Monday, October 25, 2010

Any Symptom in an Older Adult is a Medication Side Effect Until Proven Otherwise

Mike Steinman recently published a paper in JAMA about sensible medication managment in older adults.  I've had the opportunity to see him speak about this issue on a couple of occassions.  I wanted to share a few take home "GeriPal" pearls, leading with the title of the post:
  • Any symptom in an older adult is a medication side effect until proven otherwise
  • Review medication lists and sort by indication.  Most older adults are on at least one unnecessary medication, or one where the harms outweigh the benifits in light of the patient's goals, social and clinical circumstances, and life expectancy.
  • If you taper it up, taper it down
  • When starting a medication, start low, and go slow
  • Warfarin, hypoglycemic agents, and digoxin account for one-third of all adverse drug event related emergency department visits by older adults.  Doesn't mean don't prescribe them, just prescribe thoughtfully and monitor for adverse side effects.
  • Most adverse drug events are due to a failure of monitoring, not prescribing innapropriate medications
by: Alex Smith

6 comments:

Pratima said...

Great post, Alex! Thanks so much for the article as well! Have been researching this issue for my comprehensive paper (interventions to reduce polypharmacy in older adults -- lit. review) and found this very useful. I believe this is such an important issue, and needs a lot more research than has been done so far, although the answers seem pretty simple, obvious and easy to do!

Thank you!

Pratima

Kate said...

Hi ALex, wonderful post -
I do want to also share something that I've been struggling with as I teach on the inpatient wards and in the clinic - there is also a pervasive syndrome of undertreatment - as in, "I can't give them an anti-depressant, they're OLD" -- or "We shouldn't, start warfaring, because they're OLD and they MIGHT FALL". So, although I absolutely agree that caution is needed, we may need to remind our learners that caution doesn't mean absolute avoidance...
Great post!
Kate.

Helen Chen said...

Thanks, Alex! Just wanted to add an important clause to the "start low and go slow" aphorism. I can't remember who said this, but while it is essential to start low and go slow, it's also important to GO. As Kate mentioned many MDs are relucant to start meds for elders and many others never get to effective therapeutic levels because they are afraid to dose escalate. It's always bad to induce an ADE, but I think it's really sad when and ADE occurs in relation to an underprescribed medication that never had a chance to be effective for the original indication.

Alex Smith said...

Pratima, Kate, and Helen, appreciate the comments and feedback. I like the revised pearl:
-start low and go slow, but GO! Advanced age does not mean "do not treat."

Lindy said...

Terrific post, and so true. I would echo the previous comments--we use the saying "Start low, go slow, but GET SOMEWHERE." So often our older adults are started on a low dose of medication, but then that is never titrated to a therapeutic dose.

Thank you!
Lindy Swain, PharmD
www.pharmacyadvocates.com

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