Senior Health

Prescription Medication in the Elderly

Background
The Risks in Using Multiple Medications
Medications that Pose a Risk and Why
Special Considerations: Drugs Affecting the Central Nervous System
General Advice for the Elderly Population
References

Background

Elderly people are at a high risk of experiencing problems with drug therapy due to:

Age-related changes in the body (i.e., loss of organ function).
Exposure to many medications due to multiple health problems.
Social circumstances such as living alone, difficulty in visiting their primary physician and affordability of prescription medications.
Failure to comply with the complicated drug treatment plan and poor understanding of the drug treatment.
Confusion resulting from the use of multiple medications, memory problems and failing vision leading to impaired functioning.

Elderly patients take about three times as many medications as younger patients do.¹ They are also the greatest consumers of prescribed and nonprescribed medications.² There has been a gradual increase in prescription drug use in the United States. According to the Medicare, the average number of prescriptions per year, including refills, is currently 28.5 per senior (up from 19.6 in 1992). The average cost per prescription has also jumped from $28.50 in 1992 to $42.30 in 2000, an increase of 48%. Since the elderly have less participation in drug trials, there is insufficient information on the side effects and adverse reactions of drugs on the elderly. As a result, older patients have to rely on general guidelines with information extrapolated from other age groups to make decisions regarding prescription drug use.¹

The Risks in Using Multiple Medications

Prescription medications can improve the symptoms of a disorder and improve the quality of life. However, they also have the potential to cause dangerous side effects. A good guideline followed by physicians who prescribe medications to the elderly is to "start low and go slow," meaning the elderly should take new medications at a slower rate and start at about half the adult dose. As our bodies change with age, so does the need for a different dosage, interval and duration of treatment. The longer an individual is on a drug, the greater the likelihood of an adverse reaction. The effects of a harmful drug reaction can appear as an isolated symptom (drowsiness) or as a group of symptoms (depression and confusion). In the elderly, toxic reactions can occur even at low drug dosages. Therefore, the elderly should approach the use of prescription medication with caution and report any unusual or new symptoms to their health care provider. It is important to consult a health care provider before changing any prescription medication dosage.

Medications that Pose a Risk and Why:⁴

(Medications listed below are to be avoided or need close monitoring)

Medications of Risk	Problems
Benzodiazepines (antianxiety), Long acting agents Diazepam (Valium) Flurazepam (Dalmane ) Chlordiazepoxide (Librium) Alprazolam (Xanax) Barbiturates	Confusion, sedation and falls.
Antidepressants (used to treat depression), Amitryptiline (Elavil) Doxepin (Sinequan) Imipramine (Tofranil)	Confusion, sedation, hypotension, falls, and urinary retention.
Antipsychotic Agents (used to treat mental disorders) Chlorpromazine (Thorazine) Thioridazine (Mellaril) Haloperidol (Haldol)	Confusion, sedation, hypotension, falls, urinary retention, Parkinsonism (involuntary shaking and twitching), tardive dyskinesia (TD).
Antihistamines (used to treat sinus problems and allergies) Diphenhydramine (Benadryl) Hydroxyzine (Vistaril)	Confusion, sedation, hypotension, falls, and urinary retention (inability to empty bladder), sleep disturbance.
Antiemetics (used to relieve nausea) Promethazine (Phenergan) Prochlorperazine (Compazine) Thiethylperazine (Torecan)	Confusion, sedation, hypotension, falls, urinary retention, Parkinsonism (involuntary tremors and rigidity), involuntary movement (tardive dyskinesia)
Analgesics (used to relieve pain) Propoxyphene (Darvon) Meperidine (Demerol)	Constipation, confusion, & sedation.
Antiparkinsonian (used to treat Parkinsons disease) Carbidopa-Levodopa (Sinemet)	Confusion, dizziness, hypotension, increase in cardiovascular toxicity.
Cardiovascular drugs (used to treat heart and blood vessels) Digoxin (Lanoxin) Warfarin (Coumadin)	Nausea, vomiting, anorexia, weight loss.Bleeding tendencies (requires close monitoring)
Antispasmodic drugs (used to prevent or relieve spasms) Dicyclomine (Bentyl) Hyoscyamine (Levsin, Levsinex) Pro-Banthine (Propantheline)	Dry mouth, constipation, urinary retention, delirium.
Urinary Incontinence drugs Oxybutynin (Ditropan) Tolterodine (Detrol)	Dry mouth, constipation, urinary retention, delirium, confusion

Special Considerations: Drugs Affecting the Central Nervous System

Psychoactive drugs have an effect on the brain and are among the most frequent medications given to the elderly. Elderly patients generally require lower doses of psychoactive drugs, in some cases one-fourth to one-half the dose of a younger patient.³	Examples of Psychoactive Drugs: Anti-psychotics Anti-anxiety drugs Sedatives/hypnotics Anti-depressants
Psychoactive drugs are not the only type of medication that can produce dangerous side effects. Drugs that relieve pain (analgesics), drugs that act on the heart and blood vessels (cardiovascular drugs), drugs that relieve nausea (anti-emetics), and drugs that relieve allergies (antihistamines) also have the potential to produce negative side effects by acting on the brain.

Common Reasons for Overmedication by Health Care Providers:³

Social, economical, psychological, and medical reasons also play a part in overmedication or polypharmacy.

Desire to help - Health care providers want to lessen the suffering of their patients and they often prescribe drugs to do so. Although not all symptoms, conditions or behavior should be treated with drug therapy, there are conditions, such as depression, which occurs with increasing frequency in the elderly and should be treated. However, non-pharmacological approaches should be tried first, and in conjunction with medications, since they work for many common conditions like high blood pressure, diabetes mellitus, heart disease, and urinary incontinence.

Belief drugs will produce desired results - This belief is embedded in traditional medical training. Often, the medications are given credit for treating symptoms when, with time, the symptoms of many ailments would have resolved on their own.

Underestimating the side effects of a drug - The side effects of psychoactive drugs are gradual and hard to detect early on in the treatment process. Psychoactive drugs have also been strongly linked to the risks of falling. This is a serious side effect since falls are the leading cause of fatal and nonfatal injury in people 75 years and older.

Psychoactive drugs have also been linked to the risks of falling and hip fractures.

Behavioral changes - Centrally acting or psychoactive drugs themselves occasionally lead to behavioral problems and confusion.

Patient Demand - Some patients and family members are reluctant to discontinue medication use. This is especially true for some elderly patients because their medication becomes a symbol of care. ² As a result, there is a belief in the effectiveness of a drug ('more is better'), though it may have the potential to produce side effects.

Lack of Training in Non-pharmacological Approaches to Treatment - It is much easier to write a prescription for an ailment then to explore alternative approaches.

Influence of media and the drug manufacturers - Busy health care providers often rely on pharmaceutical company advertising and distributed literature for information about prescription medication. Drug manufacturers often highlight the benefits while downplaying the potential dangers of a drug. In addition, the media often encourages the public to contact their physician for new prescription medications.

General Advice for the Elderly Population

Try non-pharmacological approaches such as walking or regular activity or exercise, getting adequate sleep, quitting smoking, consuming alcohol in moderation and dietary changes toward a healthier lifestyle.

Alternatives To Using Hypnotics:

Get enough sleep. Go to bed and wake up at a fixed time.
Omit caffeine after 1:00 p.m.
Exercise and avoid daytime napping.
Avoid alcohol use close to bed time.

Alternatives To Using Laxatives:

Eat a high fiber diet.
Drink plenty of water.
Exercise regularly.
Identify medications causing constipation.

Alternatives To Using Urinary Incontinence Drugs:

Try bladder training and pelvic exercises.
Schedule a trip to the bathroom every two hours while you are awake.
Treatment of urinary infections with antibiotics.
Consider other medical conditions and medications causing incontinence.

'Start low and go slow' when taking a new prescription medication under the instruction of your physician.
Report any medications including herbal and over-the-counter (OTC) products you may be taking to your health care provider as many of them are not without adverse effects.
4. Make a list of medications you are taking and present it to your physician during your office visit.
Avoid over-the-counter (OTC) medications, if central nervous system related side effects, such as drowsiness and dizziness or other herb/drug interactions are possible with the product.

Over The Counter (OTC) Medications
Inform your health provider about all OTC products. Avoid such products if central nervous system side effects and other herb/drug interactions are possible.
Consult the Web sites Herbalgram, Food and Drug Administration, or Alternative Medicine Alert (800-688-2421) for information.

Know the following important things about your medication:

Medication name, exact spelling, purpose, and whether it is the brand name or a generic substitution (many medications have similar sounding names).
Medication's side effects or drug interactions, and what to do if they occur. Report any new symptoms to your physician.
How and when to take the medication (i.e. on an empty stomach, after meals, or at bed time).
How long the treatment with the medication is to be continued and if any blood tests are required for periodic monitoring.
What to do if you miss or forget a dosage.
How to store your medications in a refrigerator or at room temperature.

Never share your prescription medications or take medications prescribed for someone else.
Keep all medication out of the reach of (grand) children.
Maintain the continuity of care by having a primary physician, usually a family physician or general internist. Also get all of your prescription medication from one pharmacy.
Have a medication set, or medi-set, (a box which holds prescription medication with the days of the week written on each compartment) to help you remember your medication. Have caregivers supervise your medications if you start to experience memory problems.

References

Shaughnessy, F., Allen, Anderson, J., Robert, 1995. "Drug Prescribing for the Elderly." Family Practice Recertification VOL 17, No. 11: 62-69.
United States Pharmacopeia, 2000. "Guiding Principles for Enhancing the Likelihood of Positive Medication Use Outcomes in Geriatric Patients." The United States Pharmacopeial Convention.
Sherman, D. 1994. "Geriatric Psychopharmacotherapy: Issues & Concerns." Generations: Journal of The American Society on Aging VOL 18 no. 2: 34-39.
Beers, MH. "Explicit Criteria for Determining Inappropriate Medication Use By The Elderly." Arch Intern Med. 1997; 157: 1531-1536

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Last Reviewed: Dec 15, 2000

Arvind Modawal, MD, MPH, MRCGP
Professor of Family & Community Medicine, Geriatrics and Palliative Care
College of Medicine
University of Cincinnati