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Prescribing Medicine for the Elderly

PRESCRIBING FOR THE ELDERLY

By

Abdalla Ibrahim

Family Doctor, PHC, MOH, Bahrain

Accreditation Specialist, Healthcare Surveyor

Email: abdallaibrahim@hotmail.com

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2014

Mapping of the presentation 3

General principles of geriatric medicine

Especial consideration on elder-drug prescription

Guidelines

introduction 4

In elder people, an abrupt decline in any system is due

to disease and not to normal aging, that is to say, “Old

people are sick because they are sick, not because they

are old”.

Definition 5

Human aging:

A progressive constriction of each

organ system’s homeostatic reserve.

This decline is often referred to as

homeo-stenosis. It begins in the third

decade and is linear and variable

among individuals (Resnick NM, 1998).

General principles of geriatric

medicine 6

1. Disease presentation is often atypical and symptoms

depend on which organ system is the “weakest link”

often the brain, LUT, CVS and musculo-skeletal

system.

2. Because of impairment of compensatory mechanisms,

diseases in elders presents at earlier stage

General principles (cont.)

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3. Multiple abnormalities occur concurrently.

4. Many findings that are abnormal in younger

patients are common in elder and may not be

responsible for particular symptoms.

General principles (cont.)

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5. Symptoms in elder are due to multiple causes.

Think of more than one diagnosis. When diagnosis

is correct, treatment of a single disease is unlikely

to result in cure.

6. Elder respond equally or even more effectively to

treatment than younger patients (Resnick NM, 1998).

Special Consideration 9

Patient compliance

Polypharmacy

Susceptibility

Patient compliance 10

Up to 50% of patients fail to achieve full

compliance and 33% never take their medicines.

Compliance for short term and self –administered

therapies are higher (about 75%) than long –

term therapies (<25% for completion of

antibiotic therapy for acute infection).

Patient compliance (cont.)

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Compliance rates are inversely correlated with the

number of interventions prescribed, complexity and

cost. Thus regimen should be as simple as possible.

Patients recall instruction to medicines than to comply

with recommendation to follow diet, exercise and

self-care activities.

Polypharmacy 12

How elder people make their own polypharmacy?

Elder people receive multiple drugs for multiple

diseases

Self-medication from OTC based on previous

experience or prescription

Polypharmacy (cont.)

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Symptoms associated with social stress (e.g.

headache and sleeplessness) can lead to further

prescription

Manifestation of aging may be misleading for drug

prescription

Susceptibility 14

Increased permeability of the BBB

Aging of the renal system:

Limited function of the renal system

Slow excretion of drugs

Increased susceptibility to nephrotoxic drug

Guidelines 15

Indication:

First question yourself whether the drug is indicated

at all

Limit your range:

Prescribe from limited range of drugs and be

thoroughly familiar with their effect in the elderly

Guidelines (cont.)

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Reduce Dose

Dose should be lower than in younger patient and it

is common to start with 50% of adult dose

Review regularly:

You may need to reduce the dose, repeat the dose

or even stop the drug completely

Guidelines (cont.)

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Explain clearly

Write full instruction on each prescription

Repeats and disposal

Try to prescribe matching quantities. Instruct

patients what to do when drugs run out

Third party

Enrol the help of third party when necessary

Guidelines (cont.)

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Regimen and form of prescription

Regimen should be as simple as possible (once

or twice a day)

Self-administered drug is preferable (avoid

injection)

Liquid forms are preferred to tablets or

capsule ones which need ample amount of

fluid

Recommendation 19

NSAID

For osteoarthritis, soft-tissue lesion, back pain try the

following

Weight reduction, warmth, exercise and walking stick

Paracetamol with low dose opioid analgesic

Paracetamol with small dose NSAID

Monitor for GI bleeding

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Diuretics

Should not be used on long-term basis. For gravitational

oedema encourage increase movement, raising the leg

and support stockings

Hypnotics

Avoid hypnotics with long half-lives which have serious

hangover effects of drowsiness, unsteady gait, slurred

speech and confusion. Short course hypnotics are

occasionally useful to help patient go through acute

illness or some other crisis.

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