1Arch Intern Med.2003;163:2716-2724. 2JAMA.2006;296:1858-1866.

The Most Common Cause of Adverse Medication Events that Result in

Emergency Department use in the Elderly:

Hypoglycemic agents: Decreased renal clearance leads to drug accumulation and hypoglycemic episodes. Ask patients about signs and symptoms of hypoglycemia.

Digoxin (Lanoxin): Accumulates in the elderly population can lead to toxicity (nausea, anorexia, vomiting, and rarely yellow vision). Digoxin should be dosed at ≤ 0.125mg/day unless treating atrial arrhythmias. Ask patients about nausea, anorexia, vomiting and, if present, check a digoxin level.

Warfarin (Coumadin): Make sure all patients on warfarin are enrolled in pharmaco- therapy clinic.

Amiodarone (Cordarone): A major CYP-3A4 inhibitor resulting in multiple drug-drug interactions. Dose reductions are necessary for many medications including: Warfarin- 35-65% dose reduction, Digoxin- 50% dose reduction and Simvastatin- maximum dose of 20 mg.

NSAIDs: Increase incidence of GI bleed, acute renal failure and HTN in the elderly with Risk factors for GI bleed: >75 years of age, previous GI bleed, concomitant use of warfarin, long term glucocorticoid use, history of PUD. Risk factors warrant therapy with misoprostol or PPI.

Herbal products: Not regulated by FDA, many have the potential to be dangerous. Rarely considered by patients as medications and their use is often not discussed with a physician.Garlic and Gingko Biloba: Increase bleeding timeSt John’s Wort: Increased clearance of medications metabolized through CYP3A4Chromium, Gingko Biloba, Nettle: Hypoglycemia

Know what your patients are taking and evaluate for potential harm.

Other agents commonly associated with ED visits and hospitalizations in the elderly: 2

• Opioid and non-opioid analagesics• Antibiotics• ACE Inhibitors/ARBs• Antihistamines• Decongestants/Cold remedies

Medication Use and Safety in the ElderlyAmericans aged 65 and over consume 30% of all prescriptions and 40% of all OTC

medications. They are at higher risk for adverse drug events, drug-drug interactions, and therapeutic duplication.

Potentially Unsafe Medications in the Elderly1:

Pain Relievers: Propoxyphene and combination products(Darvon®, Darvocet N-100®,

Meperidine (Demerol®)Muscle Relaxants:

Carisoprodol (Soma®), cyclobenzapine (Flexeril®), metaxalone (Skelaxin®)

Antidepressants: Tricyclic Antidepressants (TCAs): ie, amitriptyline,(Elavil®),

Fluoxetine (Prozac®)Sleeping Pills and Antianxiety Medications:

Benzodiazepines: ie, Alprazolam (Xanax®), lorazepam (Ativan®), zolpidem (Ambien®)Heart Medications:

Digoxin (Lanoxin®) doses above 0.125 mg Dipyridamole (Persantine®), Methyldopa (Aldomet®), Amiodarone (Cordarone®)

Diabetes Medications: Glipizide (Glucotrol®), glyburide (Diabeta®), glimiperide

(Amaryl®), insulinStomach and Intestinal Medications:

Dicyclomine (Bentyl®),hyoscyamine (Levsin®), promethazine (Phenergan®)

Antihistamines: Chlorpheniramine (Chlor-Trimeton®), diphenhydramine

(Benadryl®), hydroxyzine (Vistaril®, Atarax®), cyproheptadine (Periactin®)

Potentially Unsafe Medications Given Disease States1:

Constipation: Calcium channel blockers Cognitive Impairment:

Anticholinergics, antispasmodics, muscle relaxantsParkinson’s Disease:

Metoclopramide (Reglan®), AntipsychoticsSIADH/ Hyponetrenia: SSRIs Bladder Outflow Obstruction:

Anticholinergics, antihistamines, antispasmodicsSyncope/Falls:

Tricyclic antidepressants, Benzodiazepines

Challenges in Prescribing for the Elderly:

•Multiple chronic medical problems•Multiple medications and prescribers•Different metabolism and responses•Supplements, herbals and OTC drugs are commonly used

Physiologic changes associated with normal aging:

•Less body water•More body fat•Less muscle mass•Slowed hepatic metabolism•Decreased renal excretion•Decreased responsiveness and sensitivity of the baroreceptor reflex

Dangers of Multiple Medications “Polypharmacy”:

•Adverse effects•Drug-drug interactions•Duplication of drug therapy•Poor adherence

•Cost•Decreased quality of life

Adverse Drug Events (ADEs):

•Adverse symptoms•Adverse patient outcomes leading to:

•ED visits and hospitalizations•Falls•Functional decline•Changes in cognition•Death

Risk Factors for ADEs:• >6 disease states•>12 doses/day•>9 medications•BMI <22 kg/m2

•Creatinine clearance <50 mL/min•Female

Funded by: DW Reynolds Foundation