ATrain Education

 

Continuing Education for Health Professionals

Overmedication: A Hazard for Elders

Module 2

Screening Strategies

 

Leona was admitted to the hospital to monitor her for adverse drug effects and medication adjustments. Her preventable hospital bill came to over $5800 for a two-day hospital stay. In collaboration with the emergency physician, hospitalist and nurses, a medication reconciliation was completed and several medications were discontinued.

She was discharged with instructions to follow up with her primary care physician. At the followup, the PCP realized that the patient had been taking medications of which he was unaware that had been prescribed by other doctors including her endocrinologist. To sum, the patient had been taking medications from various doctors and each physician was unaware of the others. Leona didn’t understand what each medication did, and she defended herself by saying “My doctor knows all about that.”

 

Beers Criteria

In 1991 Geriatrician Mark Beers and colleagues published an expert consensus document to establish criteria for identifying medications that are inappropriate for use in older adults. The Beers criteria is used to identify “potentially inappropriate medications” for older adults, meaning the risk may outweigh the benefit. More commonly known as “Beers List,” it is a set of guidelines, updated in 2015, for healthcare professionals to improve the safety of prescription medications for older adults (AGS, 2015). Research has shown that 21.3% of older Americans received at least one potentially inappropriate drug and 2.6% received an “always avoid” drug (Budnitz et al., 2011).

 

Answer: A

Test Your Knowledge

The Beers criteria are designed to identify:

  1. Medications inappropriate for use in older adults.
  2. Practitioners who write too many prescriptions.
  3. Caregivers who need education in giving medications properly.
  4. Medications with side effects known to be potentially dangerous.

The American Geriatric Society refined the Beers list in 2015 of medications by identifying drugs that should:

  • Always be avoided (have serious potential effects and alternative medications are available)
  • Are rarely appropriate
  • Have indications for use in older patients but are frequently misused (AGS, 2015)
  • An example of polypharmacy as a worldwide challenge was a study in seventeen Japanese long-term care facilities who used the Beers criteria to assess the prevalence of inappropriate medication use. It concluded that the use of inappropriate medications was similar in Japan to that of other countries. The study noted that the highest prevalence of “inappropriate medication use dependent on the disease or condition” was found in patients with chronic constipation, who were treated with medications such as calcium channel blockers, anticholinergics, and tricyclic antidepressants (Niwata, 2006). The researchers also noted 21.1% of the patients were treated with potentially inappropriate medication independent of disease or condition and 18% of patients were treated with at least one inappropriate medication dependent on the disease or condition (Niwata, 2006).

A number of other studies have identified common medication culprits, including diphenhydramine, amitriptyline, and co-administered warfarin and nonsteroidal anti-inflammatory medications (NSAIDs). Propoxyphene (Darvon), a mild pain reliever that had been on the list, was officially banned from use in November 2010 after the Food and Drug Administration (FDA) acknowledged that there were excess cardiac events, including fatal arrhythmias, associated with use of the medication (FDA, 2010). Clinicians and healthcare providers must stay alert to assess for ADRs and report them to the FDA.

Additional studies implicated pain relievers, benzodiazepines, antidepressants, and musculoskeletal agents as the cause of 61% of the incidents of inappropriate prescribing. The 2015 Beers criteria also updated the list of drugs to avoid as those having classic drug-drug interactions such as alpha-1 blockers used in combination with loop diuretics, which increases urinary incontinence, and the use of three or more central nervous system (CNS)–active drugs should be avoided as they increases the risk for falls (AGA, 2015a). Of particular note is that 66 drugs were considered by the panel to have the potential for severe adverse outcomes when used in older adults (see list).

 

Online Resource

BEERS Criteria 2015 List
https://www.guideline.gov/summaries/summary/49933

 

We are able to reproduce the 2012 Beers Criteria here; it was taken from the printable card found here.

 

From http://www.americangeriatrics.org/files/documents/beers/PrintableBeersPocketCard.pdf. Source: AGS.

TABLE 1: 2012 AGS Beers Criteria for Potentially Inappropriate
Medication Use in Older Adults

Organ System, Therapeutic Category/Drug(s)

Recommendation, Rationale,
Quality of Evidence (QE) & Strength of Recommendation (SR)

Anticholinergics (excludes TCAs)

First-generation antihistamines (as single agent or as part of combination products)

  • Brompheniramine
  • Carbinoxamine
  • Chlorpheniramine
  • Clemastine
  • Cyproheptadine
  • Dexbrompheniramine
  • Dexchlorpheniramine
  • Diphenhydramine (oral)
  • Doxylamine
  • Hydroxyzine
  • Meclizine
  • Promethazine
  • Triprolidine

Avoid.

 

Highly anticholinergic; clearance reduced with advanced age, and tolerance develops when used as hypnotic; increased risk of confusion, dry mouth, constipation, and other anticholinergic effects/toxicity.

 

Use of diphenhydramine in special situations such as acute treatment of severe allergic reaction may be appropriate.

 

QE=High (Hydroxyzine and Promethazine), Moderate (All others); SR=Strong

Antiparkinson agents

  • Benztropine (oral)
  • Trihexyphenidyl

Avoid.

 

Not recommended for prevention of extrapyramidal symptoms with antipsychotics; more effective agents available for treatment of Parkinson disease.

 

QE=Moderate, SR=Strong

Antispasmodics

  • Belladonna alkaloids
  • Clidinium-chlordiazepoxide
  • Dicyclomine
  • Hyoscyamine
  • Propantheline
  • Scopolamine

Avoid except in short-term palliative care to decrease oral secretions.

 

Highly anticholinergic, uncertain effectiveness.

 

QE=Moderate, SR=Strong

Antithrombotics

Dipyridamole, oral short-acting* (does not apply to the extended-release combination with aspirin)

Avoid.

 

May cause orthostatic hypotension; more effective alternatives available; IV form acceptable for use in cardiac stress testing.

 

QE=Moderate, SR=Strong

Ticlopidine*

Avoid.

 

Safer, effective alternatives available.

 

QE=Moderate, SR=Strong

Anti-infective

Nitrofurantoin

Avoid for long-term suppression; avoid in patients with CrCl <60 mL/min.

 

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.

 

QE=Moderate, SR=Strong

Cardiovascular

Alpha1 blockers

  • Doxazosin
  • Prazosin
  • Terazosin

Avoid use as an antihypertensive.

 

High risk of orthostatic hypotension; not recommended as routine treatment for hypertension; alternative agents have superior risk/benefit profile.

 

QE=Moderate, SR=Strong

Alpha agonists

  • Clonidine
  • Guanabenz*
  • Guanfacine*
  • Methyldopa*
  • Reserpine (>0.1 mg/day)*

Avoid clonidine as a first-line antihypertensive. Avoid others as listed.

 

High risk of adverse CNS effects; may cause bradycardia and orthostatic hypotension; not recommended as routine treatment for hypertension.

 

QE=Low, SR=Strong

Antiarrhythmic drugs (Class Ia, Ic, III)

  • Amiodarone
  • Dofetilide
  • Dronedarone
  • Flecainide
  • Ibutilide
  • Procainamide
  • Propafenone
  • Quinidine
  • Sotalol

Avoid antiarrhythmic drugs as first-line treatment of atrial fibrillation.

 

Data suggest that rate control yields better balance of benefits and harms than rhythm control for most older adults.

 

Amiodarone is associated with multiple toxicities, including thyroid disease, pulmonary disorders, and QT interval prolongation.

 

QE=High, SR=Strong

Disopyramide*

Avoid.

 

Disopyramide is a potent negative inotrope and therefore may induce heart failure in older adults; strongly anticholinergic; other antiarrhythmic drugs preferred.

 

QE=Low, SR=Strong

Dronedarone

Avoid in patients with permanent atrial fibrillation or heart failure.

 

Worse outcomes have been reported in patients taking dronedarone who have permanent atrial fibrillation or heart failure. In general, rate control is preferred over rhythm control for atrial fibrillation.

 

QE=Moderate, SR=Strong

Digoxin >0.125 mg/day

Avoid.

 

In heart failure, higher dosages associated with no additional benefit and may increase risk of toxicity; decreased renal clearance may increase risk of toxicity.

 

QE=Moderate, SR=Strong

Nifedipine, immediate release*

Avoid.

Potential for hypotension; risk of precipitating myocardial ischemia.

 

QE=High; S =Strong

Spironolactone >25 mg/day

Avoid in patients with heart failure or with a CrCl <30 mL/min.

 

In heart failure, the risk of hyperkalemia is higher in older adults if taking >25 mg/day.

 

QE=Moderate; SR=Strong

Central Nervous System

Tertiary TCAs, alone or in combination:

  • Amitriptyline
  • Chlordiazepoxide-amitriptyline
  • Clomipramine
  • Doxepin >6 mg/day
  • Imipramine
  • Perphenazine-amitriptyline
  • Trimipramine

Avoid.

 

Highly anticholinergic, sedating, and cause orthostatic hypotension; the safety profile of low-dose doxepin (≤6 mg/day) is comparable to that of placebo.

 

QE=High; SR=Strong

Antipsychotics, first- (conventional) and second- (atypical) generation (see online for full list)

Avoid use for behavioral problems of dementia unless non-pharmacologic options have failed and patient is threat to self or others.

 

Increased risk of cerebrovascular accident (stroke) and mortality in persons with dementia.

 

QE=Moderate; SR=Strong

Thioridazine

Mesoridazine

Avoid.

 

Highly anticholinergic and greater risk of QT-interval prolongation.

 

QE=Moderate; SR=Strong

Barbiturates

  • Amobarbital*
  • Butabarbital*
  • Butalbital
  • Mephobarbital*
  • Pentobarbital*
  • Phenobarbital
  • Secobarbital*

Avoid.

 

High rate of physical dependence; tolerance to sleep benefits; greater risk of overdose at low dosages.

 

QE=High; SR=Strong

Benzodiazepines
Short- and intermediate-acting:

  • Alprazolam
  • Estazolam
  • Lorazepam
  • Oxazepam
  • Temazepam
  • Triazolam

 

  • Chlorazepate
  • Chlordiazepoxide
  • Chlordiazepoxide-amitriptyline
  • Clidinium-chlordiazepoxide
  • Clonazepam
  • Diazepam
  • Flurazepam
  • Quazepam

Avoid benzodiazepines (any type) for treatment of insomnia, agitation, or delirium.

 

Older adults have increased sensitivity to benzodiazepines and decreased metabolism of long-acting agents. In general, all ben- zodiazepines increase risk of cognitive impairment, delirium, falls, fractures, and motor vehicle accidents in older adults.

 

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.

 

QE=High; SR=Strong

Chloral hydrate*

Avoid.

 

Tolerance occurs within 10 days and risk outweighs the benefits in light of overdose with doses only 3 times the recommended dose.

 

QE=Low; SR=Strong

Meprobamate

Avoid.

 

High rate of physical dependence; very sedating.

 

QE=Moderate; SR=Strong

Nonbenzodiazepine hypnotics

  • Eszopiclone
  • Zolpidem
  • Zaleplon

Avoid chronic use (>90 days).

 

Benzodiazepine-receptor agonists that have adverse events similar to those of benzodiazepines in older adults (e.g., delirium, falls, fractures); minimal improvement in sleep latency and duration.

 

QE=Moderate; SR=Strong

Ergot mesylates*

Isoxsuprine*

Avoid.

 

Lack of efficacy.

 

QE=High; SR=Strong

Endocrine

Androgens

  • Methyltestosterone*
  • Testosterone

Avoid unless indicated for moderate to severe hypogonadism.

 

Potential for cardiac problems and contraindicated in men with prostate cancer.

 

QE=Moderate; SR=Weak

Desiccated thyroid

Avoid.

 

Concerns about cardiac effects; safer alternatives available.

 

QE=Low; SR=Strong

Estrogens with or without progestins

Avoid oral and topical patch. Topical vaginal cream: Acceptable to use low-dose intravaginal estrogen for the management of dyspareunia, lower urinary tract infections, and other vaginal symptoms.

 

Evidence of carcinogenic potential (breast and endometrium); lack of cardioprotective effect and cognitive protection in older women. Evidence that vaginal estrogens for treatment of vaginal dryness is safe and effective in women with breast cancer, especially at dosages of estradiol <25 mcg twice weekly.

 

QE=High (Oral and Patch), Moderate (Topical); SR=Strong (Oral and Patch), Weak (Topical)

Growth hormone

Avoid, except as hormone replacement following pituitary gland removal.

 

Effect on body composition is small and associated with edema, arthralgia, carpal tunnel syndrome, gynecomastia, impaired fasting glucose.

 

QE=High; SR=Strong

Insulin, sliding scale

Avoid.

 

Higher risk of hypoglycemia without improvement in hyperglycemia management regardless of care setting.

 

QE=Moderate; SR=Strong

Megestrol

Avoid.

 

Minimal effect on weight; increases risk of thrombotic events and possibly death in older adults.

 

QE=Moderate; SR=Strong

Sulfonylureas, long-duration

  • Chlorpropamide
  • Glyburide

Avoid.

 

Chlorpropamide: prolonged half-life in older adults; can cause prolonged hypoglycemia; causes SIADH Glyburide: higher risk of severe prolonged hypoglycemia in older adults.

 

QE=High; SR=Strong

Gastrointestinal

Metoclopramide

Avoid, unless for gastroparesis.

 

Can cause extrapyramidal effects including tardive dyskinesia; risk may be further increased in frail older adults.

 

QE=Moderate; SR=Strong

Mineral oil, given orally

Avoid.

 

Potential for aspiration and adverse effects; safer alternatives available.

 

QE=Moderate; SR=Strong

Trimethobenzamide

Avoid.

 

One of the least effective antiemetic drugs; can cause extrapyramidal adverse effects.

 

QE=Moderate; SR=Strong

Meperidine

Avoid.

 

Not an effective oral analgesic in dosages commonly used; may cause neurotoxicity; safer alternatives available.

 

QE=High; SR=Strong

Non-COX-selective NSAIDs, oral

  • Aspirin >325 mg/day
  • Diclofenac
  • Diflunisal
  • Etodolac
  • Fenoprofen
  • Ibuprofen
  • Ketoprofen
  • Meclofenamate
  • Mefenamic acid
  • Meloxicam
  • Nabumetone
  • Naproxen
  • Oxaprozin
  • Piroxicam
  • Sulindac
  • Tolmetin

Avoid chronic use unless other alternatives are not effective and patient can take gastroprotective agent (proton-pump inhibitor or misoprostol).

 

Increases risk of GI bleeding/peptic ulcer disease in high-risk groups, including those ≥75 years old 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 about 2%–4% of patients treated for 1 year. These trends continue with longer duration of use.

 

QE=Moderate; SR=Strong

Indomethacin

Ketorolac, includes parenteral

Avoid.

 

Increases risk of GI bleeding/peptic ulcer disease in high-risk groups (See Non-COX selective NSAIDs).

 

Of all the NSAIDs, indomethacin has most adverse effects.

 

QE=Moderate (Indomethacin), High (Ketorolac); SR=Strong

Pentazocine*

Avoid.

 

Opioid analgesic that causes CNS adverse effects, including confusion and hallucinations, more commonly than other narcotic drugs; is also a mixed agonist and antagonist; safer alternatives available.

 

QE=Low; SR=Strong

Skeletal muscle relaxants

  • Carisoprodol
  • Chlorzoxazone
  • Cyclobenzaprine
  • Metaxalone
  • Methocarbamol
  • Orphenadrine

Avoid.

 

Most muscle relaxants poorly tolerated by older adults, because of anticholinergic adverse effects, sedation, increased risk of fractures; effectiveness at dosages tolerated by older adults is questionable.

 

QE=Moderate; SR=Strong

*Infrequently used drugs. Table 1 Abbreviations: ACEI, angiotensin converting-enzyme inhibitors; ARB, angiotensin receptor blockers; CNS, central nervous system; COX, cyclooxygenase; CrCl, creatinine clearance; GI, gastrointestinal; NSAIDs, nonsteroidal anti-inflammatory drugs; SIADH, syndrome of inappropriate antidiuretic hormone secretion; SR, Strength of Recommendation; TCAs, tricyclic antidepressants; QE, Quality of Evidence

 

From http://www.americangeriatrics.org/files/documents/beers/PrintableBeersPocketCard.pdf. Source: AGS.

TABLE 2: 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Due to Drug-Disease or Drug-Syndrome Interactions That May Exacerbate the Disease or Syndrome

Disease or Syndrome

Drug(s)

Recommendation, Rationale, Quality of Evidence (QE) & Strength of Recommendation (SR)

Cardiovascular

Heart failure

NSAIDs and COX-2 inhibitors

 

Nondihydropyridine CCBs (avoid only for systolic heart failure)

  • Diltiazem
  • Verapamil

 

Pioglitazone, rosiglitazone

Cilostazol

Dronedarone

Avoid.

 

Potential to promote fluid retention and/or exacerbate heart failure.

QE=Moderate (NSAIDs, CCBs, Dronedarone), High (Thiazolidinediones (glitazones)), Low (Cilostazol); SR=Strong

Syncope

Acetylcholinesterase inhibitors (AChEIs)

 

Peripheral alpha blockers

  • Doxazosin
  • Prazosin
  • Terazosin

 

Tertiary TCAs

 

Chlorpromazine, thioridazine, and olanzapine

Avoid.

 

Increases risk of orthostatic hypotension or bradycardia.

 

QE=High (Alpha blockers), Moderate (AChEIs, TCAs and antipsychotics); SR=Strong (AChEIs and TCAs), Weak (Alpha blockers and antipsychotics)

Central Nervous System

Chronic seizures or epilepsy

Bupropion

Chlorpromazine

Clozapine

Maprotiline

Olanzapine

Thioridazine

Thiothixene

Tramadol

Avoid.

 

Lowers seizure threshold; may be acceptable in patients with well-controlled seizures in whom alternative agents have not been effective.

 

QE=Moderate; SR=Strong

Delirium

All TCAs

Anticholinergics (see online for full list)

Benzodiazepines

Chlorpromazine

Corticosteroids

H2-receptor antagonist

Meperidine

Sedative hypnotics

Thioridazine

Avoid.

 

Avoid in older adults with or at high risk of delirium because of inducing or worsening delirium in older adults; if discontinuing drugs used chronically, taper to avoid withdrawal symptoms.

 

QE=Moderate; SR=Strong

Dementia & cognitive impairment

Anticholinergics (see online for full list)

Benzodiazepines

H2-receptor antagonist

Zolpidem

Antipsychotics, chronic and as-needed use

Avoid.

 

Avoid due to adverse CNS effects.

 

Avoid antipsychotics for behavioral problems of dementia unless non-pharmacologic options have failed and patient is a threat to themselves or others.

 

Antipsychotics are associated with an increased risk of cerebrovascular accident (stroke) and mortality in persons with dementia.

 

QE=High; SR=Strong

History of falls or fractures

Anticonvulsants

Antipsychotics

Benzodiazepines

Nonbenzodiazepine hypnotics

  • Eszopiclone
  • Zaleplon
  • Zolpidem

 

TCAs/SSRIs

Avoid unless safer alternatives are not available; avoid anticonvulsants except for seizure.

 

Ability to produce ataxia, impaired psychomotor function, syncope, and additional falls; shorter-acting benzodiazepines are not safer than long-acting ones.

 

QE=High; SR=Strong

Insomnia

Oral decongestants

  • Pseudoephedrine
  • Phenylephrine Stimulants
  • Amphetamine
  • Methylphenidate
  • Pemoline Theobromines
  • Theophylline
  • Caffeine

 

TCAs/SSRIs

Avoid.

 

CNS stimulant effects.

 

QE=Moderate; SR=Strong

Parkinson’s disease

All antipsychotics (see online publication for full list, except for quetiapine and clozapine)

 

Antiemetics

  • Metoclopramide
  • Prochlorperazine
  • Promethazine

Avoid.

 

Dopamine receptor antagonists with potential to worsen parkinsonian symptoms.

 

Quetiapine and clozapine appear to be less likely to precipitate worsening of Parkinson disease.

 

QE=Moderate; SR=Strong

Gastrointestinal

Chronic constipation

Oral antimuscarinics for urinary incontinence

  • Darifenacin
  • Fesoterodine
  • Oxybutynin (oral)
  • Solifenacin
  • Tolterodine
  • Trospium

 

Nondihydropyridine CCB

  • Diltiazem
  • Verapamil

 

First-generation antihistamines as single agent or part of combination products

  • Brompheniramine (various)
  • Carbinoxamine
  • Chlorpheniramine
  • Clemastine (various)
  • Cyproheptadine
  • Dexbrompheniramine
  • Dexchlorpheniramine (various)
  • Diphenhydramine
  • Doxylamine
  • Hydroxyzine
  • Promethazine
  • Triprolidine

 

Anticholinergics/antispasmodics (see online for full list of drugs with strong anticholinergic properties)

  • Antipsychotics
  • Belladonna alkaloids
  • Clidinium-chlordiazepoxide
  • Dicyclomine
  • Propantheline
  • Scopolamine
  • Tertiary TCAs (amitriptyline, clomipramine, doxepin, imipramine, and trimipramine)

Avoid unless no other alternatives.

 

Can worsen constipation; agents for urinary incontinence: antimuscarinics overall differ in incidence of constipation; response variable; consider alternative agent if constipation develops.

 

Quetiapine and clozapine appear to be less likely to precipitate worsening of Parkinson disease.

 

QE=High (For Urinary Incontinence), Moderate/Low (All Others); SR=Strong

History of gastric or duodenal ulcers

Aspirin (>325 mg/day)

Non-COX-2 selective NSAIDs

Avoid unless other alternatives are not effective and patient can take gastroprotective agent (proton-pump inhibitor or misoprostol).

 

May exacerbate existing ulcers or cause new/additional ulcers.

 

QE=Moderate; SR=Strong

Kidney/Urinary Tract

Chronic kidney disease stages IV and V

NSAIDs

 

 

 

Triamterene (alone or in combination)

Avoid.

 

May increase risk of kidney injury.

 

May increase risk of acute kidney injury.

 

QE=Moderate (NSAIDs), Low (Triamterene); SR=Strong (NSAIDs), Weak (Triamterene)

Urinary incontinence (all types) in women

Estrogen oral and transdermal (excludes intravaginal estrogen)

Avoid in women.

 

Aggravation of incontinence.

 

QE=High; SR=Strong

Lower urinary tract symptoms, benign prostatic hyperplasia

Inhaled anticholinergic agents

 

Strongly anticholinergic drugs, except antimuscarinics for urinary incontinence (see Table 9 for complete list).

Avoid in men.

 

May decrease urinary flow and cause urinary retention.

 

QE=Moderate; SR=Strong (Inhaled agents), Weak (All others)

Stress or mixed urinary incontinence

Alpha-blockers

  • Doxazosin
  • Prazosin
  • Terazosin

Avoid in women.

 

Aggravation of incontinence.

 

QE=Moderate; SR=Strong

Table 2 Abbreviations: CCBs, calcium channel blockers; AChEIs, acetylcholinesterase inhibitors; CNS, central nervous system; COX, cyclooxygenase; NSAIDs, nonsteroidal anti-inflammatory drugs; SR, Strength of Recommendation; SSRIs, selective serotonin reuptake inhibitors; TCAs, tricyclic antidepressants; QE, Quality of Evidence

 

From http://www.americangeriatrics.org/files/documents/beers/PrintableBeersPocketCard.pdf. Source: AGS.

TABLE 3: 2012 AGS Beers Criteria for Potentially Inappropriate Medications to Be Used with Caution in Older Adults

Drug(s)

Recommendation, Rational, Quality of Evidence (QE) & Strength of Recommendation (SR)

Aspirin for primary prevention of cardiac events

Use with caution in adults ≥80 years old.

 

Lack of evidence of benefit versus risk in individuals ≥80 years old.

 

QE=Low; SR=Weak

Dabigatran

Use with caution in adults ≥75 years old or if CrCl <30 mL/min.

 

Increased risk of bleeding compared with warfarin in adults ≥75 years old; lack of evidence for efficacy and safety in patients with CrCl <30 mL/min

 

QE=Moderate; SR=Weak

Prasugrel

Use with caution in adults ≥75 years old.

 

Greater risk of bleeding in older adults; risk may be offset by benefit in highest-risk older patients (eg, those with prior myocardial infarction or diabetes).

 

QE=Moderate; SR=Weak

Antipsychotics

Carbamazepine

Carboplatin

Cisplatin

Mirtazapine

SNRIs

SSRIs

TCAs

Vincristine

Use with caution.

 

May exacerbate or cause SIADH or hyponatremia; need to monitor sodium level closely when starting or changing dosages in older adults due to increased risk.

 

QE=Moderate; SR=Strong

Vasodilators

Use with caution.

 

May exacerbate episodes of syncope in individuals with history of syncope.

 

QE=Moderate; SR=Weak

Table 3 Abbreviations: CrCl, creatinine clearance; SIADH, syndrome of inappropriate antidiuretic hormone secretion; SSRIs, selective serotonin reuptake inhibitors; SNRIs, serotonin–norepinephrine reuptake inhibitors; SR, Strength of Recommendation; TCAs, tricyclic antidepressants; QE, Quality of Evidence

 

Numerous studies have helped produce evidence-based practice standards and guidelines for the most commonly misused medications. However, inappropriate prescribing is difficult to manage. Research constantly identifies more problematic medications. In addition, deciding when a medication is inappropriate because of medical condition, genetic predisposition, medical illiteracy, or age is a complex task. Recognizing the serious scope of potential dangers to our elders requires being alert to polypharmacy when caring for older adults.

 

Answer: C

Test Your Knowledge

Inappropriate prescribing is difficult to manage because:

  1. Names of medications are often similar.
  2. Patients don’t follow directions.
  3. There are many medications questionable for older adults.
  4. There are too few drugs from which to choose.

 

Apply Your Knowledge

Q: Where can you go to look up questionable medications based on research studies?
A: The Beers Criteria is found online with lists and updates at
     https://www.guideline.gov/summaries/summary/49933.

Online Resources

 

Video: Beers Criteria (2013)

https://www.youtube.com/watch?v=USCwt-ISCTY

 

Video: Changes to AGS Beers Criteria (2017)

https://www.youtube.com/watch?v=UreJioA0k_I

 

Video: Webinar by NYC Geriatrics Education Project on Medication Management in Older Adults (2013)

https://www.youtube.com/watch?v=ql44IEpyRPc

 

Additional Screening Strategies

Screening strategies include the STOPP and START, which guide healthcare professionals to the right treatments and away from potentially inappropriate prescriptions, respectively, and the ARMOR tool to guide in choosing the correct medication.

STOPP/START

Further attempts to address the complex issue of polypharmacy include START (Screening Tool to Alert doctors to the Right Treatments) and STOPP (Screening Tool of Older Persons Potentially inappropriate Prescriptions) (Hamilton et al., 2011). These criteria were developed to address both errors of omission—failure to use an appropriate drug when indicated, ie, use of an ACE Inhibitor in a diabetic patient for renal protection—and errors of commission.

As a refinement to the Beers criteria, STOPP/START addresses common prescribing patterns seen in older patients, including:

  • Use of a loop diuretic (furosemide) for ankle edema with no clinical evidence of heart failure
  • Use of tricyclic antidepressants (eg, amitriptyline) in a patient with glaucoma (likely to cause exacerbation)
  • Vasodilator drugs (nitroglycerine, various forms) in a patient with persistent postural hypotension (> 20 mmHg drop in systolic blood pressure with position change), increasing the risk of syncope and falls
  • Duplication within a drug class (opiates, others) without first optimizing monotherapy and other choices.

The ARMOR TOOL

The Armor Tool (Hague, 2009) is an additional attempt to consolidate recommendations into a functional and interactive tool easily implemented to address polypharmacy. It uses the mnemonic device ARMOR to help shield patients from inappropriate prescription of ineffective and possibly harmful medications:

  • A: Assess (medications)
  • R: Review (interactions: drug-drug, drug-disease, ADR)
  • M: Minimize (number of drugs and functional status)
  • O: optimize (for renal/hepatic clearance)
  • R: Re-assess (functional/cognitive /clinical status; compliance) to improve functional status (Hague, 2009)

This tool takes into account the patient’s clinical profile and functional status and seeks to balance evidence-based practice guidelines for pharmacologic treatment suggestions with altered physiologic states. ARMOR approaches polypharmacy in a systematic fashion with the goal of restoring and/or maintaining functional status. The ARMOR tool also emphasizes quality of life and patient preferences as key factors to consider when changing or discontinuing medications.

Implementation of ARMOR has the additional advantage of utilizing a multidisciplinary approach including input from physicians, nurses, pharmacists, physical and occupational therapists, and others, in an attempt to consider the patient in their fullest dynamic. It is meant to be used in the geriatric person who is:

  • Receiving 9 or more medications
  • Seen for an initial assessment
  • Being evaluated for falls/behaviors
  • Being admitted for rehabilitation

 

 

Apply Your Learning

Try to use the BEERS criteria or ARMOR mnemonic this week on one of your patients, (if you don’t already) to assess for medication safety.

 

Online Resources

Youtube: ARMOR: An Interdisciplinary Approach to Drug Safety

https://www.youtube.com/watch?v=sUM9BZy8iUk

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