1. 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

2. 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

3. 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: /bjgp10X BJGP July 1, 2010 vol. 60 no. 576 e285-e294.
Multimorbidity in primary care: developing the research agenda. Family Practice (2009) 26 (2): 79-80.doi:  /fampra/cmp020

4. 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 Making our health and care systems fit for an ageing population
Naylor S et al. Kings Fund Transforming our health care system: Ten priorities for commissioners.

5. 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: /bjgp10X BJGP July 1, 2010 vol. 60 no. 576 e285-e294.

6. 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 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

7. 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: /bjgp10X BJGP July 1, 2010 vol. 60 no. 576 e285-e294.

8. 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

9. 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

10. 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)

11. 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

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

14. 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

15. Screening for medicines related risk (local tool)

16. Proactively identifying those with complex needs (local tool)

17. 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

18. 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)

19. 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

20. 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)

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

22. “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:
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

23. 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

24. The Good Palliative–Geriatric Practice algorithm

25. 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

26. 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

27. Key steps in optimising an older patient's medical therapy

28. 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

29. 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

30. 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

31. 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

32. 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

34. 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:

35. 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

36. 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

39. 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 3-6 monthly
Be clear about what and ensure its in place
Look out for ADRs, geriatric syndromes, benefits,

40. 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

41. 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

42. Workshop Case scenarios

43. Thank you for listening