Welcome to this Symposium! Achieving partnership with our old patients in order to avoid poisoning them with prespcription drugs: implementing systematic medication reviews for the elderly in a GP setting
Organisers Workshop chairs: Palle Mark Christensen (Region of Southern Denmark, Denmark) Inger Nordin Olsson (Health and Social Care Inspectorate, Sweden) Jørund Straand (University of Oslo, Norway) Workshop mediators: Merete Willemoes Nielsen (Region of Southern Denmark) Bente Overgaard Larsen (Region of Southern Denmark) Kirstine Gommesen (Region of Southern Denmark) Dorte Glintborg (Danish Health and Medicines Authority)
Agenda (modified) Introduction (JS) Tools for medication review from the Nordic Countries - NORGEP criteria (Norway; JS) - IRF-list (Denmark; DG) - Quality indicators in drug treatment (Sweden; INO) Aspects of implementing medication review in the DK, S, N Questions/comments from the audience Should we establish a Nordic Network group focusing on medication review for the elderly in a general practice setting? Concluding remarks
Introduction Jørund Strand
The IRF-list A screening tool for irrational use of medication in the elderly Dorte Glintborg, cand.pharm, dip. clin.pharm. Danish Institute for Rational Pharmacotherapy
Drugs where the indication should be reassessed in the elderly Red: Avoid unless there is a very specific reason for using this drug Yellow: Follow up for correct and actual indication: Green: Reassesment due to limited evidence for long-term efficacy, adverse events etc. Drugs -most used>65 years Reason for possible discontinuation or Dose-ajustsment Fordøjelsessystem Primperan Risiko for konfusion og ekstrapyrimidale bivirkninger (parkinsonsymptomer) Dulcolax Laxoberal Toilax Langvarig brug frarådes pga. risiko for tilvænning, med mindre patienten får opioider Propose for possible alternative Seponer lægemidler som hyppigt giver kvalme Magnesia, Movicol. Seponer om muligt medicin som giver obstipation Ingen Buscopan Ercoril Tvivlsom effekt og risiko for konfusion hos ældre pga. antikolinerg effekt Antikoagulantia Asasantin Retard Dosis af ASA (50 mg dgl) er for lav Clopidogrel Magnyl 150 mg Dosis skal være 75 mg Dosisreduktion til 75 mg Magnyl 75 mg Ikke til primær profylakse Ingen Diabetes: Kun ved samtidig hjerte-karsygdom Plavix + Magnyl Efter AMI: Ikke evidens udover 12 måneder Fortsæt med Magnyl Hjerte-kar Furix Hjerteinsufficiens: Kun symptomatisk effekt Får patienten ACE-hæmmer, beta-blokker og evt. spironolacton? Obs. dosis: Hyppig årsag til indlæggelse pga. fald, elektrolytforstyrrelser, dehydrering mm. Hjerteinsufficiens Ramipril, Carvedilol, Spirix 25 mg (NYHA III-IV) Ødemer: Mobilisering, støttestrømper
Case: 88 year old woman Nursing home Alzheimer (MMSE = 17) Hypertension (110/65). IHD : AMI 2002, by-pass in 2003. Type II diabetes (HbA1c=8,2) January 2013 TCI.
Case: 88 year old woman 1. Donepezil 2. Pravastatin 3. Insulin 4. Acetylsalicylsyre 5. Dipyridamol 6. Digoxin 7. Spironolacton 8. Omeprazol 9. Paracetamol 10.Furosemid 11.Zolpidem
Case: 88 year old woman 1. Donepezil 2. Pravastatin 3. Insulin 4. Acetylsalicylsyre 5. Dipyridamol 6. Digoxin 7. Spironolacton 8. Omeprazol 9. Paracetamol 10.Furosemid 11.Zolpidem Drugs -most used>65 years Reason for possible discontinuation or Dose-ajustsment Fordøjelsessystem Primperan Risiko for konfusion og ekstrapyrimidale bivirkninger (parkinsonsymptomer) Dulcolax Laxoberal Toilax Buscopan Ercoril Langvarig brug frarådes pga. risiko for tilvænning, med mindre patienten får opioider Tvivlsom effekt og risiko for konfusion hos ældre pga. antikolinerg effekt Propose for possible alternative Seponer lægemidler som hyppigt giver kvalme Magnesia, Movicol. Seponer om muligt medicin som giver obstipation Ingen Antikoagulantia Asasantin Retard Dosis af ASA (50 mg dgl) er for lav Clopidogrel Magnyl 150 mg Dosis skal være 75 mg Dosisreduktion til 75 mg Magnyl 75 mg Ikke til primær profylakse Ingen Diabetes: Kun ved samtidig hjerte-karsygdom Plavix + Magnyl Efter AMI: Ikke evidens udover 12 måneder Fortsæt med Magnyl Hjerte-kar Furix Hjerteinsufficiens: Kun symptomatisk effekt Får patienten ACE-hæmmer, beta-blokker og evt. spironolacton? Obs. dosis: Hyppig årsag til indlæggelse pga. fald, elektrolytforstyrrelser, dehydrering mm. Ikke evidens ved hypertension Hjerteinsufficiens Ramipril, Carvedilol, Spirix 25 mg (NYHA III-IV) Ødemer: Mobilisering, støttestrømper Digoxin Interaktioner og mulig konfusion hos ældre Hjerteinsufficiens: Ikke 1. valg ved hjerteinsufficiens, men kan være Ramipril, Carvedilol, Spirix 25 mg indiceret ved samtidig atrieflimren (NYHA III-IV) Urologiske midler Detrusitol Toviaz Vesicare Analgetika Ketogan OxyContin/Morfin Effekten er marginal Ingen Risiko for konfusion hos ældre pga. antikolinerg effekt Risiko for konfusion og fald hos ældre Husk laxantia ved brug > 14 dage NSAID Risiko for mavesår, AMI, væskeretension Interaktion med warfarin = blødningsrisiko Kinin Lægkramper: Kun korttidsstudier. Lille effekt Restless legs: Ingen evidens for effekt Risiko for konfusion, tinnitus, interaktion Tramadol el. depotmorfin i lavest mulige dosis 1. Paracetamol 2. Ibuprofen + Lanzo 15 mg Lægkramper: Ingen Restless legs: Forsøg evt. Sifrol el. Requip
An example Hjerte-kar Furix Hjerteinsufficiens: Kun symptomatisk effekt Får patienten ACE-hæmmer, beta-blokker og evt. spironolacton? Obs. dosis: Hyppig årsag til indlæggelse pga. fald, elektrolytforstyrrelser, dehydrering mm. Ikke evidens ved hypertension Digoxin Interaktioner og mulig konfusion hos ældre Ikke 1. valg ved hjerteinsufficiens, men kan være indiceret ved samtidig atrieflimren Hjerteinsufficiens Ramipril, Carvedilol, Spirix 25 mg (NYHA III-IV) Ødemer: Mobilisering, støttestrømper Hjerteinsufficiens: Ramipril, Carvedilol, Spirix 25 mg (NYHA III-IV) Risk of interactions? Any indication at all? (IHD, hypertension) Dose to high? Congestive heart failure? Where are the ACE-inhibitor and beta-blocker?
How is the IRF-list developed? First version 2006 based on: Beers Criteria 1 21 Indikatorer för utvärdering av kvaliteten i äldres läkemedelsterapi 2 Practical experience from a study of medicationreview Last version updated 2011 according to: NORGEP 3 37 criteria START og STOPP: 87 criteria Tools to identify inappropiate medicines in older people 1. Fick et al. Arch Intern Med 2003 2. Socialstyrelsen 2003 3. Rognstad et al. Informa Healtcare 2009
irf.dk Toolbox for Medication-review
Drug treatment in the elderly National Board of Health and Welfare (SoS) Health and Social Care Inspectorate (IVO) Swedish Association of Local Authorities and Regions (SKL) Swedish Council on Health Technology Assessment (SBU) - Regulation - Recommendations/implementation - Inspections/supervision - Reports - Rewards
Nationell patientöversikt
Principles of good drug treatment of the elderly: There is an indication for drug treatment The actual disease or symptom is affected by treatment The advantages of treatment exceed the risks
Quality indicators Explicit and/or implicit Beers criteria MAI (medication appropriateness index) Drug specific - long acting bensodiazepins - anticholinergic drugs - NSAID/PPI/SSRI Diagnose specific - IHD/ Heart failure - COPD - DM.
Rewards (SKL and SoS) When statistical signifikant reduction -in usage of inappropriate drugs for the elderly > 75 years -in usage of NSAIDs >75 years -in usage of antipsykotic drugs for elderly >65 years with drug dispensation.
Drug treatment in the elderly Process measures Efficacy measures What is most important for you? Prioritize! Perspective: Quality of life! Patient safety included
Medication appropriateness index (MAI) Is the an indication for the drug? Is the medication effective for the condition? Is the dosage correct? Are the directions correct? Are there clinically significant drug-drug interactions? Are there clinically significant drug disease interactions? Are the directions practical? Is the drug the least expensive alternative compared with others of equal utility? Is there unnecessary duplication with other drugs? Is the duration of therapy acceptable?
Paper III. EQ-5D index and EQ VAS
Rational use of medicines: Patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements, for an adequate period of time, and at the lowest cost to them and their community (WHO 1985).
Physical exercise Norway Sweden Iceland Finland All other countries
Aspects of implementation of medication review in Denmark, Norway and Sweden
Denmark (in my practice in DK) Matter of organisation! (3 meetings before we were ready) Residents at a the nursing home Secretary screen and adjusts our medication list with the list from the nursing home via the IRF list The doctor receives the screened and adjusted list and add clinical decisions on top and then consult the patient Evaluate in 3 three months (new meetings )
Denmark Datafangst (data-capture) www.dak-e.dk
Denmark FMK: Fælles Medicin Kort English translation joint list of medications Use www.medicinkort.dk for more information
Solution in FMK: all parts of the health care system in DK access the same electronic medication list 29
Perspective (Denmark) Very good: Computer tools (FMK, data-capture) Guidelines Contracts (between health authority and GP regarding medication review ) Yet there are challenges: e.g. organisation in GP Future of medication review in DK: Good if we work hard and perhaps exchange knowledge between the Nordic countries
New regulation: Ändringsförfattning SOSFS 2012:9 Socialstyrelsens föreskrifter om ändring i föreskrifterna och allmänna råden (SOSFS 2000:1) om läkemedels-hantering i hälsooch sjukvården
SOSFS 2000:1; rev 2012:9 3 a kap Läkemedelsgenomgångar = Medication Reviews 1 En läkare ska ansvara för läkemedelsgenomgångar. Läkaren ska vid behov samarbeta med andra läkare, apotekare, sjuksköterskor och annan hälso- och sjukvårdspersonal. = A physician is responsible when performing medication reviews.
SOSFS 2012:9 Simple medication review 5 Vid enkel läkemedelsgenomgång ska det med utgångspunkt i tillgänglig dokumentation och patientens egna uppgifter så långt möjligt kartläggas 1.which drugs are precribed and why? 2.which of the drugs do the patient use? 3.are there any other drugs which the patient uses?
SOSFS 2012:9 Profound medication review 11 Vid en fördjupad läkemedelsgenomgång ska för varje ordinerat läkemedel.. 1. check the indication of each drug, 2. evaluate the effect, 3. evaluate the dosage of the drug vs. physiological functions of the patient s status, 4. evaluate if the risks of negative side effects/adrs or interactions exceed the advantages 5. evaluate the benefits of each drug in relation to the entire drug treatment.
SOSFS 2012:9 Medication reconciliation 15 When a patient has undergone a medication review and is to be discharged from the hospital the physician has an obligation to do a medication reconciliation containing information of 1. which prescriptions are changed, 2. other acts taken according to treatment 3. and reasons to the acts taken.
Municipalities Counties INTERFACE Acute care hospitals INTERFACE Primary care Counties INTERFACE INTERFACE INTERFACE INTERFACE Nursing homes, residential homes, home services Municipalities Relations between care providers in Sweden according to the Elderly Reform Published with kind permission of Ingvar Karlberg
Supervisor Controller Messenger (D) Different but shared responsibility Initiator Visionary (E) Patient transferring drug information Executer (C) Responsible for all drugs (B) Responsible for own prescriptions (A) Imposed responsibility Solitary published with permission of Pia Bastholm Rahmner
Drug treatment It should never be assumed that once a drug is started it should never be discontinued (Sloan 1992)
Norway Presentation of implementation in Norway
Questions from the audience
Should we establishing a Nordic Network on medication review? Write down your name, institution, email on the paper in front of you and give it to BOL, KG Contacted by us presentations www.forskningsenheten.no
Conclusion Each country has applicable and relevant tools for medication review, but the challenge is implementation Nordic group for exchanging knowledge in this field: www.forskningenheten.no)
Thank you for your attention