Polypharmacy in elderly patients:an intervention study in therapeutic management

POLYPHARMACY IN ELDERLY PATIENTS:

AN INTERVENTION STUDY IN THERAPEUTIC

MANAGEMENT

Rosario Falanga¹, G. Pessa¹, B. Basso²,

A. Bertoli², A. Franzo², D. Little², G. Simon² ¹General Practitioner, SIMG, Pordenone, Italy,

²Azienda per l’Assistenza Sanitaria n.5 “Friuli Occidentale”,

Pordenone, Italy

Background

The increase in average life expectancy has over time resulted in a rising incidence of chronic degenerative diseases and consequent polypharmacy in older adults, with an augmented risk of Adverse Drug Reactions (ADRs) and Potentially Inappropriate Drug Prescriptions (PIDP).

Older people are medically frail because of age-related pharmacokinetic and pharmacodynamic changes.

Deprescribing will reduce the risk of adverse drug reactions due to age-related physiological changes and inappropriate prescriptions.

PERCENTAGE OF REPORTS WITH POTENTIAL DRUG-DRUG

INTERACTIONS IN RELATION TO THE NUMBER OF DRUGS

IDENTIFYING ADVERSE DRUG REACTIONS ASSOCIATED WITH DRUG-DRUG

INTERACTIONS DATA OF A SPONTANEOUS REPORTING DATABASE IN ITALY (Leone R.,

Drug Saf 2010)

Ippocrate (460 - 335 B.C.)

“PRIMUM NON NOCERE”

(First, do not harm)

Polypharmacy in elderly patients: an intervention

study in therapeutic management

Pharmacovigilance project financed by the Italian Medicines Agency (AIFA).

Participating Organisations and Facilities:

AAS5 “Agency for Public Health Service n.5 Western Friuli” (Office of the Medical Director, Internal Medicine Department, Pharmacy Department, Territorial Health Districts, Dept. of Mental Health, Nursing Services)

General Practitioners (SIMG, Pordenone)

Nursing homes in the Province of Pordenone

Objectives

We conducted a qualitative and quantitative

analysis of polypharmacy in elderly patients, in

therapy with multiple prescription medicines

evaluating the risk of ADRs, drug interactions

and therapeutic errors before and after

adequate staff training aimed at reducing the

number of administered drugs and ADRs in this

population.

Methods (1)

A cohort of 750 elderly

patients living in 11

nursing homes, in the

province of Pordenone in

northern Italy, average

age 85 (65-103), 81%

females, were enrolled

in the study, which lasted

for 3 years (2013-2015)

and included 3 phases.

Age Phase 1

n.1123

Phase 2

Training

Phase 3

n.1112

Present

Both

phases

n.750

Min. 65 65 65

Max 106 103 103

Media 86 85 85

Female% 79 79 81

Methods (2)

Phase 1: included medical record audit, data collection of drug therapy and drug management, evaluating the risk of ADRs, drug interactions and therapeutic errors, data analysis, problems detection and planning for adequate training.

Phase 2: we carried out multidisciplinary staff training with nurses, general practitioners, specialist doctors, pharmacists and created adequate operative tools

(“Do not crush list”, a specific handbook).

Phase 3: included a second data collection and the analysis of drug management, therapy and hospital admissions for adverse events.

The analysis was conducted using 2 tools:

Beers Criteria for potentially inappropriate medications.

Micromedex 2.0 for drug interactions.

Phase 1 - Top Ten Drug Interactions

CLORPROMAZINA

QUETIAPINA

ACIDO

ACETILSALICILICO

SERTRALINA

ACIDO

ACETILSALICILICO

ENOXAPARINA

PANTOPRAZOLO

CITALOPRAM

METOCLOPRAMIDE

CLORPROMAZINA

LEVOFLOXACINA

QUETIAPINA

LEVOFLOXACINA

CLORPROMAZINA

ALOPERIDOLO

QUETIAPINA

METOCLOPRAMIDE

ALOPERIDOLO

METOCLOPRAMIDE

QUETIAPINA

These 10 drug interactions

represent 33% of all

interactions in the study

55% of patients in

the study had at

least 1 of these

interactions.

Beers Criteria for Potentially Inappropriate Medication

Therapeutic category, Drug(s) Phase 1 Phase 3 Beers Warning

Digoxin 132 106 Avoid doses >0,125mg digoxin

Furosemide+Spironolactone 75 57 Avoid doses >25mg spironolactone

Doxazosin 38 32 Avoid as first line therapy

Antiarrhythmic drugs

(Amiodarone,Flecainide,

Propafenone, Sotalol)

67 62 Avoid as first line therapy

Proton Pump Inhibitors 750 704 Avoid use for > 8 weeks unless for

high risk patient

Benzodiazepines (Lorazepam,

Triazolan, Flurazepam)

667 651 Avoid for treatment of insomnia,

agitation or delirium

Phase 2 – Multiprofessional training (Nurses,

Pharmacists, GPs, Specialist doctors)

Session 1: we discuss, clinical risk

management, therapeutic errors

Session 2: we carry out, field training

and share procedures

Session 3: we look at therapeutic

reconciliation, pharmacovigilance and

reduce polypharmacy

The practice of crushing medications

“Do not crush list”,

a specific handbook

Results (1)

Nursing home Reconciled meds N. of Interactions Crushing

1 -1,1 -29% -37%

2 +0,1 12% -3%

3 +0,04 -26% -6%

4 -0,5 41% -33%

5 +0,7 20% 8%

6 -0,2 -1% -7%

7 +0,02 8% 18%

8 +0,7 -1% 10%

9 -0,3 -33% -22%

10 -0,5 -23% 6%

11 -0,2 12% -28%

-0,1 -7% -9%

The interventions reduced the drug interactions by 7% and the

practice of crushing medication by 9%

Results (2)

N. of drugs 1-4 5-9 10+

Nursing Home 1 53% 43% 3%











34% 55% 11%

Phase 1 Phase 3

N. of drugs 1-4 5-9 10+












32% 56% 12%

The interventions reduced the proportion of patients in

therapy with more than 5 medications by 2%

Reduce and reconcile ....

... If we remove drugs, does it

worsen the state of patients’

health?

Results (3)

Pre

Intervention

(2013)

Post

Intervention

(2015)

95%

Confidence Interval

Admissions for ADRs 610 393

Hospital days 653,600 660,866

Rate post intervention 5.95 5.37 6.56

Rate pre intervention 9.33 8.61 10.10

Rate ratio 0.64 0.56 0.72

Rate difference -3.39 -4.33 -2.44

The hospital admissions for adverse events in nursing home

residents in the post intervention group were reduced by 36%.

The difference between the two rates is statistically significant.

Conclusions

The study demonstrated how health personnel training can impact upon medication management in nursing homes.

The most significant variations were evident in facilities in which it was possible to modify nursing and medical management in a multidisciplinary approach.

The best results occurred in those facilities where all health professionals participated in the project and worked together for improvement.

THANKS FOR

YOUR ATTENTION

Corrispondence to: [email protected]

Conflict of interest: none

Polypharmacy in elderly patients:an intervention study in therapeutic management

Health & Medicine