Prescribing for older patients

Prescribing for older patients presents numerous pharmacological and practical challenges, particularly in a busy emergency department where physicians have limited resources to comprehensively appraise the quality, safety and appropriateness of medication use in this heterogeneous patient group. Though the majority of older people are physically and cognitively well, emergency departments (EDs) worldwide are treating ever-increasing numbers of older patients who present with complex co-morbid illnesses, multiple concurrent medications, cognitive impairments and functional dependence, all of which increase the risk of adverse drug events (ADEs) [1-4]. Indeed, ADEs are a frequent cause of presentation to emergency departments amongst older people, common examples being falls (± injury such as hip fracture) because of sedative hypnotic drugs, gastrointestinal or intracranial haemorrhage because of anticoagulant or antiplatelet drugs, acute confusional states because of drugs with anticholinergic properties, hypoglycaemia because of antidiabetic medications and drug toxicity because of drugs with narrow therapeutic indices, e.g. digoxin [5, 6]. Most ADEs are predictable through age-related changes in pharmacokinetic (absorption, distribution, metabolism and excretion) and pharmacodynamic response to commonly prescribed drugs [7]. Physicians who assess and treat older patients in the emergency department must be mindful of these age-related physiological changes in addition to the influence of pathological processes and polypharmacy on the risk of drug-disease and drug-drug interactions, inappropriate prescribing and suboptimal adherence.