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Drug prescribing for older adults. Literature review current through. This topic last updated. May 2. 6, 2. 01. 7. INTRODUCTION — Optimizing drug therapy is an essential part of caring for an older person. The process of prescribing a medication is complex and includes: deciding that a drug is indicated, choosing the best drug, determining a dose and schedule appropriate for the patient's physiologic status, monitoring for effectiveness and toxicity, educating the patient about expected side effects, and indications for seeking consultation. Avoidable adverse drug events (ADEs) are the serious consequences of inappropriate drug prescribing.
The possibility of an ADE should always be borne in mind when evaluating an older adult individual; any new symptom should be considered drug- related until proven otherwise. Prescribing for older patients presents unique challenges. Premarketing drug trials often exclude geriatric patients and approved doses may not be appropriate for older adults [1]. Many medications need to be used with special caution because of age- related changes in pharmacokinetics (ie, absorption, distribution, metabolism, and excretion) and pharmacodynamics (the physiologic effects of the drug). Particular care must be taken in determining drug doses when prescribing for older adults. An increased volume of distribution may result from the proportional increase in body fat relative to skeletal muscle with aging.
Decreased drug clearance may result from the natural decline in renal function with age, even in the absence of renal disease [2]. Larger drug storage reservoirs and decreased clearance prolong drug half- lives and lead to increased plasma drug concentrations in older people. As examples, the volume of distribution for diazepam is increased, and the clearance rate for lithium is reduced, in older adults. The same dose of either medication would lead to higher plasma concentrations in an older, compared with younger, patient. Also, from the pharmacodynamic perspective, increasing age may result in an increased sensitivity to the effects of certain drugs, including benzodiazepines [3- 6] and opioids [7].
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Hepatic function also declines with advancing age, and age- related changes in hepatic function may account for significant variability in drug metabolism among older adults [8]. Especially when polypharmacy is a factor, decreasing hepatic function may lead to adverse drug reactions (ADRs). A stepwise approach to optimized prescribing of drug therapy for older adults will be reviewed here.
Drug treatments for specific conditions in the older population are discussed separately. MEDICATION USE BY OLDER ADULTS — Medications (prescription, over- the- counter, and herbal preparations) are widely used by older adults.
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Prescription medications — A survey in the United States of a representative sampling of 2. At least one prescription medication was used by 8. Five or more prescription medications were used by 3. In a sample of Medicare beneficiaries discharged from an acute hospitalization to a skilled nursing facility, patients were prescribed an average of 1. Herbal and dietary supplements — Use of herbal or dietary supplements (eg, ginseng, ginkgo biloba extract, and glucosamine) by older adults has been increasing, from 1. One study in over 3.
POWER-PAK C.E. - Continuing Education for Pharmacists and Pharmacy Technicians. NIH Funding Opportunities and Notices in the NIH Guide for Grants and Contracts: Translational Research to Help Older Adults Maintain their Health and Independence in. · Dietary supplement (DS) use among older adults in the USA is prevalent, and thus, healthcare professionals need to be aware of how to best advise this. · Optimizing drug therapy is an essential part of caring for an older person. The process of prescribing a medication is complex and includes: deciding that.
United States found that almost three- quarters used at least one prescription drug and one dietary supplement [1. Often, clinicians do not question patients about use of herbal medicines and patients do not routinely volunteer this information. In one United States survey, three- quarters of respondents aged 1.
Herbal medicines may interact with prescribed drug therapies and lead to adverse events, underscoring the importance of routinely questioning patients about the use of unconventional therapies. Examples of herbal- drug therapy interactions include ginkgo biloba extract taken with warfarin, causing an increased risk of bleeding, and St. John's wort taken with serotonin- reuptake inhibitors, increasing the risk of serotonin syndrome in older adults [1.
A study of the use of 2. See "Overview of herbal medicine and dietary supplements", section on 'Herb- drug interactions'.)Many older adults receive their information about herbal products from the internet.
Eighty percent of 3. St. John's wort, echinacea, ginseng, garlic, saw palmetto, kava, and valerian root) made at least one health claim suggesting that the therapy could treat, prevent, or even cure specific conditions [1.
QUALITY MEASURES OF DRUG PRESCRIBING — Multiple factors contribute to the appropriateness and overall quality of drug prescribing. These include avoidance of inappropriate medications, appropriate use of indicated medications, monitoring for side effects and drug levels, avoidance of drug- drug interactions, and involvement of the patient and integration of patient values [1. Measures of the quality of prescribing often focus on one or some of these factors, but rarely on all. Furthermore, the predictive value of these measures of "quality of prescribing" in determining important long- term outcomes of care have not been determined. Approaches to decrease inappropriate prescribing in older adults include educational interventions, computerized order entry and decision support, multidisciplinary team care led by physicians, clinical pharmacists, and combinations of these approaches. Available data for these interventions generally show significant improvements in inappropriate prescribing but mixed results for health outcomes or costs [1. A 2. 01. 6 systematic review of eight studies of different prescribing interventions in long- term care homes (medication review, case conferences, staff education, clinical decision support technology, and/or some combination of these) showed no effect of the interventions on hospital admissions, adverse drug events (ADEs), and mortality [1.
The studies that evaluated medication- related problems, appropriate prescribing, or cost of medication showed some evidence that interventions helped the recognition and solving of medication problems. A previous 2. 00. ADEs, with five studies that showed a statistically significant reduction in ADEs, four that showed nonsignificant decrease, and one study that showed no impact on rate of ADEs [1. POLYPHARMACY — Polypharmacy is defined simply as the use of multiple medications by a patient. The precise minimum number of medications used to define "polypharmacy" is variable, but generally ranges from 5 to 1. While polypharmacy most commonly refers to prescribed medications, it is important to also consider the number of over- the- counter and herbal/supplements used. The issue of polypharmacy is of particular concern in older people who, compared with younger individuals, tend to have more disease conditions for which therapies are prescribed.
It has been estimated that 2. Medicare beneficiaries have five or more chronic conditions and 5. Among ambulatory older adults with cancer, 8. The use of greater numbers of drug therapies has been independently associated with an increased risk for an adverse drug event (ADE), irrespective of age [2. However, it is difficult to eliminate the impact of confounding factors in considering the relationship between polypharmacy and a variety of outcomes in observational studies [2. There are multiple reasons why older adults are especially impacted by polypharmacy: ●Older individuals are at greater risk for ADEs due to metabolic changes and decreased drug clearance associated with aging; this risk is compounded by increasing numbers of drugs used.●Polypharmacy increases the potential for drug- drug interactions and for prescription of potentially inappropriate medications [2. Polypharmacy was an independent risk factor for hip fractures in older adults in one case- control study, although the number of drugs may have been an indicator of higher likelihood of exposure to specific types of drugs associated with falls (eg, central nervous system [CNS]- active drugs) [2.
Polypharmacy increases the possibility of "prescribing cascades" [2. A prescribing cascade develops when an ADE is misinterpreted as a new medical condition and additional drug therapy is then prescribed to treat this medical condition. See 'Prescribing cascades' below.)●Use of multiple medications can lead to problems with adherence in older adults, especially if compounded by visual or cognitive impairment. A 2. 01. 7 systematic review of observational studies suggested that drug regimen complexity is associated with medication nonadherence [2. A balance is required between over- and under- prescribing. Multiple medications are often required to manage clinically complex older adults. Clinicians are often challenged with the need to match the complex needs of their older patients with those of disease- specific clinical practice guidelines.
For a hypothetical older female patient with chronic obstructive pulmonary disease, type 2 diabetes, osteoporosis, hypertension, and osteoarthritis, clinical practice guidelines would recommend prescribing 1. A more systematic approach is required to guide the tailoring of medication regimens to the needs of individuals. One important principle is to match the medication regimen to the patient's condition and goals of care. This includes a careful consideration of the medications that should be discontinued or substituted [3. It is particularly important to reconsider medication appropriateness late in life.
A model for appropriate prescribing for patients late in life has been proposed [3. The process considers the patients’ remaining life expectancy and the goals of care in reviewing the need for existing medications and in making new prescribing decisions. For example, if a patient's life expectancy is short and the goals of care are palliative, then prescribing a prophylactic medication requiring several years to realize a benefit may not be considered appropriate.
Older People Safety - Ro. SPA. Improved living standards, better healthcare, greater awareness of the importance of a healthy diet and taking regular exercise have led to more and more people enjoying life into their 8.
However older people, in particular the frail elderly, are one of the groups of our population most vulnerable to accidents, particularly in and around the home. Those over 6. 5 years of age are most at risk, suffering both the highest mortality rate and the most severe injuries. In 2. 00. 9 in England and Wales alone, people aged 6. More dated figures relating to A& E attendances after home accidents show that falls are by far the single largest cause of attendance. In 2. 00. 2, 2. 7million people attended an A& E department in the UK following a home accident, of whom 1. Over- 6. 5s accounted for 1.
A& E home accident attendances, but 3. The majority of accidents in the older age groups also involve females rather than males. Many of the fatal and non- fatal accidents to older people are attributable wholly or in part to frailty and failing health. This can lead to failure or slowness to see and avoid risks.
By drawing the attention of older people and their carers to danger spots and unsafe habits then accidents can be reduced. Please click on your area of interest. What injuries occur?
The great majority of both fatal and non- fatal accidents involving older people are falls. Almost three- quarters of falls among the 6. Older people are also more likely to injure more than one part of their body, with 2. One in every five falls among women aged 5. Other main injuries suffered are bruising or crushing, cuts, wounds resulting from piercing and straining or twisting a part of the body.
Although most falls do not result in a serious injury, being unable to get up exposes the faller to the risk of hypothermia and pressure sores. Where do accidents happen? The most serious accidents involving older people usually happen on the stairs or in the kitchen. The bedroom and the living room are the most common locations for accidents in general.
The largest proportion of accidents are falls from stairs or steps with over 6. Fifteen per cent of falls are from a chair or out of bed (on two levels) and a similar number are caused by a slip or trip on the same level, e. What accidents happen and how to prevent them? Facing up to Falls.
Facing up to Falls, aims to provide families and older people with practical steps to avoid falls by highlighting key issues that lead to a tumble. Click here to watch this video with subtitles. Download Facing up to Falls. Download Facing up to Falls (subtitles). How to get up safely after a fall. A short video clip showing how to get up after a fall.
Hip fracture: The management of hip fracture in adults: NICE Clinical Guidance CG1. Download How to get up safely after a fall. The risk of falling in the home increases with age. A substantial number of falls are due to unspecified reasons and whilst moving about on one level. This may reflect instability associated with impaired general health. The cause of a fall is often multi- factorial, involving both environmental hazards and an underlying medical condition.
Strength, balance and gait, decline in vision, mental health problems and deficiencies in the diet are all contributory risk factors. Although prescription medicines are seldom the cause of falls, they may also be a major risk factor.
Falls affect over a third of people over 6. Risk factors for falls. Research has indicated a wide range of multiple risk factors for falls. These include. Physical ability and lack of mobility, balance and gait disorders.
Nutritional status - vitamin D and calcium deficiency. Medication - analgesics, antidepressants etc.
Acute and chronic diseases and disorders including stroke and heart disease. Female gender. Environmental hazards. A history of previous falls. Fractures, particularly hip fractures are one of the most debilitating results of an accidental fall. Ninety per cent of hip fractures occur among those aged 5. Hip fracture is a major cause of morbidity and mortality.
It can result in medical complications, infections, blood clot in the leg and failure to regain mobility. The increased popularity of hip protectors has been very useful in preventing the severity of a falls- related injury.
Click here to read the full document 'How Safe are Hip Protectors?' (PDF 1. Prevention. Avoid leaving items on the stairs - they can become a tripping hazard. Ensure stairs are carefully maintained - damaged or worn carpet should be repaired or removed. Try to avoid repetitive carpet patterns that may produce a false perception for those with poor eyesight. Landings, stairs and hallways should be well lit with two- way light switches.
Make sure banisters are sturdy. The fitting of two easy- grip handrails gives more stability. Facing up to Falls. Ro. SPA, the UK's leading accident prevention charity, has created the short film, Facing up to Falls, as part of its Safer Homes project. It aims to provide families and older people with practical steps to avoid falls by highlighting key issues that lead to a tumble. The film contains advice on preventing a fall and involves real- life experiences of older people living in the London boroughs of Hackney, Islington and Newham. More than 3,5. 00 people in England and Wales die every year as a result of a fall and nearly a third of a million people need hospital treatment.
Many older people who suffer from falls never fully recover from either the physical or psychological impact of their injuries. Over a quarter of falls result in hip fractures and the treatment of these alone is estimated to cost around £2billion 1.
Falls are a significant and growing public health issue in an ageing population. This film is downloadable to members of the public and professionals working with older people.
Can flooring and underlay materials reduce the number of hip fractures in the elderly? Hip fractures in the elderly after a fall are a major cause of morbidity and mortality. They can result in complications, infections, blood clot in the legs and failure to regain mobility. Hip fractures can have a serious impact on a person's life. One suggested method of preventing hip fracture is through the use of improved flooring. Slippery floors and unsuitable shoes are some of the major factors that contribute to over a third of all falls annually. Can flooring and underlay materials reduce the number of hip fractures in the elderly?
PDF 2. 48kb). Falls are so commonplace that they are accepted as almost inevitable. More public awareness needs to be achieved. Professionals and carers can help older people to sustain an active life where possible by helping them to identify potential hazards and making known sources of assistance.
Older people need to be made aware of. The importance of using the right equipment to carry out the task in hand. Loss of balance through sudden movements, e. The danger of slipping and tripping created by worn rugs, slippery floors or paths, uneven surfaces, trailing flexes, and items left lying around. Loose or badly worn footwear. Well- fitting shoes can help with balance and stability.
Grab rails and places to sit down in the bathroom and kitchen could be an advantage if dizzy spells occur. Spills on the floor should be cleaned up immediately to prevent slipping on them. What to do if you have a fall.
Don't panic - you will probably feel a little shocked and shaken but try and stay calm. If unhurt look for something to hold onto and something soft to put under the knees. Hold onto a firm object for support and out the soft object under the knees; place one foot flat on the floor with the knee bent in front of the body. Lean forward putting weight on hands and foot until it is possible to place other foot beside the one on the floor. Sit down and rest for a short time.
What to do if hurt. Try to get comfortable until help arrives. Keep warm, starting with feet and legs. It is uncomfortable to keep still for any length of time and this may lead to pressure problems. Moving position every half hour and moving feet helps the circulation and improves comfort. Fire- related accidents.
Poor mobility, poor sense of smell and a reduced tolerance of smoke and burns contribute to fatalities. Major sources of ignition include cookers, materials, candles, coal fires, heaters and electric blankets. Prevention. Take care with smoking materials and try to avoid smoking in bed.
Fit a fireguard. Use electric blankets correctly and have them checked regularly. Fit a smoke alarm preferably main- operated or one with a ten- year battery. Do not dry clothes on fireguards or heaters.
Medicines and gases, mainly carbon monoxide and pipeline gas, predominantly cause accidental poisoning of people over 6. Have fuel burning devices checked regularly by an expert.
Have chimneys and flues swept at least once a year. Be aware of the dangers of exceeding prescribed drug doses. Burns and scalds.
For older people the rate of risk for severe accidents involving burns and scalds is lower than other age groups. However, older people are at the highest risk for fatal injuries from burns and scalds - four to five times greater than the population as a whole. Pre- existing conditions often contribute to their deaths. Contact burns to those over 6. Frail and poor health of the victim are often contributing factors. The main sources of heat include radiators, electric fires and cookers. Many are scald injuries, involving the use of kettles.
Prevention. Encourage the use of. Coiled kettle flexes or a cordless kettle. Spout- filling or jug kettles (boil only sufficient water for immediate needs). Wall- mounted heaters instead of kettles.
Try not to carry hot liquids further than necessary. Re- arrange tea/coffee- making area to accommodate this.). Water at the point of delivery to the bath should be no more than 4. C to help prevent scalding.
Fit a thermostatic mixing valve. When running a bath, turn the cold water on first.
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