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Transcript

Lee Tetreault:

Hello and welcome to frequently asked questions from the session Clinical cases in geriatrics navigating polypharmacy in the elderly. Today I'm joined by Dr. Sarah Bradley.

Sara M. Bradley:

Hello.

Lee Tetreault:

Doctor, before we begin, can we go into some of the key pointers from today's session for our audience? 

Sara M. Bradley:

Sure. I think the real take-home points are to remember when prescribing medications for older adults start low and go slow. To perform a medication reconciliation at every visit and assess the need for all medications and always consider adverse drug events as a cause of geriatric syndromes.

Lee Tetreault:

How do you handle the patient who has been on a benzodiazepine forever and refuses to try something else.

Sara M. Bradley:

It really has to be a long slow process over months to try to reduce the benzo. I try to switch most patients to an SSRI for anxiety, which can also help with sleep and it's important to realize that the patient may not ever be able to stop the benzo completely, but even reducing the dose is a major success in reducing risk of falls and confusion. I try to use tools such as the brochure from prescribing.org, and also get the family and caregivers involved to help.

Lee Tetreault:

How effective are medications for dementia such as acetylcholinesterase inhibitors and do you recommend those to patients or try to discontinue them? 

Sara M. Bradley:

The absolute benefit of those medications is small, and they do have significant side effects such as anorexia, nausea, vomiting, diarrhea, dizziness. I do offer trial medications to patients, but always explain the risk. If they decide to still try it, we closely monitor them for a few months, and if no benefit is seen by the patient or family, I try to de-prescribe it.

Lee Tetreault:

How do you balance anti-coagulation for stroke prevention, in elderly patients with atrial fibrillation with risk of bleeding when they are at high risk of falling.

Sara M. Bradley:

It's actually a myth that older adults who fall should not be on anti-coagulation. It's estimated that patients need to fall almost 300 times a year to make the risk of a major bleed outweigh the risk of stroke from atrial fibrillation.

Lee Tetreault:

I know you have had patients who want to take 20 supplements, but barely take their prescription medication. Any suggestions on how to address this? 

Sara M. Bradley:

The risk of polypharmacy exists with supplements just as much as prescription medications, patients often falsely think that These are beneficial and have no harm at all. Most supplements are not regulated, so we don't know exactly what they contain and potential side effects are not well-studied or monitored. I try to explore with patients what effect they are looking for and try to at least reduce the number of supplements.

Lee Tetreault:

And lastly doctor, do you recommend Melatonin for sleep in older adults? 

Sara M. Bradley:

It doesn't work for everyone, but certainly safe if the patient wants to try it. Like other medications, always start low at first, and then increase gradually one milligram, then 3 milligram and so forth.

Lee Tetreault:

This is great information, Doctor, thank you so much for your time today.