Medicine Optimisation: Join the evolution...
Dr Henry J. Woodford is Chair of the BGS Medicine Optimisation SIG and works as a consultant geriatrician for Northumbria Healthcare in northeast England. He originally trained at King's College London. His role includes acute frailty assessment. He tweets @woodford_henry. Dr Lauren Ralston is Deputy Chair of BGS Medicine Optimisation SIG and works as a consultant geriatrician at Harrogate and District NHS Foundation Trust. She tweets @laurenralston2. Dr Yvonne C.M. Morrissey is Secretary of the BGS Medicine Optimisation SIG. She was a Consultant Geriatrician in East Kent for 25 years but has now retired from clinical work and is an Honorary Consultant working with the Informatics Department. She is Chair of the BGS South East Region. She is UK Rep of the FRIDS Task and Finish Group on Fall-risk Increasing Drugs.
The BGS ‘Drugs and Prescribing’ Special Interest Group (SIG) was established in 1988. Recently the name was modified to the ‘Medicines Optimisation SIG' in order to reflect the evolving way that we approach therapeutics in older people. Over the last 30 years the face of medicine has changed dramatically, including the emergence of the concept of frailty. Increased longevity has driven the accumulation of long-term conditions over our lifespan, so that most people experience older age as a state of multi-morbidity. As diagnosis drives prescription, aided by clinical guidelines, polypharmacy becomes a frequent companion. But are we providing optimal care?
Modern medicine is centred around the evidence of drug efficacy demonstrated through randomised controlled trials (RCT). We have a breadth of effective treatments for a wide range of conditions. However, these RCTs infrequently recruit people aged over 80 or those with moderate to severe frailty. The traditional way to manage this knowledge void was to extrapolate the evidence base through the logic that bad outcomes are more likely in older people, so they stand to gain most from drugs. This thinking has been increasingly questioned.1
Changes to our physiology in older age, manifested in the development of frailty, may both lower the probability of beneficial effects from medications and increase the risk of harmful effects. For example, competing causes of death in people with multi-morbidity limit the prognostic benefits of any single agent and increased susceptibility to harmful stimuli, including adverse drug reactions (ADRs), affects people with moderate to severe frailty.
Polypharmacy has varying definitions but often a value of five or more regular medications is used. This cut-off would include the majority of people aged over 80 in the UK and so might be considered the current norm in this age group. Polypharmacy is associated with many adverse outcomes such as increased risk of hospitalisation and death, although this might be explained by the fact that those taking the most medications are likely to have the most illnesses and so are more likely to do badly with or without drugs. What we do know is that being prescribed more medicines increases the chance of both ADRs and drug errors, and lowers the probability of adherence. ADRs are directly implicated in about 10% of acute hospital admissions for older people and may play a contributory role in many more.2 Potentially clinically significant drug errors occur around 66 million times each year in England alone.3 It is estimated that 30 to 50% of the medication prescribed for long term conditions is not taken as intended.4 These are alarming numbers. Surely we could be doing better?
Medicines optimisation has been defined as ‘a person-centred approach to safe and effective medicines use, to ensure people obtain the best possible outcomes from their medicines’.4 This will include deprescribing in some circumstances. Medicines optimisation is a key aspect of healthcare for older people and has the capacity to develop as a sub-speciality through medicines optimisation clinics and care home reviews. Its importance has been recognised within the draft new geriatrics training curriculum.5 Right now, prescribing for older people is coming under increased focus both among healthcare professionals and in wider society.
The Medicines Optimisation SIG wants to champion individualised care based around shared decision-making. An essential component of shared decision-making is patient awareness of the possible adverse consequences of their medication. For example, falls, a crucial geriatric syndrome and an established ADR, are potentially preventable through medication review. Knowledge dissemination among patients and doctors of fall-risk increasing drugs (FRIDs) could reduce the number of fall-related injuries.6
We aim to be a forum for the exchange of ideas and research evidence to help shape our clinical services. The BGS is developing as a multi-disciplinary group of people. Our SIG would also like to reflect this and attract additional membership from everyone involved in the healthcare of older people, including pharmacists and other non-doctor prescribers. We plan to have dedicated educational sessions in the near future.
1. Petchey L, Gentry T. More harm than good: why more isn’t always better with older people’s medicines. Age UK, 2019. www.ageuk.org.uk/globalassets/age-uk/documents/reports-and-publications/reports-and-briefings/health--wellbeing/medication/190819_more_harm_than_good.pdf
2. Alhawassi TM, Krass I, Bajorek BV et al. A systematic review of the prevalence and risk factors for adverse drug reactions in the elderly in the acute care setting. Clin Interventions Aging 2014; 9: 2079–86.
3. Elliott RA, Camacho E, Jankovic D, et al. Economic analysis of the prevalence and clinical and economic burden of medication error in England. BMJ Qual Saf 2020; doi:10.1136/bmjqs-2019-010206.
4. National Institute for Health and Care Excellence. Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes, 2015. www.nice.org.uk/guidance/ng5
5. Joint Royal College of Physicians Training Board. Curriculum for geriatric medicine training [draft, proposed implementation 2022]. Available at: www.jrcptb.org.uk/sites/default/files/DRAFT%20New%20Curriculum%20Geriatric%20Medicine%20v15%2005%20Mar.pdf
6. Seppala LJ, van der Velde N, Masud T, et al. EuGMS Task and Finish Group on Fall-Risk-Increasing Drugs (FRIDs): position on knowledge dissemination, management and future research. European Geriatr Med 2019; 10: 275-83.