1. NPS MEDICINEWISE: PROMOTING SAFE USE OF MEDICINES IN OLDER PEOPLE Zain Elgebay Program Officer NPS MedicineWise

2. NPS MEDICINEWISE Established in 1998 Funded by the Australian Government Independent, not-for-profit organisation Membership based Work in partnership -consumers -health professionals -government -industry

3. HOW WE SELECT TOPICS - Members & stakeholder consultation - Surveys of primary care networks, NPS facilitators - Drug utilisation data - Consolidated formative research reports* - Funding submissions - NPS decision algorithm - Expert Advisory groups Topic selection * Identifies key issues, barriers and enablers

4. INTERVENTIONS A range of activities are used to deliver program messages: -Academic detailing -Small group case study meeting -Clinical audits with feedback for GPs -Prescribing feedback for GPs -Print publications (for health professionals and consumers) -Webinar for nurses -Website content

5. THERAPEUTIC AREAS COVERED Older and wiser: Promoting safe use of medicines in older people (2013) Which tests make a difference? Preventive activities in general practice (2013) Cardiovascular: Antithrombotics (2013, 2009, 2003) CVD risk/ Dyslipidaemia (2011, 2002), Heart Failure (2004,1999) Hypertension (2014,2003,1999) Diabetes: Type 2 diabetes: Targets and priorities (2012, 2008, 2005, 2001) Pain: 2010, 2006, 2003, Antibiotics (2012, 2007, 2003, 2000, 1999) Respiratory: Asthma / COPD (2014, 2006, 2002) Mental health: Antipsychotics / dementia (2011, 2008), Depression (2000,2005), Sleep (2010) Womens’ health: HRT/Menopause (2007, 2000) Osteoporosis (2007)

6. OLDER AUSTRALIANS AND THEIR HEALTH A growing proportion of the population with the majority living in the community 28% live alone - proportion increases with age (53% of those aged ≥ 85 years) proportion living in cared accommodation (RACFs, hostels etc) increases with age 1% of those aged 65-74 years 7% of those aged 75-84 31% of those aged ≥ 85

7. HOW MUCH AND WHAT DO OLDER PEOPLE KNOW? 10% could name all medicines correctly 36% could specify correct dose 30% knew how frequently they should take them 20% knew why they were taking

8. OLDER AUSTRALIANS AT HIGHER RISK OF MRPS One in three unplanned hospital admissions for Australians aged over 75 years is related to medicines use; half of these are considered preventable. Older Australians account for 13% of the population but receive twice the number of prescriptions. High rates of polypharmacy evident in older people – increasing the risk of MRPs 32%, 49% and 66% of those aged 50-64, 65-74 and 75+ respectively taking ≥ 5 medicines in 2010 Census Instruments to identify patients at risk of medication-related problems no gold standard but some use evident in Australia e.g. The Medicines Risk Screen

9. WHY OLDER ADULTS ARE IMPACTED BY POLYPHARMACY Metabolic changes and decreased drug clearance associated with ageing Increases the potential for drug-drug interactions and ADRs A barrier to adherence due to complex regimen Increased risk of falls and hip-fractures Disease- specific benefits of adding a new medicine Risks from polypharmacy FALLS Hospitalisation Non-adherence

10. WHAT TO DO WITHOUT RELEVANT GUIDELINES? Use caution when applying population-based guidelines to frail older people. Clinical trial data used to create guidelines is collected from young, or healthy older patients and may not be applicable Overcome this barrier using: individualised therapy clinical judgment best available evidence a discussion between the doctor and the patient Fit Managing Well Vulnerable Frail Terminally Ill Changes in: Physical activity Cognitive function Kidney and liver function Ability to perform activities of daily living (ADL)* The changing health status 4 4 *ADL include instrumental ADL e.g. use of telephone, housework, meal preparation, shopping or managing money and basic ADL e.g. dressing, bathing, transferring, feeding, toileting

11. ASSESS MEDICINES IN THE LIGHT OF AN OLDER PATIENT’S HEALTH AND TREATMENT GOALS

12. UNDERSTAND YOUR PATIENT’S EXPECTATIONS OF MEDICINES In a recent survey, only 3% of community-dwelling older people would take medicines for cardiovascular primary prevention if the adverse effects were severe enough to affect functioning. 5 5 In a recent survey, only 3% of community-dwelling older people would take medicines for cardiovascular primary prevention if the adverse effects were severe enough to affect functioning. 5 5 Understanding a patient’s (and/or their carer’s) experience and expectations is important for safe medicine use. 1, 2 1 2 Expectations will differ, but the main concern is to maintain independence. 3,4 3 4 The values patients ascribe as relevant outcomes from medicines may differ from the prescribers: 2 2 -Personally significant factors e.g. a death with dignity -Context-dependent factors e.g. unable to drive due to sedating effects of medicines, or other unacceptable adverse effects

13. AT POINTS OF CHANGE IN YOUR OLDER PATIENT’S HEALTH... Reaffirm, prioritise, and record what the patient is trying to achieve through medicines use. Investigate the importance your patient places on health outcomes, and the degree of inconvenience and risk of adverse effects he/she is willing to tolerate. Reappraise medicines that may interfere with the patient’s desired outcomes Indication is present and consistent with treatment goals Benefits outweigh potential harms Dose, duration, frequency and formulation are appropriate

14. IDENTIFYING SPECIFIC DRUGS TO TARGET High-risk prescribing criteria criteria reviewed included Beers, McLeod, STOPP/START, MAI and Inappropriate Medication Use and Prescribing Indicators tool. Drugs involved in ADE related hospital admissions a large US study found 4 agents accounted for 67% of admissions o warfarin, insulins, oral antiplatlet agents, oral hypoglycaemic agents Focusing on medicines affected by renal impairment provide a ‘top 10’ list of drugs affected by renal impairment (e.g. digoxin, allopurinol, metformin, dabigatran)

15. IDENTIFY AND ADDRESS ACTUAL AND POTENTIAL MEDICINES-RELATED PROBLEMS Recognise and anticipate signs and symptoms of medicines-related problems, and identify contributing medicines.

16. AVOID PRESCRIBING A MEDICINE TO TREAT ADRS CAUSED BY A CURRENT MEDICINE

17. MONITOR MEDICINES CLOSELY WHEN STARTING AND DURING ONGOING TREATMENT Use non-pharmacological therapies when appropriate. Consider the patient’s cognitive ability, kidney and liver function. Check for drug interactions. Evaluate if the patient has understood instructions using a ‘teach- back’ technique. Start with a low dose, increase slowly and monitor for tolerability and response. Assess regularly for benefits, harms and ability to manage the medicine.

18. CONSIDER STOPPING A MEDICINE Medicines that are harmful, no longer needed or not consistent with the patient’s treatment goals can be stopped. Stopping medicines should be considered in the following situations: Polypharmacy High-risk medicines Falls Indications of shortened life expectancy Terminal illness or frailty

19. BARRIERS TO THE CEASING OF MEDICINES IN OLDER PEOPLE Patient barriers Lack of evidence relating to the benefits of discontinuation of medicines System barriers

20. BENEFITS OF STOPPING MEDICINES Minimises risks of adverse drug reactions and drug interactions. Improves adherence and reduces potential medication errors. Reduces potential harms associated with polypharmacy. Improves quality of life and function.  Withdrawing psychotropic medicines can reduce the rate of falls by 66% and improve physical and cognitive function.  Withdrawing benzodiazepines can improve cognition and psychomotor skills.

21. STOP MEDICINES IN PARTNERSHIP WITH YOUR PATIENT When starting a medicine; discuss with your patient that the medicine may not be needed long term. Discuss the reasons for stopping the medicine and clarify expected benefits and risks. Regularly follow-up with the patient to monitor for beneficial effects as well as withdrawal and rebound symptoms. Reinforce any noticed benefits and reassure the patient that withdrawal symptoms will resolve over time.

22. USE A STEPWISE APPROACH TO STOPPING MEDICINES TO MINIMISE WITHDRAWAL AND REBOUND SYMPTOMS

23. DEVELOP AND DOCUMENT A PLAN IN PARTNERSHIP WITH YOUR PATIENT Patient’s ability to participate List of actions agreed with your patient Treatment goals Persons responsible Dates for review and completion Patient, other healthcare professionals INVESTIGATE DEVELOP SHARE DOCUMENT

24. ENCOURAGE YOUR PATIENTS TO HAVE AN ACCURATE AND UP TO DATE MEDICINES LIST Includes prescription, over the counter and complementary medicines With documented doses, strengths and directions for use. A up to date medicines list can help you: identify potential drug-related causes of new symptoms (prevent prescribing cascade) define and eliminate duplication of therapies, correct dangerous drug interactions, save time by streamlining referrals to QUM strategies

25. KEY POINTS Assess medicines in the light of an older person’s health and treatment goals Identify and address actual and potential medicines- related problems Develop and document a plan in partnership with your patient