Rational prescribing and multimorbidity in the ageing patient

According to NICE, multimorbidity 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.

Multimobidity is a strong predictor for adverse drug reactions 

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%⁵and 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

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 Talk given at the GM Conference: Tackling the ticking timebomb of elderly healthcare.

Don’t miss Dr Sanjay Suman talking on what’s new in sarcopenia in London this October at our conference: The Ageing Patient: Midlife and Beyond. View the full CPD programme and book your place here.

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