A new article in the latest edition of Australian Prescriber highlights the risks and complexities clinicians face when prescribing medicines for frail older people.
Frail people are twice as likely to have at least one inappropriate medicine prescribed – an alarming statistic given that these patients are also more likely to experience an adverse reaction because of their other medicines.
Recent evidence suggests that an increased number of medicines can result in some patients becoming more frail. In a study of men who were initially defined as robust, each additional drug was associated with a 22% greater risk of death.
The authors of the article explain that due to frail older people’s increased susceptibility to adverse reactions, coupled with the lack of guidelines to inform clinicians about appropriate prescribing for these patients, constant vigilance and review are essential.
The article outlines the ways in which frailty status should be considered when applying the six steps in the World Health Organization’s Guide to Good Prescribing.
2. Managing medicines on sick days
Health professionals are reminded to tread cautiously when treating acute illness in patients with chronic conditions, in an article published in the latest edition of Australian Prescriber.
Patients with chronic conditions such as diabetes and chronic kidney disease could be at increased risk during periods of intercurrent illness, known as ‘sick days’. The article explains the importance of understanding pharmacokinetic factors associated with ‘sick days’ in predicting and managing these risks.
“Patients with chronic kidney disease may be at particular risk of problems because conditions that induce hypovolaemia increase the risk of acute kidney injury in those with reduced renal homeostatic reserve,” say the authors, Drs Tom Lea-Henry, Jonathan Baird-Gunning and Darren Roberts, with pharmacist Elizabeth Petzel, from Canberra hospital.
“The risk is compounded if the patient is taking drugs that compromise renal function, such as diuretics and ACE inhibitors.”
Patients with diabetes should increase their glucose monitoring on sick days. In those taking insulin, the dose may need to be increased.
3. October edition of Australian Prescriber out now
The latest issue of Australia’s free, national, independent journal of drugs and therapeutics is now available. Australian Prescriber facilitates debate about complex, controversial or uncertain therapeutic areas. Some of the highlights of the October issue include:
In Australia, suicide is the leading cause of death among those aged 16 to 24 years, while the suicide rates in men aged over 85 years are the highest for any age group. Many patients who attempt suicide visit their GP in the preceding month making GPs well placed to help reduce suicide. The article gives insights into best practices for assessing patients’ suicidality and in selecting the most appropriate management.
During intercurrent illness, the risk of an adverse drug event could be increased by the ongoing use of some medicines by patients with chronic disease. This article examines the important comorbidities that may impede a normal homeostatic response to disturbed fluid balance, the drugs associated with adverse events in intercurrent illness, and the usefulness of understanding pharmacokinetic factors associated with periods of significant illness (‘sick days’). The article advises how to predict and manage patients at risk.
This article focuses on prescription management for frail older people, including recommendations on how to tailor treatment for these patients when applying the six steps in the World Health Organization’s Guide to Good Prescribing. While there is currently no universal way to identify patients with frailty in clinical practice, the prevalence of frailty is estimated to be 10% in older adults living in the community.
Other articles in the October issue of Australian Prescriber include:
- Treatment for fibromyalgia
- Antibiotic prophylaxis for dental procedures
- Drug dosing in obese adults
- Access to unregistered drugs in Australia
Australia Prescriber is now digital only and available at www.nps.org.au/australianprescriber.
4. GPs on the front line can help lower Australia’s suicide rate
In Australia, suicide is the leading cause of death among those aged 15 to 44 years. The suicide rate for men aged over 85 years is the highest of any age group.
A new article published in the October edition of Australian Prescriber emphasises the important role GPs can play in detecting and managing suicidal patients. It is authored by Conjoint Associate Professor Josephine Anderson from the Black Dog Institute, and UNSW Professors Philip Mitchell and Henry Brodaty.
Many patients who attempt suicide visit their GP in the preceding months, making GPs well placed to help reduce the unacceptably high suicide rate in Australia.
“When a patient admits to suicidal thoughts or behaviour, understanding their predicament begins with an exploration of these ideas,” state the authors. “This includes exploring the nature of the thoughts, any plans they might have to end their life including methods and access to these methods. It’s important to discuss previous suicide attempts also.”
GPs assessing patients for the symptoms and severity of depression may use self-reporting scales such as the Patient Health Questionnaire (PHQ-9), which includes questions around thoughts of suicide and can be a useful springboard for further discussion.
However, as the article highlights, there are other vital approaches that can support suicide detection and intervention. This should include having discussions about factors contributing to poor mental health, such as recent bereavement or relationship problems, alcohol use, chronic pain, and loss of support.
For people with depression, the article lists several evidence based psychological therapies. If drug treatment is indicated, the authors advise on the choice of antidepressant. To read the full article and others visit Australian Prescriber.