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This chapter addresses the following Geriatric Fellowship Curriculum Milestones: #11, #16, #19, #25, #49, #61

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LEARNING OBJECTIVES

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Learning Objectives

  • Understand the epidemiology of drug therapy.

  • Understand the importance of pharmacokinetics and pharmacodynamics to prescribing decisions.

  • Describe practical approaches to prescribing medications to older persons including reviewing current drug therapies, discontinuing medications when no longer indicated, considering nonpharmacologic treatment options, and reducing the dose.

  • Describe measures of drug prescribing quality.

  • Understand the concept of the prescribing cascade.

  • Understand the importance of underuse of potentially beneficial drug therapy.

  • Understand the special considerations regarding drug therapy in the long-term care setting.

  • Recognize the potential gaps in information about drug therapy in older adults.

  • Describe policy issues related to drug therapy by older adults.

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Key Clinical Points

  1. Prescribing for older people offers special challenges because they take more prescribed medications than younger people. Older individuals are often at risk for drug interactions and adverse events.

  2. When prescribing medications to older adults, consider pharmacokinetic and pharmacodynamic changes that are observed with aging.

  3. Criteria have been developed by experts internationally to assess the quality of medication use in older adults that can be applied in clinical practice.

  4. Many different factors go into making the best prescribing decisions for an individual patient, and it is essential that the risks are balanced against the benefits of each medication. An important tension exists between avoiding inappropriate medications and underuse of potentially beneficial drugs.

  5. Prescribing cascades are common and important to consider in older adults with multiple chronic diseases who are likely to be prescribed multiple drug therapies.

  6. Practical steps can be taken to optimize prescribing for older adults that include reviewing current drug therapies, discontinuing potentially unnecessary drug therapies, and considering nonpharmacologic treatment approaches.

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INTRODUCTION

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Prescribing for older patients offers special challenges. Older people take about three times as many prescription medications as do younger people, mainly because of an increased prevalence of chronic medical conditions among the older population. Taking several drugs together substantially increases the risk of drug interactions and adverse events.

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While a physician can usually do little to alter the characteristics of individual older patients to affect the kinetics or dynamics of drugs, the decision whether to prescribe any drug, the choice of drug, and the manner in which it is to be used (eg, dose and duration of therapy) are all factors that are under control of the prescriber. This chapter discusses ways to optimize prescribing of drug therapy for older adults.

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EPIDEMIOLOGY OF DRUG THERAPY

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Writing a prescription is the most frequently employed medical intervention. Yet, creating optimal drug regimens that meet the complex needs of older persons requires thought and careful planning. Multiple factors contribute to inappropriate drug prescribing, including lack of adequate training of providers in safe prescribing practice, and in prescribing for geriatric patients. Further, ...

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