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Prescribing for Older Adults
“Lunch and Learn” Training Module for Physicians
Anthony Caprio, MD
Division of Geriatric Medicine
University of North Carolina at Chapel Hill
Support for the production and design of this training module
was provided by the
Donald W. Reynolds Foundation
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
Learning Objectives
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.
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
Challenges of Prescribing for 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):32–36.
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
Lots of Medications
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;11:1–41.
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
Adverse Drug Events (ADEs)
Adverse symptoms
Adverse clinical outcomes
–
–
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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
Prevalence of Adverse Drug Events (ADEs)
for Older Adults in Primary Care
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; 296:1858–1866
JAGS 1997;45:945-948. JAGS 1996;44:194–197
Am Pharm Assoc 2002;42:847–857
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
Prevalence of Adverse Drug Events (ADEs)
for Older Adults in Primary Care
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; 296:1858–1866
JAGS 1997;45:945-948. JAGS 1996;44:194–197
Am Pharm Assoc 2002;42:847–857
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
Medications Which Account for
Most Adverse Drug Events in Older Adults
Antibiotics
Anticonvulsants
Analgesics
Antipsychotics
– Opioid
– NSAIDS
Anticoagulants
Antihistamines
Cardiovascular medications
Diabetic medications
– Insulins
– Oral agent
JAMA 2006; 296:1858–1866
JAGS 2004;52:1349–1354
NEJM 2003;348:1556–64
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
Potential Risk Factors for
Adverse Drug Events (ADE)
>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;12:1103–11.
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
Physiologic Changes
Associated with Normal Aging
Less water
More fat
Less muscle mass
Slowed hepatic metabolism
Decreased renal excretion
Decreased responsiveness of the baroreceptors
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
Clinical Case: Mr. Johnson
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?
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
Rhinitis
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):110–5.
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
Do You Need to Prescribe?
Does every condition need a drug?
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–
–
–
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
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
Principle 1:“Less is More”
Keep the Medication List Short
↑ 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): 23–57.
Lancet 2000; 355: 865–872.
Ann Intern Med 1999;131:492–501.
J Gen Intern Med 2005; 20:116–122.
Clinical Case: Mr. Connor
Mr. Connor is 80 years old. He has coronary artery
disease, congestive heart failure, hypertension, and
Alzheimer’s 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?
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
Dementia and Behavioral
Disturbances
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
NEJM 2005;353:2335-41
CMAJ 176: 627-632
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
Dementia and Behavioral Disturbances
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
JAMA. 2005;293:596–608
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
Non-Pharmacologic Approach
Behavioral
– Identify antecedents
– Behavioral and environmental interventions
– Sleep hygiene
Caregiver Support
– Alzheimer’s association
– Respite
– Day programs
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
Stopping Medications
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
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
Stop Potentially Dangerous Drugs:
The Beers Criteria
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;163:2716–2724.
Online link to this article is
http:www.med.unc.edu/aging/Beerscriteria2003article.pdf
Pharmacotherapy 2005;25(6):831–838
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
Stop Potentially Dangerous Drugs:
The Beers Criteria
Beers criteria have been adopted for nursing home
regulation.
Does not account for the complexity of the entire
medication regimen.
Arch Intern Med 2003;163:2716–2724.
Online link to this article is
http:www.med.unc.edu/aging/Beerscriteria2003article.pdf
Pharmacotherapy 2005;25(6):831–838
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
Criteria for Potentially Inappropriate Medication
Use in Older Adults: (2002 Beers Criteria)
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;163:2716–2724
Tables available online at http:www.med.unc.edu/aging/Beerscriteria2003article.pdf
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
Beers: Anticholinergic Medications
Drug classes
– Tricyclic antidepressants
– Antihistamines
– Antispasmodics and muscle relaxants
Adverse Effects
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Urinary retention
Constipation
Confusion, delirium, behavior changes
Exacerbation of dementia
Beers criteria Table 1: Arch Intern Med 2003;163:2719–2720.
Link to the Beers criteria is at http:www.med.unc.edu/aging/Beerscriteria2003article.pdf
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
Beers: Benzodiazepines
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;163:2719–2720.
Link to the Beers criteria is http:www.med.unc.edu/aging/Beerscriteria2003article.pdf
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
Beers: Pain Medications
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;163:2719–2720.
Link to the Beers criteria is at http:www.med.unc.edu/aging/Beerscriteria2003article.pdf
BMJ 1997;315:1565–1571.
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
Beers: Drugs Which Can Worsen Certain
Diseases or Conditions

Parkinson’s disease:
Metoclopramide (Reglan)

Stress incontinence:
α-blockers

Hyponatremia:
selective serotonin reuptake inhibitors (SSRIs)

Constipation:
calcium channel blockers
Beers Criteria Table 2: Arch Intern Med 2003;163:2721.
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
Clinical Case: Mrs. Green
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, β-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?
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
Congestive Heart Failure
High risk for adverse drug events (ADEs)
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–
–
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
–
–
–
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Decreasing hospitalizations or extending life?
Cost?
Visual impairment?
Cognitive impairment and literacy?
Arch Intern Med. 1994;154(4):433–7.
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
Increasing Adherence
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
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
Clinical Case: Mr. Jones
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?
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
Post-Herpetic Neuralgia
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):1015–21.
Pain 1988;33(3):333–40.
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
Post-Herpetic Neuralgia
Tricyclic antidepressants
– Effective, but have anticholinergic properties.
• Amitriptyline > nortriptyline > desipramine
– Amitriptyline is a Beers criteria medication.
Gabapentin (Neurontin)
– Clinical trial doses 1800–3600 mg day in divided doses.
– Dose-reduce with renal insufficiency.
Neurology 1998;51(4):1166–71.
JAMA 1998;280(21):1837–42.
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
Principle 2: Dosing “Start Low and Go Slow…”
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.
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
“…But, Go All The Way!”
Be conservative, but don’t 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 can’t “go all the way” and
the benefit is not clear.
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
Clinical Case: Mrs. Smith
Mrs. Smith is an 85-year-old woman with Alzheimer’s
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?
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
Prescribing Cascade: Prescribing a New Drug to
Treat an Adverse Drug Event
1.
Establish the correct diagnosis.
–
–
2.
Incontinence is likely not a new diagnosis but an ADE.
Donepezil (Aricept) can worsen or precipitate urge
incontinence (pro-cholinergic effects on bladder).
Determine if treatment is necessary.
–
–
Incontinence is leading cause of nursing home
admission.
Incontinence is a significant caregiver burden.
Arch Intern Med 2005;165:808–813.
BMJ 1997;315:1096–1099.
JAGS 2004; 52:2082–2087.
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
Prescribing Cascade: Prescribing a New Drug to
Treat an Adverse Drug Event
3.
Consider drug-drug interactions (opposing
effects).
–
–
4.
Anticholinergics are often used to treat urge
incontinence.
Anticholinergics can cancel the pro-cholinergic effect of
donepezil.
Plan: Try stopping or dose-reducing donepezil.
Arch Intern Med 2005;165:808–813.
BMJ 1997;315:1096–1099.
JAGS 2004; 52:2082–2087.
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
Principle 3: “Think Drugs” Before Making a New
Diagnosis
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.
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
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)
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
Things to Remember:
Three Principles
1.
Less is More!
2.
Start Low and Go Slow, but Go All The Way!
3.
Think Drugs! (before making a new diagnosis)
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
Clinical Pearls
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.
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
Acknowledgments
Author:
Anthony J. Caprio, MD
Funding:
The Donald W. Reynolds Foundation
Educational Development:
Ellen Roberts, PhD, MPH
William Ashley Davis, BA
Christopher Osmond, MA
Center for Aging and Health:
Jan Busby-Whitehead, MD
C. Glenn Pickard, MD
Online Learning Modules Available at http://www.med.unc.edu/aging/
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