Download Prescribing and deprescribing in the older patient

Prescribing and deprescribing in
the frail older adult
Clare Bostock and Bob Caslake
Specialist Registrars in Geriatric
Medicine
Principles of drug review list
1. Identify current indication for medication.
2. Is the drug probably or possibly causing
harm? (i.e. some of the patient’s problems
could be attributable to known side effects
of the drug).
If YES  reduce or stop
3. Is the drug being given for a condition/symptom that
is now well-controlled/resolved or is no better
despite using the drug? (e.g. blood pressure,
oedema, pain, dyspepsia, agitation).
If YES  reduce or stop
4. Is it possible that long term use of this drug may
cause harm? (e.g. anticholinergic drugs, sedative
drugs).
If YES  reduce or stop
5. Is the drug likely to provide any prognostic
benefit within the patient’s expected life
time?
If NO  reduce or stop
6. Is there any medication that could be
prescribed to improve the health and
wellbeing of the patient?
If YES  start
Case 1
• 96 y/o man referred to OPC with wt loss.
• Graze on his forehead and left shoulder.
• Got up to answer the phone a few weeks ago, felt dizzy
and fell to the floor hitting his head.
• On examination he also has evidence of ankle oedema
and quadriceps wasting and has some slight difficulty
rising from a chair.
• He is mobile with one stick and has not had angina for
many years. He does not use his GTN spray.
• What advice would you give to the patient and GP
regarding medications?
Current medication
• Monomax XL (Isosorbide mononitrate MR) 30mg
od
• Amlodipine 10mg od
• GTN spray prn
• Atorvastain 10mg od
• Tamsulosin 400micrograms od
• Co-codamol 30/500 2 tabs prn
• Indoramin 20mg od
• Aspirin recently discontinued due to nose bleeds.
Case 2
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79 y/o man referred to clinic with a dry mouth.
Also problems with urinary frequency and constipation.
GP recently started a tablet to “help his water works.”
His wife thinks he has been a bit more muddled than usual,
and she tells you that he fell over last week.
Positive findings on examination are a loaded rectum on
PR, and dullness suprapubically.
What medications may be contributing to his symptoms?
What drugs may be contributing to “anticholinergic
burden”?
What suggestions would you make to his GP?
Current medication
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Ranitidine 150mg bd
Co-codamol 15/500 2 tabs prn
Amitriptyline 25mg nocte
Tolterodine XL 4mg od
Aspirin 75mg od
Fexofenadine x mg od
Atenolol 25mg od
Amlodipine 10mg od
GTN spray 2 puffs prn.
Case 3
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An 82 y/o man is admitted with confusion.
No reliable history from the patient.
His family think he is more confused than usual.
You telephone his GP for a patient summary and current list of
medications.
Past medical history: Depression 2007, Hypertension 1990,
Ischaemic heart disease 1992, COPD 2000, Appendicectomy 1945.
On examination he is delirious, T37, HR 80, BP 110/50, O2 sats 92%
on air. Examination is otherwise normal.
The biochemist phones to inform you that sodium is 118. Other
blood parameters are within normal limits.
What factors are contributing towards his delirium?
What medications will you prescribe?
Current medication
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Aspirin 75mg od
Simvastatin 40mg nocte
Omeprazole 20mg od
Temazepam 10mg on
Tiotropium 18micrograms od
Seretide 500 accuhaler 1 puff bd
Salbutamol easibreathe 2 puffs prn
Bendroflumethiazide 2.5mg od
Citalopram 20mg od
Co-codamol 30/500 2 tabs qds.
Case 4
• 87y/o lady transferred from A&E
• Fell yesterday and broke right wrist, hurting her
knee in the process
• Now struggling to mobilise
• PMHx of osteoporosis and hypothyroidism
• O/E: Right wrist in POP, requires assistance of two
to transfer bed to chair, irregular pulse
• ECG confirms AF
• What would you like to prescribe?
Current medication
• Thyroxine 75 micrograms OD
• Dihydrocodeine 30ng PRN
Advanced case
• 87 year old woman. PMHx of hypertension, type 2 diabetes, turn
diagnosed as a TIA in 1999. Independent at home until a few
months ago when she had a fall, resulting in a swollen, painful
knee. Since then, increasingly struggling at home with further falls,
incontinence of urine and sometimes faeces and increasing
confusion. She stops going to her crochet group. Rapidly increasing
care needs. Crisis point reached when her daughter, how provides a
lot of support, goes in to hospital for a knee replacement. Found on
the floor by her carer one morning and brought to A&E. On
examination: BP 89/58, pulse 122 irreg, T35.2, BMI 28, pitting
oedema of both, mild abdominal distension with lower abdominal
tenderness and a strong smell of urine. A&E diagnose with
urosepsis, give her IV amoxicillin and gentamicin and admit her to
Woodend. Investigations: ECG-AF, bloods: Na 126, Creat 240 (was
124 at time of wrist fracture), WCC 8.6, CRP<4.
Advanced current medication
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Aspirin 75mg od
Dipyridamole MR 200mg BD
Bendroflumethiazide 2.5mg od
Doxazosin MR 8mg od
Ramipril 5mg od
Felodipine MR 5mg od
Simvastatin 20mg od
Tramadol MR 100mg BD
Omeprazole 20mg od
Arthrotec 75 (Diclofenac and misoprostol) 1 tablet BD
Furosemide 40mg od
Glimepiride 4mg od
Quinine Sulphate 200mg at night
Temazepam 10mg nocte
Oxybutinin MR 10mg od