Older Person as an Agent in the Health Care Provision: an example of (non)compliance with the medication 17. rijn 2016 Faculty of Social Studies Masaryk University Jostova 10, Brno, 602 00 Czech Republic Photo detail www.stampar.hr Myth #1 •To be old is to be sick • •FACTS based on Research •People are much more likely to age well than become decrepit & dependent •Age-related disabilities declining; of those 65-74 in 1994, a full 89% reported no disability whatever Myth #2 •The secret is choose your parents wisely • •FACT •Swedish Twins Study: only 30% of physical aging can be blamed on genes, & about half the changes in mental function • •“We are, in large part, responsible for our old age.” 5 •Ageism can be coupled with other forms of oppression •sexism, racism, beautyism… • a powerful combination –It all adds up to the beliefs that – •AGING is bad •AGING is ugly •AGING is to be avoided •AGING is a social and economic crisis •We need to FIGHT AGING Combatting the Downward Spiral •Realize that older people are part of the cycle of life •Focus on HEALTH PROMOTION goals as part of healthy aging • 7 The Truth About Aging • •The truth is that most older people are more vulnerable due to losses –Physical losses •May not be able to walk, drive, grocery shop, clean house, talk on telephone, see instructions or watch television, etc. –Social losses •Loss of parents, spouse, siblings, friends •Coupled with physical, income, and cognitive, may lose ability to get to and enjoy social activities –Income losses •Retirement –Cognitive losses •Some processing changes and memory loss are normal 8 Age Discrimination & Health Care •60% of adults aged 65+ do not receive recommended –Glaucoma preventive services –40% do not receive flu and pneumonia vaccines •Only 10% of elders receive screening tests for –Bone density –Colorectal and prostate cancer – Despite the fact that the average age of colorectal cancer patients is 70, more than 70% of prostate cancer is diagnosed in men 65+, and people over 60 are 6 times more likely to have glaucoma • 9 • •Chemotherapy is underused in the treatment of breast cancer patients aged 65+ even though survival could improve •Older patients are significantly underrepresented in clinical trials for all types of cancer but notably in trials for breast cancer •Older persons are the biggest users of prescription drugs, yet 40% of clinical trials between 1991 and 2000 excluded older persons • Age Discrimination & Health Care 10 Race and Gender Discrimination in Health Care –The Effect of Race and Sex on Physicians’ Recommendations for Cardiac Catheterization – –Article in The New England Journal of Medicine, 2/25/99 –by Schulman, Berlin, Harless, Kerner, Sistrunk, Gersh, Dube, Taleghani, Burke, Williams, Eisenberg, & Escarce • 11 More Examples of Age-Related Vulnerability in Today’s World •Out of sight, out of mind? – –14,802 persons, mostly elderly, died in France during a 2003 heat wave –20% of health care providers were gone, most French families were on vacation –Should government have provided? Should people have not vacationed? The image “http://images.usatoday.com/weather/news/photos/2003-08-14-heat-ill.jpg” cannot be displayed, because it contains errors. Noncompliance in older adults aspects of ageism, research tools and practical recommendations Ageism (i.e., the complex and often negative social construction of old age) is highly prevalent. There is unequivocal evidence concerning the negative consequences associated with ageism at the individual, familial, and societal levels. The long term goal of this Action is to challenge the practice of ageism and allow older people to realize their full potential. COST Action IS1402 Ageism a multi-national, interdisciplinary perspective Healthcare system This Action will focus on various health care settings, and evaluate the healthcare provision and medication management of older adults. Potential areas of focus would be: the various stakeholders involved in this system: COST Action IS1402 Ageism • physicians, • social workers, • nurses, • patients, • etc NONCOMPLIANCE Compliance with medication “…the extent to which a person’s behaviour – taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider.” (WHO) unclesame_takeyourmeds Difference between ADHERENCE and COMPLIANCE ADHERENCE TO…. partnership between doctor and patient The patient’s conformance with the provider’s recommendation with respect to timing, dosage and frequency of medication taking COMPLIANCE WITH ….. you must, you have to take (one-way street) Patient’s passive following of provider’s orders CONCORDANCE is a related term used to describe a shared agreement between a health professional and a patient about therapeutic goals. It’s less a measure, and more a philosophical approach to implementing treatment plans. PERSISTENCE refers to the duration of conformance to a particular treatment plan, and is usually defined by the interval between when therapy is started, and when it is discontinued. Direct methods Directly observed therapy Measurement of the level of medicine or metabolite in blood Measurement of the biologic marker in blood Indirect methods Patient questionnaires, patient self-reports Pill counts Rates of prescription refills - Medication Possession Ratio (MPR) Assessment of the patient's clinical response Electronic medication monitors Patient diaries Methods of Measuring Compliance 6238965_orig Osterberg L, Blaschke T. Adherence to Medication. N Engl J Med 2005;353:487-97 Patient self-report questionnaire Advantages Disadvantages · simple · inexpensive · easy to administer · non-intrusive · the most useful method · susceptible to error with increases in time between visits · results are easily distorted by the patient The most common indirect method Self-reported questionnaire Noncompliance in older patients 1. aspects of ageism Noncompliance in the elderly can be termed as “epidemic” •more than 10% of older adult hospital admissions may be due to noncompliance with medication regimens • • •one-third (33%) of older persons admitted to the hospital had a history of noncompliance • • •Nearly one-fourth (25%) of nursing home admissions may be due to older person’s inability to self-administer medications • •approximately 125 000 deaths occur annually in the US due to noncompliance with cardiovascular medications •approximately one half of the elders who take at least one medication find compliance challenging and average compliance decreases from approximately: •80% in patients taking medication once daily to •50% in those taking medications four times a day or taking polypharmacy. For a number of chronic medical conditions •diabetes, •hypertension, •hypercholesterolemia, and •congestive heart failure higher rates of medication compliance were associated with: •lower rates of hospitalization, and • •a reduction in total medical cost Helping older patients to improve their compliance requires: 1.knowledge of their current medication use 2. 2.reasons for noncompliance 3. 3.knowledge of personal beliefs and 4. 4.health goals. By discussing concerns, patients can learn that 1. denial of their illness and 2. misconceptions about their treatment can lead to noncompliance, resulting in complications, side effects and adverse drug events. While discussing medications with elders, physicaian and pharmacist should educate the patient and/or caregiver. 1.oral counselling is imperative, but insufficient, 2. 2.the elders need also written information in a readable font and patient-friendly language, especially if changes are being made. TIP ! Asking the elder to describe the drug’s purpose, its use instructions, and its potential side effects (called “back teaching”) can help to identify knowledge gaps in the older patient. Compliance is a multidimensional phenomenon determined by the interplay of five sets of factors, termed “dimensions” by the World Health Organization: 1.Social/economic factors 2. 2.Provider-patient/health care system factors 3. 3.Condition-related factors 4. 4.Therapy-related factors 5. 5.Patient-related factors 1.Social and Economic Factors The most consistently reported factors to impact medication compliance: •low literacy •limited access to health care •lack of health insurance coverage •poor social support •family instability •homelessness 2. Health Care System-Related Factors The quality of the doctor-patient relationship is one of the most important health care system-related factors Health care systems create barriers to compliance by limiting access to health care in the following ways: •making appointments difficult to schedule •lacking continuity of provider care •using restrictive formularies and changing formularies •through high drug costs, copayments, or both. 3. Condition-Related Factors Compliance with a treatment regimens often declines significantly over time; especially true for chronic illnesses that have few or no symptoms: •high blood pressure, •diabetes •osteoporosis, •hyperlipidemia Without symptoms, a person may not be motivated to compliance with a treatment regimen. Important! •to understand the illness and •what will happen if it is not treated. 4. Therapy-Related Factors have been also associated with decreased compliance: •complexity of the medication regimen number of medications number of daily doses required •duration of therapy •therapies that are inconvenient or interfere with a person's lifestyle •medications with a social stigma attached to its use medications such as antidepressants, are slow to produce effects •administration of a medication requires the mastery of specific techniques (injections and inhalers) •medication side effects or adverse drug reaction 5. Patient-Related Factors Physical factors • Physical impairments and cognitive limitations may increase the risk for noncompliance in older adults. • Visual Impairment • Hearing Impairment • Cognitive Impairment • Impaired Mobility • Dexterity • Swallowing Problems 5. Patient-Related Factors Psychological/behavioral factors • Knowledge • Motivation • Readiness to Change Assessment • Self Efficacy • Alcohol and substance abuse Consequences of medication noncompliance Increased use of medical resources: •physician visits, •laboratory tests, •unnecessary additional treatments, •emergency department visits, •hospital or nursing home admissions • Treatment failure Noncompliance in older patients 2. research tools Adherence scales are identified mostly in the last few years (2005-2015). One of the main sources was article (Lavsa et. al) which evaluated literature describing medication adherence surveys/scales to gauge patient behaviours at the point of care. Medication Adherence Questionnaire (MAQ) MMAS – Morisky Medication Adherence Scale 4-item scale (MMAS-4) 8-item scale (MMAS-8) 1 Morisky DE, Green LW, Levine DM. Concurrent and predictive validity of a self-reported measure of medication adherence. Med Care. 1986 Jan;24(1):67-74. 1 Medication Adherence Questionnaire (MAQ) •the shortest •the easiest • •the fastest •wide range of diseases 1 The image “file:///C:/staro/c_disk/1FARMAKOEPIDEMIOLOGIJA/ADHERENCIJA/1-MAQ/IMG.jpg” cannot be displayed, because it contains errors. 4 -item scale MMAS-4 The image “file:///C:/Users/mleppee/Pictures/MP%20Navigator%20EX/2012_04_19/IMG_0001_page1_image1.jpg” cannot be displayed, because it contains errors. 1 8-item scale MMAS-8 Self-efficacy for Appropriate Medication Use Scale SEAMS ”self-efficacy” §13-item scale had good internal consistency reliability § §a reliable and valid instrument that may provide a valuable assessment of medication self-efficacy in chronic disease management § §appropriate for use in patients with low literacy skills 2 Source Risser J, Jacobson TA, Kripalani S. Development and psychometric evaluation of the Self-efficacy for Appropriate Medication Use Scale (SEAMS) in low-literacy patients with chronic disease. J Nurs Meas. 2007;15(3):203-19. 3 The Brief Medication Questionnaire BMQ a new self-report tool for screening adherence and barriers to adherence - BMQ tool is: •useful in identifying patients who need assistance with their medications, • •assessing patient concerns, and • •evaluating new programs. Svarstad BL, Chewning BA, Sleath BL, Claesson C. The Brief Medication Questionnaire: a tool for screening patient adherence and barriers to adherence. Patient Educ Couns. 1999;37(2):113-24. 3 The Brief Medication Questionnaire BMQ includes: - - 5-item Regimen Screen that asks patients how they took each medication in the past week, - 2-item Belief Screen that asks about drug effects and bothersome features, and - 2-item Recall Screen about potential difficulties remembering - 2-item Access Screen about difficulties in buying and refilling The image “file:///C:/staro/c_disk/1FARMAKOEPIDEMIOLOGIJA/ADHERENCIJA/3-BMQ/IMG_page1_image1.jpg” cannot be displayed, because it contains errors. 3 The image “file:///C:/staro/c_disk/1FARMAKOEPIDEMIOLOGIJA/ADHERENCIJA/3-BMQ/IMG_0001_NEW_0001_page1_image1.jp g” cannot be displayed, because it contains errors. Regimen screen Belief screen Recall screen Access screen 3 4 The Hill-Bone Compliance Scale assesses patient behaviors for three important behavioral domains of high blood pressure treatment: 1)reduced sodium intake; 2) 2)appointment keeping, and 3) 3)medication taking. Hill-Bone Compliance to High Blood Pressure Therapy Scale Kim MT, Hill MN, Bone LR, Levine DM. Development and testing of the Hill-Bone Compliance to High Blood Pressure Therapy Scale. Prog Cardiovasc Nurs. 2000 Summer;15(3):90-6. HILL-BONE HIGH BLOOD PRESSURE COMPLIANCE SCALE (NA=not applicable / DK=don’t know) None of the time Some of the time Most of the time All the time NA DK 1. How often do you forget to take your HBP medicine? 1 2 3 4 8 9 2. How often do you decide not to take your HBP medicine? 1 2 3 4 8 9 3. How often do you eat salty food? 1 2 3 4 8 9 4. How often do you shake salt, fondor, or aromat on your food before you eat it? 1 2 3 4 8 9 5. How often do you eat fast food? (KFC, McDonalds, fat cook, fish and chips) 1 2 3 4 8 9 6. How often do you get the next appointment before you leave the clinic? 1 2 3 4 8 9 7. How often do you miss scheduled appointments? 1 2 3 4 8 9 8. How often do you leave the dispensary without obtaining your prescribed pills? (due to long line, closure of clinic, forgot) 1 2 3 4 8 9 9. How often do you run out of HBP pills? 1 2 3 4 8 9 10. How often do you skip your HBP medicine 1–3 days before you go to the clinic? 1 2 3 4 8 9 11. How often do you miss taking your HBP pills when you feel better? 1 2 3 4 8 9 12. How often do you miss taking your HBP pills when you feel sick? 1 2 3 4 8 9 13. How often do you take someone else’s HBP pills? 1 2 3 4 8 9 14. How often do you miss taking your HBP pills when you care less? 1 2 3 4 8 9 4 This brief instrument provides: - a simple method for clinicians in various settings to use to assess patients' self reported compliance levels and - -to plan appropriate interventions. 4 5 Medication Adherence Rating Scale MARS 10-item scale includes: - - a valid and reliable measure of compliancy for psychoactive medications - - diagnosed with schizophrenia Thompson K, Kulkarni J, Sergejew AA. Reliability and validity of a new Medication Adherence Rating Scale (MARS) for the psychoses. Schizophr Res. 2000 May 5;42(3):241-7. Item Compliant Non-compliant 1 Do you ever forget to take your medication? 2 Are you careless at times at taking medication? 3 When you feel better do you sometimes stop taking your medication? 4 Sometimes if you feel worse when you take the medication do you stop taking it? 5 I take my medication only when I am sick 6 It is unnatural for my mind and body to be controlled by medication 7 My thoughts are clearer on medication 8 By staying on medication, I can prevent getting sick 9 I feel weird, like a zombie, on medication 10 Medication makes me feel tired and sluggish Compliant = ‘No’ response for questions 1-6, 9–10. ‘Yes’ response for questions 7 and 8. 5 6 Adherence to Refills and Medications Scale ARMS 14 and 12-item scale: - - chronic disease. - - low-literacy patients Kripalani S, Risser J, Gatti ME, Jacobson TA. Development and evaluation of the Adherence to Refills and Medications Scale (ARMS) among low-literacy patients with chronic disease. 2009;12(1):118-23. Scales suitable for measuring adherence at certain diseases No Scale 1 2 3 4 5 6 7 8 1. Morisky-Green + + + 2. SEAMS + + + 3. BMQ + + + 4. Hill-Bone + 5. MARS + 6. ARMS + 1 – Chronic disease 2 – Arterial hypertension 3 – Coronary heart disease 4 – Diabetes 5 – Psychosis 6 – AIDS/HIV 7 – Osteoporosis 8 – Smoking cessation Cronbach α at some articles regarding to adherence measuring No Scale Literature Cronbach α 1. Morisky-Green Morisky-Green 0.61 Toll BA, McKee SA - Duong M, Piroth L - 2. SEAMS Risser 0.89 Reynolds 0.82 3. BMQ Svarstad - Mini - Ben 0.66 4. Hill-Bone Kim 0.84 Lambert 0.79 Koschack 0.25 & 0.73 Karademir 0.72 Krousel-Wood - 5. MARS Fialko 0.60 Thompson 0.75 6. ARMS Kripalani 0.81 Compliance with medication survey conducted in Croatia MATERIALS AND METHODS the study was designed as a cross-sectional survey by use of a self-administered 33-item questionnaire The study included 635 individuals collecting or buying drugs for the treatment of chronic diseases, with special reference to subjects taking antihypertensive agents (n=361). Study was conducted at Zagreb pharmacies and the questionnaire was filled out by study subjects with instructions and help provided by the pharmacist as questionnaire administrator. questionnaire listed 16 common reasons for nonadherence. RESULTS The noncompliant subjects prevailed over compliant subjects (n=370; 58.3% vs. n=265; 41.7%) The total number of 1357 diseases was reported by survey respondents (an average of 2.1 per respondent) The most common diseases were the cardiovascular (n=500; 36.8%), followed by endocrine, nutritional and metabolic group of diseases (n=285; 21.0%). Culig J, Leppée M, Boskovic J. Eric M. Determining the difference in medication compliance between the general patient population and patients receiving antihypertensive therapy: A case study. Arch Pharm Res 2011;34(7):1143-52. DOI 10.1007/s12272-011-0712-0 Reasons for non-compliance Hypertension Dislipidemia Diabetes Back pain Depression Rank % Rank % Rank % Rank % Rank % Forgetfulness 1 60,9 1 62,4 1 61,7 1 63,5 1 63,0 Away from home 3 45,2 2 48,8 2 45,8 2 50,0 5 47,8 Out of medication 2 46,8 3 43,2 3 45,8 3 48,6 7 47,8 Different medication several times a day 4 43,8 4 40,0 4 42,5 7 39,2 6 47,8 Medication shortage in pharmacies 6 37,1 6 35,2 6 36,7 4 47,3 3 52,2 Problem in taking medication at a certain time 5 41,3 5 38,4 5 37,5 5 45,9 2 58,7 Feeling well 7 34,9 7 35,2 7 30,0 6 41,9 4 50,0 Rank of reasons for patients’ noncompliance with medication Number of diagnoses in hypertensive patients and compliance with medication Diagnosis of arterial hypertension n % Compliant patients Noncompliant patients n % n % alone 75 20,7 28 19,5 47 21,5 + one diagnosis 126 34,7 53 37,1 73 33,5 + two or more diagnosis 160 44,6 62 43,4 98 45,0 T o t a l 361 100,0 143 100,0 218 100,0 Age (years) Study population Compliant Noncompliant n % n % 26-35 16 32.0 34 68.0 36-45 22 42.3 30 57.7 46-55 50 41.0 72 59.0 56-65 62 38.3 100 61.7 66+ 115 46.2 134 53.8 Total 265 41.7 370 58.3 Medication compliance and noncompliance according to age groups 63 Diabetic patients (n=120) Compliance = 41.7% Non- diabetic patients (n=515) Compliance = 41.0% Insulin-dependent patients (n=54) Compliance = 46.3% Insulin-independent patients (n=66) Compliance = 40.9% Insulin-dependent patients’ compliance with medication is significantly higher than Insulin-independent patients’ Reasons for Self-Reported Noncompliance in Common Chronic Diseases Essential (primary) hypertension Disorders of lipoprotein metabolism and other lipidemia Insulin-dependent and non insulin-dependent diabetes mellitus Dorsalgia Depressive episode I just forgot I just forgot I just forgot I just forgot I just forgot I had consumed all of it I was not at home I was not at home I was not at home I had problems with the timing of the medication I was not at home I had consumed all of it I had consumed all of it I had consumed all of it The drug was not available due to shortage of supply MORE THAN ONE …. The existence of more than one cause of risk considerably increases the noncompliance risk of a patient. Special attention should be paid to frail older people (those which experience complex problems: disease, dependency and disability) and which often suffer from more chronic diseases. Understanding the concept of frailty may help to optimize medication prescribing for older people. Noncompliance in older patients 3. practical recommendations How to improve compliance? 1. SMS reminder 2. Electronic devices which includes alerting system Through SMS, health care providers: DOCTOR PHARMACIST ANd9GcQZ2b1omqilbXMnuSVXbMKw4dsQ_E_URy1X54WVvHeBQqitYJ6A5g can help their patients stay connected with medical professionals on an immediate basis. Screen%20shot%202012-05-17%20at%204 SMS messages are personalized and time or context-sensitive, when having to do with a patient’s health. 1. SMS reminder 2. Electronic devices which includes alerting system medication-adherence-leads-to-lower-health-care-use-and-costs-despite-increased-drug-spending-elect ronic-monitoring-devices-are-recommended-4 icon-medsmart Image result for electronic devices for adherence sensors-10-01652f2-1024 pill-case-pix2 features Two groups of patients One is connected with their own GP (general practitioners) The second one is connected with their pharmacist Mobile services poised to have significant impact th_100083382as difference between doctor's and pharmacist's action about compliance difference between SMS reminder and electronic devices system CONCLUSIONS 1 •Noncompliance with therapy has negative consequences on the health of the individual, and an adverse impact on the community • •There is no gold-standard medication compliance scale • •There are many self-report scales for measuring medication compliance and their derivatives (or subscales). • •MAQ (Morisky scale) is used frequently CONCLUSIONS 2 •Research on compliance has typically focused on the barriers that patients face in taking their medications. • •Common barriers to compliance are under the patient's control (forgetfulness was the most common, so that attention to them is a necessary and important step in improving compliance) •Additional reasons for medication noncompliance, such as being away from home, could also be associated with forgetfulness since the patient should have remembered to bring his medication along with him while going out • •Of great help could be various applications for alerting on mobile devices that are now in mass use. • CONCLUSIONS 3 •The main problem of long-term therapy is significantly decreased of compliance with medication in a very short time. • •It is important to remember that almost all the interventions effective for improving patient compliance in long-term care were complex, including a combination of: - more convenient care, – information, reminders, – self-monitoring, – manual telephone follow-up, – reinforcement, – counselling, – family therapy, – psychological therapy, – crisis intervention, – supportive care – etc. Haynes RB, Ackloo E, Sahota N, McDonald HP, Yao X. Interventions for enhancing medication adherence. Cochrane Database Syst Rev. 2008 Apr 16;(2):CD000011. doi: 10.1002/14651858.CD000011.pub3. •S Simplifying regimen characteristics •I Imparting knowledge •M Modifying patient beliefs •P Patient communication •L Leaving the bias •E Evaluating adherence CONCLUSIONS 4 SIMPLE Polypharmacy and Adverse Drug Effects (ADE) in the Elderly Polypharmacy §Definition §Causes §Complications §Prevention/management § Definition • Suboptimal prescribing • §Overuse = Polypharmacy § §Inappropriate prescribing – §Underuse § § –Hanlon JT et al. JAGS. 2001;49: 200-9. –Fisk D et al. Arch Intern Med. 2003;163: 2716-24. Overuse- multiple drugs; prescribing more drugs than clinically necessary Inappropriate prescribing- drugs with more risk than benefit; drugs contrary to accepted medical standards Underuse- omission of drugs that are indicated, e.g. undertreating CHF, CAD, depression… Causes: Age and Chronic Diseases §Increased prevalence of somatic complaints and chronic disease • §Community elders: 90% >1 med; 40% >5 meds; 12% >10 medications. • §Highest number of drugs per person in greater than 80 years olds • •. Gurwitz JH et al. JAMA. 2003;289(9): 1107-16 Nursing home- 7-8 medications Causes: Drug regimen changes §Any transition of care - discharges § §New medications, different dosses § §Changes from generic to brand-nomenclature, color and/or shape Causes: Providers/Patients §The more the providers and visits, the more the medications takes §2/3 of all physician visits end with a prescription §Expectations to receive medication §Not communicating with different physicians about medication changes §Self-treatment § • Complications of Polypharmacy §Increased incidence of side effects and adverse drug reactions (ADRs) § §Noncompliance or nonadherence • §Increased cost § • • Take Home Message §Polypharmacy is a reality of prescribing when patients have multiple comorbidities. §We must all anticipate and guard against the potential complications of polypharmacy. §Optimal prescribing is key! § Adverse Drug Reaction Definitions • • Adverse Drug Events (ADEs) is •‘any injury resulting from the use of drugs’ • • Five categories of ADEs: • 1. Adverse drug reactions • 2. Medication errors • 3. Therapeutic failures • 4. Adverse drug withdrawal events • 5. Overdoses Nebeker JR, Ann Intern Med. 2004;140(10):795-801 WHO. International drug monitoring: The role of the hospital. WHO Tech Rep. 1969; 425: 5-24 “ADR is a response to a drug that is noxious and unintended and occurs at doses normally used in man for the prophylaxis, diagnosis or therapy of disease, or for modification of physiological function” ADVERSE DRUG REACTION DEFINITION 1 Edwards & Aronson. Adverse drug reactions: definitions, diagnosis, and management. Lancet 2000; 356: 1255-59. “An appreciably harmful or unpleasant reaction, resulting from an intervention related to the use of a medicinal product, which predicts hazard from future administration and warrants prevention or specific treatment, or alteration of the dosage regimen, or withdrawal of the product.” DEFINITION 2 Side Effects and ADRs §Side effects: considered minor enough to allow continuation of therapy §Adverse Drug Reactions (ADRs): May necessitate discontinuation of drug and require treatment of adverse event. Due to: §drug-drug interactions, §drug-disease interactions, §drug-herbal interactions, §drug-food interactions • § • •“One of the greatest hazards is the use of potent drugs is their inherent toxicity…… • •…..the dangers of the drug appear to be greater now then ever before.” • • David Barr. Hazards of modern diagnosis and therapy – the price we pay. • Frank Billings Memorial Lecture. J Am Med Assoc 1955;159 (15): 1452-56. In United States ADR estimated to be between 4th and 6th leading cause of death. Lazarou JAMA 1998 ADRs §Elderly 7 times more likely to have unwanted side effect and 2-3 times more likely to have ADRs §Multiple medications is the factor most strongly correlated with increased risk of ADRs §Exponential increase in ADRs with addition of more drugs to a regimen (two drugs 15%, five drugs 50-60%) • § • For example NSAID • • 12,000 admissions/year due to GI bleed • 2000 deaths/year • 400 bed hospital working at capacity • Impact greater for >65 years: – GI bleed, – Renal impairment – – –Blower et al. Aliment Pharmacol Therap (1997) – DEFINITION Edwards & Aronson. Lancet. 2000;356: 1255-59 Why are the elderly at risk of ADRs? ADRs and Age • Incidence of ADR increases with age • • Elderly receive more medicines • Incidence of ADR increases the more • prescribed medicines taken exponentialy? • • For example: –ADR rates increase to 5% for 1 or 2 medications –Increased to 20% when >5 medications – –Grymonpre et al (1988) – study >50 yrs – Table: The Prescribing Cascade Initial treatment Adverse effect Subsequent treatment Subsequent adverse effect NSAIDs Rise in blood pressure Antihypertensive treatment Orthostatic hypotension Thiazide diuretics Hyperuricaemia Allopurinol Hypersensitivity reaction (Skin rashes) Metoclopramide treatment Parkinsonian symptoms Treatment with levodopa Visual and auditory hallucination Source: Adapted from Rochon and Gurwitz, 1997 The Evidence §Elderly not extensively studied §Usually part of general data-set §Homogeneity of studies a problem Table: ADR by Clinical Setting (Wiffen et al. 2002) Impact of inpatient ADR (Wiffen et al 2002) Cost – £380 million/year to NHS England Consuming 4% available bed-days 1. 1.Older patients more likely to be admitted with ADR 2. {76 yrs (65-83) vs 66 (46-79)} 3.4% of hospital bed capacity 4.0.15% fatality 5.Drug – drug interactions responsible for 1 in 6 ADRs 6.72% were (possibly or definitely) preventable Pirmohamed M. et al. Adverse drug reactions as cause of admission to hospital: prospective analysis of 18 820 patients. BMJ, 2004. 329(7456):15-9. ADR causing hospital admission “Older drugs continue to be the most commonly implicated in causing admissions.” Drug Common Issues Antibiotics Allergies & dosage adjustment in renal dysfunction Anticoagulants Bleeding; drug interactions, dynamic changes & environment Cardiac glycosides 1 in 5 experience ADR, NTI & kinetic issues. Diuretics Dehydration, electrolyte imbalance Hypoglycaemic agents (oral & insulin) Hypoglycaemia, changes to diet, poor monitoring NSAIDs GI bleed, renal impairment Opioid analgesia Sedation – dynamic and kinetic changes Drug’s Commonly Implicated Strategies • •Identify patients – triggers •Improve process of care •e-prescribing systems •Clinical pharmacists on rounds •Better communication across interface & with patients (carers) Prescribing to Reduce ADRs •Age, hepatic and renal disease may impair clearance of drugs so smaller doses may be needed. •Prescribe as few drugs as possible and give clear instructions to patients and carers •If serious ADRs are liable to occur warn the patient •Where possible use familiar drugs. •With new drugs be particularly alert for ADRs and unexpected event. • Assessing Medication Appropriateness in the Elderly Using Beers & STOPP START Criteria What is the Beers Criteria? •Originally conceived in 1991 by Mark Beers, MD (geriatrician) • •1991 à 1997 à 2003 à 2012 • • AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults AKA Beers List, Beers Criteria http://www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdf DrBeers • Identifies medications that pose potential risks outweighing potential benefits for people ≥65 years ↓ • Informs clinical decision-making concerning the prescribing of medications for older adults ↓ • Improves medication safety & quality of care CONTRA.jpg GRACIAS.jpg What the pocket card looks like. Intended Use • •Goal •To improve care of older adults by ↓ exposure to Potentially Inappropriate Medications (PIMs) • –Guide for identifying medications for which risks > benefits –Not meant to be punitive –Not meant to supersede clinical judgment or an individual patient’s values & needs –Underscore the importance of using a team approach & use of non-pharmacological approaches –Implicit criteria such as the STOPP/START criteria & Medication Appropriateness Index should be used in a complementary manner • 2012 AGS Beers Criteria - Categories 1st Category 2nd Category 3rd Category PIMs for older people: • Pose high risks of adverse effects OR • Appear to have limited effectiveness in older patients AND • There are alternatives to these medications PIMs for older people: • Who have certain diseases/disorders – these drugs may exacerbate the specified health problems Use with caution in older adults • May be associated with more risks than benefits in general However, may be the best choice for a particular individual if administered with caution • 53 medications or medication classes that should be avoided in older adults • 14 that should be used with caution C:\Users\Bunka\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.IE5\0NREEU04\MC900440035[1].png BEERS Tables • •Table 1 – PIMs list (with select caveats) • •Table 2 – PIMs due to Drug-Disease Interactions • •Table 3 – Medications to be used with • • C:\Users\Bunka\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.IE5\XTVIO6E1\MC900431529[1].png Table 1 - Drugs to Avoid (except if….) •Table 1 in the •pocket guide • Red Flag Table 2 – Drug - disease interactions •Table 2 in the pocket guide Red Flag Table 3 - Use with Caution •Table 3 in the pocket guide YellowFlag1 Print off the Pocket Card • Open access, available for free. • •http://www.americangeriatrics.org/files/documents/beers/PrintableBeersPocketCard.pdf • MM900288911[1] Yes, there’s an app for that! Beers App Hand A walk through the pocket guide…. Beers Pocket walking-man-black-hi • Quality of Evidence • High • Moderate • Low • Strength of Recommendation • Strong • Weak • Insufficient Validated literature evaluation tool to support recommendations C:\Users\Bunka\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.IE5\0NREEU04\MC900440035[1].png Where does Beers fit into the big picture? •Beers Criteria are only one part of quality prescribing •Correct drug for correct diagnosis •Appropriate dose •Avoid underuse of potentially important medication • *START Criteria •Avoid overuse •Avoid potentially inappropriate drugs • *STOPP & Beers Criteria •Avoid withdrawal effects with discontinuation •Consideration of cost puzzle Remember…. •Not intended to mandate drug prescribing •Intended to serve as guidance to good geriatric care & principles •To help providers best monitor older patients, reduce risk & prevent complications Fick D & Resnick B. 2012 Beers Criteria Update: How Should Practicing Nurses Use the Criteria? Journal of Gerontological Nursing. June 2012 - Volume 38 · Issue 6: 3-5 Other Tools/Resources tools Other Tools/Resources • •RxFiles Reference List of Drugs with Anticholinergic Effects •STOPP Criteria 2006 •START Criteria 2006 •Medication Appropriateness Index •Others? –The Improving Prescribing in the Elderly Tool (IPET) 2000 –McLeod Criteria 1997 • RxFiles •Academic detailing program •Not-for-profit •Funded by a grant from Saskatchewan Health •1997: began as a service to Saskatoon family physicians •2011: expanded to provide services to long-term care •This program exists to support health care professionals in making the best possible drug therapy choices for patients. •Value is found in the balanced perspectives on drug effectiveness, safety, cost, clinical evidence & patient considerations. • • rx files-final logo-PMS3298 •STOPP Criteria •Screening Tool of Older Persons’ potentially inappropriate Prescriptions • • 65 rules relating to the most common • and the most potentially dangerous • instances of inappropriate prescribing • in older people A. Cardiovascular System • •1. Digoxin at a long-term dose > 125µg/day with impaired renal function * (increased risk of toxicity). * estimated GFR <50ml/min •2. Loop diuretics: •for dependent ankle oedema only i.e. no clinical signs of heart failure (no evidence of efficacy, compression hosiery usually more appropriate). •as first-line monotherapy for hypertension (safer, more effective alternatives available). •3. Thiazide diuretic with a history of gout (may exacerbate gout). •4. Beta-blockers: •with Chronic Obstructive Pulmonary Disease (COPD) (risk of increased bronchospasm). •in combination with verapamil (risk of symptomatic heart block). •5. Use of diltiazem or verapamil with NYHA Class III or IV heart failure (may worsen heart failure). •6. Calcium channel blockers with chronic constipation (may exacerbate constipation). •7. Dipyridamole as monotherapy for cardiovascular secondary prevention (no evidence for efficacy). Heart Does not list the new oral anticoag because it is from 2006 (out of date) • •8. Aspirin: •with a past history of peptic ulcer disease without histamine H2 receptor antagonist or •Proton Pump Inhibitor (risk of bleeding). •at dose > 150mg day (increased bleeding risk, no evidence for increased efficacy). •with no history of coronary, cerebral or peripheral vascular symptoms or occlusive event (not indicated). •to treat dizziness not clearly attributable to cerebrovascular disease (not indicated). •9. Warfarin: •for first, uncomplicated deep venous thrombosis for longer than 6 months duration (no proven added benefit). •for first uncomplicated pulmonary embolus for longer than 12 months duration (no proven benefit). •10. Use of aspirin and warfarin in combination without histamine H2 receptor antagonist (except cimetidine because of interaction with warfarin) or proton pump inhibitor (high risk of gastrointestinal bleeding). •11. Aspirin, clopidogrel, dipyridamole or warfarin with concurrent bleeding disorder (high risk of bleeding). H. Drugs that adversely affect those prone to falls (≥ 1 fall in past three months) • •1. Benzodiazepines (sedative, may cause reduced sensorium, impair balance). •2. Neuroleptic drugs (may cause gait dyspraxia, Parkinsonism). •3. First generation antihistamines (sedative, may impair sensorium). •4. Vasodilator drugs known to cause hypotension in those with persistent postural hypotension i.e. recurrent > 20mmHg drop in systolic blood pressure (risk of syncope, falls). •5. Long-term opiates in those with recurrent falls (risk of drowsiness, postural hypotension, vertigo). fall •START Criteria Screening Tool to Alert doctors to the Right Treatment •22 rules relating to common instances of prescribing omission O’Mahony D, Gallagher P, Ryan C, Byrne S, Hamilton H, Barry P, O’Connor M, Kennedy J. STOPP & START criteria: A new approach to detecting potentially inappropriate prescribing in old age. European Geriatric Medicine. 2010 Jan 6; 1(1):45-51. CONTRA.jpg GRACIAS.jpg 87A1D40C-1795-40F0-9B2C-8E29C4939536