Download - Prescribing for the Frail Elderly
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Prescribing for the Frail Prescribing for the Frail ElderlyElderly
THE THE THERAPEUTIC THERAPEUTIC DRUGECTOMYDRUGECTOMY
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CASE STUDYCASE STUDY
MargaretMargaret
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• 90 years old• Discharged from hospital three months ago
with:
non-small cell carcinoma lung palliative
COPD
ankle edema
hypertension
depression
osteoporosis
dementia
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Furosemide 20 mg ODRamipril 5 mg BIDMetoprolol 25 mg BIDTiotropium MDIFluticasone/salmeterol MDIMirtazapine 15 mg HSRisedronate 5 mg ODDonepezil 5 mg ODVitamin DCalciumFolate
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HOME VISIT
S: I feel kind of tired, dizzy sometimes, no pain, breathing is okay.
O: Cheerful, cognitively grossly intact, pale
RR 28 no distress
BP 90/palp
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WHAT DO WE
DO?
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Furosemide 20 mg ODRamipril 5 mg BIDMetoprolol 12.5 mg BIDTiotropium MDIFluticasone/salmeterol MDIMirtazapine 15 mg HSRisedronate 5 mg ODDonepezil 5 mg ODVitamin DCalciumFolate
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Furosemide 20 mg OD
Metoprolol 12.5 mg BID
Fluticasone/salmeterol MDI
Mirtazapine 15 mg HS
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URGENT CALL
S: (collateral) Increased shortness of breath, more confused, less mobile.
O: pale, warm, mildly disoriented, 110/palp HR 105, no JVD, reduced air entry lungs.
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MARGARET’S OUTCOME
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WHY IS IT SO DIFFICULT?
• Prevention Doesn’t Work in Frailty
• Heterogeneity Unpredictability
• Multiple Pathology Polypharmacy
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First,
Prevention Prevention
Doesn’t WorkDoesn’t Work
if you’re Frailif you’re Frail
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FOUR GOOD REASONS
WHY NOT
1. No prediction in the unpredictable
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HETEROGENEITY
UNPREDICTABILITUNPREDICTABILITYY
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…YOU CANT PREDICT
for someone who is
UNPREDICTABLEUNPREDICTABLE
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FOUR GOOD REASONS
WHY NOT
2. NO FRAIL IN TRIALS
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Principle of Geriatrics 2
“The frail elderly are
MULTIPLY PATHOLOGICAL”
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The QUORUM EPIPHANY
Clinical trial exclusion criteria are Clinical trial exclusion criteria are unbelievably comprehensiveunbelievably comprehensive
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Trials EXCLUDE FRAILTY
You
CAN’T DO
studies that support prevention
in frailty
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FOUR GOOD REASONS
WHY NOT
3. LIMITED CHANCE OF BENEFIT
4. OFFSETTING DANGER
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Bottom Line:
FRAILTYFRAILTY
lives in anlives in an
EVIDENCE-FREE EVIDENCE-FREE ZONEZONE
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Want “evidence”?Strandberg TE, Pitkala KH, Berglind S, Nieminen MS, Tilvis RS. Multifactorial
intervention to prevent recurrent cardiovascular events in patients 75 years or older: The Drugs and Evidence-Based Medicine in the Elderly (DEBATE)
study: a randomized, controlled trial. Am Heart J 2006;152:585-592.
… not only does prevention not make sense in frailty,
IT REALLY DOESN’T WORK.
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10 RULES for
STARTING MEDICATION
in the FRAIL ELDERLY
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RULE 1
DON’T
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RULE 2
Start Low
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RULE 3
Go Slow(…but go)
RULE 3
GO SLOWGO SLOW
(but GO)(but GO)
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RULE 4
Fix ENDPOINTS for treatment in your mind
(and write them down)
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What COULD happen?
1. BENEFIT
2. ADR
3. NOTHING
4. BOTH
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BENEFIT ADR
YES NO
NO YES
YES YES
NO NO
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What you do next depends on what happens, SO…
What happens better be
MEASURABLE
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RULE 5
RETURN
to measure the
OUTCOME
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RULE 7
NO ADHERENCE NO ADHERENCE
NO PRESCRIPTIONNO PRESCRIPTION
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RULE 8RULE 8
Think Twice Think Twice
about Preventionabout Prevention
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RULE 9
ONE THING at a TIME
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RULE 10
KEEP IT
SIMPLE!
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DRUGECTOMYDRUGECTOMY
Getting rid of medication that
shouldn’t be there.
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It’s simply the
reverse
of starting medication,
and you’re just as blind
to the outcome
going in.
It’s Just Like STARTING
Medication, only in
REVERSE…
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(…you just have to be a little more careful)
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SAME RULES apply:
START LOW
GO SLOW
MEASURE OUTCOMES
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WHAT CAN HAPPEN?
1. Benefit (ADR goes away)
2. Adverse Consequence (Rebound)
of condition being treated
of condition not suspected
3. NOTHING
4. BOTH
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SAME STORY:
Get the endpoints clear
Return to measure outcome
Ready for ambiguity
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No reportNo report
Both benefit and reboundBoth benefit and rebound
Maybe so maybe noMaybe so maybe no
Intercurrent wind blowingIntercurrent wind blowing
Caregivers/patient attitudeCaregivers/patient attitude
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REMEMBER
1. Frail elderly are unique
2. THEY set the agenda
3. Comfort and function are (usually) the priorities
4. Single trial trumps population trial
5. Success depends on TRUST