Medication and Older People

Original Editor - Bhanu Ramaswamy as part of the AGILE Project.

Top Contributors - George Prudden, Admin, Shaimaa Eldib, Lucinda hampton, Evan Thomas, Kim Jackson and Aminat Abolade  

Introduction

Older people require special consideration where medication is concerned as many receive multiple medications for concurrent conditions. This practice of Polypharmacy increases the risk of drug interactions as well as adverse reactions and also affecting compliance. Basic pharmacology knowledge facilitates therapy clinical reasoning for assessment and treatment . New legislature giving physiotherapists non-medical prescribing rights has impacted on this area of practice.

Polypharmacy

Drug therapy is by far the most common form of medical intervention for many acute and chronic conditions due to its effectiveness at preventing disease or slowing disease progression. Problems occur when multiple clinical guidelines are implemented which lead to the increased risk of adverse drug events and incidences where patient’s preferences are neglected.

1. Polypharmacy means 'many medications' however in the healthcare setting it is frequently considered be when a patient takes five or more medications.
2. Polypharmacy is sometimes necessary eg secondary prevention of myocardial infarction often requires the use of four different classes of drugs (antiplatelets, statins, ACE inhibitor, beta blocker).

Inappropriate polypharmacy is present when one or more drugs are prescribed that are not or no longer needed, either because: No evidence based indication, the indication has expired or the dose is unnecessarily high.

1. 1 or more medicines fail to achieve the therapeutic objectives they are intended to achieve.
2. 1 or the combination of several drugs cause unacceptable adverse drug reactions (ADRs), or put the patient at an unacceptably high risk of such ADRs.
3. The patient is not willing or able to take one or more medicines as intended.

See Tackling Overprescription

The video below gives a music fun version of the risks and issues of polypharmacy.

Who needs a medications review?

In the absence of definitive evidence on which patients are most likely to benefit from a holistic review of their medication, the following two groups of patients will be identified as potential candidates for medication review:

• All patients in care homes age 50+ regardless of the number of medicines that they are on
• Patients who are:
  • Aged 75 and over, (consider those aged 65 and above)
  • On 10 or more medicines, one of which is a high risk medication

A medicines review should also be considered when a patients has the following:

• Multiple conditions
• Frailty
• Dominant condition - certain conditions will dominate the clinical picture. Dementia is an example where the condition's impact will affect and inform decisions.
• End of life care

Medicines and falls

Falls can be caused by almost any drug that acts on the brain or on the circulation. The mechanism that leads to a fall is one or more of the following:

1. Sedation, with slowing of reaction times and impaired balance.
2. Hypotension, including the 3 syndromes of paroxysmal hypotension:
   • Orthostatic hypotension (OH)
   • Vasodepressor carotid sinus hypersensitivity (CSH)
   • Vasovagal syncope (VVS)
3. Bradycardia, tachycardia or periods of asystole (no electrical activity recorded on an ECG monitor)

Psychotropic are drugs that act on the brain. There is have good evidence that stopping these drugs can reduce falls. Taking such a medicine roughly doubles the risk of falling. A case control study of approx 1.3 million people (over 65 )in 2017 found antidepressants were the psychotropic most strongly related to fall injuries and antipsychotics to hospitalizations and death. Number of psychotropics was associated with increased the risk of fall injuries, hospitalization and death in a dose–response manner. Among persons with dementia a dose–response relationship was found between number of psychotropics and mortality risk .

Sedatives, antipsychotics, sedating antidepressants cause drowsiness and slow reaction times. Some antidepressants and antipsychotics also cause orthostatic hypotension.

Any drug that reduces the blood pressure or slows the heart can cause falls. Symptoms are associated with feeling faint, loss of consciousness or “legs giving way”. In some patients the cause of the fall is clear.

Objectively they may be hypotensive, or have a systolic drop on standing. Other patients may have normal blood pressure but have syncope or pre-syncope from carotid sinus hypersensitivity or vasovagal syndrome. Stopping cardiovascular medication reduces syncope and falls by 50%.

Pain management for the elderly patient

Managing persistent pain in older adults is a complex task and the relevant presence of multiple comorbidities, polypharmacy and physiological vulnerability in this age-group need all be considered.The paucity and diversity in research approach of the published literature makes it difficult to report the prevalence of pain in elderly people. There is disparity within the literature as to whether or not pain increases or decreases in this age group, and if there are gender differences. There is a body of evidence that describes a higher prevalence of pain within residential care settings.

Paracetamol should be considered as first-line treatment for the management of both acute and persistent pain, particularly that which is of musculoskeletal origin, due to its well documented efficacy and there that are few absolute contraindications. It is, however, important that the maximum daily dose of 4g per hour is not exceeded.

Non-steroidal anti-inflammatory drugs (NSAIDs) should be used with caution with older people. The recommendation is that the lowest dose should be provided, for the shortest duration. For elderly people taking NSAIDs, they should also be prescribed a proton pump inhibitor (PPI) to reduce the incidence of stomach ulcers. NSAIDS are associated with gastrointestinal, renal and cardiovascular side effects, and drug–drug and drug–disease interactions. It is important for older people taking NSAIDs to be routinely monitored. NSAIDs can also increase the risk of falls, increase geriatric psychiatric events, and increase the risk of stroke. These risks and benefits should be balanced carefully in individual patients to optimize overall outcomes, especially in the elderly.

NSAIDs have also been linked with impairment in bone healing. A systematic review conducted by Marquez-Lara et al. state that there is no consensus on whether they should be recommended post orthopaedic surgery .

Opioid therapy may be considered for patients with moderate or severe pain, particularly if the pain is causing functional impairment or is reducing their quality of life. When this form of analgesia is used it is important that regimes are individualised and monitored carefully. Side effects of opioids include nausea, vomiting and constipation which should be anticipated and suitable prophylaxis provided.

Tricyclic antidepressants and anti-epileptic drugs are effective in the management of neuropathic pain. Intolerance to the medication and the occurrence of side effects limit their use in an older population. Intra-articular corticosteroid injections in osteoarthritis of the knee is effective short term analgesia with a small risk of complications or joint damage. Intra-articular hyaluronic acid is effective and free of systemic adverse effects. It should be considered in patients. Current evidence suggests that intra-articular hyaluronic has a longer effect than intra-articular steroids but has a slower onset of action. Epidural steroid injections in the management of sciatica is not recommended due to conflicting evidence and the lack of larger studies.

Exercise, Manual Therapy, Acupuncture, Transcutaneous Electrical Nerve Stimulation (TENS), Massage and psychological approaches are non-pharmacological approaches to pain relief which are well supported by the literature. These modalities should be considered in parallel with drug therapy.

Medicines support

The video below gives good advice re adherence and medication management at home.

People should be routinely encouraged in actively participate in their own care. It is essential to take steps to supporting people to manage their medicines by involving family members or carers. 'Medicines support' is defined as any support that enables a person to manage their medicines. Medicines support should be individualised and depending on their specific needs. Physical and cognitive impairments can effect an individuals ability to take medication therefore alternatives to packaging and delivery should be considered. Consider can it be swallowed easily, needs fluid to wash it down, crushed or given in liquid form. Different containers aid dispensing and concordance with medication e.g. dosage boxes, blister packs, and easy screw topped bottles, but may need to be requested specifically at the local pharmacy.

Further Reading

• Psychological Factors in Ageing
• Physiotherapy and Older People

• Dept of Health (2001). Supplement to the National Framework for Older People.
• Milton et al (2008). Prescribing for older people.
• British National Formulary (BNF)
• McKinnon J (2007). Towards prescribing practice. Chapter 1 provides an understanding of basic pharmacology.
• National Prescribing Centre (2000). Prescribing for the older person.