10 Ways (Not) to Seriously Harm a Geriatric Patient

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10 Ways (Not) to Seriously Harm a Geriatric Patient

12 Oct, 3:30 PM

welcome so uh just to tell you about today's topic we all have learned what to do in our medical school during our practice but no one has told us what not to do and drishasha will be covering this very important topic today uh 10B is not to harm geriatric patient uh thank you so much sir for taking time out for this session I'll just start playing the presentation thank you all for having the patience and waiting for this uh 10 ways not too seriously have a genetic Mission my initial topic Choice was how to seriously harm a geriatric patient but that was considered a slightly inappropriate title so how not to is the title now uh here are some suggestions that may help us make less errors first rule number one Pediatrics rule number one start low goes through this is a very common really mentioned Rule and all of you know about this Rule and this rule applies to almost everything except maybe infections so uh if you have a geriated patient who comes with benign prosthetic hypertrophy and high symptoms and you want to start them on uh say tamsulosin with finasteride if the patient is 85 years old patient has a postural drop of 20 millimeter mercury in blood pressure what will you start will you start the combination like well time F4 D plus T which contain 0.4 milligrams of translucent or will you start tamsulosin 0.2 separately from due task or finasteride separately so I would suggest that if the patient is very old and if you check your blood the patient's postural blood pressure and if there is some fall in partial BP please start with a smaller dose of tamsulosin separate from the dose of finasteride don't use the combination which is a fixed dose combination there is no 0.2 tamsulosine available in combination with finasteride and trust or drastic rate so uh that is one example how you start slow low and go slow of course you know that um in most psychiatric medications in most neuralgia medications you have to do the same thing uh I have seen you know prescriptions of gabapentin 300 milligram TDS as the first prescription of Gabapentin for say painful neuropathy it is a disaster it is uh it is something that is Criminal and we should not be allowed to do that so uh start smaller Doses and go higher doses uh since we are talking about gabapentin and pregabal I've always stressed on the importance of how to give if you have to give uh these anti-neuralgic drugs which are anti-convulsants also never I would say ever start with 75 milligrams of pregabalin or 300 milligrams of government in the first day you must start low remember 100 milligrams of pregabalin is approximately 300 to 400 milligrams of Gabapentin now if you want to start somebody on one of these two drugs use Gabapentin start with 100 milligrams which is equal to about 25 milligrams of pregabalin start with 100 meters of gabapentin and gradually build up whatever those you wish if you wish to switch to pregabalin which you like more if you do like it more then after you reach 300 millions of Gabapentin switch to 75 milligrams of pregabalin and this escalation of those can occur over a say a two week period or so so now let's talk about another example let let me see if on the on the comment section you can you can just tell me your prescription of uh of a for a 70 year old new diabetic with fasting of 200 PP of 300. after good lifestyle modification what medication and at what those will you start this patient for diabetes patient is non-obes patient is fasting 200 PP 300 if you want the HBO and C it is 8.4 and the patient is a symptomatic for diabetes patient is a newly diagnosed diabetes can I have one or two suggestions on what dose will you start at 200 and 300 fasting NPP in a 75 year old I'll wait for a couple of minutes and see what your suggestions are and if you are the kind who are more conservative variety of journalists I'm still to get suggestions uh okay so here is my suggestion to you you must realize that there is no tearing urgency uh in starting in starting high dose and controlling diabetes very quickly unless the patient has significance infection so somebody said 500 milligrams of Metformin OD and another person Dr Iqbal also has the set the same doors and somebody wants to give uh Flows In 10 milligrams OD or will dug lifting 50 BD so most of you have started with smaller Doses and one or two of you have started with a combination of those what I would I would recommend is that start low and build up over a week or 10 days also so in this patient I do not mind starting with 500 milligram metformin I do realize that the 300 milligrams uh sorry 300 boost final will mean that there is insulin opinion along with insulin resistance resist but I don't mind starting with the low dose only one cell image forming of course that remodification has already happened in this patient and build up the doors or over the next few days as I said almost never in hypertension or diabetes is an urgency to control it rapidly in hypertension a Rapid Control comes into play only if the diastolic is 120 or more at 160 by 110 you don't have to immediately within a few hours all days lower the blood pressure so I think uh the reason why I say this is because hypoglycemia if you overdose the patient immediately or hypotension can be disastrous for the elderly okay so start low go slow simple let's go to the next step too not every symptom requires a medication a geriatric patient comes to you says that I have uh some bloating or distension of government since years or months and you will give that patient panto seed you know well that dyspepsia bloating are not symptoms which are easily uh treated with PPI smart don't give a medication just because the patient has mentioned a symptom if a patient of diabetes comes with numbness in the soles of feet you don't have to give medication for that you have to first ask do does this symptom of yours require my health this is a very good question to ask do you think you need a medicine for this symptom of yours the patients you know my bloating is okay it comes once uh once in a while once in every few days I take my home remedies and ask the patient and you will get the answer of whether you need to give a medication very important a corollary to this geriatrics rule number two is that not every abnormal blood report requires a medication this is an extremely uh important thing and the mistakes made are uh just too many and just just uh again very very incorrect if a patient has a complete Health checkup done and the uric acid is 8.5 and the patient denies any gout symptoms denies had having had ever any kidney stone 8.5 9 out of 10 of us attending today will start something like February to start or xyloid please remember in an asymptomatic patient who does not have CKD that is GFR is more than 60 uric acid does not require treatment unless the uric acid level is beyond nine so you must not go go to the evidence evidence-based medicine says uric acid has to be nice if the patient is asymptomatic if the patient is symptomatic with history of recurrent stones or student gout or the position is CKD then even the level of 6.2 you you can with your therapy so it's very very important to look similarly I have seen too many wrong prescriptions of fenofibrate if the patients uh triglyceride asymptomatic non-diabetic equation has a triglyceride level of 450. again 9 out of ten generalists will start even Specialists will start phenofibrate a patient who has no cardiac disease no atherosclerotic disease a patient who has a low history of pancreatitis has a triglycerer of 450 do not medicate this patient with phenofibrate there is no evidence to suggest that phenofibrate helps it will lower the triglyceride but will it prevent anything no it will not prevent anything so please take care of I mean read the evidence of giving ferrofibrate so yeah she has had writings right induced pancreatitis then you have to give a ferrofiberate if the patient has diabetes even if well controlled has a triglyceride level of above 500 you must give a fenofibrate again in diabetics Phenom fibroid is given even at a level of 220 to 30 triglyceride there is no evidence for that so please do not be bothered by the blood level of triglyceride and Medicaid unnecessarily look for evidence and you will find evidence so easily we have access to evidence now very very easily if a patient has a report of ultrasound which shows very a young patient not a geriatric Mission which shows ovarian cysts and the patient has no problems with irregular periods more features clinical of uh hyper androgenism will you give the gift know that you will not just sonography is not enough to diagnose pcod similarly if the patient shows a prostate size of 50 grams and if the patient has no symptoms no significant post void residue on ultrasound this ultrasound feature should not become the motivation for starting BPH medication very very important that do not treat this this sign or this feature or investigation similarly if a patient comes to you with knee joint x-ray which shows severe knee osteoarthritis [Music] osteoarthritis degenerative disease will that become an indication for surgery tkr no if the patient does not have significant pain or it has other patient has manageable pain with mild analgesics you will not be operating this patient so do not do not treat the X-ray or the MRI in this situation uh oh yeah so these are many many uh signs which we treat unnecessarily many symptoms which do not the patient does not want the treatment for and therefore you should be withholding treatment in such situations uh rule number three remember and you can harm the patient many times if you don't remember this remember that the elderly often have substitute symptoms substitute symptoms are symptoms which are not classical symptoms for example a patient with severe intra-abdominal infection like pyelonephritis a diabetic elderly patient may not have the classic flank pain may not have dysuria may not have high fever for that matter or rigas that elderly may just have delirium and delirium is often a feature of acute infection so any patient who comes with acute all to it sensorium acute delirium you should think of this as a substitute symptom similarly a patient whose elderly if they have an MI they mean [Music] which are acute and which are unusual yeah so that is about [Music] the next rule Rules of Evidence evidence-based medicine is often change in the elderly now this is very very important do you know that hypothyroidism is defined as TSH about say 4.5 or 5 right give me a little now that rule has changed up to seven in a older patients about 75 up to seven is accepted as normal TSH similarly if a hypothyroid elderly is being treated your target TSH is below seven you don't have to bring it below five or up to 2.5 why don't you do that or why don't you treat the shr7 because the harm induced by thyroxine in the form of atrial fibrillation or osteomorosis is more than the benefit given by the thyroid medication so you must avoid treating hypothyroid even if the patient has antibodies to antidepio even if the patient has anti-tipo antibodies avoid if the TSH is below 7. what other evidence changes ah ba1c targets as you know hbmc Targets in the younger diabetes are below 7. one in the elderly of a Target level of 7.5 is good enough why is it good enough because over medicating over achieving diabetes control in the elderly can cause significant uh hypoglycemia hypoglycemia is much more dangerous to the elderly then a mild hyperglycemia so again that Target changes similarly in blood pressure control now this is very important very very important which I think I should um emphasize in an elderly patient if the supine blood pressure is 180 by 90 and the patient is already taking medications for blood pressure don't be tempted to increase the dose until you measure the standing blood pressure supine 180 by 90 standing might often be 130 by 70. standing BP is the BP that you have to treat in the elderly a rule which is not mentioned in textbooks so you'll have to uh in the elderly control the standing blood pressure and not the supine blood pressure very simple you will see this multiple times in your clinic a very old patient comes to you BP is 170 by 90 you are tempted to increase the dose but just if you make them stand the BP will fall by 30 40. sometimes even 50. it can fall drastically take care of this especially in patients who have had Falls episodes and you'll realize that you may have to reduce the dose even if the supine blood pressure is 170 by 90. if the standing is 120 by 60. so treat the standing blood pressure and change your dose accordingly so that is about um [Music] rules of evidence-based medicine which keep on changing similarly in distributing I'm forgetting that Statin therapy beyond the age of 75. is increasingly coming under a scanner so whether it prolongs life in those who are who have already reached 75 so if the patient has no atherosclerotic cardiovascular disease is about the age of 75 and the you do the lipid profile for the first time in the LDL cholesterol is more than 190 which is very high don't start medication even especially if the patient has no atherosclerotic cardiovascular disease so and if the patient has atherosclerotic cardiovascular disease and has reached the age of 85 consider strongly removing the starting whatever is going on even if that patient has had cmpg even if the patient has had angioplasty but the patient is 85. at this age statins will be doing more harm than good that is extremely important to realize so there is evidence for this I'm not talking about the cuff there is evidence for this now that statins in the elderly are probably not as useful as they are so that is about Rules of Evidence change now these are very important Rule and I I I'm passionate about polypharmacy and it's and it's uh it was if it's rule number five subtraction is as important as addition when it comes to geriatric prescribing polypharmacy is defined as five or more non-supplemental drugs going on in the elderly elderly comes to you with a new symptom and you will add address another new symptom will add another new drug you will rarely consider removing drugs somebody who will remove drugs will will definitely be the better physician than somebody who will add removing drugs repent of delivery Some Cuts but remember this that you are you're harming the patient by just adding every time and not considering subtraction let me ask give you an example a patient is on Phantom resolve with domperidone you know something like fantastic DSR significant heart attack here and the patient probably requires a PPI for life now DSR has been started you have to remove the DSR even if you want to give pantoprazole for life because of the very massive higher discern here which is symptomatic but there is no evidence that down perid on is necessary for this patient remove the SE are gay subtract wherever you can subtract combination therapy especially we see that you will be able to subtract there are some drugs which are utterly harmful and without evidence-based for example many patients of COPD are on deol in for Life dual in nebulization or inhaler three times a day every day now we know both of us know that all of us know that both salbutamol which are components of dueling if taken for long term are more harmful than beneficial they are short acting drugs in a COPD patient you have to give long acting drugs if you want to give lifelong like tired to Opium and for Metro or cell Metro you cannot give dueling for life for long term even for a month or two months so you have to remove dueling subtract during from the prescription then subtraction is very important in polypharmacy when it comes to uh renal toxic drug like NSAIDs many patients will be taking NSAIDs for months or weeks one thing that we have seen and you have seen and we have seen is that uh insects which are most commonly prescribed amongst all Specialties by orthopedic surgeons and saves are given for weeks days or months very difficult I do know what is the thought process but they will go first time for OA knee pain or severe lumbago and they will get 15 days of NSAID and say they will go again pain is better when digging inside but stop when after stopping and say the pain comes back another 15 days of a new NC now NCS don't cure they are a palliative drug you have to remove the NSAID from the prescription of the orthopedic surgeon we come to that again on our next slide so keep on subtracting from polypharmacy whenever you think that this subtraction is possible uh also remember the concept of nnt n n t numbers needed to treat and then there is n and H numbers needed to harm now just give you an example here some paste some maybe or elevations are given primary aspirin as prophyl I'm sorry aspirin as primary prophylaxis in the U.S it is a trend to take aspirin once you across the age of 50 60 whatever even if you have no article sclerotic cardiovascular disease primary prophylaxis with Aspirin the numbers needed to treat nnt is about 1200 what does that mean if you give aspirin as primary prophylaxis to 1200 people over five years you will reduce one heart attack 1200 people are needed to be treated for one heart attack to be prevented in primary prophylaxis now this is a ridiculous number and you can't make so many people suffer for saving one another and what is nnh in this case numbers needed to harm then if you give such people uh 250 people even 250 people given aspeners primary prophylaxis will get a major bleeding episode so while the number needed to treat are more than a thousand the numbers needed to harm are 250. so you're doing more harm than good nnt is a very good uh statistical tool it is completely underrated it is not known to the General Public Hall low model it is not known to many doctors there is a website dnt.com or whenever you want to read about it for example you want to search nnt of bisphosphonates in osteoporosis you will realize that giving these phosphorates at a minus 2.5 East Coast which is our score for osteoporosis minus 2.5 t score giving base phosphonates in a person who does not have any past history of fracture the nnt is not good at all I'll give you the energy in a moment if I can uh but the energy is more than 100 meaning 100 patients will have to be given up this phosphonate for one fracture to be prevented over a three year period in an osteoporosis of minus 2.5 if there are no vast history of fractures so this is something that if you tell the patient okay I am giving you but um I would have to give you give hundreds patients such a medicine for one fracture prevention do you think any accepting such a drug so I think we need to be more uh we need to have justification evidence-based justification to add drugs and therefore we should have evidence-based justification to delete drugs there is this combination of pantoprazole with levos sulfuride you have to delete the liver sulfurite there is nothing nothing uh it's Common Sense give yourself that we all know now causes parkinsonism we cannot allow leversulperide to continue so we have to delete drugs with bravery we should have the guts and consumption to delete drugs as much as we have to add drugs okay so that is that is ah geriatric rule number six my favorite uh uh point of irritation and says and states can go from palliation to poison before you can say etoric oxygen um I have said this again and again and again and N states are used overused abused patients are harmed patients are killed patients are maimed patients are hospitalized because of NSAIDs please understand that insids are good drugs for pain relief dental pain can be bad pain uh very severe acute sciatica can be bad pain you have to give any seeds in sharing your colic severe any colic agreed and NSAID can be used very well to relieve a patient but and sits in the long run if you give for a long time I'm going to cause more harm than benefit I will repeat this one in my previous lectures I have said this and you will be bored of hearing this but stop using etoric oxide etoric oxym is to be banned to be put in the garbage bin to be deleted from our our momentarium look at this if you're asking a stupid friend which is the safest cardio uh in terms of cardiovascular complications which is safe first and said the orthopedic friend will say with confidence and this uniform across all orthopric surgeons etoric oxip is the safest for the heart say first for the kidney say first for the GI trend who teaches them this the Medical Rep so the remember this heterogoxip was the worst ensure for the heart it is the safest and said for the stomach relatively safe it's not safe or in the form of being beneficial it is least harmful to the GI tract but it's the most harmful to the cardiovascular system into the blood pressure the specific ox2 inhibitor both cellic oxide and iterative oxy must be completely avoided anyway so ncids are a problem is on insids you if the parallel equation is getting insids from anywhere you must ask them about black stools you must check their CDC for drop in hemoglobin you must check the creative for a rising reactance that is the least you can do blood pressure and if you can you have the kind of resources please give the people your friend maybe that will motivate them to reduce their duration rule number seven this is uh I think I think many of us including me occasionally do not follow this rule investigate investigate investigate elderly patients with an unusual symptom must be investigated thoroughly money should be spent or investigations rather than empiric treatment investigations are the greatest return on investment resource for the health of the geriatric [Music] after meals two weeks of dyspepsia patient comes and this is the situation uh I will not hesitate to do an apology in law school in an elderly patient two weeks of Dyslexia is enough recent on said this problem if the patients since years they have uh bloating after meals I will not bother you must investigate thoroughly you I have seen patients with severe back pain suppose your patient has a genetic patient has back pain back pain on walking uh and he has to stop and uh that means he has claudication and that claudication is neurogenic meaning they walk they get paid in the lower limbs they stop ping does not relieve pain but sitting down release pain this classic neurogenic claudication people do excess spine why do you do excellent spine do an MRI spine an MRI diagnosis canal stenosis and x-ray does not diagnose be pushy when it comes to investigation investigates money well spent yeah and if you are again if you ask the patient then okay this this is going to cost you 5000 rupees this MRI and it will give us the final diagnosis it is the most important Mexican variety what do you think will the patient say under the patient before in which case you can send the patient to uh to a government Hospital the patient will say please do the test give me a diagnosis the patient wants the diagnosis due to this geriatric rule number Neuropsychiatric drugs need the most careful decision making amongst all prescription drugs one suggestion to all of you who are generalists meaning General Practitioners one think twice before giving any psychiatric medication to the patient we easily start acetylopram clonazepam combination easily start that in patients who seem to be having anxiety or depression please think twice because the evidence of diagnosis has to be there and it's very difficult to diagnose this diagnose depression without a proper evaluation do not start such varications without thinking or similarly with sleep medicines we often star sleep medicines in chronic insomnia chronic insomnia should be treated by a psychologist with cognitive behavioral therapy or or counseling rather than my prescription drugs acute insomnia we have the right to give drugs somebody has had bereavement and cannot sleep we can give them um but chronic insomnia I would restrict myself and maybe refer the patient to a proper Authority rather than treat so secondary drugs are a problem dementia medicines are a big problem many of us feel like starting nature medicines on our own please remember one dementia medicine the numbers needed to treat to even give a marginal benefit are very high most dementia medicines are useless most dementia medicines cause significant anorexia I would not prescribe dementia medicines at all I would send the patient of dementia to neurologists so many neurological medications left to the neurologist s psychiatric medications to the psychiatrist migraine I would be extremely Keen to treat myself almost never refer a migraine patient to a neurologist you become a migraine expert the generalist has to become a migraine expert essential tremor neurological you should be an expert in essential tremors but dementia maybe parkinsonism maybe you should lead them to the neurologist rule number nine know the red flags and the green flags now what are the green flags first green flags are symptoms which tell us that this is a be nice for example if the patient has a pain in their shoulders and the pain is also in the back of the neck not any back of the neck with shoulder pain is the pain has started together the back of the neck and the shoulder pain even if the left shoulder left arm back of the neck is a green flag you are very happy with the back of the neck pain however if the pain is in the lower jaw with chest pain that is a red flag you know that Michael infarction pain classically is in the lower jaw and the chest together and touch red flags you cannot ignore similarly if a patient can point to the chest with one finger you know that it's a green flag well as they point to the chest pain with the power of the hand or a fist it's a red flag for my wedding function so there are many red flags and green flags in many symptoms we have discussed some in our previous symptomology lectures but you came in the elderly especially you can pay attention to the symptoms and maybe decide uh which is a green flag which is a red flag so that you don't order unnecessary investigation green flags and become more alert with red flags okay so that is about um the rule number nine now we come to the rule number ten the rule number 10 is prevent prevent prevent elderly patients need prevention prevention of disease prevention of infections prevention of Falls how do you prevent many things so lifestyle modification biggest preventive measure exercises especially muscle strengthening exercises resistance exercises great prevention for Falls and vaccination great prevention for infection so I will just talk a little bit about vaccination pneumococcal vaccine you must insist on every patient about the age of 65 every Vision now remember the responsibility for giving pneumococcal vaccine is the generalist responsibility have you ever seen a cardiologist write on his or her letterhead please take pneumoco vaccine have you ever seen a cardiologist even if after a Marvel infarction in the geriatric patient do that have you ever seen neurologists write down pneumoco vaccination after a stroke in a geriatric patient have you ever seen a gastroenterologists recommend a pneumococcal vaccine after a diagnosing a patient with cirrhosis no the only specialist who does religiously give vaccination especially pneumonia vaccination is the nephrologist otherwise we know that all uh severe comorbidities coronary disease stroke liver failure lung failure kidney failure requires pneumococci vaccination your job the generalist job my job is to give the pneumocracy every older patient above 65 definitely or every patient who's below Automotive with CV severe comorbidity extremely important so that is about prevention and lots can be said about prevention but I think that's another lecture so I think that is my end of the lecture and I'm I will I'll be glad we have a few minutes for comments questions yeah thank you thank you so much for this wonderful lecture it was really amazing to learn what not to do and these 10 rules are just amazing I mean need to just embark on our brains just breathe it thank you so much thank you I'll just take up all the questions now uh I would request everyone to raise hand or if you want to interact with sir directly and want to ask you or else you can put up in the question comment section and I'll take up one by one so for now I can see two on oweni uh Dr Amit Agarwal is asking about overall uh management of way that I guess will be another lecture but if you could just highlight and there is one specific question from Dr nisserg uh 65 year old meal with mild to moderate knee pain and complaints of severe away uh me uh should we go for tkr uh as uh should we go should we go or should we not go for tkr uh considering age of the patient so what would be your advice yeah yeah so uh in a symptomatic person with OED 65 year old I think you have time it is not that at 75 you won't be able to operate 75 many common age for operating in on E so I don't think that's a that's a serious issue you must of course consider the current other comorbidities in diabetic equation coronary disease recently etcetera to decide but I would not hurry an OA knee surgery just because the patient's age is advancing in fact after 10 years the technology of TTR might be much much better than the technology even now so don't be scared of that somebody asked what is the treatment of any I'm sure they are worried that if I can't give NSAIDs what should I give um so uh so there are local now we know that in OA knee local diclofenac in a form of a spray or a or a gel is extremely effective and approved by usfd also so use local analgesia NSAIDs use physiotherapy strengthening exercises Etc and paracetimal is not useful so low dose opioids especially opioids which are not very addictive like tempered at all you should use these and push for surgery if the pain is unbearable that's the only message that I can give you for on E uh it is very easy for the patient to feel relief relief with NSAIDs and they will get habituated to acids and I think that is that is something which is to be discouraged all right thank you sir I hope this answers your question Dr Amit I'll take up another one Dr shubham is the first tool kindly summarize through and go start low and go slow was the first tool and you can watch that entire description in the replay doctor will take up another question so uh which analgesic is safe in elderly or is another one but you could highlight it once again so uh I I presume your question is which analysis uh is safe I will give it in two parts which analysis itself and which NSAID is relatively less harmful uh which enact the city safe pastimovic basketball up to 3000 milligrams per day is safe first of all up to 2000 Mega per day above those age 85. so above unit if I restrict yourself to 2000 megagram below 885 restrict yourself to three thousand milligrams uh of parastoma safe local analgesia safe local diclofenac is safe this are different at all criminals which are busy occurred safe they are relatively safe to the kidney sorry they're very safe to the people they're very safe to the heart they are very safe to GI tract but they are not very safe to the brain so our temperature Tramadol can cause addiction very rare they can cause drowsiness we can call nausea they can cause nausea so you have to use that opioids that are you know you know start low go slow fashion like you use uh all Neuropsychiatric drugs and um I think opioids are these two operators that we have in India much safer in terms of addictive potential than oxycodone or similar ones available in the west used to be available at least um so that I think would be safe which NSAID is less harmful than others very simple rule very simple victim if the patient is young use Etodolac which is a relative aux 2 inhibitor not like etoric oxide which is almost completely exclusively a selective oxidative use the total act which is partially selective box to embitter because it has less GI intolerance in the elderly use naproxen as a preferred and said because naproxen is probably the least cardiotoxic of all enzoids so of course it is cardioxic but the least of all so that is my rule of thumb naproxen elderly younger patient never exceed five days at a time in the elderly extremely important thumb rule five days enough then switch to local application Etc and uh yeah as a doctor just pointed out opioids in the elderly not only can cause nausea they can cause significant constipation I'm sorry I've forgotten that but yes constipation is a problem with opioids in the elderly yeah right thank you sir thank you for that Insight Dr Raja uh so I'll take a few raised hands Dr Vivek and Dr Desai has raised hands so I'll accept uh their requests and then we'll take up more questions from the comments hello sir um yeah we can hear you now yeah as always a lot of learning points right I just want to wait two points one is about the overuse of PPI because as we already mentioned about the PPI but now we see so many reports of Epi having so many harms whether it's a vitamin B12 or magnesium or calcium definitions were fractures or C refusal infections or even acute intestinal nephritis so Epi thinks uh we need to discourage it all age not necessarily elderly only that was one foreign is also harmful right if if we need to prescribe we need to prescribe say the low dose of beta blockers for heart failure or we need to prescribe iron if require parental iron if the patient is heart failure like that as uh under prescribing is a problem in chronic conditions all prescribing is a problem that is my general from rule but you're right in heart failure and hypertension diabetes you don't keep them uncontrolled and therefore we must treat them properly absolutely accepted thank you thank you sir is awake if you have any turn on your audio video I'll uh waiting to us so till then I'll take up another one uh hello so can you hear me I can yeah so uh what is the role of glucosamine uh in OA as this drug is so much to use nowadays is what Atomic is asking from the literature that I have read so far and the glucosamine has been there for decades now I think uh from the literature that is available so far I think because I mean is a good placebo luckily because in general please the Republic as a host osteoarthritis supplement I think it works as a placebo better than other procedures so I think if you compare problems because foreign but at the same time I do know that it is asking is CRP better than ESR in elderly uh investigations so the situation depends on your situation but I would say yes CRP is better than ESR CRP is costlier than ESR but it it is a more acute our responsiveness to infections or inflammation than ESR and it also resolves faster than ESR when the condition is treated so yes if if I have to give a broad answer CR is better thank you sir uh recently ustfa has said vitamins not useful and what is your take on that I think uh we know that vitamins are useful what is not useful probably is uh uh multivitamin oh preparations which are taken uh in bulk by patients so I think vitamins are useful we all know that right we know that calcium sorry B12 is useful in Vietnam deficient patients and paradoxin is useful and uh patients who are receiving and it's vitamins have too many utilities to to say that they are not used I will take more questions here I don't know if you can hear me but I'll just answer the questions uh normal aging can lead to immunos senescence so is crb still a valid choice I think CRP is a great choice in the elderly even if the immune response is blunted what will happen is in infection the WBC count will not rise but the CRP will definitely rise so you will see us here we have 250 in a pilonephritis patient and uh WBC count of only 9000 so that can happen uh I'm still hopeful that you can hear me I will just request uh somebody to respond and tell me that if you can hear me if nobody responds I can imagine that you can't hear me uh which this phosphonate orally is good uh the best oral biscos unit the gold standard Still Remains alendronate a weekly resource unit and the injectable misphosphorus zolotonic acid which is Once in a year is my choice of misfortunate simply because of improved improved compliance thank you okay so uh I think this hospital is you are uh clear about any other question that I am missing how is indomethazine as and naproxen as painkillers I don't know if I have done this uh lecture called the NSAID garbage bin and said garbage bin is a favorite lecture of mine where I take placards of and said names and either put them in a trash basket or keep them in our prescription basket so I just uh we have two two minutes more maybe uh if I had to keep a few NSAIDs saved and a few and said buried uh discarded burnt the ones that I will save naproxen I received because probably it has the least cardiovascular toxicity I would say because at least GI toxicity ibuprofen I would say because it's one of the cheapest and said and most commonly available injectable diclofenac I would save but overall Diagnostic and oral acetaphic neck I would trash uh mefenamic acid I would say because love uh mastal uh that I would say minimusulide I would rash peroxicam trash because it is the most likely insane to give Steven Johnson syndrome is available in injectable we already have an injectable and say in the form of black infinite which I would save Ketone Rolex keto rolack has injected gland oral forms I would save it for the dentists because dentists love to relax otherwise I don't see much use of Ketone plants yeah so there are many NSAIDs which I like some I don't like so say you have covered most of I will just take off you and if you have time and then you will wrap up exactly is it okay yeah so Dr Usha is asking flu vaccine in elderly over 75 years would you recommend one absolutely strongly recommend flu action has no age limit and flu vaccine especially in this era after the pandemic we are seeing just too many respiratory tract infections covet and non-covered and they are confusing because you know sometimes you don't know what you're dealing with and to do a swap every time in rtbc or every time for influence is expensive is difficult so do the do give the insurance vaccine you will save lives by giving influence vaccine to the elderly at the same time you will know that influence vaccine has maybe a in the best time 60 70 efficacy at that efficacy also please give introduction to everybody remember the vaccine is to be taken in Southern University vaccines to be taken by Us in India even though we are in the Northern Hemisphere and we should take the southern hemisphere in April because our influences is the monsoon season and not the winter season as in the northern hemisphere so April into the vaccine everybody whose elderly and if young people want to take it don't deny them the vaccine let them decide right thank you sir uh so there was one question very interesting and I guess important one as well uh Dr Chandra had asked uh what is the role of antioxidant in elderly and how frequently we should describe I don't even know where to begin I have seen no evidence of antioxidants uh for any disease significantly they are used by many dermatologists by many of thermologists and frankly I think the devoid of good substantial evidence I think we get enough antioxidants in our diet and to get additional antioxidants may be of no utility I may be wrong but I don't somebody has to provide me with evidence and I have no evidence right thank you sir well another question on that line is Rule of jinkoba in dementia jingle belloba I guess is what yeah I have no idea I have no idea Chinese supplemental medicine zero zero of course I know that it is not approved by any any Authority so I would not I would not recommend it all right thank you so Dr Manju is asking what about allergic reactions with diclofenac so I suppose she's asking uh when I said that like uh injectable is something I use maybe she's asking what about the allergic reaction of course a full Diclofenac ious reaction and you you any answer can cause and you have to be wary of that but you do know that many things in the end simple antibiotics that we give uh chemical CV reactions so you have to you have to uh bear with the allergic reaction there is no test those in injectable like infinite one suggestion for injectively from my side is only this that if operating comes with severeign [Music] and give two thirds of the one cc so uh low dose effective and probably less harmful yeah thank you sir thank you so much I can still see many questions pouring in but I guess we can take it in the next session or upcoming ones you can put up in the comment section as well and I will get it answered from sir I can see a lot of commenting amazing session and very important presentation thank you all doctors thank you sir so we will be back with sir again with some more interesting sections uh in this month as well as upcoming months and do stay tuned so is there any take home message for all of them like you have shared all 10 important pointers with them and have covered almost all of the questions uh so if there is anyone would love to you otherwise I'll just travel the session now thank you so much bye

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Old age is commonly associated with multiple illnesses, as well as with altered pharmacokinetics and pharmacodynamics for example, delayed renal elimination of drugs and increased sensitivity to anticholinergic and sedating effects. Certain drugs are classified as potentially inappropriate medications for the elderly because they carry an increased risk of adverse drug events in this patient group. Let's understand how can we (not) harm geriatric patients seriously with none other than the most zealous creator of Medflix - Dr. Tushar Shah in his #BlockBuster live.

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