High Risk Medications

in the Elderly
Presented by: Fatima Ali, PharmD, RPh, BCPS
Consultant Pharmacist
MediSystem Pharmacy

Prepared by Disha Shah,

imedisystem.com Pharmacy Student
University of Waterloo, 2012
 Aging and the Canadian
Population

• Seniors contribute to 13% of

total Canadian population but
receive 28-40% of all prescribed
medications
• By 2041, 1 in 5 Canadians will be
65yrs or older
• On average, elderly take 4-5 Rx
and 2 OTC medications daily

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 Age-Related Physiologic
Changes
• Amount of water in body, % of fat
tissue
– Drugs dissolving in water reach HIGHER
concentrations (less water to dilute them)
– Drugs dissolving in fat ACCUMULATE more (more
fat tissue to store them)
• Decreased renal/hepatic function:
– Renal: less able to excrete drugs into urine
– Hepatic: less able to breakdown (metabolize) drugs

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 Bottom Line

• Medications are less readily

removed from the body

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 Age-Related Physiologic
Changes
• Slower gut motility more susceptible to
constipation
• Decreased skeletal bone mass osteoporosis
and increased fractures
• Decreased ability to taste Decreased
appetite, weight loss
– Elderly may over salt their food due to reduced
ability to taste

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 Meet “EW”

EW is an 84-year-old resident on your

floor who just suffered a fall. You try to
investigate the cause of the incident
and discover that she was feeling very
dizzy. Upon further questioning, EW
tells you that for the past month or so,
she has been feeling more dizzy than
usual. You decide take a look at her
medication list.

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 Which of the following medications may be
causing sedation/dizziness?

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 Pearls for Medication Use in the
Elderly
• Goal maximize benefit, reduce harm
• Start low, titrate up the dose
• Use once daily dosing if possible (improved
adherence)
• Monitor the patient for response and adverse
effects
• Avoid prescribing cascade
– Avoid ordering medications used to treat the
adverse events of other medications

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 Considerations in Elderly

• Is the medication necessary?

• What is the Benefit/ Risk ratio?

• Appropriate dose and interval?

• Complexity of drug regimens (adherence /

compliance, pill burden, etc)

• Monitoring

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 Beers
Criteria

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 Beers List

• Developed by panel of experts in geriatrics

• Recently updated in 2015
• List of potentially inappropriate medications
for patients 65 years or older
– Either ineffective or pose a high risk
• PURPOSE: to reduce medication-related risks
– Increase nursing awareness of high-risk
medications
– Monitor adverse events

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 What medication are on
the Beers List?
Drug Class Examples
Analgesics Meloxicam (Mobicox®)
Antiarrhythmics Digoxin ≥ 0.125mg/d (Toloxin®)
Antidepressants Amitriptyline (Elavil®)
Antihistamines Diphenhydramine (Benadryl®)
Antihypertensives Doxazosin (Cardura®)
Antipsychotics Olanzapine (Zyprexa®)
Anxiolytics and Hypnotics Benzodiazepines

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ISMP Canada 2012. Potentially Harmful Medications.
 What medications are on
the Beers List?
Drug Class Examples of drugs

Gastrointestinal drugs Dimenhydrinate (Gravol®)

Hormones Estrogens oral or patch (i.e.
Premarin®)

Muscle Relaxants Methocarbamol (Robaxin®)

NSAIDS Naproxen (Aleve®)
Urinary drugs Oxybutynin (Ditropan®)

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ISMP Canada 2012. Potentially Harmful Medications.
 Beers List &
Their Side Effects
1. Anticholinergic adverse effects
– Amount of acetylcholine in the body decreases
with age. Therefore elderly are more sensitive to
anticholinergic side effects
2. Extrapyramidal adverse effects (involuntary
movement, restlessness, uncontrollable speech)
3. Orthostatic hypotension

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 Anticholinergic Adverse Effects:
Central Nervous System
• Sedation

• Decreased Concentration

• Forgetfulness

• Confusion

• Psychotic symptoms

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 Anticholinergic Adverse Effects:
Peripheral Nervous System

• Blurred vision – poor vision leading to falls

• Dry mouth – dental, speech problems, poor nutrition
• Decreased GI motility – constipation
• Decreased secretions
• Tachycardia
• Urinary bladder retention – lack of bladder control

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 Medications with HIGH
Anticholinergic Activity
• Amitriptyline (Elavil®)
• Dimenhydrinate (Gravol®)
• Diphenhydramine (Benadryl®)
• Hydroxyzine (Atarax®)
• Paroxetine (Paxil®)
• Olanzapine (Zyprexa®)
• Oxybutynin (Ditropan®)

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 Beers List: Benzodiazepines

• Avoid if possible
• Challenging to stop for patients with long-term
use
• Long-acting
– Examples: diazepam, chlordiazepoxide,
clorazepate
– Longer half-life in elderly (days)
– Cause prolonged sedation and increase risk
of falls
• Short-acting
– Examples: lorazepam, oxazepam, temazepam
– Increased sensitivity in elderly
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 Beers List: Pain Medications

• Non-COX Selective NSAIDs

– Ibuprofen
– Naproxen
– Meloxicam
• Long-term use of NSAIDs may cause:
– Potential for GI bleed
– Renal failure
– Heart failure

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 Cardiovascular Agents

• Digoxin
– In Heart Failure, higher dose not associated with any
additional benefits (ie; ≥ 0.125mg per day)
– Can lead to digoxin toxicity
• ADRs: anorexia, N/V, abdominal pain, visual
disturbances, fatigue, dizziness, confusion, and
irregular heart beats
• Amiodarone
– Associated with QT prolongation
– Many monitoring parameters (LFTs, thyroid,
pulmonary function , etc)

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 Miscellaneous Agents

• Alpha-blockers i.e. doxazosin (Cardura®)

– Stress incontinence
• Antipsychotics, Anticholinergics, Muscle
relaxants (e.g. methocarbamol)
– Cognitive impairment
• Metoclopromide
– Tardive dyskinesia

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 Other High Risk Medications

• Insulin

• Warfarin

• Digoxin

• Benzodiazepines

• Opioids

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 Insulin

Drug Potential Harm Comment Monitoring

Insulin Hypoglycemia Aggressive • Blood sugars
glycemic • HbA1C
control may • Signs of
cause greater hypoglycemia
harm than such as sweating,
benefits in confusion,
older adults shakiness, fatigue

Note: Insulin Sliding Scale is now listed on the Beer’s

list and is best avoided in LTC

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 Warfarin

Drug Potential Harm Comment Monitoring

Warfarin • GI, intracranial Risk vs. benefits • INR
bleeding analysis should • Signs of
• Not receiving strongly be bleeding and
adequate dosage considered for bruising
may result in clot each patient
formation,
causing a stroke

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Steinman, M, and Hanlon, J. Managing Medications in Clinically Complex Elders. JAMA 2010; 304 (14): 1592-1601.
 Digoxin

Drug Potential Harm Comment Monitoring

Digoxin • Cognitive • Decreased • Electrolytes (Na+,
impairment renal K+)
• Heart block clearance can • Digoxin level
lead to • Renal function
digoxin • Signs of digoxin
toxicity toxicity (CNS and
cardiac adverse
effects)

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Steinman, M, and Hanlon, J. Managing Medications in Clinically Complex Elders. JAMA 2010; 304 (14): 1592-1601.
 Benzodiazepines

Drug Potential Harm Comment Monitoring

Benzo- • ↑ risk for Falls Associated with • Vitals
diazepines • Respiratory many side effects
Depression such as drowsiness,
confusion, increased
risk of falls

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Steinman, M, and Hanlon, J. Managing Medications in Clinically Complex Elders. JAMA 2010; 304 (14): 1592-1601.
 Opiates

Drug Potential Harm Comment Monitoring

Opiates • Sedation Doses of opioid • Vitals
• Respiratory should be titrated • Bowel
depression very slowly movement
• Nausea/Vomiting Residents should • Pain
• Constipation be on laxatives assessment

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Steinman, M, and Hanlon, J. Managing Medications in Clinically Complex Elders. JAMA 2010; 304 (14): 1592-1601.
 Antipsychotics

Drug Potential Harm Comment Monitoring

Anti- • Death High risk of • Behavioural
psychotics • Cardiovascular death when changes
side effects used to treat • EPS
behavioural • QT interval
complications of • Vitals
dementia

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Steinman, M, and Hanlon, J. Managing Medications in Clinically Complex Elders. JAMA 2010; 304 (14): 1592-1601.
 Strategies to Avoid Errors with
High-Risk Medications
• Checking blood glucose before administering
insulin for residents that do not eat regularly
• Using hypoglycemia protocol when needed
• Monitor INR more frequently during antibiotic
therapy or other medication changes
• Documenting BP, HR, and behavioural changes
• De-escalating and tapering medications when
appropriate
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 Summary

• Consider appropriate drug selection, dosing,

and monitoring of medications in the elderly
• Avoid high-risk medications if possible
– Beers List
– If a high-risk medication is used, monitor
appropriately
• Recognize medications that have high
anticholinergic activity
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 Back to “EW”…

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 Which of the following medications may be
causing sedation/dizziness?

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 References
• Besdine, Richard W. “Physical Changes with Aging”. The
Merck Manual, June 2009.
• Chandler, D, Presenter. “Managing Older Adults: High Risk
Medications-Increasing Awareness and Working to Improve
Patient Outcomes”. University of Buffalo, May 2012.
• The American Geriatrics Society 2015 Beers Criteria Update
Expert Panel. “American Geriatrics Society 2015 Updated
Beers Criteria for Potentially Inappropriate Medication Use
in Older Adults”. J Am Geriatr Soc 2015.
• Viana, L and Ebsary, S, Presenters. “Anatomic and
Physiologic Changes of Aging Persons”. Waterloo School of
Pharmacy, June 2010.

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 What questions may I answer
for you?

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 High Risk Medications
in the Elderly
Presented by: Fatima Ali, PharmD, RPh, BCPS
Consultant Pharmacist
MediSystem Pharmacy

Prepared by Disha Shah,

imedisystem.com Pharmacy Student
University of Waterloo, 2012