HOW CAN WE DESCRIBE? WHAT ARE THE DANGEROUS DRUGS IN ELDERLY?

1. Pharmacotherapy Considerations in Elderly Adults
• Dr. Safaa Hussein Ali
• Lecturer of geriatric medicine
• Ain Shams university
• Cairo – Egypt
• Consultant of geriatric medicine

2. Pharmacokinetics
• Pharmacokinetics describes how the
body processes a specific drug after its
administration.
• Drug researchers are hesitant to
conduct large randomized controlled
trials in elderly patients.
• the principles of pharmacokinetics
(absorption, distribution, metabolism,
and elimination)

3. Absorption of Oral Medications
The aging process
• reduce GI motility and GI blood flow.
• Gastric acid secretion is reduced in older adults and this
can result in an elevation in gastric pH.
• may cause reduced drug absorption, whereas reduced
GI motility may result in more of the drug(s) being
absorbed.
• Concurrent use of antacids and overuse of proton pump
inhibitors may contribute greatly to these changes.
• Age-related absorptive changes can alter significantly a
drug's absorption as well as its onset of action.

4. • The absorption of drugs that undergo first-pass
metabolism also may be increased in older
people. This action is seen with nitrates and the
lipophilic [beta]-adrenergic blockers (e.g.,
propranolol).
• other problems that can affect absorption.
include swallowing difficulties, poor nutrition,
and dependence on feeding tubes.

5. Distribution
• Drug distribution refers to where the drug goes after it
enters the bloodstream. For drugs that are administered
orally, the distribution phase begins after absorption and
first-pass metabolism.
• Factors influence the volume of distribution of a drug,
including protein binding (only unbound drug is
distributed), pH, molecular size, and water or lipid
solubility (lipid-soluble drugs, in general, have a greater
volume of distribution).
• For instance, phenytoin is a highly protein (albumin)-
bound anticonvulsant that may have a significant effect in
elderly patients who have reduced albumin levels. This
leaves more free phenytoin available to cause various
adverse effects.

6. Distribution
• As the body ages, muscle mass declines and
the proportion of body fat increases; therefore,
drugs that are fat soluble will, in general, have a
greater volume of distribution in an older person
compared with a young person, but for drugs
distributed in muscle tissue, the volume of
distribution may be reduced. This effect is
observed with diazepam, which is highly fat
soluble, and this may necessitate dosing
changes

7. Metabolism
• The liver is the primary organ responsible for
drug metabolism.
• Phase 1 reactions typically involve cytochrome
P450 monooxygenase (CYP450) enzymes.
There are various types of CYP450 enzymes
and they can play a role in drug metabolism.
The CYP450 system is also where many drug–
drug interactions occur, because various drugs
can act as inducers or inhibitors of other drugs
undergoing metabolism.

8. Metabolism
• Phase 2 reactions are conjugative. Products of
conjugation reactions have increased molecular
weight and are usually inactive, unlike phase 1
reactions, which often produce active
metabolites. Some drugs undergo both phase 1
and 2 metabolism.

9. Metabolism
• The aging process also can affect drug metabolism.
Several physiological changes can greatly influence
metabolic capacity.
• In general, hepatic blood flow is reduced in elderly adults,
which can significantly affect metabolism because the
drug is introduced to the liver at a much lower rate. Liver
mass and intrinsic metabolic activity (includes the
CYP450 enzyme system) also is reduced during the
aging process.
• Phase 1 reactions are affected much more than are
phase 2 reactions. With a reduction of blood flow to the
liver and a reduction in metabolic activity, the metabolic
process is significantly reduced in older adults.

10. Metabolism
• Dosage adjustments are somewhat arbitrary, but
in older adult patients, a general
recommendation is to reduce the dosage for
those drugs undergoing hepatic metabolism.
The dose can then be titrated to efficacy or
adverse effects.

11. Excretion
• Elimination of drugs from the body occurs primarily via
renal excretion.
• As with metabolism, the half-life of drugs is increased as
renal function is reduced. As the body ages, renal
function declines, sometimes by a significant degree.
This decline is the result of several physiological
changes, which include a reduction in blood flow to the
kidneys, a decrease in kidney mass, and a reduction in
the size and number of functioning nephrons.
• Unlike hepatic effects, these changes are consistent
from one patient to another.

12. • different from hepatic changes observed with
aging, renal changes can be somewhat
predictive, thus allowing drug dose adjustment
based on renal function that is either measured
or calculated.
• Calculations based on laboratory measurements
(e.g., serum creatinine) or other data can be
used to estimate a patient's renal function.

13. Excretion
• There are several formulas that have been developed and
assessed for estimating a patient's renal function. Two
such formulas are the Cockcroft-Gault formula and the
modification of diet in renal disease (MDRD) formula.
• The Cockcroft-Gault formula is the most commonly used
calculation, although many practitioners prefer the MDRD
formula, which may prove to be more accurate than other
formulas even though it has not been used for as long as
Cockroft-Gault.
• Another formula [Chronic Kidney Disease Epidemiology
Collaboration equation] also has been suggested and it
may offer advantages over the other formulas, although it
is unclear which estimate would be best to use in elderly
adults)

15. Excretion
• Pharmaceutical manufacturers have long used
Cockroft-Gault when recommending dosage
adjustments for renally excreted drugs.
• These recommendations appear on a drug's
package insert, which is approved by the FDA.
Drug manufacturers will not change their
recommendations until required to do so by the
FDA.

16. Summary of pharmacokinetic changes observed with aging 5,7,9,14,15,17,18
Pharmacokinetic parameter Altered physiology with aging Comments
Absorption
↓Gastric secretion
↑Gastric pH
↓GI motility
↓GI blood flow
Many drugs may diminish in
their absorptive ability Time of
onset of action may be delayed
Absorption is the
pharmacokinetic parameter
least affected by aging
Distribution
↓Total body water
↓Lean body weight
↓Albumin
↑Body fat
Increased Vd of lipid-soluble
drugs
Increased free fraction of drug
Metabolism
↓Enzyme induction
↓Hepatic mass
↓Hepatic blood flow
↓ Activity in mixed function
oxydase system
Reduced hepatic clearance of
drugs
Increased potential for drug
interactions
For elderly patients, dosage
should be reduced for
hepatically cleared drugs
Elimination
↓ GFR
↓ Renal blood flow
For elderly patients, drug
accumulation will occur for
renally cleared drugs
GFR, glomerular filtration rate; GI, gastrointestinal; Vd, volume of distribution.

17. • In elderly adults, a low serum creatinine is not
always indicative of normal renal function.
Because older adults have lower muscle mass
than younger people, low serum creatinine may
not be indicative of normal renal function but
rather indicative of a reduction in muscle mass.
The same issue is noted in individuals with
amputations, malnutrition, or muscle wasting.
For patients in whom serum creatinine may not
be an accurate indicator of renal function, an
actual 24-hour creatinine collection may be
necessary.

18. Pharmacodynamics
• Pharmacokinetics is
essentially the
science of how the
body affects the drug
and
pharmacodynamics is
the study of how a
specific drug affects
the body.

19. • Because of the physiological aspects of aging, elderly
adults also may be at high risk for certain drug adverse
effects. For instance, anticholinergic/antihistamines
frequently cause urinary retention. This may not be a
problem for younger patients, but it may be a severe
problem for older male patients with benign prostatic
hypertrophy. Patients maintained on certain blood
pressure medications for many years may experience
sudden precipitous drops in blood pressure caused by
age-induced orthostatic hypotension.

20. • elderly patients, who can be extremely sensitive to any
drug-induced action on the central nervous system
including dizziness, sedation, seizures, and confusion.
• care should be used whenever new medications are
initiated in them. Starting with lower drug doses and
titrating the dose as tolerated may help to prevent
unwanted drug-related pharmacodynamic effects.

23. SPECIFIC ISSUES

24. 1. ADRs/Drug Interactions
• ADRs are considered
the sixth leading
cause of death in the
United States.

25. A number of factors in older individuals contribute to their
increased risk for developing a drug-related problem.
These include frailty, coexisting medical problems,
memory issues, and use of multiple prescribed and non-
prescribed medications
Frailty is a common clinical syndrome in
older adults that carries an increased risk
for poor health outcomes including falls,
incident disability, hospitalization, and
mortality

26. Mood and behavior changes
GI tract disturbances (constipation or diarrhea)
Table 4. Drugs that commonly cause problems in elderly adults
Drug Adverse effect
Nonsteroidal anti-inflammatory
drugs (eg, ibuprofen, naproxen)
Gastrointestinal bleeding, renal
dysfunction
Diuretics (eg, hydrochlorothiazide,
furosemide)
Hypotension, dehydration,
electrolyte disturbance
Warfarin Bleeding, many drug interactions
Angiotensin-converting enzyme
inhibitors (eg, lisinopril)
Hypotension, renal dysfunction
Antidepressants (eg, amitriptyline) Confusion, hypotension, constipation
Opiates (eg, morphine)
Confusion, disorientation,
constipation
Prednisone
Osteoporosis, gastrointestinal
problems, hyperglycemia
Benzodiazepines (eg, lorazepam) Drowsiness, confusion

27. Common ADRs in elderly adults associated with various symptomatology and drug classes
Adverse effect Manifestation of effect
Possible drugs or drug
classes involved
Com
Anticholinergic effects
Dry mouth, blurred near
vision, hypotension,
exacerbated narrow-
angle glaucoma, excessive
sedation, confusion or
disorientation,
constipation, dizziness,
impaired gait and
balance, impaired
sweating, urinary
hesitancy, urinary
retention
First-generation
antihistamines
(diphenhydramine),
antipsychotics,
antidepressants,
gastrointestinal tract
motility agents, certain
analgesics (tramadol),
over-the-counter cough
and cold preparations, etc
Common a
from comm
drugs
Adverse eff
times addit
constipatio
anticholine
narcotics)
Central ner
adverse effe
insidious an
over severa
Mental status changes
Confusion (acute or
chronic), excessive
sedation (drowsiness to
soporific states), delirium,
trouble concentrating,
cognitive impairment,
memory loss, dementia,
impaired gait and
balance, deficits in
judgment or orientation
to time, place, or person
All drug classes listed
above plus muscle
relaxants; drugs that may
affect electrolytes
(diuretics); central
nervous system effects
from other drug classes
(eg, digoxin, amiodarone)
Adverse eff
additive an
difficult to
from metab
practitione
careful dru
discern
All blood pressure
Fall risk is a

28. 2. A common cause of adverse drug
reactions in elderly patients is drug
interactions.
• As an example, the risk of bleeding
with warfarin therapy is increased with
coadministration of selective and non-selective
NSAIDs, SSRIs, omeprazole, lipid-lowering
agents, amiodarone, and fluorouracil .

29. • case control study from Canada evaluated
hospitalizations for drug-related toxicity in a
population of older patients who had received
one of three common drug therapies used in
older adults: glyburide, digoxin, or ACE inhibitor .
Hospitalization for hypoglycemia was six times
more likely in patients who had received co-
trimoxazole. Digoxin toxicity was 12 times more
likely for patients who had been started
on clarithromycin. Hyperkalemia was 20 times
more likely for patients who were treated with a
potassium sparing diuretic.

30. Table 6. Selected disease states that may be aggravated by
medications
Disease state Aggravating drug
Potential adverse
effect
Diabetes
Corticosteroids (eg,
prednisone)
Drug-induced
hyperglycemia
Osteoporosis
Corticosteroids (eg,
prednisone)
Increased fracture
risk
Constipation
Anticholinergics/an
tihistamines/narco
tics
All slow
gastrointestinal
tract motility
Parkinson Antipsychotics
Aggravate
movement disorder
Hypertension
Nonsteroidal anti-
inflammatory
drugs
Fluid retention
increases blood
pressure
Benign prostatic
hypertrophy
Anticholinergics/an
tihistamines
Urinary problems

31. 3. Polypharmacy
• Whatever the definition,
polypharmacy is an important
issue in elderly patients.
Sometimes this issue cannot be
helped, but many times
polypharmacy occurs simply
because healthcare providers
fail to communicate proper
patient recommendations to the
patient's primary care provider.
If each patient had a primary
healthcare advocate who
coordinated the patient's overall
care, then the risk of
polypharmacy could be

32. 4. Compliance
• Poor compliance in elderly adults also may be a
product of health literacy. Studies have shown
that as health literacy declines in older people,
mortality increases. Several issues related to
health literacy affect older adults, including poor
education, language barriers, and mental health
issues (eg, dementia, agitation), and all of them
must be considered to improve compliance

33. Herbal and dietary supplements
• three-quarters of respondents aged 18 years and older
reported that they did not inform their clinician that they
were using unconventional medications .
• Examples of herbal-drug therapy interactions include
ginkgo biloba extract taken with warfarin, causing an
increased risk of bleeding, and St. John's wort taken with
serotonin-reuptake inhibitors, increasing the risk of
serotonin syndrome in older adults.

34. Anticholinergic activity
• Adverse effects associated with anticholinergic
use in older adults include memory impairment,
confusion, hallucinations, dry mouth, blurred
vision, constipation, nausea, urinary retention,
impaired sweating, and tachycardia.

35. Anticholinergic activity of medications
Antiparkinson
Amantadine, bromocriptine, entacapone Low
Analgesic
Opioids (eg, codeine, hydrocodone,
fentanyl, meperidine, methadone, morphine,
oxycodone, tramadol, others)
Low
Antimuscarinic, overactive bladder
Darifenacin, fesoterodine, oxybutynin,
solifenacin, tolterodine, trospium
High
Antimuscarinic, spasmolytic
Dicyclomine, hyoscyamine, glycopyrrolate,
methscopolamine, propantheline,
scopolamine (hyoscine)
High
Antimuscarinic, inhaled bronchodilator Ipratropium, tiotropium High (local effect)
Antimuscarinic, ophthalmic drops
(mydriatic/cycloplegic)
Atropine, cyclopentolate, homatropine,
scopolamine
High (local effect)
Cardiovascular Disopyramide Low
Gastrointestinal
Antiemetics (eg, hydroxyzine, meclizine,
promethazine, scopolamine); also refer to
1
st
generation antihistamines above
High
Domperidone, loperamide, prochlorperazine Low
H2 receptor antagonists (ranitidine,
cimetidine, famotidine
¶
)
Low
Muscle relaxant
Orphenadrine, tizanidine High
Cyclobenzaprine*, baclofen,
methocarbamol
Low
Psychotropic
Antipsychotics 1
st
generation:
chlorpromazine, fluphenazine,
methotrimeprazine (levomepromazine),
thioridazine
High
Antipsychotics 1
st
generation: haloperidol,
perphenazine*, others
Low
Antipsychotics 2
nd
generation: (eg,
olanzapine*, quetiapine, iloperidone,
risperidone, others)
Low (exception clozapine-high)
Benzodiazepines: chlordiazepoxide,
clonazepam, temazepam, triazolam
Low
Selective serotonin reuptake inhibitors
(SSRI) antidepressants: citalopram, Low

36. Affordability
• A prescription may be written but not filled, or filled and
not taken regularly, due to financial considerations. This
may be a particular problem in countries where there is
no universal insurance coverage for drug therapy for
older adults.

37. Prescribing cascades
• Prescribing cascades occur when a new drug is
prescribed to treat symptoms arising from an
unrecognized adverse drug event related to an existing
therapy .
• One of the best recognized examples of a prescribing
cascade relates to the initiation of anti-Parkinson therapy
for symptoms arising from use of drugs such as
antipsychotics or metoclopramide . The anti-Parkinson
drugs can then lead to new symptoms, including
orthostatic hypotension and delirium.

38. Prescribing cascades
• cholinesterase inhibitors (eg, donepezil, rivastigmine,
and galantamine) are commonly used for the
management of dementia symptoms in older adults. The
adverse events associated with these drugs can be
viewed as the reverse of those that might be expected
with anticholinergic therapies. Accordingly, while
anticholinergic therapies may cause constipation and
urinary retention, cholinesterase inhibitors may cause
diarrhea and urinary incontinence. A prescribing cascade
occurs when the prescription of a cholinesterase inhibitor
is followed by a prescription for an anticholinergic
therapy (eg, oxybutynin) to treat incontinence.

39. Adverse drug events in long-term care
setting
• Preventable adverse drug events were most frequently
associated with atypical antipsychotics
and warfarin therapy

40. Atypical antipsychotics
• Atypical antipsychotic medications, used for the
management of the behavioral and psychological
symptoms of dementia, are among the drugs most
frequently associated with adverse events in long-term
care facilities . In particular, psychotropic medications
are associated with an increased risk for falls. In one
meta-analysis of patients age 60 or older, the odds ratio
for any psychotropic use among patients who had one or
more falls was 1.73

41. Atypical antipsychotics
• Data from 17 trials of older adult patients with dementia
have shown that those treated with atypical antipsychotic
therapy were 1.6 to 1.7 times more likely to die than
those given placebo therapy. Similar concerns have
been raised for haloperidol and other conventional
antipsychotics.
• Mortality was further increased, again by a factor of 1.55,
for patients receiving conventional antipsychotics
compared to atypical antipsychotics. These data point to
the need to rethink the role of these therapies in clinical
practice.

42. Transitions in care settings
• Transitions in care, between hospital and nursing home,
or institutional setting and home, are a common source
of medication errors and confusions:

43. Tools for Appropriate Medication Decisions
• The Beers criteria is a list of medications that, based on
the drugs' pharmacology (eg, mechanism of action,
pharmacokinetics, adverse effect profile), may cause
adverse effects in older people.
• The list was initiated in 1991 and an update was
completed by the American Geriatrics Society in 2012.

45. 2012 American Geriatrics Society Beers
Criteria for Potentially Inappropriate
Medication Use in Older Adults
First-generation antihistamines (as
single agent or as part of combination
products)
Highly anticholinergic; clearance
reduced with advanced age, and
tolerance develops when used as
hypnotic; greater risk of confusion, dry
mouth, constipation, and other
anticholinergic effects and toxicity.
Antispasmodics Highly anticholinergic,
uncertain effectiveness
Avoid except in short-
term palliative care to
decrease oral secretions
Nitrofurantoin Potential for pulmonary toxicity; safer
alternatives available; lack of efficacy
in patients with CrCl < 60 ml/min due
to inadequate drug concentration in
the urine

46. Digoxin > 0.125 mg/d In heart failure, higher dosages
associated with no additional benefit
and may increase risk of toxicity; slow
renal clearance may lead to risk of
toxic effects
Nifedipine, immediate release
*
Potential for hypotension; risk of
precipitating myocardial ischemia
Spironolactone > 25 mg/d In heart failure, the risk of
hyperkalemia is higher in older adults
especially if taking > 25 mg/d or taking
concomitant NSAID, angiotensin
converting-enzyme inhibitor,
angiotensin receptor blocker, or
potassium supplement

47. Tertiary TCAs, alone or in
combination:
Highly anticholinergic, sedating, and
cause orthostatic hypotension; safety
profile of low-dose doxepin (≥ 6 mg/d)
is comparable with that of placebo
Benzodiazepines
Short and intermediate acting:
Older adults have increased sensitivity
to benzodiazepines and slower
metabolism of long-acting agents. In
general, all benzodiazepines increase
risk of cognitive impairment, delirium,
falls, fractures, and motor vehicle
accidents in older adults. Avoid
benzodiazepines (any type) for
treatment of insomnia, agitation, or
delirium
Long acting: May be appropriate for seizure
disorders, rapid eye movement sleep
disorders, benzodiazepine withdrawal,
ethanol withdrawal, severe
generalized anxiety disorder,
periprocedural anesthesia, end-of-life
care

48. Insulin, sliding scale Higher risk of hypoglycemia without
improvement in hyperglycemia
management regardless of care
setting
Sulfonylureas, long duration Chlorpropamide: prolonged half-life in
older adults; can cause prolonged
hypoglycemia; causes syndrome of
inappropriate antidiuretic hormone
secretion.
Metoclopramide Can cause extrapyramidal effects
including tardive dyskinesia; risk may
be even greater in frail older adult

49. Non–COX-selective NSAIDs, oral Increases risk of GI bleeding and
peptic ulcer disease in high-risk
groups, including those aged > 75 or
taking oral or parenteral
corticosteroids, anticoagulants, or
antiplatelet agents. Use of proton
pump inhibitor or misoprostol reduces
but does not eliminate risk. Upper GI
ulcers, gross bleeding, or perforation
caused by NSAIDs occur in
approximately 1% of patients treated
for 3–6 months and in approximately
2–4% of patients treated for 1 year.
These trends continue with longer
duration of use
Skeletal muscle relaxants Most muscle relaxants are poorly
tolerated by older adults because of
anticholinergic adverse effects,
sedation, risk of fracture; effectiveness
at dosages tolerated by older adults is
questionable

50. Drug–Syndrome Interactions
Heart failure NSAIDs and C0X-2 inhibitors
Chronic seizures or epilepsy Bupropion, TRAMADOL
Insomnia Oral decongestants

51. • The criteria are intended to provide physicians and
healthcare providers who treat elderly patients with a
comprehensive list of medications that may be harmful to
older adult patients. The updated criteria are composed
of three detailed lists. The first list is classified as drugs
that have been demonstrated to be problematic in elderly
adults. The second classification lists drugs that may be
inappropriate for older people who have certain diseases
or risk factors. The third classification lists drugs that
should be used with caution in elderly patients. Most of
the medications on the lists are well known, and medical
evidence supports their potential to be harmful in this
patient class. The Beers criteria do not ban the use of
drugs on the list for all elderly patients; instead, they
emphasize the drugs that may pose the most harm so
that they are used judiciously and with caution

52. • Similar to but much more comprehensive than
the Beers criteria is the Screening Tool of Older
Persons' Prescriptions. Rather than a simple
checklist of medications, it attempts to assess the
use of a drug with a specific patient who has
specific comorbidities.
• Whichever tool is used, the primary purpose is to
prescribe medications to all elderly patients with
care and consideration, which ensures that each
older adult patient is provided with the best care
possible. Achieving this goal will result in happy
and healthy patients, less polypharmacy, fewer
adverse drug effects, and lower healthcare costs.

53. Methods to improve drug-related problems in elderly adults 1–7
Medication issues Comments
Improve compliance
Use as few drugs as possible
Written instructions
Council patient and family/caregiver
Improve communication skills (eg,
language)
Make medications affordable
Memory techniques (eg, calendars)
Recognize potential health literacy issues
that may cause compliance issues (eg,
language issues, dementia)
Reduce polypharmacy
Use only 1 primary care provider who
communicates with specialists
Use only 1 pharmacy
Reduce the number of drugs necessary
because of adverse effects of another agent
(eg, laxatives for drugs that cause
constipation)
Review all medications on each visit to
doctor (brown bag)
Maximize doses when possible instead of
adding a new drug
Assess patient's renal function using
specific formula on each visit (or obtain
measured creatinine clearance)

54. Practical recommendations to reduce medical
errors in the community have been proposed
• Maintain an accurate list of all medications that a patient
is currently using. This list should include the drug name
(generic and brand), dosage, frequency, route, and
indication.
• ●Advise periodic "brown bag check-ups." Instruct
patients to bring all pill bottles to each medical visit;
bottles should be checked against the medication list.
• ●Patients should be made aware of potential drug
confusions: sound-alike names, look-alike pills, and
combination medications.
• ●

55. Practical recommendations to reduce medical
errors in the community have been proposed
• Patients should be informed of both generic and brand
names, including spelling, as well as the reasons for taking
their medications. This may prevent unnecessary
confusion when drugs are inconsistently labeled. As an
example, a patient may be unaware that digoxin (generic)
and Lanoxin (brand) are the same therapy.
• ●Medication organizers that are filled by the patient, family
member, or caregiver, can facilitate compliance with drug
regimens. Blister packs for individual drugs, prepared by
the pharmacist, can also be helpful in ensuring that
patients take their medications correctly.
• ●Community pharmacists are an important resource and
can play a key role in working with older adults to reduce
medication errors.

56. A STEPWISE APPROACH TO
PRESCRIBING
• A concept of “time to benefit” (TTB) in relation to drug
prescribing for older patients with multiple morbidities
can be applied to therapeutic decisions .
• TTB, defined as the time to significant benefit observed
in trials of people treated with a drug compared to
controls, can be estimated from data from randomized
controlled trials. Such information, not currently
available, may in the future help guide decision making
for specific drug prescribing in individual patients.

57. Review current drug therapy
• Periodic evaluation of a patient's drug regimen is an
essential component of medical care for an older person.
• discontinuing a therapy prescribed for an indication that
no longer exists
• substituting a therapy with a potentially safer agent,
changing drug dosage, or adding a new medication.
• A medication review should consider whether a change in
patient status (eg renal or liver function) might necessitate
dosing adjustment, the potential for drug-drug interaction,
whether patient symptoms might reflect a drug side effect,
or whether the regimen could be simplified
• Unintended medication discrepancies, particularly likely to
occur at the time of hospital admissions, are a common
source for medication errors.

58. Discontinue unnecessary therapy
• Clinicians are often reluctant to stop medications,
especially if they did not initiate the treatment and the
patient seems to be tolerating the therapy.
• A common example is the use of digoxin in older adults,
often prescribed for indications that have not been well
documented. Renal impairment or temporary
dehydration may predispose older adults to digoxin
toxicity . Although digoxin therapy can be safely
discontinued in selected nursing home residents, it is
important to recognize that discontinuation in patients
with impaired systolic function can have a detrimental
effect

59. Consider adverse drug events for any
new symptom
• Before adding a new therapy to the patient's drug
regimen

60. Consider nonpharmacologic approaches
• The Trial of
Nonpharmacologic
Interventions in the
Elderly (TONE)
demonstrated that
weight loss and reduced
sodium intake could
allow discontinuation of
antihypertensive
medication in about 40
percent of the
intervention group

61. Substitute with safer alternatives
• As an example, in treatment of non-inflammatory
arthritis, acetaminophen may provide adequate pain
relief and be a safer alternative to NSAIDs . (See "Initial
pharmacologic therapy of osteoarthritis".) Numerous
studies have documented adverse events associated
with NSAID use in older persons, including
gastrointestinal bleeds , renal impairment , and heart
failure

62. Reduce the dose
• As an example, one study evaluated the relationship
between prescribing of the newer atypical antipsychotic
therapies (eg, olanzapine, risperidone, and quetiapine)
and the development of parkinsonism in older adults .
Relative to those dispensed a low-dose, those dispensed
a high-dose were more than twice as likely to develop
parkinsonism (HR 2.07, 95% CI 1.42-3.02). As another
example, one case-control study in patients over age 70
who received thyroid supplementation identified a
correlation between risk of fracture and dose
of levothyroxine, indicating the importance of testing for
thyroid levels in this population and adjusting the dose
accordingly

63. Simplify the dosing schedule
• hen multiple medications are required, greater regimen
complexity will increase the likelihood of poor
compliance or confusion with dosing. Older adults, and
particularly those with low health literacy, are not able to
efficiently consolidate prescription regimens to optimize
a dosing schedule

64. Prescribe beneficial therapy
• Avoiding medications with known benefits to minimize
the number of drugs prescribed is inappropriate. Patients
must be informed about the reason to initiate a new
medication, and what the expected benefits are.

65. INFORMATION FOR PATIENTS

66. References
• Up-to-date 2015
• Medscape