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Acute geriatric admissions and their medications AVERAGE NUMBER OF MEDICARE SERVICES/YEAR Use of medical services increases with age 40 Males Females 30 20 10 0 0-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 Age (years) Source: Medicare Australia 85+ Use of public hospitals and prescribed medications increases with age Public hospitals Pharmaceutical Benefits Scheme 1200 5000 Females 1000 4000 800 3000 Males Males 600 2000 400 Females 1000 200 0 0 0 10 20 30 40 Age 50 60 70 80 0 10 20 30 40 Age 50 60 70 80 A typical week for geriatrics at Concord Hospital Acute geriatric medicine in 5 steps …or… this is what I tell RMOs to make my life easier 1. Drugs look for adverse drug reactions, deprescribe 2. Bugs look for infection, give antibiotics 3. Tweak Comorbidities (but don’t get too excited) optimize treatments, but don’t expect too much 4. Seven deadly sins of immobility treat and prevent complications 5. Make a decision home/rehab/residential care/end of life / make a decision next week High risk prescribing in older people Nothing I am presenting is new …and… We haven’t changed in over 200 years Dr Philippe Pinel, French Physician and Psychiatrist 1745-1826 “It is an art of no little importance to administer medicines properly: but, it is an art of much greater and more difficult acquisition to know when to suspend or altogether to omit them.” Hospital admissions due to ADRs in WA Burgess et al MJA 2005 High risk prescribing in older people • Polypharmacy • ADRs • Potentially inappropriate medications (PIMS) • Mortality and hospitalization – Beers criteria – PRISCUS – DBI • Interacting drug pairs • Geriatric outcomes • Falls • Cognition • Institutionalization E factors for prescribing in Elderly Ethics Epistemology Exploitation Evidence We are almost totally dependent on interpreting what is published because there are few medicines where our personal experience has any value BEWARE the doc who says “in my experience…” Exploitation Provider-driven versus Patient-led health care? Doctors get paid for prescribing and often fear being sued for not ‘doing everything’ NEJM 2007 Older people are the market In older Australians, 5-10 medications with psychotropics is the norm • Hostel residents (Fisher et al 2003) – ACT n=119; 87 yrs – 5.8 ± 2.9 meds – antihypertensives 65%, benzodiazepines 34%, digoxin 28%, SSRI 12%, tricyclic antidepressants 12% • Community dwelling men – CHAMP (Dnjidic et al 2012) – Sydney n=1705; 77 yrs – 4.0 ± 2.9 meds – polypharmacy 37.7%, hyperpolypharmacy 4.8% • Nursing homes and hostels - FREE (Hien et al 2005) – Sydney n=1067, 86 yrs – 5.1 ± 3.2 to 7.1 ± 3.6 meds – 55% psychotropics Polypharmacy and CHAMP • 1705 men >70 • Concord area • Commenced 2005 Investigators: Bob Cumming, Fiona Blyth, Vasi Naganathan, Louise Waite, Helen Creasey, David Handelsman, Markus Seibel, Phil Sambrook, David Le Couteur (Rafa de Cabo, Hal Kendig, Steve Simpson) Pharmacoepidemiology: Danijela Gnjidic, Sarah Hilmer, Andrew McLachlan • What is the relationship between polypharmacy (≥5), hyperpolypharmacy (≥10) and Drug Burden Index (DBI) with frailty? • DBI is a dose-normalized measure of anti-cholinergic and sedative medications developed by Sarah Hilmer at NIA • Frailty defined by CHS criteria (weight loss, inactivity, slowness, exhaustion, weakness) Clin Pharmacol Ther 2012 Baseline association between polypharmacy and frailty Polypharmacy 38%, Hyperpolypharmacy 5% Frail 9%, Intermediate/prefrail 41%, Robust 50% The frailest people have BOTH most illnesses and most medicines Polypharmacy and incident frailty 2 yrs Polypharmacy and CHAMP: risk per additional medication * and remained highly significant with multivariate analysis Gnjidic et al 2012 Five is a reasonable definition of polypharmacy… and is the norm Drug Burden Index Dose normalised summation of anticholinergic and sedative drugs Dose normalised to minimum registered daily dose Drug Burden Index • DBI linked with – – – – – – – – Poorer physical and cognitive function Physical functional decline Falls Hospitalization Delirium Quality of life in residential care Frailty and development of frailty In many centres (Australia, USA, Europe) Sarah Hilmer RNSH A few examples of problematic ADRs 10% of hip fractures in Australia are attributable to benzodiazepines Antipsychotics in BPSD/dementia: death, strokes, falls, pneumonia Lon Schneider JAMA 2005 Meta-analysis Risk of death 1.65 (1.19-2.29) (pneumonia, stroke) Falls: Polypharmacy and psychotropic medicines Deprescribing: how, when and why? • • • • • All trials 1996-2007 Over 65 yrs, withdrawal of a single medicine 31 studies N=8972 subjects Variety of open label, observational, randomized, placebo controlled studies Drugs Aging 2008 Results • Diuretics – 4 studies, 448 subjects – Successful 51-100% subjects (recommenced mainly if heart failure) • Antihypertensives – 9 studies, 7188 subjects – 20-85% normotensive over following 6-60 mths • Psychotropics – 15 studies, 1184 subjects – ↓falls ↑ cognition and/or behaviour • Withdrawal syndromes – None reported and medicines often weaned over weeks DART-AD study Lancet Neurol 2009 • Good palliative–geriatric practice (GPGP) algorithm to deprescribe • 72 subjects aged 83±7yrs over 19 mths • Reduced medicines by 4.4±2.5 per patient (from 7.7±3.3) • 88% ↑global improvement in health scale • 2% of medicines recommenced Arch Int Med 2010 • Review of trials to reduce polypharmacy – 8 pharmacist led, 8 physician led, 13 multidisciplinary – Generally → reduction in medications – Clinical outcomes less often assessed: no adverse outcomes, reduction in ADRs, 1 study improved cognition, 1 study improved mortality Clin Geriatr Med 2012 • Polypharmacy – Physical function, cognition, falls, institutionalization, hospitalization and death – Independent of underlying comorbidities • Deprescribing can be considered when – Polypharmacy – Adverse effects – No efficacy – Change in treatment goals (palliative care, frailty, dementia) Aust Presc 2011 a single cost-saving intervention that will prevent multiple diseases in older people All RCTs provide evidence for deprescribing and not prescribing General population with disease Included Excluded Completers Completers Withdrawn In RCTs, overall benefit is accrued by only this group being on medication and withdrawing medications if adverse drug reactions occur Typical geriatric patients are those who are excluded or get adverse reactions Guidelines recommend everyone gets medication ‘mandatory’ Balancing risk and benefits We tend to underestimate adverse effects in older people which are often more frequent and severe; and overlooked Deprescribing is a ‘positive’ intervention to improve outcomes in older people We tend to focus primarily on potential or actual benefit extrapolated from younger patients