PRESENTED BY
RASHEEDA HALL

Presentation Summary

Written by Milica Maksimovic
Reviewed by Rasheeda Hall

The burden of geriatric problems together with severe cognitive impairment, frailty and polypharmacy is much higher in older adults with dialysis (≥65 years old) as compared to those without kidney failure. The fall rates of older population on hemodialysis (HD) are twofold higher than the rates of community-dwelling elders (1.60 as opposed to 0.8 falls/person-year) [1]. Additionally, HD patients are at high risk for cognitive impairment due to their older age, high prevalence of stroke, and cardiovascular risk factors. In a study that measured cognitive functions in HD patients aged 55 years and older, 37% had severe cognitive impairment compared to the age-matched group [2]. In contrast to the 7% of overall prevalence of frailty in the community-dwelling population [3], it is as high as 74% in HD patients of 60 to 70 years of age [4]. This patient population often requires 12 medications to treat five to six comorbid conditions [5]. The geriatric polypharmacy with drug-related adverse effects influence on the shared risk factors that may lead to geriatric syndromes, which may in turn lead to frailty, while feedback mechanisms further increase the presence of shared risk factors and geriatric syndromes. This course may result in poor outcomes involving disability-dependence, institutionalization, and death (Figure 1).

Figure 1. Algorithm that demonstrates the contribution of adverse drug effects to shared risk factors-geriatric syndromes-frailty-self-sustaining pathways, which may result in poor outcomes (Slide 6 [6]).

Potentially inappropriate medications

The term potentially inappropriate medications (PIMs) refers to medications that have unfavourable benefit/risk ratio for many elderly adults. There are several predisposing factors for PIMs that include polypharmacy, multiple prescribers, comorbidities and prescribing cascade. A prescribing cascade occurs when adverse effects of a drug lead to the prescription of another, which may subsequently cause additional effects, for which more medications may be prescribed, and so on (Figure 2).

The American Geriatrics Society (AGS) Beers Criteria® for PIM together with STOPP (Screening Tool of Older Person’s potentially inappropriate Prescriptions) and START (Screening Tool of Alert doctors to the Right Treatment) are reference tools widely used to minimize the improper prescribing in older population. Such categories of PIMs include sedatives, anticholinergic, muscle relaxants, opioids, alpha blockers, central alpha agonists as well as some diabetic medications.

Figure 2. The prescribing cascade illustrates adverse effects of a medication that leads to prescription of another medication [7].

PIM prevalence in kidney disease

Polypharmacy and PIM use are prevalent in chronic kidney disease (CKD) patients, with greater numbers of medications associated with higher risk of hospitalization and death [8]. Additionally, hypertension, cerebrovascular disease, and uremic toxins contribute to the adverse effects of PIMs in these patients.

Several studies evaluated the prevalence of PIMs in elderly HD patients using AGS Beers Criteria® or the STOPP/ START guidelines. Japan study indicated that the majority of the patients (57%) were prescribed a PIM [9] whereas the Norway one demonstrated PIMs ranging from 43 to 63 % [10]. The US patients without the CKD had PIMs prevalence of around 30% as opposed to around 64% in predominantly CKD patients’ cohort.

How to address the PIM prescribing

Because of the PIMs widespread use and associated major risks, optimization of suitable medication is an ongoing challenge in healthcare. Clinical trials suggest that the decrease in PIM prescribing reduce hospital usage [11], fall rate [12] as well as mortality rate [13]. The term ‘deprescribing’ has been used to describe the systematic approach that is required for safe and effective cessation of medication. The five-step patient-centered deprescribing process includes analysis of comprehensive medication history, identification of PIMs, determining whether a medication can be ceased and prioritized, planning and initiating withdrawal, and monitoring support and documentation [14].

Regarding deprescribing in dialysis, quality improvement study [15] was conducted in order to develop a deprescribing tool for target medications. The study implemented the use of specific tools and algorithms in order to guide deprescribing within five medication classes: quinine, diuretics, α1-blockers, proton pump inhibitors, and statins. Ultimately, there were 78% target medications completely deprescribed six months after the study.

Alternative medications to be used instead of the potentially high-risk medications

Hanlon et al. developed a list of alternative medications that may be used instead of the potentially high-risk ones and potentially harmful drug-disease interactions in the elderly [16]. PIM categories that are commonly used among the CKD patients, can be exacerbated in the dialysis settings, have altered clearance and a safer alternative include sedatives, opioids, antispasmodics, anticholinergics, alpha blockers, and central-acting alpha agonists (slide 13 [6]). The recent study indicated that anticholinergic antidepressant use was associated with a higher hazard of altered mental status, fall, or fracture in older HD patients further urging for use of alternative treatments [17].

Barriers and patients’ attitudes to deprescribing

There are intrinsic (knowledge, attitudes and behavior) as well as extrinsic barriers (environment) to deprescribing, many of which are interconnected (Slide 15 [6]). It is suggested that the lack of evidence and training may decrease health care provider’s efficacy for deprescribing together with poor shared decision making process and low motivation with time constraints. Providers may be hesitant to discontinue medications, particularly when the consequences of discontinuation are unknown and when they have limited access to patient-related data in order to make real-time decisions. Furthermore, various priorities may detract from a provider’s ability to invest time in assessing medication appropriateness [18].

Knowledge of patient attitudes is crucial for conducting medication deprescribing in practice [19]. The adults older than 65 years of age taking at least one regular medicine and their caregivers completed the questionnaire where a higher total score indicated a greater perceived burden, the concerns about stopping, and involvement in medication management. The analysis revealed that the patients and caregivers were evidently willing to deprescribe but they were also concerned about several barriers in that process [19].

References

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2. Murray AM, Tupper DE, Knopman DS et al. . Cognitive impairment in hemodialysis patients is common. . Neurology. 2006; 67(2):216-23. DOI: 10.1212/01.wnl.0000225182.15532.40

3. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype.. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-56. DOI: 10.1093/gerona/56.3.m146

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6. Hall R.. Addressing Potentially Inappropriate Medications in Older Adults with Kidney Disease. . 56th ERA-EDTA Congress; June 13, 2019; Budapest, Hungary. . https://www.enp-era-edta.org/material/21994/webcast-external.

7. Kannayiram Alagiakrishnan, Darren Mah, Raj Padwal. . Classic Challenges and Emerging Approaches to Medication Therapy in Older Adults. . Discovery Medicine. 2018; 26(143):137-146.

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10. Parker K, Aasebø W, Stavem K. . Potentially Inappropriate Medications in Elderly Haemodialysis Patients Using the STOPP Criteria. . Drugs – Real World Outcomes. 2016; 3:359. DOI: 10.1007/s40801-016-0088-z

11. Crotty M, Rowett D, Spurling L, Giles LC, Phillips PA. . Does the addition of a pharmacist transition coordinator improve evidence-based medication management and health outcomes in older adults moving from the hospital to a long-term care facility? Results of a randomized, controlled trial. . Am J Geriatr Pharmacother. 2004;2(4):257-64. DOI: 10.1016/j.amjopharm.2005.01.001

12. Page AT, Clifford RM, Potter K, Schwartz D, Etherton-Beer CD. The feasibility and effect of deprescribing in older adults on mortality and health: a systematic review and meta?analysis. . Br J Clin Pharmacol. 2016; Sep; 82(3): 583–623. DOI: 10.1111/bcp.12975

13. Reeve E, Shakib S, Hendrix I, Roberts MS, Wiese MD. . Review of deprescribing processes and development of an evidence-based, patient-centred deprescribing process. . Br J Clin Pharmacol. 2014;78(4):738-47. DOI: 10.1111/bcp.12386

14. McIntyre C, McQuillan R, Bell C, Battistella M. . Targeted Deprescribing in an Outpatient Hemodialysis Unit: A Quality Improvement Study to Decrease Polypharmacy. AJKD. 2017;70(5): 611–618. DOI: 10.1053/j.ajkd.2017.02.374

15. Hanlon JT, Semla TP, Schmader KE. . Alternative Medications for Medications in the Use of High-Risk Medications in the Elderly and Potentially Harmful Drug-Disease Interactions in the Elderly Quality Measures. . J Am Geriatr Soc. 2015;63(12):e8-e18. DOI: 10.1111/jgs.13807.

16. Ishida JH, McCulloch CE, Steinman MA, Grimes BA, Johansen KL. Psychoactive Medications and Adverse Outcomes among Older. Adults Receiving Hemodialysis. . JAGS.2019; 00:1–6. DOI: doi.org/10.1111/jgs.15740

17. Linsky A, Zimmerman KM.. Provider and System-Level Barriers to Deprescribing: Interconnected Problems and Solutions. . Public Policy & Aging Report.2018;28(4):129-133. DOI: doi.org/10.1093/ppar/pry030

18. Reeve E, Low LF, Shakib S, Hilmer SN.. Development and Validation of the Revised Patients’ Attitudes Towards Deprescribing (rPATD) Questionnaire: Versions for Older Adults and Caregivers.. Drugs Aging.2016; Dec;33(12):913-928. DOI: 10.1007/s40266-016-0410-1

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