Prescription for Change

How much medication is too much? When is a prescription drug treating a new condition or a side effect from another drug? Baycrest scientists and researchers are hard at work seeking answers to these and other important questions.

Seniors represent 40 per cent of prescription drug use in Canada. That may seem like a reasonable number for a population often suffering from multiple illnesses, but it is surprising given that clinical drug trials are generally conducted on younger, relatively healthy people and there is little information about the effects these drugs have on the people medicated the most – our seniors. Canada’s older adult population is predicted to grow to nearly 25 per cent by the year 2041, making this an issue of vital concern to researchers and clinicians at Baycrest.

Dr. Paula Rochon, a geriatrician and senior scientist at Baycrest’s Kunin-Lunenfeld Applied Research Unit, studies the adverse side effects of commonly prescribed drugs in the older population. Research has shown that adverse drug reactions in long-term care facilities are common and often preventable. Rochon noted that in a study they conducted on nursing home residents in Ontario, nearly a quarter of those residents were prescribed anti-psychotic drugs within a year of being admitted and 10 per cent of the initial doses exceeded recommended parameters.

Baycrest study shows 1 out of 4 Ontario nursing home residents are prescribed anti-psychotic drugs within a year of admission, and 1 out of 10 doses exceed recommended parameters. Dr. Sid Feldman and Dr. Paula Rochon says.

“At Baycrest, we promote a stepped approach to treatment and try to use means other than drugs wherever possible,” she says. But even when drugs are necessary, Rochon advocates the ‘start low and go slow’ approach, since older people may have greater difficulty in handling drugs.

“The people we’re studying are older, frailer adults. Often, we see women of advanced age, with multiple medical problems and a range of medications. [People with dementia] may also be taking drugs to manage behaviour. In some cases, drugs can be helpful, but we should always consider non-drug interventions in a treatment program, too,” she says. Nondrug interventions may include changes to a client’s living environment or involving them in an activity such as music therapy or simply being taken for a walk.

A study by Rochon and Baycrest scientists shows there is little evidence to support the benefit of the newer class of anti-psychotic drugs for managing the behavioural symptoms of dementia. “When these drugs first came out in the 1990s it was thought they were safer than the older anti-psychotics. They are better,” Rochon says, “but they can have similar side effects, particularly when higher doses are used, and must be further investigated.”

Rochon is also concerned about a problem she calls a ‘prescribing cascade.’ This begins when a drug’s side effect is misinterpreted as a new medical condition. Another drug is prescribed for this new condition, putting the individual at risk for another drug side effect. As an example, she points to the sudden occurrence of a shuffling gait and muscle stiffness, common side effects of anti-psychotic drug therapy. This type of reaction can be misdiagnosed as the development of Parkinson’s disease and the individual may then be prescribed a drug to treat that condition, which they may not have. This new drug can in turn lead to more adverse reactions and the individual can thus fall victim to an unnecessary cascade of medications – each with new side effects.

In 2004, Baycrest created a computerized physician order entry system for prescription drugs that included a set of automatic alerts to help doctors make the safest drug prescribing choices for their elderly patients. This groundbreaking system calls attention to potentially adverse drug reactions (ADRs), including allergies, risky drug interactions and possible side effects. It also allows doctors to order tests and medications on computers stationed throughout the facility. Gone are the days when nurses and pharmacists had to decipher handwritten prescriptions. “The order is now totally legible, including key details such as dosage and how long the patient should take the drug,” Rochon notes. More importantly, the system flags drug therapies that are considered inappropriate for older adults.

Baycrest has taken another step in the direction of streamlining patient care with the Baycrest On-Line Documentation project, better known as BOLD. Patient charts are now fully electronic so that their medical information can be accessed throughout the facility. This allows everyone on the care team to read from the same updated patient chart. “The use of this new technology puts Baycrest in a leadership position in terms of safety and physician support,” Rochon notes, adding that the work being done will hopefully serve as a model for other institutions.

Multiple medications in older adults, combined with a slower metabolism, may mean a higher risk for adverse drug reactions.

The recruitment of Dr. Bruce Pollock, Baycrest’s Sandra A. Rotman chair in neuropsychiatry and head of the division of geriatric psychiatry at the University of Toronto, proves that the brain drain to the U.S. can occasionally work in Canada’s favour. Internationally-recognized for his work in geriatric psychopharmacology, Pollock is engaged in pioneering research on the role of genetics on adverse drug reactions. He earned his MD at the University of Toronto and his PhD in pharmacology from the University of Pittsburgh school of medicine and recently returned to Toronto to take up his present posts.

“When you look at the treatment of diseases through the administration of drugs in older people,” he explains, “there are a thousand questions about how we can improve things regarding the benefits and risks of medication.” Multiple medications in older adults, combined with a slower metabolism, may mean a higher risk for adverse drug reactions. “But how do we identify who will benefit and who will be at risk? One way is to get a better handle on how the concentrations of medications vary in different individuals. In some cases, due to genetic differences, a person in his or her 20s may actually have poorer metabolism of a drug than a 90-year-old.”

Study shows little evidence to support benefits of newer class of anti-psychotic therapy for managing behavioural symptoms of dementia.

Working in conjunction with CAMH (The Centre for Addiction and Mental Health), Pollock and his colleagues, including Dr. Robert Bies – a leader in the field of population pharmacokinetics – are developing methodologies to assess drug exposure due to a host of reasons such as genetics, drug interactions, illness and drug adherence. “The goal,” he says, “is to individualize pharmacotherapy [the treatment of diseases with drug therapy].”

“The best place to do this kind of research is in the context of an academic institution like Baycrest,” Pollock explains. “With its superb clinical programs, a world-class group of people in cognitive sciences at The Rotman Research Institute and a cadre of concerned physicians, Baycrest provides an excellent platform for improving care,” he says.

Baycrest, together with CAMH and the University of Toronto’s department of psychiatry have created a clinical research program in geriatric neuropsychiatry which, it is hoped, will ensure new research on optimal drug prescribing is transferred rapidly to the clinical setting. Being able to one day tailor drugs to individuals based on their genetic profile will be a vast step up from the current trial-anderror approach.

“So many people have experienced … adverse drug reactions with family members, but there’s not much research evidence out there to support their experience,” Dr. Rochon says.

“Geriatrics is an area where you can make a real difference in the lives of frail, elderly people and their families,” Rochon says, noting that this was one of the things that drew her to the field. “The drug issue is a big concern in the public’s mind. So many people have experienced these kinds of adverse drug reactions with family members, but there’s not much research evidence out there to support their experience. We can do a much better job of investigating and monitoring how new drug therapies work in the older people that are going to be using them,” she asserts.