consultant pharmacist, care of older people
DESCRIPTION
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 Integrating multi morbidity (MM)medication reviews into routine care Identifying those at risk and complex cases A practical/structured approach to deprescribing Role of integrated care clinical pharmacists in the community Workshop with Case scenarioTRANSCRIPT
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