Medication Use in the Elderly

1. See Also
   1. Polypharmacy
   2. Drug-Drug Interactions in the Elderly
2. Adverse Effects: Predictors of adverse drug effects in elderly
   1. Age 85 years or older
   2. Multiple chronic medical conditions (6 or more)
   3. Creatinine Clearance <50 ml/min
   4. Low Body Mass Index
   5. Polypharmacy
      1. Medications number nine or more
      2. More than 12 medication doses daily
   6. References
      1. Fouts (1997) Consultant Pharmacist 12:1103-11
3. Management: Methods to improve medication compliance
   1. Reduce number of daily doses (once daily is best)
   2. Time doses to meal times
   3. Establish partnerships to ensure compliance
      1. Patient
      2. Family (educate on indications and adverse effects)
      3. Pharmacists
      4. Home health aids
   4. Use devices that aid taking of medication
      1. Pill boxes and pill calendars
      2. Label containers with large type
      3. Pill containers should open easily
      4. Keep accurate medication list
   5. Ensure easy access to medications
      1. Affordability
      2. Medication delivery
   6. Evaluate for patient factors affecting compliance
      1. Dementia
      2. Major Depression
4. Medications: To use lower dosages (decreased clearance)
   1. Decreased renal clearance in the elderly
      1. Aminoglycosides
      2. Vancomycin
      3. Fluoroquinolones
      4. Penicillins
      5. Imipenem
      6. Digoxin (limit dose to 0.125 mg/day, consider qod)
      7. ACE Inhibitors
      8. Beta Blockers (Atenolol, Nadolol)
      9. Sotalol
      10. Glyburide
      11. Ranitidine, Cimetidine, Famotidine
      12. Lithium
   2. Decreased hepatic clearance in the elderly
      1. Benzodiazepines
      2. Calcium Channel Blockers
      3. Lidocaine
      4. Phenytoin
      5. Celecoxib (Celebrex)
      6. Theophylline
      7. Imipramine or Desipramine, Trazodone
      8. Isoniazid
      9. Procainamide
5. Medications: Avoid in age >65 - Short List (Beer's List)
   1. Sedating Antihistamines (e.g. Diphenhydramine)
   2. Sedative-Hypnotics (e.g. Diazepam)
   3. Sedating Antidepressants (e.g. Amitriptyline)
   4. Antispasmodics (e.g. Oxybutynin, dicyclomine)
   5. Fick (2003) Arch Intern Med 163:2716
6. Medications: Avoid in age >65 - Long List
   1. Neuropsychiatric Agents and Effects
      1. Anticholinergic Agents (see Antihistamines, Antidepressants, Benzodiazepines below)
      2. Antidepressants
         1. Prozac (long half-life, other SSRIs are safer)
         2. Agents that are sedating (Elavil, Doxepin, Imipramine)
            1. Amitriptyline is highly anticholinergic
            2. Alternatives for pain: Pamelor, Neurontin, Lyrica
      3. Antihistamines that are sedating (Benadryl, Periactin, Atarax, Tylenol PM)
         1. Use second generation Antihistamines instead
         2. Avoid Antihistamines for Insomnia management
      4. Barbiturates (e.g. Fiorinal, Nembutal, Seconal)
      5. Benzodiazepines (Librium, Valium, Dalmane, Halcion)
         1. Use Benzodiazepines with caution
            1. Use shorter acting agents (e.g. Ativan, Restoril)
            2. Use low doses (<3 mg Ativan, <15 mg Restoril)
         2. Increased risk of physical performance decline
         3. Gray (2003) J Am Geriatr Soc 51:1563-70
      6. Meprobamate (addictive and sedating)
      7. Stimulants: Amphetamines and Methylphenidate (Ritalin)
      8. Skeletal Muscle Relaxants (e.g. Flexeril, Soma, Robaxin, Norflex)
      9. Thioridazine (Mellaril)
   2. Cardiovascular agents
      1. Amiodarone: Risk of QT Prolongation and Torsade de Pointes
      2. Disopyramide (Norpace): Anticholinergic, risk of Congestive Heart Failure
      3. Methyldopa
      4. Reserpine
      5. Ticlopidine
   3. Endocrine agents
      1. Chlorpropamide (Diabinese)
      2. Desiccated Thyroid (Armour Thyroid)
      3. Methyltestosterone (Provokes BPH)
   4. Pain medications
      1. Meperidine (Demerol)
      2. Propoxyphene (Darvon)
      3. Pentazocine (Talwin)
      4. NSAIDs
         1. Limit to low dose, short duration, short half-life
         2. NSAIDs to avoid completely
            1. Indomethacin (CNS and gastrointestinal effects)
            2. Ketorlac (Toradol)
            3. Long-acting NSAIDs (Feldene, Naprosyn, Daypro)
   5. Gastrointestinal and Genitourinary agents
      1. Antiemetics (Phenergan, Tigan)
      2. Gastrointestinal antispasmodics (e.g. Donnatal, Bentyl, Levsin, Clidinium)
      3. Antidiarrheal agents (Lomotil)
      4. Nitrofurantoin (Macrobid, worsens renal insufficiency)
      5. Stimulant Laxatives (worsen bowel function in elderly)
      6. Urinary antispasmodics (Ditropan)
         1. Typically marginal benefit does not outweigh significant anticholinergic effects
         2. Look for other causes of Urinary Incontinence (e.g. cholinesterase inhibitors such as Aricept)
   6. References
      1. Mcleod (1997) CMAJ 156:385-91
7. References
   1. (2011) Presc Lett 18(12): 69
   2. Curtis (2004) Arch Intern Med 164:1621-5
   3. Fick (2003) Arch Intern Med 163:2719-20
   4. Williams (2002) Am Fam Physician 66(10):1917-24