What not to prescribe to older adults and what to use instead

This transcript has been edited for clarity.

I’m Dr. Neil Skolnick. Today we’re going to talk about the updated 2023 American Geriatrics Society Beers criteria guideline for medication use in older adults. These criteria have been updated and revised approximately every 5 years since 1991 and serve to alert us to drugs for which the risk-benefit ratio is not as good in older adults as in the rest of the population.

These are important criteria because drugs are metabolized differently in older adults and have different effects compared to younger patients. For these criteria, older adults are 65 years of age or older. So we know that all 65 to 100 are not the same. As people age, they develop more comorbidities, become more frail, and are more sensitive to the effects and side effects of medications.

The guidance covers potentially inappropriate medicines for older adults. The word “potentially” is important because this is a guideline. As physicians, we make decisions that involve individuals. This guideline should be used with judgment, integrating the clinical context of the individual patient.

There is a lot in this guide. I will try to cover what I feel are the most important points.

Aspirin. Because the risk of major bleeding increases with age, for the primary prevention of atherosclerotic cardiovascular disease, the harm may outweigh the benefit in older adults, so aspirin should not be used for primary prevention. Aspirin remains indicated for secondary prevention in persons with established cardiovascular disease.

Warfarin. For the treatment of atrial fibrillation or venous thromboembolism (deep vein thrombosis or pulmonary embolism), warfarin should be avoided if possible. Warfarin has a higher risk of major bleeding, especially intracranial bleeding, than direct oral anticoagulants (DOACs); therefore the latter are preferred. Rivaroxaban should be avoided because it has a higher risk of major bleeding in older adults than other DOACs. Apixaban is preferred over dabigatran. If the patient is well controlled on warfarin, you may consider continuing that treatment.

Antipsychotics. These include first- and second-generation antipsychotics such as aripiprazole, haloperidol, olanzapine, quetiapine, risperidone, and others. The guideline says to avoid these agents except for FDA-approved indications such as schizophrenia, bipolar disorder, and adjuvant treatment of depression. Use of these antipsychotics may increase the risk of stroke, heart attack, and death. Essentially, the guideline says not to use these drugs lightly for the treatment of agitated dementia. For those of us with elderly patients, this can be tricky because dementia anxiety is a difficult issue for which there are no good effective drugs. The Beers guideline recognizes this by saying that these drugs should be avoided unless behavioral interventions have failed. So there are times when you may need to use these drugs, but use them judiciously.

For patients with dementia, anticholinergics, antipsychotics, and benzodiazepines should be avoided if possible.

Benzodiazepines. Benzodiazepines should also be avoided because older adults have an increased sensitivity to the effects of benzodiazepines due to slower metabolism and clearance of these drugs, which can lead to much longer half-lives and higher serum levels. In older adults, benzodiazepines increase the risk for cognitive impairment, delirium, falls, fractures, and even motor accidents. The same concern affects the group of non-benzodiazepine sleep medications known as “Z-drugs.”

Nonsteroidal anti-inflammatory drugs (NSAIDs). Used frequently in our practices, NSAIDs are still on the list. As we consider the risk-benefit ratio of NSAID use in older adults, we often underestimate the risks of these agents. Upper gastrointestinal ulcers with bleeding occur in approximately 1% of patients treated for 3-6 months with NSAIDs and in 2%-4% of patients treated for 1 year. NSAIDs also increase the risk of kidney damage and cardiovascular disease.

Other medicines to avoid (if possible). They include:

  • Sulfonylurea, due to high risk of hypoglycemia. If necessary, a short-acting sulfonylurea such as glipizide should be used.

  • Proton pump inhibitors should not be used long-term if this can be avoided.

  • Digoxin should not be first-line treatment for atrial fibrillation or heart failure. Decreased renal clearance in older adults can lead to toxic levels of digoxin, especially during acute illness. Avoid doses > 0.125 mg/day.

  • Nitrofurantoin should be avoided when the patient’s creatinine clearance is < 30 or for long-term suppressive therapy.

  • Avoid combining drugs that have high anticholinergic side effects, such as scopolamine, diphenhydramine, oxybutynin, cyclobenzaprine, and others.

It is always important to understand the benefits and risks of the drugs we prescribe. It is also important to remember that older adults are a particularly vulnerable population. The Beers criteria provide important guidelines that we can then use to make medication decisions for individual patients.

I’m interested in your thoughts; please leave them in the comments section.

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