The benefit of medicines that improve quality of life is clearly evident. However, preventative interventions require to some degree the clinician convincing the patient, and themselves, that treatment will provide benefit. For example, the Prospective Study of Pravastatin in the Elderly at Risk of vascular disease PROSPER trial showed that while pravastatin given to over participants aged 70 - 82 years did reduce cardiovascular morbidity and mortality, it was not associated with a reduction in all-cause mortality. Some older patients, who had elected to take a statin to reduce cardiovascular risk for primary prevention, may not have made the same decision if they had been told that treatment was unlikely to prolong their life.
However, aggressive statin treatment may be appropriate for a patient who has previously had a stroke and wishes to reduce the risk of a second, potentially more disabling event from occurring. Factors which should be considered when prescribing medicines to older people include: Life expectancy by age for older New Zealand male and female populations, - Prescribing tools provide specific examples of medicines that may be inappropriate for older people and are an effective way of reducing adverse drugs reactions. The criteria consist of two components; the first to halt inappropriate or unnecessary medicines in older patients, the second is used to consider medicine appropriateness when initiating treatment.
The Beers criteria consists of three lists of medicines ranked according to their potential for causing adverse reactions in older people. The first grouping is medicines that are known to cause adverse reactions in older people. The second classification is medicines that may be inappropriate for older people with specific diseases or risks factors. The third list is medicines that should be prescribed to older people with caution. For further information see the American Geriatrics Society. Under-prescribing is the omission of medicines which are generally recommended by clinical guidelines for the treatment or prevention of a disease or condition.
Commonly under-prescribed treatments for older people include medicines for the secondary prevention of coronary and cerebrovascular diseases and osteoporotic fractures. Although inappropriate under-prescribing should be avoided, it is complicated by the fact that clinical guidelines are generally for single conditions and do not take into account co-morbidities. The use of several different guidelines for one patient with multiple conditions may lead to inappropriate prescribing, if all advice is followed concurrently.
BPJ Managing medicines in older people
If prescribers are unsure whether a medicine is appropriate for an older patient then discussion with a geriatrician, general physician or clinical pharmacist is recommended. Consider if there are any medicines that can be altered or stopped if a new medicine is started, e. If repeating a prescription, confirm that the original is still applicable, e.
Double check the prescription is correct both before printing it out and handing it to the patient. Ensure the patient knows what medicine they have been prescribed and how it should be taken. Where appropriate, encourage people to take educational material home about both the medicine prescribed and the condition being treated. When finishing a consultation a good approach to see if the patient has understood a message is to ask them what they will say to their partner or family when they return home.
Alternative & Non-Prescription Medicines: A Practical Guide
The Ministry of Health website provides information and links to patient resources for diseases that are common in older people, e. It has been suggested that suboptimal monitoring of older people taking medicines may be a more significant problem than inappropriate prescribing. A study investigating inappropriate medicine use in 70 community dwelling older people recommended discontinuation of medications in 64 people.
Medicine groupings that may be appropriate for withdrawal in older people include; anticholinergics, antihistamines, antiplatelet medicines, centrally acting medicines e. If a medicine is withdrawn due to a suspected adverse drug reaction, symptom resolution can be expected once the medicine has been cleared from the patient's blood within three to five half-lives - if the reaction is dose dependent. A medication review guide for frail, older patients, the Pill Pruner, has been developed in New Zealand.
These are printed on a pocket-sized card. The Pill Pruner was tested at Christchurch Hospital on two groups of people aged over 75 years, consecutively admitted to hospital. Before the Pill Pruner was introduced, the mean number of medicines on discharge increased from 6. When the Pill Pruner was introduced, no statistically significant increase in discharge medicines occurred medicines increased from 6.
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Over the course of the study over medicines were stopped including: There appeared to be no harmful effects of medicine withdrawal. Medicine changes were communicated to the patient's General Practitioner and community pharmacist. The Pill Pruner has yet to be trialled in primary care. As hospital admission is frequently a period of acute illness and increased need, use of the Pill Pruner in general practice may be even more effective. Publication of the results of the Pill Pruner study is underway.
Before "de-prescribing" an unnecessary medicine, a discussion should be held with the patient as to why the change has been suggested and what can be expected. This is important, as many medicines have a placebo component to their effectiveness. Explain that the process will be monitored. If there is more than one medicine to be de-prescribed, these should be prioritised and withdrawn one at a time. The dose should be slowly reduced over a period of weeks to months and the patient warned and monitored for signs of: Clinicians should consider if any new symptoms are due to withdrawal or a re-emergence of the indicated condition.
If the patient experiences significant withdrawal, the medicine can be reintroduced, possibly at a reduced dose. Assessments should also focus on the beneficial aspects of de-prescribing, which can reinforce patient adherence and the prescriber's confidence to reduce medicines. Updated information on prescribing for elderly patients available from: Stopping medicines in older people: Follow us on facebook.
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Login to my bpac. Managing medicines in older people It is increasingly recognised that health care for older people is improved when one prescriber takes responsibility for all of a patient's medicines. In this article Prescriber responsibility and polypharmacy Standardising consultations with routine questions Actions and questions for prescribers When medicines are prescribed References In this article.
Prescriber responsibility and polypharmacy It is increasingly recognised that health care for older people is improved when one prescriber takes responsibility for all of a patient's medicines. A single prescriber provides consistency Oversight of medicines by a single prescriber allows for consistent advice and decision making. Adopting a standardised approach to prescribing for older people Three essential elements of prescribing to older people in primary care are: The introduction of a standardised format when assessing medicine use Avoiding inappropriate prescribing The use of validated tools to withdraw unnecessary medicines.
Standardising consultations with routine questions What medicines are you currently taking? Have you visited another doctor or been admitted to hospital? Do you have any concerns about any medicines you are taking? Actions and questions for prescribers Medicines information gathered from consultations can be combined with information taken from patient records including hospital discharge notes and dispensing record to reconcile the list of medicines a patient is taking.
Performing medicine reconciliations and medicine reviews Medicine reconciliation is the systematic process of obtaining a complete list of all of a patient's medicines. Before prescribing a medicine, consider the following: Assessing prescription appropriateness Factors which should be considered when prescribing medicines to older people include: Male Female Age years Expected number of years of life remaining Age years Expected number of years of life remaining 65 Consider using prescribing tools Prescribing tools provide specific examples of medicines that may be inappropriate for older people and are an effective way of reducing adverse drugs reactions.
The danger of under-prescribing Under-prescribing is the omission of medicines which are generally recommended by clinical guidelines for the treatment or prevention of a disease or condition. When medicines are prescribed Consider if there are any medicines that can be altered or stopped if a new medicine is started, e. Regular monitoring for adverse effects and treatment adherence It has been suggested that suboptimal monitoring of older people taking medicines may be a more significant problem than inappropriate prescribing.
When to decide to withdraw a medicine Medicine withdrawal should be considered for older people when: How to "de-prescribe" and issues to be aware of Before "de-prescribing" an unnecessary medicine, a discussion should be held with the patient as to why the change has been suggested and what can be expected. Prescribing for older people. Drug-drug and drug-disease interactions in the ED: Am J Emerg Med ;14 5: Is the number of prescribing physicians an independent risk factor for adverse drug events in an elderly outpatient population?
Am J Geriatr Pharmacother ;5 1: Polypharmacy in people aged over 75 years.
Health outcomes and polypharmacy in elderly individuals: J Gerontol Nurs ;31 9: Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: An easy intervention to improve short-term adherence to medications in community-dwelling older outpatients. A pilot non-randomised controlled trial. Problems with medication use in the elderly: J Pharm Pract ;36 1: Complimentary and alternative medicine use among patients starting warfarin. Br J Haematol ; 5: Complementary medicines use by Australian veterans. J Pharm Pract Res ;35 2: Polypharmacy - we make it worse!
A cross-sectional study from an acute admissions unit. Intern Med J ;42 2: Selection of tools for reconciliation, compliance and appropriateness of treatment in patients with multiple chronic conditions. Eur J Intern Med ;23 6: Healing Secrets of the Native Americans. The Touch of Healing.
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