Geriatrician interventions on medication prescribing for frail older people in residential aged care facilities

Figures & data

Table 1 High-risk medications list

Medication	ATC codes	Main concerns	References
Analgesics, anti-inflammatory
NSAID
Aspirin >325 mg/day	N02BA01	– Very high risk of gastrointestinal hemorrhage, ulceration, or perforation, which may be fatal	^Citation11
Diclofenac	M01AB05	– Risk of renal toxicity especially in patients with preexisting chronic	^Citation11
Ketoprofen	M01AE03	kidney disease	^Citation11,Citation14
Ketorolac	M01AB15		^Citation11,Citation12
Mefenamic acid	M01AG01	– Risk of fluid retention and fluid overload leading to decompensated	^Citation11,Citation12
Meloxicam	M01AC06	heart failure in patients with underlying cardiac dysfunction	^Citation11,Citation14
Naproxen	M01AE02		^Citation11
Piroxicam	M01AC01	– Indomethacin may also have CNS side effects	^Citation11,Citation12,Citation14
Indomethacin	M01AB01		^Citation11^–^Citation14
Etoricoxib	M01AH05		^Citation14
Ibuprofen	M01AE01		^Citation11
Opioid analgesics
Pethidine	N02AB02	– Elevated risk of delirium and falls	^Citation11,Citation12,Citation14
		– Risk of neurotoxicity
Antiarrhythmic
Amiodarone	C01BD01	– Predisposition to bradycardia and heart block	^Citation11
Flecainide	C01BC04	– Pro-arrhythmic effects	^Citation11,Citation14
Sotalol	C07AA07	– Pro-arrhythmic effects	^Citation11,Citation14,Citation15
Disopyramide	C01BA03	– Potent negative inotropic effects predisposing to heart failure	^Citation11^–^Citation13
		– Anticholinergic activity
Digoxin >0.125 mg/day	C01AA05	– Risk of toxicity especially in presence of renal insufficiency	^Citation11,Citation13,Citation14
Nifedipine	C08CA05	– Potential for postural hypotension	^Citation11,Citation13,Citation14
		– Short-acting formulations associated with increased mortality in elderly patients
Spironolactone >25 mg/day	C03DA01	– Risk of hyperkalemia	^Citation11
Diltiazem	C08DB01	– Potential to promote fluid retention and exacerbate heart failure	^Citation11
Verapamil	C08DA01		^Citation11
Antibiotics
Nitrofurantoin	J01XE01	– Long-term use associated with pulmonary side effects, renal impairment, liver damage	^Citation11,Citation13,Citation14
Anticholinergics
Antihistamines
Chlorpheniramine	R06AB02	– Risk of anticholinergic effect: constipation, dry mouth, visual disturbance, bladder dysfunction	^Citation11,Citation14
Cyproheptadine	R06AX02		^Citation11,Citation13
Dexchlorpheniramine	R06AB02	– Clearance reduced with advanced age	^Citation11,Citation13,Citation15
Diphenhydramine	R06AA02	– Increased risk of confusion and sedation, impaired cognitive performance	^Citation11,Citation13,Citation14
Doxylamine	R06AA09		^Citation11,Citation13,Citation14
Promethazine	R06AD02		^Citation11,Citation13,Citation15
Antiparkinson agents
Benztropine	N04AC01	– Risk of anticholinergic side effects	^Citation11
		– Not recommended for prevention of extrapyramidal symptoms due to antipsychotics
Antispasmodics
Propantheline	A03AB05	– Highly anticholinergic, uncertain effectiveness	^Citation11
Oxybutynin	G04BD04	– Anticholinergic side effects	^Citation11,Citation13,Citation14
Solifenacin	G04BD08	– ECG changes (prolonged QT)	^Citation11,Citation13,Citation14
Tolterodine (non-sustained release)	G04BD07		^Citation11,Citation13,Citation14
Antithrombotics
Dipyridamole (short-acting)	B01AC07	– Risk of orthostatic hypotension	^Citation11^–^Citation13
Warfarin	B01AA03	– Increased risk of bleeding	^Citation11,Citation14
Prasugrel	B01AC22		^Citation11,Citation14
Ticlopidine	B01AC05		^Citation11,Citation14
Antidepressants
TCA
Amitriptyline	N06AA09	– Peripheral anticholinergic side effects (eg, constipation, dry mouth, orthostatic hypotension, and cardiac arrhythmia)	^Citation11^–^Citation15
Clomipramine	N06AA04		^Citation11,Citation13^–^Citation15
Doxepin (>6 mg)	N06AA12	– Central anticholinergic side effects (drowsiness, inner unrest, confusion, other types of delirium)	^Citation11,Citation13^–^Citation15
Imipramine	N06AA02	– Cognitive impairment	^Citation11^–^Citation14
Nortriptyline	N06AA10	– Increased risk of falls	^Citation11
SSRI
Fluoxetine (daily use)	N06AB03	– CNS side effects (nausea, insomnia, dizziness, confusion)	^Citation11,Citation14,Citation15
		– Hyponatremia
Paroxetine	N06AB05	– Confusion and other types of delirium	^Citation11
		– Cognitive impairment
MAO inhibitors
Tranylcypromine	N06AF04	– Hypertensive crises	^Citation11,Citation14
		– Cerebral hemorrhage
		– Malignant hyperthermia
Antiemetic drugs
Trimethobenzamide	NA	– Can cause extrapyramidal adverse effects	^Citation11
Antiepileptic drugs (AEDs)
Phenobarbitone	N03AA02	– Sedation	^Citation11,Citation14
		– Paradoxical excitation
		– Highly addictive
Antihypertensive agents
Clonidine	C02AC01	– Hypotension (orthostatic), bradycardia, syncope	^Citation11,Citation13,Citation14
Methyldopa	C01AB01	– CNS side effects: sedation, cognitive impairment	^Citation11,Citation13,Citation14
Moxonidine	C02AC05	– H ypotension (orthostatic)	^Citation13
		– Bradycardia
		– Sedation
Nifedipine	C08CA05	– Short-acting nifedipine associated with increased risk of myocardial infarction, increased mortality in elderly patients	^Citation11,Citation13
Prazosin	C02CA01	– Hypotension	^Citation11,Citation13,Citation14
Terazosin	G04CA03	– Dry mouth	^Citation11,Citation14
		– Urinary incontinence/impaired micturition
		– Increased risk of cerebrovascular and cardiovascular disease
Antipsychotics (neuroleptic drugs)
First-generation (conventional) agents
Chlorpromazine	N05AA01	– Anticholinergic and extrapyramidal side effects	^Citation11^–^Citation13,Citation15
Fluphenazine	N05AB02	– Parkinsonism	^Citation11,Citation13,Citation14
Haloperidol (>2 mg)	N05AD01	– H ypotonia	^Citation11,Citation14
Promazine	N05AA03	– S edation and risk of falls	^Citation11,Citation13
Trifluoperazine	N05AB06	– Increased mortality in patients with dementia	^Citation11
Prochlorperazine	N05AB04		^Citation11,Citation13^–^Citation15
Second-generation (atypical) agents
Aripiprazole	N05AX12	– Fewer extrapyramidal side effects	^Citation11
Asenapine	N05AH05	– Clozapine: increased risk of agranulocytosis and myocarditis	^Citation11
Clozapine	N05AH02		^Citation11,Citation13,Citation14
Olanzapine (>10 mg)	N05AH03		^Citation11,Citation13^–^Citation15
Muscle relaxants
Baclofen	M03BX01	– CNS side effects: amnesia, confusion, falls	^Citation13,Citation14
Solifenacin	G04BD08	– Anticholinergic side effects: constipation, dry mouth, CNS side effects	^Citation11,Citation13,Citation14
Orphenadrine	N04AB02	– More sedation and anticholinergic side effects than safer alternatives	^Citation11
Sedative and hypnotics
Long-acting benzodiazepines
Clonazepam	N03AE01	In general, all benzodiazepines increase the risk of cognitive impairment, delirium, falls (muscle-relaxing effect, prolonged sedation) with risk of hip fracture, depression, psychiatric reactions (can cause paradoxical reactions, eg, agitation, irritability, hallucinations, and psychosis) and motor vehicle accidents in older adults	^Citation11
Diazepam	N05BA01		^Citation11^–^Citation15
Bromazepam	N05BA08		^Citation13,Citation14
Clobazam	N05BA09		^Citation13
Nitrazepam	N05CD02		^Citation13^–^Citation15
Flunitrazepam	N05CD03		^Citation13^–^Citation15
Short- and intermediate-acting benzodiazepines
Alprazolam	N05BA12		^Citation11,Citation13,Citation14
Lorazepam	N05BA06		^Citation11,Citation13,Citation14
Oxazepam	N05BA04		^Citation11,Citation13^–^Citation15
Temazepam	N05CD07		^Citation11,Citation13,Citation14
Triazolam	N05CD05		^Citation11^–^Citation14
Non-benzodiazepine hypnotics			^Citation11^–^Citation14
Zolpidem	N05CF02		^Citation11,Citation13,Citation14
Zopiclone	N05CF01		^Citation13^–^Citation15
Chloral hydrate	N05CC01		^Citation11,Citation14
Others
Theophylline	R03DA02	– Risk of arrhythmias	^Citation11,Citation15
		– No proof of efficacy in COPD
Glipizide	A10BB07	– Long half-life leading to possible prolonged hypoglycemia	^Citation13
Cimetidine	A02BA01	– Confusion	^Citation11^–^Citation13
		– More interactions than other H2 antagonists
Diphenoxylate	A07DA01	– No proof of efficacy	^Citation12,Citation13
		– Blocks the muscarinic receptors

Abbreviations: ATC, anatomical therapeutic chemical; COPD, chronic obstructive pulmonary disease; CNS, central nervous system; ECG, electrocardiogram; MAO, monoamine oxidase; NSAID, non-steroidal anti-inflammatory drugs; SSRI, selective serotonin reuptake inhibitors; TCA, tricyclic antidepressants.

Table 2 Demographic and clinical characteristics of study population

Characteristics	Total, N=153
Age, years
Mean ± SD	83.0±8.1
Median	83
Females, n (%)	98 (64.1)
Length of stay at the time of assessment: median length of stay, days (IQR)	488 (6–3,213)
Marital status (%)
Married	50 (32.6)
Widowed	73 (47.7)
Separated/divorced	19 (12.4)
Never married	11 (7.1)
Comorbidities (%)
Dementia	103 (67.3)
Delirium	18 (11.7)
Depression	71 (46.4)
Under nutrition	49 (32.0)
COPD/asthma	17 (11.1)
Hypertension	55 (35.9)
Diabetes	32 (20.9)
Ischemic heart disease	21 (13.7)
Prescription medications
Total number of prescribed medications	1,469
Mean ± SD	9.6±4.2
Polypharmacy categories (%)
0–4 medications (non-polypharmacy)	14 (9.2)
5–9 medications (polypharmacy)	70 (45.8)
≥10 medications (hyper-polypharmacy)	69 (45.1)

Abbreviations: COPD, chronic obstructive pulmonary disease; IQR, interquartile range; SD, standard deviation.

Table 3 Outcomes of geriatrician intervention

Interventions	No of medications	Reasons
Drug stopped (145 [9.8%])	66	Adverse effects
	63	No clear indication/medication burden
	16	Disease cured or quiescent
Dose altered (51 [3.5%])	36	Dose reduced (because of adverse effects and other factors)
	10	Dose increased (because of ineffective dose)
	5	Changed to “as required”
New drug started (102 [6.9%])	58	Untreated morbidity
	23	Better alternative to present therapy
	21	Symptom relief

Notes: Total medication prescribed: 1,469; total high-risk medications prescribed: 151 (10.3%).

Table 4 High-risk medication prescribed and geriatrician intervention

System/therapeutic category/medications	High-risk medications prescribed, N (%)	Result of geriatrician intervention
Central nervous system medications	80 (52.9)
Antidepressants	10 (6.6)	DA – 1
Antipsychotics	21 (13.9)	DS – 3
		NDS – 1
Sedative and hypnotics	49 (32.4)	DS – 5
		DA – 1
		NDS – 2
Cardiovascular system medications	21 (13.9)
Antiarrhythmic	12 (7.9)	DS – 3
		DA – 2
		NDS – 1
Antihypertensive	9 (5.9)	DS – 2
Gastrointestinal	6 (3.9)	DS – 1
Antihistamines	5 (3.3)
Antithrombotic	22 (14.5)
Antiparkinson agents	1 (0.6)
Antispasmodics	5 (3.3)	DS – 5
Analgesics	9 (5.9)	DS – 6
Antibiotics	2 (1.3)	DS – 1
Total	151 (100)	DA – 4
		DS – 26
		NDS – 4

Abbreviations: DA, dose altered; DS, drug stopped; NDS, new drug started.

Table 5 Univariate analysis of variables influencing the use of high-risk medications

Characteristics	Patients		P-value
	Without high-risk medications (n=64)	With at least one high-risk medication (n=89)
Socio-demographic
Age	83.55±8.5	82.67±7.8	0.513
Sex (female)	44 (68.8)	54 (60.7)	0.304
Clinical
Length of stay	303 (70.75–780.50)	630 (100–1,022.50)	0.044
Assessment status (within 12 weeks of admission)	18 (28.1)	19 (21.3)	0.334
Polypharmacy (>4 medications)	57 (89.1)	82 (92.1)	0.516
Comorbid conditions
Delirium	7 (10.9)	11 (12.4)	0.788
Dementia	44 (68.8)	59 (66.3)	0.749
Depression	27 (42.2)	44 (49.4)	0.375
Under nutrition	24 (37.5)	25 (28.1)	0.218

Note: Values represent frequency (% of n).

American Geriatrics Society 2012 Beers Criteria Update Expert PanelAmerican Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adultsJ Am Geriatr Soc201260461663122376048

 PubMed Web of Science ®Google Scholar

HoltSSchmiedlSThurmannPAPotentially inappropriate medications in the elderly: the PRISCUS listDtsch Arztebl Int201010731–3254355120827352

 PubMed Web of Science ®Google Scholar

McLeodPJHuangARTamblynRMGaytonDCDefining inappropriate practices in prescribing for elderly people: a national consensus panelCan Med Assoc J199715633853919033421

 PubMed Web of Science ®Google Scholar

RognstadSBrekkeMFetveitASpigsetOWyllerTBStraandJThe Norwegian General Practice (NORGEP) criteria for assessing potentially inappropriate prescriptions to elderly patients. A modified Delphi studyScand J Prim Health Care200927315315919462339

 PubMed Web of Science ®Google Scholar

LarocheMLCharmesJPMerleLPotentially inappropriate medications in the elderly: a French consensus panel listEur J Clin Pharmacol200763872573117554532

 PubMed Web of Science ®Google Scholar