Appropriate prescribing in the elderly: Current perspectives

Table 8 Clinical example

An 80-year-old lady is referred with a four day history of general malaise, nausea, vomiting and recurrent falls. Her past medical history includes paroxysmal atrial fibrillation, non-obstructive coronary artery disease, hypertension, recurrent episodes of acute gout, dependent lower limb edema and “vertigo/dizziness”. Prior to this episode she was functionally independent and had normal cognition
Her medications were as follows: Simvastatin 40 mg daily; Verapamil 240 mg daily; Quinine Sulphate 300 mg daily, Perindopril 5 mg/Indapamide 1.5 mg daily; Digoxin 250 mcg daily; Diclofenac 75 mg twice daily; Frusemide 40 mg daily; Betahistine 16 g three times per day; Paracetamol 1 g as required; Warfarin as per INR (target INR 2-3); Flurazepam 30 mg nocte. She was not taking OTC medications
On assessment she was pale and tired. Supine blood pressure was 122/70 mmHg; erect blood pressure after one minute was 92/62 mmHg
Pulse was 52 beats per minute. She had no clinical signs of congestive cardiac failure. She scored 9/10 on a short mental test score
Investigations showed a eGFR of 38 mL/min, serum potassium 2.8 mmol/L (low) and serum sodium 126 mmol/L (low). Haemoglobin was 10.2 g/dL with MCV 72fl (hypochromic microcytic anemia)
When evaluating the appropriateness of an older person’s prescription medications it is important to consider the following two questions:
1 Is there a clinical indication for the drug?
2 Could the drug be contributing to the presenting symptoms?
Using this approach each medication should be evaluated in turn and corrective action implemented
Medication	Clinical indication?	Contributing to presenting symptoms?	Action taken?
Simvastatin 40 mg	Yes (hyperlipidaemia, high cardiovascular risk)	Could cause muscle cramps and myopathy which could lead to falls (note patient prescribed quinine)	Check fasting lipid profile and creatine phosphokinase. Revise dose according to target lipid levels
Verapamil 240 mg	Yes (hypertension, arrhythmia)	Could cause hypotension and bradycardia. Increased risk of myopathy when prescribed with simvastatin	Consider discontinuation. Beta-blocker may be more appropriate choice as rate controlling agent
Quinine 300 mg	No clear indication	No	Muscle cramps may be due to statin. Review choice of statin. Discontinue Quinine
Perindopril 5 mg	Yes (hypertension)	Could contribute to postural hypotension and acute renal injury	Consider temporary withdrawal while investigating cause of renal dysfunction
Indapamide 1.5 mg	Yes (hypertension)	Could contribute to postural hypotension, acute renal injury, hyponatraemia and hypokalaemia. Can precipitate digoxin toxicity, hyperuricaemia and recurrent episodes of gout	Discontinue
Digoxin 250 mcg	Yes (atrial fibrillation)	Symptoms of digoxin toxicity. Dose too high given level of renal dysfunction	Discontinue. Beta-blocker may be more appropriate choice of rate controlling agent
Diclofenac 75 mg	Yes (acute gout)	Yes. Diclofenac may be causing renal impairment. Gastritis/peptic ulcer disease should also be considered because of nausea, vomiting and microcytic anemia. NSAIDs should not be prescribed with warfarin because of significantly increased risk of bleeding	Discontinue. Consider addition of allopurinol for gout prophylaxis
Frusemide 40 mg	Yes (hypertension)	Yes (hypotension, hyponatraemia, hypokalaemia, renal impairment)	Frusemide is not required as an anti-hypertensive in this patient. It has been prescribed to treat dependent lower limb edema. Leg elevation and compression stockings would be more appropriate
Betahistine 16 mg	No (prescribed for dizziness which is actually related to orthostatic hypotension)	No	Discontinue. No indication
Paracetamol 1 g	Yes (pain)	No	Continue
Warfarin	Yes (atrial fibrillation embolic prophylaxis)	May be contributing to anemia. Should not be co-prescribed with diclofenac as there is an increased risk of bleeding	Investigate cause of anemia. Consider future suitability for anticoagulation if high falls risk persists
Flurazepam 30 mg	No	Yes (falls, malaise)	Contact GP and pharmacy for prescription history. Do not suddenly discontinue because of risk of benzodiazepine withdrawal

INR: International normalized ratio; OTC: Over-the-counter; eGFR: Estimated glomerular filtration rate; MCV: Mean corpuscular volume.