Fátima Brañas is a consultant geriatrician and the clinical lead for orthogeriatrics at the Infanta Leonor University Hospital in Madrid (Spain). She holds a PhD, specializing in HIV infection in older adults, and is working hard in this field—from both a clinical and a research point of view—to provide all the benefits of a geriatric assessment for older HIV-infected adults. She recently co-authored ‘Frailty and physical function in older HIV-infected adults‘ @FatimaBranas
The HIV-infected population is aging due to the success of combination antiretroviral therapy, which prolongs survival, and also because of the growing number of newly diagnosed cases in older adults. Nowadays, over half of people infected with HIV are older than fifty years, which is the age cutoff accepted by the scientific community to consider someone an HIV-infected older adult. Fifty is only their chronological age, but biologically they are older, as accelerated aging in this population has been demonstrated. So, it seems that in the coming years, HIV care is going to be focused on a growing group of older adults and their specific problems. This means more than only survival, infection control, or avoiding the adverse events caused by antiretroviral drugs; it also includes consideration of comorbidities, polypharmacy, functional decline, and geriatric syndromes. Continue reading
Timo Strandberg is a Professor of Geriatrics who works at the Universities of Helsinki and Oulu.
Amid important clinical issues such as the dangers of dental amalgam fillings, the evils of chronic candida yeast syndrome, the big benefits of low-carb diets and the like, thyroxine has been on the headlines during recent years. We’ve heard especially about the lack of thyroxine, and even some distinguished colleagues seem to have thought that if you’re a bit depressed, tired, cognitively impaired, gaining weight etc. thyroxine is the drug for you. Accordingly, treatments with this hormone have clearly increased, for example in the UK 3-fold between 1998 and 2010, and treatment for marginally elevated thyroid-stimulating hormone (TSH) levels have become more common. And lo and behold: patients often get better – at least temporarily (ever heard of the placebo effect?). Continue reading
Danielle Ní Chróinín is a geriatrician at St. Vincent’s Hospital, Sydney, who has a keen interest in research, education, and anything related to geriatric medicine. Her paper on deprescribing is published in the latest edition of Age and Ageing and can be accessed online now.
Mr. T. is an 85 year-old man who has been attending your Geriatric Clinic for the last couple of years. He has a background of hypertension, ischaemic heart disease, osteoarthitis of his knees, and constipation. He now has moderate dementia, with a progressively worsening Mini-Mental State Examination score, 17/30 today. His wife, with whom he lives, has taken over the shopping and financial duties.
Blood pressure is up, once again, at clinic today. His current medications include aspirin, a statin, a calcium channel blocker, an ACE inhibitor, laxatives, donepezil, paracetamol and tramadol. If you shook him, he just might rattle…
Polypharmacy is ridiculously prevalent- 42% of over-50s in Australia are taking five or more medications; terms such as ‘hyperpolypharmacy’ (≥10 drugs), have been coined, in an attempt to stratify polydrug recipients in the context of a multiple-medications epidemic.
So, would you stop any of Mr. T.’s drugs? Which ones? Why?
Immediately, or when he becomes frailer, more demented, more dependent, or when his life-expectancy has dropped to months? The evidence base for making these types of decisions is limited. And individual doctor (de)prescribing practices vary widely. In a survey of Antipodean physicians specialising in the care of older patients, we sought to explore the factors which influence our decisions to ‘stop the drugs’.
A hundred-and-thirty-four busy physicians kindly lay down their prescribing pens to answer our survey. Given a list of factors which might influence their deprescribing practices, these doctors most commonly rated limited life expectancy (96.2%) and cognitive impairment (84.1%) as very/extremely important to deprescribing practices. Interestingly, the age and gender of the doctor appeared to influence the answers supplied. Older respondents less commonly rated functional dependency and limited life expectancy important when deprescribing. On the other hand, female participants, and trainees, more often rated adherence to evidence-based guidelines important.
Confronted with a series of five case vignettes, physicians were more likely to stop many of the listed medications as the case described a patient with increasing dependency and cognitive impairment.
So we asked: “Why are you stopping these medications?” The answers commonly centred on two central themes- dementia severity and pill burden. So it’s comforting to think that if I ever develop bad Alzheimer’s disease, one of these doctors might take a look at my medication list, and strike off a couple of tablets, so that I can enjoy an ice-cream unencumbered by hidden pills. Or that if I ever end up the victim of half-a-dozen different evidence-based guidelines, a sympathetic medic might kindly prioritise the top six or seven pharmaceuticals I really need.
But the fact is that the ‘right time’, the ‘right medications’ and the ‘right deprescriptions’ for frailer older persons aren’t always so clear. Such patients are most often notable for their absence from randomised trials. But a dramatic red pen-slash, crossing off the whole shebang, may not be appropriate outside of an end-of-life scenario. Our geriatric cohort can be the victims of missed treatment opportunities, and not just over-medication. Studies continue to evolve, assessing the benefit and harms of prescribing- and deprescribing- in such patients. In the interim, I admit I mostly rely on the good habit that my first bosses drummed into me: review the meds list regularly, and look at the whole person and not just the diagnosis list. It’s likely Mr. T. will thank you for it.
Andreas Schoenenberger works with the Division of Geriatrics, Department of General Internal Medicine at Bern University Hospital, and with the University of Bern, Switzerland. Here he describes his recent editorial in Age and Ageing journal, written with Andreas Stuck.
Despite recent efforts to improve drug management for older people, we have not yet arrived at an optimal strategy for reducing inappropriate drug use. Drugs are considered inappropriate, if the risk outweighs the potential benefit of the drug. Along with pathophysiological changes during the ageing process, and the increasing number of co-morbidities/-medications, the potential risks of drugs increase with age and adverse drug reactions (ADRs) are encountered more frequently in older persons. Continue reading
Pharmaceutical research in a laboratory and clinical practice may sometimes feel like worlds apart but it is my belief that the best informants of research are those who are actually involved in caring for the patient. This should be the principal motivation behind any research. My PhD project is based on the use of microneedles, an innovative form of transdermal drug delivery, which is rapidly gathering pace towards commercialisation. In an industry traditionally focussed on the discovery of new drugs, a new method for delivery of medication is long awaited to challenge the accepted routes of oral and parenteral delivery, which although suitable for the majority, are not without their drawbacks, particularly in the geriatric patient.
Alyson Huntley is a Research Fellow at the University of Bristol’s Centre of Academic Primary Care. She has recently published a systematic review of pharmacist-led interventions to reduce unplanned admissions for older people.
The expansion of the pharmacist’s role as a contributor to patient’s health has been championed over the last couple of decades. In addition to their traditional role, pharmacists contribute to the care of people with long term conditions by carrying out medication reviews, promoting healthy lifestyles, and supporting self-care.
The older people become, the more medications they are likely to be taking (both prescribed drugs and self-medication) leading to an increased risk of adverse reactions, interaction between drugs and poor adherence. Continue reading
Stephen Jackson is Professor of Clinical Gerontology at King’s Health Partners
This is a recent King’s Fund Report which takes another look at polypharmacy. It is unclear why as there has been a rather better report published by NHS Scotland. One would assume the King’s fund would check who is doing what before commissioning such a report. Interestingly there is no mention of the G (geriatrician) word anywhere in the report although the terms “older care clinician”, “clinicians who specialise in care of older people” and orthogeriatrician do appear. I thought there was insufficient recognition of the fact that multiple pathology and hence polypharmacy is essentially a problem associated with ageing. The authors rightly differentiate between appropriate polypharmacy and what they call problematic polypharmacy known to many as inappropriate polypharmacy. Polypharmacy merely means “many medicines” as opposed to “too many medicines”. The report could be criticised for giving the impression that appropriate prescribing is only necessary when polypharmacy is present. Continue reading
Tischa van der Cammen is a Consultant Geriatrician and Carolyn Sterkeis a public health researcher. Both are based at the Erasmus University Medical Center in Rotterdam, Netherlands and have recently published a paper in Age and Ageing journal.
Drug treatment has brought many benefits for older patients. For example, the treatment of hypertension in patients aged over 80 led to a major reduction in stroke and mortality, as was shown in the HYVET study.
As people age, diseases may accumulate, and hence older patients usually are prescribed several drugs at the same time. It is ‘rule rather than exception’ that patients above age 75 use 4 or more drugs, this is called polypharmacy. There are a variety of definitions for polypharmacy – in the UK it is generally 4 or more prescribed medicines – as specified by Department of health and Rollason.
Inappropriate poly-pharmacy in older patients may lead to negative health impacts Continue reading
Kandarp Thakkar is a member of the ImPE Supergroup at the CLAHRC for NWL and the Deputy Chief Pharmacist for Clinical Services at The Royal National Orthopaedic Hospital NHS Trust. He tweets @KandarpThakkar and is on Linkedin
My Medication Passport is a small, easy-to-read document for patients to show clinicians and carry a record of the medications they are taking. It is designed to help patients get more involved in their care. An initial report on this was featured by the HSJ in August 2012.
The passport was initially developed as part of a joint NIHR CLAHRC NWL (hosted by Chelsea and Westminster Hospital) and Imperial College Healthcare NHS Trust initiative to improve prescribing for the elderly. It is now being delivered in collaboration with AstraZeneca through a joint working agreement. Continue reading
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