Elderly - Drugs and Polypharmacy - Part 3 Flashcards
Deprescribing - To reduce, substitute or discontinue a drug
how/why is it done?
Adverse drug reaction
Drug-drug interaction
Drug-disease interaction
Better alternative
Not effective
Not indicated
Not evidence-based
Minimise polypharmacy
Proactive deprescribing is what?
main aim is to counteract polypharmacy
Systematic review of medication withdrawal trials in people aged >65 (Iyer et al Drugs Aging 2008):
- Diuretics (N=4) 51 – 100% withdrawn with v. few problems
- Antihypertensives (N=9) 20 – 85% normotensive after 6 m – 5 y, no xs deaths
- Psychotropics (N=16) Reduction in falls and improved cognition
Conclusion: Some evidence that it is safe and/or beneficial to stop antihypertensives, benzodiazepines, antipsychotics
Since then we have discovered a number of drugs that have a poor risk benefit ratio and can probably be stopped
Stopping statins towards end of life:
Deprescribing statins for people in last year of life
Higher proportion of people that stopped statins lived longer
Polypharmacy – ‘worst’ drugs?:
Drugs Most Associated With Admission Due To Adverse Drug Reaction [ADR] - what are they?
- NSAIDs 29.6%
- Diuretics 27.3%
- Warfarin 10.5%
- ACEI 7.7%
- Antidepressants 7.1%
- Beta blockers 6.8%
- Opiates 6.0%
- Digoxin 2.9%
- Prednisolone 2.5%
- Clopidogrel 2.4%
NSAIDs and diuretics give very obvious ADRs
Antidepressants and beta blockers give much more subtle ADRs
Most adverse events are from what durgs?
Anticholinergics
Sedatives
what are some common antimuscarinic effects?
Anticholinergics are classified according to the receptors that are affected: Antimuscarinic agents operate on the muscarinic acetylcholine receptors. The majority of anticholinergic drugs are antimuscarinics
what are some exampels of classical and non-classical antimuscarinic drugs?
Many antidepressants aswell
what is the anticholinergic risk scale?
These are the medications with antocholinergic side effects.
Add u the number of points on a prescription
Anticholinergic strength is rated from 1-3
If score 3 or more, then almost certain to have anticholinergic side effects
what are some problamatic drugs in psychiatric patients?
- Care with treating “agitation”
- Sedatives problematic - Increased effects of benzodiazepines (Falls, confusion)
- Anti-psychotics - Increased adverse effects (Postural hypotension, stroke, confusion, movement disorders)
- Anti-depressants - Less effective, more dangerous? - risk of falls dramatically increases
Try minimise anti-physcotics and use non-phamracological interventions
Almost all drugs are very ________ in older people and need to be used with care
problematic
what analgesia may be problematic in older people?
Particularly problematic in older people mostly due to pharmacodynamic and pharmacokinetic changes
•Opioids
- More sensitive to effects, lower doses needed
- Pethidine and tramadol may be less useful
•NSAIDs
- Increased adverse effects - Renal impairment, GI bleeding
NSAIDs – higher protein bound and renal excreted so will be particularly powerful in older people
what cardiovascular drugs may be problematic?
•Digoxin
- Increased toxicity
- Lower doses needed
•Diuretics
- Decreased peak effect, but reduced clearance - Abnormal urea and electrolytes
- Other issues around continence and mobility
- Often inappropriate indication (swollen legs)
•Anti-hypertensives
- May have exaggerated effects on BP and HR
- More likely to be issues with postural hypotension
- ACE inhibitors often pro-drugs which may not be metabolised to the active form
- Renal adverse effects
•Anti-coagulants
- More sensitive to warfarin
- Greater risk from warfarin i.e. GI bleeding, falls
Antibiotics cause increased adverse affects such as what?
- Diarrhoea and c. diff infection
- Blood dyscrasias (trimethoprim, co-trimoxazole)
- Delirium (quinolones)
- Seizures
- Renal impairment (aminoglycosides)
