1. Prescribing for the Oldest Old
Dr Angela Kydd: Associate Professor Edinburgh Napier University
Dr Anne Fleming: Independent Researcher 1

2. Why is this Important Global increase in the number of ‘oldest old’
People aged report similar functional issues as those aged 45-64
25% of people aged 85+ report moderate to severe limitations
Over the age of 65, 65% of people will have more than one chronic disease
Over the age of 85, 82% of people will have more than one chronic disease

3. The Hippocratic oath (5th Century)
I will apply, for the benefit of the sick, all measures that are required, avoiding those twin traps of overtreatment and therapeutic nihilism…I will remember that there is an art to medicine as well as a science, and that warmth, sympathy and understanding may outweigh the surgeons knife or the chemists drug…I will remember that I will not treat a fever…but a sick human being whose illness may affect the person’s family and economic stability. My responsibilities include these related problems, if I am to care adequately for the sick.

4. It is clear that doctors take these responsibilities seriously
It is clear that doctors take these responsibilities seriously. Guidelines cannot replace clinical judgement
Invite the audience to consider this point

5. January 2006-January 2016 Full text English language Literature Search
Data Sources:
Medline, Pubmed, CINAHL, Cochrane Library, ASSIA Pyschinfo, Google Scholar, Google
Inclusion criteria
January 2006-January 2016
Full text
English language

6. Articles Sourced 94 articles sourced Restricted to 2010 = 72 articles
Articles reviewed and further 23 rejected
Total 49 articles
Justification for 2010

7. Results 1. Potentially inappropriate medication
2. Geriatric Assessment
3. Clinical decision making
4. General practitioner training

8. Potentially inappropriate medication
Increase in age, disease and thus treatments, can result in polypharmacy and adverse drug events (ADE).
ADE accounts for 13% of 2 medications; 58% 5 medications and 82% with 7 or more medications
85+more susceptible to potentially inappropriate prescribing (PIP) and potentially inappropriate medications (PIMs)
Guidelines focus on single disease management
All drug related hospital admissions account for a small number of frequently used drugs
Excessive medications lead to poor adherence

9. Geriatric Assessment
Number of drugs coupled with history of adverse drug reactions (ADR) common predictor of ADEs.
Other risk factors: liver disease, heart failure and the presence of 4 or more conditions
4 most common multiple chronic conditions hypertension, dyslipidaemia, atrial fibrillation and type 2 diabetes
Some drugs for over 85s used for long term prevention. A study of 85 + patients found that they took on average 6.8 drugs – 3 for symptom relief and 3.8 for risk factor modification
GerontoNET ADR risk score (inpatients)
Burden of treatment has led to Ariandine principles of treatment (Patient at centre – all professionals involved)
Ariande NOT Ariandine

10. 3. Clinical decision making
Need for ‘rational pharmacology – what is acceptable and beneficial to the patient?
Evidence based practice for single disease management not helpful
Specialisation not preferable to generalisation
GPs work in isolation
Guidance developing - Beers criteria
(1991) STOPP, (2003), STOPP/START (2014)

11. 4. General Practitioner Training
Multimorbity affects 60% of people seeking primary care – GPs at the coal face
Scant training on the oldest old
Knowledge on frailty is not commonplace
GPs do not carry out a Comprehensive Geriatric Assessment
72% of one survey of doctors (n=89) felt inadequate knowledge was major cause of PIP

12. Summary Consultation with the individual and their family/carer
Need for frailty focussed services
To identify the oldest old as a group
Multidisciplinary input to include a pharmacist
Guidelines for the management of more than one chronic condition

13. I will remember that there is an art to medicine as well as a science, and that warmth, sympathy and understanding may outweigh the surgeons knife or the chemists drug…I will remember that I will not treat a fever…but a sick human being whose illness may affect the person’s family and economic stability.

14. Thank You