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Claire Humphries
Pharmacist Northern Beaches Health Service April 2018
Frailty: a pharmacy perspective
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Frailty
Clinical syndrome in which 3 or more present:
– Unintended weight loss (> 5kg/ past year)
– Self-reported exhaustion
– Weakness (grip strength)
– Slow walking speed
– Low physical strength
REVERSIBILITY
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Presenting Case. MC, 93 yo lady:
Mechanical fall 4/3/18
– Got up during night to go to bathroom. When tried to
manoeuvre around door slipped over. Pain in hip and
couldn't get up, so on floor overnight (CK rise)
Impression:
– R #NOF: long gamma nail inserted 5/3/18
– Peri-op: Pneumonia (WCC 16, CRP 116, CORB 2)
ceftriaxone & doxycycline
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Past Medical History
Prior falls
Haemorrhagic cerebellar stroke Jan 2016, TIA 2013
Cholecystectomy
Bowel perforation
Diverticular disease
Hypothyroid
Hypertension
1st degree AV block
Macular degeneration
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Social history
Nursing home resident (93 yo)
Dresses, showers herself
Mobilises with 4WW
Has regular physio
Meals provided, medication dispensed
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Pharmaceutical review (hyper-polypharmacy:13)
Medication Dose Issue
Macuvision 1 BD ? Vision impaired – falls risk
Lutein defence 1 BD
Thyroxine 100mcg m TFTs normal
Atorvastatin 20mg n CI post haemorrhagic stroke; muscle
weakness
Metoprolol 12.5mg BD Not indicated post stroke; ?CCF
Pantoprazole 40mg m Inc risk # & pneumonia
Colecalciferol 2000iu m
Perindopril 8mg n ? Postural hypotension
Prednisolone 5mg m Muscle weakness, delirium
Temazepam (A) 10mg n Falls risk ++
Paracetamol 1g BD
Celecoxib 200mg m CI post stroke
Loratidine *NEW* (A) 10mg d Falls risk; additive sedation
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Pharmaceutical care plan:
93 yo, 52kg, looks frail, previous falls, broken hip
1. Analgesia
2. Pneumonia treatment
3. Frailty medication review
4. Osteoporosis treatment + vitamin D
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Medication review of fall
Anti-hypertensives
– Perindopril & metoprolol
– B blockers not indicated post stroke
– Check postural BP
Counsel sit to stand slowly
Scheduled toileting; double voiding before bedtime
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Statin review
93 yo, ?near end of life, CI haemorrhagic stroke
Ref: Collins et al. Interpretation of the evidence for the efficacy and
safety of statin therapy. Lancet 2016; 388: 2532-61
– 10,000 pts treated for 5 years with effective dose of
statin:
– 5 cases of myopathy (1 might progress to
rhabdomyolysis)
– 5 - 10 haemorrhagic stroke
RCT: Kutner et al. Safety & Benefit of Discontinuing Statin Therapy in the
Setting of Advanced, Life-Limiting Illness. JAMA Intern Med. 2015; 175 (5):
691-700
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Steroid review
Initiated for post-tick bite urticaria
Myopathy
Osteoporosis—long-term corticosteroid use increases the
risk of osteoporotic fractures and accelerates bone loss.
Hypertension
Insomnia
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PPI review
Review if taking for > 4- 8 weeks and no clear indication
Increased risk of
– Low B12 and magnesium
– Bone fractures
– Pneumonia
– Clostridium Difficile
CaDeN deprescribing algorithm
Maes et al. Ther Adv Drug Saf. 2017 Sep; 8(9): 293-97
Recommend life style
changes:
• Avoid triggers – spicy
food, coffee, chocolate
• Lose weight
• Avoid food 2-3 hr
before bed
• Elevate head of bed
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Review sedative
BENZODIAZEPINE WITHDRAWAL:
– Temazepam started at NH, not on prior
– Patient unaware she was on a sleeping tablet
– Aim: wean to cease
– Add melatonin CR 2mg
- NEW LORATIDINE
- Post tick bite itch
- Additive sedation
- anticholinergic
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CaDeN:
Canadian
Deprescribing
Network
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Summary Review for postural hypotension
Physical decline
– Cease statin
– Wean prednisolone
– Wean PPI
Cognitive decline
– Wean temazepam
– Cautious use of loratidine (A)
– Trial melatonin
START osteoporosis medication & D
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Successful, unsuccessful case!
Mrs JP, 71 yo female
Admitted 6/2/18 with cholecystitis due to gallstones
Recent prior admission 31/1/18 for falls & knee fracture.
Opal Seaside NH resident
PMH: IDDM, diabetic neuropathy- toes amputated, diabetic
retinopathy; CKD; AF – warfarin; IHD; hypercholesterol
aemia; CCF- LVEF 35%; COPD- occ smoker; PPM; HTN;
depression – suicidal ideation; OP (#) + low vit D; anaemia
CrCl 36ml/min, chol 2.8, TG 2
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Medications (hyper-polypharmacy: 11) Medication Dose Issue
Warfarin 2.5mg n CHADS-VaSc 6
Diazepam (A) 2.5mg daily prn Falls risk
Olanzapine (A) 2.5mg bd CI IDDM; orthostatic hypotension
Lantus insulin 10 u mane
Novorapid 6 u tds
Duloxetine (A) 60mg m Orthostatic hypotension; bleeding risk
Spironolactone 12.5mg m Hyperkalaemia; CKD
Frusemide (A) 40mg m Dehydration; falls
Ramipril 10mg m Hyperkalaemia
Amlodipine 5mg m
Vitamin D 1000iu m Level 47 (low)
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Pharmaceutical care plan
Olanzapine – anticholinergic; falls risk and CI in IDDM
– Can increase BSLs, weight gain, dyslipidaemia +
orthostatic hypotension
– Weight 66kg, pt states has put weight on but lost during
recent hospital admission
– Chol 2.8, TG 2
– Severe depression – GP STRONGLY advised not to
withdraw (calcaneal # 2017)
– Nil postural drop
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Outcome
Olanzapine & not ideal in this patient BUT tolerating; on
lowest effective dose
Review in 6 months
Consider adding statin for TG
Consider OP medication & increase vitamin D
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Conclusion
Patient-centred decision making of upmost importance
Apply the same energy and consideration to deprescribing
as to prescribing
……Some medicines cause HARM
Use FRAILTY as a trigger for review