An 82-year-old woman is brought to the office for a new patient evaluation. She recently moved in with her daughter. The patient reports frequent dizziness but cannot provide additional details regarding her symptoms. Medical history includes moderate dementia, hypertension, transient ischemic attack, depression, and chronic insomnia. Blood pressure is 124/72 mm Hg, and pulse is 66/min and regular. Neurologic examination shows disorientation to time and place but normal deep tendon reflexes and no focal sensory or motor deficits. The patient's medication schedule includes 12 different drugs that are used to manage her chronic conditions. Which of the following medications should be discontinued at this time?
Common medications to avoid in older adults (Beers criteria) | |
Anticholinergic |
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Cardiovascular |
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CNS |
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Endocrine |
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Pain |
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NSAIDs = nonsteroidal anti-inflammatory drugs. | |
Older patients are at increased risk for adverse effects of medications due to decreased drug clearance, cognitive and sensory deficits, multiple comorbidities, drug-drug interactions, and poor drug compliance. Polypharmacy (ie, ≥5 prescription and/or over-the-counter medications) is of particular concern in the elderly and can lead to a prescribing cascade, in which additional drugs are given for adverse effects that are misinterpreted as a new medical condition.
The Beers criteria were developed to identify drugs requiring caution in geriatric patients. First-generation antihistamines (eg, diphenhydramine) and other drugs with anticholinergic activity can increase the risk of confusion, hallucinations, dizziness, dry mouth, and constipation and should be avoided in this population. Other commonly used medications that should be avoided in the elderly include benzodiazepines (and other sedating medications), antipsychotics, many antiarrhythmics (eg, digoxin), and centrally acting skeletal muscle relaxants.
(Choices A and E) Although hypotension due to excessive antihypertension medication use could cause dizziness, this patient has normal blood pressure and heart rate, making this much less likely as a cause of her dizziness. In addition, although centrally acting alpha agonists (eg, clonidine) and alpha-1 blockers (eg, doxazosin) confer a high risk of orthostatic hypotension in elderly patients, thiazide diuretics (eg, hydrochlorothiazide), calcium channel blockers (eg, amlodipine), and ACE inhibitors/angiotensin II receptor blockers are generally considered acceptable for this population.
(Choice B) Aspirin should be used with caution in older adults due to the increased risk of gastric ulcer; however, the reduced risk of cardiovascular events provided by aspirin in patients with prior transient ischemic attack or stroke likely outweighs this risk.
(Choice D) Donepezil is a cholinesterase inhibitor that is commonly used in the treatment of Alzheimer dementia. Bradycardia can occasionally occur; however, this patient has a normal heart rate.
(Choice F) Selective serotonin reuptake inhibitors (eg, sertraline) are the preferred first-line medications for depression in older adults. Serotonin-norepinephrine reuptake inhibitors (eg, duloxetine) may also be used, especially for patients with chronic pain. Tricyclic antidepressants are relatively contraindicated in the elderly due to their anticholinergic effects.
Educational objective:
The Beers criteria identify drugs that should be used with caution in geriatric patients. Common drugs to avoid include anticholinergics (eg, first-generation antihistamines), centrally acting alpha-2 agonists, tricyclic antidepressants, benzodiazepines (and other sedating medications), antipsychotics, many antiarrhythmics (eg, digoxin), and skeletal muscle relaxants.