Adverse reactions often present in the elderly in a vague and non-specific fashion. Confusion is often the presenting symptom (caused by almost any of the commonly used drugs). Other common manifestations are constipation (with antimuscarinics and many tranquillisers) and postural hypotension and falls (with diuretics and many psychotropics).
Hypnotics Many hypnotics with long half-lives have serious hangover effects, including drowsiness, unsteady gait, slurred speech, and confusion. Hypnotics with short half-lives should be used but they too can present problems (section 4.1.1). Short courses of hypnotics are occasionally useful for helping a patient through an acute illness or some other crisis but every effort must be made to avoid dependence. Benzodiazepines impair balance, which can result in falls.
Diuretics Diuretics are overprescribed in old age and should not be used on a long-term basis to treat simple gravitational oedema which will usually respond to increased movement, raising the legs, and support stockings. A few days of diuretic treatment may speed the clearing of the oedema but it should rarely need continued drug therapy.
NSAIDs Bleeding associated with aspirin and other NSAIDs is more common in the elderly who are more likely to have a fatal or serious outcome. NSAIDs are also a special hazard in patients with cardiac disease or renal impairment which may again place older patients at particular risk.
Owing to the increased susceptibility of the elderly to the side-effects ofNSAIDs the following recommendations are made:
• for osteoarthritis, soft-tissue lesions, and back pain, first try measures such as weight reduction (if obese), warmth, exercise, and use of a walking stick;
• for osteoarthritis, soft-tissue lesions, back pain, and pain in rheumatoid arthritis, paracetamol should be used first and can often provide adequate pain relief;
• alternatively, a low-dose NSAID (e.g. ibuprofen up to 1.2 g daily) may be given;
• for pain relief when either drug is inadequate, paracetamol in a full dose plus a low-dose NSAID may be given;
• if necessary, the NSAID dose can be increased or an opioid analgesic given with paracetamol;
• do not give two NSAIDs at the same time.
For advice on prophylaxis of NSAID-induced peptic ulcers if continued NSAID treatment is necessary, see section 1.3.
Other drugs Other drugs which commonly cause adverse reactions are antiparkinsonian drugs, anti-hypertensives, psychotropics, and digoxin. The usual maintenance dose of digoxin in very old patients is 125 micrograms daily (62.5 micrograms in those with renal disease); lower doses are often inadequate but toxicity is common in those given 250 micrograms daily. Drug-induced blood disorders are much more common in the elderly. Therefore drugs with a tendency to cause bone marrow depression (e.g. co-trimoxazole, mian-serin) should be avoided unless there is no acceptable alternative.
The elderly generally require a lower maintenance dose r of warfarin than younger adults; once again, the out- s come of bleeding tends to be more serious. ri i
Always consider whether a drug is indicated at all. h
Limit range It is a sensible policy to prescribe from a l limited range of drugs and to be thoroughly familiar with er their effects in the elderly. ly
Reduce dose Dosage should generally be substantially lower than for younger patients and it is common to start with about 50% of the adult dose. Some drugs (e.g. long-acting antidiabetic drugs such as gliben-clamide) should be avoided altogether.
Review regularly Review repeat prescriptions regularly. In many patients it may be possible to stop some drugs, provided that clinical progress is monitored. It may be necessary to reduce the dose of some drugs as renal function declines.
Simplify regimens Elderly patients benefit from simple treatment regimens. Only drugs with a clear indication should be prescribed and whenever possible given once or twice daily. In particular, regimens which call for a confusing array of dosage intervals should be avoided.
Explain clearly Write full instructions on every prescription (including repeat prescriptions) so that containers can be properly labelled with full directions. Avoid imprecisions like 'as directed'. Child-resistant containers may be unsuitable.
Repeats and disposal Instruct patients what to do when drugs run out, and also how to dispose of any that are no longer necessary. Try to prescribe matching quantities.
If these guidelines are followed most elderly people will cope adequately with their own medicines. If not then it is essential to enrol the help of a third party, usually a relative or a friend.
Prescribing in dental practice
The following is a list of topics of particular relevance to dental surgeons.
Advice on the drug management of dental and oral conditions has been integrated into the BNF. For ease of access, guidance on such conditions is usually identified by means of a relevant heading (e.g. Dental and Orofacial Pain) in the appropriate sections of the BNF.
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