TOP 5 IMPORTANT DRUGS IN THE OLDER PERSON Anna Byszewski BSc MD MEd FRCP(C) Division of Geriatric...

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TOP 5 IMPORTANT DRUGS IN THE OLDER PERSON Anna Byszewski BSc MD MEd FRCP(C) Division of Geriatric Medicine 4 th Annual Better Prescribing Course University of Ottawa

Transcript of TOP 5 IMPORTANT DRUGS IN THE OLDER PERSON Anna Byszewski BSc MD MEd FRCP(C) Division of Geriatric...

Page 1: TOP 5 IMPORTANT DRUGS IN THE OLDER PERSON Anna Byszewski BSc MD MEd FRCP(C) Division of Geriatric Medicine 4 th Annual Better Prescribing Course University.

TOP 5 IMPORTANT DRUGS IN THE OLDER PERSON

Anna Byszewski BSc MD MEd FRCP(C)

Division of Geriatric Medicine4th Annual Better Prescribing Course

University of Ottawa

Page 2: TOP 5 IMPORTANT DRUGS IN THE OLDER PERSON Anna Byszewski BSc MD MEd FRCP(C) Division of Geriatric Medicine 4 th Annual Better Prescribing Course University.
Page 3: TOP 5 IMPORTANT DRUGS IN THE OLDER PERSON Anna Byszewski BSc MD MEd FRCP(C) Division of Geriatric Medicine 4 th Annual Better Prescribing Course University.

Outline

Review of scope of problem of drug use in the older person

Factors contributing to ADR Important drugs in the older person Drugs to avoid in the older person Tips how to avoid pitfalls in prescribing

for the older person

Page 4: TOP 5 IMPORTANT DRUGS IN THE OLDER PERSON Anna Byszewski BSc MD MEd FRCP(C) Division of Geriatric Medicine 4 th Annual Better Prescribing Course University.

Disclosure

I have given presentations at CME events

or have received funds for unrestricted educational initiatives supported by the following:

Pfizer, Merck Frosst, Novartis, Janssen Ortho I do not hold any stocks…

Page 5: TOP 5 IMPORTANT DRUGS IN THE OLDER PERSON Anna Byszewski BSc MD MEd FRCP(C) Division of Geriatric Medicine 4 th Annual Better Prescribing Course University.

Clinical case An 80 year old woman is referred with falls and

cognitive decline. She was widowed 8 months ago and has a hx of HBP, insomnia and PMR.

Her medications: HCTZ 12.5 mg, prednisone 10 mg and ibuprofen 200 mg

Her P/E: BP 160/80, HR irreg irreg. 80, rest of exam is normal

Lab shows Normal lytes BUN/Cr, CBC,TSH, Vit. B12. CT head microvascular changes

Page 6: TOP 5 IMPORTANT DRUGS IN THE OLDER PERSON Anna Byszewski BSc MD MEd FRCP(C) Division of Geriatric Medicine 4 th Annual Better Prescribing Course University.
Page 7: TOP 5 IMPORTANT DRUGS IN THE OLDER PERSON Anna Byszewski BSc MD MEd FRCP(C) Division of Geriatric Medicine 4 th Annual Better Prescribing Course University.

Drugs and The Older PersonStatistics

30% of prescription drug use 40% of non prescription drug use Average use of 4.5 medications (community) Average use of 9.1 medications (hospitalized)

Page 8: TOP 5 IMPORTANT DRUGS IN THE OLDER PERSON Anna Byszewski BSc MD MEd FRCP(C) Division of Geriatric Medicine 4 th Annual Better Prescribing Course University.

Drugs and The Older PersonADR’s

Pharmacokinetics Pharmacodynamics Factors related to the patient:

Polysymptomatology breeds polypharmacy

Factors related to the caregiver: do something doctor!

Factors related to the physician: all those pharmacology lectures!!

Page 9: TOP 5 IMPORTANT DRUGS IN THE OLDER PERSON Anna Byszewski BSc MD MEd FRCP(C) Division of Geriatric Medicine 4 th Annual Better Prescribing Course University.

Consequences of ADR 30% of hospital admissions linked to ADR in

US ( Hanlon et al. JAGS 1997) After discharge from TOH, 23% had at least

one ADR ( Forster et al. CMAJ 2004) ADR in the older person linked to

depression, constipation, falls, immobility, confusion, and hip fractures… (Bootman et al. AIM 1997)

Page 10: TOP 5 IMPORTANT DRUGS IN THE OLDER PERSON Anna Byszewski BSc MD MEd FRCP(C) Division of Geriatric Medicine 4 th Annual Better Prescribing Course University.

Drugs and The Older PersonThe Top 5 Important Drugs

1. Antihypertensives(Diuretics, CCB, ACEI)2. Warfarin (a.fib)3. Osteoporosis treatment( Ca, Vit D,

Bisphosphonates,)4. Antidepressants5. “Sleep Hygiene Tips”/Exercise

Page 11: TOP 5 IMPORTANT DRUGS IN THE OLDER PERSON Anna Byszewski BSc MD MEd FRCP(C) Division of Geriatric Medicine 4 th Annual Better Prescribing Course University.
Page 12: TOP 5 IMPORTANT DRUGS IN THE OLDER PERSON Anna Byszewski BSc MD MEd FRCP(C) Division of Geriatric Medicine 4 th Annual Better Prescribing Course University.

1. Antihypertensives Goal of BP management to BP<140/90 Lower if end organ damage Diuretics, CCB and ACEI

(Chobanian et al. JNC 7 report JAMA 2003) Evidence for prevention of CVA, ? Dementia Even over age 80, 34% reduction in stroke,39%

reduction in CHF ( Guyeffier et al. Lancet 1999)

Page 13: TOP 5 IMPORTANT DRUGS IN THE OLDER PERSON Anna Byszewski BSc MD MEd FRCP(C) Division of Geriatric Medicine 4 th Annual Better Prescribing Course University.
Page 14: TOP 5 IMPORTANT DRUGS IN THE OLDER PERSON Anna Byszewski BSc MD MEd FRCP(C) Division of Geriatric Medicine 4 th Annual Better Prescribing Course University.

2. Warfarin

Atrial Fibrillation 5% over age 65, risk of CVA 5% per year ( higher if CHF/HBP/CVA/TIA and age>75)

Warfarin RR 65% vs. ASA 20% Risk of c/o low if monitored (Hing et al,

AIM 2003 )

Page 15: TOP 5 IMPORTANT DRUGS IN THE OLDER PERSON Anna Byszewski BSc MD MEd FRCP(C) Division of Geriatric Medicine 4 th Annual Better Prescribing Course University.
Page 16: TOP 5 IMPORTANT DRUGS IN THE OLDER PERSON Anna Byszewski BSc MD MEd FRCP(C) Division of Geriatric Medicine 4 th Annual Better Prescribing Course University.

3. Fracture prevention therapy

At age 50, need 1500 mg calcium and Vitamin D 800 IU daily – most need supplementation

Screen all at age 65 or risks (falls, steroids, etc)

(OSC CPC, CMAJ suppl. 2005)

Page 17: TOP 5 IMPORTANT DRUGS IN THE OLDER PERSON Anna Byszewski BSc MD MEd FRCP(C) Division of Geriatric Medicine 4 th Annual Better Prescribing Course University.
Page 18: TOP 5 IMPORTANT DRUGS IN THE OLDER PERSON Anna Byszewski BSc MD MEd FRCP(C) Division of Geriatric Medicine 4 th Annual Better Prescribing Course University.

4. Sleep hygiene

Nonpharmacologic therapies should be considered as first line therapy: ex. sleep hygiene

Short acting benzodiazepines, zopiclone, or trazodone can be considered as a short term therapy – ie.< 2 weeks

(Morin et al JAMA 1999)

Page 19: TOP 5 IMPORTANT DRUGS IN THE OLDER PERSON Anna Byszewski BSc MD MEd FRCP(C) Division of Geriatric Medicine 4 th Annual Better Prescribing Course University.
Page 20: TOP 5 IMPORTANT DRUGS IN THE OLDER PERSON Anna Byszewski BSc MD MEd FRCP(C) Division of Geriatric Medicine 4 th Annual Better Prescribing Course University.

5. Antidepressants Depression presents atypically in the older

person: more somatic symptoms, psychotic features, loss of memory or concentration problems rather than depressed mood

Remission rates up to 75% (CPA suppl. 1997)

Wide range of therapies– monitor for S/E: SIADH with SSRI, hypertension (venlafaxine), oversedation (mirtazepine)

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Drugs and The Older PersonThe Top 10 Drugs to Use Less

1. NSAID’s

2. Benzodiazepines

3. Neuroleptics

4. Beta Blockers

5. Cimetidine

6. Anticholinergic Drugs

7. Prozac

8. Narcotics (Talwin/Demerol)

9. Colace/Irritant laxatives

10.OTC/Herbals/ETOH

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Drugs and The Older Person10 Do’s and Don’ts of Safe Prescribing

1. Always consider drugs as potential cause for any new symptom in the elderly

2. Appropriate diagnosis vs symptomatic prescribing

3. Start all new drugs as N=1 trial4. Start low and go slow but push therapy until you

achieve therapeutic goals or side effects occur5. Start low and go slow and don’t be afraid to say

no

Page 23: TOP 5 IMPORTANT DRUGS IN THE OLDER PERSON Anna Byszewski BSc MD MEd FRCP(C) Division of Geriatric Medicine 4 th Annual Better Prescribing Course University.

Drugs and The Older Person10 Do’s and Don’t’s of Safe Prescribing

6. Know what your patient is taking: prescription, OTC, herbal

7. Know and use well a small list of drugs in the older person (“toolbox” of ~ 25 medications)

8. Tailor choice of drug to individual and comorbid disease

9. Regularly review drug regimens and try to reduce drugs

10.Keep it simple/compliance issues

Page 24: TOP 5 IMPORTANT DRUGS IN THE OLDER PERSON Anna Byszewski BSc MD MEd FRCP(C) Division of Geriatric Medicine 4 th Annual Better Prescribing Course University.
Page 25: TOP 5 IMPORTANT DRUGS IN THE OLDER PERSON Anna Byszewski BSc MD MEd FRCP(C) Division of Geriatric Medicine 4 th Annual Better Prescribing Course University.

Clinical case An 80 year old woman is referred with falls and

cognitive decline. She was widowed 8 months ago and has a hx of HBP, insomnia and PMR.

Her medications: HCTZ 12.5 mg, prednisone 10 mg and ibuprofen 200mg

Her P/E: BP 160/80, HR irreg irreg. 80, rest of exam is normal

Lab shows Normal lytes BUN/Cr, CBC,TSH, Vit. B12. CT head microvascular changes

Page 26: TOP 5 IMPORTANT DRUGS IN THE OLDER PERSON Anna Byszewski BSc MD MEd FRCP(C) Division of Geriatric Medicine 4 th Annual Better Prescribing Course University.

What can you do? Increase HCTZ or add CCB or ACEI Consider warfarin for a.fib Do DXA, add Ca/VitD and consider

antiresorptive tx Assess for depression Review sleep hygiene Try to d/c NSAID, try physio,

acetaminophen etc.

Page 27: TOP 5 IMPORTANT DRUGS IN THE OLDER PERSON Anna Byszewski BSc MD MEd FRCP(C) Division of Geriatric Medicine 4 th Annual Better Prescribing Course University.

Defining Success At age 80, success is….not

peeing in your pants.

At age 75, success is….having friends. 

At age 70, success is….having a drivers license.

At age 60, success is….having sex.

  At age 50, success

is….having money.

At age 4, success is. . . not peeing in your pants.

At age 12, success is. . . having friends.

At age 16, success is. . . having a drivers license.

At age 20, success is. . . having sex.

At age 35, success is. . . having money.

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THANK YOU!!!