Potentially Inappropriate Medication Use in Older Adults 2015 Latest Research

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1 Home Resources Potentially Inappropriate Medication Use in Older Adults 2015 Resources Potentially Inappropriate Medication Use in Older Adults 2015 Latest Research Drugs and Categories of Drugs What these drugs are Why these drugs may be Recommendations commonly used to treat inappropriate for older adults Anticholinergic drugs These drugs can cause numerous side effects in older adults including confusion, sleepiness, blurred vision, difficulty urinating, dry mouth, and constipation. "First-Generation" Antihistamines Used for allergies, hives and These drugs cause many side effects in Brompheniramine Carbinoxamine Chlorpheniramine Clemastine Cyproheptadine Dexbrompheniramine Dexchlorpheniramine eczema, and as sleep aids. They are commonly included in over-the-counter cough, cold, and sleep aid remedies. older adults, including confusion, drowsiness, blurred vision, difficulty urinating, dry mouth, and constipation. Safer medications are available. Use of diphenhydramine in special situations, such as for treating severe allergic reactions, may be appropriate. "Second- and Third-Generation" Antihistamines such as loratadine (Claritin), fexofenadine (Allegra), cetirizine (Zyrtec), and desloratadine (Clarinex) are not considered "drugs to avoid." Dimenhydrinate Diphenhydramine (oral) Doxylamine Hydroxyzine

2 Meclizine Promethazine Triprolidine Antiparkinsonian drugs Used to treat Parkinson's There are other medications that are Benztropine (oral) disease and related health usually more effective for Parkinson's Trihexyphenidyl problems. disease and related disorders. The drugs should not be used for treating side effects of other medications; for example, abnormal movements caused by antipsychotic medications. Antispasmodic medications Used to relieve intestinal It is not clear whether these drugs are Atropine (excludes cramps or spasms. effective. They have side effects including ophthalmic) confusion, drowsiness, blurred vision, Belladonna alkaloids difficulty urinating, dry mouth, and Clidinium- constipation. chlordiazepoxide Dicyclomine Hyoscyamine Propantheline Scopolamine Drugs to reduce the risk of blood clots (Antithrombotics) Dipyridamole, oral short-acting (does not apply to the extended-release combination with aspirin) Used to reduce blood clots. Dipyridamole can increase the chance of dizziness, fainting, and falling. More effective alternatives are available. Use of dipyridamole in its intravenous form acceptable for use in cardiac stress testing. Ticlopidine

3 Drugs used to treat infections (Antibiotics) Nitrofurantoin Used to treat urinary tract infections. This drug may cause side effects that affect the lungs and other organs. Safer medications are available. Avoid daily use over many months to suppress urinary infections. Short-term use, for example to treat individual episodes of urinary infection, is reasonable. Also avoid use in older adults with moderately severe decreases in kidney function. Drugs for disorders of the heart and blood vessels Peripheral Alpha-1 blockers Used to treat the prostate, When used to treat blood pressure, Avoid using to treat high blood pressure. Doxazosin also sometimes prescribed alternative treatments provide better Use to treat urinary symptoms from an Prazosin for high blood pressure. results with lower risks. enlarged prostate is reasonable. Terazosin Central alpha blockers (Alpha Used to treat high blood These drugs may cause a slow heartbeat Clonidine should not be a first-choice agonists) pressure, and sometimes for and dizziness. They are not recommended treatment for high blood pressure. The Clonidine other conditions. for routine treatment of high blood other drugs on the list should be avoided. Guanabenz pressure. Guanfacine Methyldopa Reserpine at doses greater than 0.1 milligrams daily Disopyramide Used to treat abnormal heart This drug may cause heart failure in older rhythms. adults. Potential side effects include confusion, drowsiness, blurred vision, difficulty urinating, dry mouth and constipation. Other antiarrhythmic drugs

4 are preferred. Dronedarone Used to treat abnormal heart There is a higher risk of bad outcomes Avoid in older adults with persistent atrial rhythms. from this drug in people with persistent fibrillation or who have severe or recently atrial fibrillation or who have severe or worsened heart failure. recently worsened heart failure. Digoxin Used to treat atrial fibrillation In older patients with atrial fibrillation and Avoid as first choice for treatment of atrial and heart failure. heart failure, there are more effective and fibrillation or heart failure. If used, avoid safer alternatives. In heart failure, higher doses higher than mg per day. doses may increase risk of toxicity without providing additional benefit. Dose reduction is also important in older adults with reduced kidney function. Nifedipine, immediate release Used to treat high blood This drug may cause dangerously low pressure. blood pressure and can cause heart problems. The long-acting (once-daily) form of Nifedipine is reasonable to use. Amiodarone Used to treat abnormal heart Amiodarone frequently causes serious Avoid as first choice for treating most older rhythms. side effects including thyroid, lung, and adults with atrial fibrillation. It may be a eye problems. reasonable first choice in older adults with atrial fibrillation who also have heart failure or an enlarged heart (known as "left ventricular hypertrophy"). Drugs affecting the brain and nervous system Certain Antidepressants, alone or in Used to treat depression, Potential side effects include confusion, combination: insomnia, and nerve pain. drowsiness, blurred vision, difficulty Amitriptyline urinating, dry mouth and constipation. Amoxapine Clomipramine Despiramine These drugs can also cause a drop in blood pressure and dizziness when you stand up. Safer medications are available.

5 Doxepin at doses of more than 6 milligrams per day Imipramine Nortriptyline Paroxetine Protriptyline Trimipramine Antipsychotic drugs Often used to treat behavioral problems in older adults with dementia. Also used for other mental health conditions. These drugs increase risk of stroke and death in older adults with dementia. Avoid using these drugs to treat behavioral problems in older people with memory disorders unless non-drug options haven't worked and the person is a threat to him/herself or others. These drugs may be acceptable for shortterm use to help with nausea and vomiting during chemotherapy, and in special cases of severe mental illness. Barbiturates Used to treat anxiety and These drugs can be highly addictive and Short- and intermediate-acting Amobarbital sleep disorders. have a higher risk of overdose even at low doses. Butabarbital Butalbital Mephobarbital Pentobarbital Phenobarbital Secobarbital Benzodiazepines Short- and intermediate-acting: Often used to treat anxiety and insomnia. Also used Older adults are especially sensitive to these medications. These drugs may Avoid benzodiazepines (all types) except in the specialized circumstances listed below.

6 Alprazolam Estazolam Lorazepam Oxazepam Temazepam Triazolam for other conditions including epilepsy and as a relaxant during medical procedures. increase risks of cognitive impairment, delirium, falls, fractures, and car accidents in older adults. These drugs may be appropriate in certain circumstances including the treatment of seizures, certain specialized sleep disorders, severe anxiety disorders, withdrawal from benzodiazepine drugs and alcohol, at the time of medical and surgical procedures, and in end-of-life care. Long-acting: Chlorazepate Chlordiazepoxide (alone or in combination with -amitriptyline or clidinium) - Clonazepam Diazepam Flurazepam Quazepam Meprobamate Used to treat anxiety. This drug is highly addicting and also causes sleepiness. Non-benzodiazepine, Used for insomnia. These medications have harmful effects benzodiazepine receptor agonist similar to the benzodiazepines (listed hypnotics above). They provide only minimal Eszopiclone improvement in sleep for many older Zolpidem adults. Zaleplon Ergoloid mesylates (dehydrogenated Used to relax and widen These drugs are not very effective. ergot alkaloids) Isoxuprine blood vessels for better circulation.

7 Medications for hormonal conditions Androgens Used to treat men with These drugs may cause heart problems. Use only for moderate to severe declines Methyltestosterone symptoms of low They also may promote growth of prostate in natural testosterone production, as Testosterone testosterone. cancer in men with this condition. determined by laboratory tests and with symptoms of low testosterone. Avoid using in men with prostate cancer. Desiccated thyroid Used to treat underactive This drug may cause heart problems. thyroid. There are safer alternatives available. Estrogens with or without progestins Used to treat women with These hormones may increase risks of Avoid pills and skin patches. Vaginal hot flashes and vaginal breast cancer and cancer of the lining of estrogen creams can be used at low doses atrophy and dryness. the uterus. They don't appear to help to relieve pain during sex and other vaginal protect women from heart disease or loss problems, and to prevent urinary tract of cognitive (thinking) ability in later life. infections. Estrogen cream inserted into the vagina can help vaginal dryness and is safe in women with breast cancer, especially if low doses are used. Growth hormone Sometimes used as an anti- Growth hormone has many side effects, Avoid, except in people who have had their aging therapy. including joint pain, swelling, enlargement pituitary gland removed. of breast tissue in men, and carpal tunnel syndrome. It may also increase the chance of getting diabetes. Insulin, sliding scale Used for diabetes. "Sliding scale" insulin refers to the use of short-acting insulin, which is dosed depending on blood sugar at the time, without also using a long-acting insulin given at a regular dose each day. Using the "sliding scale approach is not very effective and can increase the chance of

8 dangerously low blood sugar. Megestrol Used for unintentional This drug is not very effective at helping weight loss. people gain weight, and may increase the chance of blood clots and death. Sulfonylureas, long-duration Used for diabetes. Both medications can cause dangerous Chlorpropamide low blood sugar and other side effects in Glyburide older adults. Safer medications are available. Medications for gastrointestinal problems Metoclopramide Used to treat slow stomach This medication may cause shakiness, Avoid, except for gastroparesis, a condition emptying (gastroparesis), sleepiness, and uncontrollable abnormal in which the stomach is very slow to empty certain types of nausea, body movements. Frail older adults may its contents. vomiting, and heartburn, and be more likely to get these effects. migraines. Mineral oil, taken by mouth Used for constipation. When taken by mouth, mineral oil may be accidentally swallowed into the lungs and cause pneumonia. Safer medications are available. Proton pump inhibitors Used to treat gastroesophageal reflux (heartburn) and to protect against bleeding stomach ulcers. These medications can increase the risk of developing C. difficile colitis, a dangerous intestinal infection. They can also increase the risk of bone loss and fractures. Many older adults get started on these medications and never stop, even when Avoid daily use for more than 8 weeks unless there is a strong reason to continue. Strong reasons to continue include protection for people at higher risk of bleeding stomach ulcers, for example due to regular use of non-steroidal antiinflammatory drugs. they don t need the medication any more. Other strong reasons include treatment of esophageal irritation, and treatment of gastroesophageal reflux (heartburn) in people who need continuing use of these medications to control their symptoms.

9 Pain medications and muscle relaxants Meperidine Used to treat pain. Not a very effective pain reliever for older adults, and often has toxic effects on the brain. Safer medications are available. Avoid, especially for in older adults with chronic kidney disease. Non-COX-selective NSAIDs, oral: Used to treat pain and These painkillers increase the risk of Avoid regular long-term use, unless other Aspirin at doses inflammation. bleeding stomach ulcers. People above alternatives are not effective and the older above 325 mg per day age 75 years old or who use blood thinners or oral steroids are at especially adult can take a stomach-protecting drug such as a proton-pump inhibitor or Diclofenac high risk. misoprostol. These stomach-protecting Diflunisal drugs reduce but do not eliminate the risk Etodolac of stomach bleeding. Fenoprofen Ibuprofen Ketoprofen Meclofenamate Mefanamic acid Meloxicam Nabumetone Naproxen oxaprozin Prioxicam Sulindac Tolmetin Indomethacin Ketorolac (including Used to treat pain and These NSAIDs have particularly high rates when given through a needle) inflammation. of serious side effects, including stomach bleeding. Indomethacin is more likely than other NSAIDs to cause headaches, dizziness, and other adverse effects on the nervous system. Kertorolac has

10 0 particularly high rates of serious side effects, including stomach bleeding. Pentazocine Used to treat moderate to This opioid (narcotic) drug can cause severe pain. confusion and hallucinations more than other opioids. Safer alternatives are available. Skeletal muscle relaxants Often used to treat low back Most muscle relaxants have high risk of Carisoprodol pain and muscle spasms. causing side effects in older adults, Chlorzoxazone Cyclobenzaprine Metaxalone including sedation and increased risk of fractures. Their effectiveness at doses commonly used is questionable. Methocarbamol Orphenadrine Drugs for the urinary tract Desmopressin Used to treat nighttime High risk of causing dangerously low Avoid as treatment for nighttime urination. urination and certain causes sodium levels in the blood. Safer of excessive urination. alternatives are available.

Quality ID #238 (NQF 0022): Use of High-Risk Medications in the Elderly National Quality Strategy Domain: Patient Safety

Quality ID #238 (NQF 0022): Use of High-Risk Medications in the Elderly National Quality Strategy Domain: Patient Safety 2018 OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY MEASURE TYPE: Process DESCRIPTION: