Lower doses should be considered in the elderly for all medicines.
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 DeliriumDelirium 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: