Implications in the elderly: Update in geriatrics and polypharmacy
Dr Holly Holmes - University of Texas, Houston, USA
You have been given the task here, briefly can you tell me about this task of summarising and updating geriatrics? What do you see, you have pharmacological origins but what do you see as the challenges in geriatrics right now, just very briefly?
This year there have been some interesting developments in blood pressure targets, there have been some disappointments in dementia care and some updates in vaccination. All of those are relevant to the oncologist so I really tried to focus on those things that the oncologist might encounter.
Over-medication is a big issue and polypharmacy is one of your particular interests. Surely I know all about polypharmacy, don’t we all know all about it already?
It’s one of those things like obscenity, we think that we know what it is when we see it but we have a really hard time defining it. So some people say that it’s taking five or more medications regularly, some people say ten or more, some people call that excessive polypharmacy, but it’s taking more drugs than is indicated.
What are the things that happen, though, in your patients taking many medications?
The more drugs an older person takes the more likely they are to have an adverse drug reaction so something that would land them in the emergency room or the hospital. They’re more likely to have geriatric syndromes like falls, cognitive impairment, delirium, and they have long-term and short-term effects from over-medication.
Are there particular specifics that jump out and say this needs to be addressed quite regularly?
There are, although the challenge is that the evidence for those specific drugs being the smoking guns for the harm is really very difficult. But there are some drugs that are generally harmful – sedative hypnotics, so sleeping pills, anticholinergics, so things that are sedating like diphenhydramine. Those kinds of classes of drugs have always been implicated in falls and cognitive impairment.
The key word at the moment is multidisciplinary approach in cancer medicine so why is it the problem of the cancer doctor?
When a patient goes from their GP to their cancer doctor they run the risk of having all of their other medical problems not very well tailored as much as before. They come with this huge bag of medications, the oncologist is just going to add more medications to the mix. So it’s really important to engage the entire multidisciplinary team to think about whether all of these drugs are really the right choice for the patient, particularly as they start cancer treatment.
Depending on which country you’re in and which healthcare system, it might be hard for the GP to stay in touch. Can you tell me what are the sort of models for keeping the family practitioner and even the pharmacist also in the loop to prevent problems from too many drugs?
The models are very challenging, so not only the family practitioner, the pharmacist but even in many places there are not geriatricians to do a comprehensive geriatric assessment for oncology patients. So in the ideal setting you would be able to have all of these people at the table and they could all bill for their services individually. Many places there are bundled types of care or basically capitated care for one condition in which case everybody has to take their piece of the puzzle. So it’s key for the oncologist to recognise the role that everybody plays, that the pharmacist is probably the best person to do a very close review of medications.
So the data that the pharmacist needs would be what? Because you need to know how the effect of a drug changes with the age profile of the patient and you need to know all about interactions. What has to happen at the pharmacist level and why can that be a big hope?
The beauty is that the pharmacist already has a lot of that data from their training and at their disposal. So what they really need to know, they need to know everything the patient is currently taking including prescriptions, supplements, herbals, everything that’s over the counter. But what is really helpful for the patient with cancer is to know what is the plan for treatment. So there really has to be some communication between the oncologist, the family practitioner, the pharmacist – ‘This is the treatment we are planning, how is that going to impact all of the other comorbidity care and all of the other medications?’ That dialogue cannot happen in a vacuum.
And the pharmacist is an approachable person, isn’t he or she?
Absolutely. In the United States and I think also in many other countries, particularly in the National Health Service as well, the pharmacist is a vastly underutilised resource. It is a highly trained, highly specialised person in a place just waiting for someone to contact them. So in many places pharmacists are doing much better to reach out and really be part of that care but particularly in the US we have all of these community pharmacists who are waiting for the doctors to talk to them and to find out what to really do. There’s very little dialogue that happens.
So could you summarise for me what are the big messages for cancer clinicians, especially in the context of geriatric oncology coming out of this issue of polypharmacy?
The message is that oncologists need to be aware that they may be the one person most responsible for the patient’s medications during cancer care. Because that is the case they need to engage within a multidisciplinary team and in particular their pharmacist to help to triage those medications and to streamline them while they’re getting cancer therapy.