MKCCG PLT Prescribing Workshop

MKCCG PLT Prescribing Workshop
Thursday 25th January

CCG Update-General update
PLT Thursday 25th January Dr Nicola smith CCG Chair

CCG Update-Finance …… Made good progress on “financial turnaround” and there has been a recent slowing down of elective care. We are reasonably confident that we will end the financial year within budget Thanks to practices who have worked on prescribing, managed routine referrals within acceptable levels and adhered to low priority restrictions + thresholds. This is good for our local system as it means that we retain our autonomy and there are no additional requirements and conditions placed upon us by NHSE But… Many of the strategies we have had to use are one-off initiatives which will not continue to reap benefits in future years. For example we have delayed investments in to service improvements that will not deliver savings in the current financial year. Next year we have a “QIPP” savings target of £16 million. We know that the CCG has the capability to deliver around £8million of savings so we know that we face significant reductions or restrictions to services unless we can make significant transformational changes to the system in which we work.

STP wide Primary Care Transformation scheme
CCG Update-System transformation …… STP wide Primary Care Transformation scheme Place Based Accountable Care partnership for MK CCG alignment

Small percentage increase in uptake overall
CCG Update-Flu…… Flu season not over Small percentage increase in uptake overall Uptake in children has improved Pregnant women still an issue Pharmacies now doing around 2-3 % of patients which is small numbers but increasing Need to check if all coding is correct so will give you the final position next time Early review and planning for next year

CCG Update-IFR …… You will have noticed a growing waiting time for IFR referrals (currently at around weeks) The CCG apologises for this totally unacceptable situation The CCG has had contractual discussions with the provider of the service to reduce the wait. Due to lack of improvement in the The CCG is now taking further action to urgently resolve the situation

CCG Update-Consultant to consultant referral policy review…. ……
C2C Referrals CCG Update-Consultant to consultant referral policy review…. …… Aims As with all referrals , those made by consultants should reflect good clinical practice and make appropriate use of resources in the health system . Winning hearts and minds rather than contract challenges GP workload should not be increased inappropriately as a result of our policy The easy bit……. Consultants should always refer directly for anything urgent or 2WW referrals Consultants should refer to tertiary centres in cases where specialist expertise is required for the management of the clinical problem Consultants should generally not refer patients for problems that are completely unrelated to the problem for which the patient has been referred. The grey area…. Internal or onward referrals can be made, under certain circumstances , by consultants when the intervention of another speciality is required to manage the patient’s presenting problem. If a patient is to be referred back to their GP , the consultant should not raise the patient’s expectation of a further referral. However, GPs sometimes appreciate advice from consultants regarding the next steps for the patient. Guidance on the grey area…. A list has been created for common clinical pathways where this happens on a regular basis eg surgery to anaesthetics for pre-op assessment, rheumatology to orthopaedics for surgical intervention Monitoring Clinical audit and volumes of referrals with a view to quality improvement , not punitive challenge

CCG Update-Integrated Community Musculoskeletal and Pain Management Service (IMSK) – Ravenscroft……
Single point of access for musculoskeletal conditions (age 16+) via RMS Clinically urgent (red flag) referrals excluded. Earlier this year, MKCCG and Ravenscroft conducted a MSK Enhanced Triage pilot, offering a ‘face to face’ assessment for all T&O referrals intended for the hospital. Over the course of the pilot, a significant number of patients benefitted from further rehabilitation or conservative management rather than experiencing long waits for consultant led appointments. As a result of these benefits for patients, the CCG has commissioned Ravenscroft to continue the enhanced triage service for Milton Keynes patients. In addition, if prior approval is needed as part of that onward referral, Ravenscroft will now complete the necessary paperwork - therefore, for the conditions below GPs will no longer need to complete the prior approval request paperwork as long as the referral is sent to Ravenscroft for an assessment. Bunions,Carpal Tunnel,Hip Replacement,Knee Replacement,Dupuytren’s Contracture,Ganglion,Hip Arthroscopy & FAI,Hip Resurfacing for Advanced Arthropathy,Knee Arthroscopy,Shoulder Arthroscopy,Therapeutic Injections.Epidural Injections for Lumbar Back Pain,Therapeutic Facet Joint Injections,Thermal radiofrequency denervation of lumbar & cervical facet joints,Trigger Finger

Questions? Contact Michelle Millard, MKCCG Patient Safety Coordinator: /

Incidents and Serious Incidents
General Practice refers to internal incidents and/or occurrences outside of the ordinary which require some level of intervention as Significant Events. These are typically low harm and may require some changes and/or learning but are not usually systemic. These should be recorded internally and shared with MKCCGs Primary Care Manager quarterly. Serious Incidents are defined as incidents occurring during NHS funded healthcare (including in the community), which result in one or more of the following:- Unexpected or avoidable death of one or more people. This includes suicide/self-inflicted death; and homicide by a person in receipt of mental health care within the recent past

Serious Incidents (SIs)
Unexpected or avoidable injury to one or more people that has resulted in serious harm Unexpected or avoidable injury to one or more people that requires further treatment by a healthcare professional in order to prevent the death of the service user; or serious harm Actual or alleged abuse; sexual abuse, physical or psychological ill-treatment, or acts of omission which constitute neglect, exploitation, financial or material abuse, discriminative and organisational abuse, self-neglect, domestic abuse, human trafficking and modern day slavery A Never Event – all Never Events are defined as serious incidents although not all Never Events necessarily result in serious harm or death. See the recently updated Never Events Policy and Framework for the national definition (January 2018): An incident (or series of incidents) that prevents, or threatens to prevent, an organisation’s ability to continue to deliver an acceptable quality of healthcare services

Serious Incident (SI) Support
If in doubt, check it out: If unsure whether an incident needs to be escalated as an (SI), please discuss with MKCCGs Patient Safety Coordinator Specialist advise is also available within the CCG, e.g. around mental health, safeguarding, end of life, falls, etcetera All patient safety related incidents (whether an SI or not), should be logged on the National Reporting and Learning System: Information Governance related incidents should be logged via the IG Toolkit. Support for Primary Care is available from the IG team: Telephone – ; –

Questions? Contact Michelle Millard, MKCCG Patient Safety Coordinator: /

Milton Keynes in RED 60400 550 25800 200 7700 200 3300 1900 £459K 50 500 £829k 70 £502K 40

CCG Update-Social Prescribing ……

Report any difficulties and ideas
CCG Update-And Finally…… Report any difficulties and ideas March PLT – Blood borne viruses, MSK, Deputy Coroner May PLT – Suicide (planning afternoon and an evening session)

Polypharmacy and deprescribing
Janet Corbett, Head of Prescribing and Medicines Management

Agenda 2.20pm Introduction and welcome 2.25pm Voting buttons quiz
2.45pm Prescribing and Deprescribing for frail elderly patients – Dr Than Mya 3pm Tea break 3.20 pm Principles and Practice of Prescribing and Deprescribing in Palliative Care - Dr Jane Wale 3.50 pm Case study and round table discussion and feedback 4.20 pm Tools available to support polypharmacy and deprescribing 4.35pm Round up and close

Learning Objectives To understand appropriate and potentially inappropriate polypharmacy To understand the definition of deprescribing To be aware of the medico-legal issues relating to deprescribing To be aware of tools that support deprescribing

What is deprescribing? Deprescribing is the process of withdrawal of an unnecessary or inappropriate medication, supervised by a healthcare professional (to distinguish from patient non-adherence) with the goal of managing polypharmacy and improving outcomes.

Polypharmacy and Deprescribing - Why is this important?
There is very limited evidence on the safety and efficacy of medicines in older adults, particularly in the frail, who often have multiple comorbidities and functional impairments Polypharmacy in older people is associated with decreased physical and social functioning; increased risk of falls, delirium and other geriatric syndromes, hospital admissions and death, and reduced adherence by patients to essential medicines The HARMS Study demonstrated a clear correlation between the risk of hospital admission and the number of high risk medications prescribed Elderly people often feel better after their medication is discontinued. In a clinical trial to reduce polypharmacy in older people, the patients' global assessment scale improved in 88% and in most patients cognitive function improved Just because a specialist recommended starting two drugs last year doesn’t mean they are best-placed when it comes to stopping the drugs now …. This is usually, and appropriately, the clinical decision of the regular doctor with the general overview Practices are tasked with identifying and managing moderate and severe frailty and undertaking medications reviews

Medico-legal issues Many prescribers are understandably concerned about potential medico-legal issues of deprescribing and where they stand if they stop a medicine for which there is an evidence-based guideline to use it. The European Journal of Hospital Pharmacy (a BMJ publication) explored the concept of clinical negligence and informed patient consent. The review concluded that the law presents no barriers to deprescribing if it is undertaken in partnership with the patient, supported by knowledge, skills and experience of both parties. In addition, in March 2015, a unanimous decision in the UK Supreme Court (Montgomery v Lanarkshire Health Board) made it clear that doctors must ensure their patients are aware of the risks of any treatments they offer as well as benefits and of the availability of any reasonable alternatives. In the right setting and at the right time, deprescribing provides a real opportunity to minimise side effects, drug interactions and pill burden through a patient centred conversation. Document agreements and goals

Quiz Emma Hooton Neighbourhood/In-house pharmacist

What proportion of over 75s takes 4 or more medicines regularly?
1 - 17% 2 - 36% 3 - 40% 4 - 65% 82

What proportion of over 75s takes 4 or more medicines regularly?
1 - 17% 1% 2 - 36% 9% 3 - 40% 39% 51% 4 - 65%

Answer: 36%

What is the average number of medicines per day taken by nursing home residents?
1 - Six 2 - Eight 3 - Twelve 4 - Sixteen 84

What is the average number of medicines per day taken by nursing home residents?
1 - Six 42% 45% 2 - Eight 8% 3 - Twelve 4 - Sixteen 5%

Answer: Eight

Which of these medicines is implicated in adverse drug reactions that can increase the risk of hospital admissions? 1 - NSAIDs 2 - Antidepressants 3 - Beta blockers 4 - Clopidogrel 5 - All of the above 84

Which of these medicines is implicated in adverse drug reactions that can increase the risk of hospital admissions? Which of these medicines is implicated in adverse drug reactions that can increase the risk of hospital admissions? 1 - NSAIDs 26% 2 - Antidepressants 0% 1% 3 - Beta blockers 4 - Clopidogrel 0% 5 - All of the above 73%

Answer: All of the above

Which medicine, when taken long term, needs regular liver function tests and monitoring for pulmonary symptoms? 1 - Amoxicillin 2 - Nitrofurantoin 3 - Paracetamol 4 - Ticagrelor 83

Which medicine, when taken long term, needs regular liver function tests and monitoring for pulmonary symptoms? Which medicine, when taken long term, needs regular liver function tests and monitoring for pulmonary symptoms? 1 - Amoxicillin 1% 2 - Nitrofurantoin 61% 3 - Paracetamol 17% 20% 4 - Ticagrelor

Answer: Nitrofurantoin

What does acute kidney injury cost the NHS each year?
1 - £10m 2 - £100m 3 - £400m 4 - £620m 82

What does acute kidney injury cost the NHS each year?
1 - £10m 5% 30% 2 - £100m 49% 3 - £400m 16% 4 - £620m

Answer: £620m

What is the number needed to treat ( NNT) in an 80 year old on alendronate & calcium/vitD to prevent a further hip fracture? 1 - 50 2 - 75 81

What is the number needed to treat ( NNT) in an 80 year old on alendronate & calcium/vitD to prevent a further hip fracture? 1 - 50 21% 2 - 75 37% 23% 19%

Answer: 105

Drugs which have an anticholinergic effect can be very problematic in frail adults causing falls, declining cognitive function and tend towards increased mortality. What is the Anticholinergic burden score for solifenacin? 1: 0 2: 1 3: 2 4: 3 76

Drugs which have an anticholinergic effect can be very problematic in frail adults causing falls, declining cognitive function and tend towards increased mortality. What is the Anticholinergic burden score for solifenacin? Drugs which have an anticholinergic effect can be very problematic in frail adults causing falls, declining cognitive function and tend towards increased mortality. What is the Anticholinergic burden score for solifenacin? 1: 0 0% 2: 1 14% 55% 3: 2 4: 3 30%

Answer: 3

Which medicine has Anticholinergic burden score of 1?
1 - Paracetamol 2 - Ranitidine 3 - Paroxetine 4 - Metformin 81

Which medicine has Anticholinergic burden score of 1?
1 - Paracetamol 26% 2 - Ranitidine 43% 3 - Paroxetine 25% 4 - Metformin 6%

Answer: Ranitidine

What was the mean age range of participants in trials for sulphonylureas, as first line/monotherapy for T2DM? 78

What was the mean age range of participants in trials for sulphonylureas, as first line/monotherapy for T2DM? What was the mean age range of participants in trials for sulphonylureas, as first line/monotherapy for T2DM? 38% 24% 31% 6%

Answer: 55-68

Which of these is not a medication review tool?
1 - The Larger Criteria 2 - The Beers Criteria 3 - STOPP-START 4 - NO TEARS 76

Which of these is not a medication review tool?
1 - The Larger Criteria 28% 2 - The Beers Criteria 30% 3 - STOPP-START 7% 4 - NO TEARS 36%

Answer: The Lager Criteria

Dr Than Dar Mya MBBS ,MRCP Geriatrics ,FRCP Consultant Physician MKUH

Background Cohort Cases Process –care setting / correlation with number of prescribers

Case 1 /Prescribing cascade
90 PMH-Hypertension on Bendroflumethiazide 2.5 mg, Felodipine MR 5 mg -Recent RMCA infarct -Aspirin /Omeprazole /Atorvastatin -COPD - Recurrent Unexplained Syncopal Episodes (24 hour tape –high VEs burden on Beta-blocker –Bisoprolol 2.5 mg - Trial Levetiracetam 250 mg OD Other Drug-Diltiazem 60 mg tds -Zomorph 20 mg BD ATSP -as unresponsive –hot, pale, floppy when stood up Similar episode every time gets out of bed to mobilise with physiotherapy –significant postural drop

Medication review /PIP medication ?
1)Bendroflumethiazide 2.5 ,Felodipine MR 5 mg 2)Bisoprolol 2,5 mg od 3)Diltiazem 60 tds 4)Zomorph 20 BD 5)Aspirin ,Omeprazole &Atorvastatin 6)Trial Levetricetam 250mg OD STOPP Criteria –Avid Combined Rate limiting CCB and Beta-blocker -Adjust antihypertensive based on supine and postural BP -Avoid long term opiates in recurrent fall

Case 2 /Review medication once clinical status changed
58 male – PMH -Bipolar Disorder on long term Lithium 800 -type 1 DM on Insulin -Recent NSTEMI –CABG Dual antiplatelet therapy Atorvastatin 80 ng OD -HF reduced LVSF LVEF 37 % (Ramipril 2.5mg OD Spironolactone 25mg OD Frusemide 40 BD Bisoprolol 2.5mg OD

Presented with atypical chest pain 4 week post CABG
Bloods –urea 12.6 (6.5), Creatinine 124 (64 ), EGFR 52 Lithium 1.45 ( mmol /l ) Clinically dehydrated, Low systolic BP-100 mg, no evidence of fluid overload

Medication Review /PIP ?
1)Lithium 800 nocte 2)Dual antiplatelet therapy 3)Atorvastatin 80 mg OD 4)Bisoprolol 2.5mg OD 5)Ramipril 2.5mg OD 6)Spironolactone 25 mg OD 7)Frusemide 40 mg BD Review current valid indication and dose –with change in circumstances –new comorbidity –additional medication –biochemical profile –ADR/Interaction ESC guideline practical guide on use of HF medication in patients with HF with reduced EF

Diuretics in HF Relieve congestion –irrespective of EF
Use minimum dose necessary –euvolaemia Adjust dose –volume status Monitor renal function Cr CL <30,Creatinine >221-Thiazide

Prognostic Medication for HF reduced LVSF
Symptomatic & Survival, reduce Hospitalization. ACEI first line EF<40% MRA –EF <35 %despite BB&ACEI Start low dose Aim –highest tolerated dose – Monitor renal function 1-2/52 after initiation and titration –4/12 ACEI MRA –more close monitoring - Trouble shooting Some –abnormal – u&e Acceptable -Creatinine 50% above baseline (266 umol/l) (Egfr <30 )--/K 5.5 Further rise Stop concomitant nephrotoxic drugs & reduce diuretics if not congested Not resolved –half the dose recheck in one week-specialist Stop –Creatinine rise 100% >310 umol/l ,Egfr <20

Case 3 (potential future therapeutic benefit vs life expectancy)
Mr A 66 -Metastatic colonic cancer with peritoneal disease progression –palliative management -expected prognosis less than 12 months PMH- NSTEMI more than 1 year ago Medication –Dual Antiplatelet Therapy /Atorvastatin / Beta-blocker /Ramipril

Medication Review /Potentially Inappropriate Medication
1)Dual Antiplatelet (Aspirin and Clopidogrel ) 2)Atorvastatin 3)Bisoprolol 4) Ramipril Life limiting disease prognosis less than 12 months –Statin Dual Antiplatelet Therapy –unless recent NSTEMI –Coronary Artery Stent – risk of bleeding higher /no therapeutic advantage over single antiplatelet 12 months post event

Case 4 Medication –questionable efficacy without any evidence
78, lives alone with a cat PMH- Dementia -Heart failure with preserve LV Systolic function Ramipril 2.5 mg Frusemide 40 BD Spironolactone 25 mg -Type 2 DM on Empagliflozin 10 mg Metformin 500 BD Presented as Advanced Dementia, poor oral intake, significant dehydration –AKI (Creatinine 344 (99) Urea 49.3) Not fluid overload

1)Empagliflozin 10 mg 2)Metformin 500 BD 3)Frusemide 40 BD 4)Ramipril 2.5 mg 5)Spironolactone 25 mg EBM –HFpLVSF –no role of neuroendocrine antagonist (ACEI,ARB,Betablocker ) Gliflozin –use not advised in Elderly & those with Cr Cl<60 Renal function /Oral intake /Function –improve-usual place of residence

Case 5 -underutilization of appropriate medication Potential Prescribing Omission
Mr C, Age 72 Recurrent Embolic stroke PAF on Apixaban 2.5 mg BD –Normal Cr cl, Age 72, Body weight 82 kg Represented with Right sided weakness MRI DWI –new left thalamic lacunar infarct Medication review - ?Atorvastatin - ?Apixaban 2.5 mg BD BNF –stroke prevention in AF –Apixaban reduce dose to 2.5 mg BD if Cr CL<30ml/min and Age >80 or Body weight ,60 KG Under anticoagulation causing recurrent embolic stroke

Case 6 –Functional decline
79 PMH-Alzheimer's –Behavioural and Psychological symptoms on Risperidone 1 mg BD for 2/12 &Memantine 10mg OD . -Type2 DM on Metformin -Hypertension on Amlodipine Transferred from Psych unit because of sepsis, reduce mobility and bilateral pressure sores Sleepy most of the day, Not engaging with Physio –awaiting placement. Medication review –1)Memantine 10 mg 2)Risperidone 1 mg BD 3)Metformin 500 MG BD 4)Amlodipine 5 mg od

Prescribing in Elderly -Unique challenges
Age related physiological changes in PK/PD Unclear Evidence –outcome /appropriate dosage (trial excluded age group) Time to benefit vs life expectancy Frail, Multiple comorbidity & Poly pharmacy –risk of Adverse drug reaction/interaction –causing prescribing cascade Commonly used drug for Geriatric patients –Poorly tolerated Anticholinergics /Analgesic –opiates, NSAIDS /Delirium –antipsychotic /Antidepressant Prescribing cascade

Drugs Problem –Inappropriate –Prescribed /Dosed /Monitored
Common-ADR event –Neuropsychiatric (over drowsiness /acute delirium, confusion ) -AKI -Fall with or without Injury -Functional decline -Syncope Dose related –hip fracture study –psychotropic, hypnotic, anxiolytic, TCA, Neuroleptic, BP medication Common cause dose related ADE –failure to dose adjust as per renal insufficiency (serum creatinine may not accurately reflect renal function –reduce muscle mass ) 52% -Community –mild renal insufficiency – med require dose adjustment Start – low dose –titrate up as tolerated (monitor SE /Biochem )

Prescribing Cascade Treating ADR of previously prescribed medication
Further polypharmacy, further increase risk of ADR eg 1)polypharmacy –fall and postural hypotension /confusion –treat as ?UTI /Sepsis 2) treating antipsychotic induced extrapyramidal –with antiparkinsonian medication Suspect ADR –with any new clinical symptom unless proven otherwise Minimise risk –Medication review Review patient –PMH –Drug history

Potentially Inappropriate Prescribing
When pill burden>disease burden Over prescribing –excessive dose-weight ,biochemical profile -longer than intended duration -questionable efficacy (without valid indication ) -unfavourable risk-benefit trade off -without informed choice Under prescribing - Not prescribing clinically indicated medication without any contraindication (potential prescribing omission )

Medication Review BGS Recommendation –Annually
Actively seek Opportunity –to identify –those at risk PIP/those in need for specific medication –at every clinical encounter –in all setting Overall responsibility –medication regime –GP Aim –avoid –under and over prescribing /informed choice (pill burden and benefit vs risk), avoid flare up of LTC *minimise ADR ,improve QOL Targeted DE- prescribing -not denying effective treatment to eligible pts /about avoid ADR, simplify regimen, improve compliance &outcome Target population Process - Overall quality-appropriate poly pharmacy –good prescribing

Target population At risk of ADR, drug to drug interaction
Multiple comorbidity and Poly pharmacy Frail ELDERLY - Functional decline –house bound Cognitive dysfunction- compliance /side effect At risk of fall Limited life expectancy –prognostic medication –not be appropriate High risk &Poorly Tolerated Medication /Medication with little or no benefit Those on Long Term drug treatment-regular benefit vs harm assessment ,as clinical needs and circumstances changes –

Medication review process
1)Comprehensive - both medical and drug history, 2)Identify –indication (preventative or symptom control) for each drug and check current valid indication –help target potentially inappropriate prescribing 3)Access whether PIP can be stopped 4)Plan withdrawal regime –reduce or stop one medication at a time (easier to identify the likely cause if problem develop ). Some drugs need dose tapering –prevent withdrawal /allow monitoring –BB, opioids ,barbiturates, antidepressant, gabapentin 5)Monitor response ( benefit or harm) after each medicine has been stopped or tapered (reappearance of pre-existing disease –no adverse consequence ) 6)Involve patient /NOK –reach agreement –aim-optimize efficiency, minimise SE, improve QOL (informed choice ) 7)Any potential prescribing Omission

Cautious stepwise withdrawal
symptomatic decline if stopped Medicines for which specialist advice is strongly advised before altering include: Medicines in this group may require specialist advice. ACE inhibitors /Diuretics in heart failure (LVSD ) Medicines for heart rate or rhythm control (beta-blockers; digoxin). Opioids/antidepressants/ antipsychotics/anti epileptics/Parkinson’s Disease/clonidine/baclofen/ steroids/ benzodiazepines. Medicines prescribed by specialist teams Anticonvulsants for epilepsy. Antidepressants initiated in secondary care. Antipsychotic and mood stabilising medicines (e.g. lithium). Medicines for the management of Parkinson’s Disease. Amiodarone. DMARDs.

Poorly Tolerated In frail Elderly /High drug burden index
Risk of functional decline Anticholinergic /sedative /opiates(Analgesic and Incontinent Drugs ) – mobility cognitive decline-fall BP pills –postural hypotension Antipsychotic -atypical /conventional Tricyclic

Avoid High-risk combined regime
medication2 . NSAID + ACE inhibitor or ARB + diuretic [‘triple whammy’ combo] + eGFR less than 60 ml/min + Diagnosis heart failure + Warfarin or new oral anticoagulants (NOACs) e.g. dabigatran, apixaban, rivaroxaban + Age > 75 without PPI Warfarin with Macrolide, Quinolone, Metronidazole

Medicines and Dehydration
It may be indicated to WITHHOLD the following in patients diagnosed with severe dehydration ACE inhibitors/(ARBs)/Diuretics NSAIDs Metformin These can then be restarted when the patient has improved (e.g. after 24 to 48 hours of eating and drinking normally).

Patients at risk of falling
Medication review should be considered as part of a multifactorial assessment in patients at risk of falling. Medicines listed below associated with an increased risk of falls; long-acting or long-term hypnotic or anxiolytic Antihypertensive, beta-blockers Diuretics Antidepressants Antipsychotics, anti-epileptic medication (especially if used for pain) First generation (sedating) antihistamines Medicines used for Parkinson’s Disease (review in conjunction with specialist) Anti-cholinergic medication used for bladder spasm or other medicines with anti-cholinergic side effects e.g. TCAs

Delirium /Challenging Behaviour
90% of people with dementia experience behavioural and psychological symptoms, at some point. Distressing symptoms can be prevented or managed without medication. However, antipsychotic medications are frequently prescribed as a first resort. Benefits of antipsychotic medications are limited over longer periods. Retrospective study Dementia –new Antipsychotic Vs No –increase risk of death –at 30&180 days Antipsych group (AHR 1.55 ,CI )

Specific consideration for patients with Dementia on Antipsychotic
When to review dose/indication When not to stop antipsychotic Dementia & been on antipsychotics for more than 3 months and have stable symptoms should be reviewed with a view to reducing/stopping antipsychotic medication2. Patients with co-morbid mental illness such as schizophrenia, persistent delusional disorder, psychotic depression or bipolar affective disorder.

Anticholinergics in Elderly
Prescribe with caution Susceptible to SE Secreto –dry mouth /eye Motor –AROU /Constipation Sedation ,Confusion ,delirium ,fall Cognitive decline Number &potency –Link –Mortality

Anticholinergic –Potency ranking scale
Antihistamine (H1 /H2RA )–chlopheniramine, diphenhydramine ,hydroxyzine -fexofenitidine, loratidine -Ranitidine Anti muscarinic –overactive bladder –oxybutynin, solifenacin, tolterodine, trospium Antimascarinic –antispasmodic –atropine, hyocine, glycopyrrolate Anti emetic –promethazine, hydroxyzine (antihstamine ) Antidiarrhoea –loperamide Psychotropic –conventional (chlopromazine, haloperidol ) -atypical –Risperidone, Quatiapine, Olanzapine Antidepressant -TCA –Amitriptyline, Trazodone -SSRI –Paroxetine -Mirtazapine Baclofen Benzodiazepine Opioid Analgesics Mirtazapine Not exhausted – increasing dose and simultaneous use - anticholinergic activity

Minimise use of anticholinergics
Consider anticholinergic burden scale . Proactively monitor at regular intervals for efficacy and tolerance If suspicion of anticholinergic induced impaired cognition, MMSE , consider switching or stopping if clinically appropriate Refer patients suffering from significant anticholinergic side effects due to psychotropic medication to an appropriate specialist Avoid prescribing anticholinergics with acetylcholinesterase inhibitors e.g.donepezil, rivastigmine

Avoid underutilization of Appropriate Prescribing
START criteria 22 validated criteria to identify potential prescribing omission Organ specific guidelines vs Overall benefit Prioritize –active treatment of serious condition, > less impact on QOL – compliance /limit drug interaction Indicated drugs –too need dosed /monitored appropriately

SUMMARY Regular Review medical &drug history along with functional , cognitive ,biochemical status Reappraise with –change in clinical status /treatment goals Ask –Current valid indication / is the dose appropriate -What is intended benefit / -What is the potential harm -Time to benefit vs life expectancy -What dose patient want (best interest) - Judge organ specific EBM vs overall clinical status -Monitor –response /ADR Watch out -Poorly tolerated –AKI prone /Anticholinergic /Drowsy . High Risk combination /Duplication -Mindful of prescribing cascade at any episode of deterioration Avoid Potential Prescribing Omission

References Multimorbidity: clinical assessment and management NICE guideline [NG56] September 2016 Upto date -Drug prescribing for older adults Paula A Rochon, MD, MPH, FRCPC Section Editor:Kenneth E Schmader, MD Deputy Editor:Daniel J Sullivan, MD, MPH Int J Clin Pharmacol Ther. STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation.Gallagher P1, Ryan C, Byrne S, Kennedy J, O'Mahony D A Practical Guide for the Treatment of Symptomatic Heart Failure with Reduced Ejection Fraction (HFrEF)Brent N Reed1 and Carla A Sueta Key Considerations for Prescribing in Frail Adults GIG CAMRU NHS Wales

Refreshment Break

Principles and Practice of Prescribing and Deprescribing in Palliative Care
Dr Jane Wale Consultant Palliative Medicine

General principles of prescribing in Palliative Care
Prescribing and deprescribing in specific conditions in last 100 days of life Symptom control in the last days/ hours of life

General principles of prescribing in Palliative Medicine
1. Assessment and attention to detail 2. Information / explanation 3. Management of the problem 4. Medication 5. Monitoring and reviewing

Assessment and attention to detail
What is the problem? What is the impact of the problem on the patient and family? What does the patient think is causing the problem? What is causing the problem? What have they tried so far? What is the goal of treatment? What is the problem? How severe, how often, how debilating – is the problem bigger than the SE of medication might be What is the impact of the problem on the patient and family? – whose problem is it – I have a elderly lady with heart failure in clinic who spends a lot of the day asleep, which concerns her sister greatly, but doesn’t bother the patient one bit What does the patient think is causing the problem? This is always worth asking What is causing the problem? Is it related to medication – one of the first patients I met when I started as a consultant here was a lady in 60s with metastatic breast cancer who had previously been fit and well doing yoga and dance classes and had changed over a period of 6 months or so to being wheelchair bound, barely able to move, low mood and displaying classic signs of parkinsonism. I stopped her metoclopramide and haloperidol, she had some physio and was back at her dance classes within a couple of months. Discovering the cause of the problem is really important even in patients with advanced disease, as the treatment is different depending on the cause – and that’s true of all symptoms – for example- n + v in a lung cancer pt may be due to hypercalcaemia or brain mets- give bisphos for one, dex for the other What have they tried so far?- some times it’s a case of just tweaking this – I have an elderly patient in clinic who interpreted paracetamol 4 times a day as meaning 8am, 12pm, 4pm and 8pm . She was pain free during the day, but always woke up at night in excruitating pain – seemly retiming her medication to take on waking, lunch time, tea time and bed time resulted in a pain free night

Information/ Explanation
Improves compliance Sets realistic treatment goals Provides reassurance So for example around loss of appetite I hear that you do not feel hungry and sometimes cannot stand the sight of food. You occasionally feel nauseous, and have no problem swallowing. This is distressing your wife because she feels that you are wasting away and you are upset because she is upset . Unfortuanately this is a common problem in people with cancer. People do not feel hungry for all sorts of reasons, often because they are doing less and using less energy, sometimes its because they feel sick or are constipated. I wonder if it would be sensible to aim for you to eat a little more, but more importantly enjoy what you eat and to help manage the distress around the situation. There are different ways to manage not feeling hungary. Talk about eating little and often, favourite foods, more useful foods, making foods more califitic, no bad foods Distractions when eating, reversing size of meals – bigger breakfast, small tea Some people try supplements – can be ok for some people, but often take away any remaining pleasure from food. Talk about using dex – emphasisng short term only and protential problems What are your views, I think we should try….

Non pharmacological management/ pharmacological management
Breathlessness – breathing techniques/ fan/ relaxation / visualisation techniques Nausea – sea bands / acupuncture Pain – radiotherapy/ nerve blocks/ exercise Bowel obstruction- NG tube I want to emphasis how important the non drug management of symptoms is – its harmless and can be effective For breathlessness a hand held fan can provide really effective symptom relief as can teaching people more effective ways of breathing and helping people develop strategeries for managing their anxiety when brethless Sea bands can be helpful for multifactorial nausea, particularly associated with anxiety and there is some evidence that acupuncture is helpful Pain . Pain from bone metastates has a 50-85% chance of being helped by radiothearpy – often given as a single dose. 1/3 patients get a complete response. Response to radiotherapy is seen within 4 weeks and lasts an average of 19 weeks, but longer in prostate or breast bone mets. Its certainly something that should be considered if the patient is in the last months of life- but its important to review response and reduce meds accordingly. Nerve blocks can occasionally be useful. A few months ago, there was a lady on the ward with advanced vulvual cancer and excruitating pain, despite high dose opiates which were causing all sorts of problems. We arranged for her to have a caudal block- in which local anaesthetic and alcohol were injected resulting in blocking of the sarcal nerves and complete pain control- we reduced and stopped her opiates. Exercise has a role in reducing / preventing secondary pain

STARTING MEDICATION What’s the lowest dose that will work?
What’s the best way of giving it? Which one? Can 1 medicine do 2 things? What next? STARTING MEDICATION Am I sure that benefit>burden? Rescue medication The first question is which medicine would be best- which is most likely to work, cause the least harm and be of minimal burden Is it better to take 2 50mg tramadol tablets 4 times a day or 1 20mg zomorph tablet twice a day. Clearly some patients benefit from the effect of tramadol on the serotonin / NA pathways but is this enough to justify 6 extra tablets and 2 extra medication times. Is the patient ok with the idea of taking morphine- often there is lots to discuss around that- always provide written information The next thing I think about is what is the lowest dose that I think will work – as I’m sure we all do. I find this tricky esp with out pts – its important not to underdose but giving too much also causes problems and patients to lose trust. Generally if introducing a new med I tend to start lowish, but have a plan and written instructions to increase it if symptoms not improved, but medicine tolerated. I give pts my contact details and often phone them the next week to see how they are getting on and prompt them to increase if appropriate. The next thing to think about is how to give it – sometimes this determines what you give – if for example swallowing is a problem. A recent study (the burden of polypharmacy in pt at EOL , J pain and symp management feb 2016) showed that pts took an average of 12 different medications every day in the month before they died – that’s a lot of pills to swallow every day. Of cause we have patches we can use, and they can be very useful but are no good for uncontrolled severe pain, because they take hours to reach steady state and be effective – and can be dangerous if used inappropriately. When I was a registrar in PM I was asked to see a elderly pt on one of the surgical wards because he had deteriated quickly and was thought to be dying. He had come in 4 days previously with, vomiting, abdominal pain and constipation. The junior doctor had treated his pain by starting a 25mcg fentanyl patch (=90mg morphine). He was reviewed the following morning and was still in pain – the SpR increased his pain relief to 50mcg fent patch. The following day he still hurt and the patch strength was increase to 75mcg/hour. The following day he was unrousable, with shallow respiations and thought to be dying – but it was actually a consequence of going from no opiate to 300mg of morphine per day in 3 days . He improved with the removal of patches and treatemnet of constipation. The juniors had understood that there was no value in giving medicines orally if the patient was likely to vomit- but had not understood the principle of reversing the cause of the symptom were possible and clearly didn’t understand what they were prescribing. The next thing I think about is whether I can use one medicine to do 2 things. If someone has neuropathic pain and difficultly sleeping – it makes sense to give them amitryptiline rather than gabapentin and zopiclone. If someone is anxious and nauseous, it makes sense to give low dose haloperidol or levomepramazine, rather than cyclizine and diazepam Obviously I want to make sure that the benefit of any tx is greater than the burden, and think through any interactions and allargies or intolances. Every time I start a medicine I see if there is at least one I can stop Cost is also important to think through – and that’s the finical cost, but also the cost to the pt. Lidocaine patches are lovely and harmless, but cost a lot, so really need clear indications and expectatnts and limited trial period. The cost of medication to the pt can be huge in terms of side effects, affecting safety to drive etc Compliance is generally improved with clear instrcutions and a simplified regime, generally in Palliative care there is no need for medication to be taken with food apart from diabetes medication and pancreatic supplements On thing that’s different in prescribing for symptoms rather than for example hypertension or heart failure is the prescribing of rescue medications. With pain it is usual for patients to take modified release analgesia regularly to prevent pain, but also to be prescribed a quick acting analgesia for if the pain breaks through. With morphine and oxycontin the break through dose is 1/6 of the 24 hour dose. There ae also qucik acting fentanyls available, the dosing regime is complex and is not dependant on back ground dose- the only benefit of quick acting fentanyls is that they can be absorbed s/l or buccally. When prescribing any medicine, I always think – what next – what if this doesn’t work- what’s the next step, what will I do if the patient starts vomiting? what will I do when the patient cant swallow Any interactions/ allergies? Compliance Which medicine can I reduce/stop? Cost

Always try to provide written information similar to this

PRINCIPLES OF STOPPING MEDICATION IN PALLIATIVE PATIENTS

Any medicine causing problems?
? Two medicines doing same thing Burden of taking medication >benefit? STOPPING MEDICATION Reason for taking medication Harm of stopping So when thinking about stopping medicines I tend to have these sorts of thoughts. The easiest medicines to stop are the supernummaery ones- last week in clinic I saw a man who had been on rannitidine for 15 years for a gastric ulcer and more recently prescribed dexamethasone and lansoprazole. The dex had been stopped, but he was still taking rannitidine and lansoprazole- we managed to stop both without any problems. I’ve seen patients taking zopiclone and temazepam or codeine, tramadol and morphine- it makes sense to give a single medication. The next thing is to think about which medicine is being the most harmful- whether that’s in terms of tablet burden or side effects, an example might be NSAIDs causing indigestion, iron causing nausea and constipation and see if these can be stopped rather than adding in another medication to counteract the SE. Especially with palliative pts all interventions need to have a greater benefit than burden – with medication that require regular blood tests, such as warfarin, the burden is likely to be much higher than the benefit I find it helpful when first meeting a patient to go through the reasons they think they are taking their medications. It maybe that the reason they started a medicine 30 years ago is no longer important or relevant. For example with hypertension or diabetes, clearly in a fit person its sensible to control BP or blood sugars tightly- this is much less important if time is short. If something has been prescribed for prophylactic reasons in a patient with a prognosis of months you can just stop it- this includes aspirin, osteoporesis medication and statins. There was a paper published in 2015 that looked at stopping statins in adults with a life expectancy of less than a year had been taking statins for more than 3 months and did not have active cardiovascular disease. They enroled almost 400 pts- half stopped their statins, half didn’t. Results were that the proportion of pts who died within 60 days was the same, and overall QOL was better in the non statin group. Also need to think through the harm of stopping – important that the patient doesnt see it as giving up, but rather than doing things differently ? Indication still there ? Prophylactic

Management of diabetes in last 100 days of life
Goals of treatment Avoidance of hypoglycaemia, DKA, hyperosmolar hyperglycaemic state Avoidance of dehydration For the patient to be able to eat what she/he wants to eat Maintaining the empowerment of the individual patient in their diabetes management to the last possible stage Practical measures 1- aim for pre meal glucose between 6-15mmol/l – see if oral agents can be stopped 2- Match the regime to the meals 3- simplify regime- may make sense to have more insulin rather than tablets and insulin (most oral agents can cause problems if patients not eating much ? Change to repaglinide) 4 - when appetite very poor or oral route lost convert to once daily insulin 5 - Minimise invasive blood glucose monitoring Repanlide= meglitinide – stimuales relaese of insulin from B cells of pancreas. Works quicker and is shorter acting than sulphonureas

Non –pharmacological breathlessness management
Management of COPD in last 100 days Optimise current regime – unlikely to be able to use inhalers effectively – consider nebuliser Non –pharmacological breathlessness management Pharmacological breathlessness management: Not always clear when when last 100 days is – but it is suggested by an increase in symptom burden – symptoms such as SOB at rest , pain, functional decline, fatigue, cough, wt loss, anxiety, low mood, chest secretions

Management of heart failure in last 100 days
Goals of treatment To help symptoms – SOB, pain, cough, dry mouth, anorexia, constipation To reduce tablet burden To improve insight and understanding To plan ahead – switch off ICDs if appropriate

Medications that may need stopping
Drug Rational for stopping Nitrates Very limited role in advanced heart failure Beta blockers Low HR, low pulse, cold extremities, fatigue ACEI Concurrent illness causing hypovolaemia ARB Mineral corticoid receptor antagonist High K, renal impairment It’s interesting looking through the cardiology views on this and the palliative care views – the cardiologists advise to continue all medication apart from aspirin and statins if tolerated. However, often the symptom burden and harm caused by the medication is high at EOL Diuretic usually need to continue – can be given via a syringe driver

Management of chronic kidney disease in last 100 days
Medication Advice Statins Stop when prognosis felt to be months Aspirin Stop early, unless vascular stent-when advice is to continue Vitamin D analogues Anti hypertensive Loosen BP control- stop if tablet burden too high Phosphate binders Stop when oral intake poor Sodium bicarb Stop late – only when unable to swallow Diuretics Continue as long as possible People approaching EOL due to advanced kidney disease are in one 3 groups 1- those managed conservatively without dialysis – death usuall occurs when eGFR =5 2 those who stop dialysis – death usually within 8-10 days 3 those who deteriorate despite dialysis So these are the regular medicines that need reviewing

If fluid overload- diuretics Non pharmacological management
Symptom Treatment Breathlessness If fluid overload- diuretics Non pharmacological management Pharmacological management Pain Paracetamol Avoid NSAIDs Tramadol 50mg max bd or Oxynorm2.5 mg prn 8-12 hourly S/C Alfentanyl / Fentanyl Could use buprenorphine or fentanyl patch if pain stable Try clonazepam 0.5mg if pain sounds neuropathic Nausea + vomiting Haloperidol 0.5mg or metoclopramide 5mg tds Itch Chlorphenamine 4mg /ondansetron 4mg/pregabalin 25mg nocte Agitation Haloperidol 0.5mg And these are medications that might need starting Opiates accumulate in renal failure and its not good practice to give modified release ones. Morphine (and therefore codeine) accumulates worse of all In the hospital we use fentanyl s/c for pain relief if the patient is unable to swallow and occasionally send a patient home with fentanyl in a SD – any such patient will also be known to the community pall care team.

What not to stop Diuretics Immunosuppressants (transplant patients)
Anti HIV medication Anti convulsants immunosuppressive therapy is required to avoid allograft rejection If you decide to stop treatment, your viral load is likely to rebound within a week or two. If you stay off treatment your CD4 count will start to drop over the next few months. When this happens the risk of developing other infections and getting sick increases. Fitting at EOL is distressing for pts and carers. Midazolam can be used in a SD (20-30mg/24 hours) instead of oral anti convulsants

Last days- hours of life Anticipatory medication
So we’ve talked about medication in the last 100 days of life – I’d now like to talk about medication in the last 100 hours of life. Generally people in the last 100 hours of life are bed bound, struggle to E+D, struggle to swallow medication and have fluctuating consciousness- but still can have a high symptom burden This is a predictable problem and if not considered causes people to die in hospital when they would rather die at home. It can be managed by having appropriate injectable medication available and ready to give when symptoms arise Enabling s prompt symptom relief, regardless of day of the week or time of day It also Encourages conversations about goal of treatments, prognosis, and how to access appropriate care as the patient deteriorates It also has -+Disadvantages The drugs may remain in the community for extended periods of time The drugs may not be used The drugs potentially might not be used by the patient, but by others for recreational purposes The availability of such medication may encourage their administration without proper assessment, for example, midazolam might be given for terminal agitation when a proper assessment would have revealed a distended bladder and the need for a catheter as the cause of the patient's distress But generally if the patient is needing symptom relief in the last 100 days, they are likely to need some in the last 100 hours and it is good practice to have antecipatory meds available Further guidance is on the CCG website

Help and support for HCP
MK Palliative Care Advice Line 24/7 Palliative Medicine consultant on call

GSF= Gold Standard Framework = Good Supported Future
One more thing…. GSF= Gold Standard Framework = Good Supported Future Discharge summaries- prompt med reviews and acping

Good Supported Future I am on the GSF register
I have an Advance Care Plan I have a treatment escalation plan I have a DNACPR form Cards Lauching March

One more thing…. Dnacpr form from hospital changing from spring- prompted by the need to have teps and south central whose form we currently use, no longer exists so at some point the forms will no longer be available

Thank you Any questions?

Case study and Discussion
Over to you …………………….

Consider… The number and types of medicines being taken (appropriate and problematic polypharmacy) Any changes to the benefit to risk profile for each medicine Are all medicines fully optimised? Individualised goal setting with Irene; what is important to her?

Consider… Physiological changes that may affect drug metabolism and require dose/frequency adjustments Individualising the interpretation of national guidelines for single, long-term conditions with Irene’s multimorbidity Stopping medicines used for preventing chronic disease (time to reach benefit)

Consider… Pill (medicine) burden Adherence Patients living with frailty suffer more Adverse Drug Reactions (ADRs), drug: drug interactions and may have an exaggerated response to a minor stress, e.g. a simple infection or the addition of a new medicine

From: What constitutes good prescribing?
Rational Decision Making EFFICACY SAFETY Benificence Non-malificence PATIENT FACTORS COST Justice Patient autonomy From: What constitutes good prescribing? Barber N. BMJ 1995; 310:

Tools available to support polypharmacy and deprescribing
Some key questions 1. Is there a valid and current indication and is the dose appropriate? ? e.g. PPIs- use minimum dose to control GI symptoms - risk of c.difficile and fracture e.g. quinine use- see MHRA advice re safety e.g. long term antibiotics 2. Is the medicine preventing rapid symptomatic deterioration? Should usually be continued eg Meds for heart failure, Parkinson’s Disease 3. Is the medicine fulfilling an essential replacement function? If the medicine is serving a vital replacement function, it should continue eg levothyroxine 4. Is the medicine causing: Any actual or potential ADRs Contra-indicated drug or high risk drugs group - strongly consider stopping Poorly tolerated in frail patients - consider stopping

Some key questions cont. 4. cont. Any actual or potentially serious drug interactions – consider stopping. Particular side effects? May need to consider stopping; don’t prescribe additional medicines to counter s/e 5. Consider drug effectiveness in this patient - refer to the ‘Drug Effectiveness Summary’ which estimates effectiveness. 6. Are the form of medicine and the dosing schedule appropriate? Is there a more cost effective alternative with no detriment to patient care? Is the medicine in a form that the patient can take supplied in the most appropriate way and the least burdensome dosing strategy? Is the patient prepared to take the medication? 7. Do you have the informed agreement of the patient/carer/welfare proxy? Once all the medicines have been through steps 1 to 6, decide with the patient/carer/or welfare proxies what medicines have an effect of sufficient magnitude to consider continuation and discontinue others.

The STOPP tool is a screening tool which can be used to identify potentially inappropriate prescribing for older people. See at The Anticholinergic Cognitive Burden Scale was developed with UK Medicines Research Council is used to assess potential risk of anticholinergic side effects of commonly prescribed drugs. See Poorly tolerated drugs in frail elderly  Digoxin in doses of 187.5mcg daily or greater  Benzodiazepines and z-drugs, particularly for long-term use  Phenothiazines (e.g. prochlorperazine)  Antipsychotics  Tricyclic antidepressants (TCAs)  Anticholinergics Opioids and gabapentin / pregabalin  Combination analgesics (e.g. co-codamol)

Database of Treatment Effect This tool provides estimates of the effect of NICE recommended drugs, compared to placebo, on specific outcomes, in specific conditions. It is designed to inform discussions between patient and clinician when considering the benefits and harms of taking long term medication. Beers Criteria Lists high risk medicines and offers safer alternatives NO TEARS Helps to structure a medication review Need and indication Open questions Tests and monitoring Evidence and guidelines Adverse events Risk reduction or prevention Simplification and switches HARMS

High risk combinations Non-Steroidal Anti-inflammatory Drugs (NSAIDs)  +ACEI or A2RA + diuretic (triple whammy)  +eGFR < 60ml/min  +Diagnosis heart failure  +Warfarin or NOACs, e.g. dabigatran, rivaroxaban, apixaban  +Age >75 without PPI Warfarin or NOAC  +antiplatelet in frail patients – risk is high and combination should be challenged  +NSAID  +Macrolide and quinolone antibiotics (if concomitant use is essential, ensure appropriate INR monitoring)  +Azole antifungals including miconazole oral gel (if essential, ensure appropriate INR monitoring) Heart Failure Diagnosis  +glitazone  +NSAID  +tricyclic antidepressant The PINCER clinically important errors: 1. Patients with a history of peptic ulcer prescribed non-selective non-steroidal anti-inflammatory drugs (NSAIDs) without co-prescription of a proton-pump inhibitor 2. Patients with a history of asthma prescribed β blockers; 3. Patients > 75 years old prescribed angiotensin converting enzyme (ACE) inhibitors or loop diuretics without assessment of urea and electrolytes in the preceding 15 months.

NNT and NNH NNT NNH Helps assess benefits from drugs or interventions
Estimates the number of patients that have to be treated for one to gain a particular benefit Inverse of absolute risk reduction so patients at higher risk usually have more to gain The higher the NNT, the more patients have to be treated for benefit Time frame for delivery of benefit must be considered Estimates the number of patients who may suffer an adverse event from an intervention Eg BP control Low risk patients NNT = 80 High risk patients (Diabetes, vascular disease) NNT = 32

Patient Decision Aids Used as part of a shared decision making process, encouraging active participation by patients in healthcare decisions e.g from NICE Atrial fibrillation: medicines to help reduce your risk of a stroke – what are the options? Statin to reduce the risk of coronary heart disease and stroke Type 2 diabetes in adults: controlling your blood glucose by taking a second medicine – what are your options? eg from Chris Cates – NNT On line

Key Points No surprises, as the possibility of stopping the medicine should have been discussed with the patient before starting it Review all current medicines – on acute and repeat screens Identify any medicines to be stopped, substituted or reduced Plan a deprescribing regimen in partnership with your patient Frequent reviews and patient support GPs can safely deprescribe medications with patient agreement Doing so will decrease pill burden and improve patients quality of life

Next steps The PIS was for GPs to review three patients aged over 75 years taking at least 9 oral medicines each Mixed bag – some done well but …. Not all patients met the criteria for inclusion Not all columns completed i.e. NNT, ACB Score Some reviews had N/A or nothing to stop although patients were receiving high risk medicines To complete the PIS target, you are asked to: Re-review patients with information from today Have a practice meeting to feedback the information from today and re-challenge each other on your medication reviews Submit a final practice report with a copy of minutes from your meeting Submit the review sheets showing completed actions from the 3 medication reviews per GP to Nikki Woodhall by 31st May 2018.

Final Thought …… “Active and healthy ageing is important for everyone. Focusing on frailty now creates a golden opportunity to enable more of us to age well while planning ahead, discussing what matters most and ensuring we get the right care and support, both now, and into the future". Professor Martin Vernon, National Clinical Director for Older People, NHS England

MKCCG PLT Prescribing Workshop

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MKCCG PLT Prescribing Workshop

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