Understanding Polypharmacy in Older Adults

Polypharmacy
An introductory module
for clinicians
Lawrence Jackson
, BScPhm, CTDP
Pharmacy Clinical Coordinator,
Sunnybrook Health Sciences
This module is part of the sfCare approach
PowerPoint
Presentation
8.5 x 11
Poster
Patient
Handout
1.
Identify the factors that contribute to polypharmacy
2.
Explain the consequences of problematic
polypharmacy
3.
Describe a structured approach to the detection of
problematic polypharmacy
4.
Apply general strategies to limit problematic
polypharmacy
5.
Apply a senior friendly care approach to
polypharmacy
Objectives
Objectives
What is
polypharmacy?
Impact for the older
adult
Risk factors
Detecting
Addressing
Case study
Summary
Senior friendly
approach
Questions
While there is no consensus definition for polypharmacy, most
studies have used a numerical threshold of 
5 or more medications
per day
What is polypharmacy?
1. JAMA 2017;318(17):1728
2. Duerden M, et al. Prescriber 2014;25:44-47
Approximately 
40% of older
adults take 5-9 medications
1
Approximately 
18% of older
adults take 10 or more
medications
2
Objectives
What is
polypharmacy?
Impact for the older
adult
Risk factors
Detecting
Addressing
Case study
Summary
Senior friendly
approach
Questions
Medication optimization ensures benefits outweigh risks
Takes into consideration impact on outcomes important to the
older adult, such as
Improving the duration and quality of life
Symptom control
Prevention
It is evidence-based
Appropriate versus problematic polypharmacy
JAMA 2017;318(17):1728
Duerden M, et al. Prescriber 2014;25:44-47
Appropriate Polypharmacy
Objectives
What is
polypharmacy?
Impact for the older
adult
Risk factors
Detecting
Addressing
Case study
Summary
Senior friendly
approach
Questions
Appropriate versus problematic polypharmacy
JAMA 2017;318(17):1728
Duerden M, et al. Prescriber 2014;25:44-47
Problematic Polypharmacy
Risk of harm exceeds the
potential benefits or
coexists with the
benefits
Objectives
What is
polypharmacy?
Impact for the older
adult
Risk factors
Detecting
Addressing
Case study
Summary
Senior friendly
approach
Questions
Impact of polypharmacy on the older adult

 adverse drug reactions

 drug interactions

 cost

 risk of non adherence

 risk of medication errors
6.
Precipitate or exacerbate geriatric syndromes
The following risks accompany polypharmacy:
Objectives
What is
polypharmacy?
Impact for the older
adult
Risk factors
Detecting
Addressing
Case study
Summary
Senior friendly
approach
Questions
Impact of polypharmacy on the older adult
Falls
Functional impairment
Cognitive impairment
Urinary incontinence
Impaired nutrition
Dehydration
Constipation 
Geriatric syndromes
Objectives
What is
polypharmacy?
Impact for the older
adult
Risk factors
Detecting
Addressing
Case study
Summary
Senior friendly
approach
Questions
Risk factors for polypharmacy
=
Increased risk
of
problematic
polypharmacy
OR
harmful
medication
effects
+
+
Multiple medical
problems/ multiple
medications
Reduced
homeostatic
mechanisms and
organ dysfunction
AND/
OR
Frailty
Acute illness or
change to
medications
Objectives
What is
polypharmacy?
Impact for the older
adult
Risk factors
Detecting
Addressing
Case study
Summary
Senior friendly
approach
Questions
Risk factors for polypharmacy
Multiple medical problems/multiple medications
Treatment guideline-based prescribing
Promotes multiple medications
Conditions for deprescribing uncertain
ADRs and prescribing cascade
An adverse reaction to one drug may go unrecognized/
misinterpreted
Healthcare provider inappropriately prescribes a second drug
to treat signs/symptoms
Infrequent medication review
There is a lack of incentive to deprescribe
Unnecessary drugs or doses not adjusted
Objectives
What is
polypharmacy?
Impact for the older
adult
Risk factors
Detecting
Addressing
Case study
Summary
Senior friendly
approach
Questions
Taffet GE, Physiology of aging. In: Cassel CK, Leipzig RM, Cohen HJ, et al [eds]. Geriatric Medicine: An
Evidence-Based Approach, 4
th
 ed. New York, Springer, 2003
Risk factors for polypharmacy
Reduced Homeostatic Mechanisms & Organ Dysfunction
Objectives
What is
polypharmacy?
Impact for the older
adult
Risk factors
Detecting
Addressing
Case study
Summary
Senior friendly
approach
Questions
A decline in physiologic reserves associated with aging causes the
older adult to become less resilient to various causes of stress
such as acute illness or injury, or the effects that medications have
on the body.
The combination of increased stressors and a decrease in
physiologic reserve can lead to adverse outcomes such as
hospitalization or death.
Risk factors for polypharmacy
Pharmacokinetics
changes
Absorption
Distribution
Metabolism (liver)
Excretion (kidney
)
Changes in how the
body
 acts on the drug
Pharmacodynamics
changes
Changes in receptor
binding
↓ # of receptors and
receptor activity
↑↓ Drug efficacy
↑ Toxicity / ADRs
Changes in how the
drug
 acts on the body
Changes in
physiology
with aging:
↑ body fat
↓ body water
↓ albumin
↓ liver
metabolism
↓ renal
function
Reduced homeostatic mechanisms and organ dysfunction
Objectives
What is
polypharmacy?
Impact for the older
adult
Risk factors
Detecting
Addressing
Case study
Summary
Senior friendly
approach
Questions
Risk factors for polypharmacy
Characteristics of frailty
Unintended weight loss due to
inadequate nutrition
Slow walking speed
Impaired grip strength
Exhaustion
Self reported decline in activity
levels
Frailty
Older people are vulnerable to medication-
related problems associated with frailty.
Objectives
What is
polypharmacy?
Impact for the older
adult
Risk factors
Detecting
Addressing
Case study
Summary
Senior friendly
approach
Questions
Risk factors for polypharmacy
Older age
Multiple medical problems (or geriatric syndromes)
Taking multiple medications
Multiple psychosocial problems
One or more sensory impairments (vision, hearing)
New onset urinary or fecal incontinence
Decrease in functional status
Change in mental status- cognition/affect
Disruptive behavior or personality changes
Frequent falls
Frailty (cont.)
Several factors are known to be associated with frailty:
Objectives
What is
polypharmacy?
Impact for the older
adult
Risk factors
Detecting
Addressing
Case study
Summary
Senior friendly
approach
Questions
Risk factors for polypharmacy
With acute illness, usual medications can cause
unanticipated harm
With any change in medications or change in dose, adverse
effects can result
Acute illness or changes to medication can lead to
problematic polypharmacy
Objectives
What is
polypharmacy?
Impact for the older
adult
Risk factors
Detecting
Addressing
Case study
Summary
Senior friendly
approach
Questions
Challenges in detecting polypharmacy
Problems due to medications may occur
Without any changes to the medication
Advancing age
Coincident with acute illness or symptoms
ADRs masquerade as age-related changes
Atypical presentation of adverse effects
Side effects difficult to interpret, may go unreported
Prescribing cascade
Infrequent Medication Review
There is a lack of incentive to deprescribe
Objectives
What is
polypharmacy?
Impact for the older
adult
Risk factors
Detecting
Addressing
Case study
Summary
Senior friendly
approach
Questions
Detecting problematic polypharmacy
Problematic polypharmacy can present in atypical ways, such as …
Exaggerated medication effects
Loss of medication’s effect
Problems with taking medication
New or worsening symptoms or conditions
Decline in functional and self-care abilities
Decline in mobility
Objectives
What is
polypharmacy?
Impact for the older
adult
Risk factors
Detecting
Addressing
Case study
Summary
Senior friendly
approach
Questions
Confusion and falls 
are important clues that resilience is
compromised in an older adult and should prompt a search for
causes, including medications!
Addressing polypharmacy
Assess medication list with an available tool
Explicit criteria – list of
potentially inappropriate
medications
Implicit criteria or
comprehensive assessment
Medication assessment
framework
Objectives
What is
polypharmacy?
Impact for the older
adult
Risk factors
Detecting
Addressing
Case study
Summary
Senior friendly
approach
Questions
Addressing polypharmacy
 
STOPP/START
Explicit criteria – lists of potentially inappropriate medications
(PIM), for example
Suggests drugs to avoid and drugs to use
High alert 
medications
anticholinergic activity
Benzodiazepines
Tricyclic antidepressants
Warfarin
NSAIDs
Fluoxetine
Digoxin
Oxybutynin
Age and Aging 2015; 44(2):2013-218
J Am Geriatr Soc 2019;67(4):674-694
Suggests drugs to avoid and highlights high alert medications / patients
High alert 
patients
Impaired renal function
Impaired cognition or senses
Falls
Hypotension
Diabetes
Parkinson’s disease
Poor nutrition
Beers Criteria List
Objectives
What is
polypharmacy?
Impact for the older
adult
Risk factors
Detecting
Addressing
Case study
Summary
Senior friendly
approach
Questions
D
ose and frequency
E
ffects
B
enefit
R
isk
I
ndication
D
rug monitoring
E
xpectations
Medication
Appropriate Index
(MAI)
No TEARS
ARMOR
7-Step Review Process…
Gokula M, Homes H. Clin Geriatr Med 28 (2012) 323–341
DEBRIDE
: Medication reviews in long-term care and supportive living.  Alberta
http://www.cpsa.ca/medication-reviews-long-term-care-supportive-living-physicians-perspective/
MAI
:  Hanlon JT, et al. MAI  J Clin Epidemiol. 1992;45:1045–51
No TEARS
: BMJ 2004;329:434
ARMOR
: Haque R. Ann Long-Term Care 2009;17:26-30
Other
Medication
Assessment
Frameworks
Medication assessment frameworks
Addressing polypharmacy
 
Objectives
What is
polypharmacy?
Impact for the older
adult
Risk factors
Detecting
Addressing
Case study
Summary
Senior friendly
approach
Questions
Addressing polypharmacy
 
Implicit criteria or comprehensive assessment
Health status
Prognosis and goals of care
Benefit – risk assessment of each medication and
overall combination of medications
Objectives
What is
polypharmacy?
Impact for the older
adult
Risk factors
Detecting
Addressing
Case study
Summary
Senior friendly
approach
Questions
Addressing polypharmacy
1.
Assess risk for polypharmacy
2.
Annual review of medications in all older adults
3.
Inform caregivers of medication changes to increase the
chance of detecting problems as soon as possible
4.
Chose medications with the fewest side effects
5.
Stop unnecessary medications
6.
Consider the impact of medications on quality of life
7.
Consider the person’s ability to take medications and
remember to take them
Limiting potential harms
Objectives
What is
polypharmacy?
Impact for the older
adult
Risk factors
Detecting
Addressing
Case study
Summary
Senior friendly
approach
Questions
Addressing polypharmacy
1. Recognize
the Need
A practical guide to stopping medication…
2. Reduce or
Stop
to stop a
medicine
one medicine
at a time
3. Taper
Medicine
when
appropriate
4. Check for
Benefit or Harm
after each
medicine has
been stopped
With the
person’s
consent, view
the
discontinuation
process as a trial
At the next
scheduled visit
review progress,
then either:
Maintain
(at half dose)
Continue to
taper (e.g.
quarter
dose)
Stop
Time taken to
taper may vary
from 
days 
to
weeks
 to
months
If symptoms
worsen, may
need to
reinstate the
medication
At the first
visit, halve the
dose
Frank C, Weir E. CMAJ 2014;186(18):1369-1376
Objectives
What is
polypharmacy?
Impact for the older
adult
Risk factors
Detecting
Addressing
Case study
Summary
Senior friendly
approach
Questions
Case study: Mary
Mary is 85 years old and has 4 chronic
conditions that require 9 medications.
No changes to her medications for 5
years.
One month ago a new medication was
started. Soon after that, she began to
feel unsteady when walking and has
been incontinent of urine on 2
occasions because she is not able to
get to the bathroom fast enough. One
week ago, she fell but only sustained
some bruising of her arm.
She is mystified by these new
problems and wonders if she is getting
old and whether she can stay in her
own apartment. She wonders if she
should report these problems to her
daughter.
What’s going through your
mind?
Objectives
What is
polypharmacy?
Impact for the older
adult
Risk factors
Detecting
Addressing
Case study
Summary
Senior friendly
approach
Questions
Is Mary at risk of problematic polypharmacy?
Identify the risk factors in Mary’s case
+
+
Multiple medical
problems/ multiple
medications
Reduced
homeostatic
mechanisms and
organ dysfunction
AND/
OR
Frailty
Acute illness or
change to
medications
Objectives
What is
polypharmacy?
Impact for the older
adult
Risk factors
Detecting
Addressing
Case study
Summary
Senior friendly
approach
Questions
Is Mary at risk of problematic polypharmacy?
4 chronic
conditions that
require 9
medications:
Prescribing
cascade and
increasing
polypharmacy
Problematic
medications left
unchanged
Risk of further
decline in health
status
+
Multiple medical
problems/ multiple
medications
Reduced
homeostatic
mechanisms and
organ dysfunction
AND/
OR
Frailty
Acute illness or
change to
medications
Identify the risk factors in Mary’s case
Objectives
What is
Polypharmacy?
Impact for the Older
Person
Risk Factors
Detecting
Addressing
Case Study
Summary
Senior Friendly
Approach
Questions
New acute
condition may
have:
Compromised
her homeostatic
mechanisms; or
Worsened her
already impaired
organ function
+
Multiple medical
problems/ multiple
medications
Reduced
homeostatic
mechanisms and
organ dysfunction
AND/
OR
Frailty
Acute illness or
change to
medications
Is Mary at risk of problematic polypharmacy?
Identify the risk factors in Mary’s case
Objectives
What is
polypharmacy?
Impact for the older
adult
Risk factors
Detecting
Addressing
Case study
Summary
Senior friendly
approach
Questions
New health
problems
not attributed to
medications:
Urinary
incontinence, via
decreased mobility
Fall
Confusion: Mary is
unsure if episodes
should be reported
to daughter
Psychological
distress: Mary is
worried about
ability to live
independently
+
Multiple medical
problems/ multiple
medications
Reduced
homeostatic
mechanisms and
organ dysfunction
AND/
OR
Frailty
Acute illness or
change to
medications
Is Mary at risk of problematic polypharmacy?
Identify the risk factors in Mary’s case
Objectives
What is
polypharmacy?
Impact for the older
adult
Risk factors
Detecting
Addressing
Case study
Summary
Senior friendly
approach
Questions
Recently been
prescribed a new
medication for a new
condition/acute illness
Usual medications
have caused
unanticipated harm
Recent medications
were not
communicated to
Mary’s daughter,
leading to
insufficient health
monitoring and
reporting
No recent
medication review
+
Multiple medical
problems/ multiple
medications
Reduced
homeostatic
mechanisms and
organ dysfunction
AND/
OR
Frailty
Acute illness or
change to
medications
Is Mary at risk of problematic polypharmacy?
Identify the risk factors in Mary’s case
Objectives
What is
polypharmacy?
Impact for the older
adult
Risk factors
Detecting
Addressing
Case study
Summary
Senior friendly
approach
Questions
Case study: Mary - resolution
Finally, apply the Medication Review Framework
(DEBRIDE) to determine if Mary can benefit from de-
prescribing.
D
ose and frequency 
- 
Is the dose and frequency correct  based
on age and organ function?
E
ffects
 - 
Have the known side effects been considered?
B
enefit
 - 
Will Mary benefit from treatment given goals of care?
R
isk
 - 
Is the medication considered a high risk medication?
I
ndication
 - 
Is the indication for the new medication clear and valid?
D
rug monitoring 
- 
Is a monitoring plan in place to assess benefit
and harm?
E
xpectations
 - 
Are the expectations of benefit to be achieved
realistic?
Objectives
What is
polypharmacy?
Impact for the older
adult
Risk factors
Detecting
Addressing
Case study
Summary
Senior friendly
approach
Questions
Summary
Polypharmacy is common ≥ 65 years
due to multiple conditions requiring medications
polypharmacy can be appropriate or problematic
Risk of harm increases with # medications, frailty, and illness
inconvenience ……hospitalization………..death
Medication appropriateness may change over time
decline in functional reserves of organs (frailty)
maintenance medications may become harmful
medication changes result in adverse effects or new drug-
interactions
Medication appropriateness may change with acute illness
loss of physiologic reserve causes medications to have an
enhanced effect
Objectives
What is
polypharmacy?
Impact for the older
adult
Risk factors
Detecting
Addressing
Case study
Summary
Senior friendly
approach
Questions
Summary
medication problems can occur without a change in
medications
tools are available to structure the medication
assessment process
each patient is unique, medication decisions require
clinical judgement
all care providers can contribute to medication problem
identification and reporting
Recognizing problematic polypharmacy is difficult
Benefit/harm ratio can change in an instant or gradually over time.
Regular medication review provides an opportunity to detect
problems, adjust doses based on changing physiology and consider
medication deprescribing.
Objectives
What is
polypharmacy?
Impact for the older
adult
Risk factors
Detecting
Addressing
Case study
Summary
Senior friendly
approach
Questions
Summary
1.
Assess polypharmacy risk
2.
Annual review of medications in all older adults
3.
Inform caregivers of medication changes to increase the
chance of detecting problems as soon as possible
4.
Chose medications with the fewest side effects
5.
Stop unnecessary medications
6.
Consider the impact of medications on quality of life
7.
Consider the person’s ability to take medications and
remember to take them
Strategies to limit the potential harms due to
polypharmacy
Objectives
What is
polypharmacy?
Impact for the older
adult
Risk factors
Detecting
Addressing
Case study
Summary
Senior friendly
approach
Questions
The senior friendly approach
How all healthcare providers can address
polypharmacy using a 
senior friendly care 
approach
 
Leadership-supported medication
reviews
Providing staff and patient education
 
Changes in condition prompt a
medication review – regardless of
patient age
 
Medications are meeting the older
adult’s goals
 
Facilitate medication reviews
Medication reminder systems to
increase adherence
Organizational Support
Emotional &
Behavioural Environment
Ethics in Clinical Care
and Research
Physical Environment
Processes 
of Care
Organizational
Support
Ethics in Clinical
Care and Research
Processes 
of Care
Emotional &
Behavioural
Environment
Physical
Environment
Objectives
What is
polypharmacy?
Impact for the older
adult
Risk factors
Detecting
Addressing
Case study
Summary
Senior friendly
approach
Questions
Which of the strategies to 
limit
the potential harms due to
polypharmacy (slide 33) 
are you
already using in your practice?
What are some of the barriers
to implementing strategies to
limit the potential harms due to
polypharmacy (slide 33)?
What is one strategy that you
can implement moving
forward?
Discussion questions
Objectives
What is
polypharmacy?
Impact for the older
adult
Risk factors
Detecting
Addressing
Case study
Summary
Senior friendly
approach
Questions
The sfCare Learning Series received support from the Regional Geriatric Programs
of Ontario, through funding provided by the Ministry of Health and Long-Term Care.
V1 July 2019
Slide Note
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Polypharmacy is a common concern among older adults, with approximately 40% taking 5-9 medications and 18% taking 10 or more. This module discusses the factors contributing to polypharmacy, consequences of problematic polypharmacy, strategies for detection and intervention, and the difference between appropriate and problematic polypharmacy. It emphasizes a senior-friendly approach to medication management to optimize benefits and reduce risks for older adults.


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  1. Polypharmacy An introductory module for clinicians Lawrence Jackson, BScPhm, CTDP Pharmacy Clinical Coordinator, Sunnybrook Health Sciences

  2. This module is part of the sfCare approach Patient Handout 8.5 x 11 Poster PowerPoint Presentation 2

  3. Objectives Objectives What is 1. Identify the factors that contribute to polypharmacy polypharmacy? 2. Explain the consequences of problematic polypharmacy Impact for the older adult 3. Describe a structured approach to the detection of problematic polypharmacy Risk factors Detecting 4. Apply general strategies to limit problematic polypharmacy Addressing 5. Apply a senior friendly care approach to polypharmacy Case study Summary Senior friendly approach Questions 3

  4. What is polypharmacy? While there is no consensus definition for polypharmacy, most studies have used a numerical threshold of 5 or more medications per day Objectives What is polypharmacy? Approximately 40% of older adults take 5-9 medications1 Impact for the older adult Risk factors Approximately 18% of older adults take 10 or more medications2 Detecting Addressing Case study Summary Senior friendly approach 1. JAMA 2017;318(17):1728 2. Duerden M, et al. Prescriber 2014;25:44-47 Questions 4

  5. Appropriate versus problematic polypharmacy Objectives Appropriate Polypharmacy What is polypharmacy? Medication optimization ensures benefits outweigh risks Impact for the older Takes into consideration impact on outcomes important to the older adult, such as adult Risk factors Improving the duration and quality of life Detecting Symptom control Addressing Prevention It is evidence-based Case study Summary Senior friendly approach JAMA 2017;318(17):1728 Duerden M, et al. Prescriber 2014;25:44-47 Questions 5

  6. Appropriate versus problematic polypharmacy Objectives Problematic Polypharmacy What is polypharmacy? Risk of harm exceeds the potential benefits or coexists with the benefits Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach JAMA 2017;318(17):1728 Duerden M, et al. Prescriber 2014;25:44-47 Questions 6

  7. Impact of polypharmacy on the older adult The following risks accompany polypharmacy: Objectives What is 1. adverse drug reactions polypharmacy? 2. drug interactions Impact for the older 3. cost adult 4. risk of non adherence Risk factors 5. risk of medication errors Detecting 6. Precipitate or exacerbate geriatric syndromes Addressing Case study Summary Senior friendly approach Questions 7

  8. Impact of polypharmacy on the older adult Geriatric syndromes Objectives Falls What is Functional impairment polypharmacy? Cognitive impairment Impact for the older adult Urinary incontinence Risk factors Impaired nutrition Detecting Dehydration Constipation Addressing Case study Summary Senior friendly approach Questions 8

  9. Risk factors for polypharmacy Objectives Multiple medical problems/ multiple medications What is polypharmacy? Increased risk of problematic polypharmacy Impact for the older adult + Reduced homeostatic mechanisms and organ dysfunction Risk factors = Detecting OR Addressing + harmful medication effects Case study Acute illness or change to medications AND/ OR Summary Frailty Senior friendly approach Questions 9

  10. Risk factors for polypharmacy Multiple medical problems/multiple medications Objectives Treatment guideline-based prescribing What is Promotes multiple medications polypharmacy? Conditions for deprescribing uncertain ADRs and prescribing cascade Impact for the older adult An adverse reaction to one drug may go unrecognized/ misinterpreted Risk factors Detecting Healthcare provider inappropriately prescribes a second drug to treat signs/symptoms Infrequent medication review Addressing Case study There is a lack of incentive to deprescribe Summary Unnecessary drugs or doses not adjusted Senior friendly approach Questions 10

  11. Risk factors for polypharmacy Reduced Homeostatic Mechanisms & Organ Dysfunction Objectives A decline in physiologic reserves associated with aging causes the older adult to become less resilient to various causes of stress such as acute illness or injury, or the effects that medications have on the body. The combination of increased stressors and a decrease in physiologic reserve can lead to adverse outcomes such as hospitalization or death. What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Taffet GE, Physiology of aging. In: Cassel CK, Leipzig RM, Cohen HJ, et al [eds]. Geriatric Medicine: An Evidence-Based Approach, 4th ed. New York, Springer, 2003 Questions 11

  12. Risk factors for polypharmacy Reduced homeostatic mechanisms and organ dysfunction Objectives What is Pharmacokinetics changes Pharmacodynamics changes polypharmacy? Impact for the older adult Changes in physiology with aging: Changes in how the body acts on the drug Changes in how the drug acts on the body Risk factors Detecting Absorption Distribution Metabolism (liver) Excretion (kidney) body fat body water albumin liver metabolism renal function Changes in receptor binding # of receptors and receptor activity Drug efficacy Toxicity / ADRs Addressing Case study Summary Senior friendly approach Questions 12

  13. Risk factors for polypharmacy Frailty Objectives Older people are vulnerable to medication- related problems associated with frailty. What is polypharmacy? Characteristics of frailty Unintended weight loss due to inadequate nutrition Slow walking speed Impaired grip strength Exhaustion Self reported decline in activity levels Impact for the older adult Risk factors Detecting Addressing Case study Summary Robust 0 Pre-frail 1-2 Frail 3 Senior friendly approach Questions 13

  14. Risk factors for polypharmacy Frailty (cont.) Objectives Several factors are known to be associated with frailty: What is Older age Multiple medical problems (or geriatric syndromes) Taking multiple medications Multiple psychosocial problems One or more sensory impairments (vision, hearing) New onset urinary or fecal incontinence Decrease in functional status Change in mental status- cognition/affect Disruptive behavior or personality changes Frequent falls polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions 14

  15. Risk factors for polypharmacy Objectives Acute illness or changes to medication can lead to problematic polypharmacy What is polypharmacy? With acute illness, usual medications can cause unanticipated harm With any change in medications or change in dose, adverse effects can result Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions 15

  16. Challenges in detecting polypharmacy Problems due to medications may occur Without any changes to the medication Objectives What is polypharmacy? Advancing age Impact for the older Coincident with acute illness or symptoms adult Risk factors ADRs masquerade as age-related changes Atypical presentation of adverse effects Detecting Side effects difficult to interpret, may go unreported Addressing Prescribing cascade Case study Summary Infrequent Medication Review There is a lack of incentive to deprescribe Senior friendly approach Questions 16

  17. Detecting problematic polypharmacy Problematic polypharmacy can present in atypical ways, such as Objectives Exaggerated medication effects Loss of medication s effect Problems with taking medication New or worsening symptoms or conditions Decline in functional and self-care abilities Decline in mobility What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Confusion and falls are important clues that resilience is compromised in an older adult and should prompt a search for causes, including medications! Summary Senior friendly approach Questions 17

  18. Addressing polypharmacy Assess medication list with an available tool Objectives What is Explicit criteria list of potentially inappropriate medications Implicit criteria or comprehensive assessment Medication assessment framework polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions 18

  19. Addressing polypharmacy Explicit criteria lists of potentially inappropriate medications (PIM), for example Objectives STOPP/START What is polypharmacy? Suggests drugs to avoid and drugs to use Impact for the older Beers Criteria List adult Suggests drugs to avoid and highlights high alert medications / patients Risk factors High alert medications anticholinergic activity Benzodiazepines Tricyclic antidepressants Warfarin NSAIDs Fluoxetine Digoxin Oxybutynin High alert patients Impaired renal function Impaired cognition or senses Falls Hypotension Diabetes Parkinson s disease Poor nutrition Detecting Addressing Case study Summary Senior friendly approach Questions Age and Aging 2015; 44(2):2013-218 J Am Geriatr Soc 2019;67(4):674-694 19

  20. Addressing polypharmacy Medication assessment frameworks Objectives DEBRIDE Tool Other Medication Assessment Frameworks What is 7-Step Review Process polypharmacy? Dose and frequency Effects Benefit Risk Indication Drug monitoring Expectations Impact for the older adult Medication Appropriate Index (MAI) No TEARS ARMOR Risk factors Detecting Addressing Case study Summary Senior friendly approach Gokula M, Homes H. Clin Geriatr Med 28 (2012) 323 341 DEBRIDE: Medication reviews in long-term care and supportive living. Alberta http://www.cpsa.ca/medication-reviews-long-term-care-supportive-living-physicians-perspective/ MAI: Hanlon JT, et al. MAI J Clin Epidemiol. 1992;45:1045 51 No TEARS: BMJ 2004;329:434 ARMOR: Haque R. Ann Long-Term Care 2009;17:26-30 Questions 20

  21. Addressing polypharmacy Implicit criteria or comprehensive assessment Objectives Health status What is polypharmacy? Prognosis and goals of care Impact for the older Benefit risk assessment of each medication and overall combination of medications adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions 21

  22. Addressing polypharmacy Limiting potential harms Objectives 1. Assess risk for polypharmacy What is polypharmacy? 2. Annual review of medications in all older adults 3. Inform caregivers of medication changes to increase the chance of detecting problems as soon as possible Impact for the older adult Risk factors 4. Chose medications with the fewest side effects 5. Stop unnecessary medications Detecting 6. Consider the impact of medications on quality of life Addressing 7. Consider the person s ability to take medications and remember to take them Case study Summary Senior friendly approach Questions 22

  23. Addressing polypharmacy A practical guide to stopping medication Objectives 3. Taper Medicine when appropriate 4. Check for Benefit or Harm after each medicine has been stopped 2. Reduce or Stop one medicine at a time 1. Recognize the Need to stop a medicine What is polypharmacy? Impact for the older adult At the first visit, halve the dose At the next scheduled visit review progress, then either: Maintain (at half dose) Continue to taper (e.g. quarter dose) Stop With the person s consent, view the discontinuation process as a trial Risk factors Time taken to taper may vary from days to weeks to months If symptoms worsen, may need to reinstate the medication Detecting Addressing Case study Summary Senior friendly approach Questions Frank C, Weir E. CMAJ 2014;186(18):1369-1376 23

  24. Case study: Mary Mary is 85 years old and has 4 chronic conditions that require 9 medications. No changes to her medications for 5 years. One month ago a new medication was started. Soon after that, she began to feel unsteady when walking and has been incontinent of urine on 2 occasions because she is not able to get to the bathroom fast enough. One week ago, she fell but only sustained some bruising of her arm. She is mystified by these new problems and wonders if she is getting old and whether she can stay in her own apartment. She wonders if she should report these problems to her daughter. Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing What s going through your mind? Case study Summary Senior friendly approach Questions 24

  25. Is Mary at risk of problematic polypharmacy? Identify the risk factors in Mary s case Objectives What is polypharmacy? Multiple medical problems/ multiple medications Impact for the older adult + Risk factors Reduced homeostatic mechanisms and organ dysfunction Detecting Addressing Case study + Acute illness or change to medications Summary AND/ OR Frailty Senior friendly approach Questions 25

  26. Is Mary at risk of problematic polypharmacy? Identify the risk factors in Mary s case Objectives 4 chronic conditions that require 9 medications: Prescribing cascade and increasing polypharmacy Problematic medications left unchanged Risk of further decline in health status What is Polypharmacy? Multiple medical problems/ multiple medications Impact for the Older Person + Risk Factors Reduced homeostatic mechanisms and organ dysfunction Detecting Addressing Case Study Acute illness or change to medications Summary AND/ OR Frailty Senior Friendly Approach Questions 26

  27. Is Mary at risk of problematic polypharmacy? Identify the risk factors in Mary s case Objectives New acute condition may have: Compromised her homeostatic mechanisms; or Worsened her already impaired organ function What is polypharmacy? Multiple medical problems/ multiple medications Impact for the older adult + Risk factors Reduced homeostatic mechanisms and organ dysfunction Detecting Addressing Case study Acute illness or change to medications Summary AND/ OR Frailty Senior friendly approach Questions 27

  28. Is Mary at risk of problematic polypharmacy? Identify the risk factors in Mary s case New health problems not attributed to medications: Urinary incontinence, via decreased mobility Fall Confusion: Mary is unsure if episodes should be reported to daughter Psychological distress: Mary is worried about ability to live independently Objectives What is polypharmacy? Multiple medical problems/ multiple medications Impact for the older adult + Risk factors Reduced homeostatic mechanisms and organ dysfunction Detecting Addressing Case study Acute illness or change to medications Summary AND/ OR Frailty Senior friendly approach Questions 28

  29. Is Mary at risk of problematic polypharmacy? Recently been prescribed a new medication for a new condition/acute illness Usual medications have caused unanticipated harm Recent medications were not communicated to Mary s daughter, leading to insufficient health monitoring and reporting No recent medication review Identify the risk factors in Mary s case Objectives What is polypharmacy? Multiple medical problems/ multiple medications Impact for the older adult + Risk factors Reduced homeostatic mechanisms and organ dysfunction Detecting Addressing Case study Acute illness or change to medications Summary AND/ OR Frailty Senior friendly approach Questions 29

  30. Case study: Mary - resolution Finally, apply the Medication Review Framework (DEBRIDE) to determine if Mary can benefit from de- prescribing. Objectives What is polypharmacy? Dose and frequency - Is the dose and frequency correct based on age and organ function? Effects - Have the known side effects been considered? Benefit - Will Mary benefit from treatment given goals of care? Risk - Is the medication considered a high risk medication? Indication - Is the indication for the new medication clear and valid? Drug monitoring - Is a monitoring plan in place to assess benefit and harm? Expectations - Are the expectations of benefit to be achieved realistic? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions 30

  31. Summary Polypharmacy is common 65 years due to multiple conditions requiring medications polypharmacy can be appropriate or problematic Objectives What is polypharmacy? Risk of harm increases with # medications, frailty, and illness inconvenience hospitalization ..death Impact for the older adult Risk factors Medication appropriateness may change over time decline in functional reserves of organs (frailty) maintenance medications may become harmful medication changes result in adverse effects or new drug- interactions Detecting Addressing Case study Summary Medication appropriateness may change with acute illness loss of physiologic reserve causes medications to have an enhanced effect Senior friendly approach Questions 31

  32. Summary Recognizing problematic polypharmacy is difficult Objectives medication problems can occur without a change in medications tools are available to structure the medication assessment process each patient is unique, medication decisions require clinical judgement all care providers can contribute to medication problem identification and reporting What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Benefit/harm ratio can change in an instant or gradually over time. Regular medication review provides an opportunity to detect problems, adjust doses based on changing physiology and consider medication deprescribing. Summary Senior friendly approach Questions 32

  33. Summary Strategies to limit the potential harms due to polypharmacy Objectives What is polypharmacy? 1. Assess polypharmacy risk Impact for the older 2. Annual review of medications in all older adults adult 3. Inform caregivers of medication changes to increase the chance of detecting problems as soon as possible Risk factors Detecting 4. Chose medications with the fewest side effects 5. Stop unnecessary medications Addressing 6. Consider the impact of medications on quality of life Case study 7. Consider the person s ability to take medications and remember to take them Summary Senior friendly approach Questions 33

  34. The senior friendly approach How all healthcare providers can address polypharmacy using a senior friendly care approach Objectives Leadership-supported medication reviews Providing staff and patient education What is polypharmacy? Organizational Organizational Support Support Impact for the older adult Changes in condition prompt a medication review regardless of patient age Emotional & Risk factors Emotional & Behavioural Environment Behavioural Environment Detecting Processes of Care of Care Processes Addressing Medications are meeting the older adult s goals Ethics in Clinical Ethics in Clinical Care and Research Care and Research Case study Summary Facilitate medication reviews Medication reminder systems to increase adherence Physical Senior friendly approach Physical Environment Environment Questions 34

  35. Discussion questions Objectives What is Which of the strategies to limit the potential harms due to polypharmacy (slide 33) are you already using in your practice? What are some of the barriers to implementing strategies to limit the potential harms due to polypharmacy (slide 33)? What is one strategy that you can implement moving forward? polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions 35

  36. The sfCare Learning Series received support from the Regional Geriatric Programs of Ontario, through funding provided by the Ministry of Health and Long-Term Care. V1 July 2019

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