Dealing drugs

1
Dealing drugs

• Therapeutics in the elderly

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Objectives

• To understand the impact of aging changes on
  prescribing needs
• to know 7 principles of prescribing for the
  elderly
• to know major drugs to avoid in common drug
  classes
• to be able to optimize compliance

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The demographics of medications

• 10 of the population use 40 of meds
• 75-95 of elderly use Rx meds
• Average
• community 2-6 per pt
• LTC 3-9 per pt
• local Day Hospital 9 per pt

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What are common problems in prescribing?

• Drugs that are contraindicated!
• Little attention to pharmacokinetic changes
• Little attention to other drugs on list
• Drugs to treat drug side effects!
• Compliance
• Multiple prescribers
• Use of herbals by patients

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What are the current Top 10?

• 2000 - 2001
• atorvastatin 4.8 ODB- 87 million
• omeprazole 4.7 ODB 84
• amlodipine 3.6 ODB 64
• enalapril 57
• simvastatin 56
• olanzepine 46
• blood glucose strips 45

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What are the current Top 10?

• 2000 - 2001
• diltiazem 41 million
• fluticasone 40
• ranitidine 40
• TOTAL 562 million !!!!

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How does prescribing change with aging

• Pharmacokinetics
• alteration of body fatwater ratio
• alteration of protein binding
• altered metabolism
• decreased blood flow
• slowed P450
• altered excretion
• decreased GFR

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How does prescribing change with aging

• Pharmacodynamics
• decreased/increased receptor
• altered post-receptor reactions
• decreased end-organ function
• altered homeostasis

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The seven pillars of prescribing wisdom

• Remember that drugs may cause illness
• Strive for a diagnosis prior to Rx
• Know the pharmacology of Rxd drug
• Start low and go slow
• Be aware of patients other medications
• Compliance is always an issue
• Regularly review medications on list

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The bad drug list...

• Take 5 minutes to optimize this medication list
  prescribed by the person whose practice you have
  taken over
• P.S. there are 1000 other geriatric patients in
  the practice so you may be busy!!!!!

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Reviewing drugs caveats

• Analgesics
• NSAIDs are concerning but common
• avoid Demerol
• be aware of renal function
• use adjunctive medication but with caution

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Reviewing drugs caveats

• Antidepressants
• SSRIs remain first-line but
• drug interaction
• side effects
• long half-life are considerations
• TCAs choose low anticholinergic ones
• be aware of serotonin-syndrome

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Reviewing drugs caveats

• Antipsychotics
• beware of Ach effects
• caution with orthostatic drop with low-potency
  agents
• EPS can develop very quickly

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Reviewing drugs caveats

• Cardiac
• drug interaction
• comorbid conditions increase side effects
• dosing changes

15
What are we not using?

• Thrombolysis for acute MI
• Beta-blockers post-MI
• Coumadin for A fib
• Osteoporosis
• Analgesics in chronic pain

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Did you take your pills today? Compliance

• of meds
• complexity of regimes
• cognition
• comprehension
• accessibility
• cost
• not necessarily just aging !!

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How do you help compliance?

• Education
• Simplification
• Assistance
• Accessibility
• Minimization
• Organization
• Awareness

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Summary

• Medications can cause illness
• remember principles of prescribing (for all
  patients!)
• keep basic pharmacology in mind
• know the pharmacology of the drug being Rxd
• try to maximize compliance!

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Any questions?