Identify risk factors for adverse drug events (ADEs).

Utilize strategies for shortening medication lists

and enhancing adherence.

Identify and discontinue potentially harmful

medications.

Recognize ADEs when new symptoms are reported

by older adults.
Multiple medical conditions

Multiple medications

Multiple prescribers

Different metabolisms and responses

Lack of evidence for use in elderly

Adherence and cost

Supplements, herbals, and over-the-counter drugs

Lancet. 1995;346(8966):3236.
 2/3 of older adults are on regular medications.

People aged >65 account for 1/3 of all

prescriptions written, but they only represent 15%
of the US population.

Question: How many of your older patients have

1. More than six chronic conditions?
2. Nine or more medications?
3. Multiple medication doses?
Health Care Financ Rev. 1990;11:141.
Adverse symptoms

Adverse clinical outcomes

Doctor visits or hospitalizations
Falls
Functional decline
Changes in cognition (delirium)
Death

Poor adherence, poor quality of life

Increased cost

All Rights Reserved 2007 The

University of North Carolina at Chapel
Hill School of Medicine The Center for
Aging and Health, Division of Geriatric
Medicine
35% of community-dwelling older adults annually
experience an ADE

In the emergency department, ADEs are

experienced:
2.0 per 1000 for adults under 65
4.9 per 1000 for aged 65 years or older
6.8 per 1000 for aged 85 years or older

JAMA 2006; 296:18581866

JAGS 1997;45:945-948. JAGS 1996;44:194197
Am Pharm Assoc 2002;42:847857
1.6 per 1000 older adults require hospitalization (7
times the younger adult rate) because of ADEs.

Nearly 1/3 of all geriatric hospital admissions are

due to ADEs.

2/3 of nursing home patients experience an ADE

(over a 4-year period)

JAMA 2006; 296:18581866

JAGS 1997;45:945-948. JAGS 1996;44:194197
Am Pharm Assoc 2002;42:847857
Antibiotics Anticonvulsants

Analgesics Antipsychotics
Opioid
Cardiovascular medications
NSAIDS
Anticoagulants Diabetic medications
Insulins
Antihistamines
Oral agent

JAMA 2006; 296:18581866

JAGS 2004;52:13491354
NEJM 2003;348:155664
>6 chronic disease

>12 doses/day

9 medications

Low BMI (<22kg/m2)

Age >85 years

Creatinine clearance < 50 mL/min

History of prior ADE

Consult Pharm 1997;12:110311.
Less water

More fat

Less muscle mass

Slowed hepatic metabolism

Decreased renal excretion

Decreased responsiveness of the baroreceptors

Mr. Johnson is 83 years old. He complains of a runny
nose during meals on a daily basis. He asks if there
is a medication to stop his runny nose. Although
inconvenient at mealtime, he is not bothered by this
symptom at other times during the day.

Question: What do you prescribe?

 Likely diagnosis is vasomotor rhinitis and may
respond to ipratropium (Atrovent) nasal spray.

Could be incorrectly diagnosed as allergic rhinitis

and prescribed antihistamines.

Sedating antihistamines can have significant

anticholinergic effects.

J Allergy Clin Immunol 1989 Jan;83(1):1105.

Does every condition need a drug?
Is it a benign or self-limiting condition?
How does this condition bother the patient?
Inconvenient, but not life-threatening
Individualize treatment plans
Consider non-drug alternatives for some conditions
Diet
Exercise
Lifestyle modification
Use caution with over-the-counter (OTC) medications
Not necessarily safer than prescription drugs
Uncertain safety and efficacy of herbals and
supplements
 number of medications = risk of ADE

Question the need for new medications, stop meds if

possible

Prioritize treatments
- Avoid under treating conditions
Pain
Systolic hypertension
Anticoagulation and atrial fribrillation
- Weigh the benefits and risks of a new medication
Sedative hypnotic medications
Tight control of parameters (blood pressure, blood sugars)

Drugs Aging 2003; 20 (1): 2357. Ann Intern Med 1999;131:492501.

Lancet 2000; 355: 865872. J Gen Intern Med 2005; 20:116122.
Mr. Connor is 80 years old. He has coronary artery
disease, congestive heart failure, hypertension, and
Alzheimers dementia. His wife is the primary
caregiver. He is increasingly agitated, suspicious, and
verbally abusive. He has difficulty sleeping at night
and has wandered from the house on two occasions.

Medications: furosemide, enalapril, metoprolol,

amlodipine, aspirin, atorvastatin, alprazolam, and
donepezil (Aricept).

Question: What do you do?

Atypical antipsychotics (i.e. risperdone, quetiapine,
olanzepine)
FDA Black Box warning
Increased risk of stroke, death
? Efficacy (modest at best)

Typical antipsychotics (i.e. haloperidol)

May also carry increased risk of death
? Efficacy

Mood stabilizers (i.e. carbamazepine, valproate)

Not effective
JAMA. 2005;293:596-608 CMAJ 176: 627-632
NEJM 2005;353:2335-41
Avoid benzodiazepines
Danger of paradoxical reaction

Consider depression
Difficult to evaluate in setting of dementia
Apathy vs. depression

Acetylchoinesterase inhibitors (donepezil) might be

helpful

Not clear if memantine (Namenda) is helpful

All Rights Reserved 2007 The

JAMA. 2005;293:596608 University of North Carolina at Chapel
Hill School of Medicine The Center for
Aging and Health, Division of Geriatric
Medicine
Behavioral
Identify antecedents
Behavioral and environmental interventions
Sleep hygiene

Caregiver Support
Alzheimers association
Respite
Day programs
Why was it started?

Is it helping? (benefit)

Is it harmful? (risk)

Consider interactions with other medications

Is the dose within a therapeutic range?

Consider underlying renal and hepatic insufficiency

 The Beers criteria is a consensus-based list of
potentially inappropriate medications for older adults.
The Beers criteria were published 1991, revised 1997
and 2002.

Statistical association with adverse drug events has

been documented.

Arch Intern Med 2003;163:27162724.

Online link to this article is
http:www.med.unc.edu/aging/Beerscriteria2003article.pdf

Pharmacotherapy 2005;25(6):831838
Beers criteria have been adopted for nursing home
regulation.

Does not account for the complexity of the entire

medication regimen.

Arch Intern Med 2003;163:27162724.

Online link to this article is
http:www.med.unc.edu/aging/Beerscriteria2003article.pdf

Pharmacotherapy 2005;25(6):831838
 Table 1: Independent of disease or condition
Describes concern for prescribing certain drugs
or classes of drugs for older adults
Gives severity rating (low or high)

Table 2: Considering diagnosis or condition

Describes drugs or classes of drugs that can
cause or worsen a particular disease or
condition
Gives severity rating (high or low)
Arch Intern Med 2003;163:27162724
Tables available online at http:www.med.unc.edu/aging/Beerscriteria2003article.pdf
Drug classes
Tricyclic antidepressants
Antihistamines
Antispasmodics and muscle relaxants

Adverse Effects
Urinary retention
Constipation
Confusion, delirium, behavior changes
Exacerbation of dementia

Beers criteria Table 1: Arch Intern Med 2003;163:27192720.

Link to the Beers criteria is at http:www.med.unc.edu/aging/Beerscriteria2003article.pdf
Avoid entirely if possible

Challenging to stop for patients with long-term use

Long-acting
Prolonged half-life in older adults (days)
Sedation, cognitive impairment, depression
Increased risk of falls and fractures

Short-acting
Increased sensitivity in older adults
If necessary, use lower doses

Beers criteria Table 1: Arch Intern Med 2003;163:27192720.

Link to the Beers criteria is http:www.med.unc.edu/aging/Beerscriteria2003article.pdf
Propoxyphene (Darvon) has limited efficacy and
significant side effects

Caution with non-steroidal anti-inflammatory drugs

(NSAIDS)
Indomethacin has significant CNS side effects
Ketorolac (Toradol) can cause serious GI and renal
effects

Meperidine (Demerol) has low oral efficacy, active

metabolites and CNS effects

Beers criteria Table 1: Arch Intern Med 2003;163:27192720.

Link to the Beers criteria is at http:www.med.unc.edu/aging/Beerscriteria2003article.pdf
BMJ 1997;315:15651571.
 Parkinsons disease: Metoclopramide (Reglan)

Stress incontinence: -blockers

Hyponatremia: selective serotonin reuptake inhibitors (SSR

Constipation: calcium channel blockers

Beers Criteria Table 2: Arch Intern Med 2003;163:2721.

Mrs. Green is a 92-year-old African-American woman
with macular degeneration, dementia, CAD, CHF (lowEF),
and atrial fibrillation. She has been prescribed an ACE
inhibitor, furosemide, -blocker, nitrates, hydralazine,
digoxin, aldactone (Spironolactone), warfarin, daily
aspirin,
and a statin. Her daughter provides a strict low-sodium
diet.

Question: What else would you do for Mrs. Green?

High risk for adverse drug events (ADEs)
Digoxin is a Beers criteria medication
Dehydration and hypotension
Electrolyte disturbance
Bleeding
What is the incremental benefit of adding each
medication
Life expectancy, number needed to treat, magnitude of
benefit
Lipid lowering therapy, multi-drug CHF regimen?
Think about goals and adherence
Decreasing hospitalizations or extending life?
Cost?
Visual impairment?
Cognitive impairment and literacy?
Arch Intern Med. 1994;154(4):4337.
Keep the medication list short.

Try to use once-daily medications.

Encourage use of a pillbox.

Review bottles of medications.

Write indications for medications on prescriptions.

Medication management programs

Mr. Jones is 82 years old with a history of herpes
zoster (shingles) 6 months ago. He continues to
experience severe daily pain in the same
dermatomal distribution as the original rash.

Question: What is your diagnosis?

Question: What is the treatment?

Opiate (narcotic) medications
Effective, but constipating
Propoxyphene (Darvon) is a Beers criteria medication.

Capsaicin
OTC alternative
Topical (better than systemic)
May be poorly tolerated due to local effects.

Neurology 2002;59(7):101521.
Pain 1988;33(3):33340.
Tricyclic antidepressants
Effective, but have anticholinergic properties.
Amitriptyline > nortriptyline > desipramine
Amitriptyline is a Beers criteria medication.

Gabapentin (Neurontin)
Clinical trial doses 18003600 mg day in divided
doses.
Dose-reduce with renal insufficiency.

Neurology 1998;51(4):116671.
JAMA 1998;280(21):183742.
Start one medication at a time.

Start with a low dose and increase gradually.

Once daily is usually best.

Monitor for response and adverse effects.

Assess adherence with regimen.

Be conservative, but dont miss the target!

What is your goal? Are you achieving it?

Can you keep increasing the dose or are you

limited by side effects?

Are you observing a clinical benefit at lower doses?

Consider stopping if you cant go all the way and

the benefit is not clear.
Mrs. Smith is an 85-year-old woman with
Alzheimers Dementia. She was titrated to 10mg of
donepezil (Aricept) daily. Her daughter is now
concerned about urinary incontinence and asks
about treatment. Her urinalysis is normal.

Question: What would you do?

1. Establish the correct diagnosis.
Incontinence is likely not a new diagnosis but an
ADE.
Donepezil (Aricept) can worsen or precipitate urge
incontinence (pro-cholinergic effects on bladder).
2. Determine if treatment is necessary.
Incontinence is leading cause of nursing home
admission.
Incontinence is a significant caregiver burden.

Arch Intern Med 2005;165:808813. JAGS 2004; 52:20822087.

BMJ 1997;315:10961099.
3. Consider drug-drug interactions (opposing
effects).
Anticholinergics are often used to treat urge
incontinence.
Anticholinergics can cancel the pro-cholinergic
effect of donepezil.
4. Plan: Try stopping or dose-reducing donepezil.

Arch Intern Med 2005;165:808813. JAGS 2004; 52:20822087.

BMJ 1997;315:10961099.
Consider adverse drug effect as etiology of new
signs/symptoms.

Remember that over-the-counter drugs,

supplements, and herbals can cause adverse drug
effects.

Consider discontinuing or dose-reducing

medications rather than treating an adverse drug
effect with another medication.
Common Conditions Could
Really Be Adverse Drug Effects

Constipation CA Channel Blockers

Incontinence Alpha blockers

Memory loss Antihistamines

Syncope Tricyclics

Falls Benzodiazepines

Weight loss Fluoxetine (Prozac)

1. Less is More!

2. Start Low and Go Slow, but Go All The Way!

3. Think Drugs! (before making a new diagnosis)

 Review and reconcile meds at every visit.
Indication for each medication?
Contraindications? (renal, dementia)
Can I STOP any medication?
Write indications for each prescription.
Beers criteria medications
Consider alternatives.
Use caution when prescribing.

The Beers criteria that are referred to in this training module are on the Center for Aging and Health
webpage at the following link:
www.med.unc.edu/aging/Beerscriteria2003article.pdf
The Center for Aging and Health has obtained written permission to give this information on our training
modules. Any use of the Beers criteria by other groups is prohibited except by obtaining written permission
of the authors and editors of the article.
Online Learning Modules Available at http://www.med.unc.edu/aging/