Prescribing Medicines to Geriatric Patients: American Geriatrics Society 2023 Updates
M3 India Newsdesk Nov 28, 2023
Explore medication challenges in elderly care with insights from the updated Beers Criteria. Learn about risks and considerations for drugs like aspirin, warfarin, antipsychotics, benzodiazepines, and NSAIDs, emphasising personalised care.
Certain pharmacological classes, such as analgesics, anticoagulants, antihypertensives, antiparkinsonian medications, diuretics, hypoglycemic medications, and psychotropic medications, provide unique dangers to the elderly population. Certain medications have significant risks and should not be prescribed to older persons, even when they are suitable for use in younger adults.
The most widely used criteria for identifying such inappropriate medicines are the Beers Criteria of the American Geriatric Society.
The updated Beers Criteria of the American Geriatrics Society (2023) provided pertinent recommendations regarding the administration of medications to the elderly. Since 1991, these guidelines have been updated and changed almost every five years. They help identify drugs for which the risk-benefit ratio in older persons is not as excellent as it is in the general population.
These criteria hold significance due to the fact that medications undergo distinct metabolic processes in elderly individuals and elicit varied effects in comparison to younger patients. Older adults are those who are 65 years of age or older for the purposes of these criteria. Nevertheless, we are aware that no two people—65 or 100—are alike. People get frailer, have more comorbidities, and are more susceptible to the negative effects and side effects of medications as they age.
The recommendations address drugs that may not be suitable for elderly patients. The fact that this is a guideline makes the term "potentially" significant. Making judgements concerning persons is what we do as physicians. Using caution and taking into account each patient's unique clinical circumstances, this advice should be followed.
This advice covers a lot of ground. This article will attempt to address the key aspects.
Aspirin should not be taken for primary prevention of atherosclerotic cardiovascular disease in older persons due to the increased risk of severe bleeding, which may outweigh any potential benefits.
When used in conjunction with secondary prevention, aspirin is still recommended for those who already have cardiovascular disease.
Warfarin should be avoided if feasible while treating atrial fibrillation or venous thromboembolism (deep vein thrombosis or pulmonary embolism).
Since direct oral anticoagulants (DOACs) reduce the risk of significant bleeding, especially cerebral haemorrhage, they are favoured over warfarin. Compared to other DOACs, rivaroxaban has a greater risk of significant bleeding in older persons, which is why it should be avoided.
Consider maintaining a patient's warfarin medication if it is well managed.
- Other first- and second-generation antipsychotics
According to the guidelines, these drugs should not be used for anything other than FDA-approved conditions such as schizophrenia, bipolar disorder, and depression adjuvant therapy.
The risk of stroke, heart attack, and death may rise with the use of certain antipsychotics. In essence, the recommendations state that these drugs should not be used carelessly for treating agitated dementia.
This may become complicated for those of us who care for elderly individuals since agitated dementia is a challenging condition for which there are no excellent, efficient treatments.
This is acknowledged in the Beers recommendation, which states that these drugs should not be used until behavioural therapies have failed. Therefore, you may occasionally need to take these medications; just use them sparingly.
Anticholinergics, antipsychotics, and benzodiazepines should be avoided if at all feasible for individuals suffering from dementia.
Additionally, older persons should avoid benzodiazepines since they are more susceptible to their effects owing to slower metabolism and clearance, which may result in a considerably longer half-life and greater blood level.
Benzodiazepines increase the risk of falls, fractures, delirium, cognitive impairment, and even auto accidents in older persons. "Z-drugs," a kind of non-benzodiazepine sleeping pills (Zopiclone, eszopiclone, zaleplon and zolpidem), are also subject to these problems.
NSAIDs, or nonsteroidal anti-inflammatory medications
NSAIDs are on the list even though they are used regularly in our practices. We often underestimate the dangers associated with NSAID use in older persons when weighing the risk-benefit ratio.
About 1% of individuals treated with NSAIDs for three to six months and 2% to 4% of patients treated for a year get upper gastrointestinal ulcers with bleeding. NSAIDs raise the risk of cardiovascular disease and renal impairment as well.
Other drugs to stay away from (if at all feasible). Among them are:
- Sulfonylureas, because of the increased risk of hypoglycemia. If glipizide or any short-acting sulfonylurea is required, it should be used.
- If at all possible, proton pump inhibitors should not be administered for an extended period of time.
- If you have heart failure or atrial fibrillation, digoxin shouldn't be your primary line of therapy. Digoxin poisoning in elderly persons may result from decreased renal clearance, especially in the event of an acute illness. Don't take more than 0.125 mg daily.
- If a patient is on long-term suppressive treatment or their creatinine clearance is less than 30, they should avoid using nitrofurantoin. Steer clear of mixing drugs with a high incidence of anticholinergic adverse effects, such as oxybutynin, cyclobenzaprine, diphenhydramine, scopolamine, and others.
It's critical to comprehend both the advantages and disadvantages of the medications we recommend. It's also important to keep in mind that elderly people are a demographic that is especially susceptible. We may use the Beers criterion to make crucial judgements regarding the medications that are best for each patient.
Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.
About the author of this article: Dr Monish Raut is a practising super specialist from New Delhi.
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