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  

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

• Previous Page - Psychological Factors in Ageing
• Next Page - Physiotherapy and Older People

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.

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.

Polypharmacy means 'many medications' however in the healthcare setting it is frequently considered be when a patient takes five or more medications. 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).

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 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?

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, (progressing to 65-74 as resources allow)
  • On 10 or more medicines, one of which is a high risk medication

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

• 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

Pain management for the elderly patient

The paucity and differences in research approach in 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 demonstrated efficacy and there are few absolute contraindications. It is, however, important that the maximum daily dose (4g/24 h) 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.

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. However, this must be individualised and carefully monitored. Opioid side effects including nausea and vomiting should be anticipated and suitable prophylaxis considered. Appropriate laxative therapy, such as the combination of a stool softener and a stimulant laxative, should be prescribed throughout treatment for all older people who are prescribed opioid therapy. Tricyclic antidepressants and anti-epileptic drugs have demonstrated efficacy in several types of neuropathic pain. But, tolerability and adverse effects limit their use in an older population. Intra-articular corticosteroid injections in osteoarthritis of the knee are effective in relieving pain in the short term, with little risk of complications and/or joint damage. Intra-articular hyaluronic acid is effective and free of systemic adverse effects. It should be considered in patients who are intolerant to systemic therapy. Intra-articular hyaluronic acid appears to have a slower onset of action than intra-articular steroids, but the effects seem to last longer. The current evidence for the use of epidural steroid injections in the management of sciatica is conflicting and, until further larger studies become available, no firm recommendations can be made. There is, however, a limited body of evidence to support the use of epidural injections in spinal stenosis. The literature review suggests that assistive devices are widely used and that the ownership of devices increases with age. Such devices enable older people with chronic pain to live in the community. However, they do not necessarily reduce pain and can increase pain if used incorrectly. Increasing activity by way of exercise should be considered. This should involve strengthening, flexibility, endurance and balance, along with a programme of education. Patient preference should be given serious consideration. A number of complementary therapies have been found to have some efficacy among the older population, including acupuncture, transcutaneous electrical nerve stimulation (TENS) and massage. Such approaches can affect pain and anxiety and are worth further investigation. Some psychological approaches have been found to be useful for the older population, including guided imagery, biofeedback training and relaxation. There is also some evidence supporting the use of cognitive behavioural therapy (CBT) among nursing home populations, but of course these approaches require training and time. There are many areas that require further research, including pharmacological management where approaches are often tested in younger populations and then translated across. Prevalence studies need consistency in terms of age, diagnosis and terminology, and further work needs to be done on evaluating non-pharmacological approaches.

Medicines support

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

• 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