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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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PRESCRIBING IN THE ELDERLY Dr Rob Dent GP VTS Teaching 24th 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 • 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!!!