AGS

Medications

Medications

History

  • Who manages the medications? How are the medications organized?
  • What prescription medications and nonprescription medications or health supplements is the older adult taking?
  • How many medications is the patient taking? How many times per day?
  • How many prescribers/pharmacies?

Medication Assessment

  • Does each medication have an indication? (e.g., consider stopping medication(s) that was started for a problem that has since resolved) 24
  • Are any conditions lacking indicated medications? (e.g., consider calcium and vitamin D supplementation for those with osteoporosis)25
  • Is each medication still indicated given individualized treatment goals, the patient’s goals of care, and prognosis (e.g., A1c, blood pressure goals)?26
  • What concerns does the patient have (e.g., cost, opening pill bottles, swallowing pills, forgetting doses, adverse effects)?
  • Any difficulty taking medications (e.g., reading labels; administering patches, ointments, injections, or eye drops; keeping track of changes)?

Aging physiology changes that affect medications: start low, go slow (but get there)27

↓ GFR/creatinine clearance (with normal creatinine since decreased lean body mass) = ↑ accumulation/risk of toxicity

↓ Liver clearance = ↑ in bioavailability, longer half-life

↓ Baroreceptor responsiveness = ↑ risk of orthostasis/falls

↑ Proportion of body fat = lipophilic drugs last longer

↑ Permeability of blood-brain barrier = ↑ risk of central nervous system effects

Remember: Slowly titrate until reach therapeutic dose, and deprescribe medications that are no longer needed.

Avoid High-Risk Medications

  • Which of the patient’s medications are on the AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults?24
  • Which safer alternatives may be appropriate? (e.g., Consider nonpharmacologic therapy for pain, sleep, incontinence, depression.)
  • Avoid anticholinergic medications if possible.28
  • Look out for prescribing cascades, especially with anticholinergic drugs: drug à adverse effect à new drug29 (e.g., oxybutynin à constipation à stool softener)

Deprescribe or Prescribe (common examples)

Allergic rhinitis

  • Consider Deprescribing
    • Diphenhydramine: highly anticholinergic
  • Consider Prescribing
    • Cetirizine, fexofenadine, or loratadine: less anticholinergic because they are more selective for peripheral histamine receptors

Anxiety and Depression

  • Consider Deprescribing
    • Benzodiazepines: risk of delirium, falls, withdrawal adverse effects, and CNS adverse effects
    • Tricyclic antidepressants: risk of CNS anticholinergic effects and orthostatic hypotension
  • Consider Prescribing
    • SSRIs: less risk of adverse effects in older adults, monitor for SIADH as needed and serotonin syndrome if taking more than one medication with serotonin activity

Constipation

  • Consider Deprescribing
    • Agents with a high anticholinergic risk score
    • Docusate: minimal evidence of efficacy
  • Consider Prescribing
    • Consider nonpharmacologic options: increase fiber, fluid, and exercise; scheduled toileting
    • Osmotic laxatives (e.g., polyethylene glycol) versus a stimulant laxative (e.g., senna)

Diabetes30

  • Consider Deprescribing
    • Insulin: high risk of hypoglycemia, especially with sliding scale insulin and human insulin
    • Sulfonylureas: high risk of hypoglycemia, especially with glyburide
  • Consider Prescribing
    • Consider if patient needs glucose-lowering therapy given individualized hemoglobin A1c goal and overall health and prognosis
    • Medications with a glucose-dependent mechanism of action (e.g., metformin, DPP4 inhibitors, GLP-1 receptor agonists, SGLT-2 inhibitors, thiazolidinediones)

Pain

  • Consider Deprescribing
    • NSAIDs: risk of GI bleeding, high blood pressure, kidney damage
    • Opioids: increased risk of falls related to CNS depression, mental slowing
  • Consider Prescribing
    • Consider nonpharmacologic options
    • Scheduled acetaminophen up to 1000 mg three times daily for those with normal liver function, use lowest effective dose of opioid as needed for acute pain (with bowel regimen)

Sleep

  • Consider Deprescribing
    • Diphenhydramine, hydroxyzine: highly anticholinergic, sedating, orthostatic hypotension
    • Z-drugs and benzodiazepines: highly sedating, risk of residual CNS effects leading to increased risk of fracture and falls
  • Consider Prescribing
    • Consider nonpharmacologic options: behavioral interventions such as cognitive-behavioral therapy
    • Melatonin, lowest effective dose of mirtazapine, or trazodone

Urinary Incontinence

  • Consider Deprescribing
    • Anticholinergic medications for bladder can be sedating and can cause orthostatic hypotension
    • Terazosin: increased risk of falls because of nonselectivity
  • Consider Prescribing
    • Consider nonpharmacologic options: behavioral interventions such as scheduled toileting, dietary changes, incontinence supplies such as liners or briefs
    • Mirabegron, trospium: more selective, less risk of adverse effects

Tools to Improve Medication Adherence

After following steps to ensure that the patient’s medicines are safe and appropriate for them, consider:

  • Does patient need help managing medications (e.g., visiting nurse or caregiver to pack pillbox)?
  • Can medications be administered with an automatic pill dispenser?
  • Can medications taken more than once a day be switched to once-a-day formulations?
  • Can administration times be moved to be all at once rather than multiple times/ day?

Interprofessional Team Involvement: Consider nursing, pharmacy, occupational therapy, speech and language pathology.

Tools for Polypharmacy and Deprescribing

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