Potentially Inappropriate Medication Use in Older Adults 2015
|Drugs and Categories of Drugs||What these drugs are commonly used to treat||Why these drugs may be
inappropriate for older adults
|Anticholinergic drugs These drugs can cause numerous side effects in older adults including confusion, sleepiness, blurred vision, difficulty urinating, dry mouth, and constipation.|
||Used for allergies, hives and eczema, and as sleep aids. They are commonly included in over-the-counter cough, cold, and sleep aid remedies.||These drugs cause many side effects in older adults, including confusion, drowsiness, blurred vision, difficulty urinating, dry mouth, and constipation. Safer medications are available.||
Use of diphenhydramine in special situations, such as for treating severe allergic reactions, may be appropriate.
"Second- and Third-Generation" Antihistamines such as loratadine (Claritin), fexofenadine (Allegra), cetirizine (Zyrtec), and desloratadine (Clarinex) are not considered "drugs to avoid."
||Used to treat Parkinson's disease and related health problems.||There are other medications that are usually more effective for Parkinson's disease and related disorders. The drugs should not be used for treating side effects of other medications; for example, abnormal movements caused by antipsychotic medications.||Avoid.|
||Used to relieve intestinal cramps or spasms.||It is not clear whether these drugs are effective. They have side effects including confusion, drowsiness, blurred vision, difficulty urinating, dry mouth, and constipation.||Avoid.|
|Drugs to reduce the risk of blood clots (Antithrombotics)|
||Used to reduce blood clots.||Dipyridamole can increase the chance of dizziness, fainting, and falling. More effective alternatives are available.||
Use of dipyridamole in its intravenous form acceptable for use in cardiac stress testing.
|Drugs used to treat infections (Antibiotics)|
|Nitrofurantoin||Used to treat urinary tract infections.||This drug may cause side effects that affect the lungs and other organs. Safer medications are available.||
Avoid daily use over many months to suppress urinary infections. Short-term use, for example to treat individual episodes of urinary infection, is reasonable.
Also avoid use in older adults with moderately severe decreases in kidney function.
|Drugs for disorders of the heart and blood vessels|
|Peripheral Alpha-1 blockers
||Used to treat the prostate, also sometimes prescribed for high blood pressure.||When used to treat blood pressure, alternative treatments provide better results with lower risks.||Avoid using to treat high blood pressure. Use to treat urinary symptoms from an enlarged prostate is reasonable.|
|Central alpha blockers (Alpha agonists)
||Used to treat high blood pressure, and sometimes for other conditions.||These drugs may cause a slow heartbeat and dizziness. They are not recommended for routine treatment of high blood pressure.||Clonidine should not be a first-choice treatment for high blood pressure. The other drugs on the list should be avoided.|
|Disopyramide||Used to treat abnormal heart rhythms.||This drug may cause heart failure in older adults. Potential side effects include confusion, drowsiness, blurred vision, difficulty urinating, dry mouth and constipation. Other antiarrhythmic drugs are preferred.||Avoid.|
|Dronedarone||Used to treat abnormal heart rhythms.||There is a higher risk of bad outcomes from this drug in people with persistent atrial fibrillation or who have severe or recently worsened heart failure.||Avoid in older adults with persistent atrial fibrillation or who have severe or recently worsened heart failure.|
|Digoxin||Used to treat atrial fibrillation and heart failure.||In older patients with atrial fibrillation and heart failure, there are more effective and safer alternatives. In heart failure, higher doses may increase risk of toxicity without providing additional benefit. Dose reduction is also important in older adults with reduced kidney function.||Avoid as first choice for treatment of atrial fibrillation or heart failure. If used, avoid doses higher than 0.125 mg per day.|
|Nifedipine, immediate release||Used to treat high blood pressure.||This drug may cause dangerously low blood pressure and can cause heart problems.||
The long-acting (once-daily) form of Nifedipine is reasonable to use.
|Amiodarone||Used to treat abnormal heart rhythms.||Amiodarone frequently causes serious side effects including thyroid, lung, and eye problems.||Avoid as first choice for treating most older adults with atrial fibrillation. It may be a reasonable first choice in older adults with atrial fibrillation who also have heart failure or an enlarged heart (known as "left ventricular hypertrophy").|
|Drugs affecting the brain and nervous system|
|Certain Antidepressants, alone or in combination:
||Used to treat depression, insomnia, and nerve pain.||Potential side effects include confusion, drowsiness, blurred vision, difficulty urinating, dry mouth and constipation. These drugs can also cause a drop in blood pressure and dizziness when you stand up. Safer medications are available.||Avoid.|
|Antipsychotic drugs||Often used to treat behavioral problems in older adults with dementia. Also used for other mental health conditions.||These drugs increase risk of stroke and death in older adults with dementia.||
Avoid using these drugs to treat behavioral problems in older people with memory disorders unless non-drug options haven't worked and the person is a threat to him/herself or others.
These drugs may be acceptable for short-term use to help with nausea and vomiting during chemotherapy , and in special cases of severe mental illness.
Short- and intermediate-acting
|Used to treat anxiety and sleep disorders.||These drugs can be highly addictive and have a higher risk of overdose even at low doses.||Avoid.|
Short- and intermediate-acting:
|Often used to treat anxiety and insomnia. Also used for other conditions including epilepsy and as a relaxant during medical procedures.||Older adults are especially sensitive to these medications. These drugs may increase risks of cognitive impairment, delirium, falls, fractures, and car accidents in older adults.||
Avoid benzodiazepines (all types) except in the specialized circumstances listed below.
These drugs may be appropriate in certain circumstances including the treatment of seizures, certain specialized sleep disorders, severe anxiety disorders, withdrawal from benzodiazepine drugs and alcohol, at the time of medical and surgical procedures, and in end-of-life care.
|Meprobamate||Used to treat anxiety.||This drug is highly addicting and also causes sleepiness.||Avoid.|
|Non-benzodiazepine , benzodiazepine receptor agonist hypnotics
||Used for insomnia.||These medications have harmful effects similar to the benzodiazepines (listed above). They provide only minimal improvement in sleep for many older adults.||Avoid.|
|Ergoloid mesylates (dehydrogenated ergot alkaloids) Isoxuprine||Used to relax and widen blood vessels for better circulation.||These drugs are not very effective.||Avoid.|
|Medications for hormonal conditions|
||Used to treat men with symptoms of low testosterone.||These drugs may cause heart problems. They also may promote growth of prostate cancer in men with this condition.||Use only for moderate to severe declines in natural testosterone production, as determined by laboratory tests and with symptoms of low testosterone. Avoid using in men with prostate cancer.|
|Desiccated thyroid||Used to treat underactive thyroid.||This drug may cause heart problems. There are safer alternatives available.||Avoid.|
|Estrogens with or without progestins||Used to treat women with hot flashes and vaginal atrophy and dryness.||These hormones may increase risks of breast cancer and cancer of the lining of the uterus. They don't appear to help protect women from heart disease or loss of cognitive (thinking) ability in later life. Estrogen cream inserted into the vagina can help vaginal dryness and is safe in women with breast cancer, especially if low doses are used.||Avoid pills and skin patches. Vaginal estrogen creams can be used at low doses to relieve pain during sex and other vaginal problems, and to prevent urinary tract infections.|
|Growth hormone||Sometimes used as an anti-aging therapy.||Growth hormone has many side effects, including joint pain, swelling, enlargement of breast tissue in men, and carpal tunnel syndrome. It may also increase the chance of getting diabetes.||Avoid, except in people who have had their pituitary gland removed.|
|Insulin, sliding scale||Used for diabetes.||"Sliding scale" insulin refers to the use of short-acting insulin, which is dosed depending on blood sugar at the time, without also using a long-acting insulin given at a regular dose each day. Using the "sliding scale” approach is not very effective and can increase the chance of dangerously low blood sugar.||Avoid.|
|Megestrol||Used for unintentional weight loss.||This drug is not very effective at helping people gain weight, and may increase the chance of blood clots and death.||Avoid.|
||Used for diabetes.||Both medications can cause dangerous low blood sugar and other side effects in older adults. Safer medications are available.||Avoid.|
|Medications for gastrointestinal problems|
|Metoclopramide||Used to treat slow stomach emptying (gastroparesis), certain types of nausea, vomiting, and heartburn, and migraines.||This medication may cause shakiness, sleepiness, and uncontrollable abnormal body movements. Frail older adults may be more likely to get these effects.||Avoid, except for gastroparesis, a condition in which the stomach is very slow to empty its contents.|
|Mineral oil, taken by mouth||Used for constipation.||When taken by mouth, mineral oil may be accidentally swallowed into the lungs and cause pneumonia. Safer medications are available.||Avoid.|
|Proton pump inhibitors||Used to treat gastroesophageal reflux (heartburn) and to protect against bleeding stomach ulcers.||These medications can increase the risk of developing C. difficile colitis, a dangerous intestinal infection. They can also increase the risk of bone loss and fractures. Many older adults get started on these medications and never stop, even when they don’t need the medication any more.||
Avoid daily use for more than 8 weeks unless there is a strong reason to continue. Strong reasons to continue include protection for people at higher risk of bleeding stomach ulcers, for example due to regular use of non-steroidal anti-inflammatory drugs.
Other strong reasons include treatment of esophageal irritation, and treatment of gastroesophageal reflux (heartburn) in people who need continuing use of these medications to control their symptoms.
|Pain medications and muscle relaxants|
|Meperidine||Used to treat pain.||Not a very effective pain reliever for older adults, and often has toxic effects on the brain. Safer medications are available.||Avoid, especially for in older adults with chronic kidney disease.|
|Non-COX-selective NSAIDs, oral:
||Used to treat pain and inflammation.||These painkillers increase the risk of bleeding stomach ulcers. People above age 75 years old or who use blood thinners or oral steroids are at especially high risk.||Avoid regular long-term use, unless other alternatives are not effective and the older adult can take a stomach-protecting drug such as a proton-pump inhibitor or misoprostol. These stomach-protecting drugs reduce but do not eliminate the risk of stomach bleeding.|
|Indomethacin Ketorolac (including when given through a needle)||Used to treat pain and inflammation.||These NSAIDs have particularly high rates of serious side effects, including stomach bleeding . Indomethacin is more likely than other NSAIDs to cause headaches, dizziness, and other adverse effects on the nervous system. Kertorolac has particularly high rates of serious side effects, including stomach bleeding.||Avoid.|
|Pentazocine||Used to treat moderate to severe pain.||This opioid (narcotic) drug can cause confusion and hallucinations more than other opioids. Safer alternatives are available.||Avoid.|
|Skeletal muscle relaxants
||Often used to treat low back pain and muscle spasms.||Most muscle relaxants have high risk of causing side effects in older adults, including sedation and increased risk of fractures. Their effectiveness at doses commonly used is questionable.||Avoid.|
|Drugs for the urinary tract|
|Desmopressin||Used to treat nighttime urination and certain causes of excessive urination.||High risk of causing dangerously low sodium levels in the blood. Safer alternatives are available.||Avoid as treatment for nighttime urination.|