PRACTICE PARTNER
Dr. Heather Gilley
careful with sustained release formulations. Their
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elimination half life is even longer in seniors, and is
magnified if there is renal impairment;
I ntroduce one agent at a time, at a low dose (i.e., no
more than 50% of the suggested initial dose for adults),
followed by slow dose-titration;
llow a sufficiently large interval between introducing
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drugs or changing the dose to allow assessment of the
effect;
reatment should be constantly monitored and ad-
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justed, if required, to improve efficacy and limit adverse
events;
It may be necessary to switch opioids;
to taper and even discontinue benzodiazepines to
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reduce the risk of falls and cognitive impairment.
The 2010 guideline added that among strong opi-
oids, oxycodone and hydromorphone may be preferred
for the elderly over oral morphine (more predictable in
their effects and fewer neurotoxic metabolites). Also,
narcotic solutions are preferable to tablets in some
situations, e.g., patients with swallowing problems, or
those requiring less than 5 mg morphine equivalent/
tablet.
Other ways to reduce risks of opioids for the elderly:
Maximize
non-opioid alternatives such as regularly
scheduled acetaminophen first;
hen initiating opioids, reassess other medications
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which cause sedation, for example benzodiazepines,
sedative hypnotics (i.e., trazodone), anticonvulsants,
gabapentinoids, tricyclic medications, medications
with anticholinergic side effects, and over-the-counter
medications like dimenhydrinate and diphenhydramine;
void use of codeine (a weak opioid), as it is unpredict-
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able how much codeine will be metabolized to mor-
phine between individuals and has a high propensity to
cause sedation and constipation;
Educate
the patient (and caregiver, if applicable) about
signs of overdose;
roactively manage constipation with a bowel routine,
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and warn the patient and caregiver about increased
sedation and risk of falls;
onsider a three-day tolerance check, i.e., contact the
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patient three days after starting the prescription to
check for any signs of sedation;
Monitor
renal function (creatinine and creatinine clear-
ance); and
void opioids in cognitively impaired patients living alone
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(unless ongoing medication supervision can be organized).
Assess, diagnose, treat and monitor – that applies to
any patient around pain and opioid use. Dr. Zacharias
says you can escalate to opioids but shouldn’t make
that option #1. And if you go that route, he has advice
that applies in general to prescribing in the elderly:
“Start low and go slow.”
MD
For more information, the Institute for Safe Medication Prac-
tices Canada (ismp-canada.org) has a useful “Safer Medication
Use in Older Persons” information page. It includes links to the
Beers List (guidelines for health-care professionals on potentially
inappropriate medication use for the elderly), and high-risk
medications, along with suggestion for safer alternatives.
ISSUE 4, 2017 DIALOGUE
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