{"id":337,"date":"2020-02-16T10:50:06","date_gmt":"2020-02-16T05:20:06","guid":{"rendered":"https:\/\/medicineplexus.com\/?p=337"},"modified":"2020-02-16T10:50:06","modified_gmt":"2020-02-16T05:20:06","slug":"drug-prescribing-for-older-adults","status":"publish","type":"post","link":"https:\/\/medicineplexus.com\/drug-prescribing-for-older-adults\/","title":{"rendered":"Drug prescribing for older adults"},"content":{"rendered":"\n
Drug prescribing for older adults<\/strong><\/p>\n\n\n\n Optimizing drug therapy is an essential part of caring for an older person.<\/p>\n\n\n\n The process of prescribing a medication is complex and includes:<\/p>\n\n\n\n Avoidable adverse drug events (ADEs) are the serious consequences of inappropriate drug prescribing. The possibility of an ADE should always be borne in mind when evaluating an older adult individual; any new symptom should be considered drug-related until proven otherwise.<\/p>\n\n\n\n Prescribing for older patients presents unique challenges.<\/p>\n\n\n\n Particular care must be taken in determining drug doses when prescribing for older adults.<\/p>\n\n\n\n As examples,<\/p>\n\n\n\n Hepatic function also declines with advancing age, and age-related changes in hepatic function may account for significant variability in drug metabolism among older adults<\/p>\n\n\n\n Especially when polypharmacy is a factor, decreasing hepatic function may lead to adverse drug reactions (ADRs).<\/p>\n\n\n\n MEDICATION USE BY OLDER ADULT<\/strong><\/p>\n\n\n\n Medications (prescription, over-the-counter, and herbal preparations) are widely used by older adults.<\/p>\n\n\n\n Prescription medications<\/strong> \u2014 <\/p>\n\n\n\n A survey in the United States \u00e0 At least one prescription medication was used by 87 percent. Five or more prescription medications were used by 36 percent, and 38 percent used over-the-counter medications.<\/p>\n\n\n\n Herbal and dietary supplements<\/strong> \u2014 <\/p>\n\n\n\n Use of herbal or dietary supplements (eg, ginseng, ginkgo biloba extract, and glucosamine) by older adults has been increasing<\/p>\n\n\n\n Herbal medicines may interact with prescribed drug therapies and lead to adverse events<\/p>\n\n\n\n Examples \u00e0 ginkgo biloba extract taken with warfarin, causing an increased risk of bleeding, and St. John’s wort taken with serotonin-reuptake inhibitors, increasing the risk of serotonin syndrome in older adults<\/p>\n\n\n\n QUALITY MEASURES OF DRUG PRESCRIBIN<\/strong><\/p>\n\n\n\n Multiple factors contribute to the appropriateness and overall quality of drug prescribing.<\/p>\n\n\n\n POLYPHARMACY<\/strong><\/p>\n\n\n\n Polypharmacy is defined simply as the use of multiple medications by a patient. The precise minimum number of medications used to define “polypharmacy” is variable, but generally ranges from 5 to 10<\/p>\n\n\n\n The issue of polypharmacy is of particular concern in older people who, compared with younger individuals, tend to have more disease conditions for which therapies are prescribed.<\/p>\n\n\n\n The use of greater numbers of drug therapies has been independently associated with an increased risk for an adverse drug event (ADE), irrespective of age, and increased risk of hospital admission<\/p>\n\n\n\n There are multiple reasons why older adults are especially impacted by polypharmacy:<\/p>\n\n\n\n \u25cfOlder individuals are at greater risk for ADEs due to metabolic changes and decreased drug clearance associated with aging; this risk is compounded by increasing numbers of drugs used.<\/p>\n\n\n\n \u25cfPolypharmacy increases the potential for drug-drug interactions and for prescription of potentially inappropriate medications<\/p>\n\n\n\n \u25cfUse of multiple medications can lead to problems with adherence in older adults<\/p>\n\n\n\n INAPPROPRIATE MEDICATIONS<\/strong><\/p>\n\n\n\n Anticholinergic activity<\/strong> \u2014 <\/p>\n\n\n\n Anticholinergic medications are associated with multiple adverse effects to which older individuals are particularly susceptible.<\/p>\n\n\n\n Adverse effects associated with anticholinergic use in older adults include memory impairment, confusion, hallucinations, dry mouth, blurred vision, constipation, nausea, urinary retention, impaired sweating, and tachycardia. A<\/p>\n\n\n\n Anticholinergics can precipitate acute glaucoma episode in patients with narrow angle glaucoma and acute urinary retention in patients with benign prostatic hypertrophy.<\/p>\n\n\n\n the risk of dementia and Alzheimer’s disease increased in a dose-response relationship with use of anticholinergic drug classes (primarily first-generation antihistamines, tricyclic antidepressants, and bladder antimuscarinics)<\/p>\n\n\n\n Beers criteria<\/strong> \u2014 developed by an expert consensus panel in 1991<\/p>\n\n\n\n The criteria have been repeatedly updated, most recently in 2019 \u00e0 Selected changes<\/p>\n\n\n\n \u25cfAvoid the concurrent use of opioids with either benzodiazepines or gabapentinoids<\/strong>, due to the increased risk of overdose and severe sedation-related adverse events<\/strong> such as respiratory depression and death.<\/p>\n\n\n\n \u25cfUse caution when prescribing <\/strong>trimethoprim-sulfamethoxazole<\/u><\/strong> in patients who are taking an (ACE)<\/strong> inhibitor or (ARB), and who have decreased creatinine clearance, to avoid hyperkalemia.<\/strong><\/p>\n\n\n\n \u25cfUse caution when recommending aspirin for primary prevention of cardiovascular disease or colorectal cancer in patients age 70 or older (down from previous threshold of 80 years or older), due to increased risk of bleeding.<\/p>\n\n\n\n UNDERUTILIZATION OF APPROPRIATE MEDICATION<\/strong><\/p>\n\n\n\n Much attention has been paid to over-prescribing for older adults; under-prescribing appropriate medications is also of concern.<\/p>\n\n\n\n Prescribing strategies that seek to simply limit the overall number of drugs prescribed to older adults in the name of improving quality of care may be seriously misdirected.<\/p>\n\n\n\n START (Screening Tool to Alert doctors to the Right Treatment)<\/strong> is a set of 22 validated criteria, developed by a consensus process involving experts in geriatric pharmacotherapy, aimed to identify potential prescribing omissions in older hospitalized patients<\/strong><\/p>\n\n\n\n