Elderly people are a heterogeneous group. Levels of cognition and functional capacity may vary greatly, and individual assessment is needed to plan medication. Considering the elderly person's own wishes and aims will improve commitment to treatment.
Polypharmacy is common and increases the risk of using inappropriate medication, as well as of drug interactions and adverse effects. The aim in the treatment of elderly people is usually to keep polypharmacy under control, assessing the diseases and medication as a whole, as well as the balance of benefit and harm. This requires exact diagnosis and careful follow-up of medication.
Medication is commonly associated with the following challenges:
insufficient treatment/medication, which is often associated with underdiagnosis (e.g. cardiovascular diseases, disease prophylaxis)
inappropriate or unnecessary medication (medication without indication or a drug for which the harms outweigh the benefits).
At the final stage of life, symptomatic treatment and maintaining a good quality of life are emphasized in medication.
Medication review
Aspects to be considered in the review:
Functional capacity (planning medication depending on how frail the patient is)
Cognition (patients with memory disorder may need help with medication in practice)
Nutritional state, oral health
Mobility, muscle strength, balance (for drugs increasing the risk of falling, see Falls of the Elderly)
Kidney function (adjustment of doses or change to another group of drugs)
Compatibility of various drugs (concomitant use of antagonists, such as anticholinergics and Alzheimer's drugs, should be avoided)
Alcohol use
Drug dependence or misuse
Non-prescription products, natural products
Financial aspects (whether the patient can afford the planned medication)
New medication is usually started at the lowest dose, and the dose should be increased slowly, monitoring the response and any adverse effects.
The dose in the elderly is usually half of the dose in working-age people.
Any new symptoms or findings should be considered as adverse effects of the new drug until otherwise proven.
A balance often needs to be sought between the benefits and adverse effects of treatment.
Poor compliance in taking medicines may be due to polypharmacy, side and adverse effects, complexity of medication (several doses a day, different methods of administration), poor vision, impaired memory or impaired motor functions or dexterity (needed to open medicine containers or halve tablets).
Advanced age alone is not a contraindication for beneficial medication, and elderly people often benefit from evidence-based medication for chronic diseases (such as statins for coronary artery disease, anticoagulants for atrial fibrillation).
Pain is often inadequately diagnosed and treated in the elderly, particularly in patients with memory disorders.
Medicines that are inappropriate for the elderly
Because of frailty, multimorbidity and polypharmacy, elderly people are more susceptible to adverse drugs effects. Age-related changes often make it necessary to reduce the dose or change to more appropriate drugs.
Adverse effects cause a fifth of elderly patients' emergency visits. Typical adverse drug effects requiring hospital treatment are dizziness caused by various mechanisms and falls and fractures associated with such dizziness. The risk of falling is increased by drugs such as antipsychotic agents, benzodiazepines and drugs causing orthostatic hypotension Falls of the Elderly.
Tricyclic antidepressants (amitriptyline, doxepin) are drugs with significant anticholinergic properties that may cause confusion, memory impairment, urinary retention, constipation and worsening of glaucoma, for example.
Fluoxetine is an SSRI drug with numerous drug interactions.
Long-acting benzodiazepines, such as diazepam, are not recommended for use in the elderly.
Antipsychotics have anticholinergic and extrapyramidal effects, and they increase the risks of cerebrovascular and cardiovascular events and death.
In the treatment particularly of hospital delirium and, in patients with memory disorder, of neuropsychiatric symptoms, primarily non-pharmacological methods should be used. Antipsychotics should only be used temporarily and for the most severe symptoms.
NSAIDs may aggravate kidney or heart failure, and they increase the risk of cardiovascular events and gastrointestinal haemorrhage.
Digoxin has a narrow therapeutic range, and its daily dose should not exceed 0.125 mg (measure blood concentrations, as necessary).
Hydroxyzine has anticholinergic and sedative properties. Due to its anticholinergic effects, it is not an appropriate choice for a sleep medicine.
Deprescribing of inappropriate or unnecessary medication
Based on comprehensive review of medication, an assessment should be made of whether the patient uses any drugs that have become unnecessary or even harmful.
Drug response and adverse drug effects should be discussed with the patient and/or their relatives or caregivers.
To improve compliance, any changes to medication should preferably be done in mutual agreement. Patients may be physically and/or psychologically dependent on their medication.
In case of serious symptoms or challenging situations, medication may be reduced during a period of inpatient treatment.
Reduction of medication should preferably be done one drug at a time, gradually decreasing the dose.
It may sometimes be possible to replace a drug causing adverse effects by another drug with less adverse effects. For example, replacing:
a long-acting benzodiazepine by an intermediate-acting one, such as oxazepam or lorazepam
an NSAID by paracetamol or nonpharmacological pain management methods
warfarin by direct anticoagulants which do not require dietary restrictions or frequent laboratory monitoring
a short-acting hypnotic by long-acting melatonin or a low dose of mirtazapine (3.75-7.5 mg)
urinary anticholinergics by mirabegron.
The aetiology of itching is often dry skin, for which a good emollient is the best treatment.
When treating symptoms, it is important to find out their aetiology and how severe the patient finds the symptom. Non-pharmacological methods of treatment should always also be considered.
In most cases, the adverse effects of a medication should not be treated with another medication (with the exception of constipation caused by opioids).
Improving the safety of medication
A written, up-to-date drug list is useful not only for the elderly patient but also for family members and health care providers.
If necessary, the view of home nursing or family members may be sought as regards the actual use of medicines, drug response and any adverse effects.
Pill organisers/boxes, dose distribution at the pharmacy or an automated medicine dispensing service can be used to ensure appropriate medication.
In elderly patients, medication should be regularly reviewed. When changing medication, in particular, it is important to assess response / adverse effects after a certain period of time before making further plans.
Antipsychotics, analgesics, proton pump inhibitors and hypnotics, in particular, tend to remain on the patient's chart permanently even after the indication is no longer there (e.g. the condition has resolved) Reducing Medications in the Elderly.
New medication should be started at a low dose, the dose increased gradually, and the patient monitored both for drug response and for any adverse effects. If medication is planned for a certain period of time, only, the ending time should be defined when starting the medication already. Changes of medication should be entered in patient records together with the reasons.
Other health care professionals, such as nurses or pharmacists, can be consulted when assessing medication.
Special databases and electronic tools are available for reviewing the medication (including appropriateness and interactions) of elderly people. Check local availability.
References
Cole JA, Gonçalves-Bradley DC, Alqahtani M, et al. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev 2023;10(10):CD008165 [PubMed]
Kristensen RU, Nørgaard A, Jensen-Dahm C, et al. Polypharmacy and Potentially Inappropriate Medication in People with Dementia: A Nationwide Study. J Alzheimers Dis 2018;63(1):383-394 [PubMed]
Motter FR, Fritzen JS, Hilmer SN, et al. Potentially inappropriate medication in the elderly: a systematic review of validated explicit criteria. Eur J Clin Pharmacol 2018;74(6):679-700 [PubMed]
By the 2023 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2023;71(7):2052-2081 [PubMed]
O'Mahony D, Cherubini A, Guiteras AR, et al. Correction: STOPP/START criteria for potentially inappropriate prescribing in older people: version 3. Eur Geriatr Med 2023;14(4):633 [PubMed]
Seppala LJ, Petrovic M, Ryg J, et al. STOPPFall (Screening Tool of Older Persons Prescriptions in older adults with high fall risk): a Delphi study by the EuGMS Task and Finish Group on Fall-Risk-Increasing Drugs. Age Ageing 2021;50(4):1189-1199 [PubMed]