(seconds) afterwards 9 If clinical suspicion is high, and the result of right-sided massage is negative, repeat on the left side 124 CHAPTER 5 Falls and funny turns Falls clinics The assessment and secondary prevention of falls are complex processes best p erformed by an experienced MDT with expert knowledge, func- tioning within a \200\230falls clinic \200\231. Falls clinics have become much more common, initially a result of trials showing the power of multidisciplinary interventions to reduce falls in community-dwelling older people. More recently, the NSF has required universal UK provision. The team structure, diagnostic approach, and delivery of care varies enormously, but there are broadly two complementary approaches taken by falls clinics: \200 Focus on identifyin g and reducing syncope and near-syncope, with careful drug review and a low threshold to fu rther investigation including tilt table testing and arrhythmia detection More global approach in which cardiovascular evaluation is an important but minor part of the assessment Re \202 ecting the differing approaches, some clinics (often those practicing a more medic al model) take place in outpatient clinics, while others occur in DHs and are more routinel y multidisciplinary. Falls clinics are often led and delivered by non-physician health professionals such as exp erienced nurses, occupational therapists, and physiotherapists. Screening for modi \201 ab le medical factors should be a routine part of all assessments, with referral to a medical specialist (eg GP with a special interest (GPSI) or geriatrician) if such factors are ident i \201 ed. Referral criteria Falls are so common that health services would be swamped if all who had fallen were referred. Instead, refer those with more sinister features sug- gesting a likel ihood of recurrent falls, injury or an underlying remediable medical cause. Referral criter ia might include: \200 Recurrent ( (cid:116) 2) falls \200 Loss of consciousness , sync ope, or near-syncope \200 Injury , especially fracture or facial injury (the latter sugge sting poor saving mechanisms or loss of consciousness) Polypharmacy ( (cid:116) 4 drugs) Sources of patients include: \200 ED (assess most peopl e with non-operatively managed fractures) \200 Acute orthopedic units (hip and other oper atively managed fractures) \200 GP or community nurse \200 Medical wards \200 Self-pr esenting . Some services advertise directly, via posters and other media Further reading Gillespie LD , Robertson MC , Gillespie WJ , et al . ( 2009 ). Intervention s for preventing falls in older people living in the community . Cochrane Database Syst Rev 2 : CD007146 . 125 Chapter 6 Drugs Pharmacology in older patients 126 Prescribing \200\230rules \200\231 128 Taking a drug hi story 130 HOW TO Improve concordance 132 Drug sensitivity 134 Adverse drug reactions 135 ACE inhibitors 136 HOW TO Start ACE inhibitors 137 Amiodarone 138 HOW TO Manage amiodarone-induced thyroid dysfunction 139 Analgesia 140 HOW TO Manage pain in older patients 141 Steroids 142 Warfarin 144 HOW TO Initiate warfarin 146 HOW TO Manage drug-induced skin rashes 147 Proton pump inhibitors 148 Herbal medicines 149 Breaking the rules 150 126 CHAPTER 6 Drugs Pharmacology in older patients Perhaps the most common intervention performed by physicians is to write a prescription. Older patients will have more conditions requiring medication; polypharmacy is common. In the developed world: The over 65s typically make up around 14 % of the population yet consume 40 % of the drug budget 66 % of the over 65s, and 87 % of the over 75s are on regular medication 34 % of the over 75s are on three or more drugs \200 Care home patients are on an average of eight medications Good prescribing habits are essential for any medical practitioner, b ut especially for the geriatrician. Administration challenges include: \200 Packaging may make tablets hard to access \200 \224 childproof bottles and tablets in blister packets can be impossible to open with arthritic hands or poor vision Labels may be too small to read with failing vision \200 Tablets may be large and dif \201 cult to swallow (eg co-amoxiclav) or have an unpleasant taste (eg potassium supplements) Liquid formulations can be useful, but accurate dosage becomes harder (especially where manual dexterity is compromised) Any tablet needs around 60mL of water to wash it down and prevent adherence to the oesophag eal mucosa \200\224 a large volume for a frail older person. Some tablets (eg bisphosphona tes) require even larger volumes Multiple tablets, with different instructions (eg before/after food) are easily muddled up, or taken in a suboptimal way Some routes (eg topical to back) may be impossible without assistance Absorption \200 Many factors are different in older patients (increased gastric pH, delay ed gastric emptying, reduced intestinal motility and blood \202 ow etc.) Despite this, absorption of drugs is largely unchanged with age \200\224 exceptions include iron and calcium, which are absorbed more slowly Distribution \200 Some older people have a very low lean body mass, so if the therapeutic index for a drug is narrow (eg digoxin) the dose should be adjusted There is often an increased proportion of fat compared with water. This reduces the volume of distribution for water-soluble drugs giving a higher initial con centration (eg digoxin). It also leads to accumulation of fat-soluble drugs, prolonging eli mination and effect (eg diazepam) \200 There is reduced plasma protein binding of drugs w ith age, which increases the free fraction of protein-bound drugs such as warfarin and furosemide PHARMACOLOGY IN OLDER PATIENTS 127 Hepatic metabolism \200 Speci \201 c hepatic metabolic pathways (eg conjugation) are una ffected by age Reducing hepatic mass and blood \202 ow can impact on overall function which slows metabo lism of drugs (eg theophylline, paracetamol, diazepam, nifedipine) Drugs that undergo extensive \201 rst pass metabolism (eg propranolol, nitrates) are most affected by the reduced hepatic function Many factors interact with liver metabolism (eg nutritional state, acute illness, smoking, other medications, etc.) Renal excretion \200 Renal function declines with age (see b \200\230The ageing kidney \200\231, p.384), which has a profound impact on the handling of drugs that are predominantly handled renally Drugs, or drugs with active metabolites, that are mainly excreted in the urine include digo xin, gentamicin, lithium, furosemide, and tetracyclines Where there is a narrow therapeutic index (eg digoxin, aminoglycosides) then dose adjustment for renal impairment is required (see UK British Nati onal Formulary ( BNF ) Appendix 3) \200 Impaired renal function is exacerbated by dehydra tion and urinary sepsis \200\224 both common in older patients 128 CHAPTER 6 Drugs Prescribing \200\230rules \200\231 1. Is it indicated? Treatment of new symptom Some sympt oms trigger a re \202 ex prescription (eg constipation \200\224 laxatives; dizziness \200\224 prochlorperazine). Before starting a medication, consider: \200 What is the diag nosis? (eg dizziness due to postural drop) \200 Can something be stopped? (eg opioid anal gesia causing constipation) \200 Are there any non-drug measures? (eg increase \201 bre for constipation) Optimizing disease management For example: a diagnosis of cardiac failur e should trigger consideration of loop diuretics, spironolactone, ACE inhibitors, and B -bl ockers. \200 Ensure the diagnosis is secure before committing the patient to multiple drugs (may be dif \201 cult where there is no clear diagnostic gold standard, eg with TIAs) Do not deny older patients disease modifying treatments simply to avoid polypharmacy Do not deny treatment because of potential side effects \200\224 while these may impact on functional ability, or cause signi \201 cant morbidity (eg low blood p ressure with B -blockade in cardiac failure) and need to be discontinued, this should usual ly be after a trial of treatment with careful monitoring Conversely, do not start treatment to improve mortality from a disease if the patient has l imited life span for other reasons (eg extreme frailty) Preventative medication For example: BP and cholesterol lowering. \200 Limited evidence b ase in older patients \200\224 be guided by biological \201 tness \200 Ensure the pati ent understands the rationale for treatment 2. Are there any contraindications? \200 Review past medical history (drug-disease intera ctions common) \200 Contraindications often relative, so a trial of treatment may be indi cated, but warn patient, document risk and review impact (eg ACE inhibitors when there is r enal impairment) 3. Are there any likely interactions? \200 Review the medication list \200 Computer pre scribing assists with drug \200\223drug interactions, automatically \202 agging up potential problems 4. What is the best drug? Choose the broad category of drug (eg which antihypertensive) by con- sidering which will work best in this patient (eg ACE inhibitors work less well in Afr ican Caribbeans), which is least likely to cause side effects (eg calcium channel blockers may worsen cardiac failure) and is there any potential for dual action? (eg a patient with angina could have a B -blocker for both angina and blood pressure control). PRESCRIBING \200\230RULES \200\231 129 Within each category of medication, there are many choices: \200 Develop a personal portf olio of drugs with which you are very familiar \200 Hospital formularies will often dicta te choices within hospital \200 Cost should be a consideration \200\224 eg simvastatin i s \200\230off patent \200\231 and likely to be cheaper than a newer statin Pharmaceutical companies will try to convince you of the bene \201 ts of a new brand. Unle ss this is a novel class of drug, it is likely that existing brands have a greater proven s afety record with similar bene \201 t. Older patients have greater potential to suffer har m from new drugs, and are unlikely to have been included in clinical trials. Time will tell if there are real advantages \200\224 in general stick to what you know 2Never be the \201 rst (or last) of your peers to use a new drug. 5. What dose should be started? \200 \200\230Start low and go slow \200\231 \200 Drugs are usually better tolerated at lower doses, and can be optimized if there are no adverse reactions In most cases, bene \201 t is seen with drug initiation, further increments of bene \201 t occurring with dose optimization (eg ACE inhibitors for cardiac failure, where 1.25mg ram ipril is better than 10mg with a postural drop) However, do not under treat \200\224 use enough to achieve the therapeutic goal (eg for an gina prophylaxis, a B -blocker dose should be adequate to induce a mild bradycardia) 6. How will the impact be assessed? Schedule follow-up looking for: \200 Ef \201 cacy of the drug eg has the bradykinesia improved with a dopamine agonist? Medication for less obj ective conditions (eg pain, cognition) requires careful questioning of patient and family/c arers Any adverse events \200\224 reported by the patient spontaneously, elicited by direct ques tioning (eg headache with dipyridamole) or by checking blood tests where necessary (eg thyr oid function on amiodarone) \200 Any capacity to increase the dose to improve the effect (eg ACE inhibitors in cardiac failure) 7. What is the time frame? \200 Many older patients remain on medication for a long time. 88 % of all prescriptions in the over 65s are repeats. 60 % of prescriptions are active fo r over 2 years, 30 % over 5 years, and 6 % over 10 years \200 This may be appropriate (eg with antihypertensives) and if so, the patient should be aware of this and seek an ongoing supply from the GP \200 Some drugs sh ould never be prescribed long term (eg prochlorperazine, night sedation) Medication should be regularly reviewed and discontinued if ineffective or no longer indica ted, eg some psychotropic medications (eg lithium, depot antipsychotics) were intended for long-term use at initiation, but the patient may have had no psychiatric symptoms for years (or even decades). They can contribute to falls, and cautious withdrawal may be indicated 130 CHAPTER 6 Drugs Taking a drug history An accurate drug history includes the name, dose, timing, route, dura tion, and indication for all medication. Studies have suggested that patients will report t heir drug history accurately around half of the time, and this \201 gure falls with incre asing age. Reasons for problems arising \200 Inadequate information to the patient at the time of pr escribing \200 Multiple medications \200 Multiple changes if side effects develop \200 Use of both generic and brand names \200 Variable doses over time (eg dopa agonists, AC E inhibitors) \200 Cognitive and visual impairment \200 Over-the-counter drugs Useful sources of information \200 The patient \200\231s actual drugs \200\224 they will often bring them along in a bag to outpatients or when admitted Many seasoned patients will carry a list of their current medication \200\224 written either by them or a healthcare professional Computer-generated print outs of current medication from the GP \200 Dosette and Nomad systems will incorporate information about the medication they contain A telephone call to the GP surgery will yield a list of active prescriptions (but not over-the-counter medication) Family members will often know about medication, especially if they help administer them Medical notes will often contain a list of medication at the last hospital attendance These can be extremely useful, but have limitations. A prescription issued does not mean th at it was necessarily dispensed, or that the medication is being taken correctly and consis tently. Previously prescribed medica- tions may still be being taken and patients may occas ionally use another patient \200\231s medication (eg a spouse). Good habits \200 Every time a patient is seen (in clinic, day hospital, admission, etc.) take time to review the medication and make an up-to-date list Begin correspondence with a list of current medication \200 If changes are made, or a new medication tried and not tolerated, document the reason for this, and communicate this to all people involved in care (especially the GP) Always include allergies and intolerances in the drug history TAKING A DRUG HISTORY 131 Solutions \200 Take the drug history with meticulous care \200\224 ask directly about: Inhalers \200 Topical medication (creams, eye drops, patches, etc.) \200 Occasional use medication \200 Intermittent use medication (eg 3-monthly B 12 injections, depot antipsychotics, weekly bisphosphonates, etc.) Over-the-counter (non-prescription) medication \200\224 a growing number of drugs are available (in the UK, including proton pump inhibitors (PPIs) and stati ns) \200 Herbal and traditional remedies Clarify how often occasional use medication is taken \200\224 analgesia may be used very regularly, or not at all Be non-judgemental. If you suspect poor concordance (eg BP failing to settle despite multip le prescriptions) then the following questions can be useful to elicit an accurate response : \200 \200\230Have you managed to take all those tablets I suggested? \200\231 \200 \200\230Which tablets do you \201 nd useful? \200\231 \200 \200\230Do any of the table ts disagree with you? \200\231 \200\224 if yes, then \200\230How often do you manage to take it? \200\231 \200\230What triggers you to remember? \200\231 (eg take with each meal, leave by toothbrush, etc.) Scrutinize computer-generated lists carefully. Remember to look at when the prescription wa s last issued and estimate when they would be due to run out (eg 28 tablets to be taken onc e a day, last issued 3 months ago means that the drug has either run out, or not been taken regularly) The gold standard is to ask the patient to bring in all of the medication that they have at home \200\224 both old and new. Go through each medication and ask them to explain which they take, and how often. This allows: \200 Comparison with a list of me dication that they are supposed to be taking Old drugs to be discarded (if necessary retain them and return to drugstore) Concordance to be estimated (by looking at date of dispensing and number of tablets left) Clari \201 cation of doses, timings, and rationale for treatment. In a less-pressured setting (eg DH) it is useful to generate a list for the patient to carry wit h them (see Table 6.1 for example) Education of patient and family where needed (eg reason for taking) 132 CHAPTER 6 Drugs HOW TO Improve concordance Simplify prescription regimens \200 Convert to once-a-da y dosing where possible (eg change captopril tds to ramipril once daily (od)) Try to prescribe medications to be taken at the same time of day \200\224 this may challen ge \201 rmly held views (eg that warfarin must be taken at night) Try to use medications that have dual indications for the patient (eg B -blockade for both hypertension and angina) Consider a daily dose reminder system (eg Dosette box) or a monitored dosage system (eg Nomad ) Educate the patient and family \200 Do they understand the reason for taking the medicati on, and how to take it correctly? Are there any problems the patient is attributing to the medication ( perhaps incorrectly)? Medication summaries (see Table 6.1 ) can assist with this \200 Warn of predictable side effects that are likely to pass (eg nausea with citalopram, headache with dipyridamole) Promote personal responsibility for medication \200\224 this should not be something that the patient feels has been imposed Enlist support of family and carers in monitoring Monitor \200 Check tablet boxes and see if they are gone \200 Look at how often a repeat prescription has been requested \200 Some medications can have serum levels checked (eg digoxin, phenytoin, lithium) Some medications will produce changes detectable at physical examination (eg bradycardia wi th B -blockade, black stool with iron therapy). Table 6.1 Example of a patient drug summary sheet Medication Brand name Reason Dose Morning Lunch Evening Duration \210\232 Aspirin Thin blood, prevent heart attack 75mg Lifelong \210\232 Simvastatin Zocor Lower cholesterol; prevent heart attack 40mg Lifelong \210\232 Ramipril Tritace Lower blood pressure 5mg Lifelong Prevent heart attack \210\232 Atenolol Tenormin Lower blood pressure, prevent angina attacks 50mg Lifelong T A K N G \210\232 \210\232 Isosorbide mononitrate Ismo Prevent angina attacks 20mg Lifelong I Glyceryl trinitrate (GTN) spray Treat angina 1 puff As needed A \210\232 \210\232 \210\232 Amoxicillin Amoxil Antibiotic for chest infection 500mg 7 days D R U G H I S T O R Y 1 3 3 134 CHAPTER 6 Drugs Drug sensitivity Altered sensitivity Many older patients will have altered sensitivity to s ome drugs, for example: \200 Receptor responses may vary with age. Alterations in the fun ction of the cellular sodium/potassium pumps may account for the increased sensitivity to d igoxin seen in older people. Decreased B -adrenoceptor sensitivity means that older patient s mount less of a tachycardia when given agonists (eg salbutamol) and may become less brady cardic with B -blockers Altered coagulation factor synthesis with age leads to an increased sensitivity to the effects of warfarin The ageing CNS shows increased susceptibility to the effects of many centrally acting drugs (eg hypnotics, sedatives, antidepressants, opioid analgesia, antiparkinsonian drugs, and a ntipsychotics) Adverse reactions Certain adverse reactions are more likely in older people, because of thi s altered sensitivity: \200 Baroreceptor responses are less sensitive, making symptomatic hypotension more likely with antihypertensives Thirst responses are blunted, making hypovolaemia due to diuretics more common Thermoregulation is blunted, making hypothermia more likely with prolonged sedation Allergic responses to drugs are more common because of altered immune responses Drugs that may require dose adjustment in older patients Despite the variations in drug han dling, most drugs have a wide therapeutic index, and there is no clinical impact. Only drugs with a narrow therapeutic index or where older patients may show very marked inc reased sensitivity may require dose alteration: \200 ACE inhibitors \200 Aminoglycoside s (dose determined by weight, and reduced if impaired renal function) Diazepam (start with 2mg dose) \200 Digoxin (low body weight older patients rarely requir e more than 62.5micrograms maintenance dose) \200 Non-steroidal anti-in \202 ammatory drugs \200 O piates (start with 1.25 \200\2232.5mg morphine to assess impact on CNS) \200 Oral hypogly caemics (increased sensitivity to hypoglycaemia with decreased awareness \200\224 avoid lo ng-acting preparations such as glibenclamide, and start with lower doses of shorter-acting drugs, eg gliclazide 40mg) Warfarin (load more cautiously) ADVERSE DRUG REACTIONS 135 Adverse drug reactions More common and complex with increasing age \200\224 up to three ti mes more frequent in the over 80s. Drug reactions account for considerable mor- bidity, mor tality, and hospital admissions (one study estimated a fourth of US hospital admissions rel ate to medication complications). Older people are not a homogeneous group, and many will tolerate medications as well as you nger ones, but a number of factors contribute to the increased frequency: \200 Altered dr ug handling and sensitivity occur with age, made worse by poor appetite, nutrition and \202 uid intake Frailty and multiple diseases make drug \200\223disease interactions more common, for example: \200 Anticholinergics may precipitate urine retention in a patient w ith prostatic hypertrophy Benzodiazepines may precipitate delirium in a patient with dementia These relationships become even more complex when the large numbers of drugs that are prescribed for multiple conditions interact with the diseases as well as each other, eg an osteoporotic patient is prescribed a bisphosphonate, then sustain s a vertebral crush fracture and is given a non-steroidal which exacerbates gastric irritat ion and causes a gastrointestinal bleed Errors in drug taking make adverse reactions more likely. Mistakes increase with: \200 Increasing age \200 Increasing numbers of prescribed drugs (20 % of patients taking three drugs will make errors, rising to 95 % when 10 or more drugs are taken) Cognitive impairment \200 Living alone Strategies to minimize adverse drug reactions \200 Prescribe sensibly \200 Consider pos sible drug \200\223drug and drug \200\223disease interactions whenever a new drug is started Some drugs are associated with high rates of drug \200\223drug interaction, eg warfarin, am iodarone, SSRIs, antifungals, digoxin, phenytoin, and erythromycin For every new problem, consider if an existing medication could be the cause. Try to avoid the so-called prescribing cascade , where side effects are treated with a new prescription, rather than discontinuing the offending drug. If multiple medications are possible culprit s then stop one at a time and watch for improvement Optimize concordance \200 Use extreme caution at times of care transfer as information is often lost 136 CHAPTER 6 Drugs ACE inhibitors Common indications include blood pressure control, vascular risk reduc- tion , heart failure, and diabetic nephropathy. Cautions Renal disease \200 Use ACE inhibitors with extreme caution if there is a known h istory of renal artery stenosis, as renal failure can be precipitated. If the clinical susp icion of this is high (renal bruit, uncontrolled hypertension that is unexplained) then con sider investigating for renal asymmetry with an ultrasound before starting treatment Renal impairment per se is not a reason to withhold ACE inhibitors (indeed they are effective treatment for some types) although the dose may need to be reduc ed Monitor renal function before and after treatment. Sudden deterioration may indicate renal artery stenosis, and the ACE should be stopped pending inv estigation If a patient becomes unwell (dehydrated, septic, etc.) they may need temporary withdrawal of the ACE inhibitor Hypotension \200 Early ACE inhibitors (eg captopril) were associated with a risk of \201 rst dose hypotension, and so many patients were given an in-hospital test dose This is rare with newer ACE inhibitors, and cautious outpatient initiation is acceptable Older patients are more prone to postural hypotension. Check blood pressure lying and stand ing, and ask about postural symptoms (eg light- headedness) The risk of hypotension is greater with volume-depleted patients \200\224 eg those on high dose diuretics, on renal dialysis, dehydrated from intercurrent illness or in severe cardiac failure. Correct dehydration before initiation where possible ACE inhibitor induced hypotension is common in patients with severe aortic stenosis, and th ey should probably be avoided (unless under cardiological supervision) \200\230Start low, and go slow \200\231. Monitor carefully. This may take multiple clinic visits, but avoids complications Cough \200 Many ACE inhibitors cause a persistent dry cough. Always warn the patient abou t this, as it can cause considerable distress. Forewarned is forearmed, and many patients w ill be prepared to accept this side effect if the ACE inhibitor is the best choice for them Changing to an angiotensin receptor blocker (ARB) removes the cough in most cases, but ARBs are not quite as effective in terms of risk reduction ACE INHIBITORS 137 Hyperkalaemia \200 There is a risk of hyperkalaemia when ACE inhibitors are used with potassium-sparing diuretics, eg spironolactone (in heart failure) or with non-steroidals Be aware, and monitor electrolytes. Most tolerate a potassium of up to 5.5mmol/L The tendency to hyperkalaemia can be useful in patients who are also on potassium-losing di uretics (eg furosemide) as the two may balance each other out \200\224 overall hypokalaemi a is more common in patients with heart failure HOW TO Start ACE inhibitors \200 Screen for contraindications \200 Check baseline renal function and electrolytes \200 Warn patient about possible cough and postural symp toms An example of initiation/titration is as follows Week 1 Start ramipril 1.25mg at night. Week 2 Check renal function, blood pressure (lying and standing) and check for postural sym ptoms. Week 4 Increase ramipril to 2.5mg at night. Week 6 Check renal function, blood pressure (lying and standing) and check for postural sym ptoms. Week 8 Increase ramipril to 5mg at night. Continue titrating the dose upwards as tolerated, but most older patients will develop postural symptoms at higher doses, increasing the ris k of falls. The goal should be for safe optimization. Once established on an ACE inhibitor, periodic renal monitoring is sensible (perhaps annually). If a patient becomes acutely unwell \200 Dehydration increases susceptibility to ACE inhi bitor induced renal failure and hypotension Correct the dehydration \201 rst \200\224 treat cause, give \202 uid supplementation, and stop diuretics Temporary cessation of ACE inhibitor may be needed if dehydration prolonged ( > 24hr) Monitor renal function daily \200 Remember to restart the ACE inhibitor after recovery 138 CHAPTER 6 Drugs Amiodarone Indications include rate control and prevention of supraventricular cardiac arrh ythmias (commonly AF) and prevention of paroxysmal ventricular arrhythmias. Intravenous amiodarone is now included on the advanced life support protocols for cardiac arrest ( M www.resus.org.uk ). Cautions \200 Interacts with many drugs, including warfarin (often co-prescribed for AF stroke prophylaxis; amiodarone increases warfarin effect) and statins (increased inc idence of myopathy with higher statin doses) \200 Can cause deranged TFTs in either direc tion. Baseline thyroid function should be taken before initiation and then at 6-monthly intervals. Measure TSH, free T4 and free T3 \200\224see b \200\230HOW TO Manage amiodarone-induced thyroid dysfunction \200\231, p.139 Nausea and anorexia are common (730 % ), and may respond to dose reduction. Less frequently, liver function becomes deranged \200\224 check at baseline and every 6 months; hepatitis may reverse with dose reduction \200 Photosensitivity can occu r, so amiodarone is unlikely to be suitable for avid gardeners or outdoor workers Corneal microdeposits often occur (90 % ), that can cause a glare with night driving (if th is is likely to be a problem then avoid amiodarone); microdeposits are reversible, and do n ot threaten vision Pulmonary problems may occur ( \201 brosis, alveolitis, pneumonitis). They are the most serious amiodarone-related side effects, and often occur early (months). Any new respiratory symptoms should trigger clinical assessment, CXR, and pulmonary functio n tests Peripheral neuropathy may occur \200\224 be alert for early signs of this and stop the drug promptly to avoid progression Starting oral amiodarone 1 Check TFTs and LFTs 2 Load with: Week one \200\224 200mg tds \200 Week two \200\224 200mg twice daily (bd) 3 From week 3 onwards use the maintenance dose of 200mg od 4 See the patient at 6 \200\2238 weeks intervals to check for adverse effects and ef \201 cacy 5 Check TFTs and LFTs at 6-month intervals 6 In the longer term, the dose may be reduced fu rther in frail older patients to 100mg od (or even alternate days) without losing ef \201 cacy, as the half-lif e is extremely long Overview Despite this long list of side effects and cautions, amiodarone is often well- tol erated and effective in older patients. It is less negatively inotropic than many alternati ve antiarrhythmics, and is excreted primarily by the liver; it therefore has a useful part to play. AMIODARONE 139 HOW TO Manage amiodarone-induced thyroid dysfunction Amiodarone contains 37 % iodide, which impacts on thyroid homeostasis, causing alterations in TFTs in up to 50 % of patient s. Early amiodarone changes \200 Alterations in TFTs in a euthyroid patient most common \200 Usually high TSH or decreased thyroxine (T4) concentrations \200 This is typically transient, resolves after about 3 months and does not indicate that hypothyroidism has occurred Monitor at 3-monthly intervals Changes with longer-term amiodarone therapy include Euthyroid changes \200 Minor increase in T4 \200 Suppression of triiodothyronine (T3) \200 Suppression of TSH \200 Manage by monitoring thyroid function every 6 months Hyperthyroidism \200 More common when there is occult underlying thyroid disease and in areas with low oral iodine intake (up to 12 % incidence) Diagnose with increased free T3 and free T4 with suppressed TSH concentrations Withdraw amiodarone where possible \200 No immediate improvement as amiodarone has a long half-life \200 Where amiodarone needs to be continued, this can be treated with carbimazole as for standard hyperthyroidism. May be resistant. Adding steroids may hel p Amiodarone can also cause a destructive thyroiditis, releasing thyroid hormone into the circulation and causing hyperthyroidism. Treatment is with high-do se steroids Hypothyroidism \200 More common in areas with low iodine intake (up to 13 % incidence) \200 Diagnose with decreased free T3 and free T4 concentrations with elevated TSH concentrations An elevated TSH alone is not diagnostic \200\224 may be transient, especially in the \201 rst three months of treatment. If the patient is well, recheck in 3 months Amiodarone withdrawal is rarely necessary. Adding levothyroxine sodium will correct the problem 140 CHAPTER 6 Drugs Analgesia Older patients are more likely to suffer chronic pain than younger ones, owing to the increased frequency of conditions such as osteoarthritis, osteoporosis, etc. Pain management is more challenging and a standard \200\230pain ladder \200\231 approach n ot always useful because of the altered sensitivity of the older patient to certain classes of analgesic medication. Non-steroidal anti-in \202 ammatory drugs Includes aspirin (especially at analgesic doses) . Potential problems \200 Fluid retention causing worsening hypertension, cardiac failure, and ankle swelling Renal toxicity \200\224 risk of acute tubular necrosis, exacerbated by intercurrent infection, or dehydration Peptic ulceration and gastrointestinal bleeding \200\224 there is an increased risk with i ncreased age, and the bleeds tend to be more signi \201 cant 2The number of older patients requiring hospitalization because of NSAID-induced deteriorat ion in renal or cardiac function actually exceeds the number with gastrointestinal bleeds. \200 Age itself is probably not an independent risk factor for most complications of NSAID treatment, but factors such as comorbidities, co-medications, hydrat ion, nutritional status and frailty are linked to an increased risk, all of which are more common with advancing age Guidance for use in older patients \200 NSAIDs should be used with extreme caution in old er patients, and avoided altogether in the very frail \200 Should be given for a short period only \200 Use low-dose moderate potency NSAIDs (eg ibuprofen 0.6g/day) \200 Avoid using two NSAIDs together (this includes low-dose aspirin) \200 Consider co-prescription of a gastric-prot ective agent (eg omeprazole) for the duration of the therapy Avoid using ACE inhibitors and NSAIDs together \200\224 they have opposing effects on \202 uid handling, and are likely to cause renal toxicity in combination Opioid analgesia Wide range of drugs sharing many common features, but with qualitative and quantitative differences. Potential problems include constipation, nausea and vomiting, anorexia, confusion, drowsiness, and respiratory depression. Guidance for use in older patients \200 Most of these are dose dependant, and careful up- titration will obtain the right balance of analgesic effect and adverse effects Constipation is common (worse in older people) but can be managed with good bowel care Most adverse effects are reversible once the medication is reduced or discontinued ANALGESIA 141 HOW TO Manage pain in older patients Diagnose the cause Chronic abdominal pain may be due to constipation that will respond to bowel care rather than analgesia. Consider non-drug measures \200 Weight loss and physical activity helps with many pains ( eg arthritis) \200 Temperature treatments (eg hot/cold packs applied to painful joint) \200 TENS machines \200 Alternative therapies (eg acupuncture, aromatherapy) can help \200 Avoidance of (non-essential) activity that provokes pain if possible Consider targete d therapy For example: topical capsaicin for post-herpetic neuralgia, local nerve blocks fo r regional pain, massage for musculoskeletal pain, joint replace- ment for arthritic pain, or radiotherapy for pain from bony metastases Regular paracetamol \200 Well-tolerated and with few side effects \200 Before moving fr om this, ensure that the maximum dose is being taken regularly (ie 1g taken four times a da y) for optimal analgesic effect. Many patients will \201 nd taking an occasional paraceta mol ineffective \200\224 explain that regular dosing increases analgesic effect Opioid analgesia \200 Second line therapy in most older patients \200 Options to deal w ith mild (eg codeine, dihydrocodeine), moderate (eg tramadol) and severe pain (eg morphine, diamorphine, fentanyl) \200 Compound preparations are useful when adding an opioid to re gular paracetamol, as it limits the number of tablets taken. Co-codamol (codeine and parace tamol) has variable doses of codeine (8mg, 15mg, or 30mg per tablet) allowing up titration of the opioid component \200 All affect same receptors, so use as a continuum \200\224 i f regular maximum dose codeine is not working, then step up to the next level of opioid str ength (eg if 60mg codeine four times daily (qds) is not suf \201 cient then change to tram adol 50mg qds or morphine sulfate M/R 5mg bd) Various formulations for the delivery of strong opiates. Liquids are useful if there are swallowing problems (eg morphine sulfate solution). Slow-release ta blets (eg morphine sulfate M/R) and transdermal patches (eg fentanyl) provide constant anal gesic effect for continuous pain. Parenteral opiates are used in terminal care (subcutaneou s injections of morphine and diamorphine for intermittent pain; 24hr infusion pumps for con stant pain) \200 Monitor for side effects \200\224 active bowel care with initiation Oth er drug options \200 Very \201 t older patients can be given short courses of NSAIDs \200 Cyclo-oxygenase-2 (COX-2) inhibitors have a limited role Psychological factors \200 Depression is often coexistent (consequent or causal). Treatment can help with overall pain management Informal ( \200\230positive mental attitude \200\231) and formal psychotherapeutic approaches may be preferable to side effects of analgesic medication 142 CHAPTER 6 Drugs Steroids Oral steroids (usually prednisolone) are given for many conditions in older patien ts, commonly COPD exacerbation, polymyalgia rheumatica, rheumatoid arthritis, and colitis. Treatment may be long term. Although the bene \201 ts of treatment usually outweigh the ri sks, awareness of these can minimize harm. Discuss likely side effects with patients and ca rers. Cautions \200 Osteoporosis \200\224 this is most marked in the early stages of treatment . Older people will have diminishing bone reserves anyhow, and there is a strong argument for putting all steroid-treated older patients on bone protection at outset, unless the course is certain to be very short (eg less than 2 weeks). This should consist of daily calcium a nd vitamin D, along with a bisphosphonate (weekly preparations eg alendronate 70mg, improve concordance) Steroids can precipitate impaired glucose tolerance or frank diabetes . Monitor sugar level s periodically (eg weekly capillary blood sugar, or urinalysis) in all steroid users. Stero ids worsen control in known diabetics, necessitating more frequent monitoring Hypertension may develop because of the mineralocorticoid effect of prednisolone, and this should be checked for regularly Skin changes occur, and are particularly noticeable in older patients with less resilient skin. Purpura, bruising, thinning, and increased fragility are common Muscle weakness occurs with prolonged use, dominantly proximal in distribution. This leads to problems rising from chairs, climbing stairs etc. and may be the \201 nal straw for a frail older person with limited physical reserve. (See b \200\230Muscle symptoms \200\231, p.478) There is an increased susceptibility to infections on steroids, and the presentation may be less acute, making diagnosis more dif \201 cult. Candidiasis (oral and genital) is partic ularly common and should be treated promptly