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[Music] good evening everyone and welcome back doctor to survey and it's a great pleasure to be with you on this diet and i love the topic for simple reason that this is a topic which affects one and all and more so i am on both sides of the table when it comes to this topic of prescribing errors in the elderly because we fall now in the same category and we know that in india there are in 2019 survey india has 13.9 crore people who are above the age of 60 and it's not going to be uh double by next 40 years so uh as in one of the topics uh where i discuss the same i said that india will need more gediatricians than pediatricians because we now know that pediatric diseases are really becoming less and accept vaccinations they don't have to offer much while geriatricians a huge scope there are so many patients waiting for the right treatment because we know that old age something nobody wants it but then with increasing age expectations we have more and more people falling in that group elderly people are different than the younger counterparts in the sense that they have more uh diseases they have more pathes that they are taking advantage of whether being a allopathy homeopathy and so many others then they have many different physiological restrictions the drugs effects are also different and we cannot have a better person than dr tushar shah who is a clinician for excellence who is um not only working in the multi-facility hospitals in mumbai but also a multi-facility person as dr nita rightly said he is a humorist he is an author he is a poet and also he will talk of mainly the clinical aspects i happen to have his earlier talk also about the acute female illness and absolute clinical topic and we are eagerly awaiting sir for your discourse and that is why probably he doesn't want his slides because he is the one who talks and keep on talking and will be interrupting you sir for the sake of your rest and also the continuity so over to you sir thank you thank you sir dr mario i would in fact like you to interrupt whenever because you can not only add to what i say but also rectify any errors that i might make today's topic medication errors in the elderly i would like to rephrase the topic as ways in which our treatment can kill or almost kill the elderly because we truly can be murderous when we treat elderly patients it is said that in the u.s about 100 000 patients die because of medication errors and most of these are elderly patients so we can save lives by just not killing patients so that is what we should be doing okay so uh how can we harm patients in such a way that we can almost kill them let me go one by one we if i tell you that we can cause heart attacks you will be surprised and therefore you may even not believe me that how can doctors medications cause heart attacks so it is known that five days as little as five days of non-steroidal anti-inflammatory drugs given to susceptible individuals like elderly patients with atherosclerotic disease as few as five days of nsaids can cause an acute myocardial infarction now we see prescriptions of nsaids being given fairly frequently for fairly long periods of time by everybody i would like you as physicians tomorrow to see these prescriptions and cut down the duration at least of the nsaids because offerences are given for weeks or months especially for orthopedic problems the nsaids that are most responsible for cardiovascular side effects are the cox 2 inhibitors hitori cocci which is the one cox 2 inhibitor approved in india hitori coxy is a drug that should be relegated to the dust bin please do not use etheric oxygen ever in your life hitoricoxif is a favorite amongst orthopedic surgeons it is a hugely marketed drug with a lot of brands and lot of companies pushing the drug please do not use it or epoxip at all if you want to use a cardiac safe there is nothing like a cardiac safe and said but relatively cardiac safe and said please use naproxen ibuprofen but do not use cox-2 inhibitors so that is one if you eliminate historic oxygen from your prescription in your whole lifetime you will have saved a few lives you can cause congestive heart failure by nsaid therapy you can cause myocardial infarction by unsafe therapy any patient who's on etory coxy or any other nsaid given by somebody else or you on every follow-up please check the blood pressure please check for edema feeds look for breathlessness and rectify these problems by omitting the nsaid if you can in the cardiovascular system accelerated hypertension can be caused by many drugs instead are one of them you can cause a stroke by causing accelerated hypertension but another group of drugs that can cause high blood pressure is decongestants we all know that phenylpropylemine was banned because of accelerated hypertension similarly phenylephrine is also a decongestant which has sympathetic mimetic activities and phenylephrine is a content of several decongestants combinations like cinerest sinus 77 etcetera right to avoid phenylephrine in the elderly and especially in the elderly who have heart disease or who have high blood pressure besides heart problems you can cause of course multiple systemic problems one important problem in the elderly caused by medication errors is altered sensorium or encephalopathy if you give a patient anti-diabetic medication and if you overdose the patient or if the patient's creatinine is high and and therefore the insulin clear clearance is not very good you may cause hypoglycemia so one simple suggestion here start low and go slow in treating diabetes you see a blood report of 250 fasting 350 postprandial in an elderly patient it is very tempting to start something like glimepiride metformin bd or tds please don't do that in the elderly start low go low is the dictum that you have to follow in the elderly hypoglycemia ah can as you know kill a patient can cause strokes can cause fractures by false so take care of hypoglycemia another cns encephalopathy problem the communist drug group that causes hyponatremia as you can imagine is the diuretic group one important thing to remember is that the thiazide group that is hydrochlorothiazide chlorthalidone in the mind cause more hyponatremia than the more potent furosemide ah drug that is a loop diuretic that is because the loop diuretics cause equal excretion of sodium and water whereas hydrochlorothiazide chlorine cause more sodium loss less water loss and therefore hyponatremia is common just make sure that any patient who receives a thiazide diuretic is checked effectively for hyponatremia on a periodic basis another rule that i follow and that i should i think we should all follow in the elderly never exceed the dose of hydrochloride by to more than 12.5 and chlorthalidone to more than 6.25 as you know there are many combinations for example tell me saturn with chloro many of these combinations contain 12.5 milligrams of chlorine remember 12.5 milligrams of protein is equal to 25 milligrams of hydrochlorothiazide you must not give 12.5 at all of your helium in the elderly limit yourself to six point two five of glutathione whenever you do give another group of drugs that cause hyponatremia are the carbamazepine ox carbisoprine are drugs used in neuralgias like transmission and as antipsychotic drugs in the case of ox carboxyl especially carboxyl sorry especially ox carboxyl causes hypo hyponatremia any patient on oxytol or any such similar drug or carboxyprine must check for hyponatremia in fact if you see an elderly patient with altered sensorium the two most common causes of altered sensorium without any injury or fall are hypoglycemia and hyponatremia first things to consider would be those two and most of the causes of hypoglycemic leukemia are drug related causes so do do uh also remember that ssris snris antipsychotics all can cause hyponatremia so if your patient is on fluoxetine or peroxide in or metazapine if the patient has hyponatremia the drugs sacred drugs may be responsible for the same so again for that reason psychiatric drug doses should also be kept low and increased monitoring for hyponatremia the another area of side effects that you can cause and cause actually deaths or you know near near deaths is drugs that cause falls falling a patient can fall get a subdued hematoma get a fracture neck femur and significant morbidity and what will cause false caused by you the commonest drugs that will cause falls are the drugs that cause postural hypotension if you start an elderly patient on a prostate medicine like time solution remember tamsulosine is an alpha blocker causes postural hypotension if you cause postural hypotension and the patient wakes up in the night to go to the washroom suddenly the bp drops the patient falls how do you prevent that you must start low so when you use combinations of say finasteride with stem solution they are fixed those combinations you will always have 0.4 milligrams of m solution in those in those combinations don't start at 0.4 start at 0.2 milligrams of translucent and go up that reduces the chance of first dose hypotension which is a common phenomenon with alpha blockers all anti-hypertensive drugs can cause postural drop what do you do about that any patient who comes to your clinic if elderly if on antihypertensives never let the patient leave your clinic without checking the standing blood pressure you will be surprised so many times that the supine reading is 160 by 80 the standing reading is 110 by 70. the drops can be very huge and you must remember that you can afford a systolic blood pressure 170 but you cannot afford a postural drop of 50 points so you will have to judge your doses to prevent falls that is very important okay uh let's keep on the musculoskeletal system and how you can damage the patient's muscular skeletal system by prescriptions statins statins are very commonly used drugs and strategies of course are given to all patients who have developed who have demonstrable or clinical atherosclerotic cardiovascular disease the problem with statins is that they can cause significant muscle aches and more important than muscle aches again they can cause muscle weakness and that itself can cause false so make sure on any every follow-up of a statin taking patient ask them about muscle weakness gait problems and muscle pains and adjust the dose of statins test for cpk if necessary you must also remember that the utility of statins reduces after the age of 80. very elderly patients try not to initiate statins or even lower or withdraw the statins because statins improve long-term morbidity and mortality they are not for immediate benefit like aspirin can be for immediate benefit so if the patient's 10-year survivor is not significant you need not give statins to such patients or you can withdraw statins statins of course we know can also cause diabetes so every 200 to 50 patients you give statins to you can cause one new onset diabetes so statin should not be given easily without exactly determining the criteria for killing statins and there are very rigid criteria for if you see a patient with ldl cholesterol of 160 or even 170 a patient is 70 year old first time ldl no arthroscopic disease no diabetes don't worry about the ldl crystal of 170 often the patient will not need calculate the 10 year mortality by the risk calculator cardiac risk calculator give statins only if the criteria for giving statins which are very rigid are satisfied we tend to prescribe more than we should we we have ocd ocd is obsessive compulsive drugging we do not need to have ocd we must not treat every report we must not treat every symptom about that whenever you have a patient who has a symptom you must ask the patient does this symptom require my help the doctor's help does this symptom bother you enough to cause need for medication for example if a diabetic patient comes with choose in the feet anesthesia in the feet our automatic prescription goes to gabapentinople ask the patient few questions before you determine the need for therapy if you ask the patient how many times in a day are you bothered by this symptom and they will often tell you a few minutes or a few hours a day is the symptom very bothersome disturbs your lifestyle no it doesn't disturb me so much but you asked me for symptoms so i told you my symptoms the very fact that patient is given your symptom does not automatically mean that you have to treat that symptom you must ask the patient does this bother you and then think of treating gabapen and pregabalin are the most misused drugs in neurology you have to stop reduce abandon their use when not indicated that is very important we gobble in gaba printing cause severe severe headiness at the very first day of giving you'll have so many patients who will tell you that i could not tolerate the drug and you must and they can cause falls so you must be careful about giving those drugs another musculoskeletal problem is caused by ppis proton pump inhibitors you are we are all very fond of giving particularly pantoprazole should not be given for more than eight weeks at a time mandatory rule do not give bendable ask them to take some antacid like a liquid and acid and on an sos basis rather than penetropers on a regular basis only the patients on steroids for long term for any reason may you give penta preserve for long term otherwise please please avoid giving and giving pantoprazole with dom peridot as a combination has really no logic for the long term you cannot give this combination for long term so avoid that because once you cause a chlorohydria there is nothing to reflux and long periodontal does nothing in that situation avoid such combinations which are illogical just to answer can i add one more thing yeah look to survive yesterday only we discussed in our cutting edge show about the recent release of acg american college of gastroenterology's gerd guidelines and they exactly said what you said that please don't use api more than eight weeks and if they don't respond it's better to go for endoscopy and ppi has many problems like as you rightly said they determine b12 magnesium deficiency osteoporosis and is also known to cause acute interstitial nephritis and electron many problems so and whenever we give we should give it before meal 30 to 60 minutes before meal other than giving after meals or at wait time and as you rightly say don't combine with dom peridot especially elderly people and there can be extra pyramidal side effects along with that so very well said about ppi what i think one general rule that we should all follow is we should become under prescribers rather than over prescribers as a general rule especially for the elderly the the definition of polypharmacy is five or more drugs given to an elderly person or any person ah these five drugs do not include vitamin supplements or calcium five or more drugs one important thing to remember is for every one drug you add to the elderly patient one side effect will occur every drug you add one side effect is mandatory happening so you must take care of take care of those uh side effects another side effect that the patient gets is related to the bladder and then the bowel let me discuss the bladder first uh acute urinary retention can occur with any anti-cholinergic drug you can give something as simple as buscopan that is diceycloaming and you can get acute reunion retention you can give amitriptyline which has anticholinergic side effects and it will cause acute urine retention so take care of that whenever you prescribe a drug most most neurological drugs many many psychiatric drugs many gi drugs have anti-cholinergic side effects and you you must avoid that actually uh there is a list called the beers list b e e r s beers list in geriatric pharmacology you google peers for geriatrics and you will get the list the beers list basically is a compilation of drugs that harm the elderly the senior citizen and it's a useful list to go through so that you you know uh what drugs have to be given carefully if at all yeah so one of the histaminics antihistamines are also causing lots of anti-colonic side effects so and common prescriptions especially the first generation especially cause a lot of side effects so yeah another area is causing constipation the elderly are bothered about two things in life generally sleep and bowel movement if their sleep is good and their bowel movement is good the elderly considers himself or herself happy the relationship with their son or daughter-in-law or wife does not matter as much as the relationship of the bowel and the bladder and the sleep so you must keep the bowels open at least by not using drugs that cause problem the commonest drug that causes constipation in the elderly is calcium oral calcium supplements any patient who's on calcium elderly need calcium you cannot avoid giving cancer but any elderly patient who who comes to you on follow-up who is taking calcium please ask the patient do you have constipation if they tell you that i have so much constipation that i have to do finger evacuation then please remove the calcium and just increase dietary calcium you can't make the elderly person live with everyday severe constipation so calcium is one drug that causes there are in antihypertensive remember calcium channel blockers cause a lot of constipation so any patient who comes who is on guilty as him especially but even ambly if they have constipation you may have to consider switching the antihypertensive drug so multiple anticholinergic drugs like anticoagulant drugs cause urine retention because dryness of mouth they cause constipation all are very bothersome side effects for the elderly so any drug that has anticholinergic effect has to be given with great thought and in a small dose another thing that we see in the elderly is something called a prescription cascade what is the prescription cascade prism cascade is when you give one drug which causes a side effect you give a drug to treat that side effect that drug causes a side effect etc i'll give you an example you put the patient in america the patient comes to you after one month with edema feet you do not remove android paint because you do not think that android against the cause of editing of it which it is now you give a diuretic to that patient who has come to you with them the diuretic causes hyponatremia you increase the salt intake you give something like fluorocortisone for the hyponatremia and then that salt intake causes increased blood pressure and then you think okay i should increase the amyloid pin to tackle the high blood pressure and that continues that is a vicious cycle that you have created by treating a side effect with another drug never treat a side effect with another drug just remove the drug that is causing the side effect that should be done ah so that is about can i interrupt for a minute about the satisfied cascade you said rightly that many times we overlook the side effect of a drug that we had prescribed so as a rule of thumb we should first think of the drug there is a new symptom after preserving a new drug and one of the example you said is another is ramipril if you give any of these inhibitors patient gets cough and we prescribe codeine he gets constipation we prescribe laxatives so this is the prescribing cascade when for a simple omission of a drug would have solved the problem and yes absolutely true absolutely true another area of that i would like to discuss is about diabetes medications a new group of diabetic drugs that is sglt2 not new but relatively neutral uh group is has become very popular sglt2 inhibitors as you know the ugly flows in empirically flows in canada frozen and more are in the pipeline these new not nu but these sg82 inhibitors have become very popular because they have cardiac protection and renal protection both these groups of drugs this group of drug have both protections and more and more elderly patients are being given hdlt2 inputs i i have no argument against giving hdlt2 they are good drugs they control diabetes they cause weight loss in the overweight patient and they protect the kidney and the heart good drugs but drugs with side effects and since they are relatively new for us to know the side effect has become even more important hglt2 inhibitors cause glucosuria they remove the glucose from the bloodstream into the urine urine and by causing kozuria they cause dehydration because water goes with the glucose any patient on sglt2 you must check for dehydration postural hypotension and make sure that a patient on sglt2 ideally is not getting a diuretic ideally should not be getting both diabetic in a cl2 because you will cause dehydration in that patient also as clt2 inhibitors are very commonly causing penile or vaginal fungal infections infections are the introitus in the female and the penis in the male extremely common and often the patient will not disclose this to you on the follow-up every patient has gld2 please ask for a rash or itching at the at the introverts or penis and you'll be surprised that nearly 50 percent of patients on hdlt2 will come up with fungal infection at that site another group of drugs that is uh very important in the elder is the opioids the opioids that we use in india are codeine tremendous and pentadol besides morphine and and fentanyl of course morphine and fentanyl are not so much in the domain of the family physician or general practitioner more so are tramadol and pentadol please remember that they have to be used with extreme care the commonest indication of using triumvirative endodoll is osteoarthritis where you give paracetamol patient does not get better you can't give nsaids because the elderly patient has heart disease or kidney problems and therefore you give tremendous pain to all be careful with the dosing be careful with even prescribing the drug if you are prescribing an opioid between tramadol and depended on this is not a very well known fact between trauma and depended on choose depended all always tremendol is a pro drug metabolized by the cytochrome p450 coenzyme and converted to an active form there is a such a large degree of genetic heterogeneity that some patients will metabolize it much more much faster than some other patients so in some patients tramadol will have no effect at all because the conversion from product to active drug does not occur by the cytochrome v450 and something that will convert it so fast that travidol will cause drowsiness false so tepid doll does not get metabolized by the cytochrome p450 if you do use an opioid use depended on and not terminal the dose is the same 50 milligram tablets etc but we do know that mortality increases with opioid drugs so you have to use them very carefully similarly we have codeine but again codeine luckily is not available freely we have syrups which contain codeine and we have a codeine plasma combination available but chiefly we do use codeine only in patients who are terminally ill very severe pain unfortunately codeine all these opioids cause severe constipation and hence our use should be limited uh yeah if i can add about the tramadol please yeah tremodol as you rightly said is probably more prescribed than what it should be because it's also metabolized means one of them it has a mao inhibitions and many side effects and whenever we have nausea with the it's not easily tolerable drug whenever there is nausea weight tend to prescribe one dense satron ondensetron and tramadol is a very very deadly combinations and many drugs cause acute prolongations and one of them is stamina on densetron and tramadol and lanazolid again are another dangerous combinations which we feel that both are very safe drugs so ramadan has definitely more drug drug interaction so is with linus only and sono is on densetrol so these are the drugs we think that they are safe but they are not so ondenzetron is one more drug i think we should be more concentrating while prescribing okay since you mentioned linozoola let me talk a little bit about antibiotic therapy in the elderly one group of antibiotics that you should not give us first choice antibiotic is quinolones in the elderly avoid kundalini's as far as possible quinolones cause musculoskeletal problems you all know about tendinopathy uh due to quinoa loads but quinolones can also cause severe dysglycemia hypoglycemia sometimes hyperglycemia can occur due to quinolones uh in diabetics especially quinolones are notorious for causing delirium or encephalopathy and again a problem there is a black box warning related to quinolones for aortic aneurysm rupture or dissection and so queen rules have significant side effects and we use ornithosol or fluxes in combination in any patient comes with diarrhea very commonly such an illogical nonsensical combination to use do not use antibiotics with anidazole or imidazole combination ever be sure of what the kingdom diagnosis is and use one of the other so as a first choice antibiotic quinoa loans are really necessary really necessary and you should try to avoid quinoa as far as possible uh use penicillins use macrolides if necessary the second group that i want to talk about is macrolides within macrolides you know macrolides acid through azithromycin clear thromycin the very useless or oxitromycin the outdated erythromycin so we amongst the macrolides includingly avoid glare as far as possible clarity is the favorite amongst pulmonologists because they use it in eight typical pneumonias use acid chromatin whenever you want to have to use something for a typical pneumonia claritin causes significant qt prolongation erythromycin also causes significant drug interactions with uh many many drugs through the cytochrome p450 enzyme system for example if the patient is an attorney or statin and you give clarity medicine the levels of heterostatic can rise significantly causing myopathy so the the number of drug interactions are so many with clarithromycin that you will never know what hit the patient so don't use clarification in the elderly as far as possible sir said about linear solution uh this has said about linear solute linear solute is a drug whenever you give venezuela as you know is a drug even for gram positive infections typically given for mrsa and uh linear solid has drug interaction as i said with ssris and tramadol both linear solid causes serotonin syndrome if given with ssris or the tremor so if a patient for example is on an ssri as you know certainly in fluoxetine paroxetine or ssris if the patient is on an ssri and you have to give lenovolet you must omit the ssri before you give your insulin similarly it should not be given with alcohol with some cheese so be careful about linear solute in the elderly who is receiving other drugs uh amongst antibiotic groups as you know uh penicillins extended spectrum penicillins amphicillin augment in uh like drugs are relatively safer in the elderly than um than the other drugs so be careful about another drug that is very important very commonly given in the elderly antibiotic is nitrous urine chlorine nitrophenotone is a urinary antiseptic or antibiotic if you may this is very commonly given for prolonged periods in the elderly who get recurrent uti nitropharantone now is recommended against in people above the age of 65 for long term because it causes lung fibrosis chronic liver disease peripheral neuropathy nitropharyntene causes all these three and in the elderly you should avoid nitrogen except for short courses yeah so there are many many things in geriatrics which are a little um dangerous to the patient and we have to update ourselves for this i i think i have covered some things that i wanted to cover uh i don't mind opening up the chat or documentary if you have any comments um one more thing is about the use of egfr because there is what probably you would like to stress about every patient rather than going for only serum created in a patient at the age of seventy the serum cleanse of one point two and patient of thirty two years even one point two have mass difference almost half egfr if you calculate by the and it's easily available now it's on our hand that we can do so what about your opening about egfr yes this is an important area which i skipped but egfr must be calculated in elderly patients when you are thinking of giving some drugs for example simple metformin simple example metformin should not be given if the gfr is less than 30. similarly sclt2 inhibitor should not be given if the gfr is less than 30. so if if you have calculated the egfr you may avoid certain drugs which are going to cause a toxicity to the patient and as doctor this i said egfr calculator is easily available one suggestion is don't use the cockroft gold formula which now seems to be outdated using mdrd formula if you like which is and there are other forms like writing the mdrd formula you can easily google search for mdrd egfr formula and calculate each a horizontation based on the patient's age weight etc and yeah very important to calculate every time you you take there are some antibiotics which cannot be given if egfr is low the safe antibiotics in patients who have a low egfr are the penicillins and the cephalosporins and the macrolides like acetomachine uh toxicity is safe in patients with low eg for clindamycin is safe linen is already safe so there are some safe antibiotics that you can use if the gfr is low yes sir yeah yeah when you are talking about the phenylephrine i just wanted to add but basically that even nasal drops like autoimmune which now we see in the in the print media and in electronic media as an advertisement it also suits up the blood pressure after initial drying effect so should we not be yeah so the thumb rule in oxymetazoline and xylometazoline which are the nasal decongestants like co-driven is a brand name the thumb rule is never used for more than three days if you do use in the patient another side effect is that they cause what is known as rhinitis medical mentosa meaning they actually cause rebound congestion of the nasal mucosa when they are stopped and that causes chronic rhinitis in many patients so yes they are drugs which should be used for very short duration another drug most commonly over user on abuse is the fabrics of stat or a little rise in the uric acid so your take about the fabulous state prescriptions so one one thing that i teach students very commonly is read the patient not the report one very important thing to tell everybody is people will see a uric acid of 7.5 and they will start either xyloric that is uh aloe veranola or fabulous system don't do that if the patient is asymptomatic the patient is not ckd not a chronic failure patient if the patient does not have any history of kidney stones do not use these drugs they are not to be used lightly so the absolute value of uric acid should be nine or more to this to start these drugs in uh in a patient who doesn't have history of gout or stones so 7.5 8.5 are not reasons to start and one must remember this fabulous stat now in the us comes with a black box warning black box warnings are warnings given uh uh which for things that can cause deaths for things that can cause severe morbidity the black box warning for a fabulous stat is increased cardiac mortality due to fibric system so you must not use fabulous satellite at all thank you so for remaining and another thing is that we often overlook is that the patient receiving the non allopathic drugs herbal medicines or supplements and drugs prescriber other consultants if i am looking after the patient probably somebody else is also looking after the patients and i am prescribing one analgesic or anti-implement the another is receive another and so about the calcium and vitamin d supplements too many too many so yeah let us let us talk about the supplements first so polypharmacy is a problem right it is said that any patient who is receiving 10 drugs which includes the vitamins and supplements 80 percent of patients make mistakes on a daily basis that is the statistic 80 percent of elderly patients who receive 10 or more drugs make mistakes in taking the drug on a daily basis our job as family physicians is to remove unimportant drugs coenzyme q10 nephrosave cardiovets all these drugs which have one thing i always teach my students is if there is any brand which has the name of an organ system in the brand that is usually a placebo for example nephrosave is a placebo neuro kind is a placebo cardiovert is a placebo hepato something is a placebo so try to remove the placebos patient doesn't need such a degree of polypharmacy uh and yeah as you said rightly sometimes two doctors are treating the patient there is an overlap of prescription most most people don't know what is happening to the other consultant most people don't know what drugs have been started so you will often i have seen patients getting three antiplatelets they get a clopidol aspirin combination also and then they get us get a separate ecospirit also so many things happen which are which are due to poly not just polypharmacy but polydoctory multiple doctors seeing the patients so i think that that has to be taken care of by the central family physician who is currently the most important person for the geriatric patient one of the participants of this today's symposia is also asking about how much ethanol can be permitted uh in an elderly so uh initially sometime back we used to say that six large drinks 60 ml of spirits per week would be okay now we know that not a single drink per week is okay for anybody what happens is our main concentration was in the liver when we spoke about alcohol the liver problem is dose dependent liver problem is dependent on how many drinks per week for how many years now we know that the cardiac in the neurological problems related to alcohol can occur with small doses of alcohol so current recommendation not a single drink is safe now you will obviously individualize this the patient will want to take alcohol if they want to take alcohol you will have to individualize this you if the patient has an injection fraction of 35 you will not permit drinks if the patient is starting to get memory problems cognitive disturbance you will not permit drinks at all so you will have on an individual basis another question from the audience is about the anti-fungal drugs interaceal and broken nasal all that we described probably more often than we should be so your take on that so one thing that we must remember is that fluconazole is a drug for candidiasis intraconozol is a drug for pineal the other two commonest fungal infections we see in our practice so for example if an hglt2 inhibitor causes fungal infection at the penis extended and fluconazole is good for that if a patient has diabetes uncontrolled and has groin or auxiliary atenia that does not respond to fluconazole that responds to intraconozole so uh one thing about intercontinental intraconozole has like clarithromycin multiple drug interactions and interconnezone when you give please see the other drugs that you are giving for example eternal warfarin causes trouble it recognizes all with some beta blockers causes trouble it recognizes all with heterostatic causes trouble it draw console causes trouble so you must remember which drug interactions occur uh since we are on that i'll just tell you this uh there are some drugs that we have to put in the dust bin forever long for example i told you about utoricoxy we cannot use it or similarly in statins there are three statins which are more commonly used simva turbo and rosuva and of course there is now pita or statin etc but there is no reason to use atonva statement symbol stating now at all simus and heterostatin have significant drug interactions through cytochrome p450 enzyme system rose rosuvastatin does not have interactions through that system do not use because the cost of prosodine is not much more than the cost of atrocities stop using atrocities stop using hitoric oxime amongst nsaids and amongst alpha blockers you know that there are prostate related three alpha blockers m solution cellular dosing alpha zosin stop and fuse ocean completely if a neurologist prescribe the alpha solution you change it to cellulosic or time solution because alpha is significant drug interactions and in the elderly you will never know who will prescribe a dermatologist will prescribe interconnection the dermatologist does not know what is alpha juicing they don't know the brand names of alpha zeus and they will cause a drug interaction where alpha losing will cause severe hypotension and the patient will fall how will the patient fall the the levels of isolation go up when interconnezone is given and the patient will fall so you you other dermatologist has no idea that this can happen so you have to take care not to initiate drugs if there is a replacement available which causes less drug interaction yeah so yeah one of the we also want to know about can adrenaline be given safely in a rural setup i suppose he's asking for adrenaline for asthma i mean i don't know for anaphylactic shock everybody gives yeah uh but let me talk about both situations underlying for anaphylactic shock one important thing to remember is has to be given intramuscular and not subcutaneous not intravenous anaphylaxis intramuscular adrenaline about us i think uh the use of adeline asthma should be stopped we have so many good alternatives including nebulization etc that asthma should not be treated with adrenaline at all yes yeah then most of the elderly people are receiving multiple cardiac drugs one of them being the anticoagulant and anti platelet drugs so with the availability of noic new neo oral antiguan drugs so we still be prescribing warfarin okay so let me tell you talk about both antiplatelets and anticoagulants first i talk about antibiotics the commonest problem with antiplatelet therapy is that dual antiplatelet uh drugs are continued for very long term too large yeah we all know that aspirin club are given after an angioplasty for example the current recommendation is one year is enough for giving dual antiplatelets after a strain placement when the patient goes to cardiologists the cardiologist does only ctrl meaning the patient continues to get dual analytic therapy for one year two years three years for in a geriatric patient you cannot afford dual antiplatelet for life because the patient will fall we will get a hemorrhage we get a spontaneous bleed from the bowel due to the dual antibiotic drug so always if the patient on dual antibody therapy and if one year is passed since the interventional event then you please call up the cardiologist and say what do you say to the cuddle there are two drugs going on can i stop one what will the cuddle say no you cannot so what you have to say is there are two drugs going on the patient has some blood loss in the stool can i stop one drug and the catalyst will happily say sometimes we have to lie to get the cuddles to do the right thing uh about the anticoagulants so as you said the novel oral and equivalent slide like epic saber and derby cutron are available uh and warfarin is often used as the more common anticoagulant can we replace we can replace we should replace that couple of things to know here when we give no newer or novel orlando we are giving for non-vulvar atrial fibrillation what are we giving it for we are giving it for long term i'm talking about long term long term no acts are given typically for patients of atrial fibrillation so that they don't throw emboli from the heart into the brain or elsewhere no hacks have to cannot be given in patient with mitral stenosis with atrial fibrillation mitral regurgitation with atrial fibrillation they have to be given a non-vulvar attribution involver activation warfare still remains the gold standard therapy so in non-vulva if you have to give an anticoagulant it might be better to give a repeated ptiner requirement goes away also dietary potassium vitamin k need not be regulated as it is regulated in warfarin taking patients so you you can easily switch the cost has become less of giving no x so that that also now is an advantage the one problem with no axe of course is that if the patient gets bleeding it's not easy to get an antidote to that bleeding like we have protamine for warframe we do not have an easy access to antidotes and the antidotes are expensive that is one problem but we do we do think that no acts are a better option for non-valver atrial fibrillation yes sir and this kobit time people keep on doing the d dimer and keep the patients on anti-platelets or so is it worth doing when the patient was not hospitalized or he did not have any signs of thrombosis so we still and how long one should take this yeah so uh kovid has exposed the medical uh fraternity like no no other disease who it has exposed us for doing wrong things like no other disease has exposed us uh and one area as you said is the t diameter thing so d diver if say 500 is normal and if we see 800 d dimer we will start an anticoagulant do remember that in the elderly i am talking about the elderly first in the elderly there is a false positive elevated d dimer very commonly you will see 1000 in the elderly without any problem so ignore first of all don't do d dimer until the patient becomes hypoxic that is my thumb rule if the patient becomes hypoxic you must do the dimer if the patient is admitted even before hypoxia the patient will always be given clexane inoxa parent is a rule in every admitted cohort patient so d-dimer is a marker of of inflammation of the intimal lining of the veins and the and d diameter therefore is an inflammatory marker and use it as such in in covid never let dimer decide your outpatient anticoagulant therapy don't do that also often and we see this incorrectly happening patient is discharged on oral anticoagulants like apixaban for three weeks six weeks without any documentation of dvd or pulmonary thromboembolism don't do that to give long term that is three months or three weeks of anticoagulants you need evidence of thrombosis in the form of doppler of the legs or pulmonary city and you otherwise you don't easily give antibiotics right so we've been talking about the over prescribing but i personally feel and i need your opinion about the under prescribing of dvt profile axis in a perioperative questions particularly patients undergo surgery for the heat replacement or the knee replacement so it is not just a perioperative under prescribing it is also in icu patients yeah i see isolated with pneumonia exhibitions get admitted with many things in cardiac disease we under prescribe we under prescribe and short term prophylaxis with no acts or inoxa paren like drugs is mandatory in in patients and there are easy scores available to assess risk of dvt in patients or hospitalized so short term dvd prophylaxis is under prescribed and we should prescribe it more yeah one other important question asked from came from the audience and also would have asked the same that in spite of repeated teaching at all levels people still use sublingual nephilipine for acute lowering of the blood pressure is it not a crime as i said the lecture should be titled in how many ways can we kill patients so one of the ways is using two sublingual drugs subliminal sorbet rate and sublingual nephilim sublingual nephrodipine uh as is outdated something so one thing you remember this first in a patient who does not show end organ uh deficit meaning the patient does not have stroke doesn't have pulmonary edema doesn't have acute kidney shut down and the patient comes with 200 by 130 bp you don't have to bring the bp down in 10 minutes you can easily give oral drugs send the patient home or admit the patient if you like but don't precipitously bring down blood pressure because the patient does not have lvf if the patient is lvf give iv lasiks the furosemide and get the medium out otherwise don't don't uh precipitously bring down blood pressure that is very important also if a patient comes with stroke bringing down blood pressure precipitously can aggravate a stroke about sublingual sorbet rate uh never give sublinguals orbit in a suspected acute infection but in common chest pain patient has issue changes you know it is an infarct you know it is unstable angina don't give supplements orbit rates orbited causes the steel phenomenon it causes peripheral vasodilation coronary blood flow actually decreases your disorder rate give the patient aspirin global electrostatic if you like don't give something new uh in a patient with acute myocardial infarction this spring reduces mortality by 22 percent keep the sprain in your pockets keep the screen in the patient's pockets tell you all your patients to keep the spring with them and save lives by giving the spring rather than kill patients by giving sublinguals orbit that the patients and the relatives take pride that i have just even sorbeted because i have it and he did not have it and when we see they have hypotension syncope and all these problems another areas are that probably we are under using is the vaccinations in elderly okay yes in the elderly adult vaccination is a topic which i i hope that you will teach on netflix and uh it's a very important area but luckily with due to coverage vaccination has come into limelight uh not just covered vaccination but even flu vaccination pneumonia vaccination has come into the liver limelight so my recommendations about vaccines are very detailed but think of everybody above the age of 65 to give prevent that is the pcv 13 vaccine give pneumo wax that is the ppsv23 vaccine to elderly patients you will influence a vaccine it's a shared decision the patient is not compulsory but if the patient has comorbidity like copd give the influenza vaccine every year to such patients uh unfortunately herpes roster right not available in india there is another wax if it comes i would be keen to give the zoyster vaccine to patients there are many vaccines that you can give to the elderly and you should epidermis b vaccination is incomplete in many patients and you should take care of hepatitis b vaccination in the in the adult population many of all elderly patients are receiving drugs for parkinsonism and they themselves are very tricky problems in adjusting the dose about the anti-parks and drugs and the side effects so any specific instruction or advice you want to keep as a family physician the family will not be usually adjusting the dose of parkinson's medicines the family physician has to be aware of the side effects of the parkinson's medicine the two commonest side effects that you should be aware of are psychosis and postural hypotension with syndopa that is the combination of uh levodopa and carbidopa if the patient is on this combination every follow-up or surely blood pressure should be checked and you should ask the spouse or the family member about hallucinations if they are there you must inform the neurologist that patient is getting violent patient hassle hallucinating removing these clothes throwing things around and that can be a side effect of syndopa so side effects are most important to be aware of in neurological disorders because these drugs are not commonly given by us we are not experienced enough to regularly describe these drugs another area is dementia medicines similar dementia medicine cause significant anorexia significant gi disturbance and if the patient of alzheimer's is taking some dimension medicine like momentum alternative donors appeal then you must ask about anorexia gi disturbance like diarrhea and inform the neurologist that these side effects are occurring and should we reduce the dose because anyway as you know dementia medicines are not very effective medicines they are given because the patient has memory problems but the memory problems usually do not improve with the dementia medicines so you may want to minimize the drugs of dementia if the patient is not eating well accidents are excellent we occur practically each and every aspect of internal medicine not only in the elderly but also in the younger counterparts and given many tips and insights and we would have loved to continue but we already passed one hour and i think it's time to thank you and all the viewers and we'll definitely want you again and again on our platform to enlighten us and i also learned a lot niverita are there any persons for what we call for on the stage or the uh we do have uh raise hands um could we call dr atul parrik on stage so i'm accepting your request you'll be uh prompted to turn on your audio video uh so you'll have to turn it on when prompted and then you can come up on stage i think i did see sir on uh so we've accepted your request you'll have to turn on your audio video yeah dr atul barik is a very senior physician a very good friend and he has been a professor and as many undergraduates and polio students with him and one of the great enthusiastic persons dr atul welcome and please have your questions can you hear me hello and we are faced with one problem of patient is not relieved of their pain if we use paracetamol we have to use nsids and sometimes combine it with the steroids it is the best energy you shared nepalese but sometimes naproxen doesn't take away their pain so what else would you suggest okay so uh first of all luckily chikungunya is more common in the younger people than in the older people so that nsaid related toxins i don't think [Laughter] does not work it does not work usually we give paracetamol more as a placebo than as a real painkiller in chicken chickuna is a frank arthritis it's not just arthralgia so yeah we have to use nsaid sometimes some people use steroids also after three months of chicken many people start using disease modifying anti-rheumatic drugs for chikungunya so uh there is still confusion related to that so about nsaids ah i think the correct dose of naproxen is often not used the current rule of nephroxane is 500 bdd and we tend to usually use 250 pd so that is one thing taclophenic is a favorite amongst uh many people i have removed cyclophonic from my armamentarium completely i don't use that except as an injectable occasionally in green alcoholic uh but i don't use dicopenic at all i have made a wow not to use that ibuprofen if you want to you can correct those in a 60 kg adult is 600 milligrams tedious and not 400 millimeters so i would use ibuprofen i would use an approximate pd i would use short bursts of the drugs in an in chicago i would use for two three four five days stop withdraw ask the patient to bear the pain and use it again for a few days intermittently intermittent use reduces the chance of cardiovascular and the toxicity i will always give a ppi whenever i use uh for a prolonged period or even if intermittently so ah i such a known as a tough disease and i wish i wish more is done to prevent yeah sir uh i would not use steroids at all unless there are contraindications for nsaids so the patient's creating is 2.5 1.8 and i can't use nsaids at all okay in such a position then for inflammation i would i would use steroids otherwise i would assiduously avoid steroids steroids also cause a subtle significant relief in pain that often the patient will start self medicating with steroids so i i would be very reluctant to use and if i use i would use it in short bursts of similar to insects but and said contraindication should be there for me to use steroids but i know i know that rheumatologist routinely something wrong with oil and see using a steroid very early has definitely shown that the inflammation is less and they don't go into chronicity and using drugs like uh i would say deflector cord that we have found that there is not much side effect if you use it for a week or two and at the same time it produces significant uh reduces the morbidity yeah i have not read any papers on steroids being useful in early disease so i i would wait for such evidence to come but my reluctance is always significant uh to use drugs which do not have scientific evidence i would wait for some evidence like that somebody asked about nemesis uh similarly pneumocyte of course is uh not safer than any other drug in fact the most part toxic and said is uh pneumonia so i would i'm not very keen on unisonite if you want to use a gi safe and said then because i am saying hitoricoxy which is gi safe should not be used at all then etho dollar is a good gi safe nc it taught no lag it comes in 400 milligrams standard strength bd that you can use right but in the mesolite i don't think is available outside india anywhere i have not heard of nemesis light being used and here it's used left right and center but as you rightly say tremendous hybrid toxicity and one of the most dangerous drug to me yeah i i've never i've rarely used thank you for such a descriptive uh things you are told and the we have multiple guys that has been solved so i just want to have your experience on the topic vertigo which is commonly seen in our day to day practice and in many patients despite of knowing the reason multiple use of beta histamine nicholas in we have been using a multiple things for that so what is your approach and what is the role of this vertain and we close in and stem till in such cases please uh so there are three important causes of vertigo that we know and one of the three important causes is bppv benign positional vertigo i suppose you are asking about bppv pppv third treatment for bppv is not medication the treatment for bppv is a maneuver called the aptly maneuver epley you must learn the earthly maneuver it's a simple thing and you must do the epi maneuver before you start giving those sedatives uh what we call vestibular sedatives like mechanism or stem material etcetera uh the only drug that i do use sometimes is beta esteem which is worth in or beta word etc but aptly maneuver is something that is g treatment you may have to do it once more than once but do use everyone and always remember in the elderly what looks like bppg may not be bppv so think of central causes of vertigo in the elderly vegetable uh vegetable or sorry vertebrobasilar insufficiency should be thought of so think of think of that when the patient ataxia along with the word ego always think of whatever basically instructions thank you we must thank dr vivek for bringing out a very common problem that uh had to be discussed thank you talk to you all another doctor nagraj is asked about the antiviral drugs ah it's a big topic i suppose but if you have to say and break some things up in family practice the commonest antiviral drug that we use are those for herpes roster and uh uh the drugs like valencia well valley side whilst you know that valacyclovir acyclovir or fam cyclovir are all safe in in the elderly and you should not change the dose in the elderly and i don't know what other antiviral drugs he's talking about they give any flu generally we give tummy flow also these days with influenza sorry i forgot that yeah for influenza or cell tumor is a useful drug because we know that influenza causes more morbidity in the elderly it is much more important to start that uh start oscillator in influenza within 48 hours of onset of fever that is very important the duration has to be less than 40 hours for foreign to be effective so it is a good drug it's a it's a very good drug to prevent hospitalization in influenza and it is also useful prophylactic drug while the therapeutic drug is 75 bdd the prophylactic dose is 75 od for contracts of the elderly contacts of the patients of i think now we'll have to stop sir thank you very much for being with us and having answered all the questions and covered the topic and absolutely impressed and learned a lot and thank you so much
Medication Errors in the Elderly
Due to the general increased prevalence of chronic diseases and drug use, the elderly are the most vulnerable population group. Several aspects of ageing and geriatric medicine influence drug prescribing for the elderly. As a result, selecting appropriate pharmacotherapy for the elderly becomes a complex and difficult process. Professional errors in prescribing, preparation, dispensing, and administration have been identified as direct causes of preventable adverse events, despite the fact that adverse drug responses are the most common unavoidable adverse events. Let us hear more from Dr. Tushar Shah about reducing medication errors in the elderly.
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