What the other folks are doing: Polypharmacy Risk Reduction

Johanna Trimble Patients for Patient Safety Canada BC Polypharmacy Risk Reduction Steering Committee Fraser Health Polypharmacy Risk Reduction Working Committee

What are we trying to stop?

Example: female, 88 yrs old, discharged 2 mo. in hospital, near end-of-life New admission to RC today, phone call 1530h to sign off on drugs before 1700h.

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Megestrol 80mg po daily Rivastigmine 9.5mg patch applies daily Ferric gluconate 125mg IV every month Heparin 5000 units sc q 12 h Erythropoietin 4000 units 2 times a week IV Pravastatin 20 mg po hs Asa 325 mg po daily Hydromorphone 0.75mg po QID Tylenol 650mg po QID Citalopram 20 mg po daily Peg 3350 17g po daily Ranitidine 150mg po hs EMLA cream applied to dialysis site Alfacalcidol 0.5mcg po 3x week replavite 1 tab hs sevelamer 1600mg po od with lunch sevelamar 2400mg po daily with supper

Hydromorphone 0.5- 1 po/sc mg q 4h prn pain Lactulose 10-20mg po TID prn Bisacodyl 10 mg PR prn Senna 1-2 tabs po hs prn

Who are we doing this for?

Here is Daisy on antipsychotics and more (May 1992)

Medication review upon admission

• • • • Elizabeth chose Deltaview for Daisy based on their excellent attitude and record of compassionate care After a thorough medication review UPON ADMISSION they stepped Daisy down and off several drugs: antipsychotic, antidepressant, anti-anxiety Within a month Daisy’s blue eyes were bright again and she was feeling at ease in her skin. In December 1992 Daisy was happily chatting on the phone The change held and the family enjoyed each other until Daisy died in 2000

Daisy after drugs were reduced and antipsychotics stopped

(Dec 1992)

Fervid on 9 drugs & suffering a drug interaction: citalopram + tramadol = serotonin toxicity

Fervid, seen after the family asked for a medication review, and the drugs were stopped

Loss of Function No going home.

We learned a lot from Fervid in her remaining 4 years with us.

There is meaning for all of us as human beings… • • Fervid died blessing us and sharing her love and wisdom.

• This is our memory of her and her legacy.

If she had died 4 years earlier of a drug interaction she would have died not even recognizing us.

“Patients with life threatening and life limiting illness need a way of expressing and sharing the things that they feel still need to be said… (This not only) enhances patients’ end of life experience, it provides comfort to their friends and family.” - Dr. Harvey Chochinov, “Dignity Therapy”

It’s up to all of us.

It is not just up to medical professionals to change how we care for our elders at end of life. It’s also up to us:

“Dying, like birth, is a human experience, not just a medical experience. Care changed in birthing because people wanted it, not by medical professionals intervening.”

SWEDEN: Fas Ut (Phase Out) National de-prescribing manual • • • • • • • • Manual given to all prescribers in Sweden Prudent assessment of withdrawal of drugs, especially among the elderly. Covers more than 200 pharmaceuticals How to evaluate and stop treatment What to observe in the patient Alternative pharmacological and non pharmacological interventions 4 th edition coming in 2015 with current drugs, more evidence and translations Will be available as an open data source to integrate with electronic medical records

First Do No Harm: National Stakeholder's Meeting to Reduce Over-prescription of Drugs to Seniors Dr. Cara Tannenbaum, Scientific Director of the CIHR Institute of Gender and Health chaired a meeting Jan 23, 2015 whose stated goals were: • Create a roadmap for reducing the inappropriate use of medication among community seniors.

• Implement a plan for addressing the policy and practice factors that sustain inappropriate prescribing.

• Contribute to solutions such as resource reallocation towards non-pharmacological therapies and dissemination of de-prescribing protocols.

Shine 2012 Programme to reduce Over-medication in residential care: Funded by the Northumbria Healthcare NHS Foundations Trust

“the bit I’m most proud of is managing to give patients a voice”

Dr. Wasim Baqir Research and Development Pharmacist

Structured med reviews, multidisciplinary teams and resident/family decision-making • • • Clinical pharmacists undertook structured reviews using primary care, care home and secondary care notes.

Findings were then discussed by a multidisciplinary team: the pharmacist and a care home nurse, with input from the resident and/or their family or advocate. The best model was where GPs also attended these meetings, however as different GP practices offer varying levels of support to care homes, the project tested four different models of GP involvement.

For every medicine taken by the resident ask 3 questions:

SHINE involved the residents: 16% were able and willing partners • • • • •

SHINE: improved safety Reduced unnecessary prescribing and overmedication Released valuable nursing time Improved quality of life for the residents.

For every £1 invested in the review process, £2.38 could be released from the medicines budget

“He explained things in layman terms. The pharmacist couldn’t tell us to take her (mum) off the medication but he told us the pros and the cons and it was our decision and at least we were able to make an informed decision from the information from the pharmacist”

Daughter of resident

Empowering patients

“I remember one lady, on being told it was up to her whether she wanted to stop a particular medication she didn’t like, actually punching the air with joy. She was so pleased to have been given a say in her own treatment. That kind of informed non-compliance to medication (not taking medicines because you choose not to) can be rare in a care home, where it’s a lot harder to refuse medication, so the process was really empowering” - Wasim Baquir

Geri RxFiles (Saskatchewan) Publication, subscription updates and an app http://www.rxfiles.ca

Geri Rx Files: Organized and easy to use, created by Saskatchewan Academic Detailers

Medstopper

CLeAR: Call for Less Antipsychotics in Residential Care http://bcpsqc.ca/clinical-improvement/clear/

In BC: www.sharedcarebc.ca/initiatives/polypharmacy and Fraser Health Authority’s initiative in RC

Website: www.isyourmomondrugs.com

Email: [email protected]