How to prescribe in the elderly

How to prescribe in the elderly

With caution. Think about the risk : benefit analysis before your prescribe. For example, an 89y old does need to be started on a statin. There are 5 principles.

5 key points

1. Treat the disease process rather than symptoms – just because someone has mild oedema, it may not need to be treated
2. Be cautious about adding new medication – could you stop something instead?
3. ‘Start low, go slow’ – titrate up slowly
4. Monitor closely for side effects
5. Manage the whole of the patients treatment regimen – look at all of their drugs (see point 2).

Some more principles ..

• Use drugs that are familiar – to the prescriber
• Evidence-based is indicated for the specific age group
• Monitor therapy (particularly high-risk medication, e.g. digoxin)
• Drugs prescribed via specialist clinics – note as may not be on the patient’s record
• Over-the-counter medications (OTCs), herbal products or someone else’s medication – ditto
• Avoid the ‘prescribing cascade’ (e.g. bendroflumethazide as a treatment for amlodipine-associated ankle swelling)
• Adherence through collaboration – promote by:
  • Shared decision making with the patient and involve carers
  • Keep it simple stupid (KISS) principle – keep the medication regimen simple, taking into account pill burden and timings
  • Provide clear written instructions, with the drug name in CAPITALS, a dosing schedule and information on why the medicine has been prescribed
  • Use dosette boxes
  • Avoid medical confusing slang, e.g. using the term ‘as directed’ (to whom!?)
  • Identify over-ordering/hoarding of medicines
• Don’t assume that the patient is taking medication as prescribed
• Be aware of any transfer between care settings – and changes to medication that may occur as a result
• Be aware that people of different races and ethnicities – can have varying responses to medicines. The British National Formulary (BNF) or the individual medicine’s summary of product characteristics should always be consulted.

[“Is that all? MyHSN Ed] Yes!

Other resources

Prescribing in the elderly (BNF)
NHS Wales’ advice on reducing polypharmacy (deprescribing) in the frail elderly.