Medication review is essential in an elderly patient's comprehensive care. Both underuse of medication, which is often associated with underdiagnosis (e.g. memory diseases, heart disease, disease prophylaxis, pain), and inappropriate or excessive medication (medication without a clear indication, or a drug for which the risk of adverse events outweighs the clinical benefit) are possible.
An elderly patient appreciates a clear diagnosis and an approach where the doctor both listens and discusses the matter before starting or reducing medication - this will also improve patient compliance. An improved quality of life as the aim of medication is emphasized in elderly patients.
The elderly patients are especially susceptible to problems caused by anticholinergic drugs, sedative drugs and drugs that increase the risk of bleeding. As for analgesic medication, a balance needs to be sought with the typical adverse effects of different groups of analgesics.
Adverse effects cause a fifth of the elderly patients' emergency visits in hospital.
Assessment of current medication
Ask the patient about any prescription or over-the-counter medication he/she is taking (including NSAIDs, dermatological products, vitamins, natural remedies and eye drops). If necessary, the information may be obtained from a family member or carer.
Ask the patient whether he/she has been able to take, or remembered to take, each separate medicine.
A home visit including an assessment of the medication the patient keeps at home may clarify the situation.
Poor compliance in taking medicines may be due to polypharmacy, adverse effects, complexity of medication (several doses a day, different methods of administration), poor vision, impaired memory or lack of the dexterity needed to open medicine containers.
Take into account also potential overuse of alcohol and use of natural remedies - make it a routine to ask about them as you do regarding prescription drugs.
How to assess which medication is needed
An elderly patient will benefit from an accurate diagnosis if the suspected illness is such that curative treatment, or treatment that improves the patient's condition, is available. In most cases the symptoms are not due to old age. The patient will, however, understand that it is not possible to cure all complaints.
The significance of symptoms must be assessed, i.e. does the medication and its possible adverse effects cause more inconvenience than the symptoms themselves?
All aspects related to the medication should be considered, including memory, compliance, support from relatives or home care personnel, dependence on medicines, dietary habits and nutritional state, fluid intake, malabsorption, liver and kidney function, mobility, muscular strength and balance, possible concealed alcohol consumption.http://www.dynamed.com/condition/polypharmacy-in-older-adults#GUID-CADF6E47-A8F0-42BE-9C5C-11139CFAF8D3
Medication should always be started at the lowest possible dose, and the patient must be monitored both for the action of the medicine and for any adverse outcomes. All dose increases must be gradual. New signs and symptoms should be considered as possible adverse effects, until shown otherwise.
The dose for an elderly patient is usually half of that for a middle-aged person, particularly as regards psychotropic medication.
The cause of frequent falls may be medication that increases the risk of falling http://www.dynamed.com/condition/falls-in-older-adults#TOPIC_Q5J_THW_QHB(antipsychotics, benzodiazepines, vasodilators that cause postural hypotension) rather than any disease as such (Parkinson's disease, memory disorder, sleep disorders). Dietary deficiencies may also lead to muscle wasting and thus increase the risk of falling.
Secondary prevention has high importance in elderly persons. There is also research evidence on the benefits of primary prevention concerning at least nutrition, vitamin D, pharmacotherapy for hypertension, vaccinations and physical activity.
When assessing prognostic studies it should be borne in mind that due to methodological reasons it is often very difficult to do research among aged persons with comorbidities. Absence of research evidence does not necessarily mean absence of benefit.
The patient and/or a family member or a caregiver should be informed of all possible adverse effects.
Ask the patient whether he/she feels that withdrawing some medication may pose a problem. Discuss how dependent (physically or psychologically) the patient is on the medication.
If reduction is agreed on, an appointment should be made for a follow-up visit (phone call) in order to increase the patient's feeling of security.
If the patient has serious symptoms or the case is not otherwise straightforward, reduction of polypharmacy may also be carried out in a hospital.
Do not lose heart: reducing an elderly patient's existent medication requires effort and precision, but it is rewarding. Medication review has not been shown to affect mortality but it may, however, reduce emergency department contacts Medication Review in Hospitalised Patients to Reduce Morbidity and Mortality.
Tricyclic antidepressants (amitriptyline, doxepin): significant anticholinergic properties, may cause confusion, memory impairment, urinary retention, constipation and worsening of glaucoma.
Fluoxetine: inappropriate SSRI drug because of the risk of interaction
Long-acting benzodiazepines (half-life over 20 hours), e.g. diazepam (half-life 20-100 hours, in elderly persons even longer) are not recommended at all to be used in the elderly. They can be replaced with intermediate-acting benzodiazepines.
Intermediate-acting benzodiazepines (half-life 5-20 hours): the dose in the elderly should be less than half of the normal dose.
The recommended maximum daily dose for temazepam is 15 mg, for lorazepam 3 mg, for oxazepam 60 mg and for alprazolam 3 mg. Triazolam is not anymore recommended at all to be used in the elderly, and its availability in the pharmacies is also limited.
Ultra-short-acting hypnotics: the recommended maximum daily dose for zopiclone is 7.5 mg and for zolpidem 5 mg. Zolpidem is not recommended for patients with a memory disease.
Antipsychotics have anticholinergic and extrapyramidal effects, and they increase overall mortality in terms of both pneumonia, disorders of the cerebral circulation and cardiac deaths. Drug interactions are also significant, and they should always be checked when considering antipsychotic medication.
Dextropropoxyphene: a narrow therapeutic range
Digoxin:dose should be no higher than 0.125 mg.
Hydroxyzine: significant anticholinergic properties, causes drug interactions and often sedation. Hydroxyzine is not an appropriate choice as a sleep medicine.
Medication necessary for an elderly patient may sometimes be replaced by another drug with fewer adverse effects, for example:
a long-acting benzodiazepine replaced by an intermediate-acting one, e.g. oxazepam
an NSAID by paracetamol or nonpharmacological pain management methods
warfarin by new anticoagulants which do not require dietary restrictions or frequent laboratory monitoring
a short-acting hypnotic by a low dose of mirtazapine
old urinary anticholinergics by mirabegron.
The aetiology of itching in an elderly person is nearly always dry skin, for which a good emollient is the best treatment.
The adverse effects of a medication should not be treated with another medication.
Do not prescribe symptomatic medication for dizziness.
Underuse of medication
Advanced age alone should never be a contraindication for potentially beneficial treatment - often the opposite is true!
Osteoporosis must be diagnosed and treated Osteoporosis.
The diagnostics of memory diseases are mostly of high standard but delays in the admission to investigations may lead to delays in the confirmation of the diagnosis. Inadequate follow-up may also lead to inappropriate medication.
How to promote safe medication
An annual medication review should be carried out if the patient lives independently at homehttp://www.dynamed.com/condition/polypharmacy-in-older-adults#GENERAL_CRITERIA_FOR_EVALUATING_REGIMENS. In care facilities, the drug charts should be reviewed every three months. Antipsychotics, analgesics, gastroprotective drugs and hypnotics, in particular, tend to remain on the patient's chart long after the condition has resolved Reducing Medications in the Elderly. Proton pump inhibitors, if used "just in case" for a too long period in frail elderly patients may cause bacterial diarrhoea and pneumonias.
Do not hesitate to use the GFR calculator Gfr Calculator and locally available drug interaction databases.
The use of pill organisers/boxes should be encouraged and the dosing interval should be as long as possible, even if effectiveness must be compromised.
A written, updatable drug list is useful not only for the patient but also for family members and health care providers.
If necessary, the view of district nurses, carers and family members may be sought as regards the actual use of medicines and their possible adverse effects.
It may be appropriate in some cases that the district nurses keep the medication in their possession. However, it is important not to infringe the patient's independence.
References
Kaur S, Mitchell G, Vitetta L et al. Interventions that can reduce inappropriate prescribing in the elderly: a systematic review. Drugs Aging 2009;26(12):1013-28. [PubMed]
Jyväkorpi S. Nutrition of older people and the effect of nutritional interventions on nutrient intake, diet quality and quality of life. Academic dissertation 2016, University of Helsinki http://helda.helsinki.fi/handle/10138/160518.
Pitkälä KH, Suominen MH, Bell JS et al. Herbal medications and other dietary supplements. A clinical review for physicians caring for older people. Ann Med 2016;48(8):586-602. [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]
Rankin A, Cadogan CA, Patterson SM et al. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev 2018;9:CD008165. [PubMed]
By the 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc 2019;67(4):674-694. [PubMed]
O'Mahony D. STOPP/START criteria for potentially inappropriate medications/potential prescribing omissions in older people: origin and progress. Expert Rev Clin Pharmacol 2020;13(1):15-22. [PubMed]
Fujie K, Kamei R, Araki R et al. Prescription of potentially inappropriate medications in elderly outpatients: a survey using 2015 Japanese Guidelines. Int J Clin Pharm 2020;42(2):579-587. [PubMed]
Seppala LJ, van der Velde N, Masud T et al. EuGMS Task and Finish group on Fall-Risk-Increasing Drugs (FRIDs): Position on Knowledge Dissemination, Management, and Future Research. Drugs Aging 2019;36(4):299-307. [PubMed]