Dialogue Volume 13 Issue 4 2017 - Page 51

PRACTICE PARTNER Dr. Heather Gilley  careful with sustained release formulations. Their Be 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 A drugs or changing the dose to allow assessment of the effect;  reatment should be constantly monitored and ad- T justed, if required, to improve efficacy and limit adverse events; It may be necessary to switch opioids;  to taper and even discontinue benzodiazepines to Try 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 W 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- A 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, P and warn the patient and caregiver about increased sedation and risk of falls;  onsider a three-day tolerance check, i.e., contact the C 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 A (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 51