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GP VTS Teaching 24 th February, 2009

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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GP VTS Teaching 24 th February, 2009

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

  2. 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

  3. Prescribing In The Elderly • Polypharmacy • Dose Adjustment • Forgetfulness • Ethics • Dementia • Other Elderly Specific Drugs

  4. Polypharmacy • “I'm rattling doc!!”

  5. Polypharmacy - Interactions • Any common interactions? • Verapamil + ............. • Simvastatin + ........... • Aspirin + ............ • Bendroflumethiazide + ................

  6. Dose Adjustments • General rule: start at 50% adult dose • Reduced Renal Clearance • Occurs with age • Slow excretion • HIGHLY susceptible to nephrotoxic drugs • eg

  7. 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

  8. Dose Adjustments • Side Effects • Hypnotics • Diuretics • AntiParkinsons • Digoxin

  9. 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.......?

  10. Forgetfulness • Dosette Boxes • Combination Medicines

  11. Forgetfulness • Dosette Boxes • What are these?

  12. 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

  13. Forgetfulness • Dosette Boxes • Advantages:

  14. 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)

  15. Forgetfulness • Dosette Boxes • Disadvantages:

  16. 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)

  17. Forgetfulness • Combination Medicines • Any examples??

  18. Forgetfulness • Combination Medicines • Any examples?? • Anti hypertensives • Diuretic + ACE

  19. Forgetfulness • Combination Medicines • Any examples?? • Anti hypertensives • Diuretic + ACE (coversyl) • ACE + CCB

  20. Forgetfulness • Combination Medicines • Any examples?? • Anti hypertensives • Diuretic + ACE (coversyl) • ACE + CCB (triapin) • B-Blocker + Diuretic

  21. Forgetfulness • Combination Medicines • Any examples?? • Anti hypertensives • Diuretic + ACE (coversyl) • ACE + CCB (triapin) • B-Blocker + Diuretic (Kalten)

  22. Forgetfulness • Combination Medicines • Any examples?? • Anti hypertensives • Diuretic + ACE (coversyl) • ACE + CCB (triapin) • B-Blocker + Diuretic (Kalten) • Anti-Platelets • Aspirin + Dipyridimole

  23. Forgetfulness • Combination Medicines • Any examples?? • Anti hypertensives • Diuretic + ACE (coversyl) • ACE + CCB (triapin) • B-Blocker + Diuretic (Kalten) • Anti-Platelets • Aspirin + Dipyridimole (Asasantin)

  24. 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

  25. 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)

  26. Forgetfulness • Combination Medicines • Any examples?? • Antibiotics • Amoxicillin and clavulinic acid

  27. Forgetfulness • Combination Medicines • Any examples?? • Antibiotics • Amoxicillin and clavulinic acid (augmentin)

  28. Forgetfulness • Combination Medicines • Any examples?? • Antibiotics • Amoxicillin and clavulinic acid (augmentin) • Creams • Hydrocortisone + Miconazole )

  29. Forgetfulness • Combination Medicines • Any examples?? • Antibiotics • Amoxicillin and clavulinic acid (augmentin) • Creams • Hydrocortisone + Miconazole (Daktacort)

  30. Forgetfulness • Combination Medicines • Any examples?? • Antibiotics • Amoxicillin and clavulinic acid (augmentin) • Creams • Hydrocortisone + Miconazole (Daktacort) • Inhalers • Salmeterol + Fluticasone

  31. Forgetfulness • Combination Medicines • Any examples?? • Antibiotics • Amoxicillin and clavulinic acid (augmentin) • Creams • Hydrocortisone + Miconazole (Daktacort) • Inhalers • Salmeterol + Fluticasone (Seretide)

  32. Forgetfulness • Combination Medicines • Any examples?? • Antibiotics • Amoxicillin and clavulinic acid (augmentin) • Creams • Hydrocortisone + Miconazole (Daktacort) • Inhalers • Salmeterol + Fluticasone (Seretide) • Anti-diabetics • Metformin + Rosiglitazone

  33. Forgetfulness • Combination Medicines • Any examples?? • Antibiotics • Amoxicillin and clavulinic acid (augmentin) • Creams • Hydrocortisone + Miconazole (Daktacort) • Inhalers • Salmeterol + Fluticasone (Seretide) • Anti-diabetics • Metformin + Rosiglitazone (Avandamet)

  34. Forgetfulness • Combination Medicines • Advantages • Simpler, better compliance, cheaper (?) • Disadvatages • Harder to titrate, More expensive (?)

  35. 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

  36. Co-Prescribing • What are some examples?

  37. Co-Prescribing • What are some examples? • Codeine...............?

  38. Co-Prescribing • What are some examples? • Codeine...............+ senna

  39. Co-Prescribing • What are some examples? • Codeine...............+ senna • Diclofenac...........

  40. Co-Prescribing • What are some examples? • Codeine...............+ senna • Diclofenac...........+ lansoprazole

  41. Co-Prescribing • What are some examples? • Codeine...............+ senna • Diclofenac...........+ lansoprazole • Amoxicillin............

  42. Co-Prescribing • What are some examples? • Codeine...............+ senna • Diclofenac...........+ lansoprazole • Amoxicillin...........+ canestan

  43. Co-Prescribing • What are some examples? • Codeine...............+ senna • Diclofenac...........+ lansoprazole • Amoxicillin...........+ canestan • Prednisolone..........

  44. Co-Prescribing • What are some examples? • Codeine...............+ senna • Diclofenac...........+ lansoprazole • Amoxicillin...........+ canestan • Prednisolone..........+ alendronate

  45. 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?

  46. 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?

  47. 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!!!)

  48. 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”

  49. 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!!!

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