WORKSHOP I. CLINICAL PHARMACY_VORU, ESTONIA - PowerPoint PPT Presentation

WORKSHOP I. CLINICAL PHARMACY_VORU, ESTONIA __________________________________________________________________ Moderators: Fialová Daniela, PharmD, PhD, BCCP Dimitrow Maarit, PharmD, PhD University Educational Centre in Clinical Pharmacy Faculty of Pharmacy, Charles University in Prague , Czech Republic, Department of Geriatics and Gerontology, 1st Faculty of Medicine, Charles University, Czech Republic daniela.fialova@faf.cuni.cz

QUESTION I: The highest proportion of older adults in Europe is nowadays in: 1/ Poland, Slovac Republic and Czech Republic 2/ UK, Spain and Portugal 3/ Italy, Germany, Sweden 4/ Ireland, Norway and Netherlands

EUROPEAN COUNTRIES - population 65+ Ageing of Europe, World Healrh Statistics, 2017

QUESTION II: Considering the aging of the world population, the highest old-age dependency ratio (N of older patients/N of productive population 14- 65 years) is expected in 2050 in: 1/ Poland, Germany 2/ Finland, Sweden 3/ developing countries, e.g. India 4/ USA, Canada

Prognosis of „old - age dependency ratio“ (65+ years/100 population 15-64 years ) United Nations ´ Assembly on World Population Ageing, Figure: Prognosis for the old-age dependency ratio (ratio of the population aged 65+ per 100 persons 15-64 yrs old)

QUESTION III: Among „Top 3“ Eastern and Central EU countries with the highest proportion of older adults in 2050 year are expected to be: 1/ Poland, Slovakia, Hungary 2/ Hungary, Romania, Belarus 3/ Slovenia, Bulgaria, Czech Republic 4/ Croatia, Slovakia, Moldova

Central and Eastern European countries - growth in the proportion of older adults (65+, by 2050) 2050 year (% 65+) 1. Slovenia- 33.7% 2. Bulgaria- 31.1% 3. Czech Republic- 30.6% 4. Poland- 30.6% 5. Croatia- 29.3% 6. Slovakia- 29.4% 7. Hungary- 29.1% 8. Romania- 28.8% 9. Belarus- 28% 10. Moldova- 26.8% Mamolo M, Scherbov S. Population projections for fourty-four European countries: The ongoing population ageing. European Demographic Research Papers 2/2009, pp43-44 . Vienna Institute of Demography of the Austrian Academy of Sciences, Vienna, Austria (2009). www.oeaw.ac.at/vid/download/edrp_2_09.pdf

QUESTION IV: Expenditures for home care and nursing home care services are expected to increase by 2050 year (according to US statistics): 1/ about 30% 2/ about 50% 3/ will double 4/ will triple

Expected Increase in HC Expenditures for HC and NHC services by 2050 2050 2017 US National Statistics ´ Bureau, 2012

QUESTION V: According to the EU „ADHOC - AgeD in Home Care project “ (representative samples of HC older clients in 11 EU countries), the prevalence of polypharmacy and excessive polypharmacy in HC older clients was: 1/ > 30% 6+ drugs and >10% 9+ drugs 2/> 30% of 9+ drugs and> 60% of 6+ drugs 3/> 50% of 6+ drugs and >20% of 9+ drugs

POLYHARMACY ADHOC EU project (HC older patients) MEDS USE CZ CZ EN EN FIN IT IT NL NL ICE DE DE NO NO Total N=428 N=289 N=187 N=412 N=198 N=405 N=400 N=388 N= 2707 N >=1 97,7% 96,5% 95,2% 93.7% 95,0% 97.8% 93,3% 91,8% 95,1% 6>= 68,5% 48,4% 73,3% 36,2% 35,4% 63,7% 50,5% 33,8% 51,0% 9>= 39,0% 20,1% 41,2% 7,0% 13,1% 31,6% 18,0% 11,1% 22,2% Finne- Soveri H et al. Major drug-related characterstics of HC older population in Europe. 42nd ESCP Symposium in Prague, Czech Republic, 16.-18.10,2016

QUESTION VI: The subjective need or objective need for help in managing medications was assessed in EU home care clients in: 1/ > 15% of HC clients 2/> 30% of HC clients 3/> 40% of HC clients 4/ >60% of HC clients

POLYHARMACY Finne- Soveri H et al. Major drug-related characterstics of HC older population in Europe. 42nd ESCP Symposium in Prague, Czech Republic, 16.-18.10,2016

QUESTION VII: The most problematic ethical issue in individualized drug therapy in older patients is the fact that : 1/ medications and their basic efficacy and safety are not fully tested in RCTs 2/ we statistically estimate appropriate drug dosing for the majority of drugs in older population 3/ polypharmacy users are mostly older patients and there is a poor evidence on efficacy and safety of medications and polypharmacy in older patients

INDIVIDUALIZED DRUG PRESCRIBING Evidence-B(i)ased Medicine Geriatric patient • Age-related changes (fa-ki, fa-dy, homeostasis) • Multiple chronic disorders (drug- disease int., geriatr.is syndromes) Users Polypharmacy • Functional impairment, frailty • Long duration of treatment of meds (changes in goals of care, effectiveness, safety, etc.) RCTs • Noncompliance, psychosocial factors (dependency, rutine in drug use, expectations,..) • Highly individual outcomes • Quality of life, drug Age 60 85 safety/tolerability and cost- effectiveness are priorities (PREDICT project, 2009)

QUESTION VIII: Adequate geriatric dosing can be tested only in specific small-scale geriatric studies. Standard low-dose drug regimens has already been proved in geriatric patients for these drugs/drug groups (e.g.): 1/ Ca-blockers, ACHE-I, nitrates and ASA 2/ some NSAIDs, some statines, citalopram, omeprazol, some BBs 3/ some NOACs, pentoxyphylline, amiodarone and LABA

EFFICACY OF LOW-DOSE DRUG REGIMENS efektivní dávky léčivo CT on ger. dosing Geriatric dose Standard dose Drug doporučené denní dávky u seniorů hydrochlorothiazid 25mg 12,5mg 25mg bid captopril 50- 75mg enalapril 5mg 2,5mg atorvastatin 10mg 5mg lovastatin 20mg 10mg ibuprofen 400- 800mg tid 200mg tid diclofenac 100- 200mg 75mg misoprostol 200rg qid 50 - 100rg qid celecoxib 100mg bid 50mg bid ranitidin 150mg bid 100mg 2 krát qd x omeprazol 20mg 10mg nefazodon 100, 200 mg 100 mg 2 krát qd x x Cohen J, JAGS 2000

QUESTION IX: The ethiology of geriatric syndromes is usually complex and drugs belong to important causal risk factors of geriatric syndromes. Among major drug- related geriatric syndromes does not belong: 1/ incontinence 2/ cognitive impairment- dementia 3/ osteoporosis 4/ instability

GERIATRIC SYNDROMES _______________________________________________________________________________________________ SOMATIC PSYCHIATRIC SOCIAL • mobility problems • dementia • ↓ self performance • vertigo- instability • depression • ↑ dependence • falls and injuries • delirium • isolation • incontinence • behavior changes • violence • Impairment of • maladaptation • abusive behavior termoregulation • et al. • family problems • nutritional problems • etc. • skin problems(decubitus) • et al. Drug-related Health factors Socio-economic factors

QUESTION X: Which of these drugs do not usually cause geriatric syndromes? 1/ beta-blockers and diuretics 2/ PPIs 2/ metoclopramide and benzodiazepines 3/ metformin

DRUG-RELATED GERIATRIC SYNDROMES _______________________________________________________________________________________________ Central anticholinergic syndrom- cognitive impairment, dementia, deliria, confusion (indometacine, ranitidine, metronidazol, chinolones, benzodiazepines, digoxine, theofylíne , prednisolone, aj.) Drug-related depression (metoprolol, methyldopa, indomethacine) Drug-related parkinsonism (metoclopramide, typical antipsychotics, risperidone) OH and falls, fractures (benzodiazepiny, TCA, antipsychotika, antihypertenziva, vasodilatancia , sedativní antihistaminika) Malnutrition (PPI, polypharmacy)

QUESTION XI: Definitions of inappropriate prescribing evolved during decades and the most updated definitions differ from previous mostly in: 1/ specification of individual PIMs that should not be precribed 2/ emphases on preventability of ADEs by reducing excessive use of PIMs 3/ suggestions of safer drug alternatives

DIFFERENT DEFINITIONS OF PIMs _______________________________________________________________ BEERS 1997 criteria „… drugs (procedures) where the risk of ADEs substantially exceeds the benefit of treatment in the elderly and safer alternatives exist …„ Mc LEOD 1997 criteria „…. inappropriate prescribing presents substantial risk of serious ADEs and safer and widely available drug alternatives exist …. or the overall change in the prescription decreases substantially morbidity and mortality in the elderly …“ AGS 2015 criteria „…. avoiding the use of inappropriate and high-risk drugs is an important, simple, and effective strategy to reduce negative outcomes in the elderly. PIMs are medications having an unfavorable balance of risks and benefits by themselves and considering alternative treatments available (including non-pharmacological strategies) …. PIMs are still inappropriately used as first-line therapy.

EXPLICITE CRITERIA - PIMs „ Potentially Inappropriate Medications in the Elderly “ ______________________________________ BEERS criteria 1991- NH residents (Beers et al, Arch Intern Med. 1991) 1997- CC and NH residents (Beers et al., Arch Inter Med.1997) 2001 (Zhan et al.) - hierarchy of inappropriateness (Zhan et al., JAMA. 2001) 2003 (Fick et al.) Marc H. Beers (Fick et al Arch Intern Med. 2003) 2012- AGS 1954-2009 (Amer.Geriatr.Soci., JAGS 2012) 2015- AGS update (Amer.Geiatr. Society, JAGS 2015) and 2016- EU7 criteria Donna Fick