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Optimized Prescribing with Seniors is a joint communication of the Alberta Medical Association and the College of Physicians & Surgeons of Alberta, these articles are written by physicians for physicians prescribing in the care of older patients.
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Dr. Lesley Charles, MBChB, CCFP, is a geriatric physician at the Grey Nuns Community Hospital. Her areas of clinical interest include dementia, delirium and treatment of osteoporosis. She obtained her medical education at the University of Edinburgh then completed her family medicine residence at the University of Alberta.
Dr. Charles is an associate professor with the Department of Family Medicine (Division of Care of the Elderly) at the University of Alberta. Her research interests include the Care of the Elderly Program; Decision-Making Capacity Assessment and Implementation and Sustainability Framework; Care of the Elderly Graduates Research; Developing and the Effects of Introducing Core Competencies; and Caregivers
Monica is an 84-year-old widowed woman with a recent onset of atrial fibrillation, treated with warfarin. She presents with a one-month history of irritable mood, headaches, insomnia, weight loss, memory complaints and psychomotor retardation.
John, an 85-year-old man, presents to your office complaining of light-headedness. He was recently admitted to hospital for congestive heart failure (CHF) and was started on furosemide, metoprolol and ramipril. He has a history of hypertension, dyslipidemia, benign prostatic hypertrophy and osteoarthritis.
Smith is a 79 year old man who lives alone. He suffered a stroke two years ago so is taking Coumadin (warfarin) for non-valvular atrial fibrillation. His other significant medical history includes type 2 diabetes mellitus, hypertension, congestive heart failure and atrial fibrillation. His creatinine clearance (Crcl) is 52ml/min. He has been inconsistent with his warfarin use as it is not blister packed, which is commonly known to increase compliance. You consider starting him on a direct oral anticoagulant (DOAC, also known as novel oral anti-coagulant (NOAC)) but wonder which one to start with.
Jane, a 75-year-old woman presents to your office for routine follow-up after being recently discharged from the hospital. She reports poor sleep since discharge and wants a renewal of Zopiclone, a sedative-hypnotic. Her past medical history indicates mild cognitive impairment, hypertension, type 2 diabetes mellitus and osteoarthritis.
Cynthia, who is 80-years-old, visits you, her family physician for follow-up after discharge from hospital. She is accompanied by her daughter. Cynthia was recently discharged after a four-week stay in hospital for complications from coronary artery disease and congestive heart failure. She also suffers from diabetes, hypertension and osteoporosis. Her discharge diagnosis includes mild cognitive impairment. Towards the end of her 15-minute visit with you, you reviewed her medications and counted 12 of them!
Francis is an 84-year-old female who fell going to the bathroom one night and sustained a right hip fracture. She had a period of confusion in the hospital that has now resolved. She has returned home after a prolonged hospitalization on her usual medications of ramipril, hydrochlorothiazide, ASA, alendronate, Vitamin D, calcium, and l-thyroxine. In addition, she is also now taking quetiapine, and omeprazole. Her husband finds her to be frailer than before her admission and asks if any of her medications could be contributing to a risk for further falls.
Recent adoption of the terms "appropriate polypharmacy" and "problematic polypharmacy" reflect both the realities of treating multi-morbidity in the population and the potential harm associated with prescribing multiple medications to some individuals, particularly frail older persons and those with cognitive disorders.
Susan is a health care aide. Her grandfather, who is 86, has been fairly healthy and lives independently. He receives some support for instrumental ADL from his daughter and Susan. He has type 2 diabetes, hypertension and chronic obstructive pulmonary disease (COPD). For this he takes metformin, gliclazide, losartan and tiotropium. He has salbutamol that he uses only occasionally. Susan has heard that this flu season will be a “bad one” and wonders if he should be getting a flu shot.
George is a 93-year-old male who lives with his son and daughter-in-law. Over the last six months, he has become frailer but continues to be reasonably independent. He is treated for hypertension, dyslipidemia, BPH, and has arthritis in his knees. He complained of feeling depressed when he moved in with his son after the death of his wife five years ago. He is taking perindopril, ASA, rosuvastatin, citalopram, tamsulosin and Vitamin D. He takes ibuprofen and half a zopiclone on an as needed basis. While out for a walk in the neighbourhood, he had a fall and his son has brought him in.
Myrtle is an 87-year-old female with hypertension, urinary urgency and a mild dementia syndrome. She lives with her daughter and manages with her support. She is taking hydrochlorothiazide, amlodipine, ASA, tolterodine LA, and mirtazapine for sleep. Myrtle recently slipped on the stairs and twisted her back. Because of the pain, she started taking acetaminophen/methocarbamol. Her daughter brings her in because she has become confused.
George, a 78 year old male, comes in to your office for an initial visit as his previous physician has retired. His chronic medical issues are managed and stable, but he has been having increasing heartburn. He takes an antacid as needed but is not finding this to be sufficient.
An 82-year-old patient with longstanding type 2 diabetes mellitus (T2DM); multiple comorbidities (hypertension, dyslipidemia, severe degenerative osteoarthritis, GERD, gout and COPD); and self-managed polypharmacy, including insulin. His office visit was triggered by his stressed spouse, as there was a decline in his cognitive function in the last year and he experienced two falls in the last three months.