Dr. P. D.GUPTA
Former Director Grade Scientist, Centre for Cellular and Molecular Biology, Hyderabad, India
www.daylife.page
There are different phases in one’s life, every individual has to pass these phases in their lifetime. These are Toddler, Teen, Adult, and Older adults. Whatever medicines are prescribed for a particular disease may not be effective in all phases of life because medications are metabolized differently in toddlers, teens adults, and older adults. Pharma companies when they perform “drug trials” may not consider all the phases. Females will have another temporary phase known as pregnancy. Drug Controllers now insist on including the pregnancy phase in their drug trials to have answers about the drug effects on pregnant ladies. Most of the drugs have different effects on different phases.
For the sake of these criteria, older adults are 65 years of age or older. and everyone from 65 to 100 is not the same. As people age, they develop more co-morbidities (when a person has more than one disease or condition at the same time) they become more frail, and they are more sensitive to the effects and side effects of drugs. Here, we are mentioning the common drugs and how they are metabolizing in older adults:
Aspirin: Since the risk for major bleeding increases with age, for primary prevention of atherosclerotic cardiovascular disease, the harm can be greater than the benefit in older adults, so aspirin should not be used for primary prevention. Aspirin remains indicated for secondary prevention in individuals with established cardiovascular disease.
Warfarin: For the treatment of atrial fibrillation or venous thromboembolism (deep vein thrombosis or pulmonary embolism), warfarin should be avoided if possible. Warfarin has a higher risk for major bleeding, particularly intracranial bleeding, than direct oral anticoagulants (DOACs); therefore the latter is preferred.
Rivaroxaban should be avoided, as it has a higher risk for major bleeding in older adults than the other DOACs.
Apixaban is preferred over dabigatran. If a patient is well controlled on warfarin
Antipsychotics: These include first- and second-generation antipsychotics such as aripiprazole, haloperidol, olanzapine quetiapine, risperidone, and others. The guidance says to avoid these agents except for FDA-approved indications such as schizophrenia, bipolar disorder, and adjuvant treatment of depression. The use of these antipsychotics can increase the risk for stroke, heart attack, and mortality. Essentially, the guidance says not to use these medications lightly for the treatment of agitated dementia. For those of us with older patients, this can get tricky because agitated dementia is a difficult issue for which there are no good effective medications. So, there are times when you may need to use these medicines, but use them judiciously.
For patients with dementia, anticholinergics, antipsychotics, and benzodiazepines should be avoided if possible. In older adults, benzodiazepines increase the risk of cognitive impairment, delirium, falls, fractures, and even motor accidents. The same concerns affect the group of non-benzodiazepine sleeping medicines known as "Z-drugs."
Nonsteroidal anti-inflammatory drugs (NSAIDs). Used frequently As we think through the risk-benefit ratio of using NSAIDs in older adults, we often underappreciate the risks of these agents. Upper gastrointestinal ulcers with bleeding occur in approximately 1% of patients treated for 3-6 months with an NSAID and in 2%-4% of patients treated for a year. NSAIDs also increase the risk of renal impairment and cardiovascular disease.
Other medications to avoid (if possible). These include:
Sulfonylureas, due to a high risk for hypoglycemia. A short-acting sulfonylurea, such as glipizide, should be used if one is needed.
Proton pump inhibitors should not be used long-term if it can be avoided.
Digoxin should not be the first-line treatment for atrial fibrillation or heart failure. Decreased renal clearance in older adults can lead to toxic levels of digoxin, particularly during acute illnesses. Avoid doses > 0.125 mg/day.
Nitrofurantoin should be avoided when the patient's creatinine clearance is < 30 or for long-term suppressive therapy.
Avoid combining medications that have high anticholinergic side effects, such as scopolamine, diphenhydramine, oxybutynin, cyclobenzaprine, and others.
It is always important to understand the benefits and risks of the prescribed drugs. It is also important to remember that older adults are a particularly vulnerable population.
Note: This article is too technical for the common person, It is written just for awareness so patients can ask the physician if such a situation arises. It is prepared on the basis information of from the article published by the American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults.
Source: The American Geriatrics Society. J Am Geriatr Soc.2023;71:2052–2081
