December 2nd, 2015
A Melange of Medications
It’s unavoidable — treating the frail, confused, 80 year-old patient with congestive heart failure, atrial fibrillation, type 2 diabetes mellitus and chronic kidney disease in your office, emergency department, or hospital ward. In geriatrics, often acute presentations are the result of harmful medical interactions, resulting in falls, toxicity, delirium, or acute kidney injury.
Over time, many medications are prescribed with good intentions but are not reevaluated or stopped. The result is a melange of medication lists and prescriptions stashed in an older adult’s kitchen cupboard, used either inappropriately or accidentally. The arduous task of clarifying medications requires detective skills — especially when you’ve been given a handwritten scrap of paper listing twenty medications, many crossed out and rewritten with questionable doses.
As a physician assistant or nurse practitioner, we are often the first to assess and initiate workup, order diagnostic tests, and tailor treatment plans for older adults. We can help to identify potentially harmful medication interactions, dose antibiotics for renal function, or consider alternative medications to reduce falls, delirium or worsening dementia. With all that is required of clinicians, delving into the pages of pharmacopoeia for guidance is simply daunting.
The Beers Criteria, first published in 2012, is a comprehensive list of potentially harmful medications for older adults extensively researched and published in the Journal of the American Geriatrics Society. The aim of the 2015 Beers Criteria is to create heightened awareness of potentially harmful medications to stimulate clinicians to weigh the risks and benefits of starting a mediation or to consider an alternative. Recognizing common drugs that carry potential for mishap — including first-generation antihistamines, tricyclics, peripheral alpha 1 blockers, sulfonylureas, and oral NSAIDs — is a good step in reducing polypharmacy. Below are a few medications highlighted in the “American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults” review, published in November’s Journal of the American Geriatrics Society 1:
- Proton-pump inhibitors are a new addition to the Beers Criteria due to the increased risk of C. difficile, fractures and bone loss and should not prescribed for >8 weeks. In the setting of chronic NSAID use or erosive esophagitis, a PPI course may be extended.
- It’s known that there’s an increased risk of mortality with first- and second-generation antipsychotics. The new update recommends avoiding antipsychotics in dementia patients or delirious patients with behavioral issues and, instead, to focus on nonpharmacological approaches. If the patient is a harm to themselves or others (as in psychosis), starting risperidone or quetiapine at the lowest dose possible may be considered.
- Digoxin, commonly used for rate control in atrial fibrillation, was newly added to the list of potentially harmful medications. Choose other rate control medications over digoxin due to elevated risks for mortality and hospitalizations. Higher doses are not shown to improve symptom management and lead to toxicity. So, avoid dosages > 0.125 mg/d if digoxin is the only option for atrial fibrillation and heart failure.
- It’s not surprising that benzodiazepines are still on the list, but this drug class frequently is prescribed among older adults in the community. According to the Beers Criteria, benzodiazepines increase risk of cognitive impairment, delirium, falls, fractures, and motor vehicle accidents. If pharmacologic treatment is required for anxiety, consider an SSRI or Buspar.
Of course, there are circumstances in which potentially harmful drugs need to be prescribed. Obviously, every clinical scenario is unique, so simply use your clinical judgement. Taking the extra time to review a medication list may give you the answer to diagnosing vague symptoms or a patient’s confused state. The older adult will be appreciative, and no one will fault you for paying attention to the details.
1 J Am Geriatr Soc. 2015 Nov;63(11):2227-46. doi: 10.1111/jgs.13702. Epub 2015 Oct 8.