Rocking the Boat vs. Staying the course The Perils and Pluses of Stopping Meds in Long Term Care

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Rocking the Boat vs. Staying the courseThe
Perils and Pluses of Stopping Medsin Long Term
Care

• Janet Kushner Kow MD, MEd, FRCPC
• UBC Division of Geriatric Medicine

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Objectives

• Review general principles of medication use in
  Long Term Care
• Review concept of Life Expectancy and Quality of
  Life to help assess medication choices, using
  cholinesterase inhibitors and bisphosphonates as
  examples

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Case Mrs DS

• 89 y.o. female
• Admission history of Alzheimers dementia,
  hypertension, osteoporosis (previous hip
  fracture), angina
• Medications donepezil, alendronate, calcium, vit
  D, hydrochlorthiazide, ramipril, cardizem, nitro
  patch, risperidone, ASA

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• Admitted with MMSE of 6/30, incontinent x2,
  language deteriorating
• What should we do about her medications?

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Why review?

• NH residents average 7-8 meds/ person
• First time to properly review
• Admission from hospital
• (Near) 100 adherence
• Frailty marker

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Why review?

• Unique opportunity to taper, switch over
• 24hr observation on effects

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Principle 1

• What is her LIFE EXPECTANCY?
• Stage 4 heart failure, Child-Pugh C 1 year
• Severe dementia 1-3 years

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Principle 2

• There is little to no evidence for almost all
  conditions in patients over 80 particularly in
  the frail
• The ART of Medicine

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Principle 3

• Is this medication of any use?
• 1. What is the target problem (if any) being
  treated?
• 2. Is the drug necessary?
• 3. Are nonpharmacologic therapies available?
• 4. Is this the lowest practical dose?
• 5. Is this the most cost-effective choice?

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Behavioural disturbance in Dementia

• Unusual behaviour in the elderly is not
  necessarily an indication for drug intervention.
• The safest therapeutic approach is personal
  attention and support, which can be highly
  effective and is often preferable to sedation.

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Principle 4

• What are the medications effects?
• Impact on Quantity of Life vs Impact on Quality
  of Life

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Quality of life

• Symptoms
• pain, shortness of breath, angina, agitation
• Prevention nearing the end of life
• broken hip
• re-emergence of behavioural disturbance
• Stroke and CV prevention what are the likely
  deficits if she has an event?

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Quality of life

• Sequelae of medications
• multiple administration, swallowing difficulties,
  side-effects eg. GERD
• polypharmacy increased risks, side effects

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Principle 4

• What do the patient and/or family think?

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Mrs DS ending 1

• Didnt actually have angina
• Had increased agitation after bisphosphonate
• BP 105/80 sit 95/60 standing
• family felt donepezil helpful

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Ending 1

• Final med list
• donepezil
• calcium vitamin D

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Mrs DS Ending 2

• BP 145/70
• Stopping HCTZ not of any use but BP not any
  higher
• Definitiely had angina - clutched chest at times
• Family didnt feel donepezil was useful, tapering
  off no difference
• High fall risk
• Doesnt like taking big pills

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Ending 2

• Final med list
• alendronate
• vitamin D
• ramipril
• nitro patch
• ASA

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Conclusions

• Life expectancy
• Lack of EBM
• Symptoms and/or prevention
• Informed consent

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Reference

• Avorn J. Gurwitz JH. Drug Use in the Nursing
  Home Ann Intern Med August 1995 123(3) 195-204