Cumulative Medicines Risk

Adverse effects and polypharmacy

Older adults are often more sensitive to medicines and disproportionately experience medicine-related harms.⁶ Their altered physiology (relative to younger adults) changes the way medicines are metabolised and excreted, most importantly reduced renal and hepatic function, which increases the risk of AEs.⁷ At the time of an accredited pharmacist-led Medicines Review, up to a quarter of older people are experiencing adverse effects of their medicines and on average four medicine related problems are detected.^8, 9

Factors contributing to polypharmacy includes:

• Medicines are sometimes added to treat temporary symptoms, this includes over the counter (OTC) products, and may not be reassessed by the primary prescriber.¹⁰
• Multi-morbidity increases the chance of multiple prescribers for the patient; in some cases the doctor may be unaware of this.^11, 12
• The doctor may fear symptom rebound and be uncertain how to reduce dosage and be concerned about hindering continuity of care or losing the patient’s trust._¹²
• Research indicates that clinicians perceive a lack of advice about deprescribing including availability of specific guidelines.¹³
• Dealing with a large number of medicines may feel overwhelming – so called ‘therapeutic inertia’ is common and understandable. Clinicians may feel they haven’t got enough time or won’t be adequately remunerated for their deprescribing effort.^11, 13

Consider a Medicines Review

Who should I talk to about a Medicines Review?^{14, 15}

• frail older people, especially those who have a history of falls or who you consider a falls risk
• patients troubled by symptoms that could be linked with medicines
• patients recently discharged from hospital or who have had a significant change in circumstances e.g. new diagnosis of dementia, malignancy
• all patients in aged care facilities, especially on admission to the facility (“despite RMMRs being a key means for minimising medication-related harm, MBS claims for RMMRs are lodged for only a fraction of residents who enter Residential Aged Care Facilities (RACFs)”)¹⁶

What should I talk to my patients about?

Talk to your patient about what is important to them - shared decision making is central to successful deprescribing.¹⁷ Explain that medicines are always worth reviewing especially as circumstances change. Patients tend to have a high level of trust in their GP and are usually happy to have a conversation about their medicines.¹⁸

Ask your patient what they understand about their medicines and how they are managing them.

• do they feel they are taking too many medicines?
• are they taking other medicines or supplements that you have not prescribed?
• ask specifically about over the counter (OTC) products or other medicines prescribed by another health professional.

Talk about potential adverse effects. Patients may be experiencing symptoms that could relate to their medicines without realising it.

Reassure your patient that in many cases they could safely reduce or stop a medicine. In some cases non-drug approaches could be safer and more effective e.g. psychological approaches for insomnia or physical therapy for musculoskeletal pain. Allied health services are available through the Department of Veterans' Affairs (DVA) for all Gold Card holders, White Card holders for accepted conditions, or for all via Medicare’s chronic disease management items.

Use a 'patient centred' stepwise approach to deprescribing

Deprescribing can be beneficial and is unlikely to cause harm.¹²

GPs are ideally suited to start a conversation with patients about their medicines and, if there is good reason, to consider trialling a reduced dose or ceasing altogether.

The following stepwise approach may help (adapted from Reeve et al (2014),¹⁹ Scottish polypharmacy guidelines 20183 and Primary Health Tasmania¹⁵).

1. Patient engagement and information gathering

The patient is central in any Medicines Review process – engage with them and explain that you want to talk about all their medicines. Reassure them that you will provide support during the process. Gather all relevant information about their medicines including ones they take regularly, as needed and any over the counter products including complementary medicines.^10, 20 Are they having any problems taking any of their medicines?

2. Document indications, benefits and potential harms

Establish treatment objectives together. What is important to the person at this time? Discuss indications, benefits and potential harms. This can help patients understand the trade-off between potential benefit and adverse effects and help clarify their values, priorities and preferences.

i Identify the necessary or appropriate medicines on the list.

Medicines that if stopped would cause serious withdrawal symptoms or worsen existing clinical issues, e.g. medicines for epilepsy or arrhythmias.

ii Identify unnecessary or inappropriate medicines on the list.

Are there ineffective medicines? Does the medicine cause more harm than benefit? Was it only ever for a short-term indication? Has the potential benefit been reduced due to changes in the patient’s situation and limited life expectancy e.g. statins or antihypertensives.

iii Consider if any of the patient’s medicines are causing adverse effects.

The risk of adverse effects may accumulate over time, some of these effects may be obvious, others more subtle and not recognised. Some may be mistaken as symptoms of chronic disease or ageing.21 Always ask if there are any symptoms that are bothering your patient.

Use the cumulative risk tool

The Medicines Review process

The simplest intervention to organise and, arguably most beneficial to the patient, is to organise a Home Medicines Review (HMR) or Residential Medication Management Review (RMMR) with an accredited pharmacist (see Medicare benefit items 900 and 903 www9.health.gov.au/mbs/fullDisplay.cfm?type=item&q=900&qt=item). These are structured evaluations of a patient’s medication list that improve the patient’s understanding of their medicines, optimise their medicine use and help prevent medication-related problems.

Medicine reviews may improve compliance and reduce:²²

• adverse effects and unnecessary hospital admissions
• risk of falls
• cognitive impairment
• medication burden.

The patient’s home is the preferred location for an HMR. However, in response to the COVID-19 pandemic, HMRs may occur via telehealth where a patient meets the eligibility criteria (aged over 70, has a chronic health condition or is immunocompromised).

A ‘patient centred’ deprescribing process usually generates a significant amount of information to share with an accredited pharmacist. Referral should list the patient’s clinical conditions, medicines (including those that you think may be ceased) and any specific areas of concern, for instance, physical symptoms that you think are linked with medicines. After the initial interview, the accredited pharmacist produces an HMR Report that outlines their findings. The report aims to improve the referrer’s understanding of how the patient is using their medicines, and make recommendations that help the referrer and patient develop a medication management plan.

Share the report with the patient, carers and other relevant members of the health care team, such as nurses in aged care facilities or other community settings as well as the response you have provided to the pharmacist.https://www9.health.gov.au/mbs/fullDisplay.cfm?type=item&q=900&qt=item)

Polypharmacy case scenario

Background

78 year old veteran with multiple comorbidities including ischaemic heart disease (IHD) (coronary artery stenting some years ago), hypertension (last office BP was 118/75), atrial fibrillation (AF), gastro-oesophageal reflux disease (GORD). He has chronic low back and neck pain, depression and is overweight.

He has been feeling more dizzy and nauseated recently, and has noticed ankle swelling. His wife has seen more bruising on his forearms, and feels he has worsening cognitive decline, is becoming more unsteady on his feet and is feeling less safe in the car when he drives.

He has a usual GP and a cardiologist and is awaiting geriatrician review.

He reports taking fish oil for joint pain as he believes it may be ‘good for that as well as his heart health and memory’. He has not had any recent episodes of chest pain and has not used his GTN spray for years.

His Mini Mental State Examination (MMSE) is 23/30. BP measures in clinic today suggest a postural drop; 123/79 sitting and 112/70 standing.

You have decided to refer for an HMR but want to do a full assessment first by following a stepwise process to help guide your referral to the pharmacist.

References

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2. Lim R, Semple S, Kalisch Ellett L, Roughead L. Medicine saftey: Take care. Pharmaceutical Society of Australia. 2019.
3. Scottish Government Polypharmacy Model of Care Group. Polypharmacy guidance, realistic prescribing. Scottish Government. 3rd edn. 2018.
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