TOP 5 IMPORTANT DRUGS IN THE OLDER PERSONAnna Byszewski BSc MD MEd FRCP(C)Division of Geriatric Medicine4th Annual Better Prescribing CourseUniversity of Ottawa

OutlineReview of scope of problem of drug use in the older personFactors contributing to ADRImportant drugs in the older personDrugs to avoid in the older personTips how to avoid pitfalls in prescribing for the older person

DisclosureI have given presentations at CME eventsor have received funds for unrestricted educational initiatives supported by the following:Pfizer, Merck Frosst, Novartis, Janssen OrthoI do not hold any stocks

Clinical caseAn 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 mgHer P/E: BP 160/80, HR irreg irreg. 80, rest of exam is normalLab shows Normal lytes BUN/Cr, CBC,TSH, Vit. B12. CT head microvascular changes

Drugs and The Older PersonStatistics30% of prescription drug use40% of non prescription drug useAverage use of 4.5 medications (community)Average use of 9.1 medications (hospitalized)

Drugs and The Older PersonADRsPharmacokineticsPharmacodynamicsFactors related to the patient: Polysymptomatology breeds polypharmacyFactors related to the caregiver: do something doctor!Factors related to the physician: all those pharmacology lectures!!

Consequences of ADR30% 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)

Drugs and The Older PersonThe Top 5 Important DrugsAntihypertensives(Diuretics, CCB, ACEI)Warfarin (a.fib)Osteoporosis treatment( Ca, Vit D, Bisphosphonates,)AntidepressantsSleep Hygiene Tips/Exercise

1. AntihypertensivesGoal of BP management to BP

2. WarfarinAtrial 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 )

3. Fracture prevention therapyAt age 50, need 1500 mg calcium and Vitamin D 800 IU daily most need supplementationScreen all at age 65 or risks (falls, steroids, etc)(OSC CPC, CMAJ suppl. 2005)

4. Sleep hygieneNonpharmacologic therapies should be considered as first line therapy: ex. sleep hygieneShort acting benzodiazepines, zopiclone, or trazodone can be considered as a short term therapy ie.< 2 weeks(Morin et al JAMA 1999)

5. AntidepressantsDepression presents atypically in the older person: more somatic symptoms, psychotic features, loss of memory or concentration problems rather than depressed moodRemission rates up to 75%(CPA suppl. 1997)Wide range of therapies monitor for S/E: SIADH with SSRI, hypertension (venlafaxine), oversedation (mirtazepine)

Drugs and The Older PersonThe Top 10 Drugs to Use LessNSAIDs

Benzodiazepines

Neuroleptics

Beta Blockers

CimetidineAnticholinergic Drugs

Prozac

Narcotics (Talwin/Demerol)Colace/Irritant laxatives

OTC/Herbals/ETOH

Drugs and The Older Person10 Dos and Donts of Safe PrescribingAlways consider drugs as potential cause for any new symptom in the elderlyAppropriate diagnosis vs symptomatic prescribingStart all new drugs as N=1 trialStart low and go slow but push therapy until you achieve therapeutic goals or side effects occurStart low and go slow and dont be afraid to say no

Drugs and The Older Person10 Dos and Donts of Safe PrescribingKnow what your patient is taking: prescription, OTC, herbalKnow and use well a small list of drugs in the older person (toolbox of ~ 25 medications)Tailor choice of drug to individual and comorbid diseaseRegularly review drug regimens and try to reduce drugs Keep it simple/compliance issues

Clinical caseAn 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 200mgHer P/E: BP 160/80, HR irreg irreg. 80, rest of exam is normalLab shows Normal lytes BUN/Cr, CBC,TSH, Vit. B12. CT head microvascular changes

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.

Defining SuccessAt 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.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.

THANK YOU!!!