Introduction

Elderly people are unique. They are in a time of losses and poor reserve with atypical presentation; more degenerative disorders; multiple co-morbidity; unreported illnesses e.g. depression, urinary incontinence or dementia. It is very important to differentiate the aged-related changes from true disease process so as to prevent iatrogenic problem. Poly-pharmacy arises because of the multiple co-morbidity (morbidities) in elderly and as a result there are more adverse drug reactions. Also, prescribing for elderly patients presents unique-challenges. 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).

Optimizing drug therapy is an essential part of caring for the elderly. The process of prescribing a medication is complex, and includes:

1. deciding that a drug is indicated;
2. choosing the best drug;
3. determining a dose and schedule appropriate for the patient’s physiologic status; monitoring for effectiveness and toxicity;
4. educating the patient about expected side- effects, and indications for seeking consultation.

Boyd, CM, et al. in JAMA  discussed potential limitations of Clinical Practice Guidelines (CPG) in elders1.  Hypothetically, elder would receive 12 medications, about 19 doses per day or USD$5,000.00 per year! 8 of 9 guidelines (HTN, CHF, angina, AF, hypercholesterolemia, DM, OA, COPD, OP) don’t qualify benefits with patient factors for example life expectancy. 5 of 9 guidelines don’t address use with multiple co-morbidities. All the guideline don’t address adverse drug and disease interactions and they don’t address disruption of daily routines, social activities and non-adherence.

 “If medication related problems were ranked as a disease, it would be the 5th  leading cause of death in the US!

Sign and Symptom

Types of adverse drug reactions in the elderly is as follows:

1. Primary drug reactions (1 drug with 1Side-Effect.) e.g. Cimetidine  psychosis,  Theophylline  seizures.
2. Secondary drugs Interactions requires at least 2 drugs to cause  interactions for example.  Erythromycin and Theophylline or Indometacin and Propanolol.
3. Drug withdrawal syndromes which can be of addictive and non-addictive withdrawal for examples B-blocker withdrawal causing angina symptoms  or “Addictive  drug”  withdrawal syndromes from benzodiazepines or narcotics.
4. Tertiary  “extra-pharmacologic”  effects  which is measure  by  epidemiological  studies  or pharmaco-economics for  falls and  traumatic  injuries  from orthostatic  hypotension.

Complication

The followings are some consequences of poly-pharmacy in elderly:

1. Medical errors (from the medicine; at the pharmacy and by nursing staffs)
2. Decreased adherence
3. Adverse Drug Reactions
4. Increased risk of hospitalization
5. Drug-Drug and Drug-Disease interactions
6. Disrupted daily routines and social activities
7. Increased medical costs (medication, adverse events, monitoring)

Some reasons for adverse drug reactions and drug interactions are as follows:

1. Inadequate assessment and incorrect diagnosis from the start as elderly people have atypical and altered presentation.
2. Excessive prescribing with multiple- complex drug regimens because of the multiple co-morbidities.
3. Inadequate supervision of long- term medication and lack of compliance from the complicated regime.
4. Taking “Over-The- Counter” or traditional medications. Almost all elderly tend to take non prescribed medication, alternative complimentary medications and supplementation.
5. In Malaysia, elderly patient tend to go doctor- hopping and that they will visit 1 doctor after another doctor until they meet the one that satisfied them most. The multiple physicians they visited may prescribe drugs of similar indication but of different brand names.
6. There are altered pharmacokinetics and pharmacodynamics  in older peoples.

Treatment

Appropriate drug use in elderly will increase quality of life and reduces disabilities from illnesses. However the treatment of illness in elderly is very challenging as it involved the patient, the prescriber and the drugs. As mentioned prescribing in elderly is very complex and intrigued and it is not easy for doctors to stay up to date with all the new medications and let alone memorize all the new medications.

The aim of prescribing in elderly is to minimize mistakes.The following are steps in proper prescribing :

Always remember “primum non nocere” or “do no harm”:

1. The patients should have thorough evaluation before prescribed with medications.
2. Use  non-pharmacological  therapy.
3. Know the pharmacology of  the drug(s).
4. Careful drug history  and try to avoid poly-pharmacy (Simplify regimen).
5. Avoid potential adverse drug interactions.
6. Use of small dose and adjust or work upwards: Start low and go slow – titrate and reach there!
7. Review regularly
   • Avoid automatic repeat prescription
   • Look for other sources of medications- Over The Counter (OTC)
   • Caution with multiple providers (different Doctors)
   • Don’t use medications to treat side -effects of other medications
   • What can you discontinue or substitute for safer medicine?
   • Check  labels  and drugs at each  visit.
   • Use medication cards.
   • Destroy all  old medicines.
   • Check serum  levels.
   • Instruct family.
   • Be sure patients are aware of medicine that can cause  and  also  cure  illness.

Prevention

Avoidable adverse drug events are the serious consequences of inappropriate drug- prescribing. The possibility of an adverse drug event should always be borne in mind when evaluating an elderly individual; any new symptom should be considered drug-related until proven otherwise.

Also consider the following steps when prescribing to prevent poly-pharmacy:

Step 1- Step 5: Gathering information

1. Determine all medications being used.
2. Identify medications by generic name and drug class.
3. Identify the clinical indication of each medication.
4. Know the side- effect profile of each medication.
5. Identify risk- factors for an adverse drug reaction.

Step 6 – Step 10 (Eliminate, substitute and simplify)

6. Eliminate medication with no therapeutic benefit.
7. Eliminate medication with no clinical indication.
8. Substitute a safer medication.
9. Avoid treating an adverse drug reaction with a drug.
10. Use a single drug with an infrequent dosing schedule.

References

1. Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA. 2005;294:716-24. [PMID: 16091574]
2. Beers MH. Updating the Beers Crieria for 003Potentially Inappropriate Medication Use in Older Adults. Arch Internal Med. 2003: 2716-2724.
3. Bosker et al,, Geriatric Emergency Medicine, 1st ed, Mosby Year Book, St Louise, Missouri. 1990
4. Kessler DA.  JAMA 1993;269:2765-68;
5. Geriatrics 1996; 51(July): 26-35