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Primary Care Pharmacists Association
Practice Pharmacists Group Symposium 2016
10th March 2016 : The Studio, Birmingham
Priorities in the
Management of Older People
DR GRAHAM STRETCH, PRESCRIBING LEAD
ARGYLE SURGERY & FLORENCE ROAD SURGERY, EALING, LONDON
[email protected]
@GRAHAMSTRETCH
Well, the Glaxo pill protects my heart from the side
effects of the Pfizer pill that prevents potential liver
failure due to the Merck pill that minimises the risk of
stroke posed by the Novartis pill that reduces blood
clots caused by the Glaxo pill…
The devil of
it is I can’t
remember
the illness
that started
all this
Activity


Three ‘Brainstorm’ Walls
1.
Physiological changes in aging
2.
Common morbidity in the elderly
3.
Drugs associated with adverse
reactions / poor outcomes in the
Elderly
Post-it Notes
Pharmacokinetics
PB, Metabolism,
Clearance, Elimination,
BBB
Pharmacodynamics
GI motility =
Constipation
Sensitivity, Response,
Compensation
Orthostatic
circulatory
responses
Blunting of reflex
tachycardia=postural
hypotension, On rising
from rest, BP should
increase doesn’t =
postural hypotension
= FALLS
Postural control
 in dopamine receptors in
stratum
 Static postural reflexes
 FALLS/fractures
Prostatic hypertrophy, OAB,
urethral dysfunction
=
Incontinence
Cognitive function
change in CNS = confusion
The Geriatric Giants

Bernard Isaacs (1924-1995)


Professor of Geriatric Medicine, Birmingham, 1972
Geriatric Giants

incontinence

immobility

instability(falls)

intellectual impairment
Falls
Cognitive
Constipation
Impairment
Delirium
Incontinence
Frailty
Dehydration
Pain
Immobility
Malnutrition
Depression
Resilience
Functional abilities
Minor Illness in Fit Older Person
Minor Illness in Frail Older Person
INDEPENDENCE
DEPENDENCE
Clegg et al, Lancet, Volume 381, Issue 9868, 2–8 March 2013, Pages 752–762
ADRs
Most common drug groups associated with admission:

NSAIDs 29.6%

Diuretics 27.3%

Warfarin 10.5%

ACE 7.7%

Antidepressants 7.1%

Beta blockers 6.8%

Opiates 6.0%

Digoxin 2.9%

Prednisolone 2.5%

Clopidogrel 2.4%
Pirmohamed, et al. BMJ 2004. 329; 15-19
Case 1
Case 1
AKI - iotrogenic

5 “Usual Suspects”

NSAID

ACE

ARB

Diuretic

Antibiotics


(aminoglycosides, cephalosporins)
‘Triple Whammy’

ACE, NSAID, Diuretic
NSAID
Diuretic
ACE/
ARB

Suspend

metformin (risk of lactic
acidosis)

diuretic (worsening of
dehydration)

ACE (risk of AKI)

NSAID (risk of AKI)
At Review

Aspirin - CHA2DS2-VASc=3, HASBLED=3


Anti Coag?
eGFR 45 – metformin?

Sulphonylurea?

DPP-4 inh?

CKD3A – review NSAID

‘Triple Whammy’ – combination of NSAID, diuretic and ACE in
elderly (High risk combination BP, renal and cardiac) eGFR 45
(stop naproxen?)

Bleeding risk – on Aspirin, Naproxen and SSRI – review & add
PPI (stop naproxen?), also had prn gaviscon, Hb = 11.2, slightly
low – Ferritin?

Amlodipine and simvastatin 40mg – MHRA alert (risk of
myopathy) switch statin or reduce to 20mg

Citalopram 30mg >65yrs max 20mg (risk of QT prolongation)

Switch naproxen, to paracetamol +/- codeine, topical NSAID
Case 2

Hx

20 Mar 2000 Essential hypertension (XE0Uc)

01 Feb 2008 Rheumatoid Arthritis (N040..)

10 May 2002 Hypothyroidism (X40IQ)

01 Feb 2008 Dyspepsia - symptoms Dyspepsia

02 Sep 2002 Deep vein phlebitis (XE0VY)

27 Jun 2008 Morbid obesity (X40YQ)

02 Sep 2002 H/O: pulmonary embolus (14AC.)

19 Mar 2010 Osteoarthritis Hip pain (X75rv)

24 Nov 2005 Urinary incontinence (1A23.)

11 Oct 2010 Haemorrhoid (G84..)

24 Oct 2006 Knee joint operations (7K3..)

25 Sep 2012 Dry eyes (1B88.)

13 Dec 2006 Asthma monitoring (XM1Xb)

07 Jun 2013 Microcytic hypochromic anaemia (D00y1)

04 Aug 2007 Glaucoma

07 Jun 2013 Anaemia - iron deficiency

18 Dec 2007 Serum cholesterol raised (44P3.)

05 Sep 2013 Hodgkin's disease (B61..)

18 Dec 2007 Hyperlipidaemia

27 Mar 2014 Supraventricular tachycardia (Xa0k6)

01 Feb 2008 Indigestion (1954.)
•
•
•
Repeat File
Amitriptyline 10mg Tablets
Buprenorphine 10micrograms/hour transdermal
patches
Celluvisc 1% eye drops 0.4ml unit dose (Allergan
Ltd)
Co-dydramol 10mg/500mg tablets
Dilzem XL 180 capsules (Teva UK Ltd)
Domperidone 10mg tablets
Folic acid 5mg tablets
Gabapentin 100mg capsules
Lacri-lube eye ointment (Allergan Ltd)
Lactulose 3.1-3.7g/5ml oral solution
Latanoprost 50micrograms/ml eye drops
Levothyroxine sodium 25microgram tablets
Levothyroxine sodium 50microgram tablets
•
•
Omeprazole 20mg gastro-resistant capsules
Oramorph 10mg/5ml oral solution (Boehringer
Ingelheim Ltd)
Paracetamol 500mg tablets
Promethazine 25mg Tablets
Salazopyrin EN-Tabs 500mg (Pfizer Ltd)
Salbutamol 100micrograms/dose inhaler CFC free
Scheriproct ointment (Bayer Plc)
Seretide 125 Evohaler (GlaxoSmithKline UK Ltd)
Simvastatin 40mg tablets
Solifenacin 5mg tablets
Trospium chloride 60mg modified-release capsules
Warfarin 1mg tablets
Warfarin 3mg tablets
Warfarin 5mg tablets
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Rationalise

Try mirabegron for OAB - replace anti cholinergics, No INR recorded requested warfarin –
indication? stop

Pain relief Butrans 20, paracetamol 2 qds and oramorph 2.5-5mg 4hr prn record usage

Stop amitriptyline / promethazine / domperidone

repeat levothyroxine, salazopyrin, salbutamol and seretide.

Simvastatin to be reviewed non-concordant - stop?
New Rx

Buprenorphine 20micrograms/hour transdermal patches - 4 patch - apply one as directed

Gabapentin 100mg capsules - 100 capsule – I tds

Mirabegron 50mg MR Tabs – 30 tabs – 1 OD

Oramorph 10mg/5ml oral solution (Boehringer Ingelheim Ltd) - 300 ml - 5MLS WHEN REQUIRED UPTO
4-6 HOURLY

Scheriproct ointment (Bayer Plc) - 30 gram - apply twice daily as needed

(R) Levothyroxine sodium 25microgram tablets - 56 tablet - EVERY DAY

(R) Levothyroxine sodium 50microgram tablets - 56 tablet – OD

(R) Paracetamol 500mg tablets - 224 tablet - 2 FOUR TIMES A DAY regularily

(R) Salazopyrin EN-Tabs 500mg (Pfizer Ltd) - 224 tablet - 2 TABLETS TWICE DAILY (AS ADVISED BY
HOSPITAL)

(R) Salbutamol 100micrograms/dose inhaler CFC free - 200 dose - 1-2 PUFFS WHEN REQUIRED

(R) Seretide 125 Evohaler (GlaxoSmithKline UK Ltd) - 120 dose - ONE PUFF TWICE A DAY
ADRs
Constipation
Opiates, antihistamines, iron, calcium channel blockers, anticholinergics
Nausea and vomiting
Many drugs
Postural hypotension, falls
Sedatives, Antiparkinson drugs, antihypertensives, alcohol, psychotropics
Impaired cognition
Most CNS drugs e.g TCAs, , anticholinergics
Blood disorders
Methotrexate, Carbemazepine, Sulphasalazine
GI bleeds
Aspirin, NSAIDs, Warfarin, SSRIs, Prednisolone
Confusion
Cimetidine, hypnotics, anticholinergics
Blurred vision
Anticholinergics, antihistamines, TCAs
Renal failure
ACEI, NSAIDs
Hypertension
NSAIDs
Extrapyramidal effects
Metoclopramide, prochloperazine, antipsychotic
Anorexia
Digoxin
Altered taste
ACEIs, metronidazole, zopiclone
ACh
Autonomic NS
NA
“Higher cumulative anticholinergic
use is associated with an increased
risk for dementia”
Gray et al. Cumulative use of strong anticholinergics and
incident dementia: a prospective cohort study.
JAMA Intern Med. 2015;175:401-7
The Headlines
Study suggests sleeping drugs can increase risk of Alzheimer’s. The Guardian, 27 January 2015
Popular sleep remedies and hay fever pills 'increase risk of Alzheimer's by more than 50%'. Daily Mail, 26 January 2015
Hay fever and sleeping tablets 'can increase risk of Alzheimer's and dementia'. Daily Mirror, 26 January 2015
Routine drugs for elderly ‘raise risk of dementia’. The Times, 26 January 2015
Hayfever pills and sleeping aids can 'significantly increase' risk of Alzheimer’s, says US study. The Independent, 26 January
2015
Hayfever drugs raise risk of Alzheimer's disease, say scientists. The Daily Telegraph, 26 January 2015
Dementia 'linked' to common over-the-counter drugs. BBC News, 27 January 2015
AChE Inh
(eg Donepezil)
Anticholinergics
Risk for incident dementia and Alzheimer disease with 9-year cumulative
anticholinergic use with 2-year lag time
TSDD
Follow-up time
(person-years)
Dementia
Alzheimer Disease
0
6137
Number of
Events
154
1-90
7861
208
0.89
0.71-1.11
172
0.94
0.74-1.20
91-365
4849
171
1.21
0.96-1.52
128
1.19
0.92-1.55
3661095
2461
94
1.15
0.88-1.52
80
1.30
0.96-1.75
>1095
3712
170
1.49
1.17-1.89
133
1.59
1.22-2.08
HR (95% CI)
1.00
Reference
Number of
Events
124
HR (95% CI)
1.00
Reference
n=3434, mean follow-up 7.3y, 797 (23.2%) dementia (637 [79.9%] AD)
“The use of medications with
anticholinergic activity increases the
cumulative risk of cognitive
impairment and mortality.”
Fox et al. Anticholinergic medication use and cognitive
impairment in the older population: the medical research
council cognitive function and ageing study.
J Am Geriatr Soc. 2011 Aug;59(8):1477-83
Fox et al. 2011

Thirteen thousand and four participants from
UK aged 65 and older.

Worsening brain function: participants ACB
score 5 + scored 4% lower test (MMSE).

Increased death rate:


End year 2: 20% people scoring 4 + vs. 7% scoring 0.

Every extra ACB point scored odds dying ↑ 26%
Cumulative risk both no. anticholinergic drugs &
strength each drug’s anticholinergic effect
“…a risk increase for dementia by the chronic
use of drugs with anticholinergic properties…In
terms of dementia prevention, centrally acting
anticholinergic drugs should be strictly
avoided, because of long-term dementia risk
increase in addition to acute negative effects
on cognition..”
German, n=2600, Use anti-cholinergics associated ↑ risk dementia (HR:
2.081; p < 0.001), Classified strength AC activity (1 to 4) - dose effect
– Level 1 – HR: 1.800; p < 0.001
– Level 2 – HR: 1.534; p = 0.105
– Level 3 – HR: 2.584; p = 0.002
– Level 4 – HR: 3.361; p < 0.001
Jessen et al. Anticholinergic drug use and risk for dementia: target
for dementia prevention.
Eur Arch Psychiatry Clin Neurosci (2010) 260:111–115
“Eighteen studies …(124 286 participants).
Exposure …was associated with increased
odds of cognitive impairment (OR 1.45, 95% CI
1.16- 1.73)...a unit increase in the ACB scale
was associated with a doubling in odds of allcause mortality (OR 2.06, 95% CI 1.82- 2.33).”
Ruxton, K., Woodman, R. J., and Mangoni, A. A. (2015)
Drugs with anticholinergic effects and cognitive impairment,
falls and all-cause mortality in older adults: A systematic
review and meta-analysis.
Br J Clin Pharmacol. doi: 10.1111/bcp.12617. (MAY 2015)
“Prescribers should be aware…when
considering anticholinergic
medications for their older patients
and should consider alternatives
when possible”
Gray et al. Cumulative use of strong anticholinergics and
incident dementia: a prospective cohort study.
JAMA Intern Med. 2015 Mar;175:401-7
Alternatives?
TCA

Depression


SSRI

Sertraline

Citalopram

Duloxetine
Trazodone
Neuropathic
gabapentin
 pregabalin



• ‘1st Gen’
– chlorpheniramine
– diphenhydramine
– promethazine
SNRI


Antihistamine
Lyrica
duloxetine
• Current
Indication?
•
‘2nd Gen’
– loratadine
– cetirizine
OAB
• Anti-Chol
–
–
–
–
–
oxybutynin
tolterodine
solifenacin
trospium
darfenacin
• SNRI
– duloxetine
• B3 agonist
– mirabegron
Polypharmacy
“…should be conceptually
perceived as a ‘disease’ with
potentially more serious
complications than those of the
diseases these different drugs
have been prescribed for”
Gafinkel et al.
Arch Intern Med. 2010;170(18):1648–1654
Medicines Optimisation
“a person-centred approach to safe
and effective medicines use, to
ensure people obtain the best
possible outcomes from their
medicines.”
NICE guidelines [NG5] March 2015
Deprescribing
“the process of tapering, withdrawing,
discontinuing or stopping medications to
reduce polypharmacy, adverse drug
effects and inappropriate or ineffective
medication use by re-evaluating the
ongoing reasons for, and effectiveness of
medication therapy.”
Gnjidic et al. Clin Geriatr Med 2012;28:237–253
Overdiagnosis
“...the related problems of over
medicalisation and subsequent
overtreatment, diagnosis creep, shifting
thresholds, and disease mongering, all
processes helping to reclassify healthy
people with mild problems or at low risk
as sick.”
Moynihan et al. Preventing overdiagnosis:
how to stop harming the healthy. BMJ 2012;344
November 2013
http://tinyurl.com/medsopt
Stopp Start

A Toolkit
Gallagher et al. Int J Clin Pharmacol Ther. 2008 46(2):72-83.
Gafinkel et al.
Arch Intern Med.
2010;170(18):164
8–1654
Everybody’s business

Structured approach integrated with clinical judgement
is required.

Acknowledge some meds may be restarted – it’s a trial

Full engagement of patient, family, carers is imperative
and honesty all round

The MDT

Share the workload with pharmacists/specialists

Patients, relatives, carers, community pharmacists, OTs, nurses
etc can monitor drug effects and feedback

Focus on patients with the highest medication related
risks and morbidities

For individual patients, focus on the drugs with the
highest risks or highest benefits
…..less is more
References

[email protected]

American Geriatric Society (2012). Updated Beers criteria for potentially
inappropriate medication use in older adults. J Am Geriatr Soc

Barber ND, Alldred DP, Raynor DK et al 2009.The Care Homes’ Use of Medicines
Study. Quality and Safety in Health Care 18, pp.341-6.

Cochrane Collaboration 2012 Interventions to improve the appropriate use of
polypharmacy for older people.

Gallagher P et al. Screening tool of older people’s potentially inappropriate
prescriptions. In J Clin Pharmacol Ther 2008;46:72-83 (STOPP)

Gallagher P et al. Screening tool to alert doctors to right treatment. In J Clin
Pharmacol Ther 2008;46:72-83

Garfinkel D, Mangin D. Feasibility study of a systematic approach for discontinuation
of multiple medications in older adults: addressing polypharmacy. Arch. Intern Med
2012;170:1648-54.

Hanlon J et al. Medication Appropriateness Index- MAI. J Clin Epidemiol
1992;45:1045-51

NHS Highland. Polypharmacy: Guidance for prescribing in frail elderly 2013

O’Mahony, O’Connor. Pharmacotherapy at the end-of-life. Age and ageing
2011;40;419-22

Steinman M, Hanlon J. Managing medications in complex elders: There’s got to be a
happy medium. JAMA 2010;304(14):1592-1601

http://www.prescqipp.info/projects/polypharmacy-and-deprescribing

Thanks also to Lelly Oboh, Consultant pharmacist, Care of older people Guys & St
Thomas NHS Community Health services, East & South East England NHS Specialist
Pharmacy Services