How to prescribe The elderly Andi Shirtcliffe Pharmacist

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
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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:
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Dementia
Frequent falls
OA (knees)
Vitamin B12 deficiency
Case 1 continued
• Medicines:
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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
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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
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Diazepam enema prn
Glyerin supps prn
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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
Case Two
• Dx:
– 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
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’
Team assessment – most recent
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!
Case 3
• Dx:
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Dementia
Hypertension
IHD
LIH 2005
L eye ectropion
Case 3 continued
• Medicines
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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,
Case 4
• Dx:
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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
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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
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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?
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Osteoporosis
Isolates systolic hypertension
Neuronal degeneration (dementia)
Decreased immune function
Glaucoma
Macular degeneration
Muscle loss
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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
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• 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
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• 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 P450, 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?
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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
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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