Canadian Society of Internal Medicine Annual Meeting 2019 Halifax, NS Geriatrics 2019 Update: Pills and Falls Dr. Kim Babb MD FRCPC Memorial University of Newfoundland kimberly.babb@easternhealth.ca
CSIM Annual Meeting 2019 The following presentation represents the views of the speaker at the time of the presentation. This information is meant for educational purposes, and should not replace other sources of information or your medical judgment. Learning Objectives 1. Appreciate the overall importance of active deprescribing in the older adult. 2. Understand how failure to deprescribe may promote frailty. 3. Learn practical strategies and clinical significance of deprescribing in the older adult. 4. Identify effective fall-prevention strategies.
CSIM Annual Meeting 2019 Conflict Disclosures I have the following conflicts to declare: • Member of the Scientific Planning Committee for Core Geriatric Experiences in Primary Care (NLMA Family Practice Renewal Program) • Author and speaker for the Frailty I and II programs • Received honoraria from Pfizer for delivering CME on “Caring for our Elderly Patients: A Focus on OAB and AF”
Audience Participation Website: PollEV.com/kimbabb743 Text: KIMBABB743 to 22333 once to join
The Case of Ed
The Case of Ed • 83M referred for a cognitive assessment • PMHx: 1. Depression 2. Atrial fibrillation 3. TIIDM (HgA1c 6.2%) 4. HTN 5. DLP 6. OA 7. Urinary incontinence (indwelling foley for 1 month) 8. Recurrent UTIs 9. CKD (eGFR ~30%)
The Case of Ed 1. ASA 81 mg daily 10. Multivitamin daily 2. HCTZ 12.5mg daily 11. Mg supplement daily 3. Candesartan/HCTZ 16/12.5mg daily 12. Senna 2-4 tablets qhs 4. Simvastatin 40mg daily 13. Lorazepam 2mg po qid 5. Solifenacin 10mg daily 14. Pregabalin 75mg qhs 6. Omega 3 1000mg tid 15. Tylenol 650mg tid prn 7. Docusate sodium 100mg bid 16. Ranitidine 150mg bid 8. Insulin NPH 16u qhs 17. Pantoprazole 40mg daily 9. Insulin R 22u breakfast, 9u lunch, 18. Folic Acid 1mg daily 14u supper **warfarin recently d/c by FP secondary to falls
Audience Poll Q: Which statement is true? a. The overall anticholinergic burden is low. b. The overall anticholinergic burden is high. c. Regardless of anticholinergic burden, the medications seem reasonable, so no need to make adjustments. d. I have no idea how to calculate anticholinergic burden.
The Case of Ed • Appeared frail • Wheelchair, unable to stand unassisted • BP 130/60 sitting, 98/48 standing • HR 78 sitting, 90 standing • MMSE 22/30 – 8/10 orientation, 1/5 concentration, 2/3 recall, 2/3 command
The Case of Ed 1. ASA 81 mg daily 10. Multivitamin daily 2. HCTZ 12.5mg daily 11. Mg supplement daily 3. Candesartan/HCTZ 16/12.5mg daily 12. Senna 2-4 tablets qhs 4. Simvastatin 40mg daily 13. Lorazepam 2mg po qid 5. Solifenacin 10mg daily 14. Pregabalin 75mg qhs 6. Omega 3 1000mg tid 15. Tylenol 650mg tid prn 7. Docusate sodium 100mg bid 16. Ranitidine 150mg bid 8. Insulin NPH 16u qhs 17. Pantoprazole 40mg daily 9. Insulin R 22u breakfast, 9u lunch, 18. Folic Acid 1mg daily 14u supper **warfarin recently d/c by FP secondary to falls
Polypharmacy Definition: LOTSA + MEDS • More medications than clinically indicated • Use of those carrying a high risk of adverse drug events • Increasingly refers to underuse of potentially useful medication
Polypharmacy • Polypharmacy is commonly seen in frailty – Complex association • Polypharmacy can promote frailty
Frailty A physiologic decline in later life characterized by marked vulnerability to adverse health outcomes.
Frailty
Frailty at SCMH Percentage of Frail Elderly Acute Care Medicine Patients SCMH 120 562 IM inpatients 100 80% screened 80 vulnerable to frail 74 60 83 86 40 20 26 17 14 0 7 West 7 East 4 West % Screen negative ( 3 or less) % Screen positive (4 or more)
Frailty at SCMH Clinical Frailty Scores 120 100 80 60 40 20 0 Very fit Well Managing Vulnerable Mildly frail Moderately Severely Very Terminally well frail frail severely ill frail Total number of patients Percentage of patients
Polypharmacy • Polypharmacy is commonly seen in frailty – Complex association • Response to multimorbidity • Can mimic geriatric syndromes • Multimorbidity + Geriatric syndromes Frailty
Polypharmacy can promote frailty
Polypharmacy Polypharmacy outcomes • Increased hospitalizations • Cognitive impairment • Functional impairment • Prolonged hospitalizations/readmissions • Poor compliance • Mortality • Falls • Independent risk factor for hip fracture
Polypharmacy • Drug-induced events can mimic other geriatric syndromes – Urinary incontinence, confusion, falls – Often leads to prescribing cascade
Prescribing Cascade Bladder CCB antimuscarinic • HTN • Incontinence • Arthritis • Ankle edema NSAID Diuretic
http://www.slideshare.net/prashantshukla927/polypharmacy-57404596
Why Deprescribe? Polypharmacy outcomes • Increased hospitalizations • Falls • Cognitive impairment • Functional impairment • Prolonged hospitalizations/readmissions • Poor compliance • Mortality • Frailty
Why Deprescribe? • Estimates noncompliance in the elderly vary – 40 - 75% • Decreased compliance with • 3 more more drugs • Dosing more than once a day • Side effect profile
Why Deprescribe? Adverse drug reactions • 1/3 of people taking ≥ 5 medications will have an adverse drug reaction – About 2/3 of these will require medical attention American Family Physician Dec 15th, 2007 Pham and Dickman
Deprescribing • Robust patients – Mobile and functionally independent • Medication focus on prevention, treatment/alleviation of symptoms and delay morbidity and mortality • Frail patients – Less mobile, functionally dependent • Medication focus on maintaining function and quality of life
Deprescribing • A process! • Tapering, withdrawing, discontinuing medications • Often involves substitution for a safer agent • Goal is improving outcomes
Deprescribing Golden Rules: • Fight complacency!!! • The goal is NOT zero • One thing at a time, and that one thing slowly • Go slow…but GO • Shared decision making model • Think about conditions that are undertreated
Audience Poll Q: Which medication class is often under-prescribed in older adults? a. Beta-blockers b. Statins c. Statins d. Hypoglycemics
Deprescribing Challenges: • Clinical practice guidelines are not focused on older adults – Rarely (if ever) focused on frailty • Evidence does not always inform practice • Generalists do not like to interfere with the specialists medication prescribing • Transitions of care
Deprescribing • Reasons to continue medications: – Important indications (ex: AF, osteoporosis) – Low tolerance for symptoms/cannot tolerate tapering • Reasons to wean/stop medications: – Adverse drug reactions – No indication – Treating side effect of another medication (cascade)
Deprescribing Tools (1) Beers Criteria • What not to use (2) STOPP/START • Systems based approach to starting appropriate and stopping inappropriate meds • “Toolkit”
Anticholinergic Burden • Older adults have diminished reserved of acetylcholine • Resultantly, more susceptible to adverse effects of anticholinergic medications – Especially cognitive effects
Anticholinergic Burden • Medications can be classified based on degree of anticholinergic activity – None, low, medium, high • Beware the “anticholinergic burden” – Cumulative adverse effects of overall anticholinergic “load”
The Case of Ed 1. ASA 81 mg daily 10. Multivitamin daily 2. HCTZ 12.5mg daily 11. Mg supplement daily 3. Candesartan/HCTZ 16/12.5mg daily 12. Senna 2-4 tablets qhs 4. Simvastatin 40mg daily 13. Lorazepam 2mg po qid 5. Solifenacin 10mg daily 14. Pregabalin 75mg qhs 6. Omega 3 1000mg tid 15. Tylenol 650mg tid prn 7. Docusate sodium 100mg bid 16. Ranitidine 150mg bid 8. Insulin NPH 16u qhs 17. Pantoprazole 40mg daily 9. Insulin R 22u breakfast, 9u lunch, 18. Folic Acid 1mg daily 14u supper
The Case of Ed 1. ASA 81 mg daily 10. Multivitamin daily 2. HCTZ 12.5mg daily 11. Mg supplement daily 3. Candesartan/HCTZ 16/12.5mg daily 12. Senna 2-4 tablets qhs 4. Simvastatin 40mg daily 13. Lorazepam 2mg po qid 5. Solifenacin 10mg daily 14. Pregabalin 75mg qhs 6. Omega 3 1000mg tid 15. Tylenol 650mg tid prn 7. Docusate sodium 100mg bid 16. Ranitidine 150mg bid 8. Insulin NPH 16u qhs 17. Pantoprazole 40mg daily 9. Insulin R 22u breakfast, 9u lunch, 18. Folic Acid 1mg daily 14u supper
Deprescribing My approach: 1. Is the patient ready? 2. Problem list/Medication list* 3. Assess frailty Assess use of preventative medications in – terminal/end stage disease 4. Prescribing cascade? 5. Anticholinergic burden? 6. Deprescribing tools as resources (BEERS Criteria, STOPP/START, etc)
Recommend
More recommend
