Prescribing for the Frail Prescribing for the Frail ElderlyElderly

THE THE THERAPEUTIC THERAPEUTIC DRUGECTOMYDRUGECTOMY

CASE STUDYCASE STUDY

MargaretMargaret

• 90 years old• Discharged from hospital three months ago

with:

non-small cell carcinoma lung palliative

COPD

ankle edema

hypertension

depression

osteoporosis

dementia

Furosemide 20 mg ODRamipril 5 mg BIDMetoprolol 25 mg BIDTiotropium MDIFluticasone/salmeterol MDIMirtazapine 15 mg HSRisedronate 5 mg ODDonepezil 5 mg ODVitamin DCalciumFolate

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

WHAT DO WE

DO?

Furosemide 20 mg ODRamipril 5 mg BIDMetoprolol 12.5 mg BIDTiotropium MDIFluticasone/salmeterol MDIMirtazapine 15 mg HSRisedronate 5 mg ODDonepezil 5 mg ODVitamin DCalciumFolate

Furosemide 20 mg OD

Metoprolol 12.5 mg BID

Fluticasone/salmeterol MDI

Mirtazapine 15 mg HS

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.

MARGARET’S OUTCOME

WHY IS IT SO DIFFICULT?

• Prevention Doesn’t Work in Frailty

• Heterogeneity Unpredictability

• Multiple Pathology Polypharmacy

First,

Prevention Prevention

Doesn’t WorkDoesn’t Work

if you’re Frailif you’re Frail

FOUR GOOD REASONS

WHY NOT

1. No prediction in the unpredictable

HETEROGENEITY

UNPREDICTABILITUNPREDICTABILITYY

…YOU CANT PREDICT

for someone who is

UNPREDICTABLEUNPREDICTABLE

FOUR GOOD REASONS

WHY NOT

2. NO FRAIL IN TRIALS

Principle of Geriatrics 2

“The frail elderly are

MULTIPLY PATHOLOGICAL”

The QUORUM EPIPHANY

Clinical trial exclusion criteria are Clinical trial exclusion criteria are unbelievably comprehensiveunbelievably comprehensive

Trials EXCLUDE FRAILTY

You

CAN’T DO

studies that support prevention

in frailty

FOUR GOOD REASONS

WHY NOT

3. LIMITED CHANCE OF BENEFIT

4. OFFSETTING DANGER

Bottom Line:

FRAILTYFRAILTY

lives in anlives in an

EVIDENCE-FREE EVIDENCE-FREE ZONEZONE

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.

10 RULES for

STARTING MEDICATION

in the FRAIL ELDERLY

RULE 1

DON’T

RULE 2

Start Low

RULE 3

Go Slow(…but go)

RULE 3

GO SLOWGO SLOW

(but GO)(but GO)

RULE 4

Fix ENDPOINTS for treatment in your mind

(and write them down)

What COULD happen?

1. BENEFIT

2. ADR

3. NOTHING

4. BOTH

BENEFIT ADR

YES NO

NO YES

YES YES

NO NO

What you do next depends on what happens, SO…

What happens better be

MEASURABLE

RULE 5

RETURN

to measure the

OUTCOME

RULE 7

NO ADHERENCE NO ADHERENCE

NO PRESCRIPTIONNO PRESCRIPTION

RULE 8RULE 8

Think Twice Think Twice

about Preventionabout Prevention

RULE 9

ONE THING at a TIME

RULE 10

KEEP IT

SIMPLE!

DRUGECTOMYDRUGECTOMY

Getting rid of medication that

shouldn’t be there.

It’s simply the

reverse

of starting medication,

and you’re just as blind

to the outcome

going in.

It’s Just Like STARTING

Medication, only in

REVERSE…

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

SAME RULES apply:

START LOW

GO SLOW

MEASURE OUTCOMES

WHAT CAN HAPPEN?

1. Benefit (ADR goes away)

2. Adverse Consequence (Rebound)

of condition being treated

of condition not suspected

3. NOTHING

4. BOTH

SAME STORY:

Get the endpoints clear

Return to measure outcome

Ready for ambiguity

No reportNo report

Both benefit and reboundBoth benefit and rebound

Maybe so maybe noMaybe so maybe no

Intercurrent wind blowingIntercurrent wind blowing

Caregivers/patient attitudeCaregivers/patient attitude

REMEMBER

1. Frail elderly are unique

2. THEY set the agenda

3. Comfort and function are (usually) the priorities

4. Single trial trumps population trial

5. Success depends on TRUST