Grant Macdonald

 Appropriate polypharmacy describes treatment where a patient has multiple morbidities, and/or a complex condition, that is being managed with more than one medicine, where the potential benefits outweigh the potential harms.  Problematic polypharmacy describes a patient receiving multiple medicines, where one or more of these medicines have potential harms that outweigh the potential benefits

 Balancing the potential benefits and harms  Among older patients polypharmacy is associated with: ◦ falls and fractures, ◦ dehydration and acute kidney injury(AKI), ◦ delirium, ◦ hypoglycaemia, ◦ malnutrition, ◦ Hospitalisation and death.  However, polypharmacy is not necessarily harmful  multiple medicines may increase life expectancy and improve quality of life.

 An aging population with increasing comorbidities  Multiple prescribers and multiple pharmacies  Self medicating (OTC and herbal)  Prescribing cascade  Ineffective communication and coordination  Not assessing symptoms thoroughly

 Improved communication between the physician, nurse, and pharmacist  Know which drugs are inappropriate or risky  Up to date drug histories and reconciliations  Look for duplications or redundancies  Simplify regimes to maximise compliance  Encourage the use of ONE pharmacy

 Before prescribing prescribers should consider the following: ◦ Am I treating the condition or a symptom? ◦ Have I considered non-pharmacological treatments? ◦ Is the medicine appropriate to the patients condition and stage of life? ◦ The STOPP/START criteria

 General practitioners  Nurse specialists  Dentists  Midwives  Specialists  Emergency specialists  Pharmacists  So who does a patient see if an adverse effect occurs?

 All medicines have ADRs  Some ADRs are dose related (Type 1)  Some are not dose related (Type 2)  Aged patients have increased risks of ADRs  With several medicines brings increased rates of ADRs  Report all new symptoms when new medications are started and assume its medicine related till proven not to be

 Many different mechanisms for drug interactions  The more medications taken the greater risk of drug interactions  is a easy to use online check  Text books such as stockleys book of interactions have well described interactions

 Name some common adverse reactions you see with clients?  ADRs with opiates?  ADRs with Felodipine?  ADRs with diazepam?  ADRs with sodium valproate?

Ankle oedema due to a calcium channel blocker → diuretic. NSAID → increase in blood pressure → addition of an antihypertensive drug After an increase amitriptyline from 25 – 50 mg the patient complains of incontinence and oxybutynin is prescribed. The incontinence worsens, the dose of oxybutynin is increased. The patient complains of constipation and a laxative is given. Amitriptyline has anticholinergic actions and can cause urinary retention leading to overflow incontinence which was not recognised. Oxybutynin also has anticholinergic actions but is used for urge incontinence. The situation worsens, the person gets constipated and a laxative is prescribed. “I do not want two diseases – one nature-made, one doctor-made” Napoleon Bonaparte, 1820

 Help in stopping medicines at the right time  Reduce tablet load  All prescribers working to the same plan  4Requires clear communication between all health providers

 Screening tool of older people's prescriptions (STOPP) and  Screening tool to alert to right treatment (START) criteria  Is a systematic assessment tool that can be used to assess medicines.  Very long and complex approach

 Aim to eliminate redundant medicines or of a high toxicity  Ideally these should be performed at least annually  Assesseach drug, dose, duration, continuation  Can assist in optimising and minimising the medications being taken → reducing ADRs

 structured and systematic  to help the patient find out about – ◦ medicines they are taking; ◦ identify any problems ◦ improve the effectiveness of the medicines being taken  collaboration and teamwork with the local community healthcare team.

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 Ask your clients what medicines they use. These include inhalers, OTC, eye drops  Check which pharmacies they go to  When new medicines started assess for ADRs  Check new medicines having clear durations, review dates and goals  If unsure ask if you suspect a medicine issue