1. Medicines management in the elderly Trudi McIntosh and Kim Munro School of Pharmacy and Life Sciences RGU

2. Objectives To use patient profiles, patient ‘voices’ and validated assessment tools to identify and prioritise elderly patients at risk of medication misadventure To consider options to rationalise these patients’ medication regimens to reduce this risk To consider own prescribing practice in relation to risks of medication misadventure

3. Medication misadventure? Aging population: co-morbidities polypharmacy + complex medication regimens increased risk of interactions effect of aging on metabolism of drugs reduced dexterity possible cognitive decline social circumstances etc

4. Guidance: national and local Polypharmacy Guidance 2012 Scottish Government http://www.central.knowledge.scot.nhs.uk/upload/Polypharmacy%20full%20 guidance%20v2.pdf http://www.central.knowledge.scot.nhs.uk/upload/Polypharmacy%20full%20 guidance%20v2.pdf NHS Grampian guidance on reducing polypharmacy in frail older people http://www.nhsgrampian.com/grampianfoi/files/PolyPh_538_0912.pdf

5. Tools to assess ‘risk’ Beers criteria: potentially inappropriate medication use in older adults STOPP-START: screening tools for potentially inappropriate meds/ right meds Morisky medication adherence scale Medication regimen complexity index Anticholinergic risk scale plus others

6. Initial thoughts Miss Agnes Smith and Mrs Susan Green Patient profile + Polypharmacy Guidance, Scottish Government. Initial thoughts? Complexity? Medication Regimen Complexity Index

7. Adherence Miss Agnes Smith and Mrs Susan Green Patient interviews Video clip: ‘Morisky questions’ to assess adherence

8. Anticholinergic risk scale Anticholinergic burden may contribute to falls, delirium, cognitive impairment, dry mouth, constipation etc Assess patients’ risk of medicine misadventure due to anticholinergic risk

9. Prioritisation and rationalisation How will you prioritise the patients? How might you start to rationalise their medications? Impact on your own prescribing practice?

10. References Fick, D.M. et al. 2003. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts Archives of Internal Medicine, 163(22), pp. 2716–2724. Gallagher P, et al. 2008. STOPP (Screening Tool of Older Persons’ Prescriptions) and START (Screening Tool to Alert Doctors to Right Treatment): Consensus Validation. Int J Clin Pharmacol Therapy, 46(2), pp.72 – 83. George, J. et al., 2004. Development and validation of the medication regimen complexity index. The Annals of Pharmacotherapy, 38(9), pp. 1369-1376. Morisky, D.E., Green, L.W. and Levine, D.M., 1986. Concurrent and predictive validity of a self-reported measure of medication adherence. Med Care,;24, pp. 67- 74. Rudolph, J.L. et al.,2008. The anticholinergic risk scale and anticholinergic adverse effects in older persons. Archives of Internal Medicine, 168(5), pp.508-513.