Simple guide on essential precaution on prescribing medicine for elder population.

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Prescribing Medicine for the Elderly

2. PRESCRIBING FOR THE ELDERLY
By
Abdalla Ibrahim
Family Doctor, PHC, MOH, Bahrain
Accreditation Specialist, Healthcare Surveyor
Email: abdallaibrahim@hotmail.com
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2014

3. Mapping of the presentation
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General principles of geriatric medicine
Especial consideration on elder-drug prescription
Guidelines

4. introduction
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In elder people, an abrupt decline in any system is due to disease and not to normal aging, that is to say, “Old people are sick because they are sick, not because they are old”.

5. Definition
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Human aging:
A progressive constriction of each organ system’s homeostatic reserve. This decline is often referred to as homeo-stenosis. It begins in the third decade and is linear and variable among individuals (Resnick NM, 1998).

6. General principles of geriatric medicine
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1.Disease presentation is often atypical and symptoms depend on which organ system is the “weakest link” often the brain, LUT, CVS and musculo-skeletal system.
2.Because of impairment of compensatory mechanisms, diseases in elders presents at earlier stage

7. General principles (cont.)
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3.Multiple abnormalities occur concurrently.
4.Many findings that are abnormal in younger patients are common in elder and may not be responsible for particular symptoms.

8. General principles (cont.)
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5.Symptoms in elder are due to multiple causes. Think of more than one diagnosis. When diagnosis is correct, treatment of a single disease is unlikely to result in cure.
6.Elder respond equally or even more effectively to treatment than younger patients (Resnick NM, 1998).

9. Special Consideration
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Patient compliance
Polypharmacy
Susceptibility

10. Patient compliance
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Up to 50% of patients fail to achieve full compliance and 33% never take their medicines.
Compliance for short term and self –administered therapies are higher (about 75%) than long – term therapies (<25% for completion of antibiotic therapy for acute infection).

11. Patient compliance (cont.)
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Compliance rates are inversely correlated with the number of interventions prescribed, complexity and cost. Thus regimen should be as simple as possible.
Patients recall instruction to medicines than to comply with recommendation to follow diet, exercise and self-care activities.

12. Polypharmacy
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How elder people make their own polypharmacy?
Elder people receive multiple drugs for multiple diseases
Self-medication from OTC based on previous experience or prescription

13. Polypharmacy (cont.)
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Symptoms associated with social stress (e.g. headache and sleeplessness) can lead to further prescription
Manifestation of aging may be misleading for drug prescription

14. Susceptibility
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Increased permeability of the BBB
Aging of the renal system:
Limited function of the renal system
Slow excretion of drugs
Increased susceptibility to nephrotoxic drug

15. Guidelines
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Indication:
First question yourself whether the drug is indicated at all
Limit your range:
Prescribe from limited range of drugs and be thoroughly familiar with their effect in the elderly

16. Guidelines (cont.)
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Reduce Dose
Dose should be lower than in younger patient and it is common to start with 50% of adult dose
Review regularly:
You may need to reduce the dose, repeat the dose or even stop the drug completely

17. Guidelines (cont.)
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Explain clearly
Write full instruction on each prescription
Repeats and disposal
Try to prescribe matching quantities. Instruct patients what to do when drugs run out
Third party
Enrol the help of third party when necessary

18. Guidelines (cont.)
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Regimen and form of prescription
Regimen should be as simple as possible (once or twice a day)
Self-administered drug is preferable (avoid injection)
Liquid forms are preferred to tablets or capsule ones which need ample amount of fluid

19. Recommendation
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NSAID
For osteoarthritis, soft-tissue lesion, back pain try the following
Weight reduction, warmth, exercise and walking stick
Paracetamol with low dose opioid analgesic
Paracetamol with small dose NSAID
Monitor for GI bleeding

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Diuretics
Should not be used on long-term basis. For gravitational oedema encourage increase movement, raising the leg and support stockings
Hypnotics
Avoid hypnotics with long half-lives which have serious hangover effects of drowsiness, unsteady gait, slurred speech and confusion. Short course hypnotics are occasionally useful to help patient go through acute illness or some other crisis.

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