14 - Polypharmacy and Deprescribing

Question 1

How many medicines do you need to take to qualify as polypharmacy?

Answer 1

5 or more

Question 2

What are the two types of polypharmacy?

Answer 2

Appropriate polypharmacy
Problematic polypharmacy

Question 3

What percentage of over 65s are taking more than 10 medications?

Answer 3

16%

Question 4

What are the commonest implicated medications in adverse drug reactions?

Answer 4

• Aspirin, NSAIDs, anticoagulants
• Diuretics
• Antidiabetic drugs

Question 5

How can the route of administration differ in elderly Ps?

Answer 5

• Dysphagia is more common
• IV access may be difficult (delirium, dementia)
• Compliance may be difficult

Question 6

What alternatives routes to administration are there if a patient has difficulty with the oral route?

Answer 6

Patches / Topical
PR
Liquid medications
S/C or I/M
Once daily ABx?

Question 7

Why can distribution be affected in elderly Ps?

Answer 7

Lean mody mass and relative increase in body fat - can affect water soluble drugs.

Ps can also have lower albumin levels - often as a result of chronic inflammation or malnutrition.

Question 8

Why can absorption change in elderly Ps?

Answer 8

Different physiological changes
Diseases can affect (e.g. IBD, Coeliac)
Poly-pharmacy - other drugs can alter absorption (iron, antacids, omeprazole)

Question 9

How does metabolism change in elderly Ps?

Answer 9

Reduced liver mass & blood flow =
(1) first pass metabolism is reduced
(2). drugs which are excreted by the liver accumulate (e.g. morphine)

Polypharmacy = induction / inducers from other drugs

Question 10

Which drugs are considered enzyme inhibitors?

SICKFACE.COM

Answer 10

Question 11

Which drugs are considered enzyme inducers?

SCRAP GP

Answer 11

Question 12

How is elimination affected by ageing?

Answer 12

Reduced eGFR
Reduced liver function

Question 14

How is the cardiovascular system affected by ageing?

Answer 14

Question 14

How can psychotropic drugs affect the elderly?

Answer 14

Inc extra pyramidal side effects (antipsychotics)
Increased delirium (anticholinergics)
Increased sedation at lower dose

Question 15

How is Vitamin K affected by Ps on warfarin in the elderly?

Answer 15

Is subjected to greater inhibition

Question 16

What tips should you remember when prescribing new drugs to elderly Ps?

Answer 16

Start low and slow, always consider other options first

Prescribe for quality of life - not the disease

Don’t start 2 new drugs at the same time

Don’t prescribe to treat drug side effects

Question 17

When is a medication review required?

Answer 17

> 10 drugs
ADR
Inc incidence of falls

Question 18

Which tool can be utilised to review polypharmacy in elderly Ps?

Answer 18

STOPP / START criteria

Question 19

Why are up to 50% of medications not taken as prescribed?

Answer 19

Question 20

What can be done to aid concordance with medication?

Answer 20

Question 21

Answer 21

D

Question 22

Why do elderly Ps often have several diseases?

Answer 22

Many conditions are more prevalent in older Ps - can be a reflection of this.

Some chronic diseases have complications which affect several systems or predispose to other disorders.

One risk factor may predispose a P to many conditions (e.g. smoking)

Multiple diseases = multiple drugs = can lead to further problems

Question 23

How do elderly Ps differ in response symptoms of disease?

Answer 23

Can have different presentations to younger Ps - signs +/- symptoms of disease may be missing in frail older Ps.