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 nonpharmacological interventions
• 4th 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
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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:
isyourmomondrugs@gmail.com