Medication review at the End of Life Dr Helen Wilson Consultant Geriatric Medicine January 2014 Geriatric medicine dept – dynamic Developed stroke services, thrombolysis Developed orthogeriatrics for frail elderly with hip fractures and plans to expand Recently appointed a fracture liaison nurse to help with bone health and falls assessments Falls service Embracing the integrated care agenda with Intermediate care – now frail elderly project

Stop the Medicalisation of Old Age Medical ageism… now includes over-investigation and subjecting frail elders to unpleasant, unnecessary, and unproved procedures and therapies.

Half of patients >75 years are taking more than four drugs Medication review Half of patients >75 years are taking more than four drugs Associated with Falls Hip fractures Hospitalisation Death Financial cost Practicalities

Efficacy and Safety in Elderly Paucity of studies in elderly Time to benefit Amount of benefit Compliance Adverse drug reactions Reduced ability to metabolise or excrete drugs

What do patients want / expect from medication? Effective Relief of symptoms Prevention of disease / disability Safe – low incidence of adverse effects Easy to take And at the end of life the priority is usually symptom control

Treating the doctor or the patient? I used to be normal, 80 and normal: I woke up every morning alive. I fed my dog Bruno, I’d read the papers, drink my coffee and walk the dog. Lower is good my doctor said – lower cholesterol, lower blood pressure, lower blood sugar. I feel good, but my numbers should be lower my doctor said. I think clearly, but I have a case of MIND, my doctor said: Memory Impairment No Dementia (yet). New prescriptions now: cholesterol pills, sugar pills, pressure pills, memory pills. Now my numbers are normal, my doctor says. My doctor is happy. But I feel bad. I think slow, my muscles ache. Here comes Mr Frail. I am OK now, my doctor says. (Ode to Mr Frail, M Raji)

Potentially Inappropriate Prescription (PIP) A medication for which the potential harm outweighs the benefit and for which a suitable alternative is available

PIP in fallers attending A&E 1016 patients Half required admission 63% took more than four drugs 42% had one or more PIP 30% had received hypnosedatives in the preceding year 17% were taking anxiolytics 15% were prescribed antipsychotics Age and Aging 2014;43:44-50

Inappropriate Prescription Wrong indication No indication Inappropriate dose High risk of adverse event Of unlikely benefit Unnecessarily expensive Too short or too long a time period Under-prescribing

Evidence for Drug cessation at the end of life Discontinuation of drugs aimed at prolonging or preventing clinical events with no symptomatic benefit Very little published Recent review article Tischa JM Age and Aging 2014;43:20-25 Need to develop a consensus criteria for inappropriate prescriptions at the end of life

De-prescribing towards the end of life In conjunction with patient / carer Establishing priorities Relaxing targets for therapy such as BP and blood sugars Avoid sense of hopelessness

Mark Beers, American Geriatrician 1991 Beers Criteria Mark Beers, American Geriatrician 1991 Catalogue of potentially inappropriate medications for the elderly due to pharmacological properties and physiological changes in aging Updated and evidence based 2012 Based on US prescribing

STOPP / START tool – O’Mahony and Gallagher Screening Tool of Older Peoples potentially inappropriate Prescriptions START Screening Tool to Alert doctors to Right Treatments Gallagher et al, Age and Aging 2009, 38(5), 603

18 expert opinions Delphi technique (2 rounds) STOPP criteria (65) START criteria (22)

Secondary Care Nursing Homes Primary Care Use of STOPP / START Secondary Care Potentially inappropriate prescribing (STOPP) 34% Potential Omissions (START) 57% Gallagher et al, Age and Aging, 2008 Nursing Homes Potentially inappropriate prescribing (STOPP) 55% Ryan et al, Ir J Med Sci, 2009 O’Sullivan et al, Eur Ger Med, 2010 Primary Care Potentially inappropriate prescribing (STOPP) 21% Potential Omissions (START) 22% Ryan et al,Br J Clin Pharm, 2009

Financial Implications of STOPP Economic Implications of potentially inappropriate prescribing Irish Population based study 36% inappropriate prescribing 45 million Euro Cahir et al, Br J Clin Pharmacology 2010, 69, 543

Evidence for De-prescribing Israeli paper Discontinued 332 drugs in 119 patients Followed evidence based consensus where adverse effects outweighed any benefits De-prescribing failed in 18% patients Mortality fell (21% compared with 45% in control group) Fewer patients required hospital admission

Is associated with reduction in mortality De-prescribing Is associated with reduction in mortality Reduction in hospital admissions Reduced falls

British Geriatric Society Support Autumn meeting Commissioning for care homes Session on dying in care homes not hospital Anticipatory care documentation – less than 8% have anything written down

The Kings Fund

Is the drug still needed? Has the condition changed? Questions to ask Is the drug still needed? Has the condition changed? Can the patient continue to benefit? Has the evidence changed? Have the guidelines changed? Is the drug being used to treat an iatrogenic problem? What are the ethical issues about withholding care? Would discontinuation cause problems? Some therapies should not be stopped abruptly following long-term use. Stopping Medicines, WeMeReC 2010

Would I be surprised if this person were to die in the next 12 months? Boyd and Murray, 2010 Would I be surprised if this person were to die in the next 12 months? Review goals of care Revision of treatments – particularly those for secondary prevention Limit investigations

Previously at home with qds care package Case Study Frail 84 year old lady Previously at home with qds care package Being discharged to NH following admission with hip fracture and profound anaemia Rotunda transfers to recliner chair Needs assistance with all ADLs Doubly incontinent

Vascular Dementia (MMSE 14) Ischaemic heart disease – no recent angina Medical Problem List Vascular Dementia (MMSE 14) Ischaemic heart disease – no recent angina Atrial Fibrillation with no history of stroke Admission with Congestive cardiac failure 2 yrs ago Diabetes – was overweight but lost 4 st over last yr History of bullous pemphigoid 5 yrs ago Anaemia investigated 5 yrs ago and attributed to diverticulosis CKD stage 4

Exercise in De-prescribing at End of Life Digoxin 125mcg Warfarin 3mg Bisoprolol 2.5mg Ramipril 2.5mg Bumetanide 1mg od Simvastatin 40mg Metformin 500mg bd Gliclazide 40mg od Certirazine 10mg Lansoprazole 15mg Prednisolone 5mg Paracetamol 1g qds Ferrous sulphate 200mg bd Adcal D3 bd Nitrazepam 5mg

Exercise in De-prescribing at End of Life Digoxin 125mcg Warfarin 3mg Bisoprolol 2.5mg Ramipril 2.5mg Bumetanide 1mg od Simvastatin 40mg Metformin 500mg bd Gliclazide 40mg od Certirazine 10mg Lansoprazole 15mg Prednisolone 5mg Paracetamol 1g qds Ferrous sulphate 200mg bd Adcal D3 bd Nitrazepam 5mg