Some medications are riskier for older adults because of changes in body composition and metabolism. There are differences in the amount of muscle mass and body fat in older adults, who also tend to have lowered metabolism. These changes cause some drugs to metabolize differently leading to a need for lower doses to avoid build-up of the medication or its metabolites. Older adults also tend to have comorbidities that can affect how medications are absorbed, metabolized, or eliminated, and the dosage may need to be adjusted, or a different medication chosen.

The Beers Criteria^(R) documents the medications that are most likely to cause an issue in older adults. The American Geriatrics Society (AGS) updated the Beers Criteria^(R) for Potentially Inappropriate Medication Use in Older Adults (2019a). An individual patient may not have an issue, but medications on the list should be assessed for appropriateness (AGS, 2019b). Note-this list should not be used for older adults in hospice or palliative care. Some of these medications are described below (AGS, 2019a).

1. First-generation antihistamines such as diphenhydramine should be avoided. Alternatives may include saline nasal rinse, steroid nasal sprays such as fluticasone, and allergy products such as cetirizine, fexofenadine, and loratadine.

2. Tricyclic antidepressants (used for depression), including amitriptyline can be of concern for older adults. Alternatives may include bupropion, or selective serotonin reuptake inhibitors (SSRIs); or sertraline.

3. Sleeping aids such as zolpidem, zaleplon, or eszopiclone should be replaced with sleep hygiene education and habits, if possible.

4. Pain medication should be used cautiously with patients who have renal disease. Nonsteroidal anti-inflammatory medications should be avoided due to risk of increased blood pressure, heart failure exacerbation, impact on kidney function, and risk of bleeding. Alternatives may include acetaminophen, topical products, and serotonin-norepinephrine reuptake inhibitors such as duloxetine and venlafaxine.

5. Benzodiazepines, such as alprazolam, lorazepam, and diazepam should be avoided in patients with a fall history. Alternatives for anxiety include buspirone, or SSRIs.

6. Hormone therapy should be replaced with topical estrogen creams for vaginal dryness, and gabapentin or SSRIs for hot flashes and night sweats.

Some medications should be used with caution due to serious adverse effects. If the medication is deemed appropriate, educate the patient to report any issues to avoid serious incidents or hospitalizations. Some of these medications include, but are not limited to, digoxin, which can be toxic to older adults and those with kidney disease; diabetes drugs such as glyburide and chlorpropamide, which can cause hypoglycemia; and muscle relaxants, such as cyclobenzaprine, methocarbamol, and carisoprodol, which can increase the risk of falls, confusion, constipation, and dry mouth. Antipsychotics (for those not being treated for psychosis), such as haloperidol, risperidone, or quetiapine can increase the risk of strokes and falls, and cause tremors (AGS, 2019a).

Finding the best fit of safe, effective medications is the role of all members of the home healthcare team. Visit the AGS site (http://GeriatricsCareOnline.org) for a full listing of medications, risks, alternative medications, and more information.

REFERENCES