gp vts teaching 24 th february, 2009 prescribing in the elderly dr rob dent
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GP VTS Teaching 24th February, 2009
PRESCRIBING IN THE ELDERLYDr Rob Dent
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● Dose Adjustment● Forgetfulness● Ethics● Dementia● Other Elderly Specific Drugs
Polypharmacy
● “I'm rattling doc!!”
Polypharmacy - Interactions
● Any common interactions?– Verapamil + .............– Simvastatin + ...........– Aspirin + ............– Bendroflumethiazide + ................
Dose Adjustments
● General rule: start at 50% adult dose● Reduced Renal Clearance
– Occurs with age– Slow excretion– HIGHLY susceptible to nephrotoxic drugs– eg
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 Adjustments
● Side Effects– Hypnotics– Diuretics– AntiParkinsons– Digoxin
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.......?
Forgetfulness
● Dosette Boxes● Combination
Medicines
Forgetfulness
● Dosette Boxes– What are these?
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
Forgetfulness
● Dosette Boxes– Advantages:
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)
Forgetfulness
● Dosette Boxes– Disadvantages:
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)
Forgetfulness
● Combination Medicines– Any examples??
Forgetfulness
● Combination Medicines– Any examples??
● Anti hypertensives– Diuretic + ACE
Forgetfulness
● Combination Medicines– Any examples??
● Anti hypertensives– Diuretic + ACE (coversyl)– ACE + CCB
Forgetfulness
● Combination Medicines– Any examples??
● Anti hypertensives– Diuretic + ACE (coversyl)– ACE + CCB (triapin)– B-Blocker + Diuretic
Forgetfulness
● Combination Medicines– Any examples??
● Anti hypertensives– Diuretic + ACE (coversyl)– ACE + CCB (triapin)– B-Blocker + Diuretic (Kalten)
Forgetfulness
● Combination Medicines– Any examples??
● Anti hypertensives– Diuretic + ACE (coversyl)– ACE + CCB (triapin)– B-Blocker + Diuretic (Kalten)
● Anti-Platelets– Aspirin + Dipyridimole
Forgetfulness
● Combination Medicines– Any examples??
● Anti hypertensives– Diuretic + ACE (coversyl)– ACE + CCB (triapin)– B-Blocker + Diuretic (Kalten)
● Anti-Platelets– Aspirin + Dipyridimole (Asasantin)
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
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)
Forgetfulness
● Combination Medicines– Any examples??
● Antibiotics– Amoxicillin and clavulinic acid
Forgetfulness
● Combination Medicines– Any examples??
● Antibiotics– Amoxicillin and clavulinic acid (augmentin)
Forgetfulness
● Combination Medicines– Any examples??
● Antibiotics– Amoxicillin and clavulinic acid (augmentin)
● Creams– Hydrocortisone + Miconazole )
Forgetfulness
● Combination Medicines– Any examples??
● Antibiotics– Amoxicillin and clavulinic acid (augmentin)
● Creams– Hydrocortisone + Miconazole (Daktacort)
Forgetfulness
● Combination Medicines– Any examples??
● Antibiotics– Amoxicillin and clavulinic acid (augmentin)
● Creams– Hydrocortisone + Miconazole (Daktacort)
● Inhalers– Salmeterol + Fluticasone
Forgetfulness
● Combination Medicines– Any examples??
● Antibiotics– Amoxicillin and clavulinic acid (augmentin)
● Creams– Hydrocortisone + Miconazole (Daktacort)
● Inhalers– Salmeterol + Fluticasone (Seretide)
Forgetfulness
● Combination Medicines– Any examples??
● Antibiotics– Amoxicillin and clavulinic acid (augmentin)
● Creams– Hydrocortisone + Miconazole (Daktacort)
● Inhalers– Salmeterol + Fluticasone (Seretide)
● Anti-diabetics– Metformin + Rosiglitazone
Forgetfulness
● Combination Medicines– Any examples??
● Antibiotics– Amoxicillin and clavulinic acid (augmentin)
● Creams– Hydrocortisone + Miconazole (Daktacort)
● Inhalers– Salmeterol + Fluticasone (Seretide)
● Anti-diabetics– Metformin + Rosiglitazone (Avandamet)
Forgetfulness
● Combination Medicines– Advantages
● Simpler, better compliance, cheaper (?)
– Disadvatages● Harder to titrate, More expensive (?)
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-Prescribing
● What are some examples?
Co-Prescribing
● What are some examples?– Codeine...............?
Co-Prescribing
● What are some examples?– Codeine...............+ senna
Co-Prescribing
● What are some examples?– Codeine...............+ senna– Diclofenac...........
Co-Prescribing
● What are some examples?– Codeine...............+ senna– Diclofenac...........+ lansoprazole
Co-Prescribing
● What are some examples?– Codeine...............+ senna– Diclofenac...........+ lansoprazole– Amoxicillin............
Co-Prescribing
● What are some examples?– Codeine...............+ senna– Diclofenac...........+ lansoprazole– Amoxicillin...........+ canestan
Co-Prescribing
● What are some examples?– Codeine...............+ senna– Diclofenac...........+ lansoprazole– Amoxicillin...........+ canestan– Prednisolone..........
Co-Prescribing
● What are some examples?– Codeine...............+ senna– Diclofenac...........+ lansoprazole– Amoxicillin...........+ canestan– Prednisolone..........+ alendronate
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?
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?
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!!!)
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
● 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!!!
Warfarin
● How can the situation be improved?– ???
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
● 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
● 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
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