GP VTS Teaching 24 th February, 2009

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

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!!!