Polypharmacy in a Geriatric Day Hospital - Regional Geriatric ...

Barbara Farrell BScPhm, PharmD, FCSHP
Bruyère Geriatric Day Hospital

What is polypharmacy?
Context: Bruyère Geriatric Day Hospital
GDH case reports: objectives and methods
Example of contributions to cases and
outcomes
Cost-analysis – methods and results
Questions and discussion

Polypharmacy
◦ Concurrent use of > 5-10 medications
◦ Use of ‘inappropriate’ medication choices or doses
◦ More medications than clinically indicated
Associated with…
◦ Adverse drug reactions
◦ Drug interactions
◦ Inappropriate use
◦ Non-adherence
◦ ER and hospital admissions
◦ Significant health care costs

Canadian Institute of Health Information (2009)
◦ 63% of seniors had claims for ≥ 5 drug classes
◦ 23% had claims for ≥ 10 drug classes
◦ 30% of >85 had claims for ≥ 10 drug classes
National Population Health Survey
◦ 5 medications used by 13% of community dwelling and
53% of those in institutions
Ontario Drug Benefit claims
◦ Increased by 214% in last decade while those >65
increased by only 18%
At Bruyère GDH, patients referred for medication
assessment take an average of 15 medications

amipril
Need for CV
protection
Cough
ASA
dextromethorphan
Increased blood
pressure
ibuprofen
Need for GI
prophylaxis
amlodipine
Heartburn
lansoprazole
Ankle
swelling
Incontinence
oxybutynin
furosemide
Incontinence
Decreased vitamin
absorption
Low
potassium
dimenhydrinate
Incontinence
Incontinence
Vitamin B12
potassium
Nausea
lorazepam

Intentional
- too many, why
bother?
Non-intentional
– complex, forgets
Intentional medication nonadherence in a geriatric
day hospital. CPJ 2011;144(6): 260.
Multi-compartment compliance aids: friend or foe?
Drugs and Aging 2012;29(3):249.

CIHI (2013) - $33 billion spent in 2012
Up to 25% of all hospital admissions and ER
visits are drug-related (CIHI 2013)
Up to ¼ of those who visit ERs due to ADRs
are admitted to hospital (CIHI 2013)
Those with adverse drug reactions incur more
health services

Age-related changes
◦ Absorption: altered bioavailability (↓ transport, ↓
first pass)
◦ Distribution: ↑ body fat, ↓ body water
◦ Metabolism: ↓ oxidative metabolism
◦ Excretion: ↓ renal function (increases half-life)
Altered pharmacodynamics
◦ Changes in receptor numbers, postreceptor
alterations
◦ Impaired homeostatic mechanisms
Increasing comorbidity
Medications not well studied in frail elderly

Prevalence of chronic conditions increases with
age:
◦ 65-69: men 35%, women 45%
◦ > 80: men 53%, women 70%
As comorbidities accumulate, management
becomes more challenging:
◦ “Guideline gridlock”
One comorbidity can increase risk of another
◦ E.g. dementia and delirium
More specialists involved = competing priorities
and risk for miscommunication
Patient’s priorities often lost

Multiple medications (sometimes > 25)
Medications contributing to geriatric
syndromes (e.g. cognitive impairment, falls)
Prescribing cascades
Many medications no longer needed
Patients and caregivers
◦ Unclear about purpose of medications
◦ Confused about how to take them
Some conditions undertreated
Drug-related problems in the frail
elderly. Can Fam Phys 2011;57:168.

Salima Shamji, Barbara Farrell, Anne Monahan, Veronique French
Bruyere Academic Medical Organization Incentive Fund 2011

Develop a series of case reports that highlight
common medication conundrums in the frail
elderly population, describe relevant literature
and approaches for medication management
taken by the Bruyère GDH interprofessional team
Ensure case reports useable by family physicians
and pharmacists to improve skills at managing
complex polypharmacy issues in the frail elderly
and facilitate their collaboration in this
endeavour
Provide cases for use by geriatrics and
interprofessional collaboration educators

Waterloo pharmacy co-op student assistance
◦ Karishma Kak, Nafisa Ingar, Wade Thompson, Dan
Dalton
Eight cases selected to illustrate variety of
polypharmacy challenges
Publication status:
◦ Canadian Pharmacists Journal (1+ 3)
• In press (1 + 2); accepted (1)
◦ Canadian Family Physician (1+ 3)
• In press (1 + 2); under review (1)
◦ Canadian Medical Association Journal (2)
• In press (2)

Pharmacotherapy assessment
◦ Is this caused by a drug?
◦ Indication
◦ Effectiveness
◦ Safety
◦ Adherence and understanding

Provider
Physiotherapist
Occupational
therapist
Social worker
Dietician
Nurse
Provides:
exercise programs, mobility aids to better manage pain &
optimize balance and strength to reduce fall risk
assistive devices, equipment to reduce fall risk and improve
function & pain management; falls prevention strategies
and joint protection education
relaxation and insomnia management strategies to
minimize psychotropic use; counselling for mood disorders
dietary approaches for nutritional deficiencies; counselling
re: salt reduction to reduce diuretic & antihypertensive use
monitoring of vitals and symptoms to assess medication
changes; non-pharmacological approaches (e.g. sleep
hygiene, heartburn management, incontinence, orthostatic
hypotension, constipation, compression stockings); assess
medication management ability & provide individualized
education (e.g. teaching re: dosette filling)

Provider
Recreation
therapist
Psychometrist
Speech
language
pathologist
General aide
Physician
Pharmacist
Patient and
caregiver(s)
Provides:
access to programs to minimize isolation & maintain
activity level to reduce risk of depression
clarification of cognitive deficits ensuring appropriate
support for medication management
strategies to manage dry mouth and swallowing difficulties
monitoring of impact of medication changes on sleep,
function and pain
medical assessment, treatment evaluation, medication
changes and nonpharmacologic options
medication assessment, pharmacy care plan, medication
intervention management, education and monitoring
buy-in for and monitoring of effects of medication changes

77 year old woman
Referred: mobility and falls,
chronic pain, constipation,
cognition, and polypharmacy
PMH: cerebrovascular disease,
CAD, hypertension, dementia,
fibromyalgia, myositis, bipolar
disorder, arthritis, remote
duodenal ulcer, hypothyroidism
Frustrated by loss of
independence (daily assistance
with washing and dressing)
Retirement residence staff
managing medications
LTC placement being considered
On admission: wheelchairbound,
heavily sedated, making
interviewing and assessment
difficult
Near-falls attempting to selftransfer
and could not stand
unsupported (also OH)
Creatinine clearance 30 mL/min
(Cockcroft-Gault equation with
ideal body weight)
Farrell B, French Merkley V, Thompson W. Adding up
the impact of medications from multiple prescribers –
managing polypharmacy. CMAJ (in press)

Quinapril 40mg daily
Amlodipine 5mg daily
Diltiazem ER 360mg daily
Acebutolol 200mg twice daily
Nitroglycerin patch 0.6mg/h qhs
Nitroglycerin 0.4mg spray prn
Furosemide 40mg daily
Dipyridamole/ASA 200/25 mg bid
Rosuvastatin 20mg twice daily
Levothyroxine 0.088mg daily
Tiotropium 18mcg daily
Salbutamol 100mcg, 2 puffs qid prn
Galantamine ER 16mg daily
Levofloxacin 250mg daily
Morphine 10mg qhs
Acetaminophen 650mg q4-6h
prn
Cyclobenzaprine 5mg tid
Glucosamine 500mg bid
Amitriptyline 75mg qhs
Oxazepam 15mg qhs
Lactulose 15mL daily prn
Magnesium hydroxide 311 mg
1-2 tablets qhs
Fibre in water
Carter’s liver pill 2 pills prn
“Suppository”
Cranberry 500mg tid
Carbamazepine 200mg bid
Omeprazole 20mg daily

Farrell B, French Merkley V, Thompson
W. Adding up the impact of medications
from multiple prescribers – managing
polypharmacy. CMAJ (in press)

Process of lowering doses, tapering and/or
stopping medications
When in doubt, taper
Monitor for adverse drug withdrawal events:
◦ Physiological
◦ Rebound
◦ Withdrawal

Berg Balance Score improved from 18 to 31/56
Progressed from wheelchair to walker, then cane
No falls from fourth week onward
No worsening of pain
Reporting increased self-confidence and independence
Constipation resolved
Resumed old hobbies
Improved social interaction
Nightime sleeping improved; daytime napping
eliminated
Cognitive findings in keeping with stroke, not dementia

Morning
Quinapril 40mg
Diltiazem ER 360mg
Furosemide 10mg
Levothyroxine 0.088mg
Tiotropium 18mcg
Dipyridamole/ASA 200/25 mg
Galantamine ER 16 mg
Cranberry Complex 500 mg
Polyethylene glycol 3350 1 tbsp
Vitamin D 1000 IU
Supper
Dipyridamole/ASA 200/25 mg
Cranberry Complex 500 mg
Bedtime
Cyclobenzaprine 5 mg
Oxazepam 15mg
Cranberry Complex 500 mg
Rosuvastatin 20 mg
Carbamazepine 100 mg
As needed
Nitroglycerin spray 0.4mg
Acetaminophen 650mg
Saliva substitute (Moi-Stir)

Waterloo pharmacy co-op students
◦ Evan Steed, Danielle Paes
Methods
◦ Pre & post admission medication numbers for
prescription and non-prescription drugs, including
pill burden (# of oral doses)
◦ Projected Ontario Drug Benefit (ODB) savings in
drug acquisition costs
◦ Extrapolated savings based on GDH yearly
admission rates

Assessment rules:
• 2013 ODB pricing data used (exclusion: OTC and
prn medications)
• Lowest-priced generics used when available
(consistent brand for uniformity)
• 15 mL once daily dosing convention used for
fibre/psyllium (if unspecified)
• Only ODB-covered acetaminophen dosage forms
used (ie., not 650mg EC)
• If range prescribed (i.e. 1-2 tablets), higher end of
range used

N=8
On
admission
At
discharge
Reduction
# of
medications
17.5 (8-28) 13.1 (6-20) 4.4
Average
(per
person)
Daily
Monthly
(30 days)
Pill burden 21.8 (9-32) 16.6 (7-21) 5.2
Cost $6.62 $4.08 $2.54
Cost $198.68 $122.27 $76.41
Yearly
(365 days)
Cost $2417.27 $1487.63 $929.64

Extrapolated to 350 yearly GDH patient
admissions, interventions to reduce
polypharmacy could result in ODB medication
cost savings of approximately $325,000
annually

Patient selection bias (selected from numerous
similar cases to illustrate variety of drug-related
problems and interventions)
Small sample size
Cost not used as an intervention criteria
Cost analyses does not include non-ODB
medications, dispensing fees or mark-up fees
Impact on patient outcome not measured
No follow-up beyond GDH admission to
determine sustainability of medication changes
done

Should include
◦ Costs related to medications not covered by ODB
◦ Costs related to mark-up and dispensing fees
◦ Outcomes of pharmacotherapy optimization (e.g.
hospitalization, falls etc.)
◦ Work time and resources required to perform
assessments and interventions

Interprofessional medication review and
interventions during GDH admissions:
◦ Reduced medication use and pill burden (which
could improve adherence)
◦ Resulted in ODB cost savings (which could be
significant if all patients included)

With the 8 case reports:
◦ Assess changes in Berg Balance and walking
distance?
◦ Assess impact?
Patients and government payers stand to
benefit from optimization of drug therapy
through GDH programs that emphasize
polypharmacy reduction
◦ How can we fully understand the benefits?
◦ What do we need to measure?
◦ What is the real potential to reduce health care
costs and improve care?

Team approach to benzodiazepine tapering
◦ CIHR funded meeting grant (to discuss adaptations
to a team approach to benzodiazepine tapering for
different environments: FHT, CHC, GDH, LTC
◦ Sept 23 and 24th at Bruyère Continuing Care
◦ Recruiting 1-2 representatives of each Day Hospital
◦ Request for expressions of interest sent
◦ So far, responses from:
• Bruyere and QCH
If interested, tell me, or e-mail
Courtney Pelley: cpelley@bruyere.org
◦ Follow up to:
• Discontinuing benzodiazepine therapy: An interdisciplinary
approach at a geriatric day hospital. Can Pharm Journal
2010;143:286.

Editors
◦ Diane Kelsall, John Fletcher, Renee Dykeman,
Rosemary Killeen, Nick Pimlott
Authors
◦ Salima Shamji, Veronique French-Merkley, Anne
Monahan, Pamela Eisener-Parsche, Nafisa Ingar,
Wade Thompson, Dan Dalton
Other students (University of Waterloo)
◦ Karishma Kak, Evan Steed, Danielle Paes
Funding
◦ Bruyère Academic Medical Organization

One of the causes of polypharmacy is the reluctance to change treatment because of other
prescribers involved. For healthcare systems where there are multiple prescribers but no main
healthcare provider or family physician, how do we overcome the reluctance to change the
treatment? Especially if there is an implication that the duty of care would be transferred to the
prescriber that does the active intervention of changing treatment.
What sort of patient-centered outcome measures might health system leaders look at to
understand this issue?
How can we better understand the impact of polypharmacy on patient experience?
Shouldn’t medications be reviewed when a prescription needs to be renewed? How do our systems
fail us here?
What is the impact of polypharmacy on younger patients? (or are they simply more robust than the
frail elderly and able to tolerate a mix of drugs?)
What could be the role of patients and patient education in addressing polypharmacy?
What are the major occasions where medicines are introduced over a patient's lifetime? Which of
these could be minimized?
From the perspective of a pharmaceutical company, what are the implications associated with
polypharmacy? How could they be motivated to collaborate on this issue?
From the perspective of a payor, how could you estimate the financial implications / benefits
associated with deprescribing?
How to take into consideration which comorbidity the patient values the highest? e.g. perhaps the
very old or frail are more interested in pain management rather than disease management.