prescribing in the elderly dr rob dent l.
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PRESCRIBING IN THE ELDERLY Dr Rob Dent. GP VTS Teaching 24 th February, 2009. Introduction. 4 in 5 people over 75 take at least 1 medicine 36% take 4 or more Up to 17% admissions are drug related Half of NHS drugs bill spent on older people. Prescribing In The Elderly. Polypharmacy

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introduction
Introduction
  • 4 in 5 people over 75 take at least 1 medicine
  • 36% take 4 or more
  • Up to 17% admissions are drug related
  • Half of NHS drugs bill spent on older people
prescribing in the elderly
Prescribing In The Elderly
  • Polypharmacy
  • Dose Adjustment
  • Forgetfulness
  • Ethics
  • Dementia
  • Other Elderly Specific Drugs
polypharmacy
Polypharmacy
  • “I'm rattling doc!!”
polypharmacy interactions
Polypharmacy - Interactions
  • Any common interactions?
    • Verapamil + .............
    • Simvastatin + ...........
    • Aspirin + ............
    • Bendroflumethiazide + ................
dose adjustments
Dose Adjustments
  • General rule: start at 50% adult dose
  • Reduced Renal Clearance
    • Occurs with age
    • Slow excretion
    • HIGHLY susceptible to nephrotoxic drugs
    • eg
dose adjustments7
Dose Adjustments
  • General rule: start at 50% adult dose
  • Reduced Renal Clearance
    • Occurs with age
    • Slow excretion
    • HIGHLY susceptible to nephrotoxic drugs
    • eg Aminoglycosides, NSAIDs, Lithium, ACEIs
dose adjustments8
Dose Adjustments
  • Side Effects
    • Hypnotics
    • Diuretics
    • AntiParkinsons
    • Digoxin
forgetfulness
Forgetfulness
  • Older people will forget medicines more
  • The more tablets there are, the more potential there is for confusing them or missing one out
  • Any suggestions to help this.......?
forgetfulness10
Forgetfulness
  • Dosette Boxes
  • Combination Medicines
forgetfulness11
Forgetfulness
  • Dosette Boxes
    • What are these?
forgetfulness13
Forgetfulness
  • Dosette Boxes
    • Like a chocolate advent calendar
    • Boxes which have the medicines arranged according to day and time
    • Have 7 days (!)
    • Come with 3, 4 and 6 different time slots
    • Pharmacist puts all the medicines in the correct time and day
    • Each time slot has foil covering and the patient simply pops the foil off and takes all the tablets inside
forgetfulness14
Forgetfulness
  • Dosette Boxes
    • Advantages:
forgetfulness15
Forgetfulness
  • Dosette Boxes
    • Advantages:
      • Simple for patient
      • Increases compliance for doctor
      • Easier to quickly see which medicines being taken when patient goes to hospital
      • Less wastage (medicines-only weekly script)
forgetfulness16
Forgetfulness
  • Dosette Boxes
    • Disadvantages:
forgetfulness17
Forgetfulness
  • Dosette Boxes
    • Disadvantages:
      • Most pharmacies insist on weekly scripts
      • Harder to change medicines quickly (warfarin – see later)
      • Pt confusion if semi “tup” (eg my patient JJ)
      • More wastage (plastic)
forgetfulness18
Forgetfulness
  • Combination Medicines
    • Any examples??
forgetfulness19
Forgetfulness
  • Combination Medicines
    • Any examples??
      • Anti hypertensives
        • Diuretic + ACE
forgetfulness20
Forgetfulness
  • Combination Medicines
    • Any examples??
      • Anti hypertensives
        • Diuretic + ACE (coversyl)
        • ACE + CCB
forgetfulness21
Forgetfulness
  • Combination Medicines
    • Any examples??
      • Anti hypertensives
        • Diuretic + ACE (coversyl)
        • ACE + CCB (triapin)
        • B-Blocker + Diuretic
forgetfulness22
Forgetfulness
  • Combination Medicines
    • Any examples??
      • Anti hypertensives
        • Diuretic + ACE (coversyl)
        • ACE + CCB (triapin)
        • B-Blocker + Diuretic (Kalten)
forgetfulness23
Forgetfulness
  • Combination Medicines
    • Any examples??
      • Anti hypertensives
        • Diuretic + ACE (coversyl)
        • ACE + CCB (triapin)
        • B-Blocker + Diuretic (Kalten)
      • Anti-Platelets
        • Aspirin + Dipyridimole
forgetfulness24
Forgetfulness
  • Combination Medicines
    • Any examples??
      • Anti hypertensives
        • Diuretic + ACE (coversyl)
        • ACE + CCB (triapin)
        • B-Blocker + Diuretic (Kalten)
      • Anti-Platelets
        • Aspirin + Dipyridimole (Asasantin)
forgetfulness25
Forgetfulness
  • Combination Medicines
    • Any examples??
      • Anti hypertensives
        • Diuretic + ACE (coversyl)
        • ACE + CCB (triapin)
        • B-Blocker + Diuretic (Kalten)
      • Anti-Platelets
        • Aspirin + Dipyridimole (Asasantin)
      • Anti-Parkinson's
        • Levodopa + Carbidopa
forgetfulness26
Forgetfulness
  • Combination Medicines
    • Any examples??
      • Anti hypertensives
        • Diuretic + ACE (coversyl)
        • ACE + CCB (triapin)
        • B-Blocker + Diuretic (Kalten)
      • Anti-Platelets
        • Aspirin + Dipyridimole (Asasantin)
      • Anti-Parkinson's
        • Levodopa + Carbidopa (Sinemet)
forgetfulness27
Forgetfulness
  • Combination Medicines
    • Any examples??
      • Antibiotics
        • Amoxicillin and clavulinic acid
forgetfulness28
Forgetfulness
  • Combination Medicines
    • Any examples??
      • Antibiotics
        • Amoxicillin and clavulinic acid (augmentin)
forgetfulness29
Forgetfulness
  • Combination Medicines
    • Any examples??
      • Antibiotics
        • Amoxicillin and clavulinic acid (augmentin)
      • Creams
        • Hydrocortisone + Miconazole )
forgetfulness30
Forgetfulness
  • Combination Medicines
    • Any examples??
      • Antibiotics
        • Amoxicillin and clavulinic acid (augmentin)
      • Creams
        • Hydrocortisone + Miconazole (Daktacort)
forgetfulness31
Forgetfulness
  • Combination Medicines
    • Any examples??
      • Antibiotics
        • Amoxicillin and clavulinic acid (augmentin)
      • Creams
        • Hydrocortisone + Miconazole (Daktacort)
      • Inhalers
        • Salmeterol + Fluticasone
forgetfulness32
Forgetfulness
  • Combination Medicines
    • Any examples??
      • Antibiotics
        • Amoxicillin and clavulinic acid (augmentin)
      • Creams
        • Hydrocortisone + Miconazole (Daktacort)
      • Inhalers
        • Salmeterol + Fluticasone (Seretide)
forgetfulness33
Forgetfulness
  • Combination Medicines
    • Any examples??
      • Antibiotics
        • Amoxicillin and clavulinic acid (augmentin)
      • Creams
        • Hydrocortisone + Miconazole (Daktacort)
      • Inhalers
        • Salmeterol + Fluticasone (Seretide)
      • Anti-diabetics
        • Metformin + Rosiglitazone
forgetfulness34
Forgetfulness
  • Combination Medicines
    • Any examples??
      • Antibiotics
        • Amoxicillin and clavulinic acid (augmentin)
      • Creams
        • Hydrocortisone + Miconazole (Daktacort)
      • Inhalers
        • Salmeterol + Fluticasone (Seretide)
      • Anti-diabetics
        • Metformin + Rosiglitazone (Avandamet)
forgetfulness35
Forgetfulness
  • Combination Medicines
    • Advantages
      • Simpler, better compliance, cheaper (?)
    • Disadvatages
      • Harder to titrate, More expensive (?)
co prescribing
Co-Prescribing
  • When there are predicatble side effects, it may be worth preempting them by prescribing another drug
    • This is not only true in elderly, but is more important since they will not report andthey are more susceptible
co prescribing37
Co-Prescribing
  • What are some examples?
co prescribing38
Co-Prescribing
  • What are some examples?
    • Codeine...............?
co prescribing39
Co-Prescribing
  • What are some examples?
    • Codeine...............+ senna
co prescribing40
Co-Prescribing
  • What are some examples?
    • Codeine...............+ senna
    • Diclofenac...........
co prescribing41
Co-Prescribing
  • What are some examples?
    • Codeine...............+ senna
    • Diclofenac...........+ lansoprazole
co prescribing42
Co-Prescribing
  • What are some examples?
    • Codeine...............+ senna
    • Diclofenac...........+ lansoprazole
    • Amoxicillin............
co prescribing43
Co-Prescribing
  • What are some examples?
    • Codeine...............+ senna
    • Diclofenac...........+ lansoprazole
    • Amoxicillin...........+ canestan
co prescribing44
Co-Prescribing
  • What are some examples?
    • Codeine...............+ senna
    • Diclofenac...........+ lansoprazole
    • Amoxicillin...........+ canestan
    • Prednisolone..........
co prescribing45
Co-Prescribing
  • What are some examples?
    • Codeine...............+ senna
    • Diclofenac...........+ lansoprazole
    • Amoxicillin...........+ canestan
    • Prednisolone..........+ alendronate
ethics
Ethics
  • While we practice preventitive medicine all the time for most of the population, should we be doing this in the elderly???
    • (I don't have the answer!!!)
    • Can you think of examples where it may be inappropriate?
ethics47
Ethics
  • While we practice preventitive medicine all the time for most of the population, should we be doing this in the elderly???
    • (I don't have the answer!!!)
    • Can you think of examples where it may be inappropriate?
      • Giving a statin to a 90 year old with hyperchlesterolaemia?
ethics48
Ethics
  • While we practice preventitive medicine all the time for most of the population, should we be doing this in the elderly???
    • (I don't have the answer!!!)
ethics49
Ethics
  • Can you think of examples where it may be inappropriate?
      • Giving a statin to a 90 year old with hyperchlesterolaemia?
      • Starting an ACE in the elderly patient with mild CCF?
  • Current BNF:
    • “In some cases prophylactic drugs are inappropriate if they are likely to complicate existing treatment or introduce unnecessary side-effects, especially in elderly patients with poor prognosis or with poor overall health”
warfarin
Warfarin
  • Mostly a medicine of the elderly (anyone with AF PLUS HTN over 75 gets it, and more beside)
  • Higher risk of haemorrhage in the elderly (especially over 85)
  • But it is also the medicine which requires the most frequent dose adjustment of all medicines
  • Recipe for disaster!!!
warfarin51
Warfarin
  • How can the situation be improved?
    • ???
warfarin52
Warfarin
  • How can the situation be improved?
    • Dosette Boxes?
      • Swansea man who took 5 x 5mg tabs instead of 5 x 1mg tabs...
    • LES rather than hospital prescribing? Or vv
    • Yellow books vs computer print outs?
    • Pharmacy checks now in place
other prescribing tips in the elderly
Other Prescribing Tips in The Elderly
  • Consider non pharmacological measures
  • Form of medicine
    • Would she be better with liquid form?
  • Sensitivity
    • Nervous system more affected
      • Analgesics, Bzs, Anti-psychotics, Anti-parkinsonians
effective interventions
Effective Interventions
  • National Service Framework For Older People
    • Active Monitoring of Treatment
    • Review of Repeat Prescribing Systems
    • Medication Review
    • Education and Training
          • http://www.wales.nhs.uk/sites3/documents/439/NSF%20for%20Older%20People%20-%20Medicines%20and%20Older%20People.pdf