Polypharmacy

Question 1

Which drugs do elderly people have an increased sensitivity to?

Answer 1

Opioids
Benzodiazepines
Neuroleptics

Question 2

Which drugs do elderly people have a decreased sensitivity to?

Answer 2

Beta-agonist
Beta-blovkers
Furosemide

Question 3

How is the distribution of drugs affected with age?

Answer 3

With ageing, total body fat increases therefore increasing the volume of distribution for fat soluble drugs.
Total body water however decreases, decreasing the volume of distribution of water soluble drugs.
Serum albumin also decreases and this increases the effects of albumin-bound drugs as the levels of unbound drug increase as a consequence.

Question 4

How is hepatic metabolism affected with age?

Answer 4

The majority of drugs are metabolised via the hepatic route.
Reduced liver volume and enzyme activity means that hepatic metabolism of many drugs decreases.
To prevent toxic accumulation doses must be reduced or dosing interval should be increased.

Question 5

How is renal elimination affected with age?

Answer 5

Reduction in the glomerular filtration rate, GFR, is important for drugs that are excreted via the kidneys.
Changes in the GFR decrease the excretion of these drugs.
Digoxin is an example of a renally excreted drug with a narrow therapeutic index that often requires a dose reduction as we get older to prevent drug toxicity.
Again to prevent toxic accumulation doses must be reduced or dosing interval should be increased.

Question 6

What are the recommendations for drugs for the cardiovascular system (STOPP)?

Answer 6

Digoxin > 125μg/day with impaired renal function
Loop diuretic for dependent ankle oedema only
Loop diuretic as first-line monotherapy for hypertension
Thiazide diuretic with a history of gout
Non-cardioselective beta-blocker with COPD
Beta-blocker in combination with verapamil
Use of diltiazem or verapamil with NYHA Class III or IV heart failure
Calcium channel blockers with chronic constipation
Use of aspirin + warfarin without stomach protection
Dipyridamole as monotherapy for cardiovascular prevention
Aspirin + PMH of ulcer disease without stomach protection
Aspirin at dose > 150mg day
Aspirin with no history of coronary, cerebral or peripheral arterial symptoms or occlusive arterial event
Aspirin to treat dizziness not clearly attributable to cerebrovascular disease
Warfarin for first, uncomplicated deep venous thrombosis for longer than 6 months duration
Warfarin for first uncomplicated pulmonary embolus for longer than 12 months duration
Aspirin, clopidogrel, dipyridamole or warfarin with concurrent bleeding disorder

Question 7

Which drugs are on the START criteria?

Answer 7

ACE inhibitor 
Simvastatin 
Salbutamol 
Bisphopshonate 
Warfarin

Question 8

Which drugs are on the STOPP criteria?

Answer 8

Prednisolone 
Amitriptyline 
Codeine 
Morphine 
Paracetamol

Question 9

What occurs with absorption of drugs with ageing?

Answer 9

Age-related changes in GI tract are not clinically significant as they do not affect the absorption of most drugs
Lowered by amount of saliva, gastric acid secretion, surface area, GI motility and active transport mechanism
Raised by gastric pH and gastric emptying time

Question 10

What are the consequences of inappropriate prescribing?

Answer 10

Length of stay- IP can prolong the length of hospital stays
Mortality & morbidity- IP can increase mortality & morbidity
Adverse drug reactions- IP can increase the risk of ADRs which may account for up to 30% of hospital admissions in older people
Compliance- patients with poorer compliance when on multiple medications

Question 11

What are the recommendations for the drugs of the central nervous system? (STOPP)

Answer 11

 Tricyclic antidepressants (TCA’s) with dementia
 TCA’s with glaucoma
 TCA’s with cardiac conductive abnormalities
 TCA’s with constipation
 TCA’s with an opiate or calcium channel blocker
 TCA’s with prostatism or prior history of urinary retention
 Long-term long-acting benzodiazepines e.g. chlordiazepoxide, fluazepam, nitrazepam, chlorazepate and benzodiazepines with long-acting metabolites e.g. diazepam
 Long-term neuroleptics as long-term hypnotics
 Long-term neuroleptics in those with parkinsonism
 Phenothiazines in patients with epilepsy
 Anticholinergics to treat extra-pyramidal side-effects of neuroleptic medications
 Selective serotonin re-uptake inhibitors (SSRI’s) with a history of clinically significant
hyponatraemia
 Prolonged use (> 1 week) of first generation antihistamines i.e. diphenydramine, chlorpheniramine, cyclizine, promethazine

Question 12

What are the recommendations for the drugs of the GI system? (STOPP)

Answer 12

 Diphenoxylate, loperamide or codeine phosphate for treatment of diarrhoea of unknown cause
 Diphenoxylate, loperamide or codeine phosphate for treatment of severe infective gastroenteritis i.e. bloody
 diarrhoea, high fever or severe systemic toxicity
 Prochlorperazine (Stemetil) or metoclopramide with Parkinsonism
 PPI for peptic ulcer disease at full therapeutic dosage for > 8 weeks
 Anticholinergic antispasmodic drugs with chronic constipation

Question 13

What are the recommendations for the drugs of the respiratory system? (STOPP)

Answer 13

 Theophylline as a monotherapy for COPD
 Systemic corticosteroids instead of inhaled corticosteroids for maintenance in moderate- severe COPD
 Nebulised ipratropium with glaucoma

Question 14

What are the recommendations for the drugs of the MSK system? (STOPP)

Answer 14

 NSAID with history of peptic ulcer disease or gastrointestinal bleeding, unless with stomach protection
 NSAID with moderate-severe hypertension
 NSAID with heart failure
 Long-term use of NSAID (>3 months) for relief of mild joint pain in osteoarthtitis

 Warfarin and NSAID together
 NSAID with chronic renal failure
 Long-term corticosteroids (>3 months) as monotherapy for rheumatoid arthrtitis or osterarthritis
 Long-term NSAID or colchicine for chronic treatment of gout where there is no contraindication to allopurinol

Question 15

What are the recommendations for the drugs of the urogenital system? (STOPP)

Answer 15

 Bladder antimuscarinic drugs with dementia
 Bladder antimuscarinic drugs with chronic glaucoma
 Bladder antimuscarinic drugs with chronic constipation
 Bladder antimuscarinic drugs with chronic prostatism
 Alpha-blockers in males with frequent incontinence
 Alpha-blockers with long-term urinary catheter in situ

Question 16

What are the recommendations for the drugs of the endocrine system? (STOPP)

Answer 16

 Glibenclamide or chlorpropamide with type 2 diabetes mellitus
 Beta-blockers in those with diabetes mellitus and frequent hypoglycaemic episodes i.e. ≥ 1
episode per month
 Oestrogens with a history of breast cancer or venous thromboembolism
 Oestrogens without progestogen in patients with intact uterus

Question 17

What are the recommendations for the drugs for falls risk? (STOPP)

Answer 17

 Benzodiazepines (sedative, may cause reduced sensorium, impair balance)
 Neuroleptic drugs (may cause gait dyspraxia, Parkinsonism).
 First generation antihistamines (sedative, may impair sensorium).
 Vasodilator drugs known to cause hypotension in those with persistent postural hypotension
i.e. recurrent >20mmHg drop in systolic blood pressure (risk of syncope, falls).
 Long-term opiates in those with recurrent falls (risk of drowsiness, postural hypotension, vertigo).

Question 18

What are the recommendations for the drugs for analgesia? (STOPP)

Answer 18

 Use of long-term powerful opiates e.g. morphine or fentanyl as first line therapy for mild- moderate pain
 Regular opiates for more than 2 weeks in those with chronic constipation without concurrent use of laxatives
 Long-term opiates in those with dementia unless indicated for palliative care or management of moderate/severe chronic pain syndrome

Question 19

What are the recommendations for duplicate drug classes? (STOPP)

Answer 19

	Any regular duplicate drug class prescription
	e.g. two concurrent opiates, NSAID’s, SSRI’s, loop diuretics, ACE inhibitors (optimisation of monotherapy within a single drug class should be observed prior to considering a new class of drug).
	This excludes duplicate prescribing of drugs that may be required on a prn basis e.g. inhaled beta2 agonists (long and short acting) for asthma or COPD, and opiates for management of breakthrough pain.

Question 20

What is the START criteria for the cardiovascular system?

Answer 20

 Warfarin in the presence of chronic atrial fibrillation
 Aspirin in the presence of chronic atrial fibrillation, where warfarin is contraindicated.

 Aspirin or clopidogrel with a documented history of atherosclerotic coronary, cerebral or peripheral vascular disease in patients with sinus rhythm.
 Antihypertensive therapy where systolic blood pressure consistently >160 mmHg.
 Statin therapy with a documented history of coronary, cerebral or peripheral vascular
disease, where the patient’s functional status remains independent for activities of daily living
and life expectancy is > 5 years.
 Angiotensin Converting Enzyme (ACE) inhibitor with chronic heart failure.
 ACE inhibitor following acute myocardial infarction.
 Beta-blocker with chronic stable angina.

Question 21

What is the START criteria for the CNS?

Answer 21

 L-DOPA in idiopathic Parkinson’s disease with definite functional impairment and resultant
disability.
 Antidepressant drug in the presence of moderate-severe depressive symptoms lasting at least three months.

Question 22

What is the START criteria for the GI system?

Answer 22

 Proton Pump Inhibitor with severe gastro-oesophageal acid reflux disease or peptic stricture requiring dilatation.
 Fibre supplement for chronic, symptomatic diverticular disease with constipation.

Question 23

What is the START criteria for the respiratory system?

Answer 23

 Regular inhaled beta 2 agonist or anticholinergic agent for mild to moderate asthma or COPD.
 Regular inhaled corticosteroid for moderate-severe asthma or COPD, where predicted FEV1
<50%.
 Home continuous oxygen with documented chronic type 1 respiratory failure (pO2 < 8.0kPa, pCO2 <6.5kPa) or type 2 respiratory failure (pO2 < 8.0kPa, pCO2 > 6.5kPa).

Question 24

What is the START criteria for the MSK system?

Answer 24

 Disease-modifying anti-rheumatic drug (DMARD) with active moderate-severe rheumatoid disease lasting >12 weeks.
 Bisphosphonates in patients taking maintenance oral corticosteroid therapy.
 Calcium and Vitamin D supplement in patients with known osteoporosis (radiological evidence or previous fragility fracture or acquired dorsal kyphosis).

Question 25

What is the START criteria for the endocrine system?

Answer 25

 Metformin with type 2 diabetes +/- metabolic syndrome
 ACE inhibitor or Angiotensin Receptor Blocker in diabetes with nephropathy i.e. overt urinalysis proteinuria or micoralbuminuria (>30mg/24 hours) +/- serum biochemical renal impairment
 Antiplatelet therapy in diabetes mellitus if one or more co-existing major cardiovascular risk factor present (hypertension, hypercholesterolaemia, smoking history).
 Statin therapy in diabetes mellitus if one or more co-existing major cardiovascular risk factor present