concurrent medication?
“I’ve been feeling so much better since I’ve run
out of those pills you gave me”
STOPP/START
• STOPP-Screening Tool for Older
Persons Prescriptions
• START- Screening Tool to Alert
Doctors to Right Treatment
http://ageing.oxfordjournals.org
March 2015 Supplementary data,
Appendix 1-4
Use of STOPP / START
• Secondary Care
• Potentially inappropriate prescribing (STOPP) 34%
• Potential Omissions (START) 57%
Gallagher et al, Age and Aging, 2008
• Nursing Homes
• Potentially inappropriate prescribing (STOPP) 55%
Ryan et al, Ir J Med Sci, 2009
O’Sullivan et al, Eur Ger Med, 2010
• Primary Care
• Potentially inappropriate prescribing (STOPP) 21%
• Potential Omissions (START) 22%
Ryan et al,Br J Clin Pharm, 2009
STOPP: Urogenital System
• Antimuscarinic drugs with dementia or
chronic cognitive impairment or narrow
angle glaucoma or chronic prostatism
• Selective alpha-1 blockers in those with
symptomatic orthostatic hypotension or
micturition syncope
STOPP: Central Nervous System and Psychotropic Drugs
• Anticholinergics/antimuscarinics to treat
extra-pyramidal side effect of neuroleptic
medications
• Anticholinergics/antimuscarinics in patients
with dementia
• Neuroleptic antipsychotics in patients with
behavioural and psychological symptoms of
dementia unless symptoms are severe and
other non-pharmacological options have failed
• Neuroleptics as hypnotics-unless sleep
disorder is due to psychosis or dementia
Effects of anticholinergics/antimuscarinics
• Central
• Acute impairment
of:
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Working memory
Attention deficit
Psychomotor speed
hallucinations
• Global cognitive
impairment
• Peripheral
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Dry mouth
Tachycardia
Urinary retention
Constipation
Worsening of
glaucoma
Anticholinergic/antimuscarinic drugs in the elderly
• Prevalence of anticholinergic use 8-37% in
older adults
• Primary care urban setting USA-60%
• Nursing homes-30% takes more than 2
drug, 5% up to 5 drugs!
Shelly L. at al.: Cumulative use of Strong Anticholinergic
Medications and Incident Dementia, JAMA Internal Medicine,
March 2015 (2)
• Prospective cohort study, based in Seattle
• 3,434 participants aged ≥65 with no known dementia
• Most common anticholinergics – antidepressants,
antihistamines, bladder antimuscarinics (>90% anticholinergic
exposure)
• Followed up over 10 year period
• Cognitive function assessed biannually by neurologists,
geriatricians and neuropsychological testing
• Pharmacy dispensing data analysed to assess cumulative
anticholinergic exposure
• Over mean follow-up of 7.3 years 797 participants (23%)
developed dementia.
• Concluded that higher cumulative anticholinergic medication use
is associated with an increased risk for dementia.
Comparison
• Prevalence of dementia in ≥65: 7.1%
(Alzheimer’s UK, 2013 population data)
VS
• Prevalence of dementia in those using anticholinergics: 23%
• Higher cumulative use of anticholinergics is associated
with increased risk for dementia
Why are older adults more susceptible?
• Age-related changes in pharmacokinetics
and pharmacodynamics
• Reduced acetylcholine mediated
transmission in the brain
• Increased permeability of the blood-brain
barrier
Possible biological mechanisms
• Possible pathologic changes similar to Alzheimer’s
disease
• Amyloid plaque densities were more than 2.5-fold
higher in Parkinson’s patients treated with
anticholinergics
• Neurofibrillary tangle densities were also higher
Perry at al. 2003
• Genetic component: Increased cognitive sensitivity
in subjects with ApoE ɛ4 allele after acute
anticholinergic administration
• Disruption of cholinergic neurons throughout
the basal and rostral pathways
• Level of acetylcholine reduced
• Cognitive impairment and behavioural
symptoms
Pharmacological antagonism
cholinesterase inhibitors
anticholinergics
Atropine –successful antidote for
cholinesterase inhibitor overdose
Anticholinergic activity of drugs
• Anticholinergic activity as measured by pmol/ml
of Atropine equivalent
• 15+ amitriptyline, atropine, clozapine,, doxepin,
L-hyoscyamine, thioridazine, and tolterodine
• 5-15 Chlorpromazine, nortriptyline, olanzapine,
oxybutynin, paroxetine
• <5 Citalopram, escitalopram, fluoxetine, lithium,
mirtazapine, quetiapine, ranitidine, temazepam
• Chew at al, J. American Geriatric Society, 2008
Determining the anticholinergic effect of
medications
• Serum Radio-receptor Anticholinergic Assay
(SAA)
• In vitro measurement of drug affinity to
muscarinic receptors
• Expert based list of medications with
anticholinergic affinity
Tools to determine anticholinergic risk
• Anticholinergic Risk Scale ARS (0-3)
• Anticholinergic Drug Scale
ADS (0-3)
• Anticholinergic Cognitive
Burden Score ABS
Score 1
Score 2
Score 3
Atenolol
Amantadine
Amitriptyline
Captopril
Belladonna alkaloids
Atropine
Chlorthalidone
Carbamazepine
Benztropine
Cimetidine
Cyproheptadine (antihist.)
Brompheniramine
Ranitidine
Meperidine (pethidine)
Chlorpheniramine
Codeine
Levomepromazine
Chlorpromazine
Colchicine
Oxcarbazepine
Clomipramine
Diazepam
Pimozide
Clozapine
Digoxin
Darifenacin
Dypiridamole
Desipramine
Fentanyl
Dicyclomine
Frusemide
Doxepin
Fluvoxamine
Flavoxate
Haloperidol
Hydroxyzine
Hydralazine
Hyoscyamine
Hydrocortisone
Imipramine
Isosorbide
Nortriptyline
Loperamide
Olanzapine
Score 1
Score 2
Score 3
Metoprolol
Oxybutinine
Morphine
Paroxetine
Nifedipine
Procyclidine
Prednisone
Promazine
Quinidine
Promethazine
Risperidone
Quetiapine
Theophylline
Scopolamine
Trazodone
Thioridazine
Triamterene
Tolterodine
Trifluoperazine
Trimipramine
NICE
• CG 171(2013-Urinary incontinence in women)
• When offering antimuscarinic drugs to treat OAB always
take account of:
• the woman's coexisting conditions (for example, poor bladder
emptying)
• use of other existing medication affecting the total
anticholinergic load
• risk of adverse effects. [new 2013]
• Do not offer oxybutynin (immediate release) to frail older
women[8]. [new 2013]
• Review women who remain on long-term drug treatment
for UI or OAB every 6 months for women over 75). [new
2013]
NICE
• CG 42 (2006, Dementia)
Antidepressant drugs with anticholinergic effects should
be avoided because they may adversely affect
cognition…

TA 290 (2013, Mirabegron)


is recommended as an option for treating the symptoms
of overactive bladder for people in whom antimuscarinic
drugs are contraindicated or clinically ineffective, or have
unacceptable side effects.
CG185 (Sept. 2014 (Bipolar disorder)

take into account the negative impact that anticholinergic
medication, or drugs with anticholinergic activity can
have on cognitive function and mobility…
Drug management of overactive bladder
• Conservative interventions for incontinence in people with
dementia or cognitive impairment, living at home: a
systematic review- Drennan at al., BMC Geriatr. 2012; 12:77
• Insufficient evidence, from any studies to recommend any
strategies
• Does Oxybutynin add to the effectiveness of prompted voiding for
urinary incontinence among nursing home residents?-Ouslander at
al. J. Am Geriatric Soc. 1995
• Statistically significant but clinically not
meaningful
Practical implications
• Older adult with cognitive symptoms, dementia,
MCI or delirium
• Taking one medication with ACB score of >2 or
total ACB score 3+
• Consider alternative medication with ACB
score <3 or reduce total score <3
• Discuss benefits and risks before starting
therapy
• Use lowest effective dose
• Discontinue if ineffective