6 - Rehabilitation and medicines management

Topic 6: References and resources

• Polypharmacy is common in frail older people, and important to address as it can be a cause of attendance as well as contributing to the risk of developing complications such as delirium or constipation. 
• The Screening Tool of Older People’s Prescriptions (STOPP) is used in older people to identify potential medication-related patient safety incidents.
  The Screening Tool to Alert doctors to the Right Treatment (START) address’ potential errors, omission or underutilisation of medication.
  Frail patients often, though not invariably, have multiple comorbidities, with the consequent iatrogenic (illness caused by medication, examination or treatment) risks of multiple medications. Always consider opportunities for de-prescribing: you may find the STOPP-START criteria a useful tool:
• STOPP criteria medications are significantly associated with harm, e.g. adverse drug events.
• STOPP/START criteria as an intervention applied at a single time during hospitalisation for acute illness in older people significantly improve medication appropriateness, an effect that is maintained six months after the intervention.
• STOPP/START criteria as an intervention applied within 72 hours of admission significantly reduces adverse drug reactions (ADRs) (with an absolute risk reduction of 9.3%; number needed to treat = 11; which means that for every 11 patients assessed and managed using the tool, one ADR will be avoided). It also reduces average length of stay by three days in older people hospitalised with unselected acute illnesses.
• Another useful approach is to address drugs that contribute to anticholinergic burden, which is associated with delirium, constipation, urinary retention and falls. Anticholinergic burden scores can identify a wide range of drugs with anticholinergic activity, many of which can been suspended or stopped in the context of an acute presentation, in order to improve recovery, for example from delirium, or to prevent the development of adverse drug events.
• Anticholinergic burden: http://www.acbcalc.com
• http://www.medichec.com
• As well as rendering the person vulnerable to minor stresses, the altered homeostasis (regulation of functions of body systems) of frailty affects drug handling. When introducing new medications, ‘start low, go slow’.