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NPS MEDICINEWISE:
PROMOTING SAFE USE
OF MEDICINES IN OLDER
PEOPLE
Zain Elgebay
Program Officer
NPS MedicineWise
NPS MEDICINEWISE
Established in 1998
Funded by the Australian
Government
Independent, not-for-profit
organisation
Membership based
Work in partnership
- consumers
- health professionals
- government
- industry
HOW WE SELECT TOPICS
- Members & stakeholder consultation
- Surveys of primary care networks,
NPS facilitators
- Drug utilisation data
- Consolidated formative research
reports*
- NPS decision algorithm
- Expert Advisory groups
- Funding submissions
* Identifies key issues, barriers and enablers
Topic selection
INTERVENTIONS
A range of activities are used to deliver program messages:
- Academic detailing
- Small group case study meeting
- Clinical audits with feedback for GPs
- Prescribing feedback for GPs
- Print publications (for health professionals and consumers)
- Webinar for nurses
- Website content
THERAPEUTIC AREAS COVERED
Older and wiser: Promoting safe use of medicines in older people (2013)
Which tests make a difference? Preventive activities in general practice (2013)
Cardiovascular: Antithrombotics (2013, 2009, 2003) CVD risk/ Dyslipidaemia (2011, 2002),
Heart Failure (2004,1999) Hypertension (2014,2003,1999)
Diabetes: Type 2 diabetes: Targets and priorities (2012, 2008, 2005, 2001)
Pain: 2010, 2006, 2003,
Antibiotics (2012, 2007, 2003, 2000, 1999)
Respiratory: Asthma / COPD (2014, 2006, 2002)
Mental health: Antipsychotics / dementia (2011, 2008), Depression (2000,2005), Sleep (2010)
Womens’ health: HRT/Menopause (2007, 2000)
Osteoporosis (2007)
OLDER AUSTRALIANS AND THEIR HEALTH
A growing proportion of the population with the majority living in the
community
• 28% live alone - proportion increases with age (53% of those aged ≥
85 years)
• proportion living in cared accommodation (RACFs, hostels etc)
increases with age
• 1% of those aged 65-74 years
• 7% of those aged 75-84
• 31% of those aged ≥ 85
HOW MUCH AND WHAT DO OLDER PEOPLE KNOW?
• 10% could name all medicines correctly
• 36% could specify correct dose
• 30% knew how frequently they should take them
• 20% knew why they were taking
OLDER AUSTRALIANS AT HIGHER RISK OF MRPS
One in three unplanned hospital admissions for Australians aged over 75
years is related to medicines use; half of these are considered preventable.
Older Australians account for 13% of the population but receive twice the
number of prescriptions.
High rates of polypharmacy evident in older people – increasing the risk of
MRPs
•
32%, 49% and 66% of those aged 50-64, 65-74 and 75+ respectively taking
≥ 5 medicines in 2010 Census
Instruments to identify patients at risk of medication-related problems
•
no gold standard but some use evident in Australia
• e.g. The Medicines Risk Screen
WHY OLDER ADULTS ARE IMPACTED BY
POLYPHARMACY
Metabolic changes and decreased drug clearance associated with
ageing
Increases the potential for drug-drug interactions and ADRs
A barrier to adherence due to complex regimen
Increased risk of falls and hip-fractures
WHAT TO DO WITHOUT RELEVANT GUIDELINES?
Use caution when applying
population-based guidelines to frail
older people. Clinical trial data used
to create guidelines is collected from
young, or healthy older patients and
may not be applicable
The changing health status4
Fit
Managing Well
Vulnerable
Overcome this barrier using:
Changes in:
Physical activity
•
individualised therapy
•
clinical judgment
•
best available evidence
•
a discussion between the doctor and
the patient
Frail
Cognitive function
Kidney and liver function
Terminally
Ill
Ability to perform activities of daily living (ADL)*
*ADL include instrumental ADL e.g. use of telephone,
housework, meal preparation, shopping or managing money
and basic ADL e.g. dressing, bathing, transferring, feeding,
toileting
ASSESS MEDICINES IN THE LIGHT OF AN OLDER
PATIENT’S HEALTH AND TREATMENT GOALS
UNDERSTAND YOUR PATIENT’S EXPECTATIONS OF
MEDICINES
Understanding a patient’s (and/or their carer’s) experience and
expectations is important for safe medicine use.1, 2
Expectations will differ, but the main concern is to maintain independence. 3 ,4
The values patients ascribe as relevant outcomes from medicines may differ
from the prescribers:2
- Personally significant factors e.g. a death with dignity
- Context-dependent factors e.g. unable to drive due to sedating effects of
medicines, or other unacceptable adverse effects
In a recent survey, only 3% of community-dwelling older
people would take medicines for cardiovascular primary
prevention if the adverse effects were severe enough to
affect functioning.5
AT POINTS OF CHANGE IN YOUR OLDER PATIENT’S
HEALTH...
Reaffirm, prioritise, and record what the patient is trying to achieve
through medicines use.
Investigate the importance your patient places on health outcomes,
and the degree of inconvenience and risk of adverse effects he/she
is willing to tolerate.
Reappraise medicines that may interfere with the patient’s desired
outcomes
 Indication is present and consistent with treatment goals
 Benefits outweigh potential harms
 Dose, duration, frequency and formulation are appropriate
IDENTIFYING SPECIFIC DRUGS TO TARGET
High-risk prescribing criteria
•
criteria reviewed included Beers, McLeod, STOPP/START, MAI and
Inappropriate Medication Use and Prescribing Indicators tool.
Drugs involved in ADE related hospital admissions
•
a large US study found 4 agents accounted for 67% of admissions
o warfarin, insulins, oral antiplatlet agents, oral hypoglycaemic agents
Focusing on medicines affected by renal impairment
•
provide a ‘top 10’ list of drugs affected by renal impairment (e.g. digoxin,
allopurinol, metformin, dabigatran)
IDENTIFY AND ADDRESS ACTUAL AND POTENTIAL
MEDICINES-RELATED PROBLEMS
Recognise and anticipate signs and symptoms of medicines-related problems,
and identify contributing medicines.
AVOID PRESCRIBING A MEDICINE TO TREAT ADRS CAUSED BY A CURRENT
MEDICINE
MONITOR MEDICINES CLOSELY WHEN STARTING
AND DURING ONGOING TREATMENT
Use non-pharmacological therapies when appropriate.
Consider the patient’s cognitive ability, kidney and liver function.
Check for drug interactions.
Evaluate if the patient has understood instructions using a ‘teachback’ technique.
Start with a low dose, increase slowly and monitor for tolerability and
response.
Assess regularly for benefits, harms and ability to manage the
medicine.
CONSIDER STOPPING A MEDICINE
Medicines that are harmful, no longer needed or not
consistent with the patient’s treatment goals can be
stopped.
Stopping medicines should be considered in the
following situations:
• Polypharmacy
• High-risk medicines
• Falls
• Indications of shortened life expectancy
• Terminal illness or frailty
BARRIERS TO THE CEASING OF MEDICINES IN
OLDER PEOPLE
Patient barriers
Lack of evidence relating to the benefits of
discontinuation of medicines
System barriers
BENEFITS OF STOPPING MEDICINES
Minimises risks of adverse drug reactions and drug
interactions.
Improves adherence and reduces potential medication
errors.
Reduces potential harms associated with polypharmacy.
Improves quality of life and function.
 Withdrawing psychotropic medicines can reduce the rate of falls by
66% and improve physical and cognitive function.
 Withdrawing benzodiazepines can improve cognition and
psychomotor skills.
STOP MEDICINES IN PARTNERSHIP WITH YOUR
PATIENT
When starting a medicine; discuss with your patient that
the medicine may not be needed long term.
Discuss the reasons for stopping the medicine and
clarify expected benefits and risks.
Regularly follow-up with the patient to monitor for
beneficial effects as well as withdrawal and rebound
symptoms.
Reinforce any noticed benefits and reassure the patient
that withdrawal symptoms will resolve over time.
USE A STEPWISE APPROACH TO STOPPING MEDICINES TO
MINIMISE WITHDRAWAL AND REBOUND SYMPTOMS
DEVELOP AND DOCUMENT A PLAN IN PARTNERSHIP WITH
YOUR PATIENT
INVESTIGATE
Patient’s ability to participate
DEVELOP
List of actions agreed with your patient
Treatment goals
Persons responsible
Dates for review and completion
SHARE
Patient, other healthcare professionals
DOCUMENT
ENCOURAGE YOUR PATIENTS TO HAVE AN ACCURATE AND UP
TO DATE MEDICINES LIST
Includes prescription, over the counter and complementary
medicines
With documented doses, strengths and directions for use.
A up to date medicines list can help you:
• identify potential drug-related causes of new symptoms (prevent
prescribing cascade)
• define and eliminate duplication of therapies,
• correct dangerous drug interactions,
• save time by streamlining referrals to QUM strategies
KEY POINTS
Assess medicines in the light of an older person’s health
and treatment goals
Identify and address actual and potential medicinesrelated problems
Develop and document a plan in partnership with your
patient