Consultant Pharmacist, Care of Older People
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 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 Integratingmulti morbidity (MM)medication reviews intoroutine care Identifying those at risk and complex cases A practical/structured approach to deprescribing Role of integrated care clinical pharmacists in the community Workshopwith Case scenario 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: /bjgp10X BJGP July 1, 2010 vol. 60 no. 576 e285-e294. Multimorbidity in primary care: developing the research agenda. Family Practice(2009)26(2):79-80.doi: /fampra/cmp020 Multi-morbidity and medicines
Multi-morbidity and polypharmacy intertwinedincrease clinical workload and negative outcomes Optimising the use of medicines can have a high impacton patient experience, health outcomes and costs1 Reducing polypharmacy (deprescribing) is an importantcomponent of improving care of frail older people2 Kings Fund Making our health and care systems fit for an ageing population Naylor S et al. Kings Fund Transforming our health care system: Ten priorities for commissioners. Challenges: GPs & pharmacists views
Lack of time Communication difficulties with other care providers Fragmentation of care Professional isolation Clinical uncertainty lacked confidence or clinicalcompetence, often dont know solution to identified problems Difficulties with decisions to stop medicines need forgeriatricians and specialist pharmacists Primary Smith S et al. GPs' and pharmacists' experiences of managing multimorbidity: a Pandora's box. doi: /bjgp10X BJGP July 1, 2010 vol. 60 no. 576 e285-e294. 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 centredassessment and care planning1,2 Interventions targeted at specific2,3 Combinations of common conditions Problems for patients e.g. medicines interventions tacklingpolypharmacy and complex dosing regimens Collaborative/multidisciplinary approach Kings Fund 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 What works? GPs & pharmacists views
GPs managing patients in primary care One clinic and one nominated GP 45mins at least/plustimely 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 specificdisease outcome Smith S et alGPs' and pharmacists' experiences of managing multimorbidity: a Pandora's box. doi: /bjgp10X BJGP July 1, 2010 vol. 60 no. 576 e285-e294. 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 ( 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 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 andsynergies managing different conditions Duplication of therapy, inefficiencies e.g. polypharmacy Poor patient motivation and self management Proactively Identify those at high risk from medicines for domiciliary med review
Clinical Pharmacist Undertakes Patient centred Comprehensiveassessment ofneeds & Jointly agrees plan Liaises with others tofacilitate Implementation of care plan Monitor & review GSTT model: Integrating MM medication review into the frail older people care pathway using clinical pharmacists in community Community Pharmacist (investigating) Who is at the highest risk from polypharmacy?
Frail older people Aged over 75, often over 85, with multiplediseases, which may include dementia. (British Geriatric Society) Reduced functional reserve morevulnerable to developing complicationswhile in hospital Less resilient to external stressors andtake more time to recover Frequent hospital admissions withgeriatric syndromes such as falls,immobility and confusion Identifying frailty Morley JE et al. J Am Med Dir Assoc ; 2013 Jan 1;14(6):3927 Urgent response & maximising independence Integrated Care Managers
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 @Home team Rapid response Team Supported dischargeteam Reablement teams Community Matrons 15-20% : Integrated Care Managers Community MDTs :Support case managers to manage most complex cases 70-80% of LTC population Screening for medicines related risk (local tool) Proactively identifying those with complex needs (local tool) Challenging cognitive, physical, functional & sensory impairments
Evaluation of serviceCollaboration 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 adherencesupport 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 supportand referral to pharmacist include Advanced ageHistory of falls Multiple pathologies Polypharmacy New medicines Challenging cognitive,physical,functional & sensory impairments 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 prescribedfor (Doron Garfinkel 2010) 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) andadverse effects. Improve adherence and understanding of medicines Reduce utilisation of emergency services through bettertherapeutic control of multiple morbidities Facilitate partnership working across agencies and improvemedicines use during transitions of care Deprescribing Oligopharmacy
The complex process required for the safe and effectivecessation (withdrawal) of inappropriate medications .Takes into account the patients physical functioning,co-morbidities, preferences and lifestyle (DTB 52:2014) Oligopharmacy Deliberate avoidance of polypharmacy i.e. less than 5prescription drugs daily (OMahoney. 2011) Deprescribing:Getting the right balance
Life expectancy, co-morbidity burden, care goals patient preferences, benefits of medicines ADRs, risks and harms of medicines Deprescribing-What the literature show1-3
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 Theres 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 olderadults: addressing polypharmacy. Arch. Intern Med 2012;170: OMahony, OConnor. 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 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 The Good PalliativeGeriatric Practice algorithm
OMahoney 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 forprescribing (cf Garfinkel) Drugs for primary and life extension Drugs for secondary prevention except benefits Aim for