1. Prescribing and deprescribing in the frail older adult Clare Bostock and Bob Caslake Specialist Registrars in Geriatric Medicine

2. Principles of drug review list 1.Identify current indication for medication. 2.Is the drug probably or possibly causing harm? (i.e. some of the patient’s problems could be attributable to known side effects of the drug).If YES  reduce or stop

3. 3. Is the drug being given for a condition/symptom that is now well-controlled/resolved or is no better despite using the drug? (e.g. blood pressure, oedema, pain, dyspepsia, agitation). If YES  reduce or stop 4. Is it possible that long term use of this drug may cause harm? (e.g. anticholinergic drugs, sedative drugs). If YES  reduce or stop

4. 5. Is the drug likely to provide any prognostic benefit within the patient’s expected life time? If NO  reduce or stop 6. Is there any medication that could be prescribed to improve the health and wellbeing of the patient? If YES  start

5. Case 1 96 y/o man referred to OPC with wt loss. Graze on his forehead and left shoulder. Got up to answer the phone a few weeks ago, felt dizzy and fell to the floor hitting his head. On examination he also has evidence of ankle oedema and quadriceps wasting and has some slight difficulty rising from a chair. He is mobile with one stick and has not had angina for many years. He does not use his GTN spray. What advice would you give to the patient and GP regarding medications?

6. Current medication Monomax XL (Isosorbide mononitrate MR) 30mg od Amlodipine 10mg od GTN spray prn Atorvastain 10mg od Tamsulosin 400micrograms od Co-codamol 30/500 2 tabs prn Indoramin 20mg od Aspirin recently discontinued due to nose bleeds.

7. Case 2 79 y/o man referred to clinic with a dry mouth. Also problems with urinary frequency and constipation. GP recently started a tablet to “help his water works.” His wife thinks he has been a bit more muddled than usual, and she tells you that he fell over last week. Positive findings on examination are a loaded rectum on PR, and dullness suprapubically. What medications may be contributing to his symptoms? What drugs may be contributing to “anticholinergic burden”? What suggestions would you make to his GP?

8. Current medication Ranitidine 150mg bd Co-codamol 15/500 2 tabs prn Amitriptyline 25mg nocte Tolterodine XL 4mg od Aspirin 75mg od Fexofenadine x mg od Atenolol 25mg od Amlodipine 10mg od GTN spray 2 puffs prn.

9. Case 3 An 82 y/o man is admitted with confusion. No reliable history from the patient. His family think he is more confused than usual. You telephone his GP for a patient summary and current list of medications. Past medical history: Depression 2007, Hypertension 1990, Ischaemic heart disease 1992, COPD 2000, Appendicectomy 1945. On examination he is delirious, T37, HR 80, BP 110/50, O2 sats 92% on air. Examination is otherwise normal. The biochemist phones to inform you that sodium is 118. Other blood parameters are within normal limits. What factors are contributing towards his delirium? What medications will you prescribe?

10. Current medication Aspirin 75mg od Simvastatin 40mg nocte Omeprazole 20mg od Temazepam 10mg on Tiotropium 18micrograms od Seretide 500 accuhaler 1 puff bd Salbutamol easibreathe 2 puffs prn Bendroflumethiazide 2.5mg od Citalopram 20mg od Co-codamol 30/500 2 tabs qds.

11. Case 4 87y/o lady transferred from A&E Fell yesterday and broke right wrist, hurting her knee in the process Now struggling to mobilise PMHx of osteoporosis and hypothyroidism O/E: Right wrist in POP, requires assistance of two to transfer bed to chair, irregular pulse ECG confirms AF What would you like to prescribe?

12. Current medication Thyroxine 75 micrograms OD Dihydrocodeine 30ng PRN

14. Advanced case 87 year old woman. PMHx of hypertension, type 2 diabetes, turn diagnosed as a TIA in 1999. Independent at home until a few months ago when she had a fall, resulting in a swollen, painful knee. Since then, increasingly struggling at home with further falls, incontinence of urine and sometimes faeces and increasing confusion. She stops going to her crochet group. Rapidly increasing care needs. Crisis point reached when her daughter, how provides a lot of support, goes in to hospital for a knee replacement. Found on the floor by her carer one morning and brought to A&E. On examination: BP 89/58, pulse 122 irreg, T35.2, BMI 28, pitting oedema of both, mild abdominal distension with lower abdominal tenderness and a strong smell of urine. A&E diagnose with urosepsis, give her IV amoxicillin and gentamicin and admit her to Woodend. Investigations: ECG-AF, bloods: Na 126, Creat 240 (was 124 at time of wrist fracture), WCC 8.6, CRP<4.

15. Advanced current medication Aspirin 75mg od Dipyridamole MR 200mg BD Bendroflumethiazide 2.5mg od Doxazosin MR 8mg od Ramipril 5mg od Felodipine MR 5mg od Simvastatin 20mg od Tramadol MR 100mg BD Omeprazole 20mg od Arthrotec 75 (Diclofenac and misoprostol) 1 tablet BD Furosemide 40mg od Glimepiride 4mg od Quinine Sulphate 200mg at night Temazepam 10mg nocte Oxybutinin MR 10mg od