To Med Rec and Beyond: Addressing Polypharmacy in the Long-Term Care SettingDr. Keith WhiteClinical lead, medication reconciliation

Polypharmacy in Long-term Care

A Growing Concernpolypharmacy /poly·phar·ma·cy/ (-fahr´mah-se). 1. administration of many drugs together. 2. administration of excessive medication.

PolyPharmacy: What We Know

• Average number of meds in LTC = 9• Range of 0 to 55!!!!!

• Affects Quality of Life & Resident Safety• Decreases in:

• Global health• Cognitive function

• Increases in:• Transfers to acute care• Risk of falls

Adverse Drug Events

• Drug Interactions• Warfarin and antibiotics, PPI’s

• Aricept (donepezil) and anticholinergics• Falls• Delirium• Extra Pyramidal Symptoms (EPS)• Diarrhea

How Did We Get Here?

• Treating symptoms and numbers• Treating side effects with another pill• Telephone or Faxed based medicine• Lack of evidence for “Chemoprevention”• Discharge from acute care

• No information or explanation provided for medication changes/additions

• Lack of awareness of medications that are anticholinergics

Medication Reviews for LTC

• Occur every 6 months• Why aren’t they working?

• MRP (most responsible physician) often not present

• Faxed Med Review becomes a scan, rather than an active review

• Easier to start or continue a drug than to stop it• Fear that an adverse event will be correlated

with stopping a medication• Pharmacist lacks authority to makes changes

Drugs of Concern• Drugs associated with:

• Confusional states • Antipsychotics, Antidepressants, Opioid Analgesics,

Hypnotics• Falls

• Antipsychotics, antidepressants (tricyclics), hypnotics, antihypertensives, hypoglycemics, anticonvulsants, antiparkinson meds, antihistamines

• Bleeding • Warfarin, Antiplatelet Meds

• Indications not or no longer present • Statins, PPIs, Analgesics, Osteoporosis meds,

Antihypertensives, Antianginals, Antipsychotics, Antidepressants

• Significant anticholinergic effects • Antidepressants (tricyclics), Antihistamines

“Hidden” Anticholinergics•Benadryl (diphenhydramine)•Gravol (dimenhydrinate)•Flexeril (cyclobenzaprine)•Ditropan (oxybutynin)•Cogentin (benztropine)

•Side Effects•Atxia..loss of coordination •Decreased mucus production in the nose and throat; consequent dry, sore throat •Xerostomia or dry-mouth with possible acceleration of dental caries •Cessation of perspiration; consequent decreased epidermal thermal dissipation leading to warm, blotchy, or red skin •Increased body temperature •Pupil dilation (mydriasis); consequent sensitivity to bright light (photophobia) •Loss of accommodation (loss of focusing ability, blurred vision — cycloplegia) •Double-vision (diplopia) •Increased heart rate (tachycardia) •Tendency to be easily startled •Urinary retention •Diminished bowel movement, sometimes ileus - (decreases motility via the vagus nerve) •Increased intraocular pressure; dangerous for people with narrow-angle glaucoma •Shaking

Possible effects in the central nervous system resemble those associated with delirium, and may include:•Confusion •Disorientation •Agitation

And The List Goes On…..• Euphoria or dysphoria • Respiratory depression • Memory problems[3] • Inability to concentrate • Wandering thoughts; inability to sustain a train of thought • Incoherent speech • Wakeful myoclonic jerking • Unusual sensitivity to sudden sounds • Illogical thinking • Photophobia • Visual disturbances

• Periodic flashes of light • Periodic changes in visual field • Visual snow • Restricted or "tunnel vision"

• Visual, auditory, or other sensory hallucinations[3] • Warping or waving of surfaces and edges • Textured surfaces • "Dancing" lines; "spiders", insects; form constants • Lifelike objects indistinguishable from reality • Hallucinated presence of people not actually there

• Rarely: seizures, coma, and death • Orthostatic hypotension (sudden dropping of systolic blood pressure when standing up suddenly) and significantly

increased risk of falls in the elderly population.[4]

What Else Do We Know?• Studies show 50% of meds can be stopped

with resultant improvement in global health and cognitive function

• Only 2% of meds need to be restarted due to recurrence of indication

• Physicians, pharmacists, nursing, and family need a solid platform from which to make decisions

What Is The Right Balance?

• Level of intervention updates important

• Hidden Costs to Nursing/LPN resources

• Important to ask family “What would (resident) want?” rather than

“What do you want?”• Must consider benefit to harm concept

• NNT vs NNH (www.thennt.com)

• Garfinkel algorithm

“Take one of these out every four hours.”

DRAFT 23-04-08Medication Rationalization with LTC Residents

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Fijate!• When weaning meds, we must be aware of

withdrawal or discontinuation syndromes and not confuse them with recurrence of symptoms

• This process will require close collaboration between physician, pharmacists, nursing and family• Circle of care

What are we doing in BC?

What are we doing in BC?• Med Rec at Admission to Long-term Care• Shared Care Committee: Joint BCMA/MoH

Committee• Polypharmacy in Long-term Care Working

Group• Polypharmacy Reduction Initiative prototype

in several geographic areas• Our aim is to provide sites with a solid process to

implement a Polypharmacy Reduction process tailored to their particular needs

Polypharmacy Reduction Initiative• We are, or will be prototyping a Polypharmacy

Reduction initiative in several geographic areas.

Abbotsford West Kootenay Boundary

Prince George White Rock/SurreyChilliwack South IslandSouth Okanagan

• Each area is different and has, or will soon have various levels of “Enhanced Residential Care Physician” teams

• These teams are essentially created by collaboration between HA’s and Divisions of Family Practice

QUESTIONS?

“One of the first duties of the physician is to educate the masses not to take medicine.”

Sir William Osler 1849-1919