Prescribing in the older patient

Question 1

in the older patient, is gastric pH higher or lower than when younger

Answer 1

higher (more basic)

Question 2

does albumin bind to (transport) basic or acidic drugs

Answer 2

acidic

Question 3

does alpha-1 acid glycoprotein bind to basic or acidic drugs

Answer 3

basic

Question 4

what does the volume of distribution tell us

Answer 4

how lipophilic the drug is (high volume of distribution means long half-life??)
so be careful of older patients taking patients with high volume of distribution

Question 5

why do we need to be careful prescribing in CKD in elderly

Answer 5

half life is longer? can quickly become toxic

Question 6

renal metabolism differences in older patients

Answer 6

• lower GFR
• serum creatinine not a reliable measure because it relies on muscle mass

any doubt - use renal/hepatic impairment advice in the BNF

Question 7

general principle: _________ doses achieve the same effect in the elderly

Answer 7

lower

(but some effects are decreased e.g. beta blockers and heart rate)

Question 8

10 drugs with a narrow therapeutic index

Answer 8

• theophylline
• warfarin
• lithium
• digoxin
• gentamicin
• vancomycin
• phenytoin
• cyclosporin
• carbamazepine
• levothyroxine

Question 9

therapeutic window of drugs get smaller as you get older, true or false

Answer 9

true

Question 10

opioid main side effect and how can we prevent

Answer 10

constipation
- so begin laxative prophylactically

Question 11

steroids main side effects

Answer 11

osteoporosis prevention needed

steroid induced diabetes

Question 12

levothyroxine and calcium

Answer 12

calcium stops the absorption of levothyroxine - so if patient is taking both take one in morning and one at night

Question 13

side effects of NSAIDs

Answer 13

• GI haemorrhage
• decline in GFR
• decreased effectiveness of diuretics, anti-hypertensive agents

Question 14

opioids and benzodiazepines side effects

Answer 14

• impair psychomotor function
• falls and confusion

Question 15

antibiotics side effects

Answer 15

resistance and c.diff diarrhoea

Question 16

what things would make an older patient “at risk”

Answer 16

• recent discharge from hospital
• use of multiple drugs
• multiple prescribers
• impaired cognitive status and/or communication problems
• use of drugs with a narrow therapeutic index
• use of drugs commonly associated with adverse drug effects
• use of OTC or complementary medications
• a change in the condition of the patient

Question 17

beers criteria for older people

Answer 17

50 drugs split into:
- never use
- potentially use
- use with caution

Question 18

what is the STOPP-START criteria used for

Answer 18

drugs that are potentially inappropriate for older patients

drugs that should be considered

Question 19

can beta blockers be taken in combination with verapamil

Answer 19

no, avoid

Question 20

who should you avoid using CCBs in

Answer 20

patients with chronic constipation

Question 21

if in doubt about drug/prescribing in older patients, what tool can be used?

Answer 21

STOPP-START