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TOP 5 IMPORTANT DRUGS IN THE OLDER PERSON

TOP 5 IMPORTANT DRUGS IN THE OLDER PERSON. Anna Byszewski BSc MD MEd FRCP(C) Division of Geriatric Medicine 4 th Annual Better Prescribing Course University of Ottawa. Outline. Review of scope of problem of drug use in the older person Factors contributing to ADR

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TOP 5 IMPORTANT DRUGS IN THE OLDER PERSON

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  1. TOP 5 IMPORTANT DRUGS IN THE OLDER PERSON Anna Byszewski BSc MD MEd FRCP(C) Division of Geriatric Medicine 4th Annual Better Prescribing Course University of Ottawa

  2. Outline • Review of scope of problem of drug use in the older person • Factors contributing to ADR • Important drugs in the older person • Drugs to avoid in the older person • Tips how to avoid pitfalls in prescribing for the older person

  3. Disclosure • I have given presentations at CME events or have received funds for unrestricted educational initiatives supported by the following: Pfizer, Merck Frosst, Novartis, Janssen Ortho • I do not hold any stocks…

  4. Clinical case • An 80 year old woman is referred with falls and cognitive decline. She was widowed 8 months ago and has a hx of HBP, insomnia and PMR. • Her medications: HCTZ 12.5 mg, prednisone 10 mg and ibuprofen 200 mg • Her P/E: BP 160/80, HR irreg irreg. 80, rest of exam is normal • Lab shows Normal lytes BUN/Cr, CBC,TSH, Vit. B12. CT head microvascular changes

  5. Drugs and The Older PersonStatistics • 30% of prescription drug use • 40% of non prescription drug use • Average use of 4.5 medications (community) • Average use of 9.1 medications (hospitalized)

  6. Drugs and The Older PersonADR’s • Pharmacokinetics • Pharmacodynamics • Factors related to the patient: Polysymptomatology breeds polypharmacy • Factors related to the caregiver: do something doctor! • Factors related to the physician: all those pharmacology lectures!!

  7. Consequences of ADR • 30% of hospital admissions linked to ADR in US ( Hanlon et al. JAGS 1997) • After discharge from TOH, 23% had at least one ADR ( Forster et al. CMAJ 2004) • ADR in the older person linked to depression, constipation, falls, immobility, confusion, and hip fractures… (Bootman et al. AIM 1997)

  8. Drugs and The Older PersonThe Top 5 Important Drugs • Antihypertensives(Diuretics, CCB, ACEI) • Warfarin (a.fib) • Osteoporosis treatment( Ca, Vit D, Bisphosphonates,) • Antidepressants • “Sleep Hygiene Tips”/Exercise

  9. 1. Antihypertensives • Goal of BP management to BP<140/90 • Lower if end organ damage • Diuretics, CCB and ACEI • (Chobanian et al. JNC 7 report JAMA 2003) • Evidence for prevention of CVA, ? Dementia • Even over age 80, 34% reduction in stroke,39% reduction in CHF ( Guyeffier et al. Lancet 1999)

  10. 2. Warfarin • Atrial Fibrillation 5% over age 65, risk of CVA 5% per year ( higher if CHF/HBP/CVA/TIA and age>75) • Warfarin RR 65% vs. ASA 20% • Risk of c/o low if monitored (Hing et al, AIM 2003 )

  11. 3. Fracture prevention therapy • At age 50, need 1500 mg calcium and Vitamin D 800 IU daily – most need supplementation • Screen all at age 65 or risks (falls, steroids, etc) • (OSC CPC, CMAJ suppl. 2005)

  12. 4. Sleep hygiene • Nonpharmacologic therapies should be considered as first line therapy: ex. sleep hygiene • Short acting benzodiazepines, zopiclone, or trazodone can be considered as a short term therapy – ie.< 2 weeks • (Morin et al JAMA 1999)

  13. 5. Antidepressants • Depression presents atypically in the older person: more somatic symptoms, psychotic features, loss of memory or concentration problems rather than depressed mood • Remission rates up to 75% • (CPA suppl. 1997) • Wide range of therapies– monitor for S/E: SIADH with SSRI, hypertension (venlafaxine), oversedation (mirtazepine)

  14. Drugs and The Older PersonThe Top 10 Drugs to Use Less • NSAID’s • Benzodiazepines • Neuroleptics • Beta Blockers • Cimetidine • Anticholinergic Drugs • Prozac • Narcotics (Talwin/Demerol) • Colace/Irritant laxatives • OTC/Herbals/ETOH

  15. Drugs and The Older Person10 Do’s and Don’ts of Safe Prescribing • Always consider drugs as potential cause for any new symptom in the elderly • Appropriate diagnosis vs symptomatic prescribing • Start all new drugs as N=1 trial • Start low and go slow but push therapy until you achieve therapeutic goals or side effects occur • Start low and go slow and don’t be afraid to say no

  16. Drugs and The Older Person10 Do’s and Don’t’s of Safe Prescribing • Know what your patient is taking: prescription, OTC, herbal • Know and use well a small list of drugs in the older person (“toolbox” of ~ 25 medications) • Tailor choice of drug to individual and comorbid disease • Regularly review drug regimens and try to reduce drugs • Keep it simple/compliance issues

  17. Clinical case • An 80 year old woman is referred with falls and cognitive decline. She was widowed 8 months ago and has a hx of HBP, insomnia and PMR. • Her medications: HCTZ 12.5 mg, prednisone 10 mg and ibuprofen 200mg • Her P/E: BP 160/80, HR irreg irreg. 80, rest of exam is normal • Lab shows Normal lytes BUN/Cr, CBC,TSH, Vit. B12. CT head microvascular changes

  18. What can you do? • Increase HCTZ or add CCB or ACEI • Consider warfarin for a.fib • Do DXA, add Ca/VitD and consider antiresorptive tx • Assess for depression • Review sleep hygiene • Try to d/c NSAID, try physio, acetaminophen etc.

  19. Defining Success • At age 80, success is….not peeing in your pants. • At age 75, success is….having friends.  • At age 70, success is….having a drivers license. • At age 60, success is….having sex. • At age 50, success is….having money. • At age 4, success is. . . not peeing in your pants. • At age 12, success is. . . having friends. • At age 16, success is. . . having a drivers license. • At age 20, success is. . . having sex. • At age 35, success is. . . having money.

  20. THANK YOU!!!

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