Consultant Pharmacist, Care of Older People Polypharmacy and Medicines Optimisation in Older People Multiple Morbidity Clinics Lelly Oboh Consultant Pharmacist, Care of Older People Guys & ST Thomas NHS Trust East & South East England NHS Specialist Pharmacy Services 18th June 2014

Overview of workshop Medicines and multiple morbidities in older people Managing polypharmacy in the community Evidence of what works Guidance The case for multi morbidity clinics Integrating multi morbidity (MM)medication reviews into routine care Identifying those at risk and complex cases A practical/structured approach to deprescribing Role of integrated care clinical pharmacists in the community Workshop with Case scenario

Multiple morbidity The co-existence of 2 or more long-term conditions (LTCs) More holistic definition should include LTCs, risk factors and psychosocial distresses The norm in primary care and more common in elderly population Associated with poorer health and functioning, higher rates of attendance in 10 care and specialty settings Loss of function Multiple medicine use Negative effects on wellbeing, relationships, and coordination of care Limited research on effective interventions for complex patients Quality of clinical encounter as important as co-ordination of care Smith S et al. GPs' and pharmacists' experiences of managing multimorbidity: a ‘Pandora's box’. doi: 10.3399/bjgp10X514756 BJGP July 1, 2010 vol. 60 no. 576 e285-e294. http://bjgp.org/content/60/576/e285.full Multimorbidity in primary care: developing the research agenda. Family Practice (2009) 26 (2): 79-80.doi: 10.1093/fampra/cmp020 http://fampra.oxfordjournals.org/content/26/2/79.full

Multi-morbidity and medicines Multi-morbidity and polypharmacy intertwined increase clinical workload and negative outcomes Optimising the use of medicines can have a high impact on patient experience, health outcomes and costs1 Reducing polypharmacy (deprescribing) is an important component of improving care of frail older people2 Kings Fund 2014. Making our health and care systems fit for an ageing population Naylor S et al. Kings Fund 2013. Transforming our health care system: Ten priorities for commissioners.

Challenges: GPs & pharmacists views Lack of time Communication difficulties with other care providers Fragmentation of care Professional isolation Clinical uncertainty lacked confidence or clinical competence, often don’t know solution to identified problems Difficulties with decisions to stop medicines need for geriatricians and specialist pharmacists Primary Smith S et al. GPs' and pharmacists' experiences of managing multimorbidity: a ‘Pandora's box’. doi: 10.3399/bjgp10X514756 BJGP July 1, 2010 vol. 60 no. 576 e285-e294. http://bjgp.org/content/60/576/e285.full

What works? Generally Personalised and holistic approach Care organised around the patient, not the disease Multiple physical and psychosocial conditions taken into account Co-ordinated approach with case finding, patient centred assessment and care planning1,2 Interventions targeted at specific2,3 Combinations of common conditions Problems for patients e.g. medicines interventions tackling polypharmacy and complex dosing regimens Collaborative/multidisciplinary approach Kings Fund 2011. Case Management RCGP Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities? Interventions for improving outcomes in patients with multimorbidity in primary care and community settings. Cochrane Review 2012

What works? GPs & pharmacists views GPs managing patients in primary care One clinic and one nominated GP 45mins at least/plus timely input from geriatricians/specialists if out of depth Pharmacist access to patient information Planned care Referral for time limited “rehabilitation” type program Outcome should focus on function rather than specific disease outcome Smith S et alGPs' and pharmacists' experiences of managing multimorbidity: a ‘Pandora's box’. doi: 10.3399/bjgp10X514756 BJGP July 1, 2010 vol. 60 no. 576 e285-e294. http://bjgp.org/content/60/576/e285.full

What works? Guidance1-5 Ongoing, periodic medication review Patient centred patients given essential information and involved in decisions Holistic – Done in context of overall patient goals Focused medication review consultations with sufficient time to address MMs (involve clinical pharmacists if complex) MMs reviewed by lead clinician who co-ordinates care Multidisciplinary approach Close collaboration of pharmacists and doctors (Holland et al 2005; Salter et al 2007). Improved co-ordination/communication during transition of care between community and specialist care ( BGS Quest for quality in care homes 2011 CHUM Study 2009 Kings Fund. Polypharmacy 2013 Kings Fund. Quality of GP prescribing 2011 NICE Managing medicines in care homes 2014

Summary: Single vs. MMs clinics Single condition clinics Target driven, focused on disease rather than fulfilling the patient agenda Poor co-ordination of care, transfer of information and communication Difficulties tackling specific problems relating to MMs e.g non-adherence Inconvenience of attending multiple clinic appointments Difficulties managing patients within limited consultation time Addresses condition in isolation vs. context of psychosocial needs and overall function Poor consideration of impact of disease:disease interactions and synergies managing different conditions Duplication of therapy, inefficiencies e.g. polypharmacy Poor patient motivation and self management

Proactively Identify those at high risk from medicines for domiciliary med review Clinical Pharmacist Undertakes Patient centred Comprehensive assessment of needs & Jointly agrees plan Liaises with others to facilitate Implementation of care plan Monitor & review GSTT model: Integrating MM medication review into the frail older people care pathway using clinical pharmacists in community Community Pharmacist (investigating)

Who is at the highest risk from polypharmacy? Frail older people Aged over 75, often over 85, with multiple diseases, which may include dementia. (British Geriatric Society) Reduced functional reserve more vulnerable to developing complications while in hospital Less resilient to external stressors and take more time to recover Frequent hospital admissions with geriatric syndromes such as falls, immobility and confusion

Identifying frailty Morley JE et al. J Am Med Dir Assoc ; 2013 Jan 1;14(6):392–7

Urgent response & maximising independence Integrated Care Managers A Pragmatic approach Identify population and screen for risk factors Southwark & Lambeth Integrated care (SLIC) Pathway for Frail Older People Program Urgent response & maximising independence Case management @Home team Rapid response Team Supported discharge team Reablement teams Community Matrons 15-20% : Integrated Care Managers Community MDTs : Support case managers to manage most complex cases 70-80% of LTC population

Screening for medicines related risk (local tool)

Proactively identifying those with complex needs (local tool)

Challenging cognitive, physical, functional & sensory impairments Evaluation of service Collaboration with researcher, UCL School of Pharmacy Analysis of 143 patients data from over 300 reviews Average of 9 LTCs and 14 medicines per patient 67% of patients over 75 years and 53% live alone 43% reported at least 1 or more problems with taking medicines 95% use one regular community pharmacy, mainly for access and adherence support 376 medicines related problems (3.8/patient) Contact with a wide range of health and social care staff Factors contributing to the greater need for enhanced community support and referral to pharmacist include Advanced age History of falls Multiple pathologies Polypharmacy New medicines Challenging cognitive, physical, functional & sensory impairments

Many drugs are often continued beyond the point at which they are beneficial and may actually cause harm (DTB 52:2014) Polypharmacy itself should be conceptually perceived as a “disease” with potentially more serious complications than those of the diseases these different drugs have been prescribed for (Doron Garfinkel 2010)

Pharmacist led MM medication review Aims to optimise medicines use by taking the lead to identify, resolve and co-ordinate all aspects of patient care relating to medicines use Reduce inappropriate polypharmacy (deprescribing) and adverse effects. Improve adherence and understanding of medicines Reduce utilisation of emergency services through better therapeutic control of multiple morbidities Facilitate partnership working across agencies and improve medicines use during transitions of care

Deprescribing Oligopharmacy The complex process required for the safe and effective cessation (withdrawal) of inappropriate medications . Takes into account the patient’s physical functioning, co-morbidities, preferences and lifestyle (DTB 52:2014) Oligopharmacy Deliberate avoidance of polypharmacy i.e. less than 5 prescription drugs daily (O’Mahoney. 2011)

Deprescribing:Getting the right balance Life expectancy, co-morbidity burden, care goals patient preferences, benefits of medicines ADRs, risks and harms of medicines

“Deprescribing”-What the literature show1-3 No long term outcome data .......BUT, reduces drug usage/costs & unlikely to cause harm Must involve patients, carers & multidisciplinary working Involves managing multivariate interconnected causes associated with frailty There’s enough evidence to stop certain drugs Many challenges and barriers Must be done sequentially, slowly over a period of time Complex, time consuming, dynamic process requiring co-ordination by a lead clinician with strong therapeutic and interpersonal skills Requires extensive communication, frequent monitoring and reviews  Structured approach needed (7 steps identified) Garfinkel D, Mangin D. Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: addressing polypharmacy. Arch. Intern Med 2012;170:1648-54. O’Mahony, O’Connor. Pharmacotherapy at the end-of-life. Age and ageing 2011;40;419-22 Hilmer SN, Gnjidic D and Le Couteur D.Thinking through the medication list. Australian Family Physician 2012 Vol 41 no 12, p924

Garfinkel et al 2010 Feasibility study of a systematic approach for discontinuation of multiple medication in older adults 70 community dwelling older adults (Feb 05-Jun 08) Follow up every 3-6 months Algorithm based on evidence for drug indication Algorithm identified 311drugs (in 64 pts) to stop 256 drugs considered after family discussion 81% discontinued 2% restarted 88% reported global improvements in health. 100% success for benzodiazepines

The Good Palliative–Geriatric Practice algorithm http://archinte.jamanetwork.com/article.aspx?articleid=226051.

O’Mahoney et al (of STOPP/START fame…) Review of principles for best practice in oligopharmacy Focus  End-of-life or pre-terminal phase Differentiates between starting new drugs vs stopping existing drugs Suggests using STOPP tool to identify drugs for stopping Considers suitability/need for drug classes rather than indication for prescribing (cf Garfinkel) Drugs for primary and life extension Drugs for secondary prevention except benefits Aim for <5 medicines, minimise tablet count and doses per day Optimise formulation and administration methods (liaise with community pharmacist) & refer for MUR where appropriate

Hilmer S 2012 Differentiates between robust vs frail older people Evidence based discussion for appropriate prescribing and deprescribing Differentiates between robust vs frail older people Considers appropriateness based on current poor evidence for commonly prescribed medicines in older people Drug assessment based on adherence, ADRs, indications and interactions Considers ethical principles Multidisciplinary support required for GP to deprescribe safely

Key steps in optimising an older patient's medical therapy http://www.racgp.org.au/afp/2012/december/medication-list/

Summarising the literature Key steps Garfinkel O’Mahoney Hilmer Assess patient  Define overall patient goals Identify inappropriate drugs from accurate list of medication GP-GP Algorithm STOPP tool EBM/ethics Assess each drug for specific risks vs. benefits in context Life extending 10/20 prevention drugs ADR, adherence, indication, interactions Decide to stop or reduce dose Communicate with GP Monitor regularly and adjust accordingly

A structured approach to reducing polypharmacy: Key stages http://www Assess patient Define overall treatment goals Identify inappropriate drugs from accurate medicines list Assess each drug for specific risks & benefits in the context of individual patient Decide to stop or reduce dose Communicate with GP Monitor regularly & adjust

Our Approach to medicines optimisation (1) Patient needs-led approach to assessment Patient & carer needs aligned with specific desired outcomes Patient access to a range of tailored interventions across agencies Assessment tool and process designed to consider the whole range of patient’s medicines needs Pharmacist as patient advocate on all aspects of medicines use Pharmacist manages and monitors interventions Pharmacist is an integral and visible member of the MDT Focus on how care works together vs. discrete contributions of individual parts Everyone’s business, but led and co-ordinated by the pharmacy team towards the common goal

Our Approach to Medicines optimisation (2) Integrating best research evidence with clinical expertise and patient values (Sackett et al. 2000) Patient's goals, values & wishes Patient's circumstances Best available research evidence Clinical expertise of the practitioner Best available research evidence Clinical expertise of the practitioner Patient's circumstances Patient's goals, values & wishes Patient involved in decision making Consider patient views, beliefs, values, goals & fears Focus on patient outcomes Provide personalised information & support interventions Promote Safety , wellbeing & independence

Define overall care goals Assess patient With patient and carers Medical history Functional history Estimate frailty, life expectancy (NHS highland tool4) & trajectory decline Define overall care goals In frail older patients, the main priorities are Symptom control/palliation Maintaining function Addressing end-of-life issues Maintaining dignity

Identify inappropriate drugs from an accurate list of medication Evidence based tools Consensus guidance to support use in older people1 Estimates of risks/benefits Drugs for 10 prevention  No place Drugs for 20 prevention ONLY if time to benefit exceeds life expectancy STOPP/ START tool2 GP-GP algorithm MAI tool3 Clinical judgement/experience Does each drug have a matching indication, is indication still valid? Does the drug produce limited benefit for that indication Is it a high risk drug? Are the benefits overweighed by unfavourable ADRs in OP NHS Highland. Polypharmacy: Guidance for prescribing in frail elderly 2011 Gallagher P et al. Screening tool of older people’s potentially inappropriate prescriptions. Int J Clin Pharmacol Ther 2008;46:72-83 Hanlon J et al. Medication Appropriateness Index- MAI. J Clin Epidemiol 1992;45:1045-51

Inability to apply existing knowledge to a new and complex situation contributes more often to the occurrence of adverse events in older than younger patients Merten Het al. Scale, nature, preventability and causes of adverse events in hospitalised older patients. Age Ageing 2012

Assess each drug for specific risks & benefits in the context of patient circumstance EACH medicine is tailored to the patient’s Defined overall goal Circumstances Clinical reality and social situation Morbidities Experience, preferences and ability to comply Life expectancy

Plan- stop or adjust or continue Discontinue Stop one at a time Gradually Consider rebound Enlist help of peers or specialists Adjust or Continue Optimise therapy Reduce dose/frequency/ prn Substitute with a safer drug, formulation, schedule Wait and see COMMUNICATE-simple format e.g ICARUS GRID MONITOR regularly as needed or @least 3-6 monthly Be clear about what and ensure its in place Look out for ADRs, geriatric syndromes, benefits,

Barriers to deprescribing: Our experience Easier to maintain the status quo, “Let sleeping dogs lie” General poor monitoring Lack of clarity re indications/ treatment goals Little evidence/guidance how to deprescribe safely unpredictable/risky, Time consuming re changing, monitoring/follow up Drugs started by specialists +ve guideline recommendations Fear of complaint, litigation Poor patient engagement and feedback about actual drug effects “Consent and capacity” issues

Summary Multiple morbidity medication reviews are need to address complexities A Structured approach integrated with clinical judgement is required. Acknowledgment that some medicines may be restarted – it’s a trial Full engagement of patient, family, carers is imperative and honesty all round Pharmacists can lead the process but MUST work with MDT Share the workload with specialists Patients, relatives, carers, community pharmacists, OTs, nurses etc can monitor drug effects and feedback Focus on complex patients and those with the highest medication related risks/morbidities For individual patients, focus on the problems/drugs with the highest risks or highest benefits

Workshop Case scenarios

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