Prescribing and Polypharmacy

Question 1

Acidic drugs bind to what molecule in the body?

Basic drugs bind to what molecule in the body?

Typically, what are the quantities of these binding molecules in the elderly?

Answer 1

Albumin

Alpha 1 acid glycoprotein

They often have low albumin, but high A1AG

Question 2

In older people there is increased fat in proportion to muscle mass - what is the effect of this?

In older people there is often decreased body water - what is the effect of this?

Answer 2

There is an increased volume of distribution for lipophilic drugs, so they have a longer half life

There is a decreased volume of distribution for hydrophilic drugs, so they have a shorter half life

Question 3

In the elderly, there is often decreased liver function. What is the effect of this?

In the elderly, there is often a lower GFR. What is the effect of this?

Answer 3

Decreased first pass metabolism

Decreased renal excretion

Question 4

On the whole, in elderly people lower doses of drugs achieve the same effect. However, what is an exception to this rule?

Answer 4

Beta blockers will have decreased effect in the elderly

Question 5

What is a common side effect of opioid medications?

What should be prescribed prophylactically alongside these to avoid this?

Opioids and benzodiazepines are also well known for causing what other side effects in the elderly?

Answer 5

Constipation

A laxative (lactulose or senna)

Falls and confusion

Question 6

What metabolic problem can steroids cause?

If steroids are to be used long term, prophylaxis against what should be given?

Answer 6

Diabetes

Osteoporosis

Question 7

Levothyroxine should not be prescribed alongside what other drug?

Why is this?

Answer 7

Calcium

Ca++ causes decreased absorption from the GI tract and so decreases absorption of levothyroxine

Question 8

What are the main reasons for trying to avoid NSAID use in the elderly?

Using NSAIDs can decrease the effectiveness of which other drugs?

If NSAIDs do have to be used, what is a better option?

What medication is equally as effective as NSAIDs in mild osteoarthritis and should be used instead?

Answer 8

Increased risk of GI bleed

Decline in GFR

Diuretics and anti-hypertensives

Selective COX2 inhibitors

Paracetamol

Question 9

What are the main reasons for being strict when it comes to antibiotic prescribing in the elderly?

Answer 9

Resistance

C. Diff risk

Question 10

Which drugs should not be used for treatment of diarrhoea of unknown cause in the elderly, as they can exacerbate the condition and result in constipation with overflow diarrhoea?

What are some other reasons why these should not be used?

Answer 10

Loperamine or codeine phosphate

Can precipitate toxic megacolon in IBD

May delay recovery in unrecognised gastroenteritis

Question 11

Metaclopramide and prochlorperazine should be avoided in patients with which condition and why?

Answer 11

Parkinson’s

Can exacerbate symptoms

Question 12

Why should laxatives not be used in intestinal obstruction?

Answer 12

Risk of bowel perforation

Question 13

A beta blocker should not be prescribed alongside verapamil for what reason?

Non-cardioselective beta blockers should not be used in patients with what condition and why?

In patients with chronic constipation, which CV drug should be avoided?

Answer 13

Increases risk of symptomatic heart block

COPD/asthma - risk of bronchospasm

Ca++ blockers

Question 14

Dipyridamole should no longer be used for what?

What is the exception to this?

Answer 14

Monotherapy for CV secondary prevention

If the patient is intolerant to aspirin or clopidogrel

Question 15

When should PPIs be prescribed?

Answer 15

For severe GORD

Patients aged 80+ on anti-platelets or SSRIs

If aspirin and warfarin are being used in combination (unlikely)

Question 16

When should fibre supplements be prescribed?

Answer 16

For diverticular disease which is symptomatic with constipation

Question 17

When should elderly people be given an antihypertensive?

When should elderly people be given an ACE inhibitor?

When should elderly people be given warfarin or a DOAC?

Answer 17

If systolic BP > 160

If they have heart failure or post-MI

In chronic AF or following a DVT/PE if benefit > risk

Question 18

Codeine and tamsulosin are both drugs which are known for causing what adverse effect in the elderly?

Which drug is particularly well known for precipitating/prolonging delirium?

An alpha blocker (e.g. tamsulosin for prostatism) and an anti-hypertensive in combination often shows what adverse effect?

A combination of trimethoprim and an ACE inhibitor is most likely to cause what adverse affect?

Answer 18

Cognitive decline

Benzodiazepines

Postural hypotension

Decline in renal function

Question 19

What is the risk of drugs causing problems with cognition and consciousness in the elderly?

What problem with regards to bowel function are elderly people more likely to suffer from as a medication side effect?

What are some drug side effects which affect dizziness and balance? What is the risk of these?

Answer 19

Increased risk of delirium

Constipation

Parkinsonism and postural hypotension, increases risk of immobility and falls

Question 20

If a patient has a bleeding ulcer, what drug should be stopped?

If a patient has kidney failure, what drug should be stopped?

If a patient has hyponatraemia, what drug should be stopped?

Answer 20

NSAID

ACE inhibitor

Anti-depressant

Question 21

Why should gabapentin not be used in the elderly?

When should you stop using primary prevention in elderly people?

Answer 21

Dizziness, fatigue, visual disturbance - confusion

If they have a short life expectancy

Question 22

Describe the concept of anti-cholinergic burden?

Answer 22

The more of these drugs that patients are on, the more side effects they will get (summative effect)