Older people & polypharmacy:

Getting their medication right

Older people & polypharmacy: getting their medication right

New trial aims to help older patients take the right medicines at the right time, all the time - improing their health and reducing hospital readmission

 

A typical patient admitted to the geriatric ward at the University Hospitals Leuven in Belgium is already taking 10 medicines. With an average age of 85, they are likely to have accumulated several non-communicable diseases (NCDs) which are managed by a range of healthcare professionals. These conditions can include heart failure, chronic lung disease, urinary incontinence, diabetes, depression and dementia.

‘The therapies may have been initiated by different doctors and are not always reviewed by the same specialist that prescribed the drug,’ explains Prof Jos Tournoy, head of the department of Gerontology and Geriatrics at the University Hospital of Leuven. ‘On average, two of these 10 medications are inappropriate – meaning they are no longer a good therapy choice for the patient at this time.’

The challenge of balancing the potential benefits and potential side effects of multiple treatments is a growing issue in ageing populations. Polypharmacy – where patient takes several medicines – can increase hospital admissions in older people.1, 2 ‘As many as one in three emergency department admissions in older people are related to drug intake and side effects,’ says Prof Tournoy   .

Complex medication lists can bring other problems too. Around half of all patients underuse recommended medicines and many patients struggle to recall which pills to take. Upon admission to hospital, patients are often asked what medicines they are taking. In older people on multiple therapies, this list is often incorrect or incomplete, according to Prof Tournoy. If the patient forgets to mention a vitamin supplement, the immediate risk may be low. However, if doctors are unaware that the patient is taking an anticoagulant, it could have major implications should the patient undergo surgery

Changing clinical practice

Prof Tournoy and his team have launched a new clinical trial designed to help patients take the medicines they need and improve adherence after discharge. The study is part of a broader programme called Project chAnGE, supported by Upjohn, a Pfizer division, launched under the European Innovation Partnership Action on Health Ageing (EIP on AHA). Project chAnGE aims to identify gaps in Europe in relation to healthy ageing in people with non-communicable diseases and support the necessary changes in clinical practice.

More than 800 older patients admitted to a geriatric ward will be assigned to one of two groups. The first group will receive standard care while the second will be offered a new approach with greater input from a clinical pharmacist.

‘Pharmacists can play an important role and have been shown to improve prescribing practices,’ 3 says Prof Tournoy. ‘We see an opportunity to address inappropriate prescribing by collaborating with clinical pharmacists in a geriatric setting, while working with GPs and community pharmacists to improve the patient pathway after they are discharged.’

The first step for the group receiving the new model of care will be to have an extensive medication review. This will allow the team to eliminate inappropriate therapies and to start new medications where needed. ‘It’s not always a question of giving fewer drugs – it’s about giving the most appropriate medicines,’ Prof Tournoy explains. ‘For example, there are patients at risk of stroke, or suffering from heart failure or diabetes, who are not being treated.’

At discharge, the team will discuss the new drug regimen with patients, explaining the reason for each prescription and emphasising the importance of consistently taking the medication as recommended. To support adherence to therapy, the hospital-based clinicians will engage with the patient’s GP and pharmacist to explain the rationale behind the new medication list. The community-based healthcare professionals will be invited to contact the hospital team to discuss the patient’s prescriptions at any time.

Health system sustainability

The project offers a unique opportunity to study the impact on outcomes of involving clinical pharmacists in geriatric teams across the whole patient pathway. The ultimate goal will be to improve patient health by reducing their readmission to hospital. A range of secondary outcomes will also be measured including mortality, the number of falls, adverse drug reactions, quality of life, pain and cost effectiveness.

Previous research has shown that around 39% of patients discharged from geriatric wards are readmitted at least once in the first three months after leaving hospital. For older patients, average hospital stays can be longer than 10 days and cost society at least €700 per night.

‘A significant part of the healthcare budget is spent on people in their final year of life,’ says Prof Tournoy.4 ‘The level of spending is so high that if we can reduce hospitalisation even by a fraction, there could be significant cost savings – on top of the quality of life benefits that the patient gets from avoiding a hospital stay.’

As European populations age, and the number of frail and vulnerable older people increases, rethinking clinical practice to improve patient outcomes and make health systems more efficient will be essential.

[1] Oscanoa TJ, Lizaraso F, Carvajal A. Hospital admissions due to adverse drug reactions in the elderly. A meta-analysis. European Journal of Clinical Pharmacology. 2017:1-12. doi: 10.1007/s00228-017-2225-3

[2] El Morabet N, Uitvlugt EB, van den Bemt BJF, van den Bemt PMLA, Janssen MJA, Karapinar-Çarkit F. Prevalence and Preventability of Drug-Related Hospital Readmissions: A Systematic Review. J Am Geriatr Soc. 2018;66(3):602-8. Epub 2018/02/22. doi: 10.1111/jgs.15244. PubMed PMID: 29468640

[3] Spinewine A, Swine C, Dhillon S, Lambert P, Nachega JB, Wilmotte L, et al. Effect of a collaborative approach on the quality of prescribing for geriatric inpatients: A randomized, controlled trial. Journal of the American Geriatrics Society. 2007;55(5):658-65. doi:10.1111/j.1532-5415.2007.01132.x.

[4] French E. et al. End-Of-Life Medical Spending In Last Twelve Months Of Life Is Lower Than Previously Reported. Health Affairs. July 2017 https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2017.0174