Some drug categories (eg, analgesics, anticoagulants, antihypertensives, antiparkinsonian drugs, diuretics, hypoglycemic drugs, psychoactive drugs) pose special risks for older adults. Some drugs, although reasonable for use in younger adults, are so risky they should be considered inappropriate for older adults. The American Geriatric Society Beers Criteria® are most commonly used to identify such inappropriate drugs (see table Potentially Inappropriate Drugs in Older Adults) (1). The Beers Criteria categorize potentially inappropriate drugs into 3 groups:
Potentially inappropriate for all older adults: To be avoided if possible
Potentially inappropriate due to drug-disease and drug-syndrome interactions: To be avoided in older adults with certain diseases or syndromes
To be used with caution: Benefit may offset risk in some patients
Analgesics
Oral nonsteroidal anti-inflammatory drugs (NSAIDs) are used by > 30% of people aged 65 to 89, and half of all NSAID prescriptions are for people > 60. Several NSAIDs are available without prescription.
Older adults may be prone to adverse effects of these drugs, and adverse effects may be more severe because of the following:
NSAIDs are highly lipid-soluble, and because adipose tissue usually increases with age, distribution of the drugs is more extensive.
Plasma protein is often decreased, resulting in higher levels of unbound drug and exaggerated pharmacologic effects for drugs that are highly protein-bound.
Renal function is reduced in many older adults, resulting in decreased renal clearance and higher drug levels.
NSAIDs can also increase blood pressure; this effect may be unrecognized and lead to intensification of antihypertensive treatment (a prescribing cascade). Thus, clinicians should keep this effect in mind when blood pressure increases in older adults and ask them about their use of NSAIDs, particularly over-the-counter NSAIDs.
Anticoagulants
Antidepressants
Antihyperglycemics
Doses of antihyperglycemics should be titrated carefully in patients with diabetes mellitus. Risk of hypoglycemia due to sulfonylureas may increase with age. As described in the table Potentially Inappropriate Drugs in Older Adults
insulin and can be effective given alone or with sulfonylureas. Risk of lactic acidosis, a rare but serious complication, increases with degree of renal impairment and with patient age. Symptomatic heart failure is a contraindication.
Antihypertensives
Antiparkinsonian drugs
Antipsychotics
Antipsychotics should be used only for psychosis. In nonpsychotic, agitated patients, antipsychotics control symptoms only marginally better than placebo and can have severe adverse effects. In people with dementia, studies showed antipsychotics increased mortality and risk of stroke, leading the U.S. Food and Drug Administration (FDA) to issue a black box warning on their use in such patients. Generally, dementia-related behavior problems (eg, wandering, yelling, uncooperativeness) do not respond to antipsychotics. Antipsychotics should not be used merely because a behavioral problem (eg, yelling, repeating phrases) is annoying to people other than the patient.
When an antipsychotic is used, the starting dose should be about one quarter the usual starting adult dose and should be increased gradually with frequent monitoring for response and adverse effects. Once the patient responds, the dose should be titrated down, if possible, to the lowest effective dose. The drug needs to be stopped if it is ineffective. Clinical trial data relating to dosing, efficacy, and safety of these drugs in older adults are limited.
Antipsychotics can reduce paranoia but may worsen confusion (see also Antipsychotic Drugs: Conventional antipsychotics). Older adults, especially women, are at increased risk of tardive dyskinesia, which is often irreversible. Sedation, orthostatic hypotension, anticholinergic effects, and akathisia (subjective motor restlessness) can occur in up to 20% of older adults taking an antipsychotic, and drug-induced parkinsonism can persist for up to 6 to 9 months after the drug is stopped.
Anxiolytics and hypnotics
Treatable causes of insomnia should be sought and managed before using hypnotics
Duration of anxiolytic or hypnotic therapy should be limited if possible because tolerance and dependence may develop; withdrawal may lead to rebound anxiety or insomnia.
Digoxin
≤>≥® suggest avoiding doses > 0.125 mg/day (1
Diuretics
Reference
1. The American Geriatrics Society 2019 Beers Criteria Update Expert Panel: American Geriatrics Society updated Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc 67(4):674-694, 2019. doi:10.1111/jgs.15767
