These prescribing indicators are sensitive to inappropriate prescribing for elderly medical inpatients and cover a wide range of therapeutic areas. They should enable changes in prescribing quality to be measured objectively. Interhospital variation in casemix resulted in substantial differences in the proportion of patients in whom it would have been appropriate to prescribe specific drugs or combinations and prevented derivation of reference ranges of optimal prescribing for four indicators.

To identify and improve suboptimal prescribing for elderly patients we have developed a number of prescribing indicators which focus on areas of concern and allow evaluation of the benefit of interventions. We report here on fourteen indicators

This study has examined the contribution of decrease in liver size to the decline in drug metabolising capacity which occurs with ageing. Liver volume and antipyrine kinetics were measured in two groups of healthy individuals aged 20 to 29 years and 75 to 86 years and in a group of hospitalised patients aged 70 to 89 years. Liver volume was reduced in both groups of elderly people compared to the young group. Antipyrine plasma half-life was prolonged and antipyrine clearance was reduced in the group of elderly normal individuals. In this group the index--antipyrine clearance per unit liver volume--was also reduced in comparison to that of the young group. Measurements of antipyrine elimination in the hospitalised elderly group did not differ significantly from those in the young group. It is concluded that both decreased liver mass and decreased hepatic enzyme activity contribute to the impairment of drug oxidation which occurs in the elderly and which may warrant a reduction in dosage of some drugs. However, differences have been demonstrated between groups of elderly people suggesting that under certain circumstances standard doses of such drugs may be normally tolerated.

1 Methods of varying complexity have been devised to measure movements involved in the control of posture (sway). 2 Dose-related effects of centrally acting drugs on postural sway have been demonstrated.

1 The immediate and residual response to single doses of oral diazepam 10 mg was measured in 11 young and 12 elderly healthy volunteers using postural sway, digit symbol substitution scores and subjective ratings. 2 The effect on postural sway was markedly accentuated in the older volunteers, but the difference between groups in the effect on the other measures used did not achieve significance. 3 The corresponding plasma total diazepam concentrations were lower in the older subjects beyond 0.5 h post dose and the concentrations of plasma desmethyldiazepam did not differ between the groups. 4 Diazepam plasma protein binding was significantly reduced in the elderly subjects, but the plasma free (unbound) diazepam concentrations did not exceed those in the young group. 5 There was poor correlation between the responses measured and the concentrations of either total diazepam, desmethyldiazepam or free diazepam. 6 The results suggest the occurrence of a non-uniform effect of age on different aspects of benzodiazepine response, and that where an accentuated effect occurs the mechanisms are substantially pharmacodynamic.

SummaryUse of over-the-counter (OTC) medications by elderly patients is often not identified. This survey was performed to study the use of OTCs by medical inpatients aged 65 and over. Data on the use of OTC medications before and during hospital admission were collected by questioning patients and case notes were examined for documentation of their use of OTC medications. OTC medications were used by 44 of 138 (32%) patients interviewed. Patients used a total of 70 OTC medications before admission and six OTC medications were being used during hospital admission. There was no documentation of pre-admission and inhospital OTC medicine use in the clinical notes and patients had little knowledge of the potential harm some products can cause. As more products become available over the counter, doctors should record their use in patients' notes and patients should be encouraged to seek professional advice before purchasing OTC medicines and to read the product information leaflets.Keywords: over-the-counter medications, elderlyThe range of medicines obtainable over-thecounter (OTC) is set to increase,' which will allow patients even greater freedom to chose self-treatment for palliation and cure. The Health of the nation report suggests that individuals should take greater responsibility for their health and a possible consequence of this will be an increase in self-medication.2 A series of articles on OTCs has highlighted the need for increased public awareness of health and medicines, and the changing responsibility of the doctor and pharmacist.3Many OTC medicines, including traditional herbal remedies, cause a variety of adverse drug reactions4-6 and it has been reported that almost 20% of all drug-related admissions to a medical service resulted from the use of nonprescribed medication.7 It is therefore essential that physicians be aware of the active ingredients present in OTC medicines and make concerted efforts to identify which OTC medicines patients are using.8 Studies haveshown that neither general practitioners nor hospital physicians take accurate histories of medication use and frequently fail to identify the use of OTC drugs in medication histories.9"0 Doctors dealing with elderly patients should be particularly aware of possible OTC medicine use, as elderly patients have a higher incidence of adverse drug reactions." A study from the US showed that up to 96% of patients of all ages surveyed used OTCs and aspirin was the most commonly used drug.'2 A further survey of community patients aged 75 years and over in the UK found almost half the patients admitted to taking non-prescribed medicines." Elderly patients have been shown to take OTC analgesics more often, for longer periods and in combination with a greater number of prescribed medicines,'4 and a further study found just over a third of the OTCs used by elderly people in the community were analgesics or aspirin."5To our knowledge, there are no data on OTC use by medical in-patients. This survey was performed to study the use of OTC medicines by el...

1 The pharmacokinetics of the benzodiazepine hypnotic, loprazolam (1.0 mg orally), and the pharmacodynamic response to single oral doses (0.5 mg and 1.0 mg) have been compared in young and elderly healthy volunteers.2 No difference between the groups in peak plasma concentration (Cma,) or in the time to peak (tmax) was found, but the elimination half-life t½,2z and area under the plasma concentration-time curve (AUC) were significantly greater in the elderly group. 3 The immediate effects of loprazolam on all three performance tests used (postural sway, critical flicker fusion threshold (CFFT) and choice reaction time (CRT)) and on subjective sedation tended to be more pronounced in the elderly subjects, though intersubject variability in response was high in both groups. The corresponding plasma concentrations did not differ significantly between the two groups. 4 The higher (1.0 mg) dosage was associated with significant residual (11 h) impairment of standing steadiness in the elderly subjects. No other hangover effects were observed. 5 The results are compatible with previous evidence of increased 'sensitivity' to benzodiazepines in the elderly and suggest that a lower (0.5 mg) starting dose of loprazolam would be appropriate for older recipients. 6 Further investigation would be necessary to establish whether clinically relevant accumulation of loprazolam occurs in the elderly following repeated dosage.

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