Polypharmacy Pharmacist Consultant Liz Butterfield FRPharmS KSS ASHN Expo 19th January 2016 1

Polypharmacy

Background to polypharmacy in older people Particular concern in older population as medicines are not broken down in the body as effectively as when younger Multi-morbidity common and multiple medicines also common. Older person in a care home is prescribed an average 9 medicines Complications can lead to new illness, accidents such as falls, cognitive decline and increased risk of admission to hospital Polyprescribing – can result from prescribing cascade Kings Fund report 2013 – Polypharmacy and Medicines Optimisation – Making it Safe and Sound – Appropriate Polypharmacy and Problematic Polypharmacy End of Life care – continuation of preventative medicines?

Anticholinergic drugs cause cognitive impairment Anticholinergics Procyclidine Orphenadrine Trihexyphenidyl(Benzhexol) Atropine Antipsychotics Olanzapine Risperidone Quetiapine Haloperidol Aripiprazole Antihistamines Promethazine Hydroxyzine Chlorphenamine Cinnarizine Tricyclic Antidepressants Amitriptyline Dosulepin Clomipramine Nortriptyline Urinary Incontinence Oxybutynin Tolterodine Solifenacin Propantheline Sedating drugs can cause cognitive impairment Benzodiazepines Diazepam Lorazepam Oxazepam Temazepam Clonazepam Opioid Analgesics Codeine Fentanyl Morphine Oxycodone Tramadol Antidepressants Mirtazapine Trazodone Hypnotics Zopiclone Zolpidem Anticonvulsants Carbamazepine Valproate Levetiracetam Pregabalin Gabapentin

Key Challenges for Medicines Optimisation Ensuring that Appropriate Polypharmacy is still appropriate Strategies to minimise Problematic Polypharmacy Approaches to prescribing in the elderly to prevent polypharmacy – prescribing cascade Skills and training around deprescribing Multi-morbidity – should we follow national guidelines for combination of conditions – particularly preventative therapies Patient-centered approach with shared decision making Regular Medication Review?

Overview of AHSN Polypharmacy Project plans Aim to generate cash releasing savings Plan to work with care homes to undertake/increase number and pace of medicine reviews Plan to work with 4 localities across Kent Surrey Sussex who have already made some progress with polypharmacy Support will depend on needs of locality to progress their work – might be funding, project management support, clinical support etc. Project to focus on solid action, metrics and impact Plan to broaden reach in year 2

Some examples of good practice in KSS Care Home Medication reviews scheme, Brighton and Hove moving into its 5th year from April Guildford and Waverley, polypharmacy reviews in older people Medway – Polypharmacy in the elderly Coastal West Sussex – Proactive Care Multi-disciplinary teams