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Appropriate Prescribing and the Elderly - Coggle Diagram
Appropriate Prescribing and the Elderly
Appropriate Prescribing
G
rand
P
arents'
N
ew
B
eds
D
emand
F
requent
F
luffling
I
nspections to
U
nfailingly
D
etermine the
M
ost
C
omfort
G - Guidlines
P - Problem
Evaluate the pts problem
N - Need
IS a drug needed - indication
B - Best choice
What is the best choice - Consider contraindications, allergiers, previous adverse reactions
D - Dose
Correct dose
F - Frequency
Correct frequency of drug
F - Form
Correct form (oral, subcut, iv)
I - Interactions
Consider drug-drug interactions and drug-disease interactions
U - Understanding
Does the pt understand how to take the drug
D - Duration
Is the duration of the drug acceptable / feasible
M - Monitoring
Will the drug require monitoring
C - Cost
Is it cost effective
Inappropriate Prescribing
The practice of administering a drug in a manner that poses ore risk than clincial benefit
/
Under-use of clinically indicated beneficial medicines
No indication
Wrong indication
Incorrect dose, frequncy or form
High risk of clinically significant drug-drug interactions
High risk of clinically significant drug-disease interactions
Incorrect duration
Adverse Drug Reactions (ADRs)
Definition
A response to a drug that is noxious and unintended and occurs at doses normally used in man for the prophylaxis, diagnosis or therapy of disease, or for modification of physiological function
Not overdose
Most Common in Eldery
Falls
Delirium
New onset orthostatic hypotension
Major serum electrolyte disturbance
Symptomatic bradycardia
New onset major constipation
Acute bleeding
Acute kidney injury
Acute dyspepsia or nausea or vomiting
Acute diarrhoea
Symptomatic hypoglycaemia
Interactions
Cytochrome P450 enzyme systems
Enzyme inducers
CRAP GPS induce me to madness!
P - Phenytoin
C - Carbamazepine
R - Rifampicin
A - Alcohol
G - Griseofulvin
Phenobarbitone
S - Sulphonylureas / St. John's Wart
Enzyme Inhibitors
SICKFACES.COM
Sodium valproate
Isoniazid
Cimetidine
Ketoconazole
Fluconazole
Alcohol & Grapefruit juice
Chloramphenicol
Erythromycin
Sulfonamides
Ciprofloxacin
Omeprazole
Metronidazole
Drug - Drug
Anti-hypotensive agents + NSAID
↓ Antihypertensive effects
Aspirin + NSAIDs, Steroid, SSRIs
Peptic Ulcer
Ca+ channel blocker + Inducers
↓Antihypertensive effect
Digoxin + Diuretic
↑ Conc. of Digoxin - Arrhythmia, toxicity
Digoxin + Amiodarone, Diltiazem, Verapamil
↑ Digoxin - arrhythmia, toxicity
Thyroxine + Enzyme Inducers
↓Effect of Thyroxine
Drug - Disease
Chronic Cardiac Failure + Steroid / NSAID
Exacerbation of HF
Peptid ulcer disease / GORD + Biphosphonate, Antiplatelet, NSAID, Anticoagulant
↑ Risk of Oesophagitis +/- GI haemorrhage
Parkinson's disease + Metoclopramide
Worsening Parkinson's symptoms
Falls + Benzodiazepines, Opiates, Antipsychotics
↑ Risk of falls
Demetia + Opiates
↑ Confusion
Orthstatic hypotension + Antihypertension, Anaticholinergics
Dizziness, falls, fracture
Considerations in Elderly
Physiological Changes
Issue
Age related changes to drug
Absorption
Distribution
Metabolism
Excretion
Approach
Start with low doses and titrate slowly
Monitor for efficacy and side effects
Normal Changes
CVS
Arterial stiffening
Pulmonary
Reduced elasticity and chest wall compliance
GI
Decreased absorption and motility
Renal
Decreased mass
Fibrosis
Neurological
Sigh, hearing, cognition decrease
Polypharmacy
Issues
Increased comorbidities leads to increased drug use
Prescribing cascade
Drugs prescribed to treat an adverse effect caused by a previous drug
Drug-drug interactions
Decreased adherence with increased polypharmacy
Regularly taking 5 or more medications
Appraoch
Review medications - include herbal, over-the counter and foods
Minimise unnecessary drugs
Simplify regimens
Comorbidities
Issue
Can complicate medicatio choices
Approach
Choose treatments that can cmanage multiple conditions
Be mindful of how medications may exacerbate conditions / other medications
Sensory / Cognitive Impairements
Issue
Impairs ability to follow medication instruction
Impairs ability to take medication correctly or consistently
Approach
Clear simple instruction
Consider pill organisers
Involve caregivers
Adherence
Issues
Polypharmacy causes decreased adherence
Financial restraints
Side effects
Approach
Simplify regimens where possible
Discuss and manage side effects
Consider financial situation
Prescribing Resources
Handbooks / Databases
Medicines Complete
IMF
Stockleys
BNF
Renal drug handbook
Guidlines
National and hospital guidlines
MDT
Senior doctors
Geriatricians
Clinical pharmacologists
Ward pharmacists