1. Reducing Medication Burden and Improving Adherence in Polypharmacy
A Plethora of Pills:
Reducing Medication Burden and Improving Adherence in Polypharmacy
American College of Physicians - Maine Chapter
Autumn Meeting in Bar Harbor
September, 2014
Stephanie Nichols, Pharm.D., BCPS, BCPP
Associate Professor – Husson University School of Pharmacy
Clinical Pharmacist – Psychiatry & Adult Inpatient Medicine

2. Objectives Define polypharmacy and recall it's prevalence
Illustrate why recognition and management of polypharmacy is important
Demonstrate strategies to avoid polypharmacy
Assess high risk polypharmacy situations and formulate a plan to initiate pharmacological debridement
Employ strategies to improve medication adherence in patients with a high pill burden

3. Define Polypharmacy and Recall it’s Prevalence

4. Polypharmacy is….. X+ chronic daily medications?
OTCs/Herbals
Ex. HF or COPD
“High Risk Polypharmacy”
Ex. 2+ narcotics, 2+ benzos, 3+ oral hypoglycemics
2+ drugs in the same class?
More drugs prescribed than warranted clinically ?
“Prescribing cascade”

5. Polypharmacy?
Now we know what it is (sort of) and why we care about it, lets get into the meat and potatoes of how to avoid it, how to assess it’s occurrence and attempt to reduce burden, and what strategies may help with patient adherence

6. Polypharmacy in the Ambulatory Community
Kaufman, Kelly, Rosenberg, Anderson, Mitchell. JAMA 2002;287:

7. Post Discharge Medications in 65+ year olds
Mean number of meds per patient = 13.5
Nearly a quarter had >16 meds
OR 4.75 (95% CI: 1.0 – 11.2) for polypharmacy with 2+ high risk diagnoses
COPD, CA, DM, CHF, CAD
Rohrer JE et al. J Prim Care Community Health Apr 1;4(2):101-5.

8. Polypharmacy post-discharge approaches 75% & persists for at least 365 days
Defined as 5+ drugs in patients admitted for CAP
Gamble JM et al. Therapeutics and Clinical Risk Management 2014:10 189–196

9. Slabaugh, Maio, Templin, Abouzaid. Drugs & Aging

10. Illustrate Why Recognition and Management of Polypharmacy is Important

11. drugs

12. Drug Related Problems (DRPs)
827 patients
DRPs = an event or circumstance involving drug therapy that actually or potentially interferes with desired health outcomes
Non optimal dose > need for monitoring and medical chart error < non optimal drug
Drug Related Problems (DRPs)
↑ by 8.6% per medication
Viktil GK, Blix HS, Moger TA, Reikvam A. Brit J of Clin Pharmacol 2006;63(2):

13. Examples of Drug Related Problems
Errors
Order clarification necessary
Prescribing
Dispensing
Duplicate medication/class
Administration
Adverse Reactions
Medication omission
Interactions
Lack of dose adjustment with AKI or liver failure
Drug-Drug
Dynamic
Kinetic
Drug-Disease

14. Polypharmacy is associated with….
Low Adherence
Falls and Fractures
ED visits and admissions
Increased healthcare costs
Reduced quality of life
Increased mortality
Circulation. 2010; 122:A14790
Hip fracture OR ~8 for 10+ vs 0-1 drug
Lyles, Culver, Ivester, Potter. Consult Pharm Dec;28(12):793-9.
Lai, Liao, Liao, Muo, Liu, Sung. Medicine (Baltimore) 2010;89(5):295.

15. Polypharmacy leads to ADR-related admissions
4.2% of admissions due to ADRs
Number of Drugs
Odds Ratio of ADR Admission
95% CI
≤ 2
1.0
(Reference)
3 - 5
5.07
2.71 – 9.59
6 – 9
5.9
3.16 – 11.0
10 +
8.94
4.73 – 16.89
RAS blocker + diuretic
Antiplt
RAS + diuretic + NSAID
NSAID
Benzo/DAntag
Pedros C et al. Eur J Clin Pharmacol Mar;70(3):361-7.

16. % of admissions related to ADRs is much higher in patients with polypharmacy than those without.
Pedros C et al. Eur J Clin Pharmacol Mar;70(3):361-7.

17. Demonstrate Strategies to Avoid Polypharmacy

18. STEPS on the Path to Successful Pharmacotherapy
Safety
Tolerability
Effectiveness
Price
Simplicity

19. Decreasing ADEs Reframing Our Approach
Only benefit assessed
Probabilistic assessment of risk vs benefit on initial Rx
Actual assessment
of benefits and harms in an ongoing fashion

20. Steinman MA et al. J AM Geriatr Soc 2011;59:1513-20.

21. Assess High Risk Polypharmacy Situations & Formulate a Plan to Initiate Pharmacological Debridement

22. Pocket Card AGS iGeriatrics App - $2.99
2003
Pocket Card
AGS iGeriatrics App - $2.99

23. STOPP & START Criteria
STOPP - Screening Tool of Older People’s potentially inappropriate Prescriptions
65 recommendations
START - Screening Tool to Alert doctors to the Right Treatment
22 recommendations
Gallagher P, Ryan C, Byrne S, Kennedy J, O'Mahony D. Int J Clin Pharmacol Ther Feb;46(2):72-83.

24. Assess the Anticholinergic Burden
Rudolph, Salow, Angelini, McGlinchey. Arch Intern Med. 2008;168(5):508.
Carnahan, Lund, Perry, Pollock, Culp. J Clin Pharmacol 2006;46:
Boustani, Campbell, Munger, Maidment, Fox. Aging Health 2008;4:

25. Match Drugs and Problems
Find an indication for each drug
Goal of therapy?
Are we using the best drug for each problem/disease/disorder in this patient?
Eg. HTN and beta blockers

26. Compare the Actual Medications to the Medication List
Schedule a “brown bag” appointment periodically

27. Include the Pharmacist
When switching from one agent to another, or stopping an agent completely…
…ask the community pharmacy to d/c the old prescription
Periodically compare medication lists with the pharmacist/pharmacy

28. New Symptoms or ADRs?
When new symptoms emerge, particularly in geriatric patients, think about medication AEs

29. Employ Strategies to Improve Medication Adherence in Patients With a High Pill Burden

30. ½ ¼ 1/8 http://www.acpm.org/?MedAdherTT_ClinRef

31. Keep it SIMPLE
S implify regimen  I mpart knowledge M odify patient beliefs and human behavior  P rovide communication and trust  L eave the bias E valuate adherence
Atreja A, Bellam N, Levy S. Medacapt Gen Med. 2005:7(1): 4.

32. Simplify the Regimen Daily or BID dosing Combination products
One-a-day formulations (incl. patches)
Match to ADLs (ex. breakfast)
Combination products
Caution: loss of dosing flexibility
Treat multiple conditions with one agent
Caution: commonly 2 agents are safer
d/c extraneous or unnecessary medications
Adherence 79%, 69%, 65%, 51%

33. Impart Knowledge Focus on shared decision making
Discuss purposes and side effects of medications
Use the teach-back method
Employ verbal and written instructions
Give contact information for further questions

34. Gauge Health Literacy & Avoid Ambiguity
REALM Assessment
“As Needed for Water Retention”
“Take two every day”

35. Active and Ongoing Discussion About Pharmacotherapy
Presentation of the advantages and disadvantages of each medication in a way that is understandable to your patient
Discuss # of missed doses at each visit, non-punitively
Telephone counselling
41% reduction in all cause mortality with regular pharmacist telephone consult in patients with polypharmacy

36. Motivational Interviewing
Empathy, supporting self-efficacy, avoiding argumentation, rolling with resistance, and developing discrepancy
PSAPs VII; Book 8. Motivational Interviewing. Kavookjian J.

37. Modify Behaviors Empower patients to self-manage
Ask about specific needs, fears, and concerns
Identify perceived barriers (ex. financial)
Ensure knowledge of the actual risks of missing medications

38. Provide Communication
Confirm your patient’s message and paraphrase it
Provide empathy and give feedback
Involve your patient in decision making
Use plain language and confirm understanding

39. Leaving the Bias Take the time to overcome cultural barriers
Tailor education to the appropriate level of complexity for your patient’s optimal understanding

40. Evaluating Adherence Ask direct questions and ask them often
Every visit
Identify adherence barriers
Recognize lack of perceived benefit

41. Medication Possession Ratio
30 day fills on Jan 1st, Feb 7th, Mar 18th, Apr 26th, & June 1st
5 fills * 30d each = 150 days supply
Jan 1st – Jun 1st = 151 days + 30 days supply = 181 days
150/181 = 83% MPR

42. Adherence Tools and Tricks
Wallet cards – medication lists
Pill containers and counting
Blister packs
Pre-packed kits (ex. Medrol)
Textured covers with vision impairment
Alarms
On the bottle
Via
Team based care!

43. Polypharmacy and Adherence in Psychiatric Patients
Consider Long-Acting Injectable Antipsychotics
Engage the patient in the treatment decision when able, particularly regarding AEs
Ask the pharmacist to partner with the treatment team to alert of non-timely filling

44. Psychiatric Patients and Adherence
Depressed patients are 3x more likely to be non-adherent with medical treatment regimens (non psychotropic)
DiMatteo MR, Lepper HS, Croghan TW. Arch Int Med. 2000;160(14):2101.

45. Take Home Points Polypharmacy is prevalent, particularly in those 65+
Polypharmacy increases morbidity, mortality, & healthcare costs, and decreases quality of life
Perform ongoing medication assessment with tools, like STEPS, to avoid polypharmacy
Use scores, scales, and lists to optimize medication regimens, avoid unnecessary medications, and/or reduce medication burden
To improve medication adherence in polypharmacy, simplify the medication regimen and have ongoing dialogue with your patient about risks and benefits of each drug being used

46. Thank you!! Stephanie Nichols, Pharm.D., BCPS, BCPP
Associate Professor, Husson University School of Pharmacy Clinical Psychiatric Pharmacist, Maine Medical Center

47. Steinman MA et al. J AM Geriatr Soc 2011;59:1513-20.