In some cases, it may be jointly decided by patient and clinician to stop, or not to initiate, treatment. Older people frequently have multiple co-morbidities and reduced renal and hepatic function. They are therefore more likely to be affected by adverse drug reactions than younger people. It is also important to find out if the patient is adhering to their prescribed medicines. Medicine non-adherence in older people may occur due to forgetfulness, adverse effects, limited organisational skills or belief that the medicine is unnecessary, ineffective or too costly.
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Medicine organisers or blister packs may be introduced for patients who experience confusion or forget to take their medicines regularly. What medicines do you buy yourself and do you take medicines prescribed for anybody else? Some patients may not consider products that they have purchased from the supermarket or health store as medicines.
Specifically asking about medicine purchasing habits may reveal relevant information. For example, an older person with chronic kidney disease taking angiotensin converting enzyme inhibitors ACEIs and diuretics will be at increased risk of developing acute kidney injury if they also take ibuprofen purchased from a supermarket.
Sharing of medicines is also common among older people. Over-the-counter OTC products and complementary and alternative medicines can also have significant interactions with prescribed medicines, e. Primary care management of medicines requires timely information about prescribing changes initiated in secondary care.
Asking patients if they have visited another health professional is a simple way of checking if their medicine regimen has been altered. If the patient has had a consultation with another clinician, ask if they were prescribed any new medicines, or if they were told that they could stop taking medicines that had been previously prescribed. Hospital admission in older people is associated with an increase in the number of long-term medicines taken.
A New Zealand study of over older people found that following a stay in hospital, the average number of medicines prescribed to patients increased from 6.
Furthermore, some medicines initiated in secondary care may not be intended for long-term use, e. Secondary care initiation of uncommon medicines can also present challenges to primary care prescribers assessing the risk and benefits of continuing these medicines.
Similarly, if secondary care prescribers are unaware of the indications for continuing some medicines, e. Practices may consider implementing a system where older patients who have been recently discharged from hospital for non-routine events, are phoned and offered a follow-up consultation to discuss any possible changes to their treatment. Regularly assessing medicine effectiveness including asking patients if they feel their medicines help and monitoring for adverse effects allows for appropriate dose adjustment and the risk of long-term adverse drug reactions to be minimised.
This question also provides a prompt for some older patients who may just "put up" with adverse effects without mentioning them. Discussing concerns may also increase patients' health literacy and improve treatment adherence. Medicines information gathered from consultations can be combined with information taken from patient records including hospital discharge notes and dispensing record to reconcile the list of medicines a patient is taking.
Medicine reconciliation is the systematic process of obtaining a complete list of all of a patient's medicines. It should be performed whenever a patient is seen for the first time, or discharged from hospital. This list should include doses, regimen, administration routes and last dose taken.
Many older patients take their medicines from blister packs and have limited knowledge about some medicines prescribed to them. Suggesting that patients bring their medications to the consultation and performing a "brown-bag review" can assist the reconciliation process. Medicine reviews aim to eliminate medicines that are no longer required or have a high risk of toxicity. These should be conducted annually for all older patients taking medicines and every six months for those taking multiple medicines, e.
Specifically trained clinical pharmacists can provide another level of expertise by contributing to medicine management through clinical recommendation. To assist pharmacists, an objective assessment tool has been developed. Patients can be referred to be assessed by indicating "Refer for LTC assessment" on a prescription or by contacting the pharmacist directly. Family members and patients themselves can also request an LTC assessment.
Pharmacists will be funded to assist in the management of patients referred for LTC assessment. Part of the assessment will be to determine dispensing frequency. Patients who are currently dispensed their medicines under Close Control can remain on this dispensing frequency until they are assessed for LTC eligibility.
Pharmacists have until 31 January to complete these assessments.
In addition to the LTC service, some DHBs are still funding medicine use reviews by accredited pharmacists to improve patient education and adherence. To find out if this service is available in your area, contact your local DHB. For further information see: Am I treating the condition or a symptom?
It is important to establish a diagnosis so that treatment will target the underlying process rather than an isolated symptom. If a patient is taking multiple medicines, clinicians should exclude the possibility that any new symptoms may be due to adverse drug reactions. Be aware of the possibility of the prescribing cascade concept, which can begin when an adverse drug reaction is misinterpreted as a new medical condition. This can result in a new medicine being unnecessarily prescribed to treat the adverse reaction which in turn increases the risk of the patient experiencing another adverse drug reaction.
An example of this is the use of prochlorperazine for the treatment of dizziness in patients taking medicines such as antihypertensives. Have I considered non-pharmacological treatment? Non-pharmacological interventions, in some cases, can provide both physical and psychological health benefits to older people, e. Improving nutrition and physical activity can also reduce people's risk of chronic disease and increase their independence.
The introduction of mobility aids, e. The Ministry of Health provide nutrition guidelines for healthy older people, available from: Is the medicine appropriate to the patient's condition and stage of life? When considering prescribing medicines to older people it can be useful to group medicines into those that improve quality of life, e.
The benefit of medicines that improve quality of life is clearly evident. However, preventative interventions require to some degree the clinician convincing the patient, and themselves, that treatment will provide benefit. For example, the Prospective Study of Pravastatin in the Elderly at Risk of vascular disease PROSPER trial showed that while pravastatin given to over participants aged 70 - 82 years did reduce cardiovascular morbidity and mortality, it was not associated with a reduction in all-cause mortality.
Some older patients, who had elected to take a statin to reduce cardiovascular risk for primary prevention, may not have made the same decision if they had been told that treatment was unlikely to prolong their life. However, aggressive statin treatment may be appropriate for a patient who has previously had a stroke and wishes to reduce the risk of a second, potentially more disabling event from occurring.
Factors which should be considered when prescribing medicines to older people include: Life expectancy by age for older New Zealand male and female populations, - Discontinuation syndrome appears to occur more frequently with paroxetine and venlafaxine. This may partly be due to the shorter half-life of these drugs. TCAs Tricyclic and related antidepressants e. MAOIs Withdraw slowly Neuropsychiatric symptoms may be more prominent and include severe anxiety, agitation, altered sleep, hallucinations, delirium and paranoid psychosis Benzodiazepines Regular and prolonged use of hypnotics should be avoided because of the risk of tolerance to effects, dependence and an increased risk of adverse events.
A guide to discontinuing benzodiazepines Tapering guide Withdrawal effects Slowly taper the dose in steps of approximately one-eighth of the daily dose every two weeks 18 If withdrawal symptoms occur, maintain at the current dose until symptoms settle and then continue to taper, usually at a slower rate Wide range of symptoms including anxiety, mood changes, insomnia, palpitations, tremor, headache, gastrointestinal disturbance, muscle stiffness and spasms Benzodiazepine withdrawal syndrome Alternative withdrawal method 18 Dose equivalence 15,18,20 Transfer patient to an equivalent daily dose of diazepam, preferably taken at night Reduce the dose of diazepam every two to three weeks by 2 or 2.
If withdrawal symptoms occur, maintain this dose until there is improvement. Continue to reduce the dose, if necessary by smaller amounts. It is better to reduce too slowly rather than too quickly. The withdrawal period may vary from about four weeks to more than one year. Approximate equivalent doses for diazepam 5 mg: Antihypertensives Beta-blockers are the cardiovascular medicine most often associated with adverse withdrawal events. A guide to discontinuing antihypertensives 18 General tapering guide Withdrawal effects Most antihypertensives should be tapered.
Taper dose at approximately monthly intervals, over three to six months. Wide range depending on the specific medicine and the condition being treated. May include ankle oedema, weight gain, headache, tachycardia, increased blood pressure, worsening heart failure or angina, myocardial infarction. Specific classes Withdrawal effects Beta-Blockers Gradual dose reduction necessary Sudden withdrawal may cause or exacerbate angina Calcium channel blockers Consider gradual reduction Sudden withdrawal may exacerbate angina Thiazides It may not be practical to cut tablets so either stop or consider alternate day dosing initially then twice weekly dosing Possible exacerbation of the underlying condition Angiotensin-converting enzyme inhibitors Consider gradual reduction Possible exacerbation of the underlying condition.
Statins The decision to stop a statin is based on an assessment of individual benefits and risks. Warfarin In older people taking warfarin, low initial and maintenance dosages are recommended e. A guide to discontinuing warfarin Tapering guide Withdrawal effects Stop abruptly or Taper over several weeks A rebound hypercoagulable state with a risk of thrombosis, has been reported in some patients but this can occur even if the dose is tapered and may reflect the initial pro-thrombotic state for which treatment was started A guide to discontinuing NSAIDs Tapering guide Withdrawal effects Consider prn use or regular use at a lower dose Can be stopped abruptly or Halve the dose for two to four weeks then stop Review the need for gastric protection therapy i.
Acid suppressants Many people remain on acid suppressants despite there being no ongoing clinical indication e. A guide to discontinuing acid suppressants General tapering guide Withdrawal effects Halve the dose for four to eight weeks then stop or step down to a less potent agent Consider providing an antacid for dyspepsia symptoms Recurrence of oesophagitis and indigestion symptoms Specific medicines Withdrawal effects Proton pump inhibitors PPI Consider alternate day dosing. Capsules cannot be halved.
Bisphosphonates The beneficial effects e. Alendronate can be stopped abruptly without the need for tapering. A guide to discontinuing oral corticosteroids Tapering guide Comments For patients who have been on corticosteroid treatment for three weeks or longer reduce the dose, e. Once the dose has reached 5—10 mg daily, reduce the dose more slowly, e. Reduce more slowly initially if it is likely that the disease will relapse e.
Antiparkinson agents The majority of patients respond initially to levodopa and its use improves the quality of life. A guide to discontinuing antiparkinsonian medicines Tapering guide Withdrawal effects Antiparkinsonian medicines should not be stopped abruptly as there is a small risk of neuroleptic malignant syndrome 18 Reduce the dose gradually over about four weeks Sinemet CR tablets are scored and may be administered as half tablets Hypotension, psychosis, pulmonary embolism, rigidity, tremor A symptom complex resembling the neuroleptic malignant syndrome may occur.
Symptoms include muscular rigidity, elevated body temperature, mental changes, diaphoresis, tachycardia, and tachypnea. There may be an increase in serum creatine kinase concentration. Measuring the quality of medicine use in older adults. J Am Geriatr Soc ; Reconsidering medicine appropriateness for patients late in life. Arch Intern Med ; Dilemmas in prescribing for elderly people.
Why is it difficult? Prioritizing and stopping prescription medicines. Rational prescribing for patients with a reduced life expectancy. Clin Pharm Ther ;85 1: Managing comorbidities in patients at the end of life. Potentially inappropriate medicine use in the community-dwelling elderly. Inappropriate prescribing for elderly americans in a large outpatient population. Arch Int Med ; Dextropropoxyphene — review concludes risk-benefit balance unfavourable.
Prescriber Update ;31 1: Potentially inappropriate prescribing in an Irish elderly population in primary care. Br J Clin Pharmacol ;68 6: Inappropriate drug prescribing in older adults: Br J Clin Pharmacol ;60 2: Medicine withdrawal trials in people aged 65 years and older: Drugs Aging ;25 J Am Geriatr Soc ; 56 Effects of continuing or stopping alendronate after 5 years of treatment: Therapeutic Guidelines Limited; Tapering tips to ease distressing symptoms.
Curr Psych ;9 3: Identification of common mental disorders and management of depression in primary care. An evidence-based best practice guideline. Benzodiazepine and z-drug withdrawal. Randomized clinical trial of supervised tapering and cognitive behavior therapy to facilitate benzodiazepine discontinuation in older adults with chronic insomnia. Am J Psych ; Serotonergic agents and discontinuation syndrome — reminder. Guidelines on oral anticoagulation warfarin: British Society for Haematology ; Qvigstad G, Waldum H. Rebound hypersecretion after inhibition of gastric acid secretion.
Basic Clin Pharm Tox ; The complete drug reference. Pharmaceutical Press, London, March Martin TJ, Grill V. Bisphosphonates - mechanisms of action. Comments There are currently no comments for this article. Please login to make a comment. This article is 8 years and 8 months old. In this issue A practical guide to stopping medicines in older people Medicines for weight loss - do they work Common issues in paediatric oral health Care of stroke survivors Influenza immunisation programme Upfront: When is enough enough?
Stopping medicines in older people Correspondence: Pregnancy; Polypharmacy Quiz feedback: Stopping meds in older people, Meds for weight loss, Paediatric oral health. You may also like Stopping medicines in older people: Discussion on Zostavax Zostavax vaccine: The majority of older people who require drug therapy take multiple medicines Withdrawing medicines may be the best clinical decision Factors to consider when deciding if a medicine can be stopped include the wishes of the patient, clinical indication and benefit, appropriateness, duration of use, adherence and the prescribing cascade Only stop or reduce one medicine at a time Tapering the dose helps reduce the likelihood of an adverse withdrawal event.
Antidepressant discontinuation syndrome can occur with rapid discontinuation of any antidepressant. An antidepressant should not be stopped abruptly if it has been taken for six weeks or more The dose should be reduced gradually over at least four weeks, or longer if withdrawal symptoms emerge Wide range of symptoms including anxiety, gastrointestinal disturbance, headache, insomnia, irritability, malaise, myalgia, recurrence of depression. SSRIs and venlafaxine Taper slowly over several weeks or months e. Mild self limiting symptoms above may occur within a few days.
In addition to antidepressant discontinuation syndrome, rapid withdrawal may produce symptoms associated with cholinergic rebound e. Neuropsychiatric symptoms may be more prominent and include severe anxiety, agitation, altered sleep, hallucinations, delirium and paranoid psychosis Slowly taper the dose in steps of approximately one-eighth of the daily dose every two weeks 18 If withdrawal symptoms occur, maintain at the current dose until symptoms settle and then continue to taper, usually at a slower rate.
Refresh and try again. Open Preview See a Problem? Thanks for telling us about the problem. Return to Book Page. A Practical Guide by Christina Bunce ,. Drugs have played a major role in medical treatment for thousands of years. Most of us have taken, or will take, medicines at some time in our lives to cure, prevent, delay or mask the symptoms of ill health. Clear Drugs have played a major role in medical treatment for thousands of years.