By Alan Lukazewski, R.Ph., CDE
With increased longevity there is a higher number of diseases or conditions that co-exist, also known as co-morbidity. Each condition is associated with a drug treatment and as the number of medications increase, so does the risk for developing an adverse medication event (AME). Fact: While America's senior society (over age 65) comprises only 13% of the population it uses 35% of all medications dispensed, and 21% of all hospital admissions are related to adverse medication events (AME s), of which 50% are thought to be preventable. This article outlines key points to help minimize the risk of developing AME's for individuals over the age of 65.
It has already been determined that many medications are not suitable for use in the elderly due to reduced elimination, altered dynamics in the body, and drug-drug or
drug-disease interactions. This data is useful to assist consumers and practitioners to identify and find suitable drug alternatives that are less likely to cause an AME.
This list identifies drugs that are widely recognized to be unsuitable for many elderly, yet not contraindicated in every case. It also includes medications that are supported by known fact of repeated occurrences and not isolated instances or hypothetical consideration. If you are taking one of these medications, it may be in your best interests to discuss a more suitable alternative with your physician.
Elavil (amitriptyline, antidepressant) - Known to cause intense anticholinergic (ACH) effects in the elderly which can mimic dementia by causing confusion and hallucinations. It can also cause urinary retention, constipation, cardiac disturbances, sedation, dizziness, and aggravate glaucoma. A more suitable antidepressant alternative would be Celexa or Zoloft. However, keep in mind that Elavil in low doses is effective in managing chronic pain caused by neuropathies and is better tolerated at lower doses.
Sinequan (doxepin, antidepressant) - Known to cause intense anticholinergic (ACH) effects in the elderly which can mimic dementia by causing confusion and hallucinations. It can also cause urinary retention, constipation, cardiac disturbances, sedation, dizziness, and aggravate glaucoma. A more suitable antidepressant alternative would be Celexa or Zoloft. However, keep in mind that Sinequan in low doses is effective in managing chronic pain caused by neuropathies and is better tolerated at lower doses.
Indocin (indomethacin, antiarthritic) - Indocin has the most central nervous system (CNS) side effects of all non-steroid anti-inflammatory agents (NSAIDS) including Motrin, Naprosyn and Relafen among many others. These CNS effects can cause extreme sedation, hallucinations and effects on cognition. Indocin is also the most potent NSAID in terms of its risk for causing gastrointestinal ulceration. Its use should be minimized, less than 7 days, for the treatment of acute gout. Suitable alternatives for the management of arthritis include Celebrex or Vioxx, which have less adverse effects on the GI tract and carry minimal risk of causing GI bleeding/ulceration. Over 16,000 American's die each year secondary to the GI bleeding caused by NSAIDS.
Dalmane (flurazepam, hypnotic) - Dalmane is a long-acting hypnotic agent that accumulates in the body with repeated dosing. Due to its long action, the drug accumulates to high levels causing cognitive decline, sedation, dizziness, and falls. This class of drugs, benzodiazepines (BNZD's), is strongly associated with increased falls and fractures. Suitable hypnotic agent alternatives are Ambien or Sonata. However, please note that hypnotic agents should only be used periodically (ideally
Valium (diazepam, anti-anxiety) - Valium is a long-acting anti-anxiety agent that accumulates in the body with repeated dosing. Due to its long action, the drug accumulates to high levels causing cognitive decline, sedation, dizziness, and falls. This class of drugs, benzodiazepines (BNZD's), is strongly associated with increased falls and fractures. A suitable alternative would be Buspar, which has no association with loss of cognition or increase in falls. Ativan or Serax are also safe alternatives for the elderly.
Darvocet (propoxyphene, narcotic analgesic) - Propoxyphene is a narcotic analgesic that is documented to be no more effective than maximum strength Tylenol (acetaminophen); however, has narcotic-like side-effects including sedation, loss of cognition and hallucinations. More suitable alternatives are Tylenol up to 4gm/day or safer a NSAID's as mentioned above.
Benadryl (diphenhydramine, antihistamine/hypnotic) - Benadryl is a potent antihistamine that causes sedation and significant anticholinergic effects such as constipation, urinary retention, confusion, and blurred vision among others. Claritin, a safer allergy medication, is considered to be non-sedating and does not possess strong anticholinergic effects. If Benadryl is used for insomnia, please remember the effects last no more than 3 days yet, its side effects linger. Always consult with your physician or pharmacist on sleep hygiene prior to starting a medication for insomnia.
Lanoxin (digoxin, heart arrhythmia/congestive heart failure) - It is known that the place of Lanoxin in congestive heart failure is now replaced with safer medications. However, Lanoxin still has a place in managing cardiac arrhythmia or conduction disturbances such as atrial fibrillation. However, due to declining kidney function seen with aging, Lanoxin is eliminated less efficiently and tends to accumulate and cause toxicity, which can be fatal. Therefore, it is recommended that doses do not exceed greater than 0.125mg/day, although larger doses may be needed for the management of atrial arrhythmia. Signs to watch out for with Lanoxin toxicity are bluish/yellowish tinted vision, a "halo" around objects, generalized GI disturbances, palpitations, confusion, or hallucinations. Therapy of Lanoxin should be monitored closely via serum Lanoxin levels.
Norpace (disopyramide, antiarryhthmic) - Norpace is used to manage certain heart rhythm disturbances, but has been shown to precipitate congestive heart failure and has significant anticholingeric side-effects. With safer alternatives available, Norpace should be considered a last-line therapy.
Diabenese (chlorpromamide, antidiabetic) — Diabenese, which is eliminated by the kidneys, tends to accumulate in the elderly due to its long duration of action. This may cause prolonged and severe low blood sugar or hypoglycemia. A more suitable alternative is Glucotrol (glipizide).
Diabeta/Micronase Glynase (glyburide, antidiabetic) — Glyburide, which is eliminated by the kidneys, tends to accumulate in the elderly due to its long duration of action. This may cause prolonged and severe low blood sugar or hypoglycemia. A more suitable alternative is Glucotrol (glipizide).
Glucophage (metformin, antidiabetic) - Glucophage is useful in the management of diabetes, but needs to be used with caution in the elderly. Rarely, it is rarely associated with a condition called lactic acidosis, which is fatal 50% of the time. Individuals taking Glucophage with reduced kidney function; CHF; liver disease; alcohol abuse; or surgical procedures involving radio contrast dyes, respiratory insufficiencies, or certain interacting medications are at increased risk for developing lactic acidosis. Maximum doses in the elderly should not exceed 2000mg (2gm) per day. Signs and symptoms of lactic acidosis include fast, shallow breathing, diarrhea, muscle pain or cramping, unusual sleepiness, unusual tiredness or weakness.
Xanax (alprazolam - antianxiety) - Xanax is a short to intermediate-acting BNZD, as compared to Valium. However, even though it is short acting, it is the most potent BNZD available. Thus, physiologic dependence or addiction potential is extremely high and a tolerance level develops. Therefore, long-term use is associated with a need to increase dosing, which also increases the risk for impaired cognition and falls. More suitable BNZD's are Ativan (lorazepam) and Serax (oxazepam). Use of Xanax should be kept short term and intermittent.
Ticlid (ticlopidone, antiplatelet) - Although Ticlid has been useful in reducing incidence of thrombotic events such as stroke or heart attack, it is associated with serious blood disorders. Therefore, using a substitute like Plavix is recommended. (Plavix is also associated with blood disorders but at a much lower rate.)
Bentyl, Urispas, Probanthine, Levsin (multiple names, anticholinergic agents) - These medications are commonly used in bladder conditions such as urinary incontinence. However, they have potent anticholinergic side effects that can cause sedation, confusion, delirium, blurred vision, urinary retention, and dizziness among others. With newer, more tolerable agents available (e.g., Ditropan and Detrol), use of these agents is no longer needed.
Aldomet (methyldopa, antihypertensive) - Aldomet has numerous CNS side effects such as sedation, confusion, dizziness, and blood disorders. With new, clean acting antihypertensive agents available, Aldomet has little place in the management of high blood pressure.
Demerol (meperidine, narcotic analgesic) - Demerol can cause hallucinations and produce a metabolite that can accumulate and lower the seizure threshold causing seizures. It is limited for short-term use, 1-2 days, and not indicated for long term or chronic pain relief. More suitable alternatives are morphine or oxycodone.
Talwin (pentazocine, narcotic analgesic) - Talwin is a very effective analgesic but can cause agitation and hallucinations. More suitable analgesics are available.
Flexeril (cyclobenzaprine, muscle relaxant/antispasmodic) - Flexeril can cause excessive sedation and anticholinergic effects, which are undesirable in the elderly. A more suitable alternative is Zanaflex.
Tagamet (cimetidine, antiulcer) - Tagamet has numerous drug interactions and can also cause hallucinations. A more suitable alternative is Zantac (ranitidine).
Serpasil (reserpine, antihypertensive) - Reserpine is an age-old drug that has outlived its usefulness, except in unique circumstances such as for Huntigton's. It causes depression and may induce Parkinsonism. Safer, more suitable alternatives exist.
(The above list is not comprehensive, but includes the most common drug therapies considered to be inappropriate for use in the elderly. For a more comprehensive assessment, please utilize our Medication Assessment or contact a qualified geriatrician or pharmacist.)
Regardless of new and better-tolerated drug therapies, there are other considerations such as drug-drug interactions and drug-disease interactions that may cause AME's in the elderly. It is advised that all drug regimens be reviewed on a routine basis by a pharmacist or physician experienced in the uniqueness of the aging body. New medications can slow the metabolism of other medications, which can reach toxic levels in the body, or medications can aggravate a known condition that it was not intended to be used for. For example, the use of a beta-blocker, like Lopressor or
Toprol can mask the signs and symptoms of low blood sugar in someone being treated for diabetes.
Use these tips to minimize AME's:
1. Use the most appropriate agent.
2. Start with a low dose and increase slowly until therapeutic response is desired or AME is experienced.
3. When utilizing multiple prescriptions/physicians, always notify the physician of your medication regimen or have an experienced geriatric pharmacist review your drug regimen for drug interactions, drug-disease interactions and appropriate therapies.
4. When using psychoactive medications always consider that a dose reduction can be made over time since the medication may not be needed indefinitely. This would include anti-anxiety medications, antidepressants and medications used for agitated behaviors in those with forms of dementia or hypnotic for sleep.
5. Report any potential side effect to your physician or pharmacist as soon as possible.