Impact of Multidisciplinary Team Care on Older People

with Polypharmacy

Liang-Kung ChenCenter for Geriatrics and

GerontologyTaipei Veterans General Hospital

National Yang Ming University School of Medicine

Roman poet Ovid43 B.C. – 17 A. D.

3.1 in 1991 3.8 in 1999

4.6 at admissions6 during admissions8 at discharge

Medicine has largely become the practice of drug prescribing

Signs and symptoms reflexively trigger a change in pharmacologic management

Non-pharmacologic interventions are often available but difficult to implement

Evidence-based pharmacotherapy

Limited evidence in older people, especially older people with frailty

Gurwitz J. Arch Intern Med 2004;164:2031-7.

Nelson MR, et al. BMJ 2002;325:815-9.

Holmes HM, et al. Arch Intern Med 2006;166:605-609.

Williams CM. Am Fam Phys 2002;66:1917-24.

Is there an indication for the drug? Is the medication effective for the condition? Is the dosage correct? Are the directions correct? Are the directions practical? Are there clinically significant drug-drug interactions? Are there clinically significant drug-disease

interactions? Is there unnecessary duplication with other drugs? Is the duration of therapy acceptable?Is this drug the least expensive alternative compared

to others of equal utility?

Holmes HM, et al. Arch Intern Med 2006;166:605-609.

Tan HH, et al. Diabetes Care 2004;27:2797-9

ACEI showed no protective effect against heart failure in patients aged over 75

Anticoagulant plays no protective role in older patients with atrial fibrillation but no other risk factor against stroke in terms of quality-adjusted life expectancy

Medication Quality Indicators- Prescribing indicated medications- Avoiding inappropriate medications- Education, continuity, and documentation- Medication monitoring

Hospital indicators Ambulatory indicators All vulnerable older adults

should not be prescribed a medication with strong anticholinergic side effects if alternatives are available

If a vulnerable older adult is prescribed a new drug, THEN the prescribed drug should have a clearly defined indication documented in the chart

All vulnerable older adults should not be prescribed a medication with strong anticholinergic side effects if alternatives are available

If a vulnerable older adults is prescribed a new drug, THEN the patient (or caregiver) should receive education about the purpose of the new drug, how to take it, and the expected side effects or important adverse reactions

Ambulatory indicators Ambulatory indicators If a vulnerable older adult is

prescribed a new drug, THEN the prescribed drug should have a clearly defined indication documented in the record

Every new drug that is prescribed to a vulnerable older adult on an ongoing basis for chronic medical condition should have a documentation of response to therapy within 6 months

If a vulnerable older adult is newly started on a diuretic, THEN serum potassium and creatinine levels should be checked within 1 month of initiation of therapy

If a vulnerable older adult is prescribed a thiazide or loop diuretic, THEN s/he should have electrolyte levels checked at least yearly

Ambulatory indicators Ambulatory indicators If a vulnerable older adult

is newly started on an ACE inhibitor, THEN serum potassium and creatinine levels should be checked within 1 month of the initiation of therapy

If a vulnerable older adult is prescribed warfarin, THEN an INR should be determined within 4 days after initiation of therapy

If a vulnerable older adult is prescribed warfarin, THEN an INR should be determined at least every six weeks y

Principles of Optimal Prescribing for Older Patients1. Start low, go slow, but get there2. Periodic medication review and document indications of your prescriptions3. Avoid any agent with strong anticholinergic effect if better alternative is available4. Periodic review of effectiveness of drugs prescribed in this age group5. Take into considerations of older patients’ life expectancy, function, and frailty6. Think every symptoms related to prescribed medications and medication untrial

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Integrated

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P both < 0.001

Item reduced 32.3%Dose reduced 42.4%

N=43, Mean age=81.4±4.5 years, 76.7% males