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Prescribing for older people
- Peter M Lapsley (14 March 2008)
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The Pen is Mightier Than the Sword.
- Philip M Dainty, Stafford General Hospital. (16 March 2008)
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Adherence and the dosset box
- Mohammed A Butt, Mallick S, F1 elderly care medicine, Syed Y ST2 general medicine, O'Neal H, consultant physician in medicine for the elderly (19 March 2008)
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buying time and making trade-offs is th art of succesful ageing
- oscar,m jolobe (19 March 2008)
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Adverse drug reactions and prescribing in older people
- Simran Gandhi, Sunku H Guptha, Consultant Physician (21 March 2008)
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Internet Access
- John H Ferriman, Tom Owen (18 April 2008)
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Is age the key determinant of prescribing demand? Results from the ASSET (Age/Sex Standardised Estimates of Treatment) study
- Giampiero Favato (28 April 2008)
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We need more CME on geriatric pharmacology
- Om Prakash (1 May 2008)
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Peter M Lapsley, Patient editor, BMJ, BMA House, Tavistock Square, London WC1H 9JR
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In their paper , Milton et al provide useful guidelines for prescribing for older people. Such prescribing has as much to do with practicability as with safety and efficacy. Patients who find it difficult to self-administer treatments may well stop taking them. My step-mother is 91-years old with severe macular degeneration and fingers markedly less nimble than they once were. She lives at home, on her own, with a carer coming in most days. She is reluctant to accept help of any sort, fearing that to do so would be further to surrender her independence. She is meticulously adherent to the treatment regimens prescribed for her. Amongst two or three other medications, she takes digoxin for arrhythmia - two tablets daily to make up the total dose. The tablets are 5mm in diameter. One used to be pink, the other blue. They are now pink and white respectively. She is not sure what they are for but knows she has to take one pink one and one white one at breakfast time each morning. Recently, when she insisted on taking them unaided, I watched for a full five minutes as she wrestled with the blister pack, becoming increasingly agitated and frustrated, and losing one pill on the floor before eventually I intervened. Since then, she has been provided with a unit dose box with single, daily compartments into which her carer decants the tablets. This helps, but she still struggles with such tiny pills, quite frequently dropping and losing one and then having to engage in a sometimes protracted search. The Association of the British Pharmaceutical Industry (ABPI) say that the move to blister packs is driven by European legislation, which requires each patient to be given a patient information leaflet with any medication they receive. Additionally, the manufacturing rules require that medicines should be in a tamper-proof packs and presented in as child -resistant form as possible. It is this, they say, that has led to the development of the medicine pack consisting of the packaging and label, the patient information leaflet and the medicine itself. They say also that blister packs make counterfeiting more difficult. They point out that many pharmacies offer assistance by loading unit dose boxes for patients and that, under their new contract, pharmacists are now more likely to provide this type of service. The ABPI say that potentially confusing changes of pills’ colours are due to the fact that, while branded medicines are required to be consistent in terms of size and colour, no such requirement is placed on the manufacturers of generic treatments. All these issues – blister packs, very small pills and variations in pill colours – make life difficult for patients, especially those with poor eyesight, limited dexterity or both, and they need to be addressed. It seems very unlikely that the pharmaceutical industry’s drive to have all pills provided in blister packs will be halted or reversed. National healthcare regulators could and should, however, require pills to be of a minimum size (say 10mm), and the manufacturers of generics should be required to provide pills and capsules similar in colour to their branded equivalents. In the meantime, doctors need to be aware of the sizes of the pills they prescribe, and of the implications for patients of small pill sizes, which could be achieved by simple descriptions of pill and capsule sizes in the formulary publications to which they refer. ENDS Competing interests: The writer is patient editor of the bmj. |
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Philip M Dainty, Specialist Registrar Geriatric Medicine Mid-Staffs Foundation Trust, Stafford General Hospital.
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Sir, Milton et al (1) are to be congratulated for both raising awareness of, and providing guidance to improve, the problems of substandard prescribing practice in the elderly. Within the general adult population, adverse drug reactions have been shown to contribute significantly to emergency admissions (and subsequent costs and complications thereof)(2), with numbers likely to be proportionally higher among elderly patients (3). For most practitioners, the most dangerous and risky thing that we will ever do professionally is put pen to paper and prescribe. Given this, it is essential that attention is paid to robust teaching of pharmaclogy and safe prescribing at undergraduate level, before costly mistakes can be made and bad habits established. This fact is increasingly recognised by newly qualified doctors, significant proprtions of who feel underprepared for this 'basic' clinical task(4). Improved undergraduate education is only the starting point of improving standards of prescribing. More seasoned physicians must lead by example, and evidence-based medicine, for all its plus points, must be scrutinised more carefully with particular consideration of inclusion and exclusion criteria. A wise man once said the 'the pen is mightier than the sword'. In modern medical care this has never been truer. (1) Milton JC, Hill-Smith I and Jackson SHD. Prescribing for Older People. BMJ, 2008: 336; 606-609. (2) Pirmohammed M, James S, Meakin S et al. Adverse drug reactions as cause of admission to hospital: prospective analysis. BMJ, 2004: 329; 15- 19. (3) Col N, Fanale JE, Kronholm P. The role of medication noncompliance and adverse drug reactions in hospitalizations of the elderly. Arch Int Med, 1990: 150; 841-845 (4)Tobaiqy M, McLay J and Ross S. Foundation year 1 doctors and clinical pharmacology and therapeutics teaching. A retrospective review in light of experience. Br J Clin Pharmacol, 2007; 64(3): 363-372 Competing interests: None declared |
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Mohammed A Butt, ST2 general medicine Department of elderly care medicine, Worthing Hospital, Sussex BN11 2DH, Mallick S, F1 elderly care medicine, Syed Y ST2 general medicine, O'Neal H, consultant physician in medicine for the elderly
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Milton et al write an excellent review on factors related to prescription in the elderly [1]. However, they omit the problem of poor compliance with multiple prescriptions noted in this population. Poor adherence reduces the clinical effectiveness of treatment, and in some patients with epilepsy for example, may raise significant safety issues. Furthermore, it is of importance when assessing the cost effectiveness of treatment. In the elderly poor adherence is due to several factors; difficulty of patients organising themselves to take often complex medication regimes, a belief that they are well so they don’t need the tablets, apathy, and an inability to remember if and when a tablet has been taken. Whilst the ‘guidelines for good prescribing in elderly patients’ described in Milton’s review will help improve compliance, they did not mention a key tool used specifically to increase adherence to treatment in elderly populations; ‘the dosset box’. In secondary care astute nursing staff normally highlight the possible requirement for medication delivery via a dosset box. Pharmacists usually then perform a comprehensive assessment scoring compliance issues with the patient [Table 1]. After completion, the general practitioner and local pharmacy are informed ensuring continuity of the system on discharge. ________________________________________________________ Table 1: Pharmacists medication compliance questionnaire ________________________________________________________ What assistance does the patient currently have? Is the medication regime stable? Can the medications be packaged in dosset boxes? Can the medications be simplified? Can the patient read label instructions? Can the patient understand instructions? Can the patient remember when medicines are due? Can the patient differentiate between regular and prn medication? Does the patient understand the reason for each medicine? Does the patient know when to order medicines? Can the patient open and close boxes? Can the patient pop out tablets from a calendar pack? Can the patient open CRC (child resistant cap) lids? Can the patient open screw lids? Can the patient measure out a liquid? Can the patient swallow medication safely? ________________________________________________________ Dosset boxes consist of a plastic grid with clear windows, labelled with the time for medication and the days of the week. They improve adherence by clearly displaying medication required, and highlight missed doses to both patients and their carers. There is extensive evidence of the benefits in elderly patients of organised packs on adherence by pill counts [2,3], and treatment outcomes by clinical measures [4] in comparison to normal delivery systems without an organiser. The evidence underlines the benefits of the dosset box for medication delivery in the elderly. References: 1. Milton JC, Hill-Smith I, Jackson SHD. “Prescribing for older people.” BMJ 2008;336:606-609. 2. Wong BS, Norman DC. “Evaluation of a novel medication aid, the calendar blister-pack, and its effect on drug compliance in a geriatric outpatient clinic.” J Am Geriatr Soc 1987;35:21–6. 3. Ware GJ, Holford NH, Davison JG et al. “Unit dose calendar packaging and elderly patient compliance.” NZ Med J 1991;104:495–7. 4. Schneider PJ, Murphy JE, Pedersen CA. “Impact of medication packaging on adherence and treatment outcomes in older ambulatory patients.” J Am Pharm Assoc (2003) 2008 Jan-Feb;48(1):58-63. Competing interests: None declared |
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oscar,m jolobe, retired geriatrician manchester medical society, c/0 john rylands university library, oxford road, manchester M13 9PP
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Such are the hazards of medication in older people(1) that succesful ageing might well be defined as the art of buying time and making trade- offs between symptoms one can put up with vs hazards of medical intervention. The operation of this priciple is exemplfied by the management of age-related disorders such as benign prostatic hypertrophy, hypertension, atrial fibrillation(AF), and primary hypothyroidism. For those who want to make a trade-off between lower urinary tract symptoms and procedure-related risks of trans-urethral prostatectomy, a range of options was recently outlined for buying time so as to delay surgical intervention(2). For those who have hypertension and wish to buy time so as to delay the onset of hypertension-related atrial fibrillation, losartan might be the treatment of choice due to its ability to reduce the incidence of hypertension-related new-onset AF(3). For those who already have AF and have the misfortune of having co-existing primary hypothyroidism(4) buying time might consist of avoiding injudicious and, perhaps, inappropriate thyroid replacement therapy given the fact that injudicious treatment can cause an abrupt increase in metabolic rate which may precipitate congestive heart failure. Accordingly, masterly inactivity may well be the management strategy of choice for AF patients with mild to moderate degrees of hypothyroidism. Favouring masterly inactivity in the "oldest old" with primary hypothyroidism is a study which enrolled 599 subjects aged 85, including 67 with levels of thyroid stimulating hormone(TSH) in the range 4.86-33 miu/L(all hypothyroid) These subjects were followed up for an average period of 3.7(standard deviation 1.7) years. Over that period, increasing TSH levels at baseline "were associated with a significant decelerated increase in disability"(5).Furthermore, "participants with abnormally high thyrotropin levels and abnormally low levels of free thyroxine had the lowest mortality rate(Cox regression, P for trend=0.03)"(5). Twenty five of the 67 hypothyroid subjects had TSH levels < 10 miu/L in association with normal levels of free thyroxine. According to the recent proposal for an age-specific reference range for TSH(6), many of the hypothyroid patients in the subgroup in whom TSH < 10 miu/L co-existed with normal levels of free thyroxine would have been categorised as euthyroid. The authors of the study(6) held the view that in elderly subjects previously categorised as hypothyroid but now categorised by the new criteria as euthyroid "unnecessary treatment with levothyroxine might not provide benefit and could adversely affect their health"(6). References (1) Milton JC., Hill-Smith I., Jackson SHD Prescribing for older people British Medical Journal 2008:336:606-9 (2) Wilt TJ., N'Dow J Benign prostatic hyperplasia Part 2-Management British Medical Journal 2008:336:206-10 (3) Wachtell K., Lehto M., Gerdts E et al Angiotensin II receptor blockade reduces new-onset atrial fibrillation and subsequent stroke compared to atenolol; The Losartan Intervention for End Point Reduction in Hypertension(LIFE) Study Journal of the American College of Cardiology 2005:45:712-9 (4) Cappola AR., Fried LP., Arnold AM et al Thyroid status, cardiovascular risk, and mortality in older adults: The cardiovascular health study Journal of the American Medical Association 2006:295:1033-41 (5) Gussekloo J., van Exel E., de Craen AJ et al Thyroid status, disability and cognitive function, and survival in old age Journal of the American Medical Association 2004:292:2591-9 (6) Surks MI., Hollowell JG Age-specific distribution of serum thyrotropin and antithyroid antibodies in the U.S. population: Implications for the prevalence of subclinical hypothyroidism Journal of Clinical Endoscrinology and Metabolism 2007:92:4575-82 Competing interests: None declared |
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Simran Gandhi, Senior House Officer Edith Cavell Hospital, Peterborough and Stamford NHSTrust, Peterborough, PE3 9GZ, Sunku H Guptha, Consultant Physician
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Dear Sir Prescribing in older people is complicated given the presence of multiple co-morbidities and age related changes in pharmacokinetics as described in their article by Milton et al.[1] The risk of an adverse drug reaction(ADR) increases with age and is proportional to the number of drugs prescribed and is often a cause for an acute medical admission.[2] In our audit on 32 consecutive admissions over a week to our ward in the department of medicine for older people, we found 22 patients(68%) had one or more ADRs at the time of their admission. Patients who had an ADR were older(mean age of 86 versus 83yrs) and were prescribed more drugs(5.13 versus 2.3 items). The most common prescriptions in patients with ADR were for cardiovascular illness(46%, 52/113) followed by paracetamol and opiate analgesics(12%), ulcer healing drugs(8%), bisphosphanates and calcium supplements(8%). Prescriptions for sedatives and tricyclic antidepressants(4%) and non steroidal anti-inflammatory agents(3%) were observed in only a minority of patients. The most frequent ADR that was definite was hypotension(41%) followed by electrolyte imbalance(32%). A number of patients(36%)had new onset anaemia with normal reticulocyte count and normal investigations into inflammatory, bleeding, nutritional, renal and liver disorders indicating a probable ADR. It is clear that ADRs in our older patients were commonly due to a prescription for cardiovascular illness and were often precipitated by an acute illness such as an infection. It is often necessary to temporarily discontinue these prescriptions while waiting for recovery from the acute medical illness. In some patients we had to discontinue the prescriptions but we were able to do this in a controlled hospital environment. It is difficult to see how a pharmacist or doctor can do this in the community without the provision of close supervision. References: 1. Milton JC, Hill-Smith I and Jackson SHD. Prescribing for Older People. BMJ, 2008: 336; 606-609. 2. Pirmohammed M, James S, Meakin S et al. Adverse drug reactions as cause of admission to hospital: prospective analysis. BMJ, 2004: 329; 15- 19. Competing interests: None declared |
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John H Ferriman, GP Monkseaton Medical Centre, Whitley Bay NE25 9PH, Tom Owen
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In the box of Additional Educational Resources two web sites are given under "information for patients." 71% of people over 65 had never accessed the internet in 2007 (National Statistics - Internet Access 2007. http://webapp.doctors.org.uk/Redirect/www.statistics.gov.uk/pdfdir/inta0807.pdf ) We need to provide information in the form users are likely to access. Competing interests: None declared |
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Giampiero Favato, Academic Fellow Henley Management College, Greenlands, RG9 3AU UK
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Understanding the determinants of demand for pharmaceuticals is critical for a better assessment of the forces that increase prescribing expenditures. Ageing and technological change play a major role in this context with cohorts living longer that consume increasing amounts of intensive, previously unavailable treatments. The primary objective of the ASSET study (1) was to make the first step in the modelling of pharmaceutical demand in Italy, by deriving a weighted capitation model to account for demographic differences among general practices. The experimental model was called ASSET (Age/Sex Standardised Estimates of Treatment). Individual prescription costs and demographic data referred to 3,175,691 Italian subjects were collected directly from three Regional Health Authorities over the 12-month period between September 2004 and August 2005. The mean annual prescription cost per individual was similar for males (196.13 euro) and females (195.12 euro). After 65 years of age, the mean prescribing costs for males were significantly higher than females. On average, a 75 year old subject would cost 12 times a 25-34 years old one if male, 8 times if female. Subjects over 65 years of age (22% of total population) accounted for 56% of total prescribing costs. The ASSET weightings were able to explain only about 25% of the variation in prescribing costs among individuals: the causes of the remaining 75% variation in prescribing costs remained unknown. The magnitude of individual variance was extremely significant: the individual costs value in the ASSET sample ranged between 0 and >40,000 euros. The ASSET sample included the registered persons who did not receive any prescription in the same time period: 808,464 subjects (26% of the total sample) did not receive a prescription, of whom 488,120 males (32% of total males) and 320,344 females (20% of total females). From a different perspective, the ranking by total pharmaceutical annual cost of the 50,000 individuals included in the randomly drawn sample utilised to test the ASSET model, showed that the first decile of highest spending subjects was associated with 51.4% of total pharmaceutical spending. The ranking of individual prescribing costs in descending order suggested a possible explanation to the poor ASSET’s power to predict individual prescribing costs: the top decile of subjects in the sample actually used 64.4% of the total pharmaceutical resources, while they should have used just 19% of them according to the age/sex standardised estimates. If age is a marginal predictor of prescribing cost variance, the analysis of individual cost data for the top decile “high spenders” subjects did not provide additional elements to better identify a priori those individual subjects. Therapeutic needs seemed to have a certain importance as drivers of prescribing costs. 75% of the top decile subjects reported prescribing costs in an individual ATC class higher than 50% of total individual costs. This would suggest the relevance of specific clinical conditions as drivers of unusually elevated individual prescribing costs. The limited identification of the factors driving unusually high individual prescribing costs represented the major limitation of the ASSET model, and, at the same time provided a valuable opportunity to conduct further research to explore the determinants of large individual variations in individual prescribing needs. Age and clinical needs certainly play a key role in this mechanism of exponential growth of pharmaceutical prescribing, but other factors should be taken into consideration. Our data did not permit to obtain the diagnoses leading to prescription: this also should be an area for further research to determine the potential correlation between the rarity and the severity of diagnosed disease with the cost of treatment. Additional determinants of prescribing demand should have been considered, such as morbidity and mortality ratios, chronic illness rates, deprivation and access to healthcare, together with other relevant socioeconomic determinants, like disposable income and level of education. Differences in prescribing patterns among general practitioners should also further investigated, to determine the relevance of the prescribing effect on individual cost differences. (1) Favato G, Mariani P, Mills RW, Capone A, Pelagatti M, et al. (2007) ASSET (Age/Sex Standardised Estimates of Treatment): A Research Model to Improve the Governance of Prescribing Funds in Italy. PLoS ONE 2(7): e592. doi:10.1371/journal.pone.0000592 Competing interests: None declared |
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Om Prakash, Assistant Professor of Psychiatry Geriatric Clinic & Services, Department of Psychiatry, NIMHANS, Bangalore, INDIA
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I found the review on drug prescription in the elderly by Milton et al. (1) timely and comprehensive. The review highlighted various issues related to the most neglected patient population. I would suggest more CME/workshops/seminars on geriatric pharmacology so that general practitioners may learn the right prescription for the elderly. They must learn drug-drug interactions, side effect profile and dosage of various pharmacological agents. The Medical Associations should make this a priority. REFERENCE 1.James C Milton, Ian Hill-Smith, and Stephen H D Jackson. Prescribing for older people. BMJ 2008; 336: 606-609. Competing interests: None declared |
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