Prescribing for the Oldest Old

1. Prescribing for the Oldest Old Dr Angela Kydd: Associate Professor Edinburgh Napier University a.kydd@napier.ac.uk Dr Anne Fleming: Independent Researcher afm.fleming@btinternet.com

2. Why is this Important • Global increase in the number of ‘oldest old’ • People aged 65-75 report similar functional issues as those aged 45-64 • 25% of people aged 85+ report moderate to severe limitations • Over the age of 65, 65% of people will have more than one chronic disease • Over the age of 85, 82% of people will have more than one chronic disease

3. The Hippocratic oath (5th Century) • I will apply, for the benefit of the sick, all measures that are required, avoiding those twin traps of overtreatment and therapeutic nihilism…I will remember that there is an art to medicine as well as a science, and that warmth, sympathy and understanding may outweigh the surgeons knife or the chemists drug…I will remember that I will not treat a fever…but a sick human being whose illness may affect the person’s family and economic stability. My responsibilities include these related problems, if I am to care adequately for the sick.

4. It is clear that doctors take these responsibilities seriously. Guidelines cannot replace clinical judgement

5. Literature Search • Data Sources: • Medline, Pubmed, CINAHL, Cochrane Library, ASSIA Pyschinfo, Google Scholar, Google • Inclusion criteria • January 2006-January 2016 • Full text • English language

6. Articles Sourced • 94 articles sourced • Restricted to 2010 = 72 articles • Articles reviewed and further 23 rejected • Total 49 articles

7. Results • 1. Potentially inappropriate medication • 2. Geriatric Assessment • 3. Clinical decision making • 4. General practitioner training

8. Potentially inappropriate medication • Increase in age, disease and thus treatments, can result in polypharmacy and adverse drug events (ADE). • ADE accounts for 13% of 2 medications; 58% 5 medications and 82% with 7 or more medications • 85+more susceptible to potentially inappropriate prescribing (PIP) and potentially inappropriate medications (PIMs) • Guidelines focus on single disease management • All drug related hospital admissions account for a small number of frequently used drugs • Excessive medications lead to poor adherence

9. Geriatric Assessment • Number of drugs coupled with history of adverse drug reactions (ADR) common predictor of ADEs. • Other risk factors: liver disease, heart failure and the presence of 4 or more conditions • 4 most common multiple chronic conditions hypertension, dyslipidaemia, atrial fibrillation and type 2 diabetes • Some drugs for over 85s used for long term prevention. A study of 85 + patients found that they took on average 6.8 drugs – 3 for symptom relief and 3.8 for risk factor modification • GerontoNET ADR risk score (inpatients) • Burden of treatment has led to Ariandine principles of treatment (Patient at centre – all professionals involved)

10. 3. Clinical decision making • Need for ‘rational pharmacology – what is acceptable and beneficial to the patient? • Evidence based practice for single disease management not helpful • Specialisation not preferable to generalisation • GPs work in isolation • Guidance developing - Beers criteria • (1991) STOPP, (2003), STOPP/START (2014)

11. 4. General Practitioner Training • Multimorbity affects 60% of people seeking primary care – GPs at the coal face • Scant training on the oldest old • Knowledge on frailty is not commonplace • GPs do not carry out a Comprehensive Geriatric Assessment • 72% of one survey of doctors (n=89) felt inadequate knowledge was major cause of PIP

12. Summary • Consultation with the individual and their family/carer • Need for frailty focussed services • To identify the oldest old as a group • Multidisciplinary input to include a pharmacist • Guidelines for the management of more than one chronic condition

13. I will remember that there is an art to medicine as well as a science, and that warmth, sympathy and understanding may outweigh the surgeons knife or the chemists drug…I will remember that I will not treat a fever…but a sick human being whose illness may affect the person’s family and economic stability.

14. Thank You