Monitoring for problems requires consideration of the increased risk of doing harm in elderly people from altered pharmacokinetics,
comorbidity and polypharmacy. Some drugs, when used in elderly people, are more likely to be associated with an increased
risk of adverse events.
Many symptoms can be caused by medication.
The common ones are:
- Confusion or altered cognition
- Decrease in functional ability
- Unexplained tiredness
Assessing each individual patient for problems will generally mean knowing age, weight, general well being, cognitive
function, use of OTC and complementary medications, specific renal and hepatic function, likely compliance, and an accurate
understanding of the patient's other conditions and medications.
Serum levels for specific drugs, especially those with a narrow therapeutic index (eg. lithium, digoxin, warfarin, anticonvulsants)
can help guide dosing.
Monitoring is required particularly when any new medication is started, with at least one follow up visit to check on
response and look for adverse effects. Long term medications also need review because changes in the medical status of
the patient over time can result in the medications becoming ineffective or unsafe.6
Many older people will be able to be titrated off medications that are no longer required. This should be discussed
at yearly reviews.
Medication reviews are therefore recommended:
- on an annual basis
- with new medication
- after discharge from hospital
- after any change in condition of the patient (both exacerbations and improvements)
The assistance of a pharmacist can be very helpful for patients with complex regimens.
Manage the whole of a patient's treatment regimen
"Ideally a single GP should take overall responsibility for managing and coordinating the medication regimen for a patient."7
If you don't take charge, who will?
GPs are ideally placed to be able to manage all medications used by their patients. Never assume you are the only prescriber
or that the patient is taking what you prescribed. There is evidence that elderly people visit multiple GPs and new medication
may be prescribed at discharge from hospital, outpatient clinics, after hours clinics and emergency department visits.
Sharing of information is vital. Accurate knowledge can only be acquired with good patient-doctor communication and
relies heavily on effective communication between primary and secondary care.
Situations when patients are most at risk can become opportunities for taking control of a medication regimen
The key task is to identify those patients at risk. There are many risk factors likely to cause drug related problems
in elderly people including;
- Recent discharge from hospital
- Use of multiple drugs
- Multiple prescribers
- Impaired cognitive status and/or communication problems
- Use of drugs with a narrow therapeutic index
- Use of drugs commonly associated with adverse drug effects
- Initiation of any new medicine
- Use of OTC or complementary medications
- A change in the condition of the patient
A 'brown bag review' can be the first step in regaining control
Once those at risk are identified, a useful initial tool is the "brown bag review".8 As the name implies
this is simply getting your patient to bring in all their medication in a bag -something GPs have been doing for years.
GPs or practice nurses can then get an accurate understanding of all the medications the patients are currently on (and
often many that they are not taking, but still have on hand).
Best practice tip
A Christchurch GP offers us his best practice tip for taking control of treatment for his elderly patients.
"After elderly patients are discharged from hospital for a non-routine event, they are phoned by my practice
nurse and invited to make an appointment for a 'debriefing session' with me.
I review their medication and discuss what events and procedures took place at hospital and what, if any,
problems were encountered.
This enables me to take control of my patients' overall treatment and facilitate understanding and communication
Asking simple questions about what, why and how patients take their medication, can help reveal gaps in understanding
and offer opportunities for patient education and improve compliance and outcome. Be prepared to stop unnecessary or inappropriate
medication if it does not appear to be working or has the potential to do harm.
Discontinuing medication prescribed by others can raise uncomfortable feelings for the GP, but this should be balanced
by the knowledge that you are likely to have the most complete picture of your patient's circumstances. Involving your
patient in the decision will help overcome any resistance to change.
A "brown bag review" may uncover problems that require a more formal review. This review may involve GP, practice nurse
and pharmacist in a team approach. Don't forget to complete an up-to-date medication card.
The overall goal when prescribing for elderly people should be appropriate monitored medication use that will "enhance
functional ability and life expectancy and result in improved quality of life".8