In 1991, a report titled defined criteria for inappropriate prescribing in the elderly.
Another panel of 13 experts in geriatrics and pharmacology later put together a list of 23 therapeutic agents which they said should not be provided to the elderly whether or not they are in nursing homes. This list added three antihypertensives to the original list issued in 1991.
One focus of the list was on agents with centrally acting anticholinergic effects. These agents decrease cognitive function and cause drowsiness. The potential exists for a drug-induced dementia. (Cognex, a new agent to increase cognitive function in patient's with Alzheimer's Disease is a cholinergic agent.)
Amitriptyline (Evalil, Levate) has the most central anticholinergic effects of any tricyclic antidepressant and may not be a good choice even at low 'for sleep' doses. Of the neuroleptics, haloperidol (Haldol) has the least anticholinergic side effects; however, if centrally acting anticholinergics Cogentin or Benadryl are added to control EPS side effects then haloperidol loses its advantage.
Some of the agents have exceptions. For example, indomethacin is indicated for gouty arthritis, Reiter's Syndrome, and ankyloosing spondylitis. However, less than 1 percent of the elderly were taking indomethacin for one of those indications.
The conclusion reached was that 'Physicians prescribe potentially inappropriate medications for almost a quarter of the older people living in the community, placing them at risk of adverse effects such as cognitive impairment and sedation.'
Benzodiazepines which undergo oxidative metabolism have prolonged duration of action in the elderly. Flurazepam has been reported to have a half-life over 250 hours in the elderly, meaning that a single dose is still detectable for over 1,000 hours. Serax and Ativan undergo only conjugative metabolism and would seem to be the best choices in the elderly and those with hepatic insufficiency.
Benzodiaepines are safer for sedation. Longer acting agents such as phenobarbital are preferable for epilepsy.
Amitriptyline has strong CNS anticholinergic effects and can cause orthostatic hypotension. Individual agents in combination drugs cannot be titrated to individual needs.
Indomethacin has legitimate uses in a small number of disease states (see introductory text above), but it has CNS toxicity and its stronger prostaglandin inhibition increases the risk of GI and renal adverse effects. Phenylbutazolidin has a higher degree of bone marrow depression than other NASA agents.
Chlorpropamide has a very long duration of action and lactic acidosis and SIADH can occur.
These agent are ineffective and useless.
Dipyridamole, except as an adjunct therapy for patients with artificial heart valves, has doubtful efficacy. 'Coronary Steal' may occur.
The CNS toxicitiy of these agents outweigh any benefits. Drowsiness can lead to falls. Consider a conjugatively metabolized benzodiazepine for short term treatment.
Trimethobenzamide is less effective and has more EPS side effects than other antiemetic agents.
Propranolol is a controversial addition, especially since new studies have indicated that beta blockers probably do not cause depression as previously thought. Nevertheless, unless beta2 blockade is required, as for the treatment of migraines, 'stage fright' or tremors, it would seem that cardioselective beta blockers should be chosen. Methyldopa can cause jaundice and hepatotoxicity and has generally been replaced by clonidine. Reserpine can cause depression, but many patients have been on reserpine for years with few adverse effects.
