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Polypharmacy and Medicines
Optimisation in Older People
Multiple Morbidity Clinics
Lelly Oboh
Consultant Pharmacist, Care of Older People
Guys & ST Thomas NHS Trust
East & South East England NHS Specialist Pharmacy Services
18th June 2014
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Overview of workshop
• Medicines and multiple morbidities in older people
• Managing polypharmacy in the community
• Evidence of what works
• Guidance
• The case for multi morbidity clinics
• Integrating multi morbidity (MM)medication reviews into
routine care
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Identifying those at risk and complex cases
A practical/structured approach to deprescribing
Role of integrated care clinical pharmacists in the community
Workshop with Case scenario
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Multiple morbidity
• The co-existence of 2 or more long-term conditions (LTCs)
• More holistic definition should include LTCs, risk factors and
psychosocial distresses
• The norm in primary care and more common in elderly population
• Associated with poorer health and functioning, higher rates of
attendance in 10 care and specialty settings
• Loss of function
• Multiple medicine use
• Negative effects on wellbeing, relationships, and coordination of care
• Limited research on effective interventions for complex patients
• Quality of clinical encounter as important as co-ordination of care
•Smith S et al. GPs' and pharmacists' experiences of managing multimorbidity: a ‘Pandora's box’. doi: 10.3399/bjgp10X514756 BJGP July
1, 2010 vol. 60 no. 576 e285-e294. http://bjgp.org/content/60/576/e285.full
•Multimorbidity in primary care: developing the research agenda. Family Practice (2009) 26 (2): 79-80.doi: 10.1093/fampra/cmp020
http://fampra.oxfordjournals.org/content/26/2/79.full
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Multi-morbidity and medicines
• Multi-morbidity and polypharmacy intertwined
increase clinical workload and negative outcomes
• Optimising the use of medicines can have a high impact
on patient experience, health outcomes and costs1
• Reducing polypharmacy (deprescribing) is an important
component of improving care of frail older people2
1.
2.
Kings Fund 2014. Making our health and care systems fit for an ageing population
Naylor S et al. Kings Fund 2013. Transforming our health care system: Ten priorities for commissioners.
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Challenges: GPs & pharmacists views
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Lack of time
Communication difficulties with other care providers
Fragmentation of care
Professional isolation
• Clinical uncertainty lacked confidence or clinical
competence, often don’t know solution to identified problems
• Difficulties with decisions to stop medicines need for
geriatricians and specialist pharmacists
Smith S et al. GPs' and pharmacists' experiences of managing multimorbidity: a ‘Pandora's box’. doi: 10.3399/bjgp10X514756 BJGP
July 1, 2010 vol. 60 no. 576 e285-e294. http://bjgp.org/content/60/576/e285.full
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What works? Generally
• Personalised and holistic approach
• Care organised around the patient, not the disease
• Multiple physical and psychosocial conditions taken into account
• Co-ordinated approach with case finding, patient centred
assessment and care planning1,2
• Interventions targeted at specific2,3
• Combinations of common conditions
• Problems for patients e.g. medicines interventions tackling
polypharmacy and complex dosing regimens
• Collaborative/multidisciplinary approach
1.
2.
3.
Kings Fund 2011. Case Management
RCGP Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities?
Interventions for improving outcomes in patients with multimorbidity in primary care and community settings. Cochrane Review
2012
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What works? GPs & pharmacists views
• GPs managing patients in primary care
• One clinic and one nominated GP 45mins at least/plus
timely input from geriatricians/specialists if out of depth
• Pharmacist access to patient information
• Planned care
• Referral for time limited “rehabilitation” type program
• Outcome should focus on function rather than specific
disease outcome
Smith S et alGPs' and pharmacists' experiences of managing multimorbidity: a ‘Pandora's box’. doi: 10.3399/bjgp10X514756
BJGP July 1, 2010 vol. 60 no. 576 e285-e294. http://bjgp.org/content/60/576/e285.full
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What works? Guidance1-5
Ongoing, periodic medication review
• Patient centred patients given essential information and
involved in decisions
• Holistic – Done in context of overall patient goals
• Focused medication review consultations with sufficient time to
address MMs (involve clinical pharmacists if complex)
• MMs reviewed by lead clinician who co-ordinates care
• Multidisciplinary approach Close collaboration of pharmacists
and doctors (Holland et al 2005; Salter et al 2007).
• Improved co-ordination/communication during transition of
care between community and specialist care
1.
2.
3.
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BGS Quest for quality in care homes 2011
CHUM Study 2009
Kings Fund. Polypharmacy 2013
Kings Fund. Quality of GP prescribing 2011
NICE Managing medicines in care homes 2014
(
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Summary: Single vs. MMs clinics
Single condition clinics
Target driven, focused on disease rather than fulfilling the patient agenda
Poor co-ordination of care, transfer of information and communication
Difficulties tackling specific problems relating to MMs e.g non-adherence
Inconvenience of attending multiple clinic appointments
Difficulties managing patients within limited consultation time
Addresses condition in isolation vs. context of psychosocial needs and
overall function
Poor consideration of impact of disease:disease interactions and
synergies managing different conditions Duplication of therapy,
inefficiencies e.g. polypharmacy
Poor patient motivation and self management
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GSTT model: Integrating MM medication
review into the frail older people care pathway
using clinical pharmacists in community
Proactively
Identify those
at high risk
from
medicines for
domiciliary
med review
Clinical Pharmacist
Undertakes Patient
centred
Comprehensive
assessment of
needs
&
Liaises with
others to
facilitate
Implementation
of care plan
Monitor &
review
Jointly agrees plan
Community
Pharmacist
(investigating)
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Who is at the highest risk from polypharmacy?
Frail older people
• Aged over 75, often over 85, with multiple
diseases, which may include dementia.
(British Geriatric Society)
• Reduced functional reserve more
vulnerable to developing complications
while in hospital
• Less resilient to external stressors and
take more time to recover
• Frequent hospital admissions with
geriatric syndromes such as falls,
immobility and confusion
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Identifying frailty
Morley JE et al. J Am Med Dir Assoc ; 2013 Jan 1;14(6):392–7
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A Pragmatic approach
Identify population and screen for risk factors
Southwark & Lambeth Integrated care (SLIC) Pathway for
Frail Older People Program
Urgent response &
maximising independence
Case management
Community Matrons
15-20%
Integrated Care
Managers
Community MDTs : Support
case managers to manage
most complex cases
•@Home team
•Rapid response Team
•Supported discharge team
•Reablement
teams
:
70-80% of LTC
population
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Screening for medicines related risk (local tool)
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Proactively identifying those with complex needs (local
tool)
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Evaluation of service
Collaboration with researcher, UCL School of Pharmacy
• Analysis of 143 patients data from over 300 reviews
• Average of 9 LTCs and 14 medicines per patient
• 67% of patients over 75 years and 53% live alone
• 43% reported at least 1 or more problems with taking medicines
• 95% use one regular community pharmacy, mainly for access and adherence
support
• 376 medicines related problems (3.8/patient)
• Contact with a wide range of health and social care staff
• Factors contributing to the greater need for enhanced community support
and referral to pharmacist include
Advanced age History of falls Multiple pathologies
Polypharmacy
New medicines
Challenging cognitive, physical, functional & sensory impairments
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Many drugs are often continued beyond the
point at which they are beneficial and may
actually cause harm (DTB 52:2014)
Polypharmacy itself should be conceptually
perceived as a “disease” with potentially more
serious complications than those of the
diseases these different drugs have been
prescribed for (Doron Garfinkel 2010)
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Pharmacist led MM medication review
Aims to optimise medicines use by taking the lead to
identify, resolve and co-ordinate all aspects of patient
care relating to medicines use
• Reduce inappropriate polypharmacy (deprescribing) and
adverse effects.
• Improve adherence and understanding of medicines
• Reduce utilisation of emergency services through better
therapeutic control of multiple morbidities
• Facilitate partnership working across agencies and improve
medicines use during transitions of care
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Deprescribing
• The complex process required for the safe and effective
cessation (withdrawal) of inappropriate medications .
Takes into account the patient’s physical functioning,
co-morbidities, preferences and lifestyle (DTB 52:2014)
Oligopharmacy
• Deliberate avoidance of polypharmacy i.e. less than 5
prescription drugs daily
(O’Mahoney. 2011)
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Deprescribing:Getting the right balance
Life expectancy, co-morbidity
burden, care goals patient
preferences, benefits of
medicines
ADRs, risks and harms
of medicines
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“Deprescribing”-What the literature show1-3
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No long term outcome data
.......BUT, reduces drug usage/costs & unlikely to cause harm
Must involve patients, carers & multidisciplinary working
Involves managing multivariate interconnected causes associated
with frailty
There’s enough evidence to stop certain drugs
Many challenges and barriers
Must be done sequentially, slowly over a period of time
Complex, time consuming, dynamic process requiring co-ordination
by a lead clinician with strong therapeutic and interpersonal skills
Requires extensive communication, frequent monitoring and
reviews
Structured approach needed (7 steps identified)
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.
O’Mahony, O’Connor. Pharmacotherapy at the end-of-life. Age and ageing 2011;40;419-22
Hilmer SN, Gnjidic D and Le Couteur D.Thinking through the medication list. Australian Family Physician 2012 Vol 41 no 12, p924
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Garfinkel et al 2010
Feasibility study of a systematic approach for discontinuation of multiple medication in older adults
• 70 community dwelling older adults (Feb 05-Jun 08)
• Follow up every 3-6 months
• Algorithm based on evidence for drug indication
• Algorithm identified 311drugs (in 64 pts) to stop
• 256 drugs considered after family discussion
• 81% discontinued
• 2% restarted
• 88% reported global improvements in health.
• 100% success for benzodiazepines
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The Good Palliative–Geriatric Practice algorithm
http://archinte.jamanetwork.com/article.aspx?articleid=226051.
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O’Mahoney et al (of STOPP/START fame…)
Review of principles for best practice in oligopharmacy
• Focus  End-of-life or pre-terminal phase
• Differentiates between starting new drugs vs stopping existing drugs
• Suggests using STOPP tool to identify drugs for stopping
• Considers suitability/need for drug classes rather than indication for
prescribing (cf Garfinkel)
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Drugs for primary and life extension
Drugs for secondary prevention except benefits
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Aim for <5 medicines, minimise tablet count and doses per day
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Optimise formulation and administration methods (liaise with
community pharmacist) & refer for MUR where appropriate
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Hilmer S 2012
Evidence based discussion for appropriate prescribing and deprescribing
• Differentiates between robust vs frail older people
• Considers appropriateness based on current poor evidence for
commonly prescribed medicines in older people
• Drug assessment based on adherence, ADRs, indications and
interactions
• Considers ethical principles
• Multidisciplinary support required for GP to deprescribe safely
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Key steps in optimising an older patient's medical therapy
http://www.racgp.org.au/afp/2012/december/medication-list/
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Summarising the literature
O’Mahoney
Garfinkel
Key steps
Hilmer
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2. Define overall patient 
goals
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3. Identify inappropriate GP-GP
drugs from accurate Algorithm
list of medication
STOPP tool
EBM/ethics
4. Assess each drug for GP-GP
Algorithm
specific risks vs.
benefits in context
Life extending
10/20 prevention
drugs
ADR, adherence,
indication,
interactions
1. Assess patient
5. Decide to stop or
reduce dose
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6. Communicate with
GP
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7. Monitor regularly and 
adjust accordingly
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A structured approach to reducing
polypharmacy: Key stages
http://www.medicinesresources.nhs.uk/en/Communities/NHS/SPS-E-and-SE-England/Search/?parent=514083&query=older
Monitor regularly
& adjust
Communicate with GP
Decide to stop or reduce dose
Assess each drug for specific risks & benefits
in the context of individual patient
Identify inappropriate drugs from accurate medicines list
Define overall treatment goals
Assess patient
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Our Approach to medicines optimisation (1)
• Patient needs-led approach to assessment
• Patient & carer needs aligned with specific desired outcomes
• Patient access to a range of tailored interventions across
agencies
• Assessment tool and process designed to consider the whole
range of patient’s medicines needs
• Pharmacist as patient advocate on all aspects of medicines use
• Pharmacist manages and monitors interventions
• Pharmacist is an integral and visible member of the MDT
• Focus on how care works together vs. discrete contributions of
individual parts
• Everyone’s business, but led and co-ordinated by the pharmacy
team towards the common goal
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Our Approach to Medicines optimisation (2)
Integrating best research evidence with clinical expertise and patient values (Sackett et al. 2000)
Patient's
Best available
goals, values
research
& wishes
evidence
Clinicalcircumstances
expertise of the practitioner
Patient's
Patient's
circumstances
Best
available
research evidence
Patient's goals, values & wishes
Clinical expertise of the practitioner
Patient
involved in
decision
making
Promote
Safety ,
wellbeing &
independence
Provide
personalised
information &
support
interventions
Consider
patient views,
beliefs, values,
goals & fears
Focus on
patient
outcomes
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Assess patient
With patient and carers
• Medical history
• Functional history
• Estimate frailty, life expectancy (NHS highland tool4) &
trajectory decline
Define overall care goals
In frail older patients, the main priorities are
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Symptom control/palliation
Maintaining function
Addressing end-of-life issues
Maintaining dignity
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Identify inappropriate drugs from an accurate
list of medication
Evidence based tools
Clinical judgement/experience
• Consensus guidance to support
use in older people1
• Does each drug have a matching
indication, is indication still valid?
• Estimates of risks/benefits
• Does the drug produce limited
benefit for that indication
• Drugs for 10 prevention  No place
• Drugs for 20 prevention ONLY if time
to benefit exceeds life expectancy
• STOPP/ START tool2
• GP-GP algorithm
• Is it a high risk drug?
• Are the benefits overweighed by
unfavourable ADRs in OP
• MAI tool3
1.
2.
3.
NHS Highland. Polypharmacy: Guidance for prescribing in frail elderly 2011
Gallagher P et al. Screening tool of older people’s potentially inappropriate prescriptions. Int J Clin Pharmacol
Ther 2008;46:72-83
Hanlon J et al. Medication Appropriateness Index- MAI. J Clin Epidemiol 1992;45:1045-51
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Inability to apply existing
knowledge to a new and complex
situation contributes more often
to the occurrence of adverse
events in older than younger
patients
Merten Het al. Scale, nature, preventability and causes of adverse
events in hospitalised older patients. Age Ageing 2012
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Assess each drug for specific risks & benefits
in the context of patient circumstance
EACH medicine is tailored to the patient’s
• Defined overall goal
• Circumstances
• Clinical reality and social situation
• Morbidities
• Experience, preferences and ability to comply
• Life expectancy
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Plan- stop or adjust or continue
Discontinue
Adjust or Continue
• Stop one at a time
• Optimise therapy
• Reduce dose/frequency/ prn
• Substitute with a safer drug,
formulation, schedule
• Wait and see
• Gradually
• Consider rebound
• Enlist help of peers or
specialists
•COMMUNICATE-simple format e.g ICARUS GRID
•MONITOR regularly as needed or @least 3-6 monthly
•Be clear about what and ensure its in place
•Look out for ADRs, geriatric syndromes, benefits,
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Barriers to deprescribing: Our experience
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Easier to maintain the status quo, “Let sleeping dogs lie”
General poor monitoring
Lack of clarity re indications/ treatment goals
Little evidence/guidance how to deprescribe safely
unpredictable/risky,
Time consuming re changing, monitoring/follow up
Drugs started by specialists
+ve guideline recommendations Fear of complaint,
litigation
Poor patient engagement and feedback about actual drug
effects
“Consent and capacity” issues
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Summary
• Multiple morbidity medication reviews are need to address complexities
• A Structured approach integrated with clinical judgement is required.
• Acknowledgment that some medicines may be restarted – it’s a trial
• Full engagement of patient, family, carers is imperative and honesty all round
• Pharmacists can lead the process but MUST work with MDT
• Share the workload with specialists
• Patients, relatives, carers, community pharmacists, OTs, nurses etc can monitor
drug effects and feedback
• Focus on complex patients and those with the highest medication related
risks/morbidities
• For individual patients, focus on the problems/drugs with the highest risks or
highest benefits
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Workshop
Case scenarios
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Thank you for listening