Appendix 3 – Care Home Enhanced Service April 2018
Patient Outcome Medicines Safety Indicators (POMSIs)
There are well documented common medication related causes for harm and/or admission to hospital. Studies have estimated at least 5% of hospital admissions are medicines related with around half potentially preventable. Four classes of medicines have been identified with around half of preventable admissions – antiplatelets (including aspirin), anticoagulants, NSAIDs and diuretics. There are also identified risk factors such as older age, co-morbidity, dependent living situation and polypharmacy which increase the risk of a medicines related admission.
Within this Care Home enhanced service five key areas relating to 10 indicators have been identified. The aim is to try and reduce the potential for medication related harm within the care home setting by identifying the residents who are at risk from receiving these medicines and encourage multi professional discussion with the GP, practice pharmacist, nurse, carer, resident and/or family member to reduce the number of residents at recognised risk.
The five key areas are -
1. Bleeds 2. Falls 3. Renal function 4. Infection 5. Confusion
Bleeds
Drug-induced bleeding is commonly thought of as gastrointestinal (GI) bleeding resulting from the use of non steroidal anti-inflammatory drugs (NSAIDs). Nosebleeds and abnormal bruising, in addition to GI bleeding, may be linked to the use of oral anticoagulants.
Falls
Between 230,000 and 460,000 people over the age of 60 fall in Wales each year. Falls are one of the leading causes of admission to hospital, with around 21,000 fall related in-patient admissions each year, which result in length of stays which are twice as long as the average. On an individual level falls have a profoundly negative impact on a person’s life leading to reduced confidence and independence. Falls are not an inevitable part of ageing; there are many factors which can contribute to a fall, with medication, poor eyesight and lack of exercise being amongst the key risks. Studies have identified nine major classes of medication which have a significant association with falls - neuroleptics, antipsychotics, antihypertensives, diuretics, beta-blockers, sedatives and hypnotics, benzodiazepines, non-steroidal anti-inflammatory drugs or narcotics. Stopping, reducing or monitoring (such as lying and standing blood pressure) these medicines will reduce an individuals risk of falling. Appendix 3 – Care Home Enhanced Service April 2018
Renal Function (Acute Kidney Injury (AKI))
Acute kidney injury (AKI) is the sudden loss of kidney function over a period of hours or days. Since the kidneys are one of the major excretory pathways for the removal of drugs from the body, this sudden loss of kidney function can have major implications for a patient’s prescribed medication regime.
Renal function declines with age; many elderly patients have renal impairment but because of reduced muscle mass, this may not be indicated by a raised serum creatinine. Many drugs can be harmful to the kidneys especially in people with AKI or at risk of it for non-pharmacological reasons. In addition, other drugs – such as those with a narrow therapeutic range and those that are cleared by the kidneys – may cause toxicity in the setting of AKI and acute illness, requiring additional monitoring, dose adjustment and measurement of drug levels
Clostridium difficile infection
There are growing concerns about long term treatment with Proton Pump Inhibitor (PPI) therapy and association with, amongst others, Clostridium difficile infection and increased risk of bone fractures in susceptible populations. PPIs have recognised benefits in certain GI conditions but gastric acid suppression has been a suggested risk factor for Clostridium difficile infection.
Confusion
Behavioural and psychological symptoms (BPSD), such as restlessness and shouting, are very commonly experienced at points in time in people with dementia. Antipsychotic medications are frequently prescribed first line to treat BPSD though it has been estimated that around two thirds of these prescriptions are inappropriate and the symptoms can be managed without medication. Evidence appears to show that the benefits of antipsychotic use is limited over longer periods. Antipsychotics are associated with an increased risk of falls, delirium, cerebrovascular events and all-cause death.
Anticholinergic medication can produce adverse effects such as constipation, urinary retention, dry mouth/eyes, sedation, confusion, delirium, photophobia, falls and reduced cognition (may lead to wrong diagnosis of dementia). There is also a suggested link between increased mortality and the number and potency of anticholinergic agents prescribed. Elderly patients are more likely to experience these adverse effects so should be used cautiously with increasing age.
The Anticholinergic Risk Scale is useful to raise awareness of anticholinergic effects of different medicines. A number of studies have been published which aim to assign drugs with one, two or three points; the higher the number, the stronger the anticholinergic effect. Appendix 3 – Care Home Enhanced Service April 2018
1 Point 2 Points 3 Points Amiodarone Amantadine Alimemazine (trimeprazine) Aripiprazole Chlorphenamine Amitriptyline Bromocriptine Desipramine Atropine Carbamazepine Dicycloverine Benztropine Citalopram (dicyclomine) Chlorpromazine Diazepam Dimenhydrinate Clemastine Domperidone Diphenhydramine Clomipramine Fentanyl Disopyramide Clozapine Fluoxetine Levomepromazine Cyproheptadine Fluphenazine Olanzapine Dothiepin (dosulepin) Hydroxyzine Paroxetine Doxepin Iloperidone Pethidine Hyoscine hydrobromide Lithium Pimozide Imipramine Mirtazepine Prochlorperazine Lofepramine Perphenazine Promazine Nortriptyline Prednisolone Propantheline Orphenadrine Quinidine Quetiapine Oxybutynin Sertindole Tolterodine Procyclidine Sertraline Trifluoperazine Promethazine Solifenacin Trihexyphenidryl (benzhexol) Temazepam Trimipramine http://www.awmsg.org/docs/awmsg/medman/National%20Prescribing%20Indicators%202017-2018.pdf
Ten indicators for audit
Drug/Class Referral/review Include (generic and brands) criteria 1 Proton Pump At high or treatment Pantoprazole 40mg Inhibitor dose for over 8 weeks Lansoprazole 30mg Omeprazole 40mg Esomeprazole 40mg Rabeprazole 20mg 2 Hypnotics and Long term (over 4 All oral benzodiazepines and Benzodiazepines weeks) “Z-drugs”. 3 Antipsychotics Currently prescribed All oral antipsychotics.
4 Antipsychotics With dementia All oral antipsychotics
5 NSAIDs and/or Long term (over 3 All oral non-steroidal anti- COX II months) inflammatories. 6 NSAIDs and/or Without PPI/H2RA All oral non-steroidal anti- COX II inflammatories. 7 Bisphosphonates Unable to take dose All oral bisphosphonates. correctly - stay fully upright for at least 30 minutes or one hour after taking the tablet 8 Anticholinergic Aged 75 and over, and All medicines listed in Burden currently prescribed – anticholinergic effects table Appendix 3 – Care Home Enhanced Service April 2018
with cumulative score below. of 3 or over 9 Antihypertensives Does not have a blood All regular antihypertensives pressure recorded in (as per BNF listing) last 6 months 10 Warfarin, Does not have an up to All patients receiving warfarin, Methotrexate, date monitoring booklet methotrexate or lithium Lithium
Method
The contracted pharmacy is required to identify the number of residents in each home who meet the above indicators. This may involve liaising with the home to seek further individual resident information. For all indicators the number of residents currently in the home and the number meeting each indicator should be recorded on NECAF.
A list of residents meeting each indicator should also be produced for each home/GP and discussed with the residents GP and/or practice pharmacist (unless otherwise advised by Health Board), in addition to understanding the reasoning behind the risks and a suggested action plan for the residents.
This process will be repeated and reported every six months.
Outcomes
The number of residents meeting each indicator will be reviewed at a Health Board and national level with an expectation of a reduction within these identified risk areas which evidence suggests will improve outcomes for the individual residents.
References and suggested reading
AWMSG Polypharmacy Guidance for Prescribing - http://www.awmsg.org/docs/awmsg/medman/Polypharmacy%20- %20Guidance%20for%20Prescribing.pdf
WeMeReC - www.wemerec.org/Documents/enotes/StoppingPPIsenotes.pdf
WeMeReC - www.wemerec.org/Documents/enotes/WithdrawingBenzodiazepine2009.pdf
AWMSG Towards appropriate NSAID prescribing - http://www.awmsg.org/docs/awmsg/medman/All%20Wales%20Audit%20- %20Towards%20Appropriate%20NSAID%20Prescribing.pdf
Bisphosphonates – https://www.gov.uk/government/publications/bisphosphonates-use-and- safety/bisphosphonates-use-and-safety
Warfarin – http://www.nrls.npsa.nhs.uk/resources/?EntryId45=61777
Appendix 3 – Care Home Enhanced Service April 2018
Methotrexate - http://www.nrls.npsa.nhs.uk/resources/?entryid45=59800
Lithium - http://www.nrls.npsa.nhs.uk/alerts/?entryid45=65426
Renal (AKI) - https://www.thinkkidneys.nhs.uk/aki/wp- content/uploads/sites/2/2016/03/Guidelines-for-Medicines-optimisation-in-patients- with-AKI-final.pdf
Meds related admission - https://www.wemerec.org/Documents/Bulletins/Medicines- related%20admissions-online.pdf