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Medications to Avoid in the Elderly

The elderly are especially vulnerable to the adverse effects of medications. The incidence of adverse drug reactions is two to three times that found in younger adults but may be underestimated because adverse reactions may go unrecognized. The symptoms of an adverse drug reaction may be mistaken for normal aging or worsening of a chronic illness. Some symptoms associated with adverse drug reactions include:

  • fatigue
  • confusion
  • agitation
  • falling
  • dizziness
  • constipation
  • blurred vision
  • depression

Many adverse reactions are preventable. Examples of preventable adverse effects include consequences of known drug-drug interactions or prescribing an inappropriate dose for the elderly.

The increased incidence of adverse reactions in the elderly results from altered pharmacokinetics, altered pharmacodynamics, increased opportunities for drug interactions, and prescribing of potentially inappropriate medications (drugs where the possible risk outweighs the anticipated benefit for most elderly patients). Older patients may have a decreased rate of drug clearance because of decreased liver metabolism by oxidative pathways and/or decreased renal elimination. Also, there may be changes at the receptor site and in homeostatic reserve that result in an altered response to a medication. While these changes in pharmacokinetics and pharmacodynamics are well recognized, age-related effects are not always noted in compendia such as the Physician's Desk Reference (PDR).

The elderly are also at increased risk of suffering adverse consequences of drug interactions. The elderly generally consume a greater total number of drugs than younger patients, because they are more likely to receive treatment for multiple chronic diseases. The risk of adverse effects resulting from drug interactions becomes more difficult to predict as the number of medications prescribed increases. Drug interactions are more likely to result in adverse effects in elderly patients because these patients may already have altered drug pharmacokinetics and increased sensitivity to the drug effects for each drug alone. For example, elderly patients may already show decreased metabolic clearance of a drug, and when a second drug that inhibits the metabolic clearance of the first is administered, the resulting serum concentrations and drug effect are greater than would be seen in a younger patient.

Inappropriate prescribing can lead to an increase in adverse events to medications. Dr. Beers and colleagues1 developed criteria to identify medications whose use was potentially inappropriate in the general elderly population and in elderly patients with specific diagnoses. These medications should generally be avoided in elderly patients. Many of them that are prescribed in the acute care setting are listed in the table of DOs and DON'Ts below.


DO all of these DON'T do any of these
Weigh the potential benefit and risk for each medication. Prescribe a safer drug whenever possible. assume that medication-related problems will be addressed after the patient leaves the hospital.
Ask about over-the-counter medications and dietary supplements. prescribe a drug to treat the adverse effects of another drug.
Assess whether your patient may already be suffering from an adverse drug effect before adding more drugs. prescribe anticholinergic drugs (list), especially to patients with delirium, dementia, constipation or prostatic hypertrophy.
Discontinue medications without an indication or where the desired effect has not been achieved.

prescribe diphenhydramine (Benadryl®) for sleep in elderly patients.

Estimate renal function before selecting doses for renally eliminated drugs. prescribe long-acting benzodiazepines (chlordiazepoxide (Librium®), diazepam (Valium®), flurazepam (Dalmane®)).
Adjust the dose of medications that undergo hepatic oxidative metabolism. change the outpatient regimen without communicating to patient, family, and post-hospital care providers, including home health care.
Monitor elderly patients closely for adverse effects when adding new drugs. prescribe excessive doses of any benzodiazepine.
Consider that the risk of falling is increased for patients taking >= 4 total drugs or >= 2 psychotropic drugs. prescribe high doses of digoxin (>0.125 mg/day) for elderly patients except when treating atrial arrhythmias.
Review discharge medication orders; include all needed medications for post-acute and chronic care. Ensure that patients have prescriptions and can obtain medicines at the time of hospital discharge. prescribe propoxyphene (Darvon®, Darvocet®) or meperidine (Demerol®) to treat pain.

References:

  1. Beers MH. Arch Intern Med 1997;157:1531-1536.

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