GP VTS Teaching 24 th February, 2009 PRESCRIBING IN THE ELDERLY Dr Rob Dent.

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


● Anti hypertensives– Diuretic + ACE

Forgetfulness


● Anti hypertensives– Diuretic + ACE (coversyl)– ACE + CCB

Forgetfulness


● Anti hypertensives– Diuretic + ACE (coversyl)– ACE + CCB (triapin)– B-Blocker + Diuretic

Forgetfulness


● Anti hypertensives– Diuretic + ACE (coversyl)– ACE + CCB (triapin)– B-Blocker + Diuretic (Kalten)

Forgetfulness



● Anti-Platelets– Aspirin + Dipyridimole

Forgetfulness



● Anti-Platelets– Aspirin + Dipyridimole (Asasantin)

Forgetfulness




● Anti-Parkinson's– Levodopa + Carbidopa

Forgetfulness




● Anti-Parkinson's– Levodopa + Carbidopa (Sinemet)

Forgetfulness


● Antibiotics– Amoxicillin and clavulinic acid

Forgetfulness


● Antibiotics– Amoxicillin and clavulinic acid (augmentin)

Forgetfulness



● Creams– Hydrocortisone + Miconazole )

Forgetfulness



● Creams– Hydrocortisone + Miconazole (Daktacort)

Forgetfulness




● Inhalers– Salmeterol + Fluticasone

Forgetfulness




● Inhalers– Salmeterol + Fluticasone (Seretide)

Forgetfulness





● Anti-diabetics– Metformin + Rosiglitazone

Forgetfulness





● 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

GP VTS Teaching 24 th February, 2009 PRESCRIBING IN THE ELDERLY Dr Rob Dent.

Documents

Transcript of GP VTS Teaching 24 th February, 2009 PRESCRIBING IN THE ELDERLY Dr Rob Dent.