Medication Prescribing for Older Adults

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1 REVIEW Medication Prescribing for Older Adults Barbara Roehl, MD, MBA, Amy Talati, PharmD, and Susan Parks, MD The frequency of chronic illness increases with age. As a result, elderly persons receive a disproportionate number of medications when compared to the general population. While many medications are safe and effective in older persons, this population is at increased risk for adverse drug events and drug interactions due to altered pharmacokinetics and polypharmacy. Inappropriate prescribing, underprescribing, use of nonprescription medications, and poor adherence to medications also put these individuals at risk. In order to improve health outcomes, providers need to find a balance between prescribing medically necessary and safe medications and preventing adverse drug events. This will require the health care team to address issues of polypharmacy, restrict prescribing to medications that pose the least risk for older persons, and eliminate barriers to medication adherence. (Annals of Long-Term Care: Clinical Care and Aging 2006;14[6]:33-39) Dr. Roehl and Dr. Parks are in the Department of Family and Community Medicine, and Dr. Talati is in the Department of Health Policy, Thomas Jefferson University, Philadelphia, PA. INTRODUCTION Persons over age 65 represent about 12% of the population, yet they receive over 25% of all prescribed drugs in the United States. 1 One national survey showed that 50% of community-dwelling elderly over age 65 used five or more prescription and over-the-counter (OTC) medications per week, and 12% used 10 or more. 2 Thirty percent of hospital admissions in elderly patients can be linked to adverse drug events, defined as noxious and unintended patient events (ie, symptoms, signs, and laboratory abnormalities) caused by a drug. The most common cause of adverse drug events is inappropriate medication prescribing. 3 Medications are deemed to be inappropriate if they pose more risk than benefit to the individual. The risk of adverse drug events resulting from inappropriate medication prescribing range from weakness, to falls and fractures, to even life-threatening events. 4,5 Studies show prevalence of at least one inappropriate medication being prescribed for up to 40% of nursing home residents and 21% of community-dwelling elderly. 6 Underprescribing of medically indicated drugs such as low-dose aspirin can also place a person at risk. Suboptimal prescribing has been shown to adversely impact outcomes for many diagnoses, including cardiovascular disease, stroke prevention, and osteoporosis prevention. 7-9 Underuse of medications can result from fear of prescribing a medication that might lead to adverse events, attempts to prevent polypharmacy, economic barriers, or lack of patient adherence to medications. 10 Thus, providers must balance the pros and cons of each medication that they prescribe for their older patients. Achieving adherence to needed medications can be challenging. 11 Factors affecting adherence that are disproportionately represented in the elderly include polypharmacy, polydosing, cognitive deficits, and impaired physical function. Lack of adherence to prescribed medicines increases the likelihood of an adverse outcome, including treatment failure, medication overdose, and avoidable hospitalization Annals of Long-Term Care / Volume 14, Number 6 / June 2006

2 PHYSIOLOGIC CHANGES WITH AGING Pharmacokinetics refers to drug absorption, distribution, metabolism, and elimination. While drug absorption is typically slowed but complete in the elderly, aging has profound affects on distribution, metabolism, and excretion of drugs. Volume of distribution of medications is decreased by the reduced muscle mass and total body water typical of aging. As a result, medications will attain higher plasma concentrations if they distribute into muscle or total body water. This is particularly important for medications that require loading doses. Another typical change with aging is increased fat mass, which acts as a depot for lipophilic drugs such as benzodiazepines and amiodarone. 13 Drug potency and duration of action are often increased in the elderly due to decreased renal and hepatic function. The Cockroft-Gault formula should be used to estimate creatinine clearance in older adults when prescribing a new medication or when changing doses: Creatinine clearance = (140-age) x weight (kg) (x 0.85 for women) 72 x serum creatinine Serum creatinine does not accurately reflect renal function in older persons because of decreased lean body mass. 14 COMMON CHARACTERISTICS OF OLDER ADULTS WITH MEDICATION-RELATED PROBLEMS In addition to physiologic changes of aging, the accumulation of medical diagnoses also contributes to medication-related problems. Certain patient characteristics should prompt the provider to pay special attention to potential prescribing problems. Persons at particular risk are over age 85, take nine or more medications or more than 12 doses of medication per day, or have at least six active chronic medical diagnoses, especially renal impairment. 15 MEDICATIONS COMMONLY LEADING TO ADVERSE EVENTS: BEERS CRITERIA The Beers criteria is one of the most widely used consensus criteria for appropriate medication use in the elderly patient population. 16 Originally developed in 1991 for the nursing home setting, the criteria were updated in 1997 to include all geriatric patients regardless of setting. 17 The Beers criteria were last updated in 2003 to include new evidence on the pharmacologic changes associated with aging and its impact on safety and effectiveness. 18 The list of criteria was developed by a national panel of experts in geriatric care and pharmacology to include 48 medications or classes of medications to avoid in individuals age 65 or older, and 20 medications that should not be used in older persons known to have specific conditions. Drugs are deemed inappropriate for use among the elderly population due to: Lack of proven efficacy, high likelihood of adverse drug effects, potential for severe effects, or a high potential for an interaction with another medication or class of drug Specific medications or classes of medications that should not be used routinely in elderly patients with specific disease states Specific medications that pose a serious risk of causing an adverse event when safer alternatives are available High doses of certain medications Excessive dosing frequencies, which complicate compliance for elderly patients Extended duration of medications that were intended to be used for a limited time Table I, adapted from the 2003 Beers criteria, details common medications that can potentially lead to a serious adverse event in elderly patients. Most of the medications listed in the table are to be avoided in those over the age of 65, while others such as short-acting benzodiazepines, fluoxetine, and digoxin are appropriate at lower doses. Many drugs classified as inappropriate for elderly persons produce minor anticholinergic effects such as dry mouth, constipation, 34 Annals of Long-Term Care / Volume 14, Number 6 / June 2006

3 Table I: Drug Therapy with Potential for Severe Adverse Outcomes Medication Class Medication Summary of Prescribing Concerns for the Elderly Anticholinergics methocarbamol Very anticholinergic and produce toxic effects in the carisoprodol elderly, including cardiac arrhythmia, dry mouth and chlorzoxazone eyes, and urinary retention. Best to avoid in the elderly, metaxalone especially for long-term use. Limit use for 7 days or less, cyclobenzaprine and not more frequently than every 3 mo. oxybutynin dicyclomine hyoscyamine belladonna chlorpheniramine hydroxyzine cyproheptadine promethazine Psychotropics amitriptyline Strong anticholinergic and sedating properties. chlordiazepoxide-amitriptyline perphenazine-amitriptyline fluoxetine Long-acting benzodiazepines chlordiazepoxide, chlordiazepoxideamitriptyline, clidiniumchlordiazepoxide, diazepam, flurazepam Short-acting benzodiazepines at doses greater than: lorazepam, 3 mg; oxazepam, 60 mg; alprazolam, 2 mg; temazepam, 15 mg; and triazolam, 0.25 mg diphenhydramine meprobamate doxepin Long half-life and risk of produce excessive CNS stimulation, sleep disturbances, and agitation at doses greater than 20 mg/day. Long half-life in the elderly. Produce prolonged sedation, increased risk of falls and fractures. Smaller doses are effective and safer in elderly persons because of increased sensitivity. May cause confusion and sedation. Should NOT be used as a hypnotic. Use smallest dose possible if using to treat an allergic reaction. Highly addictive and sedating anxiolytic. Strong anticholinergic and sedating properties. Not a common antidepressant of choice for the elderly. Analgesics indomethacin Produces many CNS side effects and risk of GI bleed. ketorolac Avoid immediate and long-term use in elderly since many have asymptomatic GI conditions. continued 35 Annals of Long-Term Care / Volume 14, Number 6 / June 2006

4 continued Medication Class Medication Summary of Prescribing Concerns for the Elderly Analgesics Long term use of full dosage, Potential to produce GI bleeding, renal failure, high (continued) longer half-life, non-cox-selective blood pressure, and heart failure. NSAIDs: naproxen, oxaprozin, and piroxicam meperidine propoxyphene pentazocine Not an effective oral analgesic. CNS effects, breakdown product can cause convulsions. Limited advantage of acetaminophen, but has the adverse effects of other narcotic drugs. Causes more CNS side effects than other narcotic drugs, including confusion and hallucinations. Cardiovascular digoxin >0.125mg/day Avoid doses > mg/day in the elderly because of Medications decreased renal clearance, except when treating atrial arrhythmias. clonidine amiodarone disopyramide doxazosin methyldopa methyldopa/hydrochlorothiazide Potential for hypotension and CNS effects. Lack of efficacy in older adults and risk of torsades de pointes. Strongly anticholinergic. Negative inotrope that may induce heart failure. Potential for hypotension, dry mouth, and urinary problems. May cause bradycardia and exacerbate depression. Alternative antihypertensives are preferred. Miscellaneous ticlopidine Not better than aspirin in preventing clotting, and Medications considerably more toxic. chlorpropamide trimethobenzamide barbiturates (all except phenobarbital) Prolonged half-life in the elderly, which may prolong hypoglycemia. Causes syndrome of inappropriate antidiuretic hormone. Not a very effective antiemetic. Can cause extrapyramidal side effects. Higher incidence of side effects when compared to most other sedatives and hypnotics used in the elderly. Highly addictive. Can be used to control seizures. Adapted from 2003 Beers Criteria and blurred vision. More serious anticholinergic symptoms such as hypotension, cardiac arrhythmias, urinary retention, and confusion can also occur. In general, agents that cause anticholinergic properties should be avoided in this vulnerable population. 19 In addition to anticholinergic agents, the Beers criteria identify several commonly used medications that place patients at increased risk for incurring adverse events. 36 Annals of Long-Term Care / Volume 14, Number 6 / June 2006

5 Examples of these medications include long-acting benzodiazepines, amiodarone, doxazosin, diphenhydramine, meperidine, propoxyphene, and long-term use of full dose nonsteroidal anti-inflammatory drugs (NSAIDs) APPROACH TO MEDICATION PRESCRIBING AND MANAGEMENT FOR OLDER PERSONS Polypharmacy and inappropriate medication prescribing are key issues for older persons. Reduction of medication-related problems in the elderly can take place at the point of initial prescribing, when reviewing ongoing medications, and when determining whether to stop medications. Involvement of the entire health care team, including the pharmacist and caregiver, can play a role in medication prescribing and adherence. Medication Prescribing and Review At the point of initial prescribing, it is important to avoid using medications that are potentially inappropriate in the elderly. Reliance on the Beers criteria can help guide use of medications associated with the least risk for the elderly. The Beers criteria can be accessed online at pdf or downloaded to a PDA at freewarepalm.com/medical/beers list.shtml. When starting a new medication, use the lowest possible dose and titrate slowly. A rule of thumb to help prevent potentially harmful iatrogenic illness is to initiate a medication at one-third to one-half of the manufacturer s recommended dosage. 23 Whenever possible, once-a-day dosing is preferred since complex dosing makes it difficult for patients to adhere to medications. 24 Table II describes a general approach to medication prescribing in the elderly. Healthcare providers have an opportunity at every visit to review and withdraw medications as needed. Healthy People 2010, a national initiative to improve the health of Americans, calls for regular medication reviews in older patients. 25 To assist in the medication review for noninstitutionalized patients, individuals should bring all of their medications in a bag to each office visit. 26 Likewise, for patients who may be cognitively impaired, it is important to review the medications with the person responsible for administering them. 27 Certain circumstances can alert providers to consider discontinuing medications. When a patient presents with new signs or symptoms, consider whether the symptoms might be a result of current drug therapy. If a medication is being added to combat the side effects of previously prescribed medications, consider whether the first medication truly warrants use. If a medication is not improving patient health or comfort, it should be discontinued. 28 Be attuned to unnecessary medications that may linger following transitions in level and site of care. Multidisciplinary geriatric assessments can reduce inappropriate drug use and underuse in the inpatient and outpatient setting. 29 Table II: Approach to Medication Prescribing in the Elderly Use the least possible number of medications and the simplest possible dosing regimen. Start at the lowest drug dose, and titrate slowly. Avoid medications known to be potentially harmful in the elderly; use the Beers criteria. Match each medication with its diagnosis, and eliminate those without a clear indication. Do not add a medication to combat the side effects of another one. Eliminate medications that are having no benefit. When multiple medications are used for one diagnosis, consider maximizing doses and decreasing the number of medications. Eliminate all PRN medications that have not been used in the past month. Write a time-limited prescription. Rule out side effects as a cause of new symptoms such as confusion or memory loss. Use a team approach; involve the family, caregiver, pharmacist. Use of OTC and Complementary Medications in the Older Adult The use of OTC agents and herbal preparations adds to the challenge of prescribing appropriate medications for older patients. The presence of polypharmacy puts elderly persons at risk for herb-drug interac- 37 Annals of Long-Term Care / Volume 14, Number 6 / June 2006

6 Table III: Tips to Improve Patient Understanding and Medication Adherence Have patients bring all medication bottles to each visit. Include the diagnosis on the prescription so it will appear on the medication bottles. Have the patient use only one pharmacy so the pharmacist can help identify duplicate medications from different providers and monitor for possible drug interactions. Have visiting nurses check medications. Use reminder devices such as pillboxes; some pharmacies will pre-package pills. Write down medication directions. tions. Over the past decade, the use of OTCs has been increasing, with 31-96% of adults age 65 and older using them. The most commonly used classes of OTC medications include analgesics, laxatives, and vitamins and minerals. 30 A national survey found that 12.9% of elderly persons had used an herbal product in the last year, such as glucosamine, echinacea, and garlic. Less than half of users discussed their herbal supplements with providers. 31 Due to the high prevalence of these agents in the elderly population, providers need to include nonprescription medications in the medication review. Prescribing Issues Unique to the Long-Term Care Setting Healthcare providers face a unique set of challenges when prescribing medications to older residents in the long-term care setting. 32 In this highly regulated setting, use of more than nine medications, including OTC products such as vitamins and calcium supplements, is considered polypharmacy. 33 These residents are at high risk for hospitalization and often have multiple specialists involved in their care. Transitions of care and multiple prescribers pose risks to maintaining an accurate and appropriate list of medications. For example, upon return from a hospitalization, newly prescribed proton pump inhibitors or histamine blockers should be discontinued unless there is a clear indication. Likewise, after recovering from a COPD exacerbation, it is important to discontinue any forgotten steroids. Providers need to remember to discontinue medicines not central to patient comfort when the decision for palliative care or hospice is made. 34 Improving Medication Adherence Achieving medication adherence is a particularly important issue for elderly persons who are still managing medications independently. Medication adherence rates are as low as 50% for chronic conditions. 35 Lack of adherence can be attributed to complicated regimens, lack of understanding, physical and cognitive deficits, anticipation of side effects, and financial obstacles. 36,37 A number of strategies can be used to try to improve medication adherence (Table III). Initially and with regimen changes, the patient should be given a complete list of his or her medications, including why they are taking them 38 (Table IV). Coordinate with the caregiver, pharmacy, and other providers. Use of reminder devices such as pillboxes can benefit some patients. 39 If a patient is having adherence issues, a home care consult can help to assess the situation. Broader Strategies to Improve Prescribing In addition to the endeavors of the individual provider, institutions have a role in improving pre- Table IV: Sample Medication Dosing Chart for Patients Medication Dose Breakfast Lunch Dinner Bedtime Reason Prescribed & Special Instructions 38 Annals of Long-Term Care / Volume 14, Number 6 / June 2006

7 scribing and adherence by instituting elder-friendly formularies and protocols. 40 Computerized physician order entry and electronic health records can flag potential medication risks and drug interactions. 41 Challenges beyond the level of the institution are the large number of insurance company formularies, including the new Medicare Part D prescription drug plan. In order to systematically address medication prescribing issues, improved infrastructures within both the office and long-term care settings need to be explored. On a broader level, older persons, including the institutionalized elderly, need to be included in clinical trials to assess safety and efficacy of medications in this population. CONCLUSION Persons over age 65 use more medications than their younger counterparts. The combined effect of aging and polypharmacy places older persons at increased risk for adverse drug events, some of which are preventable. To improve outcomes, it is important to eliminate unnecessary medications and restrict medications to those with proven efficacy and the least chance of adverse drug effects. Using an evidence-based resource such as the Beers criteria can assist in medication prescribing. Caution is advised when prescribing any medication for this vulnerable population. Due to the potential for adverse drug events, the healthcare team needs to regularly review medication regimens and opportunities to withdraw unnecessary medications. At the same time, desire to reduce polypharmacy should not prevent providers from prescribing medications to older persons when they are medically indicated. The quality of care provided and the individual s quality of life may be significantly enhanced by improved prescribing. The authors report no relevant financial relationships. References 1. Lamy PP. Prescribing for the Elderly. Littleton, MA: PSG Publishing Co; Kaufman DW, Kelly JP, Rosenberg L, et al. Recent patterns of medication use in the ambulatory adult population of the United States: The Slone Survey. JAMA 2002;287(3): Naranjo CA, Shear NH, Lanctot KL. Advances in the diagnosis of adverse drug reactions. J Clin Pharmacol 1992;32(10): Beers MH, Ouslander JG, Rollingher I, et al. Explicit criteria for determining inappropriate medication use in nursing home residents. Arch Intern Med 1991;151(9): Hanlon JT, Schmader KE, Kornkowski MJ, et al. Adverse drug events in high risk older outpatients. J Am Geriatr Soc 1997; 45(8): Liu GG, Christensen DB. The continuing challenge of inappropriate prescribing in the elderly: An update of the evidence. J Am Pharm Assoc 2002;42(6): McCormick D, Gurwitz JH, Lessard D, et al. Use of aspirin, beta-blockers, and lipid-lowering medications before recurrent acute myocardial infarction: Missed opportunities for prevention? Arch Intern Med 1999;159(6): McCormick D, Gurwitz JH, Goldberg RJ, et al. Prevalence and quality of warfarin use for patients with atrial fibrillation in the long-term care setting. Arch Intern Med 2001;161(20): Onder G, Pedone C, Gambassi, et al; Investigators of the GIFA Study. Treatment of osteoporosis among older adults discharged from hospital in Italy. Eur J Clin Pharmacol 2001;57(8): Simon SR, Gurwitz JH. Drug therapy in the elderly: Improving quality and access. Clin Pharmacol Ther 2003;73(5): Glazier, RH. Interventions to improve adherence to prescriptions tend to produce only modest benefits. Evidence Based Healthcare 2003;7(2): Col N, Fanale JE, Kronholm P. The role of medication noncompliance and adverse drug reactions in hospitalizations of the elderly. Arch Intern Med 1990;150(4): Bressler R, Bahl JJ. Principles of drug therapy for the elderly patient. Mayo Clin Proc 2003;78(12): Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron 1976;16(1): Fouts M, Hanlon J, Pieper C, et al. Identification of elderly nursing home residents at high risk for drug-related problems. Consult Pharm 1997;12: Simon SR, Chan KA, Soumerai SB, et al. Potentially inappropriate medication use by elderly persons in U.S. Health Maintenance Organizations, J Am Geriatr Soc 2005;53(2): Beers MH. Explicit criteria for determining potentially inappropriate medication use by the elderly. An update. Arch Intern Med 1997;157(14): Fick DM, Cooper JW, Wade WE, et al. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a U.S. consensus panel of experts. Arch Intern Med 2003;163(22): [Erratum in: Arch Intern Med 2004;164(3):298] 19. Monane M, Avorn J, Beers MH, Everitt DE. Anticholinergic drug use and bowel function in nursing home patients. Arch Intern Med 1993;153(5): Gurwitz JH, Field TS, Judge J, et al. The incidence of adverse drug events in two large academic long-term care facilities. Am J Med 2005;118(3): Goulding MR. Inappropriate medication prescribing for elderly ambulatory care patients. Arch Intern Med 2004;164(3): Maio V, Hartmann CW, Poston S, et al. Inappropriate prescribing for elderly patients in two outpatient settings. American Journal of Medical Quality. In press. 23. Carlson JE. Perils of polypharmacy: 10 steps to prudent prescribing. Geriatrics 1996;51(7):26-30, Greenberg RN. Overview of patient compliance with medication dosing: a literature review. Clin Ther 1984;6(5): U.S. Department of Health and Human services. The Healthy People 2010 page. Available at: Accessed February 21, Thomas DR. The brown bag and other approaches to decreasing polypharmacy in the elderly. N C Med J 1991;52(11): Holmes SB, Adler D. Dementia care: Critical interactions among primary care physicians, patients, and caregivers. Prim Care 2005;32(3): Petrone K, Katz P. Approaches to appropriate drug prescribing for the older adult. Prim Care 2005;32(3): Schmader KE, Hanlon JT, Pieper CF, et al. Effects of geriatric evaluation and management on adverse drug reactions and suboptimal prescribing in the frail elderly. Am J Med 2004;116(6): Hanlon JT, Fillenbaum GG, Ruby CM, et al. Epidemiology of over-the-counter drug use in community dwelling elderly. A United States perspective. Drugs Aging 2001;18(2): Bruno JJ, Ellis JJ. Herbal use among US elderly: 2002 National Health Interview Survey. Ann Pharmacother 2005;39(4): Rancourt C, Moisan J, Baillargeon L, et al. Potentially inappropriate prescriptions for older patients in long term care. BMC Geriatr 2004;4: Beyth RJ, Shorr RI. Epidemiology of adverse drug reactions in the elderly by drug class. Drugs Aging 1999;14(3): Brazeau S. Polypharmacy and the elderly. The Canadian Journal of CME 2001;2: Bazian Report. The effects of education on patient adherence to medication. Evidenc-Based Health & Public Health 2005;9(6): Heidenreich PA. Patient adherence: The next frontier in quality improvement. Am J Med 2004;117(2): Shaya FT. Compliance with medicine. Ophtalmol Clin North Am 2005;18(4): Gottlieb H. Medication nonadherence: Finding a solution to a costly medical problem. Drug Benefit Trends 2000;12(6): McDonald HP, Garg AX, Haynes RB. Interventions to enhance patient adherence to medication prescriptions: Scientific review. JAMA 2002;288(22): [Erratum in: JAMA 2003;289(4): Henkel G. Long term care formularies: Good for the patient or the bottom line? Caring Ages 2001;10(2). Available at Accessed February 21, Koppel R, Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA 2005;293(10): Annals of Long-Term Care / Volume 14, Number 6 / June 2006

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