Rational prescribing and multimorbidity

According to NICE, multimobidity refers to the presence of two or more long-term health conditions.1 Over 50% of patients aged over 85 years have three or more long-term conditions.

There is a treatment burden in multimorbidity often due to aggressive primary prevention and also guidelines aimed at single health conditions. This guidance is also usually drawn from people who take fewer medications.

This multimorbidity burden leads to multiple clinic appointments where prescribers often work in silos, focusing on their bit of the pathology and communicating poorly with each other. It is not uncommon for a patient to be seeing a respiratory and community heart failure team at the same time. It seems that no one healthcare professional ‘owns’ the patient.

Over 45% of all medications are prescribed for individuals over 65 years.2 This means that polypharmacy is another issue with multimobidity. This is when a patient is prescribed more than four drugs. It is a strong predictor for adverse drug reactions (ADRs). This is because as the number of medications prescribed increases so does the number of drug-drug interactions, errors in dispensing, non-compliance and the risk of overdose.

Drug-related factors include complex regimes and narrow therapeutic index drugs. Patient-related factors are living alone, cognitive impairment, physical frailty, poor vision/dexterity and poor compliance. Clinical-related issues include inappropriate prescribing, failure to adjust dose or monitor and analyse risk versus benefit.3

ADRs account for 6.5% of hospital admissions and 70% of these are avoidable.4 The case fatality for those admitted to hospital is 4.7%5 and the cost to the NHS is £466 million per annum.6

Ageing enhances susceptibility to ADRs because of pharmacokinetics, which is how the body handles drugs and pharmacodynamics, which is how the drug affects the body.

There is also decreased cholinergic activity that affects drugs acting on the central nervous system. This can impact on delirium, cognitive impairment and falls. A decreased baroreceptor reflex affects vasodilators and can lead to postural hypotension and falls.

Non-pharmacological measures remain underutilised in our elderly patients and life expectancy, functional and cognitive status should play a role in decision making as quality of life is important.

Other considerations when prescribing for elderly patients is to treat any new symptom as a potential adverse drug event. We need to start low and go slow, but also to use enough.

Effective tools for polypharmacy reduction include the Beer’s Criteria, which is a list of 53 potentially inappropriate medications and is endorsed by American Geriatrics Society. The STOPP/START is another and the criteria was developed by a panel of British and Irish experts. It is endorsed by British Geriatrics Society as part of comprehensive geriatrics assessment.

In conclusion, inappropriate prescribing runs the risk of adverse effects particularly for the frail elderly. We need to establish local systems for regular medication reviews leading to rational prescribing for people with multimorbidity.

Report based on a talk by Dr Sanjay Suman, Consultant Geriatrician, Medway NHS Foundation Trust, Kent

 

1. NICE.https://www.nice.org.uk/guidance/ng56

2. Wynne HA, et al. Maturitas 2010; 66(3): 246–50

3. Roughead EE, et al. Pharmacoepidemiol Drug Saf 2004; 13: 83–87

4. Medicines optimisation: www.rpharms.com/promotingpharms-pdfs

5. Wu TY, et al. JR Soc Med 2010; 103(6): 239–50

6. Pirmohamed M, et al. BMJ 2004; 329: 15–19

 


Type 2 diabetes in the older patient

Diabetes prevalence just keeps increasing and risk factors include a family history of type 2 diabetes, non-white ethnicity, ageing, hypertension, dyslipidaemia, obesity, lack of exercise and drugs such as thiazides, beta-blockers, atypical, antipsychotics, steroids and ventolin tablets.

Hypoglycaemia is a huge concern for older patients, but staff just don’t seem to appreciate the significance of them and a lot of patients also deny having them. There is over reliance on patient recall, which may be uncertain when cerebral function is impaired during hypoglycaemia. One study suggested that questioning patients alone did not provide an accurate record of clinical hypoglycaemic episodes. It is important, therefore, to involve patients’ relatives and carers.7

Symptoms of hypoglycaemia in the elderly are poor concentration, confusion, sweating, trembling, weakness, inco-ordination, unsteadiness and light headedness. These symptoms may change over the years, yet they are often still not recognised in emergency rooms and dismissed as confusion or even a fit.

Risk factors for hypoglycaemia include recent change of agent, type or dose, hospitalisation, any failure in comorbidities, elderly single male, alcohol, cognitive impairment and increasing age.

To reduce the risk of hypoglycaemia, relaxation of the standard haemoglobin A(1c) (HbA(1c)) goals has been proposed for frail elderly patients. However, the risk of hypoglycaemia in this population with higher HbA(1c) levels is unknown. A study found that raising HbA(1C) goals may not be adequate to prevent hypoglycaemia in this population.8 Of the total of 102 hypoglycaemic episodes, 95 (93%) were unrecognised by finger-stick glucose measurements performed four times a day or by symptoms.

But why do they matter so much? A longitudinal cohort study from 1980–2007 of 16,667 patients with a mean age of 65 years and type 2 diabetes in northern California looked at whether hypoglycaemic episodes severe enough to require hospitalisation are associated with an increased risk of dementia. This was in a population of older patients with type 2 diabetes followed up for 27 years. It found that older patients with type 2 diabetes and a history of severe hypoglycaemic episodes were associated with a greater risk of dementia. Whether minor hypoglycaemic episodes increase risk of dementia is unknown.9

Another study looked at whether hypoglycaemia commonly occurs in patients with diabetes and negatively influences cognitive performance. Also whether cognitive impairment in turn can compromise diabetes management and lead to hypoglycaemia. During the 12-year follow-up period, 61 participants (7.8%) had a reported hypoglycaemic event, and 148 (18.9%) developed dementia. Those who experienced a hypoglycaemic event had a twofold increased risk for developing dementia compared with those who did not have a hypoglycaemic event.10

Similarly, older adults with diabetes who developed dementia had a greater risk for having a subsequent hypoglycaemic event compared with participants who did not develop dementia.

The aim of diabetes treatment 30 years ago was to control glucose. Today it is to control glucose, avoid hypos, reduce weight, make sure it is safe in renal impairment, avoid small and large vessel disease as well as reducing costs.

Report based on a talk by Dr Simon Croxson, Consultant Physician

 

7. Heller S, et al. Unreliability of reports of hypoglycaemia by diabetic patients. BMJ 1995; 310: 440

8. Munshi MN, et al. Frequent hypoglycemia among elderly patients with poor glycemic control. Arch Intern Med 2011; 171(4): 362-4

9. Whitmer RA, et al. Hypoglycemic episodes and risk of dementia in older patients with type 2 diabetes mellitus. JAMA 2009; 301(15): 1565–72.

10. Yaffe K, et al. Association between hypoglycemia and dementia in a biracial cohort of older adults with diabetes mellitus JAMA Intern Med 2013; 173(14): 1300–1306

 


The ageing population and primary care

The number of people aged over 75 years is set to double in the next ten years and people over the age of 65 years are going to make up the majority of the population. It is a credit to the NHS that the reason we have this problem is because we have a healthcare system that is delivering. However, this ticking time bomb of the elderly population means that we need a debate about how we keep people healthy for as long as possible. Also what happens when they are not healthy.

When I worked in a practice in Tower Hamlets, a very elderly frail lady in a wheelchair came to see me one day with her family. Her only problem was that she was constipated. I went into her records and saw that she was on 17 medications and she had six or seven different comorbidities. Even though I had been practicing for over 25 years, I didn’t know what to do to help her. I didn’t know where to start and which of these medications was causing the problem. An elderly care consultant might say start working through the drugs, but the side effects of 17 different medications is a pharmacological stew. By the time you get to five medications you cannot make any valid predictions.

At the time I was chair of the Royal College of GPs and I was writing the vision for general practice and collecting the evidence for this. This patient made me have a light bulb moment. We might be putting our patients on all these fantastic medications to keep their quantity of life going, but what about their quality of life and those who were caring for the quality of their life such their GPs?

GPs do a lot for elderly patients from admission avoidance, follow up with secondary care, over 75 years health checks, and flu vaccinations. But are elderly patients too complex for a generalist?

When I started my training at University College Hospital, they developed a specialty called neonatology for the very young patients and took it away from the paediatricians. Perhaps as a GPs no matter how much additional training we have, maybe we won’t ever be skilled enough to manage the very elderly.

Many people might disagree with this and talk about holistic care of the patient, but I actually think my profession is not ever going to be competent or confident enough to manage these patients.

Of course, I’m not saying that we don’t look after these patients. We also look after the very tiny babies, but the difference is that we don’t take responsibility for their care. Going forward, we need to be looking at new models of delivering care for this older population.

Some areas have started doing this with small multidisciplinary teams that include GPs and elderly care doctors working in a holistic way to deliver a different sort of care to these patients.

We also need to think about the role of the community in helping our elders and how the community can support them at the end of their life. Most discussions are always about what can the state do; what additional services can be added? The costs of supporting the ticking time bomb of this population is going to be astronomical and can we really expect the state to intervene at every level?

GPs have seen an enormous rise in consultation rates for this age group. An average patient over the age of 75 years will consult around 12-14 times a year and many of these are doctor initiated. Can a GP continue to absorb this workload?

Another issue is the medicalisation of old age. We sometimes spin this fantasy that death is something we can prevent with modern medicine. We are excellent at providing healthcare to patients, but we need a sensible debate about when prevention is too much and when death is the natural end to a fulfilling life.

The ticking time bomb of an ageing population is also us. We have to decide what we want as we grow older and how we want be supported by our family and friends, communities and GPs.

Based on a talk by Dr Clare Gerada, Medical Director, NHS Practitioner Health Programme