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Prescribing for the Frail Elderly

Prescribing for the Frail Elderly

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Prescribing for the Frail Elderly

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  1. Prescribing for the Frail Elderly THE THERAPEUTIC DRUGECTOMY

  2. CASE STUDY Margaret

  3. 90 years old • Discharged from hospital three months ago with: non-small cell carcinoma lung palliative COPD ankle edema hypertension depression osteoporosis dementia

  4. Furosemide 20 mg OD Ramipril 5 mg BID Metoprolol 25 mg BID Tiotropium MDI Fluticasone/salmeterol MDI Mirtazapine 15 mg HS Risedronate 5 mg OD Donepezil 5 mg OD Vitamin D Calcium Folate

  5. HOME VISIT S: I feel kind of tired, dizzy sometimes, no pain, breathing is okay. O: Cheerful, cognitively grossly intact, pale RR 28 no distress BP 90/palp

  6. WHAT DO WE DO?

  7. Furosemide 20 mg OD Ramipril 5 mg BID Metoprolol 12.5 mg BID Tiotropium MDI Fluticasone/salmeterol MDI Mirtazapine 15 mg HS Risedronate 5 mg OD Donepezil 5 mg OD Vitamin D Calcium Folate

  8. Furosemide 20 mg OD Metoprolol 12.5 mg BID Fluticasone/salmeterol MDI Mirtazapine 15 mg HS

  9. URGENT CALL S: (collateral) Increased shortness of breath, more confused, less mobile. O: pale, warm, mildly disoriented, 110/palp HR 105, no JVD, reduced air entry lungs.

  10. MARGARET’S OUTCOME

  11. WHY IS IT SO DIFFICULT? • Prevention Doesn’t Work in Frailty • Heterogeneity Unpredictability • Multiple Pathology Polypharmacy

  12. First, Prevention Doesn’t Work if you’re Frail

  13. FOUR GOOD REASONS WHY NOT • No prediction in the unpredictable

  14. HETEROGENEITY UNPREDICTABILITY

  15. …YOU CANT PREDICT for someone who is UNPREDICTABLE

  16. FOUR GOOD REASONS WHY NOT 2. NO FRAIL IN TRIALS

  17. Principle of Geriatrics 2 “The frail elderly are MULTIPLY PATHOLOGICAL”

  18. The QUORUM EPIPHANY Clinical trial exclusion criteria are unbelievably comprehensive

  19. Trials EXCLUDE FRAILTY You CAN’T DO studies that support prevention in frailty

  20. FOUR GOOD REASONS WHY NOT LIMITED CHANCE OF BENEFIT OFFSETTING DANGER

  21. Bottom Line: FRAILTY lives in an EVIDENCE-FREE ZONE

  22. Want “evidence”? Strandberg TE, Pitkala KH, Berglind S, Nieminen MS, Tilvis RS. Multifactorial intervention to prevent recurrent cardiovascular events in patients 75 years or older: The Drugs and Evidence-Based Medicine in the Elderly (DEBATE) study: a randomized, controlled trial. Am Heart J 2006;152:585-592. … not only does prevention not make sense in frailty, IT REALLY DOESN’T WORK.

  23. 10 RULESfor STARTINGMEDICATION in the FRAIL ELDERLY

  24. RULE 1 DON’T

  25. RULE 2 Start Low

  26. RULE 3 RULE 3 Go Slow (…but go) GO SLOW (but GO)

  27. RULE 4 Fix ENDPOINTS for treatment in your mind (and write them down)

  28. What COULD happen? • BENEFIT • ADR • NOTHING • BOTH

  29. What you do next depends on what happens, SO… What happens better be MEASURABLE

  30. RULE 5 RETURN to measure the OUTCOME

  31. RULE 7 NO ADHERENCE NO PRESCRIPTION

  32. RULE 8 Think Twice about Prevention

  33. RULE 9 ONE THING at a TIME

  34. RULE 10 KEEP IT SIMPLE!

  35. DRUGECTOMY Getting rid of medication that shouldn’t be there.

  36. It’s Just Like STARTING Medication, only in REVERSE… It’s simply the reverse of starting medication, and you’re just as blind to the outcome going in.

  37. (…you just have to be a little more careful)

  38. SAME RULES apply: START LOW GO SLOW MEASURE OUTCOMES

  39. WHAT CAN HAPPEN? • Benefit (ADR goes away) • Adverse Consequence (Rebound) of condition being treated of condition not suspected • NOTHING • BOTH

  40. SAME STORY: Get the endpoints clear Return to measure outcome Ready for ambiguity

  41. No report Both benefit and rebound Maybe so maybe no Intercurrent wind blowing Caregivers/patient attitude

  42. REMEMBER • Frail elderly are unique 2. THEY set the agenda • Comfort and function are (usually) the priorities • Single trial trumps population trial • Success depends on TRUST