Consumer And Clinician Perspectives On Adverse Drug Events And Adverse Drug Withdrawal Effects Of Heart Failure Medications In Frail Older People

• By: DUONG, Mai (Faculty of Medicine and Health, The University of Sydney and the Northern Sydney Local Health District, Australia)
• Co-author(s): Ms Mai Duong (Ageing and Pharmacology Laboratory, Kolling Institute, Faculty of Medicine and Health, The University of Sydney and the Northern Sydney Local Health District, Sydney, Australia)
  Associate Professor Danijela Gnjidic (Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia)
  Prof Andrew McLachlan (Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia)
  Doctor Lisa Kouladjian O’Donnell (Ageing and Pharmacology Laboratory, Kolling Institute, Faculty of Medicine and Health, The University of Sydney and the Northern Sydney Local Health District, Sydney, Australia)
  Ms Ritu Trivedi (Westmead Applied Research Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia)
  Associate Professor Rebecc Kozor (Cardiovascular Magnetic Resonance Group, Kolling Institute, Faculty of Medicine and Health, The University of Sydney and the Northern Sydney Local Health District, Sydney, Australia)
  Professor Sarah Hilmer (Ageing and Pharmacology Laboratory, Kolling Institute, Faculty of Medicine and Health, The University of Sydney and the Northern Sydney Local Health District, Sydney, Australia)
  
• Abstract:

  Background Information:
  Heart failure (HF) is increasingly prevalent in the ageing population and associated with high mortality and hospitalisation, particularly in people aged over 75 years. Frailty is defined as a reversible syndrome involving multi-system deficiencies. Optimising HF medications in frail older people can be complex due to multi-morbidities, polypharmacy (>5 medications), deficits in multiple health domains and changes in life expectancy, cognition and patient priorities. Older HF patients living in the community are mostly frail and experience at least one adverse drug event (ADE) from their HF medications; yet are poorly represented in clinical trials and observational studies.
  
  Purpose:
  To examine consumer and clinician perspectives of ADEs and adverse drug withdrawal effects (ADWEs) from HF medications in frail older people.
  
  Methods:
  Qualitative interviews and focus groups were conducted with consumers (carers, advocates or older individuals living with HF and frailty) and clinicians (pharmacists, nurses, geriatricians, specialist physicians) involved in caring for frail older patients with HF. Semi-structured interview questions were informed by the literature and piloted with clinicians. Recruitment of a purposive sample of participants involved electronic distribution of advertisements through professional and community networks and invited to respond; or contacted directly through snowballing in acute, aged care and community settings across Australia. Interviews were conducted by a pharmacist researcher via videoconference or phone, audio-recorded, transcribed and de-identified. A general inductive content analysis approach was used to identify themes to address the aims.
  
  Results:
  To date, 24 participants (2 consumers, 4 geriatricians and cardiologists, 7 nurses and 11 pharmacists) have participated in interviews and focus groups. Preliminary analyses identified eight themes relating to characteristics and management of ADEs and ADWEs experienced by frail older people. Participants acknowledged the importance of addressing individuals’ physical and emotional function to support individual goals and ability to live independently. Clinicians recognised frailty status was important but not routinely measured nor included in medication management plans. Complex patient factors, medication management and identification of common ADEs could be supported with patient education and communication of the benefits and adverse effects of HF medications across multiple clinical outcomes. Participants described ongoing challenges of multi-disciplinary collaboration, particularly during transitions of care.
  
  Common ADEs identified by participants included hypotension (e.g. falls, dizziness, light-headed) and renal impairment, which warranted clinician intervention. Diuretics (furosemide) frequently caused urinary incontinence which was mostly patient self-managed to balance social and emotional disruption. Common ADWEs included cardiovascular events (e.g., worsening HF symptoms). A participant described, “the big problem is the number of medications that they're on and potential interactions. One of our big issues is patients falling down with hypotensive drugs. With [furosemide], needing to get to the bathroom quickly [can be a] falls concern” [nurse 013].
  
  Conclusion:
  Based on results so far, this study identified several perspectives unique to medication management in frail older patients with HF. Findings revealed treatment priorities and opportunities to include frailty status in medication management plans. Future observational studies are needed to determine how this information can be applied to support individualised care plans.