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Deprescribing of Psychotropic Drugs in Patients Admitted to Orthogeriatric and Geriatric Wards

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Deprescribing of Psychotropic Drugs in Patients Admitted to Orthogeriatric and Geriatric Wards GHENT UNIVERSITY FACULTY OF PHARMACEUTICAL SCIENCES ACADEMIC YEAR 2016 - 2017 DEPRESCRIBING OF PSYCHOTROPIC DRUGS IN PATIENTS ADMITTED TO ORTHOGERIATRIC AND GERIATRIC WARDS Saïn VANDEPOELE INTERUNIVERSITY PROGRAMME: MASTER OF SCIENCE IN HOSPITAL PHARMACY SUPERVISOR KATY VERHELLE, PharmD ANNE VERHAEGHE, PharmD ACADEMIC PROMOTER PROF. ANNEMIE SOMERS, PharmD, PhD GHENT UNIVERSITY FACULTY OF PHARMACEUTICAL SCIENCES ACADEMIC YEAR 2016 - 2017 DEPRESCRIBING OF PSYCHOTROPIC DRUGS IN PATIENTS ADMITTED TO ORTHOGERIATRIC AND GERIATRIC WARDS Saïn VANDEPOELE INTERUNIVERSITY PROGRAMME: MASTER OF SCIENCE IN HOSPITAL PHARMACY SUPERVISOR KATY VERHELLE, PharmD ANNE VERHAEGHE, PharmD ACADEMIC PROMOTER PROF. ANNEMIE SOMERS, PharmD, PhD WORDS OF THANKS _______________________________________________________________________________________ Without the support and contribution of many people, this work would not have become what it is today. Therefore I would like to take the opportunity to thank some people for their help and inspiration. First of all, I am very grateful to Katy, head of pharmacy, and the rest of the hospital pharmacy team for the fascinating internship in the ‘Groeninge’ hospital in which I got excellent guidance and was offered exciting opportunities. In particular, I would like to thank my internal supervisor Anne for her enthusiastic guidance in which she taught a lot of clinical pharmacy knowledge. I also want to thank Annemie Somers for the follow-up of my research and the detailed and extensive readings of my study despite her many other work. I would like to thank my closest colleague Eva who accompanied me during the whole internship, for sharing the moments of happiness and frustration, for her support and help. A special word of thanks to Tom who always believed in me, who helped me with reasoning questions or layout issues and who gave me advice when I was stuck. Thanks to my parents and sisters for giving me the opportunity to graduate as a hospital pharmacist and to support this choice in all areas. I II Deze pagina is niet beschikbaar omdat ze persoonsgegevens bevat. Universiteitsbibliotheek Gent, 2021. This page is not available because it contains personal information. Ghent Universit , Librar , 2021. IV SUMMARY _______________________________________________________________________________________ Elderly have a great potential to benefit from their medication, but are also more vulnerable to adverse drug reactions. Especially the use of psychotropic medications can increase the risk on confusion, falls and cognitive impairment. Age related changing pharmacokinetics, polypharmacy and presence of multiple comorbidities, noncompliance and reduced capabilities for safe and appropriate handling of drugs are risk factors for drug related problems with adverse outcomes. Deprescribing may be one way to reduce the number of medicines, to improve appropriate prescriptions and to avoid adverse drug reactions. Deprescribing is the act of tapering, reducing or stopping medication supervised by a health care professional with the goal to improve outcomes. In this study, one of the main objectives was to determine the prevalence of potentially inappropriate prescriptions in a geriatric population. In addition, the acceptation rates of the recommendations, suggested by the pharmacist, were determined and the added value of multidisciplinary communication with healthcare providers was investigated. Patients, aged over 75 with a minimum intake of 5 drugs, were screened at the geriatric and orthogeriatric ward of the ‘Groeninge’ Hospital in Kortrijk for inclusion in this deprescribing study. Different tools are available to support health professionals for deprescribing, including implicit and explicit tools. In this research inappropriate prescriptions were identified by using chapter ‘D’ of the STOPP criteria. In addition, standardized tapering schemes were introduced and applied in practice. These schemes could be adapted according to the needs of the patient. Patients, eligible for a withdrawal scheme, were approached by the clinical pharmacist in training. They were informed about the potential risks and long-term side effects. Afterwards their willingness to reduce psychotropic drugs was questioned. Also geriatricians and general practitioners were involved. Their shared-decision determined if a recommendation could be implemented for a patient. Deprescribing is a process that needs a close follow-up and careful data collection. In this study, a follow-up call after discharge was conducted by the clinical pharmacist to detect problems with withdrawal schemes. In this study, 398 of the 470 screened patients were included. At least one intervention was suggested by the clinical pharmacist in 89.7% of the included patients. The overall acceptation rate of the geriatricians was 80.4%. After counseling by the pharmacist, still 20.9% patients were unwilling to discontinue their psychotropic drugs. Deprescribing was refused because of fear for return of their disease or fear for withdrawal effects. In this study, 145 general practitioners and 104 community pharmacists were contacted to give their approval on the tapering schedule and follow-up. After discharge, 59 patients were called by the pharmacist to detect possible problems with withdrawal schedules. These schedules were interrupted by 31.1% of this patients. Lack of motivation of the patient and insufficient follow-up by the first line caregivers were the main reasons for discontinuation. There is growing evidence that indicates that deprescribing for older people is safe and feasible. Deprescribing can improve optimal and appropriate medication use for elderly patients. However, a frequent medication review should be conducted in the older patient to detect inappropriate prescriptions and to maintain the motivation of the patients. In addition, multidisciplinary cooperation between all healthcare providers is necessary for seamless pharmaceutical care and a proper follow-up after discharge. V VI SAMENVATTING _______________________________________________________________________________________ Ouderen hebben een groot potentieel om positieve effecten van hun medicijnen te ervaren, maar zijn ook kwetsbaarder voor bijwerkingen. Vooral het gebruik van psychofarmaca kan het risico op verwardheid, valincidenten en cognitieve achteruitgang verhogen. Risicofactoren voor deze slechte gevolgen zijn onder andere leeftijdsgerelateerde veranderingen in de farmacokinetiek, polyfarmacie, de aanwezigheid van comorbiditeiten, therapieontrouw en verminderde vaardigheden om medicatie correct in te nemen. Deprescribing kan het aantal geneesmiddelen doen dalen, het geschikt voorschrijven verbeteren en bijwerkingen voorkomen. Deprescribing is een proces van afbouwen, verminderen of stoppen van geneesmiddelen onder toezicht van een zorgverlener met als doel de eindpunten te verbeteren. In deze studie was een van de hoofddoelstellingen om de prevalentie van potentieel ongeschikt voorschrijven in een geriatrische populatie te bepalen. Daarnaast werd het aanvaardingspercentage van de aanbevelingen, voorgesteld door de apotheker, nagegaan en werd de meerwaarde van de transmurale communicatie met zorgverleners onderzocht. Patiënten ouder dan 75 jaar die minstens 5 geneesmiddelen innamen werden gescreend op geriatrie en orthogeriatrie in AZ Groeninge in Kortrijk voor inclusie in deze afbouwstudie. Verschillende ‘deprescribing’ hulpmiddelen zijn beschikbaar om gezondheidsverstrekkers te helpen, inclusief impliciete en expliciete hulpmiddelen. In dit onderzoek werden ongeschikte voorschriften geïdentificeerd aan de hand van hoofdstuk D van de STOPP criteria. Daarnaast werden standaard afbouwschema's toegepast in de praktijk. Deze schema's kunnen aangepast worden naargelang de noden van de patiënt. Patiënten die in aanmerking komen voor een afbouwschema werden benaderd door de klinisch apotheker in opleiding. Ze werden geïnformeerd over de potentiële risico's en langdurige bijwerkingen en hun bereidheid tot afbouw van psychofarmaca werd bevraagd. Ook de geriaters en huisartsen waren betrokken en hun gezamenlijke beslissing bepaalde of het advies van de apotheker werd opgevolgd. Deprescribing is een proces dat een nauwgezette follow-up en gegevensverzameling vereist. In deze masterproef werd de patiënt opgebeld na ontslag door de klinisch apotheker om mogelijke problemen rond afbouwschema’s op te sporen. In totaal werden 398 van de 470 gescreende patiënten in deze studie geïncludeerd. Bij 89,7% van de geïncludeerde patiënten werd minstens één interventie voorgesteld door de klinisch apotheker. Hiervan werden 80,4% adviezen aanvaard door de geriaters. Toch waren 20,9% van de patiënten niet bereid om hun psychofarmaca af te bouwen na advies door de apotheker. Afbouw werd geweigerd uit angst voor het terugkeren van de aandoening of uit angst voor ontwenningsverschijnselen. In deze studie werden 145 huisartsen en 104 officina- apothekers gecontacteerd met de vraag of ze akkoord gingen met het afbouwschema en of ze wilden instaan voor verdere opvolging. Na ontslag werden 59 patiënten gecontacteerd door de klinisch apotheker om problemen met afbouwschema’s op te sporen. De afbouwschema's werden onderbroken bij 31,1% van de patiënten. Gebrek aan motivatie van de patiënt en onvoldoende follow-up door zorgverstrekkers uit 1e lijn waren redenen voor stopzetting. Er is steeds meer evidentie dat ‘deprescribing’ in de oudere populatie veilig en haalbaar is. ‘Deprescribing’ kan het optimaal en geschikt geneesmiddelengebruik
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