Appropriate prescribing for older people

Question 1

What are the key concepts to remember when prescribing in elderly people?

Answer 1

• Ask the patient what their priorities are
• Start low, go slow
• Try and pick drugs with multiple benefits
• Review prescribing regularly
• Be as quick to stop as you are to start

Question 2

Define what is meant by the number needed to treat (NNT)?

Answer 2

The NNT tells you how many people need to take treatment for a given amount of time to prevent one event

E.g. 1 year NNT of 30 = 30 people need to take the drug for 1 year to prevent 1 event

Question 3

Define what is meant by number needed to harm (NNH)

Answer 3

This tells you how many patients need to be exposed to a risk factor over a specific period of time to cause harm in one patient who would have not otherwise have been harmed

Question 4

Case example:

Lady has diabetes, hypertension, and AF – she has just had a small stroke and has recently suffered a couple of falls

What are the pros and cons of her starting warfarin ?

Answer 4

Pros:

• High risk of stroke (>20% per year); warfarin will reduce to 7% per year

Cons:

• Risk of intracerebral bleed if she falls and hits head
• Will require blood tests (INR for warfarin use)
• Needs to remember to take meds
• Interactions with meds she is already on

Question 5

Case example:

Lady has diabetes, hypertension, and AF – she has just had a small stroke and has recently suffered a couple of falls

Should she be started on warfarin ?

Answer 5

Ask the patient!

1. If she is worried about having a further stroke, advise warfarin
2. If she is more worried about bleeding, advise against warfarin
3. If she is worried about blood tests, consider alternatives (e.g. dabigatran)

Question 6

What principles should you follow for deciding when a drug should be stopped in a patient and provide examples ?

Answer 6

1) Drugs which are causing side effects e.g. Aspirin in someone with iron deficiency anaemia as it can cause gastric bleeding and inturn anaemia
2) Drugs where we know there is a high risk of adverse events e.g. Zopiclone (sleeping pill) in someone at high risk of falls
3) Drugs that are ineffective
4) Drugs where the risk outweighs the benefit
5) Drugs that may not be harmful, but might not be doing much good

Question 7

What drugs do you need to be careful of in older people ?

Answer 7

• Sedatives
• Acid-suppressant drugs
• Antipsychotics
• Antiplatelets
• Combinations of ACEi/ARB/diuretics
• Anticholinergic medications
• NSAIDs
• Opioids

Question 8

Bunch of cases for rest of lecture so just flick over them