Rational Prescribing for Elderly Patients

General
Rational prescribers should attempt to:

Maximize clinical effectiveness

Minimize harms
Avoid wasting scarce healthcare resources
Respect patient choice

Goals of therapy may include:

Curing a disease (eg breast cancer, chest infection)

Relieving symptoms without affecting the underlying condition (eg headache, diarrhea)
Combining both of the above goals (eg inflammatory bowel disease, rheumatoid arthritis)
Long-term prevention (eg hypertension, osteoporosis)
Replacing deficiencies (eg hypothyroidism)
Addressing lifestyle wishes (eg hormonal contraception) and, occasionally,
Therapeutic trials to aid diagnosis (eg edrophonium to diagnose myasthenia gravis).

Patient Factors Influencing Drug Selection

1. Previous adverse drug reactions
Knowledge of previous adverse reactions will affect drug or dose selection but this is reliant on
taking a careful drug history. This is particularly important in the case of allergic reactions to drugs
(eg beta-lactam antibiotics).
2. Vulnerability to adverse effects
Some patients will have organ damage that may affect drug choices. For instance, beta-
adrenoceptor antagonists for angina may be undesirable in patients with peripheral vascular
disease or asthma (because they precipitate vasoconstriction and bronchoconstriction) but
attractive in those with heart failure (for which they are also indicated) . Older patients are more
vulnerable to the adverse effects of many drugs (eg anticholinergics, central nervous system
depressants, vasoactive drugs) because of age-related reduction in the function of vital organs (eg
the central nervous and cardiovascular system) and this may necessitate dosage reductions
3. Current drug therapy
Any current drug therapy may affect drug or dosage selection, mainly because of potential drug
interactions. For example, the dose of simvastatin should not be increased beyond 20 mg at night
in patients also taking amiodarone or verapamil because of the increased risk of muscle toxicity.
4. Other patient factors
 The likelihood that patients will adhere to
therapy or follow-up monitoring is
important for drugs such as warfarin and
insulin, which have a low therapeutic index,
and where alternatives are less effective.
However, patients who cannot meet these
arrangements will be more vulnerable to
serious adverse outcomes.

Health beliefs and attitude to risk can

influence the initial decision to prescribe or
the choice of medicine. This is particularly
obvious in long-term preventive therapy
when benefits may be imperceptible. About
half of patients adhere poorly to such
treatments, emphasising the role of patient
partnership in making rational prescribing
decisions with which the patient agrees.

Some patients may not be able to administer

the medicine correctly, leading to
unintentional non-adherence (eg lacking the
manual dexterity and timing to use
metered-dose inhalers). For others,
swallowing tablets may present difficulties
so liquid formulations would be more
suitable.

Prescriber Factors Influencing Drug Selection

1. Familiarity
If a prescriber lacks familiarity with
medicines, it increases the chance of
adverse outcomes; continuing professional
development is required. However, lack of
experience should not impede the
introduction of new, more rational
prescribing practices when they become
available.
2. Ease of follow up
Some medicines require careful review and monitoring to ensure that safety is maximised or dose
titration is optimal. If the appropriate supervision cannot be guaranteed then alternative
treatment options (or no treatment) might be preferred.
Elderly
Changes in Elderly

Sehubungan dengan perubahan fisiologis seiring dengan bertambahnya usia, maka dalam
obatpun akan berubah dari segi farmakokinetik dan farmakodinamiknya, hal ini dapat
menurunkan atau menaikkan jumlah pengobatan dan interaksi dari obat ke obat.
Farmakokinetik mengacu pada respons tubuh terhadap obat termasuk absorpsi, distribusi,
metabolisme, dan excresi. Perubahan usia (aging) berhubungan dengan gastrointestinal dan
kulit yang menyebabkan penurunan efek yang sedikit, kecuali obat obat yg memerlukan active
gastrointestinal transport (vitamin dan mineral) yang menurun seiring bertambahnya usia.

Changes of pharmacokinetics: Pada penuaan, komposisi air menurun dan komposisi lemak
meningkat sehingga volume distribusi obat larut lemak semakin meningkat, sepert
benzodiazepine; eliminasi obat menurun karena creatinine clearance menurun, dan
penurunan massa otot akan menurunkan serum kreatinin.
Changes of pharmacodynamics: Perubahan Receptor bindin, jumlah reseptor dan perubahan
respon translasi terhadap reseptor (contoh: penurunan aktivitas -adrenergic sehingga
respon terhadap -blocker dan -agonist menurun).

Principles of Rational Drug Use in the Elderly

1. Give a list all of the drugs -including prescribed drugs, over-the-counter drugs, herbs, vitamins and
nutritional supplements, to the patient or caregiver
a. The drug name (both generic and brand), dosage, frequency, route and indication should
always be integrated.
b. The patient or the caregiver should be informed based on this detailed list
2. Check the drugs taken by the patient with the list given by the physician.
3. Review the current drug therapy for indication, appropriateness and possible switch to a safer or
cheaper agent, minimum effective dosage, timing, effectiveness, side effects and toxicity, and
potential drug-drug interaction. Consider non-pharmacological approaches. Match each drug with
its indicative disease. Ask for effectiveness and side-effects of each single drug. Compare the
benefits and risks of the drugs individually. This checking should be performed in a periodical
manner (at least once a year) and also whenever a decline in function or an onset or worsening of
geriatric syndromes occur.
4. Inform the patient or caregiver for common side effects and when to seek medical advice related
to use of drugs.
5. Try to simplify the medication dosing schedule
 a. Try to minimize dosing frequency
i. Prescribe longer-acting medications- if suitable
ii. Dose different drugs at the same time- if suitable
b. Try to use medications that can treat two or three conditions simultaneously- if suitable
6. Address the adherence.
7. Consider the new or worsening symptoms as possible side effects of the current medications.
8. Monitor for effective level and toxicity of high risk drugs.
9. Do not underuse the potentially useful drugs.
10. Determine the goals of care for each individual patient and determine the prioritizations
Involve the patient and/or caregiver to the treatment plan, integrate the patient values.
11. Integrate quality of life as an essential part of managing an elderly.
12. Try to withdraw medications by gradually tapering off to minimize withdrawal reactions and to
allow symptom monitoring, unless dangerous signs or symptoms indicate a need for abrupt
medication withdrawal.

Selected High Risk Drug

Drug Classes to Avoid

Antihistamines: Nonsedating antihistamines (e.g., fexofenadine, loratadine) are considered

safer
Antispasmodics: May result in anticholinergic side effects, sedation, and generalized
weakness
Barbiturates: Highly addictive with many side effects; numerous other agents for sedation are
preferred
GI antispasmodic drugs (e.g., dicyclomine, hyoscyamine): Highly anticholinergic
Long-acting benzodiazepines (e.g., chlordiazepoxide, diazepam): Short- or medium-acting
agents are preferred; start with smaller doses
Muscle relaxants: May result in anticholinergic side effects, sedation, and generalized
weakness

Specific Drugs to Avoid

Amitriptyline: Highly anticholinergic; use newer antidepressants or less anticholinergic

tricyclics
 Chlorpropamide: Long half-life leads to increased risk of hypoglycemia; newer insulin
secretagogues are preferred
Dipyridamole: May cause dizziness and hypotension
Disopyramide: Anticholinergic and negative inotropic properties
Doxepin: Highly anticholinergic; use newer antidepressants or less anticholinergic tricyclics
Indomethacin: Compared with other NSAIDs, risk of CNS, GI, and renal side effects is greater
Meperidine: Active metabolite normeperidine may accumulate and cause CNS stimulation
and seizures
Meprobamate: Highly addictive; may worsen depression; other anxiolytics preferred
Methyldopa: Common side effects include depression, sedation, and edema; multiple
antihypertensive options are available
Pentazocine: Mixed narcotic agonistantagonist with potent CNS effects
Phenylbutazone: May cause severe bone marrow suppression; other NSAIDs are preferred
Propoxyphene: Weak narcotic pain reliever (probably no better than acetaminophen alone)
but has same side profile as other narcotics
Reserpine: CNS side effects include sedation and depression; multiple antihypertensive
options are available
Ticlopidine: More toxic effects than aspirin or clopidogrel
Trimethobenzamide: May cause extrapyramidal side effects; numerous alternative
antiemetics are available

Drugs to Limit

Digoxin: Limit to <0.125 mg/day in most elderly patients

Ferrous sulfate: Limit to <325 mg/day in most elderly patients
Spironolactone: >50 mg; avoid in patients with heart failure or creatinine clearance <30
mL/min

Medication Checklist

Is there a clear indication for this medication?

Is it working?
Are there side effects?
Is the patient taking the medication routinely?
Does the medication need laboratory monitoring?
Is it still needed?