Prescribing in the Frail and Elderly
Old age is a marker of frailty and vulnerability to harm from medicines.
Lower doses should be used in frail and older patients.
More frequent review of medicines and their doses is needed, as patients get older and frailer.
General Advice
- Also see Individualising Drug Therapy.
- When prescribing ‘Start low and go slow’
- Reduce dose of renally elimainated medicines according to renal function.
- Manage polypharmacy.
- Treat based on goals of care – quality of life is always a goal; mortality (living longer) is sometimes a goal.
- Review each medicine regularly and discontinue unnecessary medicines.
- Titrate doses to effects.
- Communicate, have a plan agreed with the patient and check the patient/care-giver understands the plan.
Pharmacokinetic Issues
- Drug clearance declines by approximately 1% per year after the age of 40 years for all routes of elimination.
- With CKD renal drug clearance declines in proportion to GFR.
- Frailty is associated with decreased drug metabolism over and above the decrease associated with age.
Pharmacodynamic Issues
- Altered sensitivity (mostly increased) to most medicines causes:
- adverse drug reactions (ADRs), e.g. opioids and constipation.
- impaired ability to compensate for increased effects, e.g. antihypertensives and postural hypertension.
- increased susceptibility to toxicities, e.g. NSAIDs and nephrotoxicity.
- Increased PD interactions with polypharmacy: e.g. anticholinergic, serotonin syndrome, QT-prolongation.
- Medicines can contribute to falls (see Falls Assessment and Falls Prevention on Hospital HealthPathways).
- Medicines can contribute to delirium (see Delirium, Delirium in Palliative Care, and Non-specific Deterioration in an Older Adult on Hospital HealthPathways).
Pharmaceutic Issues
- Use appropriate dose forms:
- Understand modified release dose forms.
- Some medicines are available in multiple formulations with different onset and duration of effect.
- Difficulty swallowing may require changing formulation so the patient can take their medicines.
- Loss of strength or co-ordination may limit use of some forms, e.g. inhalers and nasal sprays.
Medication Management
- Older, frailer patients have more medicines which increases the complexity of medicine management.
- The rate of adverse events increases exponentially with the number of medicines a patient is on.
- The patient or caregiver should be confident about taking the prescribed medicines, aided by:
- Verbal counselling from doctor, pharmacist, and/or nurse.
- Patient Information Leaflets (PILs).
- Providing or updating the patient's yellow medications card. Discuss with ward pharmacist.
- Employing a compliance aid e.g. blister pack when appropriate. Discuss with ward pharmacist.
- Community medication management service may be available. Discuss with ward pharmacist.
Topic Code: 93232
