Prescribing Practices in Geriatrics for MCCQE1 Preparation

Introduction

Prescribing practices in geriatrics are a critical component of the MCCQE1 exam and an essential skill for Canadian physicians. This comprehensive guide will help you prepare for the MCCQE1 by covering key concepts, Canadian guidelines, and providing practice questions tailored to the Canadian healthcare context.

Key Principles of Geriatric Prescribing

1. Physiological Changes in Aging

2. Polypharmacy

Polypharmacy, the use of multiple medications, is common in geriatric patients and poses significant risks.

Risks of Polypharmacy:

• Increased risk of adverse drug reactions
• Drug-drug interactions
• Decreased medication adherence
• Increased healthcare costs

3. Beers Criteria

The Beers Criteria, developed by the American Geriatrics Society, is widely used in Canada to identify potentially inappropriate medications for older adults.

4. STOPP/START Criteria

The STOPP (Screening Tool of Older People's Prescriptions) and START (Screening Tool to Alert to Right Treatment) criteria are used in Canada to optimize prescribing in older adults.

Canadian Guidelines for Prescribing in Geriatrics

The Canadian Geriatrics Society (CGS) provides guidelines for prescribing in older adults, which are essential for MCCQE1 preparation:

1. Comprehensive Geriatric Assessment: Conduct a thorough evaluation of medical, functional, and psychosocial factors before prescribing.

2. Deprescribing: Regularly review medications and consider discontinuing unnecessary or potentially harmful drugs.

3. Start Low, Go Slow: Begin with lower doses and titrate slowly when introducing new medications.

4. Monitoring: Regularly assess for adverse effects and drug interactions.

5. Patient Education: Provide clear instructions and ensure patient understanding of medication regimens.

6. Collaboration: Work with pharmacists and other healthcare providers to optimize medication management.

Canadian Deprescribing Network (CaDeN)

The Canadian Deprescribing Network provides resources and guidelines for safe deprescribing in older adults. Key medications to consider for deprescribing include:

• Proton pump inhibitors (PPIs)
• Benzodiazepines
• Antipsychotics for behavioural and psychological symptoms of dementia (BPSD)
• Cholinesterase inhibitors and memantine
• Statins for primary prevention

Prescribing Considerations for Common Geriatric Conditions

1. Hypertension

• First-line agents: ACE inhibitors, ARBs, calcium channel blockers, thiazide diuretics
• Target BP: <140/90 mmHg for most older adults, <150/90 mmHg for frail elderly

2. Type 2 Diabetes

• Individualize HbA1c targets based on frailty and life expectancy
• Avoid sulfonylureas due to hypoglycemia risk
• Consider DPP-4 inhibitors or GLP-1 receptor agonists

3. Osteoporosis

• First-line: Bisphosphonates (e.g., alendronate, risedronate)
• Consider drug holidays after 3-5 years of treatment
• Ensure adequate calcium and vitamin D intake

4. Dementia

• Cholinesterase inhibitors (donepezil, rivastigmine, galantamine) for mild to moderate Alzheimer's disease
• Memantine for moderate to severe Alzheimer's disease
• Avoid anticholinergics and sedating medications

5. Depression

• Start with SSRIs (e.g., sertraline, escitalopram)
• Avoid tricyclic antidepressants due to anticholinergic effects
• Monitor for hyponatremia, especially with SSRIs

Key Points to Remember for MCCQE1

1. Understand physiological changes in aging and their impact on pharmacokinetics and pharmacodynamics.
2. Be familiar with the Beers Criteria and STOPP/START criteria for inappropriate medications in older adults.
3. Know Canadian guidelines for prescribing in geriatrics, including the importance of deprescribing.
4. Recognize the risks of polypharmacy and strategies to mitigate them.
5. Be able to apply the "Start Low, Go Slow" principle when initiating new medications in older adults.
6. Understand prescribing considerations for common geriatric conditions, including hypertension, diabetes, osteoporosis, dementia, and depression.
7. Be aware of the Canadian Deprescribing Network (CaDeN) and its resources for safe deprescribing.

Sample Question

A 78-year-old woman presents to your family practice clinic for a medication review. She has a history of hypertension, osteoarthritis, and insomnia. Her current medications include hydrochlorothiazide 25 mg daily, naproxen 500 mg twice daily, and zopiclone 7.5 mg at bedtime. Which one of the following changes to her medication regimen is most appropriate?

• A. Increase the dose of hydrochlorothiazide to 50 mg daily
• B. Switch naproxen to celecoxib 200 mg daily
• C. Increase the dose of zopiclone to 15 mg at bedtime
• D. Discontinue zopiclone and initiate non-pharmacological sleep hygiene measures
• E. Add ramipril 5 mg daily for additional blood pressure control

Explanation

The correct answer is:

• D. Discontinue zopiclone and initiate non-pharmacological sleep hygiene measures

Explanation: This question tests your knowledge of appropriate prescribing practices in geriatrics, which is crucial for the MCCQE1 exam. Let's analyze each option:

A. Increasing hydrochlorothiazide is incorrect. The current dose is already at the upper limit for older adults, and increasing it may lead to electrolyte imbalances and falls.

B. Switching to celecoxib is not the best choice. While it may have a lower risk of GI side effects, NSAIDs should generally be avoided in older adults due to risks of renal impairment, hypertension, and GI bleeding.

C. Increasing zopiclone is inappropriate. Benzodiazepine receptor agonists like zopiclone are on the Beers list of potentially inappropriate medications for older adults due to increased risk of cognitive impairment, delirium, falls, and fractures.

D. This is the correct answer. Discontinuing zopiclone aligns with the Beers Criteria and Canadian guidelines for deprescribing in older adults. Non-pharmacological sleep hygiene measures are the preferred first-line treatment for insomnia in the elderly.

E. Adding ramipril is not necessary based on the information provided. It's important to avoid unnecessary polypharmacy in older adults.

This question highlights the importance of deprescribing potentially inappropriate medications and prioritizing non-pharmacological interventions in geriatric patients, which is a key concept for the MCCQE1 exam.

References

1. Canadian Geriatrics Society. (2021). CGS Journal of CME: Prescribing Guidelines for Elderly Patients. https://canadiangeriatrics.ca/ (opens in a new tab)

2. By the American Geriatrics Society 2019 Beers Criteria® Update Expert Panel. (2019). American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society, 67(4), 674-694.

3. Canadian Deprescribing Network. (2023). Deprescribing Guidelines and Algorithms. https://deprescribing.org/ (opens in a new tab)

4. Rochon, P. A., & Gurwitz, J. H. (2017). The prescribing cascade revisited. The Lancet, 389(10081), 1778-1780.

5. Canadian Institute for Health Information. (2022). Drug Use Among Seniors in Canada. https://www.cihi.ca/ (opens in a new tab)

6. Frank, C., & Weir, E. (2014). Deprescribing for older patients. CMAJ, 186(18), 1369-1376.

7. Farrell, B., Pottie, K., Thompson, W., Boghossian, T., Pizzola, L., Rashid, F. J., ... & Moayyedi, P. (2017). Deprescribing proton pump inhibitors: Evidence-based clinical practice guideline. Canadian Family Physician, 63(5), 354-364.