Prescribing and Deprescribing in the Elderly

Question 1

What are some of the problems associated with medicines in the elderly?

Answer 1

• Multimorbidity ⇒ Polypharmacy
• Altered drug handling
• Organ impairment
• Problems with concordance
• Social factors - support, mobility, getting to care providers / pharmacy, concordance
• Don’t be ageist

Question 2

What are the physiological changes associated with ageing which affect pharmacokinetics and pharmacodynamics?

Answer 2

• Reduced renal clearance.
• Reduced liver size and blood flow, reduced enzyme activity.
• Pharmacodynamic changes - reduced homeostatic reserve, receptor changes.
• Increased sensitivity to certain medicines - CNS, CV function, GI side effects, haematological effects.

Question 3

Which particular drugs are tolerated poorly in elderly / frail adults?

Answer 3

• Antipsychotics
• NSAIDs
• Digoxin (doses ≥250µg)
• Benzodiazepines
• Opiates / combination analgesics
• Anticholinergics

Question 4

What are the general principles of prescribing in the elderly?

Answer 4

• Limit range
• Consider risk / benefit
• Reduce dose
• Start low, go slow
• Regular review
• Simplify regimens
• Explain clearly
• Check if there are concordance problems
• Be alert during acute illnesses
• Medicine reconciliation before changing medicines

Question 5

What is medicines reconciliation and why is it important?

Answer 5

• A complete list of medications, accurately communicated.
• More than 50% of errors happen at transitions of care - admission, transfers, discharge.
• Use structured template if available.
• Use more than one information source.
• Resolve any discrepancies.
• Include OTC and complementary medicines.

Question 6

What are the benefits of taking the time to carry out medicines reconciliation?

Answer 6

• Improves safety
• Improves efficiency
• Improves therapeutic outcomes
• Reduces medication errors / near misses / missed doses
• Reduces delays to treatment
• Savings to NHS from prevented errors

Question 7

Describe ‘appropriate’ polypharmacy.

Answer 7

• All medicines are prescribed for the purpose of achieving specific therapeutic objectives that have been agreed by the patient.
• Therapeutic objectives are achieved / achievable.
• Therapy has been optimised to minimise ADRs.
• Patient is motivated and able to take medicines as intended.

Question 8

Describe the conditions under which polypharmacy is inappropriate.

Answer 8

• No evidence based indication or the dose is unnecissarily high.
• One or more medicines fail to achieve the therapeutic objectives.
• One or the combination of several drugs causes unacceptable ADRs.
• Patient is not willing or able to take one or more medicines as intended.

Question 9

What are the factors which make it difficult to reduce polypharmacy:

• In primary care?
• In the acute setting?

Answer 9

• Primary care
  
  • ​Patient is stable
  • Easier to maintain status quo
  • Deprescribing risk
  • Limited time
• Acute
  
  • ​Deal with presenting complaint
  • Not the right time?
  • Limited information on DHx
  • Specialty focus vs totality of medicines burden

Question 10

Which patients should be targeted first for medicines reviews?

Answer 10

• High degree of frailty.
• On high-risk medication(s) based on side-effect profiles.
• Prescribed 10 or more medicines.
• Palliative care patients.
• Acute admissions.

Question 11

What are the highest risk medicines (based on ADR risks and admission rates)?

Answer 11

Question 12

What are the 7 steps to appropriate polypharmacy?

Answer 12

1. What matters to the patient?
   
   • ​​What are you hoping to achieve?
     
     • Management of existing health problems?
     • Prevention of future health problems?
   • Identify therapeutic objectives:
     
     • Ask the patient what matters to them.
     • Shared decision making.
2. Identify essential drug therapy
   
   • ​​Does it have an essential replacement function?
     
     • E.g. Levothyroxine, Insulin, Steroids for Addisons.
   • Does it prevent rapid symptomatic decline?
     
     • E.g. drugs for Parkinson’s, heart failure, bioplar disorder.
3. Identify unnecessary drug therapy
   
   • ​​Expired indication?
   • Higher than usual maintenance doses
   • With limited benefit for that indication?
   • With limited benefit for that patient?
4. Are the therapeutic objectives being achieved?
   
   • ​​Symptoms controlled?
   • Biochemical / clinical targets reached?
   • Preventing disease progression / exacerbation?
5. Safety
   
   • ​​Identify patient safety risks
   • Identify ADRs
6. Is the drug cost effective?
   
   • ​​Balance costs aginst effectiveness and safety
7. Patient centeredness
   
   • ​​Does the patient understand the outcome of the review?
   • Is the patient concordant / adherent?
   • Agree and communicat plan with patient and / or carer / caregiver.

Question 13

Which drugs have an anticholinergic burden?

Include those which get:

• 1 point
• 2 points
• 3 points

Answer 13