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  Important drugs in the older person  Drugs to avoid in the older person  Tips how to avoid pitfalls in prescribing for the older person

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…

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

Drugs and The Older Person Statistics  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)

Drugs and The Older Person ADR’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!!

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)

Drugs and The Older Person The Top 5 Important Drugs 1.Antihypertensives(Diuretics, CCB, ACEI) 2.Warfarin (a.fib) 3.Osteoporosis treatment( Ca, Vit D, Bisphosphonates,) 4.Antidepressants 5.“Sleep Hygiene Tips”/Exercise

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)

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 )

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)

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)

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)

Drugs and The Older Person The Top 10 Drugs to Use Less 1.NSAID’s 2.Benzodiazepines 3.Neuroleptics 4.Beta Blockers 5.Cimetidine 6.Anticholinergic Drugs 7.Prozac 8.Narcotics (Talwin/Demerol) 9.Colace/Irritant laxatives 10.OTC/Herbals/ETOH

Drugs and The Older Person 10 Do’s and Don’ts of Safe Prescribing 1.Always consider drugs as potential cause for any new symptom in the elderly 2.Appropriate diagnosis vs symptomatic prescribing 3.Start all new drugs as N=1 trial 4.Start low and go slow but push therapy until you achieve therapeutic goals or side effects occur 5.Start low and go slow and don’t be afraid to say no

Drugs and The Older Person 10 Do’s and Don’t’s of Safe Prescribing 6.Know what your patient is taking: prescription, OTC, herbal 7.Know and use well a small list of drugs in the older person (“toolbox” of ~ 25 medications) 8.Tailor choice of drug to individual and comorbid disease 9.Regularly review drug regimens and try to reduce drugs 10.Keep it simple/compliance issues

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

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.

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.

THANK YOU!!!