How to prescribe The elderly Andi Shirtcliffe Pharmacist
Psycho geriatric long stay hospital Rest home Generalist in a specialist setting
Workshop outline Step through how I perform a medicine review Cases Didactic stuff! Resources
Medicine Reviews Medicine Diagnosis? Diagnosis Medicine? Renal (liver?)? Other labs (and BP) Drug Interactions? Documented ADRs/allergies? Simplifications (& switches)? Non-pharmacological interventions?
NO TEARS! I feed the results of this process into a form I ve devised around the NO TEARS concept Document ideas down one side of page Document recommendation after team input down the other i.e. what I decided! Tessa L. Lewis, MD Geriatrics Aging. 2005;8(6):43-45. 2005 1453987 Ontario, Ltd.
Case 1 Dx: Dementia Frequent falls OA (knees) Vitamin B12 deficiency
Case 1 continued Medicines: Quetiapine 200mg nocte Haloperidol 1.5mg daily and0.25ml qid prn Sodium valproate 200mg daily Paracetamol 1g qid prn Lemnis Fatty Cream bd Ketoconazole shampoo twice per week Diclofenac 50mg tds prn Furosemide 40mg daily Aspirin 150mg daily Lorazepam 0.5mg bd Pimafucort Cream bd
Case 1 current meds Lactulose 20ml bd Docusate sodium with senna 2 bd Paracetamol 250mg/5ml 10ml qid Vitamin B12 injection q3/12 Tears naturale 1 drop BE tds Sodium valproate 200mg/5ml 200mg daily Diazepam enema prn Glyerin supps prn Aqueous cream as a soap substitute Health E cream bd as an emollient
Case 1 continued Team assessment at admission: Doubly incontinent, agitated, very drowsy at lunch time, oedema in legs, no signs of heart failure, previous scan indicates 2-3 strokes in the past, usually ok with cares. Team assessment most recent Doubly incontinent, Sleeps well, Good appetite, Medical review = stable, attending hydrotherapy
Dx: Case Two Dementia (aggression, paranoia) OA, shoulder (L)
Case Two continued Medicines: Clonazepam 0.5mg bd and 0.5mg qqh prn Haloperidol 2.5mg nocte and 2.5-5mg q2-4h po/im prn Docusate sodium with senna 2 bd Diclofenac 50mg up to tds prn Zopiclone 7.5mg nocte
Current meds Calciferol strong monthly Calcium 500mg daily Paracetamol 1g qid Lorazepam 0.5mg bd and up to qid prn for agitation Docusate sodium with senna 2 daily prn Zopiclone 3.75 7.5mg nocte prn
Case Two continued Team assessment at admission Team assessment most recent Confused, talkative, inclined to wander, physical aggression, good skin at risk of pressure, sleeps in clothes, no Hx of falls, very agitated post admission requiring some injections Still paranoid but can be dealt with by distraction techniques, generally sleeps well at nights, lorazepam hasn t made any difference so to be reduced and stopped, resistive to showers = most common cause of aggression therefore give a bath!
Dx: Case 3 Dementia Hypertension IHD LIH 2005 L eye ectropion
Case 3 continued Medicines Paracetamol 250mg/5ml 20ml nocte Cilazapril 0.5mg daily Zopiclone 7.5mg nocte Indapamide 2.5mg daily Lorazepam 0.5mg qqh prn Docusate sodium with senna 2 daily prn Diclofenac D 50mg tds prn GTN SL prn Fucithalmic Eye drops prn
Current medicines Lacrilube Occ bd Paracetamol 250mg/5ml bd regularly and additional bd prn Lorazepam 0.5mg qqh prn (maximum 2mg in 24 hours) Docusate sodium with senna 2 daily prn
Case 3 continued Team assessment at admission: Not sleeping well, at risk of absconding, walks very fast and is very fit, not sure if zopiclone is helping, IHD diagnosis?incorrect, unpredictable behaviour, a few incidents of violence, more aggressive in the evenings Team assessment most recent Stable, ectropion well managed (no Infections), bowels regular, sleeps well, eating and drinking well,
Dx: Case 4 Dementia with aggressive behaviour OA L2-3 + hips Folate and vitamin B12 deficiency Ex-smoker Oesophageal reflux Hx of EtOH abuse Hx of seizures
Medicines Docusate sodium with senna 2 daily Zopiclone 7.5mg nocte Panadeine 2 tablets qid Omeprazole 20mg daily Sodium valproate EC 200mg bd Neo-cytamen 1000mcg IM 3/12 Folic acid 5mg daily Glyerin supps 2 prn Microlax enema prn Locoid cream bd
Current medicines Docusate sodium with senna 2 bd Omeprazole 10mg mane Kiwi Crush 100ml daily Sodium valproate 800mg bd Paracetamol 1g bd regularly and addition bd (+heat packs + hydrotherapy + activities) Glyerin supps 2 prn Health E cream bd
Case 4 continued Team assessment at admission: Anxious, dribbling, aggressive, wanders a lot, sleeping ok, problems with constipation, problems with redness (pressure area?) on sacrum Team assessment most recent Stable, doubly incontinent, sleeps well, not aggressive, requires assistance with cares, requires repositioning at night to prevent pressure areas
What are the real diseases of aging? Osteoporosis Isolates systolic hypertension Neuronal degeneration (dementia) Decreased immune function Glaucoma Macular degeneration Muscle loss
Common problems Pain Confusion / cognition Falls (postural hypotension) Urinary incontinence General poor health (non specific presentation of illness) Reluctance, acceptance, stoic Nutrition, mobility, isolation
Excretion - renal egfr What it is Use in the older person Renal function and medicines Allopurinol ACE Inhibitors The dangerous trio / triple whammy (diuretic + NSAID / COX-2 + ACE Inhibitor / AIIA)
Medicines of concern NSAID cognition, hypertension, GI bleed, CHF, renal impairment Anticoagulants dosing, interactions, bleeds Corticosteroids cognition Psychotrophics Benzodiazepines / zopiclone memory, confusion Antipsychotics confusion, postural hypotension, constipation Antinauseants (prochlorperazine) cognition, falls Antidepressants cognition, hyponatraemia (3/12), blurred vision, hypotension, constipation, urinary retention
Medicines of concern Diuretics dehydration, hyponatraemia (2/52) Anticholinergics cognition, blurred vision, postural hypotension, constipation Digoxin confusion, GI upset Opioids (not forgetting Tramadol) cognition, sedation, constipation Antihypertensives postural hypotension
Metabolism Cytochrome P 450, p-glycoprotein Debated Inter-individual differences probably more important than age alone May be effect of metabolism + volume of distribution = more sensitive to lipophilic medicines
Dose / dosing Start low, go slow The golden rule but how practical in practice? Does it confuse the person re: compliance? Monitor Note that the same applies to withdrawal of medicines!!
Issues for the elderly chronic pain 36 88% of the older population reports some degree of pain that may interfere with daily activities or QoL Generally more likely to be joint-type pain (osteoarthritis, rheumatoid arthritis, PMR) and neuropathy (post-herpetic neuralgia, trigeminal neuralgia) Why don t older people get adequate pain relief? Co-morbidities Increased risk of ADRs Reluctance to prescribe opiates Inadequate assessment, monitoring Patient perceptions and unwillingness to use Pain and depression often intensify each other
Issues for the elderly osteoarthritis Osteoarthritis Pain, expense, loss of function, loss of dependence, psychological impact, QoL 70% of people older than 65 years will have signs of osteoarthritis, but less have clinical symptoms Treatment Increased activity / weight loss (caution) Education / support Paracetamol / NSAID / opiates Intra-articular corticosteroids Glucosamine / capsaicin / Hyaluronan (Synvisc ) Monitor
Management of hypertension in the elderly patient. Stokes GS. Clin Interv Aging. 2009;4:379-89. Epub 2009 Oct 12. Review.PMID: 19851513 Free text Hypertension in the very elderly: Brief review of management. Zeglin MA, Pacos J, Bisognano JD. Cardiol J. 2009;16(4):379-85. Review.PMID: 19653187 Free text Prevention of osteoporosis-related fractures among postmenopausal women and older men. Rahmani P, Morin S. CMAJ. 2009 Nov 24;181(11):815-20. Epub 2009 Oct 19. Review. No abstract available. PMID: 19841053 Free text
Chronic pain management in older adults: special considerations. Fine PG. J Pain Symptom Manage. 2009 Aug;38(2 Suppl):S4-S14. Review.PMID: 19671470 Pharmacological management of neuropathic pain in older adults: an update on peripherally and centrally acting agents. McGeeney BE. J Pain Symptom Manage. 2009 Aug;38(2 Suppl):S15-27. Review.PMID: 19671468
Resources www.saferx.co.nz Bpacnz resources Polypharmacy bulletin May 2006 Dilemmas in Prescribing for Elderly People, Best Practice, Issue 11 Renal Update, Best Practice, Issue 6 Antipsychotics in Dementia www.bpac.org.nz/a4d Best Practice Issue 15, 26 & 27