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Elderly Medicine

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Important features in the history

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Important features in the Examination

Red Flags

Medicines in the Elderly

  • MEDICINES & FALLS
      • People aged 65 and older have the highest risk of falling, with 30% of people older than 65 and 50% of people older than 80 falling at least once a year.  So, it’s important to reduce polypharmacy and avoid unnecessary medicines.
      • The two groups of drugs that have the highest propensity to cause falls are those acting on the brain and those acting on the heart and circulation.
      • There is good evidence that stopping psychotropic drugs (including opioid analgesics) can reduce falls.
      • Taking a psychotropic medication approximately doubles the risk of falls:
      • More from these wonderful websites: STOPPFall and Care Homes Guidance: PRESCQIPP
  • HOW TO DECIDE TO PRESCRIBE
      • Remember the NNTs behind the evidence base – often these are extrapolated to older age groups without any specific evidence of benefit.
      • NNTs tell us that most medicines do not produce optimal effects in most people, but all may experience adverse effects.
      • Recommend focus on person-centred outcomes to assess benefit. The benefit/risk ratio will change as we age.
  • DON’T JUST LEAVE PATIENTS ON REPEATS FOR EVER
      • Review repeat medications – have a system for repeat medications in place.
      • A drug may be necessary but also can be a potential risk.  For example, remember that with age there is often declining renal function and changing pharmacokinetics and pharmacodynamics in older people.
      • Clarity about the indication and the intended outcome for each medicine is needed, especially now we have a wider range of prescribing colleagues.
      • If a patient is non concordant with their prescribed medication, maybe they are giving you a valuable hint. Iatrogenic illness causes significant morbidity and mortality. One question required, is this treatment essential?  If no… stop it’. Evidence tells us that 30 – 50% of people do not take medicines as prescribed.
      • Nitrofurantoin: long-term (greater than six months) use of nitrofurantoin is associated with pulmonary toxicity. CARM have received over 60 reports of serious pulmonary reactions following the use of nitrofurantoin.
  • MEDICATION REVIEWS
      • It is always worth being alert to the triggers that signal the need for consideration of a timely medication review and potential deprescribing; these include:
          1. request for a dosette box
          2. a fall
          3. increasing confusion/drowsiness
          4. constipation
          5. admission to a care home due to increasing frailty etc

De-Prescribing

 Fall-risk assessment:
In which cases to consider withdrawal?a
Is stepwise withdrawal needed?bMonitoring after deprescribingc
Always -If no indication for prescribing-If safer alternative available  -Fall incidence and change in symptoms e.g. OH, blurred vision, dizziness-Organise follow-ups on individual basis 
Benzodiazepines (BZD) and BZD-related drugs -If daytime sedation, cognitive impairment, or psychomotor impairments
-In case of both indications: sleep and anxiety disorder 
In general needed -Monitor: anxiety, insomnia, agitation
-Consider monitoring: delirium, seizures, confusion 
Antipsychotics -If extrapyramidal or cardiac side effects, sedation, signs of sedation, dizziness, or blurred vision
-If given for BPSD or sleep disorder, possibly if given for bipolar disorder 
In general needed -Monitor: recurrence of symptoms (psychosis, aggression, agitation, delusion, hallucination)
-Consider monitoring: insomnia 
Opioids -If slow reactions, impaired balance, or sedative symptoms
-If given for chronic pain, and possibly if given for acute pain 
In general needed -Monitor: recurrence of pain
-Consider monitoring: musculoskeletal symptoms, restlessness, gastrointestinal symptoms, anxiety, insomnia, diaphoresis, anger, chills 
Antidepressants -If hyponatremia, OH, dizziness, sedative symptoms, or tachycardia/arrhythmia
-If given for depression but depended on symptom-free time and history of symptoms or given for sleep disorder, and possibly if given for neuropathic pain or anxiety disorder 
In general needed -Monitor: recurrence of depression, anxiety, irritability and insomnia
-Consider monitoring: headache, malaise, gastrointestinal symptoms 
Antiepileptics -If ataxia, somnolence, impaired balance, or possibly in case of dizziness
-If given for anxiety disorder or neuropathic pain 
Consider -Monitor: recurrence of seizures
-Consider monitoring: anxiety, restlessness, insomnia, headache 
Diuretics -If OH, hypotension, or electrolyte disturbance and possibly if urinary incontinence
-possibly if given for hypertension 
Consider -Monitor: heart failure, hypertension, signs of fluid retention 
Alpha-blockers (AB) used as antihypertensives -If hypotension, OH, or dizziness Consider -Monitor: hypertension
-Consider monitoring: palpitations, headache 
AB for prostate hyperplasia -If hypotension, OH, or dizziness In general not needed -Monitor: return of symptoms 
Centrally-acting antihypertensives -If hypotension, OH, or sedative symptoms Consider -Monitor: hypertension 
Sedative antihistamines -If confusion, drowsiness, dizziness, or blurred vision
-In case of all indications: hypnotic/sedative, chronic itch, allergic symptoms 
Consider -Monitor: return of symptoms
-Consider monitoring: insomnia, anxiety 
Vasodilators used in cardiac diseases -If hypotension, OH, or dizziness Consider -Monitor: symptoms of Angina Pectoris 
Overactive bladder and incontinence medications -If dizziness, confusion, blurred vision, drowsiness, or increased QT-interval Consider -Monitor: return of symptoms 

aThis column includes answer categories that were chosen by more than 70% of the experts. In addition, after word ‘possibly’ are indicated the categories that were selected by 30–70% of the experts.

b‘In general needed’ indicates that >70% of experts chose categories of yes or depending. ‘Consider’ indicates that 30–70% of experts chose categories of yes or depending. ‘In general not needed’ indicates that <30% of experts chose categories of yes or depending.

c‘Monitor’ refers to >70% of the experts selecting these symptoms. ‘Consider monitoring’ refers to 30–70% of the experts selecting these symptoms. BPSD, behavioural and psychological symptoms of dementia; OH, orthostatic hypotension.

STOPPFrail  Version 2

STOPPFrrail is a list of potentially inappropriate prescribing indicators designed to assist physicians with deprescribing decisions. It is intended for older people with limited life expectancy for whom the goal of care is to optimise quality of life and minimise the risk of drug-related morbidity. Goals of care should be clearly defined, and, where possible, medication changes should be discussed and agreed with patient and/or family.
Appropriate candidates for STOPPFrail-guided deprescribing typically meet ALL of the following criteria:
1. Activities of daily living dependency (i.e. assistance with dressing, washing, transferring, walking) and/or severe chronic disease and/or terminal illness. 2. Severe irreversible frailty, i.e. high risk of acute medical complications and clinical deterioration. 3. Physician overseeing care of patient would not be surprised if the patient died in the next 12 months. 

Section A: General 

• Any drug that the patient persistently fails to take or tolerate despite adequate education and consideration of all appropriate formulations.
• Any drug without a clear clinical indication.
• Any drug for symptoms which have now resolved (e.g. pain, nausea, vertigo, pruritus) 

Section B: Cardiology system  • Lipid-lowering therapies (statins, ezetimibe, bile acid sequestrants, fibrates, nicotinic acid, lomitapide and acipimox).
• Antihypertensive therapies: Carefully reduce or discontinue these drugs in patients with systolic blood pressure (SBP) persistently <130 mmHg. An appropriate SBP target in frail older people is 130–160 mmHg. Before stopping, consider whether the drug is treating additional conditions (e.g. beta-blocker for rate control in atrial fibrillation, diuretics for symptomatic heart failure).
• Anti-anginal therapy (specifically nitrates, nicorandil, ranolazine): None of these anti-anginal drugs have been proven to reduce cardiovascular mortality or the rate of myocardial infarction. Aim to carefully reduce and discontinue these drugs in patients who have had no reported anginal symptoms in the previous 12 months AND who have no proven or objective evidence of coronary artery disease. 
Section C: Coagulation system  • Anti-platelets: No evidence of benefit for primary (as distinct from secondary) cardiovascular prevention.
• Aspirin for stroke prevention in atrial fibrillation: Aspirin has little or no role for stroke prevention in frail older people who are not candidates for anticoagulation therapy and may significantly increase bleeding risk. 
Section D: Central nervous system  • Neuroleptic antipsychotics in patients with dementia: Aim to reduce dose and discontinue these drugs in patients taking them for longer than 12 weeks if there are no current clinical features of behavioural and psychiatric symptoms of dementia (BPSD).
• Memantine: Discontinue and monitor in patients with moderate to severe dementia, unless memantine has clearly improved BPSD. 
Section E: Gastrointestinal system  • Proton pump Inhibitors: Reduce dose of proton pump inhibitors when used at full therapeutic dose ≥8 weeks, unless persistent dyspeptic symptoms at lower maintenance dose.
• H2 receptor antagonist: Reduce dose of H2 receptor antagonists when used at full therapeutic dose for ≥8 weeks, unless persistent dyspeptic symptoms at lower maintenance dose. 
Section F: Respiratory system  • Theophylline and aminophylline: These drugs have a narrow therapeutic index, have doubtful therapeutic benefit and require monitoring of serum levels and interact with other commonly prescribed drugs putting patients at an increased risk of ADEs.
• Leukotriene antagonists (montelukast, zafirlukast): These drugs have no proven role in chronic obstructive pulmonary disease; they are indicated only in asthma. 
Section G: Musculoskeletal system  • Calcium supplements: Unlikely to be of any benefit in short-term unless proven, symptomatic hypocalcaemia.
• Vitamin D (ergocalciferol and colecalciferol): Lack of clear evidence to support the use of vitamin D to prevent falls and fractures, cardiovascular events or cancers.
• Anti-resorptive/bone anabolic drugs for osteoporosis (bisphosphonates, strontium, teriparatide, denosumab)
• Long-term oral nonsteroidal anti-inflammatory drugs: Increased risk of side effects (e.g. peptic ulcer disease, bleeding, worsening heart failure) when taken regularly for ≥2 months.
• Long-term oral corticosteroids: Increased risk of major side effects (e.g. fragility fractures, proximal myopathy, peptic ulcer disease) when taken regularly for ≥2 months. Consider careful dose reduction and discontinuation. 
Section H: Urogenital system  • Drugs for benign prostatic hyperplasia (5-alpha reductase inhibitors and alpha-blockers) in catheterised male patients: No benefit with long-term bladder catheterisation.
• Drugs for overactive bladder (muscarinic antagonists and mirabegron): No benefit in patients with persistent, irreversible urinary incontinence unless clear history of painful detrusor hyperactivity. 
Section I: Endocrine system  • Anti-diabetic drugs: De-intensify therapy. Avoid HbA1c targets (HbA1C <7.5% [58 mmol/mol] associated with net harm in this population). The goal of care is to minimise symptoms related to hyperglycaemia (e.g. excessive thirst, polyuria). 
Section J: Miscellaneous  • Multivitamin combination supplements: Discontinue when prescribed for prophylaxis rather than treatment of hypovitaminosis.
• Folic acid: Discontinue when treatment course is completed. The usual treatment duration is 1–4 months unless malabsorption, malnutrition or concomitant methotrexate use.
• Nutritional supplements: Discontinue when prescribed for prophylaxis rather than treatment of malnutrition. 
Disclaimer (STOPPFrail): While every effort has been made to ensure that the potentially inappropriate deprescribing criteria listed in STOPPFrail are accurate and evidence-based, it is emphasised that the final decision to deprescribe any drug referred to in these criteria rests entirely with the prescriber. It is also to be noted that the evidence base underlying certain criteria in STOPPFrail may change after the time of publication of these criteria. Therefore, it is advisable that deprescribing decisions should take account of current published evidence in support of or against the use of drugs or drug classes described in STOPPFrail. 

Good Resources

  • KIK Medication Withdrawal Decision Tree
  • STOPFALL – prescribing & de-prescribing in the elderly to prevent falls
  • STOPPFrail version 2 – see above
  • MEDICHEC tool – Medichec helps to identify medications that might have a negative effect on cognitive function and/or other adverse effects in older people. Medichec analyses medication that may have anticholinergic effects, defines the extent of the effect and the cumulative implications of multiple drugs. Medications with a high anticholinergic burden can increase the risk of cognitive impairment in older people and research evidence indicates associations with an increased risk of developing dementia and early death.  Medichec also identifies medications that are reported to cause dizziness and drowsiness and ranks them according to the frequency of reported adverse effects. Dizziness and drowsiness can add to cognitive impairment and confusion in older people and can increase the risk of falls.
  • NHS Scotland: 7 Steps Approach to Medication Review & Polypharmacy
  • Canadian deprescribing resources

When de-prescribing, is a stepwise withdrawal is needed in general for the following medications?

Other Top Tips

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