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Polypharmacy PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled "Polypharmacy - An introductory module for clinicians” by Lawrence Jackson, BScPhm, CTDP.

This medical PowerPoint presentation is about polypharmacy, the use of multiple medications by an individual to treat various health conditions. This can occur when a person sees multiple healthcare providers, each prescribing medications independently without knowledge of the other prescriptions, or when a healthcare provider prescribes multiple medications for a single condition or a cluster of conditions.

Polypharmacy can be beneficial in some cases where multiple conditions need to be treated, but it can also lead to adverse drug reactions, drug interactions, and decreased medication adherence. It is particularly problematic in older adults, who may have multiple chronic health conditions and a higher risk of adverse drug events.

To manage polypharmacy, healthcare providers should regularly review a patients medications and evaluate the need for each medication, as well as potential interactions and adverse effects. Patients can also play an active role by keeping a medication list, notifying their healthcare provider of all medications they are taking, and reporting any adverse effects or concerns they may have.

Tags : Polypharmacy, multiple medications, Geriatrics, Geriatric Medicine, Geriatrics PowerPoint presentation

Published on : May 09, 2023 | Views : 1007 | Downloads : 5

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Slide 1-

Polypharmacy An introductory module for clinicians Lawrence Jackson, BScPhm, CTDP Pharmacy Clinical Coordinator, Sunnybrook Health Sciences
Slide 2-

This module is part of the sfCare approach PowerPoint Presentation 8.5 x 11 Poster Patient Handout
Slide 3-

Identify the factors that contribute to polypharmacy Explain the consequences of problematic polypharmacy Describe a structured approach to the detection of problematic polypharmacy Apply general strategies to limit problematic polypharmacy Apply a senior friendly care approach to polypharmacy Objectives Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions
Slide 4-

While there is no consensus definition for polypharmacy, most studies have used a numerical threshold of 5 or more medications per day What is polypharmacy? 1. JAMA 2017;318(17):1728 2. Duerden M, et al. Prescriber 2014;25:44-47 Approximately 40% of older adults take 5-9 medications1 Approximately 18% of older adults take 10 or more medications2 Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions
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Medication optimization ensures benefits outweigh risks Takes into consideration impact on outcomes important to the older adult, such as Improving the duration and quality of life Symptom control Prevention It is evidence-based Appropriate versus problematic polypharmacy JAMA 2017;318(17):1728 Duerden M, et al. Prescriber 2014;25:44-47 Appropriate Polypharmacy Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions
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Appropriate versus problematic polypharmacy JAMA 2017;318(17):1728 Duerden M, et al. Prescriber 2014;25:44-47 Problematic Polypharmacy Risk of harm exceeds the potential benefits or coexists with the benefits Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions
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Impact of polypharmacy on the older adult  adverse drug reactions  drug interactions  cost  risk of non adherence  risk of medication errors Precipitate or exacerbate geriatric syndromes The following risks accompany polypharmacy: Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions
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Impact of polypharmacy on the older adult Falls Functional impairment Cognitive impairment Urinary incontinence Impaired nutrition Dehydration Constipation Geriatric syndromes Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions
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Risk factors for polypharmacy = Increased risk of problematic polypharmacy OR harmful medication effects + + Multiple medical problems/ multiple medications Reduced homeostatic mechanisms and organ dysfunction AND/OR Frailty Acute illness or change to medications Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions
Slide 10-

Risk factors for polypharmacy Multiple medical problems/multiple medications Treatment guideline-based prescribing Promotes multiple medications Conditions for deprescribing uncertain ADRs and prescribing cascade An adverse reaction to one drug may go unrecognized/ misinterpreted Healthcare provider inappropriately prescribes a second drug to treat signs/symptoms Infrequent medication review There is a lack of incentive to deprescribe Unnecessary drugs or doses not adjusted Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions
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Taffet GE, Physiology of aging. In: Cassel CK, Leipzig RM, Cohen HJ, et al [eds]. Geriatric Medicine: An Evidence-Based Approach, 4th ed. New York, Springer, 2003 Risk factors for polypharmacy Reduced Homeostatic Mechanisms & Organ Dysfunction Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions A decline in physiologic reserves associated with aging causes the older adult to become less resilient to various causes of stress such as acute illness or injury, or the effects that medications have on the body. The combination of increased stressors and a decrease in physiologic reserve can lead to adverse outcomes such as hospitalization or death.
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Risk factors for polypharmacy Pharmacokinetics changes Absorption Distribution Metabolism (liver) Excretion (kidney) Changes in how the body acts on the drug Pharmacodynamics changes Changes in receptor binding ↓ # of receptors and receptor activity ↑↓ Drug efficacy ↑ Toxicity / ADRs Changes in how the drug acts on the body Changes in physiology with aging: ↑ body fat ↓ body water ↓ albumin ↓ liver metabolism ↓ renal function Reduced homeostatic mechanisms and organ dysfunction Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions
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Risk factors for polypharmacy Characteristics of frailty Unintended weight loss due to inadequate nutrition Slow walking speed Impaired grip strength Exhaustion Self reported decline in activity levels Frailty Older people are vulnerable to medication-related problems associated with frailty. Robust Pre-frail Frail 0 1-2 ≥3 Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions
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Risk factors for polypharmacy Older age Multiple medical problems (or geriatric syndromes) Taking multiple medications Multiple psychosocial problems One or more sensory impairments (vision, hearing) New onset urinary or fecal incontinence Decrease in functional status Change in mental status- cognition/affect Disruptive behavior or personality changes Frequent falls Frailty (cont.) Several factors are known to be associated with frailty: Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions
Slide 15-

Risk factors for polypharmacy With acute illness, usual medications can cause unanticipated harm With any change in medications or change in dose, adverse effects can result Acute illness or changes to medication can lead to problematic polypharmacy Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions
Slide 16-

Challenges in detecting polypharmacy Problems due to medications may occur Without any changes to the medication Advancing age Coincident with acute illness or symptoms ADRs masquerade as age-related changes Atypical presentation of adverse effects Side effects difficult to interpret, may go unreported Prescribing cascade Infrequent Medication Review There is a lack of incentive to deprescribe Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions
Slide 17-

Detecting problematic polypharmacy Problematic polypharmacy can present in atypical ways, such as … Exaggerated medication effects Loss of medication’s effect Problems with taking medication New or worsening symptoms or conditions Decline in functional and self-care abilities Decline in mobility Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions Confusion and falls are important clues that resilience is compromised in an older adult and should prompt a search for causes, including medications!
Slide 18-

Addressing polypharmacy Assess medication list with an available tool Explicit criteria – list of potentially inappropriate medications Implicit criteria or comprehensive assessment Medication assessment framework Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions
Slide 19-

Addressing polypharmacy STOPP/START Explicit criteria – lists of potentially inappropriate medications (PIM), for example Suggests drugs to avoid and drugs to use High alert medications anticholinergic activity Benzodiazepines Tricyclic antidepressants Warfarin NSAIDs Fluoxetine Digoxin Oxybutynin Age and Aging 2015; 44(2):2013-218 J Am Geriatr Soc 2019;67(4):674-694 Suggests drugs to avoid and highlights high alert medications / patients High alert patients Impaired renal function Impaired cognition or senses Falls Hypotension Diabetes Parkinson’s disease Poor nutrition Beers Criteria List Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions
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Dose and frequencyEffectsBenefitRiskIndicationDrug monitoringExpectations Medication Appropriate Index (MAI) No TEARS ARMOR 7-Step Review Process… Gokula M, Homes H. Clin Geriatr Med 28 (2012) 323–341 DEBRIDE: Medication reviews in long-term care and supportive living. Alberta http://www.cpsa.ca/medication-reviews-long-term-care-supportive-living-physicians-perspective/ MAI: Hanlon JT, et al. MAI J Clin Epidemiol. 1992;45:1045–51 No TEARS: BMJ 2004;329:434 ARMOR: Haque R. Ann Long-Term Care 2009;17:26-30 Other Medication Assessment Frameworks Medication assessment frameworks Addressing polypharmacy Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions
Slide 21-

Addressing polypharmacy Implicit criteria or comprehensive assessment Health status Prognosis and goals of care Benefit – risk assessment of each medication and overall combination of medications Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions
Slide 22-

Addressing polypharmacy Assess risk for polypharmacy Annual review of medications in all older adults Inform caregivers of medication changes to increase the chance of detecting problems as soon as possible Chose medications with the fewest side effects Stop unnecessary medications Consider the impact of medications on quality of life Consider the person’s ability to take medications and remember to take them Limiting potential harms Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions
Slide 23-

Addressing polypharmacy 1. Recognize the Need A practical guide to stopping medication… 2. Reduce or Stop to stop a medicine one medicine at a time 3. Taper Medicine when appropriate 4. Check for Benefit or Harm after each medicine has been stopped With the person’s consent, view the discontinuation process as a trial At the next scheduled visit review progress, then either: Maintain (at half dose) Continue to taper (e.g. quarter dose) Stop Time taken to taper may vary from days to weeks to months If symptoms worsen, may need to reinstate the medication At the first visit, halve the dose Frank C, Weir E. CMAJ 2014;186(18):1369-1376 Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions
Slide 24-

Case study: Mary Mary is 85 years old and has 4 chronic conditions that require 9 medications. No changes to her medications for 5 years. One month ago a new medication was started. Soon after that, she began to feel unsteady when walking and has been incontinent of urine on 2 occasions because she is not able to get to the bathroom fast enough. One week ago, she fell but only sustained some bruising of her arm. She is mystified by these new problems and wonders if she is getting old and whether she can stay in her own apartment. She wonders if she should report these problems to her daughter. What’s going through your mind? Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions
Slide 25-

Is Mary at risk of problematic polypharmacy? Identify the risk factors in Mary’s case + + Multiple medical problems/ multiple medications Reduced homeostatic mechanisms and organ dysfunction AND/OR Frailty Acute illness or change to medications Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions
Slide 26-

Is Mary at risk of problematic polypharmacy? 4 chronic conditions that require 9 medications: Prescribing cascade and increasing polypharmacy Problematic medications left unchanged Risk of further decline in health status + Multiple medical problems/ multiple medications Reduced homeostatic mechanisms and organ dysfunction AND/OR Frailty Acute illness or change to medications Identify the risk factors in Mary’s case Objectives What is Polypharmacy? Impact for the Older Person Risk Factors Detecting Addressing Case Study Summary Senior Friendly Approach Questions
Slide 27-

New acute condition may have: Compromised her homeostatic mechanisms; or Worsened her already impaired organ function + Multiple medical problems/ multiple medications Reduced homeostatic mechanisms and organ dysfunction AND/OR Frailty Acute illness or change to medications Is Mary at risk of problematic polypharmacy? Identify the risk factors in Mary’s case Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions
Slide 28-

New health problems not attributed to medications: Urinary incontinence, via decreased mobility Fall Confusion: Mary is unsure if episodes should be reported to daughter Psychological distress: Mary is worried about ability to live independently + Multiple medical problems/ multiple medications Reduced homeostatic mechanisms and organ dysfunction AND/OR Frailty Acute illness or change to medications Is Mary at risk of problematic polypharmacy? Identify the risk factors in Mary’s case Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions
Slide 29-

Recently been prescribed a new medication for a new condition/acute illness Usual medications have caused unanticipated harm Recent medications were not communicated to Mary’s daughter, leading to insufficient health monitoring and reporting No recent medication review + Multiple medical problems/ multiple medications Reduced homeostatic mechanisms and organ dysfunction AND/OR Frailty Acute illness or change to medications Is Mary at risk of problematic polypharmacy? Identify the risk factors in Mary’s case Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions
Slide 30-

Case study: Mary - resolution Finally, apply the Medication Review Framework (DEBRIDE) to determine if Mary can benefit from de-prescribing. Dose and frequency - Is the dose and frequency correct based on age and organ function? Effects - Have the known side effects been considered? Benefit - Will Mary benefit from treatment given goals of care? Risk - Is the medication considered a high risk medication? Indication - Is the indication for the new medication clear and valid? Drug monitoring - Is a monitoring plan in place to assess benefit and harm? Expectations - Are the expectations of benefit to be achieved realistic? Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions
Slide 31-

Summary Polypharmacy is common ≥ 65 years due to multiple conditions requiring medications polypharmacy can be appropriate or problematic Risk of harm increases with # medications, frailty, and illness inconvenience ……hospitalization………..death Medication appropriateness may change over time decline in functional reserves of organs (frailty) maintenance medications may become harmful medication changes result in adverse effects or new drug-interactions Medication appropriateness may change with acute illness loss of physiologic reserve causes medications to have an enhanced effect Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions
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Summary medication problems can occur without a change in medications tools are available to structure the medication assessment process each patient is unique, medication decisions require clinical judgement all care providers can contribute to medication problem identification and reporting Recognizing problematic polypharmacy is difficult Benefit/harm ratio can change in an instant or gradually over time. Regular medication review provides an opportunity to detect problems, adjust doses based on changing physiology and consider medication deprescribing. Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions
Slide 33-

Summary Assess polypharmacy risk Annual review of medications in all older adults Inform caregivers of medication changes to increase the chance of detecting problems as soon as possible Chose medications with the fewest side effects Stop unnecessary medications Consider the impact of medications on quality of life Consider the person’s ability to take medications and remember to take them Strategies to limit the potential harms due to polypharmacy Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions
Slide 34-

The senior friendly approach How all healthcare providers can address polypharmacy using a senior friendly care approach Leadership-supported medication reviews Providing staff and patient education Changes in condition prompt a medication review – regardless of patient age Medications are meeting the older adult’s goals Facilitate medication reviews Medication reminder systems to increase adherence Organizational Support Emotional & Behavioural Environment Ethics in Clinical Care and Research Physical Environment Processes of Care Organizational Support Ethics in Clinical Care and Research Processes of Care Emotional & Behavioural Environment Physical Environment Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions
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Which of the strategies to limit the potential harms due to polypharmacy (slide 33) are you already using in your practice? What are some of the barriers to implementing strategies to limit the potential harms due to polypharmacy (slide 33)? What is one strategy that you can implement moving forward? Discussion questions Objectives What is polypharmacy? Impact for the older adult Risk factors Detecting Addressing Case study Summary Senior friendly approach Questions
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The sfCare Learning Series received support from the Regional Geriatric Programs of Ontario, through funding provided by the Ministry of Health and Long-Term Care. V1 July 2019