Download Drugs - Dr. Anna Byszewski

TOP 5 IMPORTANT DRUGS
IN THE OLDER PERSON
Anna Byszewski BSc MD MEd
FRCP(C)
Division of Geriatric Medicine
4th Annual Better Prescribing Course
University of Ottawa
Outline
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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
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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
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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
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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
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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
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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
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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
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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
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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)
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(OSC CPC, CMAJ suppl. 2005)
4. Sleep hygiene
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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
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(Morin et al JAMA 1999)
5. Antidepressants
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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%
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(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
6. Anticholinergic Drugs
2. Benzodiazepines
7. Prozac
3. Neuroleptics
4. Beta Blockers
8. Narcotics
(Talwin/Demerol)
9. Colace/Irritant laxatives
5. Cimetidine
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
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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?
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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
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At age 4, success is. . .
not peeing in your pants.
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At age 80, success is….not
peeing in your pants.
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At age 12, success is. . .
having friends.
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At age 75, success
is….having friends.
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At age 16, success is. . .
having a drivers license.
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At age 70, success
is….having a drivers license.
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At age 20, success is. . .
having sex.
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At age 60, success
is….having sex.
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At age 35, success is. . .
having money.
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At age 50, success
is….having money.
THANK YOU!!!