Prescribing in older people

Richard WongConsultant Geriatrician

UHL

Problems of Prescribing for the Older Population

• Adverse Drug Reactions (ADRs)Any response to a drug which is noxious and unintendedCan occur at normal treatment dosesDose-relatedCommon (in >70s up to 17% of hospitalisations for ADRs)

• Common Offenders (modified from Beers Criteria 2012)NSAIDSBenzodiazepines / Sedatives Medications with anticholinergic properties (esp. TCAs)DoxazosinLong-acting oral hypoglycaemics

NB ≥4 drugs is independent RF for falls in the elderly

NB: Some drugs that can be associated with rapid symptomatic decline if stopped:

Problems of Prescribing for the Older Population

Cautious stepwise withdrawal:

• ACE inhibitors and/or Diuretics in HF• Steroids• Anti- anginals• Drugs for heart rate control

Consider specialist advice before withdrawal:

• Anticonvulsants for epilepsy• Antidepressant, antipsychotic and mood stabilising drugs• Drugs for the management of Parkinson’s Disease• Disease-modifying antirheumatic drugs

Case 1

• 85 y male– Collapsed when he went to answer door– Legs buckled and gave way, no dizziness or pain– Recurrent falls– PMH: HT, Diet-controlled DM, CKD3, Vascular

Dementia– DH: Felodipine, Bendroflumethiazide, Doxazosin,

Aspirin– Vital signs: SR 78, BP 110/52

– What are the key pharmacological issues to consider?

Treating HT in the (v) elderly• HYVET trial (>80 yrs)

– Fatal stroke – HF episodes– All cause mortality– Fit older people (Excluded: haemorrhagic stroke, heart failure, CKD,

dementia, requiring nursing care)

• Observational data– For Frail Older people (inability to walk 6 m in < 8 s) – No association between BP and mortality – Higher BP associated with lower mortality among the most frail (ie those

who could not walk the distance at all)

(NNT ~ 50 per year)

(NNT ~ 100 per year)

(NNT ~ 100 per year)

Treating HT in the (v) elderly

– In older people mostly ISH– Care with overzealous treatment (cerebral perfusion is less

tolerant postural hypotension, syncope, falls, confusion)

‘A Pharmacodynamic effect’

Individual anti-HT agents

• Thiazides hyponatraemia – ~ 10% incidence in elderly (idiosyncratic, unpredictable)

• Calcium blockers (Amlodipine + related)– Peripheral oedema.

• ACEI ARF with:– Coincident renovascular disease– Dehydration– Co-prescription with NSAIDs

• Rationalising in syncope – Greater risks with volume depleters, smooth muscle relaxants – (diuretics, -blockers, calcium blockers)

Compliance

• Practical issues to consider:

– Rationalise? – Timing? Eg nocte medications– Routes of administration– Odd doses, non-responders– Dosette / Electronic Dosette / Supervised admin– Make use of Pharmacological Properties

• Transdermal preparations• Liquid forms• Special situations: eg Statins / Atorvastatin

Case 2

• 87 y male– PMH: HT, IHD– DH: Aspirin, Ramipril, Amlodipine, ISMN, Furosemide– Presents with swollen, painful wrist– Diagnosed with polyarticular gout

– How might we treat this and what concerns do we have?

NSAIDs

• Top drug class causing ADRs in elderly (30% - BMJ 2004)• GI bleeding, AKI, worsening HF• PG synthesis (gastroprotective, renal vasodilatory)

• But incidence of pain / inflammatory conditions in the elderly eg OA, gout

• Use NSAIDs sparingly (short courses only <1 wk, monitor U&Es, use gastroprotection/PPI, consider other anti-inflammatories eg corticosteroids for gout)

Case 3

• 80 y female in RH– BG: HT, Stroke, Epilepsy, Dementia, Immobile/Hoisted– DH: Clopidogrel 75mg OD

Simvastatin 40mg ONRamipril 5mg ODEpilim 1g BDAmitryptiline 25mg ON

– Adm to hospital with oral intake, mobility– Recent shaking episodes – Epilim dose for this

– What pharmacological issues may be contributing?

Drugs with anticholinergic activity

• TCAs (eg Amitryptiline, Dosulepin)• Drugs for over-active bladder (eg Oxybutinin)• Drug class most associated with delirium• May worsen confusion (cf cholinergic basis of Alzheimer’s)• (lower seizure threshold)

• Preference for:– SSRIs for depression– Gabapentin/newer neuropathic blocking agents– Non-pharmacological measures for urge incontinence/overactive

bladder

ClozapineChlorphenaramineAmitriptylineClomipramine

Drugs with anticholinergic activity

Major Anticholinergic Burden (ACB – 3)*

* Adapted from Fox et al, MRC Cognitive Function and Ageing Study 2011

AtenololBeclometasoneCimetidineCodeineColchicineDiazepamDigoxinDipyridamoleFentanylFurosemideHaloperidol Hydralazine

HydrocortisoneIsosorbide preparationsLoperamideMetoprololMorphineNifedipineOlanzapinePrednisoloneRanitidineTheophyllineTimolol maleateWarfarin

Drugs with anticholinergic activityMild Anticholinergic Burden (ACB – 1)*

* Adapted from Fox et al, MRC Cognitive Function and Ageing Study 2011

CarbamazepineHydroxyzineImipramineNortriptylineOxybutyninParoxetineProchlorperazineProcyclidineTolterodine

Drugs with anticholinergic activity

Moderate Anticholinergic Burden (ACB – 2)*

* Adapted from Fox et al, MRC Cognitive Function and Ageing Study 2011

Statins in the elderly

In real terms:• 2 prevention:

– all-cause ╬ 15.6% with statins vs 18.7% with placebo over 5 yrs (NNT ~ 150 over 1 year to save 1 life)

• 1 prevention: – less clear– Effects over 5 yrs– Only minimal benefits over placebo seen in the first year.

• No trials recruited primarily above 85 yrs– Only 1 dedicated trial for older population (75-82 yrs)– Frail older patients may have been excluded because of comorbidity or

organ dysfunction

Case 4

• 82 y female in RH

– BG: OA, HT, CKD, Recurrent dizziness and falls, Depression– DH: Cocodamol, Prochlorperazine, Bendroflumethiazide,

Olanzapine

– Adm with mobility and oral intake

– Pharmacological approach to the problem?

Anti-psychotic medications

• Overused for sedation / behaviour control (non-medical management should be 1st line)

• Sedation and Extrapyramidal S/E common• Neuroleptic Malignant Syndrome (NMS) may occur• View mild extrapyramidal features (neuroleptic reaction) and

NMS as being different ends of a spectrum• Look for signs of tone

• Also postural hypotension (many phenothiazine antipsychotics possess 1-blocking activity)

Case 5

• 76 y male– PMH: Type 2 Diabetes, HT, OA– DH: Gliclazide, Lisinopril, Paracetamol, Butrans 5 patch

– Recent D&V for 1 week.– Then presented with collapse– Found to be in AF– New renal injury noted (Na 130, K 4.9, U 15, Cr 225)

– What pharmacological lessons are there?– Once recovered, would you anticoagulate for AF?

? To Anticoagulate for AF

• CHADSVASC (stroke risk)– CCF, HT, Age, DM, Stroke, Vasc RF, Sex Category– Approx 2% stroke risk p.a per point

• HAS BLED (OAC bleeding risk)– HT, Abnormal U&E/LFT, Stroke, Bleeding, Labile INR,

Elderly (>65), Drugs (Antiplatelets, Alcohol)– Caution if ≥ 3 (~ Min 6% bleeding risk p.a)

• Little role for Aspirin unless concurrent Vasc Dis.

Case 6

• 76 y female– PMH: Insulin-treated diabetes, HT, CKD4

– Presented with a fall and subsequent back pain– Osteoporotic crush # L2. Severe pain– Given Codeine Phosphate 60mg QDS– Very drowsy with this

– How might you manage her pain?

Opioid prescribing

• Beware Codeine / Morphine in RF (≥CKD 4)– All opioids metabolised by liver and metabolites are all

excreted via kidneys– BUT hepatic metabolites of Codeine and Morphine are

active still– Safer options: Tramadol (but ↑ dosing interval),

Buprenorphine, Oxycodone (still some caution), Fentanyl (but ↑ dosing interval)

• Differing S/E profile of opioids– Buprenorphine: nausea– Codeine/Morphine: constipation

Case 7

• 90 y male– Known HF, IHD– DH: Aspirin, Furosemide, Simvastatin, Lansoprazole

– Feeling generally unwell, lethargic, breathless– Na 125, K 3.8, U 6, Cr 82, eGFR 78

– Suggestions on management?

Hyponatraemia

• Which diuretics?

• Common drugs:– Thiazides (Spironolactone), SSRIs, PPIs, Carbamazepine

Loops

Thiazides

Medullary Na gradient

Thiazides

vs

Loops

Resources

SIGN guidelines – Prescribing in Older People

http://www.nhshighland.scot.nhs.uk/publications/documents/guidelines/polypharmacy%20guidance%20for%20prescribing%20in%20frail%20adults.pdf