Cardiovascular disease in older people
The risk of cardiovascular disease (CVD) increases with age. Therefore, older people have a higher prevalence of cardiovascular long-term conditions (LTC), like hypertension, coronary heart disease (CHD), heart failure and atrial fibrillation (AF).
Older people also have a higher prevalence of associated adverse events, such as stroke, myocardial infarction, revascularisation and hospitalisation, compared to younger adults.
Cardiovascular medicines and risk
Cardiovascular medicines are the most frequently prescribed class in older people and are associated with a high incidence of adverse drug events (ADEs).
The risk of multimorbidity (the presence of two or more diseases) and frailty also increase with age. A Lancet study reported 75% of 75year olds in the UK having more than one long-term condition, rising to 82% of 85year olds. A further study has shown that 20-50% of older people with CVD also live with frailty.
Principles for medicines optimisation
In older people CVD should not be managed in isolation, but in the context of frailty, multimorbidity and other vulnerabilities.
The principles for managing CVD in older people include:
- Holistic, patient centred goal setting – establishing what matters most to the patient
- Evidence and guideline limitations in this population
- Adverse drug events – identify actual ADEs and consider the risks of potential ADEs when prescribing
- Review medication regularly recognising co-morbidities and changing patient priorities
- Therapy modification in line with the principles of good prescribing practice and appropriate deprescribing
Applying medicines optimisation principles
CVD should not be managed in isolation in older people, but in the context of frailty, multimorbidity and other vulnerabilities.
NICE CG56 guidance and British Geriatric Society Fit for Frailty part 1 recommend general principles for managing multimorbidity. The Journal of the American Geriatrics Society and the Journal of the American College of Cardiology provide useful strategies, specifically for managing CVD in frailty and multimorbidity.
The principles support the following actions the healthcare practitioner should take when optimising medicines in older people:
- identify and prioritise those most vulnerable to ADEs
- screen for and assess frailty as part of overall care
- apply a biopsychosocial approach that is patient centred and individualised. This takes into account biological, psychological, and social aspects
- align each older person’s individual preferences with the care offered
- coordinate care between multiple health and social practitioners, providers and systems
- pay attention to polypharmacy, pill burden and treatment burden such as multiple appointments
- pay attention to non-adherence as up to 60% of patients with cardiovascular LTCs are non-adherent to therapy within 3 years
- undertake regular medication reviews particularly after initial prescribing and use a structured evidence based patient centred framework.
- use clinical judgment and personalised goals when applying disease-based clinical guidelines to drug management decisions
- generate a personalised shared care and support plan which includes the treatment goals, interventions, follow up reviews, a crisis plan, with sustained support over a long time, continued through intervening crises and adverse events
Challenges in managing CVD in older people
Consideration should be given to the following challenges in the therapeutic management of CVD in older people:
- heterogeneity of older people: In relation to health, functioning and resilience to stressors. There is a wide variation between older people of a similar age therefore assessing their cardiovascular risks and benefits from therapy needs an individualised approach
- limitations of current research evidence and the application to frailty
- increased risk of ADEs due to age-related physiological (pharmacokinetic and pharmacodynamic) changes that alter drug handling
- presence of frailty syndromes that increase vulnerability to ADEs
- various health, functional and psychosocial circumstances that impact on the patient’s willingness and capability to take/use medicines as prescribed
- limited life expectancy in frailty alters the risk: benefit ratio for patient outcomes
- shift in care goals from preventative to mainly palliative in later years. Outcomes set in clinical trials for younger people often differ from the outcomes important to older people
Implementing evidence-based practice
Resources and tools are available to support a holistic and individualised approach to medicines review and optimisation in older people. They use a patient centred approach that aims to address some of the challenges.
The resources and tools incorporate shared decision making throughout the process to consider the best available research, alongside the patient’s perspectives a well as the clinical expertise and judgment of the practitioner.
Medicines optimisation in frailty, multimorbidities and vulnerabilities
A 95 year old lady living in a warden controlled flat with no support with taking medicines. She was living with moderately frailty, multi-morbidities and polypharmacy (7 medicines).
Her repeat medicines were:
- Digoxin tablets 125 micrograms once a day
- Simvastatin tablets 20mg once a day
- Dipyridamole tablets 100mg – 2 tablets twice a day
- Furosemide tablets 40mg – 2 tablets once day
- Perindopril erbumine tablets 8mg once a day
- Allopurinol tablets 100mg twice a day
- Ferrous fumarate tablets 210mg three times a day
She had started to forget whether she had taken her medicines and was taking them less regularly.
She had poor renal function (CrCl~10ml/min).
During the medication review with the pharmacist, they agreed to reduce her pill burden and simplify her medicines regimen in order to increase the likelihood of adherence to the essential medicines:
- ferrous fumarate was stopped due to high ferritin level
- allopurinol was reduced to once daily due to renal impairment
- dipyridamole was changed to clopidogrel once daily in line with the current stroke guidelines
- simvastatin was discontinued due to the patient’s advanced frailty and increased risk of myopathy in view of renal impairment
- the indication for digoxin was unclear in the GP records so the elderly care specialist was contacted to review the ongoing need for digoxin in the context of frailty, poor renal function and increased risk of toxicity, falls and confusion
Deprescribing in patients with polypharmacy
An 87 year old lady with mild frailty, multi morbidity, polypharmacy (17 medicines) and uncontrolled hypertension (BP 198/103mmHg) despite being prescribed six antihypertensive agents.
Her antihypertensive therapy included:
- Candesartan tablets 32mg daily
- Amlodipine tablets 10mg daily
- Atenolol/Chlorthalidone tablet 100/25mg daily
- Doxazosin 8mg tablets twice daily
- Moxonidine tablets 300mg daily
Due to her high blood pressure, she had been unable to receive zoledronic acid infusion which was indicated for low bone mineral density and osteoporosis. This was impacting negatively on her quality of life.
During the medication review visit, the pharmacist found out that she disliked her medicines dispensed into a multi-compartment compliance aid (MCA). She was concerned about the frequent changes in appearance of her tablets that were due to brand substitutions by her community pharmacy. She did not trust that she was being given the right medicines in the MCA, and so decided not to take the tablets.
They both agreed a plan and with her consent, the pharmacist arranged for medicines to be supplied in their original packaging and provided a Medicine Record Card with details of the medicines prescribed, including what for, how often to take them and other useful information.
The pharmacist also discussed with her consultant from the Hypertension Clinic and it was agreed to stop all antihypertensives except candesartan and amlodipine. Her blood pressure was monitored twice weekly.
By the next clinic appointment her blood pressure had reduced to 122/68mmHg and the dose of amlodipine was further reduced to 5mg a day. Subsequently she was able to get an appointment for the zoledronic injection.
With thanks to:
Lelly Oboh, Consultant Pharmacist, Care of older people
NHS Specialist Pharmacy Services (Medicines Use and Safety Team), Guys and St Thomas NHS Foundation Trust
Alison Warren, Consultant Pharmacist Cardiology
Brighton and Sussex University Hospitals NHS Trust and Brighton and Hove CCG
Nina Barnett, Consultant Pharmacist, Care of older people
NHS Specialist Pharmacy Services (Medicines Use and Safety Team)