Inappropriate Prescribing in Elderly

IPE Fundamentals - Elder Rx Red Flags

• IPE Definition: Prescribing potentially inappropriate medications (PIMs) to elderly; risk outweighs potential benefit.
• Prevalence: High, ↑ with age, number of comorbidities, and polypharmacy.
• Significance: ↑ Adverse drug events (ADEs), hospitalizations, mortality, healthcare costs.
• Key Contributing Factors:
  • Polypharmacy (≥ 5 drugs).
  • Altered Pharmacokinetics (PK): ↓ renal/hepatic clearance, altered drug distribution (e.g., ↑ Vd for lipophilic drugs).
  • Altered Pharmacodynamics (PD): ↑ sensitivity to drugs (e.g., anticholinergics, benzodiazepines).
  • Multiple prescribers, poor communication.
  • Prescribing cascade.

⭐ Polypharmacy (concurrent use of 5 or more medications) is a major risk factor for IPE, significantly increasing the likelihood of adverse drug events in older adults.

Screening Tools - IPE Detective Kits

• Standardized tools aid in identifying Potentially Inappropriate Medications (PIMs) & Prescribing Omissions (PPOs).
• Key Explicit Criteria (Rule-Based):
  • Beers Criteria (AGS):
    • Lists PIMs to avoid or use with caution in adults ≥65 years.
    • Considers drug-disease, drug-drug interactions, kidney function.
    • 📌 "BEERS": Better Evaluate Elders' Rx Safely.
  • STOPP/START Criteria:
    • STOPP (Screening Tool of Older People's Prescriptions): Identifies PIMs.
    • START (Screening Tool to Alert to Right Treatment): Identifies PPOs.
    • Often used together for comprehensive review.
• Other Tools: MAI (Medication Appropriateness Index), FORTA (Fit fOR The Aged).

⭐ The Beers Criteria are updated approximately every 3 years by the American Geriatrics Society (AGS).

Risky Medications - The Geriatric No-Go List

• Anticholinergics:
  • Risks: Confusion, falls. 📌 "Can't see, can't pee, can't spit, can't shit".
  • E.g., Diphenhydramine, Amitriptyline.
• Benzodiazepines & Z-drugs:
  • Risks: ↑Fall/fracture risk, cognitive decline, delirium, dependence.
  • E.g., Diazepam, Lorazepam, Zolpidem.
• NSAIDs (Chronic use):
  • Risks: GI bleeds, renal damage, ↑BP, exacerbate HF.
  • Avoid chronic use; consider gastroprotection if essential.
• Antipsychotics:
  • Risks: ↑Mortality, stroke, EPS. Avoid for non-psychotic behavioral symptoms.
  • E.g., Haloperidol, Risperidone.
• Long-acting Sulfonylureas:
  • Risks: Severe prolonged hypoglycemia.
  • E.g., Glibenclamide (Glyburide).
• Sliding Scale Insulin:
  • Risks: Hypoglycemia, poor glycemic control.
• Skeletal Muscle Relaxants:
  • Risks: Sedation, anticholinergic effects, falls. Limited efficacy.
  • E.g., Cyclobenzaprine.
• Proton Pump Inhibitors (PPIs):
  • Risks: C. diff infection, fractures, pneumonia, hypomagnesemia. Re-evaluate need.
  • E.g., Omeprazole.

⭐ Beers Criteria: A key guideline for identifying Potentially Inappropriate Medications (PIMs) in older adults, aiming to improve safety.

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IPE Outcomes & Solutions - Fixing Faulty Prescriptions

IPE Consequences:

• ↑ Adverse Drug Events (ADEs), drug-drug interactions.
• ↑ Hospitalizations, emergency visits, healthcare costs.
• ↑ Morbidity (e.g., falls, fractures) & mortality.
• ↓ Quality of Life (QoL), functional independence.
• Cognitive impairment, delirium.

Solutions & Management:

• Medication Review:
  • Comprehensive (CMR), periodic. Brown Bag Review 🛍️.
• Deprescribing:
  • Systematic PIM withdrawal; patient-centered, shared decisions.
• Key Screening Tools:
  • Beers Criteria (USA): Identifies PIMs.
  • STOPP/START criteria (Europe): Detects PIMs & omissions.
• Team Approach: Pharmacist-led, physician collaboration.
• Education: Empowering patients & caregivers.

⭐ The Beers Criteria, updated by AGS, lists PIMs to avoid or use cautiously in adults ≥65 years, aiming to reduce ADEs.

High‑Yield Points - ⚡ Biggest Takeaways

• Beers Criteria & STOPP/START criteria identify PIMs in older adults.
• Polypharmacy (≥5 drugs) ↑ risk of ADEs, falls, and hospital admission.
• Avoid PIMs: long-acting BZDs, 1st-gen antihistamines, some NSAIDs, TCAs.
• High anticholinergic burden impairs cognition, causes delirium, and ↑ fall risk.
• Adjust drug doses for ↓ renal function (eGFR); "start low, go slow".
• Recognize the "prescribing cascade": ADE treated as a new medical problem.