Important Considerations
- Is the patient having concerning symptoms attributable to medication side-effects?
- Always consider non-pharmacological interventions first.
- Start with the lowest recommended dose (or even less) and titrate up slowly.
- Assess risk of drug-drug interactions:
- Polypharmacy (the likelihood is almost 100% with ≥8 drugs).
- Increased number of physicians treating the patient.
- Concomitant use of drugs that cause additive hypotension, sedation, or anticholinergic effects.
- Are the directions practical for patients with poor cognition, vision or dexterity?
- For patients with shorter life expectancy, consider simplifying the medication regimen with emphasis on symptom control.
- Frailer patients with more comorbidities are likely to be different than patients in randomized controlled trials; think critically before adding drugs in this population.
Pharmacokinetics and Pharmacodynamics in Aging
|
|
Age-related change |
Effect |
Example |
|---|---|---|---|
|
Absorption |
|
No changes despite slower gastric emptying and decreased gastric acid production |
|
|
Distribution |
Body fat |
Fat soluble drugs have longer half-lives |
amiodarone, diazepam, verapamil |
|
|
Total body water |
Water-soluble drugs become more concentrated. |
lithium, digoxin |
|
|
Serum albumin |
Highly protein-bound drugs have a greater free (active) concentration |
warfarin, phenytoin, theophylline, digoxin, sulfonamides |
|
Metabolism |
GFR |
Lower dosages may be therapeutic or toxic. |
morphine |
|
|
Hepatic perfusion and phase I metabolism |
Drugs with significant hepatic first pass metabolism may have higher bioavailability and faster onset |
beta-blockers, nitrates, TCAs |
|
Pharmaco-dynamics |
Exaggerated response to centrally acting drugs |
Lower dosages may be therapeutic and adverse reactions like sedation may be more common |
opioids, TCAs, benzos |
|
|
Baroreceptor responsiveness and sensitivity |
Increased risk of postural hypotension |
Alpha-blockers, diuretics, nifedipine, nitroglycerin, phenothiazines |
Drugs to Avoid in the Elderly
- Medications with anticholinergic effects
- Limit use in elderly given constipation, urinary retention, cognitive impairment, delirium, sedation, dry mouth (decreased PO intake, trouble with dentures), orthostatic hypotension, and cardiac arrhythmias.
- Common culprit medications are: antihistamines (diphenhydramine, high dose H2 blockers), TCAs, meclizine, promethazine, typical and atypical antipsychotics, oxybutynin, cyclobenzaprine, dicyclomine.
- Although not on the Beer’s Criteria, fluoroquinolones (ciprofloxacin, levofloxacin, moxifloxacin) should be used with caution in the elderly given risks of C. Difficile, delirium, QT prolongation, tendinitis and tendon rupture, and aortic dissection
Important Beers Criteria Medications*
|
DRUGS BY INDICATION |
DRAWBACKS |
ALTERNATIVES |
|---|---|---|
|
Analgesics |
|
|
|
Ketorolac (Toradol), indomethacin, other NSAIDs |
GI toxicity, renal toxicity, HTN |
Tylenol. If using NSAIDs long-term, consider monitoring renal function and using PPI |
|
Meperidine (Demerol) |
Confusion, convulsions, ataxia, dizziness |
Oxycodone, morphine (if no renal impairment) |
|
Antidepressants |
|
|
|
Amitriptyline (Elavil) Doxepin (Sinequan) Nortriptyline |
Anticholinergic effects |
SSRIs (other than daily fluoxetine) and other antidepressants |
|
Paroxetine (Paxil) |
Confusion, drowsiness |
Other SSRIs |
|
Antihistamines, 1st Generation |
|
|
|
Diphenhydramine (Benadryl) Hydroxyzine (Vistaril, Atarax) |
Anticholinergic effects. Some such as diphenhydramine and promethazine are highly sedating |
2nd generation antihistamines, such as fexofenadine or loratadine |
|
Antiemetics |
|
|
|
Promethazine (Phenergan) Prochlorperazine (Compazine) |
Drug-induced parkinsonism |
Ondansetron |
|
Metoclopramide |
Higher risk of extrapyramidal symptoms including tardive dyskinesia in elderly |
Avoid, unless for gastroparesis with duration of use not to exceed 12 weeks |
|
Proton pump inhibitors |
Risk of Clostridium difficile infection, bone loss, fractures |
Avoid use for >8 weeks unless high risk patients with demonstrated need for maintenance treatment |
|
Muscle relaxants |
|
|
|
Carisoprodol (Soma) Cyclobenzaprine (Flexeril) Metaxalone (Skelaxin) |
Anticholinergic effects, sedation, limited effectiveness at tolerated doses |
Topical agents, Lidoderm patch, physical therapy |
|
Sedatives |
|
|
|
Barbiturates |
Sedation, addiction |
If used for seizure disorder use another antiepileptic agent |
|
Benzodiazepines, long-acting - Chlordiazepoxide (Librium) - Diazepam (Valium) |
Prolonged sedation |
Avoid all benzodiazepines where possible. If absolutely necessary (indications include seizures, alcohol withdrawal, periprocedural anesthesia) choose low dose short-acting benzos. Best to use lorazepam, oxazepam, temazepam which do not require hepatic oxidation (reduced in the elderly) |
|
Sedative-hypnotics - Zolpidem (Ambien) - Eszopiclone (Lunesta) - Zaleplon |
Sedations, falls, delirium |
Melatonin, trazodone |
|
Diabetes medications |
|
|
|
Long-acting sulfonylureas: - Glimepiride - Glyburide - Chlorpropamide |
Higher risk of prolonged hypoglycemia |
Avoid sulfonylureas. If having to use one, consider short-acting ones such as glipizide |
|
Thiazolidinediones - Pioglitazone - Rosiglitazone |
Increased risk of fluid retention and heart failure |
Other diabetes medications including SGLT-2 inhibitors |
|
Antibiotics |
|
|
|
Nitrofurantoin (Macrobid) |
Limited efficacy in renal impairment |
Use other antibiotics if renal impairment present. Avoid use for long-term suppression |
*For a complete list, see the American Geriatric Society’s 2019 Updated Beers Criteria, available at: https://qioprogram.org/sites/default/files/2019BeersCriteria_JAGS.pdf
Deprescribing
Deprescribing is the planned and supervised process of dose reduction or stopping of medication that might be causing harm, or no longer be of benefit.
Process of deprescribing
- Establish medications and indications
- Determine overall risk for drug-induced harm
- Assess drug eligibility for discontinuation
- Prioritize drugs for discontinuation
- Implement and monitor
- Repeat
In the hospital setting, involve the primary care physician or geriatrician for deprescribing initiatives.
Common medication classes to consider deprescribing:
- Diabetes medications (A1C goal 7-7.5% for healthy older adults, 7.5-8% if moderate comorbidity, and 8-9% if limited life expectancy)
- Antihypertensive medications (allowing for a more lenient goal in frail adults with limited life expectancy)
- Antipsychotics and benzodiazepines
- Proton pump inhibitors (particularly >8 weeks and if there is no clear indication)
- Cholinesterase inhibitors and memantine (limited benefit particularly in advanced dementia)
If adding an indicated medication on discharge, consider working to deprescribe another medication to minimize risk of worsening polypharmacy and drug-drug interactions.
AGS Choosing Wisely Workgroup. "American Geriatrics Society identifies five things that healthcare providers and patients should question." Journal of the American Geriatrics Society 61.4 (2013): 622-631.
Deprescribing.org - Optimizing Medication Use. (n.d.). Retrieved June 7, 2020, from https://deprescribing.org/