Author: Shannon Pearce, DNP & Michelle Peck, ANP
There are some medications that should be avoided in the elderly altogether, and some that should be avoided in the presence of certain medical conditions. Some are appropriate to use, but with caution in the elderly. Changes brought about by aging make elders more vulnerable to the harmful effects of some medications.
In older adults, the following physiological changes occur with aging:
The central nervous system is more sensitive to the effects of sedating medications such as benzodiazepines. These and anti-cholinergic medications promote delirium. Anti-cholinergic medications also promote sedation, urinary retention, dry mouth, constipation, orthostatic hypotension, and other problems.
|AVOID IF POSSIBLE IN THE ELDERLY|
|first generation (sedating) antihistamines||diphenhydramine
doxylamine (and others)
|sedating and strongly anti-cholinergic; promote delirium, falls, urinary retention, dry mouth, constipation; use of diphenhydramine may be appropriate for acute treatment of severe allergic reactions|
oxybutynin (immediate release)
|sedating and strong anti-cholinergic properties; promote delirium, falls, urinary retention, dry mouth, constipation; use of hyocyamine, scopolamine, and belladonna alkaloids to dry secretions in palliative medical care may be appropriate|
nortriptyline (and others)
|avoid in the elderly; sedating and strong anti-cholinergic properties promote delirium, falls, urinary retention, constipation, and orthostatic hypotension|
|Anti-cholinergic antiparkinson agent||benztropine
|avoid due to sedation, anti-cholinergic properties; not recommended for prevention of antipyramidal side effects from antipsychotic medications and better medications available for Parkinson|
metaxalone (and others)
|avoid in the elderly due to sedation and anti-cholinergic properties; questionable effectiveness in tolerable doses, and promotes delirium, sedation, and falls|
chlorazepate (and others)
|avoid in the elderly for control of delirium, sleep disorders, or agitation; elders are more sensitive to the delirium promoting and fall promoting side effects of these medications; may be appropriate for some conditions such as alcohol withdrawal, or benzodiazepine withdrawal|
|Non-benzodiazepine hypnotics||Zolpidem (and others)||Avoid due to sedation; promotes delirium, falls, and fractures in the elderly like the benzodiazepines do|
|Antipsychotic agents (atypical and conventional)||Haloperidol
Risperidone (and others)
|Because of increased risk of stroke and death, avoid for behavioral problems in the elderly unless non-pharmacologic measures have failed and the patient is a risk to themselves or others|
|Alpha 1 blockers||doxazosin
|avoid use as antihypertensive due to high risk of orthostatic hypotension and better agents are available|
|CNS acting alpha agonist hypotensive agents||clonidine
|associated with bradycardia, orthostatic hypotension, sedation, delirium, depression; avoid methyldopa and clonidine should not be first-line for hypertension|
|cardiac glycoside||digoxin over 0.125mg daily||Higher doses used in heart failure increases risk of toxicity without adding benefit; reduced renal function may increase risk of toxicity|
disopyramide (and others)
|risk – benefit analysis favors rate control over rhythm control in most older adults; amiodarone associated with thyroid problems, pulmonary problems and QT prolongation; disopyramide may have a negative ionotropic effect and may precipitate heart failure, it is also anticholinergic|
|Non-COX selective NSAIDS||Aspirin > 325mg/day
Indomethacin (and others)
|Avoid chronic use unless other measures fail and can use PPI with it; risk of GI bleeding, reduced renal function, exacerbation of heart failure|
|Long acting sulfonylureas||Chlorpropamide
|Avoid in the elderly because of increased risk of prolonged hypoglycemia|
|a urinary anti-infective agent||nitrofurantoin||contraindicated in those with creatinine clearances below 60ml/min because of failure to reach therapeutic concentrations in the urine and increased risk of nerve and liver toxicity|
Table adapted from: Identifying Medications that Older Adults Should Avoid or Use with Caution: the 2012 American Geriatrics Society Updated Beers Criteria. Retrieved from http://www.americangeriatrics.org/files/documents/beers/BeersCriteriaPublic Translation.pdf
American Society of Health-System Pharmacists (2013). AHFS Drug Information. Bethesda, Maryland: American Society of Health-System Pharmacists.
Avorn, J., (Ed.), (2003). Principles of pharmacology. Geriatric Medicine: An Evidence Based Approach, 4th Ed. New York, NY: Springer-Verlag; 2003:127.
Expert Panel. American Geriatrics Society (2012). Updated Beers Criteria for potentially inappropriate medication use in older adults. Journal of American Geriatric Society; 60(4):616-31.
O'Mahoney, D., & Gallagher, P.F. (2008). Inappropriate prescribing in the older population: Need for new criteria. Age and Ageing; 37(2):138-141.