Medication and Older People: Difference between revisions

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=== Introduction ===
== Introduction ==
Basic pharmacology knowledge supports physiotherapy clinical reasoning for assessment and treatment . New legislature giving physiotherapists non-medical prescribing rights has impacted on this area of practice.<ref name=":1">Independent prescribing [Internet]. The Chartered Society of Physiotherapy. 2018 [cited 17 May 2018]. Available from: http://www.csp.org.uk/tagged/independent-prescribing</ref>
 
== Polypharmacy ==
 
Drug therapy is effective in preventing disease or slowing disease progression Medication is by far the most common form of medical intervention for many acute and chronic conditions. <ref name=":3">Polypharmacy Guidance [Internet]. Sehd.scot.nhs.uk. 2015 [cited 17 May 2018]. Available from: http://www.sehd.scot.nhs.uk/publications/DC20150415polypharmacy.pdf</ref> Problems can occur when the implementation of the sum of evidence based recommendations may: not be rational; increase the risk of adverse drug events and misaligned with the patient’s preferences.<ref name=":3" />


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.  
Polypharmacy means 'many medications' however in the healthcare setting it is frequently consider be when a patient takes five or more medications.<ref name=":3" /> Polypharmacy is sometimes necessary for example, secondary prevention of myocardial infarction often already requires the use of four different classes of drugs (antiplatelets, statins, ACE inhibitor, beta blocker). <ref name=":3" />


Basic pharmacology knowledge supports physiotherapy clinical reasoning for assessment and treatment . New legislature giving physiotherapists non-medical prescribing rights has impacted on this area of practice.<ref name=":1">Independent prescribing [Internet]. The Chartered Society of Physiotherapy. 2018 [cited 17 May 2018]. Available from: http://www.csp.org.uk/tagged/independent-prescribing</ref>
Inappropriate polypharmacy is present: when one or more drugs are prescribed that are not or no longer needed, either because: <ref name=":3" />  
*No evidence based indication, the indication has expired or the dose is unnecessarily high
*1 or more medicines fail to achieve the therapeutic objectives they are intended to achieve
*1 or the combination of several drugs cause inacceptable adverse drug reactions (ADRs), or put the patient at an unacceptably high risk of such ADRs
*The patient is not willing or able to take one or more medicines as intended.


The nervous system is susceptible to common drugs like opioid analgesics, benzodiazepines, antipsychotics and antiparkinsonian drugs prescribed in the older population. They must be used with caution as the adverse drug reactions can be vague and non-specific, such as confusion, drowsiness, constipation, hypotension and falls. Organs and systems may be vulnerable to drugs such as anti-hypertensives and non-steroidal medications used as analgesics. It is therefore vital that medication of older people is reviewed regularly and they are maintained on the lowest dosage of a drug as is possible to gain the desired effect.
=== Who needs a medications review? ===


Ageing reduces renal clearance so drug excretion is slower with increased impact of nephrotoxic drugs. Acute illness and dehydration exacerbate this effect. Liver metabolism of the drug can also be reduced. Overall, pharmacokinetic changes can increase the tissue concentration of a drug by 50% or more if the person has greater frailty. In the very old, manifestations of normal ageing may be taken as signs of disease and lead to inappropriate prescribing. Self-medication with over-the-counter drugs or leftover tablets from a previous illness may also add to the complication.
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:<ref name=":3" />
*All patients in care homes age 50+ regardless of the number of medicines that they are on
*Patients who are:
**Aged 75 and over, (progressing to 65-74 as resources allow)
**On 10 or more medicines, one of which is a high risk medication
**and with a SPARRA score in the range 40 to 60%


Non-pharmacological management is strongly advocated. An example following bereavement would be to provide counselling for low mood as the preferred coping option instead of prescribing sedatives and anti-depressive medication. If a poor prognosis or side-effects anticipated, prophylactic medications should be reconsidered and possibly withdrawn; however the older person should not be denied effective treatments if they are of benefit.
A medicines review should also be considered when a patients as the following:<ref name=":3" />
*Multiple conditions
*Frailty
*Dominant condition - certain conditions will dominate the clinical picture. Dementia is an example of such a condition where its impact affects and informs decisions.
*End of life care


=== Medicines support ===
=== Medicines support ===

Revision as of 13:27, 17 May 2018

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

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

This page is a part of a series on Older People and Geriatrics.

Introduction[edit | edit source]

Basic pharmacology knowledge supports physiotherapy clinical reasoning for assessment and treatment . New legislature giving physiotherapists non-medical prescribing rights has impacted on this area of practice.[1]

Polypharmacy[edit | edit source]

Drug therapy is effective in preventing disease or slowing disease progression Medication is by far the most common form of medical intervention for many acute and chronic conditions. [2] Problems can occur when the implementation of the sum of evidence based recommendations may: not be rational; increase the risk of adverse drug events and misaligned with the patient’s preferences.[2]

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

Inappropriate polypharmacy is present: when one or more drugs are prescribed that are not or no longer needed, either because: [2]

  • No evidence based indication, the indication has expired or the dose is unnecessarily high
  • 1 or more medicines fail to achieve the therapeutic objectives they are intended to achieve
  • 1 or the combination of several drugs cause inacceptable adverse drug reactions (ADRs), or put the patient at an unacceptably high risk of such ADRs
  • The patient is not willing or able to take one or more medicines as intended.

Who needs a medications review?[edit | edit source]

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:[2]

  • All patients in care homes age 50+ regardless of the number of medicines that they are on
  • Patients who are:
    • Aged 75 and over, (progressing to 65-74 as resources allow)
    • On 10 or more medicines, one of which is a high risk medication
    • and with a SPARRA score in the range 40 to 60%

A medicines review should also be considered when a patients as the following:[2]

  • Multiple conditions
  • Frailty
  • Dominant condition - certain conditions will dominate the clinical picture. Dementia is an example of such a condition where its impact affects and informs decisions.
  • End of life care

Medicines support[edit | edit source]

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.[3] 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[edit | edit source]

  • Dept of Health (2001). Supplement to the National Framework for Older People.
  • Milton et al (2008). Prescribing for older people.
  • British National Formulary (BNF) - It is a joint publication of the British Medical Association and the Royal Pharmaceutical Society of Great Britain with a good section reviewing changes in medicines management for older people.
  • McKinnon J (2007). Towards prescribing practice. Chapter 1 provides an understanding of basic pharmacology
  • National Prescribing Centre (2000). Prescribing for the older person. MeReC Bulletin

References[edit | edit source]

  1. ↑ Independent prescribing [Internet]. The Chartered Society of Physiotherapy. 2018 [cited 17 May 2018]. Available from: http://www.csp.org.uk/tagged/independent-prescribing
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 Polypharmacy Guidance [Internet]. Sehd.scot.nhs.uk. 2015 [cited 17 May 2018]. Available from: http://www.sehd.scot.nhs.uk/publications/DC20150415polypharmacy.pdf
  3. ↑ National Institute for Health and Care Excellence (2017) Managing medicines for adults receiving social care in the community. NICE guideline (NG67)
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