Impact of Multidisciplinary Team Care on Older People with Polypharmacy Liang-Kung Chen Center for Geriatrics and Gerontology Taipei Veterans General Hospital National Yang Ming University School of Medicine

Roman poet Ovid 43 B.C. – 17 A. D.

3.1 in in at admissions 6 during admissions 8 at discharge

Medicine has largely become the practice of drug prescribing Signs and symptoms reflexively trigger a change in pharmacologic management Non-pharmacologic interventions are often available but difficult to implement Evidence-based pharmacotherapy Limited evidence in older people, especially older people with frailty

Gurwitz J. Arch Intern Med 2004;164:

Nelson MR, et al. BMJ 2002;325:815-9.

Holmes HM, et al. Arch Intern Med 2006;166: Williams CM. Am Fam Phys 2002;66:

Is there an indication for the drug? Is the medication effective for the condition? Is the dosage correct? Are the directions correct? Are the directions practical? Are there clinically significant drug-drug interactions? Are there clinically significant drug-disease interactions? Is there unnecessary duplication with other drugs? Is the duration of therapy acceptable? Is this drug the least expensive alternative compared to others of equal utility? Holmes HM, et al. Arch Intern Med 2006;166:

Limited life expectancy A certain range of time is needed to show benefits of pharmacotherapy Example: Elderly diabetic patients should have at least 5 years to show the benefits of pharmacological therapy Constraints of care time A number of health care issues to be addressed in the late life, function and quality of life may be superior to disease treatment Goal of chronic disease management deserves re- consideration Frail older people Constraints of medication harms A significantly higher risk of adverse drug events for older patients Polypharmacy is associated with poorer quality of life and poorer health care outcomes Polypharmacy sometimes becomes common in modern health care

Tan HH, et al. Diabetes Care 2004;27:2797-9

ACEI showed no protective effect against heart failure in patients aged over 75 Anticoagulant plays no protective role in older patients with atrial fibrillation but no other risk factor against stroke in terms of quality-adjusted life expectancy

Medication Quality Indicators - Prescribing indicated medications - Avoiding inappropriate medications - Education, continuity, and documentation - Medication monitoring

Hospital indicatorsAmbulatory indicators All vulnerable older adults should not be prescribed a medication with strong anticholinergic side effects if alternatives are available If a vulnerable older adult is prescribed a new drug, THEN the prescribed drug should have a clearly defined indication documented in the chart All vulnerable older adults should not be prescribed a medication with strong anticholinergic side effects if alternatives are available If a vulnerable older adults is prescribed a new drug, THEN the patient (or caregiver) should receive education about the purpose of the new drug, how to take it, and the expected side effects or important adverse reactions

Ambulatory indicators If a vulnerable older adult is prescribed a new drug, THEN the prescribed drug should have a clearly defined indication documented in the record Every new drug that is prescribed to a vulnerable older adult on an ongoing basis for chronic medical condition should have a documentation of response to therapy within 6 months If a vulnerable older adult is newly started on a diuretic, THEN serum potassium and creatinine levels should be checked within 1 month of initiation of therapy If a vulnerable older adult is prescribed a thiazide or loop diuretic, THEN s/he should have electrolyte levels checked at least yearly

Ambulatory indicators If a vulnerable older adult is newly started on an ACE inhibitor, THEN serum potassium and creatinine levels should be checked within 1 month of the initiation of therapy If a vulnerable older adult is prescribed warfarin, THEN an INR should be determined within 4 days after initiation of therapy If a vulnerable older adult is prescribed warfarin, THEN an INR should be determined at least every six weeks y

Principles of Optimal Prescribing for Older Patients 1. Start low, go slow, but get there 2. Periodic medication review and document indications of your prescriptions 3. Avoid any agent with strong anticholinergic effect if better alternative is available 4. Periodic review of effectiveness of drugs prescribed in this age group 5. Take into considerations of older patients’ life expectancy, function, and frailty 6. Think every symptoms related to prescribed medications and medication untrial

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P both < Item reduced 32.3% Dose reduced 42.4% N=43, Mean age=81.4±4.5 years, 76.7% males