Managing medication for older

people across the interface

Katherine Le Bosquet

Integrated Care Pharmacist

Guy’s & St Thomas’ NHS Trust

(Community Health Services)

Slides adapted from:

Lelly Oboh

Consultant Pharmacist, Care of older people

Learning Outcomes

• Describe the interplay between health and social care and its

impact on pharmaceutical care.

• Demonstrate knowledge of agencies involved in community

care and the effect of this on medicines management.

• Identify the barriers to optimising medicines when working

across healthcare interfaces and employ strategies to overcome

them.

• Demonstrate understanding of the possible toxic effects of

drugs in patients taking multiple medicines, especially for

patients with sub-optimal organ function.

Older people: A growing population

• 18% of UK population are over 651

• Expected to rise to 25% by 20512

• Increasing population of frail OP

• The number of centenarians living in the UK has risen by 65%

over the last decade

• Not a homogenous group

• Take more medicines (mostly repeats)

• Higher risks of adverse drug events (ADEs)

• High users of NHS and Social Care resources

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Frail Older People

• 10% of over 65s and 25-50% over 85s3

• Many are care home and dementia patients

• Frequent hospital admissions and longer stays

• Social vulnerability

• More reliant on others for support

• Poor patient engagement

• Multiple individuals/teams involved with medicines

• Complex pathways and processes across organisations

2

Typical frail older person profile

• Very old female

• Living alone

• Multiple LTC

• Multiple medications

Poor resilience to stressors

Rockwood Score – Clinical Frailty Scale

• Older adults account for half (170

million) GP consultations in the UK

annually.

• 2–3% of all primary care encounters

result in a patient safety incident,

with 1 in 25 causing a serious harm

outcome.

• 170,000 older adults each year in

the UK may receive care that

causes death or severe adverse

outcomes.

• Frequency of unsafe care in

hospitals estimated at twice as high

for older adults compared to

younger age groups.

Sources of unsafe primary care for older adults: a mixed-methods analysis of

patient safety incident reports. Age and ageing May 2017

Key points

Older adults are at risk of health-

care-related harm in primary care

settings.

main sources of unsafe care:

• medication-related incidents

• communication-related incidents

• clinical decision-related incidents

Agencies involved in care – The cycle of care for frail patients in

Lambeth.

@Home team

GP/practice nurse

Ambulance

Hospital

District nurse Community

Matron

Community Pharmacist

ERR/SDT

Example of people involved in care of one patient in

Lambeth

• Family / Neighbours / Friends

• GP

• ERR/SDT

• @Home Service

• District Nurses

• Social Services

• Private Carers

• Social Services Carers

• CMHT

• Ambulance Services

• Consultant reviews in hospital

• Community Matron

• Bedded units i.e Pullross/ARU

• Integrated Care Teams (HF, Diabetes, Pharmacy)

• Falls and Balance Classes

• CRAFTS (physio at home)

• OT Input

Computer systems

used: EPR

CareNotes

Local Care Record

SLAM (eJPS)

Mosaiq/CIS (cancer services)

E-noting

EMIS

DOCMAN

St Georges Hospital records

Medicines Optimisation Outcome focused approach to safe and effective use of medicines that takes into account the patient’s values, perception and experience of taking their medicines Important Outcomes for

adults4

• Improved quality of life

• Making a positive contribution

• Improved health and emotional wellbeing

• Personal Dignity

• Control and choice

• Economic wellbeing

• Freedom from discrimination

Independence Well-being and Choice 2005, Our health, our care, our say 2006, Strong and Prosperous Communities 2006

http://www.rpharms.com/promoting-pharmacy-pdfs/helping-patients-make-the-most-of-their-medicines.pdf

Barriers to optimising medicines

across healthcare interfaces

• Poor communication

• Poor patient engagement or involvement

• Poor knowledge of care provider and stakeholders

• Multiple care providers

• Multiple computer systems and noting systems

• Segmented care

• Time pressures

• Who takes responsibility?

Barriers to optimising medication in Older People

• Patient- different information to different people.

• Time

• Indication and initiation of medication

• Specialism of the prescribing team

• Lack of perceived risk

• Poor understanding of medication effects in the

elderly

• Target driven not patient focused i.e. Blood pressure

targets move a systolic BP <120 is associated with

higher mortality in over 80’s.

Strategies to overcome barriers

• COMMUNICATION

• Clear and precise instructions

• Complete actions don’t pass the buck

– “GP to start…”

• “GP to review” – review what element

and why, what actions should they

take

• No “As Directed” “Affected area”

• Follow up

Prescribing Cascade5

Drug 1

ADE interpreted as new medical

condition

Drug 2

ADE interpreted as new medical

condition

Drug 3

Misinterpretation of ADR to one drug (as a new medical condition) leading to

subsequent inappropriate prescription of a second drug

Examples of prescribing cascade

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Initial Treatment Adverse Effect Subsequent Treatment

NSAID Rise in blood pressure Antihypertensive

Thiazide diuretics Hyperurucaemia Gout Treatment

Metoclopramide Parkinsonian symptoms Levodopa

Cholinesterase inhibitor Urinary incontinence Oxybutinin

Amitriptyline Dry eyes Hypromellose

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Ageing process pharmacokinetic and pharmacodynamic changes

Characterised by • Progressive loss of functional capacities of most body organs Renal,

Hepatic, Cardiac, Respiratory

• Changes in response to receptor stimulation

• Decrease in homeostatic or counter regulatory mechanisms

• Loss of body water and increase in body fat content

These changes in body function and composition affect drug

handling and may require adjustment of drug

selection/dosage to reduce ADEs and improve outcomes

Drug Distribution

Only significant if there is considerable decrease in plasma protein (PP)

e.g malnutrition, post surgery, renal/hepatic impairment

Drugs highly bound to PP (>90%) free drug concentration

Toxicity e.g. Warfarin (99%) , Phenytoin (90%), Diazepam (99%)

Drug Metabolism

Significant in frail and malnourished older people

toxicity phenytoin, prednisolone, hepatotoxic drugs like phenothiazines

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Drug Elimination

Most significant and important age related change

renal mass, blood flow & function

Predictable and can be estimated

Decline starts about mid-thirties

Failure to excrete Accumulation Toxicity

Concentration may increase by up to 50% e.g. Diazepam t1/2 may

increase to 96 hrs

Drugs accumulate slowly in chronic use signs of toxicity may not appear

till days/weeks

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Drug Elimination

Some drugs cease to be effective with reduced renal function e.g Thiazides <eGFR 30

Other complications

Diabetes, Hypertension, Heart failure

Dehydration e.g. acute illness chest infection, post MI

Sensitivity to some drugs even when elimination is unimpaired e.g ACEIs, NSAIDs

Many side-effects are poorly tolerated by those with renal failure

Generally

Assume older people have mild renal failure - Initiate with low dose

Then titrate upward against response/physiological parameter/target dose e.g

ACEIs, antihypertensives

Consider other factors that worsen renal function

Pharacodynamics (Organ or System changes)

Blunting of reflex tachycardia

Poor postural control -Falls

Structural and neuro-chemical changes in CNS e.g reduced

dopamine, acetylcholine

Impaired thermoregulation

Reduced visceral muscle function

Due to the impaired homeostatic mechanisms older people have

an increased susceptibility to drug induced side effects such

as urinary incontinence, urine retention, confusional states,

hypothermia and postural hypotension.

Altered receptor sensitivity

CNS sensitivity. agitation, insomnia, confusion, dizziness, extrapyramidal effects

Opiates, Psychotropics

Benzodiazepines,

GI sensitivity n&v, diarrhoea, constipation, GI bleed, dyspepsia

NSAIDs, SSRIs, Prednisolone

Warfarin receptor sensitivity

bleeding, bruising Require 25% less dose

Digoxin receptor sensitivity

Confusion, Hallucinations 125/62.5mcg sufficient for most

Benzodiazepine receptor sensitivity

Increased and prolonged sedative effects

Need lower doses and shorter acting BZDs

Acetylcholinergic receptor sensitivity

confusion, blurred vision, constipation, increased HR with TCAs

Amytriptiline,

Oxybutinin, Hyoscine

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Polypharmacy

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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 (Doran Gafinkel 2010)

Different targets based on different needs and life

expectancy

• Little to no evidence for elderly patients treatments

• Multimorbidity

• NICE – BP target in over 80’s 150/80

• HbA1c can be relaxed International diabetes federation(IDF) state

• Pill burden of treatment

• IDF Global Guideline for Managing Older People with Type 2 Diabetes6

HbA1c BP (diabetic patients)

Functionally Independent 7.0%-7.5% 140/90

Functionally dependant 7.0%-8%

Frail/Dementia Up to 8.5% Frail 150/90

Dementia 140/90

EOL Simply avoid symptomatic

hyperglycaemia

Anti Cholinergic Risk Scale7

A total drug burden or score of 3 or more is associated with increased risk of death

and cognitive impairment. Commonly used drugs with a score of 3 include

hyoscine, oxybutynin, amitriptyline, promethazine

Why is ACB important7

Anticholinergic drugs have a cumulative effect

- For each 1 point increase in the Anticholinergic Cognitive Burden

scale (ACB)

-a decline in MMSE of 0.33 points over 2 years

‐ 26% increase in the risk of death

Recommend to keep the ACB score to a minimum

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Assess needs, review & individualise therapy

Assessment is about putting together information on a person’s needs and circumstances, making sense of the

information in order to identify needs and agreeing what advice, support or

treatment to provide9

• Gathering information

• Medicines reconciliation- Patient list

• The patient’s narrative of their experience

• Reviewing the research evidence: tools to identify PIMs e.g. STOPP/START

• Applying clinical judgement and personalising therapy

Collaboration, communication & care co-ordination

Thank You

Questions and Reflections

References

The World Bank, 2015 (data.worldbank.org)

National population projections, 2010-based, Office for National Statistics, 2011

Clegg A, Young J, Iliffe S, Rikkert M, Rockwood K. Frailty in elderly people. Lancet.

2013;381(9868):752-62

Independence Well-being and Choice 2005, Our health, our care, our say 2006, Strong and Prosperous Communities 2006

Rochon PA, Gurwitz JH. Optimizing drug treatment in elderly people: the prescribing cascase. BMJ

International Diabetes federation guideline – Global guideline for managing older people with Type 2 diabetes.

Anti Cholinergic Risk Scale Bishara et al. Int J Geriatr Psychiatry 2016 June 9 doi: 10.1002/gps.45071997;315:1097.

www.medicinesresources.nhs.uk/en/Communities/NHS/SPS-E-and-SE-England/Meds-use-and-safety/Service-deliv-and-devel/Older-people-care-homes/Polypharmacy-oligopharmacy--deprescribing-resources-to-support-local-delivery/

DoH. Common Assessment Framework for Adults. 2009