1. GP VTS Teaching 24 th February, 2009 PRESCRIBING IN THE ELDERLY Dr Rob Dent

2. 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

3. Prescribing In The Elderly ● Polypharmacy ● Dose Adjustment ● Forgetfulness ● Ethics ● Dementia ● Other Elderly Specific Drugs

4. Polypharmacy ● “I'm rattling doc!!”

5. Polypharmacy - Interactions ● Any common interactions? – Verapamil +............. – Simvastatin +........... – Aspirin +............ – Bendroflumethiazide +................

6. Dose Adjustments ● General rule: start at 50% adult dose ● Reduced Renal Clearance – Occurs with age – Slow excretion – HIGHLY susceptible to nephrotoxic drugs – eg

7. 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

8. Dose Adjustments ● Side Effects – Hypnotics – Diuretics – AntiParkinsons – Digoxin

9. 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.......?

10. Forgetfulness ● Dosette Boxes ● Combination Medicines

11. Forgetfulness ● Dosette Boxes – What are these?

13. 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

14. Forgetfulness ● Dosette Boxes – Advantages:

15. 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)

16. Forgetfulness ● Dosette Boxes – Disadvantages:

17. 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)

18. Forgetfulness ● Combination Medicines – Any examples??

19. Forgetfulness ● Combination Medicines – Any examples?? ● Anti hypertensives – Diuretic + ACE

20. Forgetfulness ● Combination Medicines – Any examples?? ● Anti hypertensives – Diuretic + ACE (coversyl) – ACE + CCB

21. Forgetfulness ● Combination Medicines – Any examples?? ● Anti hypertensives – Diuretic + ACE (coversyl) – ACE + CCB (triapin) – B-Blocker + Diuretic

22. Forgetfulness ● Combination Medicines – Any examples?? ● Anti hypertensives – Diuretic + ACE (coversyl) – ACE + CCB (triapin) – B-Blocker + Diuretic (Kalten)

23. Forgetfulness ● Combination Medicines – Any examples?? ● Anti hypertensives – Diuretic + ACE (coversyl) – ACE + CCB (triapin) – B-Blocker + Diuretic (Kalten) ● Anti-Platelets – Aspirin + Dipyridimole

24. Forgetfulness ● Combination Medicines – Any examples?? ● Anti hypertensives – Diuretic + ACE (coversyl) – ACE + CCB (triapin) – B-Blocker + Diuretic (Kalten) ● Anti-Platelets – Aspirin + Dipyridimole (Asasantin)

25. 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

26. 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)

27. Forgetfulness ● Combination Medicines – Any examples?? ● Antibiotics – Amoxicillin and clavulinic acid

28. Forgetfulness ● Combination Medicines – Any examples?? ● Antibiotics – Amoxicillin and clavulinic acid (augmentin)

29. Forgetfulness ● Combination Medicines – Any examples?? ● Antibiotics – Amoxicillin and clavulinic acid (augmentin) ● Creams – Hydrocortisone + Miconazole )

30. Forgetfulness ● Combination Medicines – Any examples?? ● Antibiotics – Amoxicillin and clavulinic acid (augmentin) ● Creams – Hydrocortisone + Miconazole (Daktacort)

31. Forgetfulness ● Combination Medicines – Any examples?? ● Antibiotics – Amoxicillin and clavulinic acid (augmentin) ● Creams – Hydrocortisone + Miconazole (Daktacort) ● Inhalers – Salmeterol + Fluticasone

32. Forgetfulness ● Combination Medicines – Any examples?? ● Antibiotics – Amoxicillin and clavulinic acid (augmentin) ● Creams – Hydrocortisone + Miconazole (Daktacort) ● Inhalers – Salmeterol + Fluticasone (Seretide)

33. Forgetfulness ● Combination Medicines – Any examples?? ● Antibiotics – Amoxicillin and clavulinic acid (augmentin) ● Creams – Hydrocortisone + Miconazole (Daktacort) ● Inhalers – Salmeterol + Fluticasone (Seretide) ● Anti-diabetics – Metformin + Rosiglitazone

34. Forgetfulness ● Combination Medicines – Any examples?? ● Antibiotics – Amoxicillin and clavulinic acid (augmentin) ● Creams – Hydrocortisone + Miconazole (Daktacort) ● Inhalers – Salmeterol + Fluticasone (Seretide) ● Anti-diabetics – Metformin + Rosiglitazone (Avandamet)

35. Forgetfulness ● Combination Medicines – Advantages ● Simpler, better compliance, cheaper (?) – Disadvatages ● Harder to titrate, More expensive (?)

36. 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

37. Co-Prescribing ● What are some examples?

38. Co-Prescribing ● What are some examples? – Codeine...............?

39. Co-Prescribing ● What are some examples? – Codeine...............+ senna

40. Co-Prescribing ● What are some examples? – Codeine...............+ senna – Diclofenac...........

41. Co-Prescribing ● What are some examples? – Codeine...............+ senna – Diclofenac...........+ lansoprazole

42. Co-Prescribing ● What are some examples? – Codeine...............+ senna – Diclofenac...........+ lansoprazole – Amoxicillin............

43. Co-Prescribing ● What are some examples? – Codeine...............+ senna – Diclofenac...........+ lansoprazole – Amoxicillin...........+ canestan

44. Co-Prescribing ● What are some examples? – Codeine...............+ senna – Diclofenac...........+ lansoprazole – Amoxicillin...........+ canestan – Prednisolone..........

45. Co-Prescribing ● What are some examples? – Codeine...............+ senna – Diclofenac...........+ lansoprazole – Amoxicillin...........+ canestan – Prednisolone..........+ alendronate

46. 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?

47. 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?

48. 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!!!)

49. 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”

50. 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!!!

51. Warfarin ● How can the situation be improved? – ???

52. Warfarin ● How can the situation be improved? – Dosette Boxes? ● Swansea man who took 5 x 5mg tabs instead of 5 x 1mg tabs... – LES rather than hospital prescribing? Or vv – Yellow books vs computer print outs? – Pharmacy checks now in place

53. Other Prescribing Tips in The Elderly ● Consider non pharmacological measures ● Form of medicine – Would she be better with liquid form? ● Sensitivity – Nervous system more affected ● Analgesics, Bzs, Anti-psychotics, Anti-parkinsonians

54. Effective Interventions ● National Service Framework For Older People – Active Monitoring of Treatment – Review of Repeat Prescribing Systems – Medication Review – Education and Training ● http://www.wales.nhs.uk/sites3/documents/439/NSF%20for%2 0Older%20People%20- %20Medicines%20and%20Older%20People.pdf