MPA | Pharmacy News

by Nicole Humbert, Pharm.D., PGY1 pharmacy resident, St. Joseph Mercy Ann Arbor 

Falls in the older adult can be due to numerous factors, including physiological changes, environmental hazards and medication misuse. In the geriatric population, multiple medications are often prescribed due to numerous medical problems. With this increased medication use comes an increased risk of adverse effects, including falls. It is estimated that more than one-third of adults older than 65 years of age fall each year and more than one in six elderly Americans are taking prescription drugs that are not suited for geriatric patients. Falls in the elderly are one of the most common causes of nonfatal injuries, injury-related deaths and hospital admissions. 

Orthostatic hypotension is a common problem among elderly patients, which can contribute to falls. Acute orthostatic hypotension is usually secondary to medication, fluid or blood loss, or adrenal insufficiency. Antihypertensives, especially alpha-blockers, are common contributors to orthostatic hypotension. Titrating down the dose, if discontinuation is not an option, can help reduce symptoms and decrease fall risk. Also, ensuring that patients stand up slowly and brace themselves with a wall or chair can also limit risk of falls. 

Medication misuse can be avoided in the geriatric population by obtaining guidance from the Beers List. The Beers List is a list of medications compiled by experts whose risk of adverse events potentially outweigh the benefits in the geriatric population. There are 53 individual medications or classes of medications recommended to avoid or use with caution in older adults. Many medications such as central nervous system (CNS) depressants/psychoactive drugs on the Beers List have been associated with an increased risk of falls. CNS depressants can cause sedation and cognitive impairment resulting in falls in the elderly. Table 1 lists some of the medications that should be avoided in elderly patients based on the Beers List. The Beers List can be used to evaluate medication use and as a guide to make interventions for pharmacotherapy changes. 

Table 1. High-risk Targeted Medications

Drug Concern Alternatives/Comments
Amitriptyline (Elavil®) Highly anticholinergic and sedating
  • For neuropathy: consider gabapentin (Neurontin®)
  • For depression: consider a selective serotonin re-uptake inhibitor [SSRI] (or mirtazapine [Remeron®] if the patient also has insomnia or anorexia)
  • If a tricyclic antidepressant is required, consider nortriptyline (Pamelor®)
Benzodiazepines Prolonged sedation, dependence, depression, confusion and fall/fractures
  • Consider tapering if possible
  • Depending on indication, consider using an antidepressant.
Digoxin (Lanoxin®) Assess for toxicity due to reduced renal clearance (bradycardia, gastrointestinal disturbances, central nervous system effects, visual disturbances)
  • If evidence of toxicity, decrease dose or discontinue drug
Diphenhydramine (Benadryl®) Anticholinergic and sedating
  • For sleep: consider melatonin or trazodone
  • For allergic rhinitis: loratadine (Claritin®) or another non-sedating antihistamine
  • May still be used for acute allergic reaction
Doxepin (Sinequan®) Highly anticholinergic and sedating
  • For neuropathy: consider gabapentin (Neurontin®)
  • For depression: consider a SSRI (or mirtazapine [Remeron®] if the patient also has insomnia or anorexia)
Hydroxyzine (Atarax®) Anticholinergic and sedating
  • Alternative: loratadine (Claritin®) or another non-sedating antihistamine
Indomethacin (Indocin®) NSAID with the most CNS adverse effects, GI effects, fluid retention
  • Alternative: ibuprofen, acetaminophen
  • For chronic gout: allopurinol 
  • For acute gout: ibuprofen or alternative nonsteroidal anti-inflammatory drug, short-term use of indomethacin
Promethazine (Phenergan®) Anticholinergic and sedating
  • For nausea: prochlorperazine (Compazine®) or ondansetron (Zofran®)
  • For allergic rhinitis: loratadine (Claritin®) or another non-sedating antihistamine
Trimethobenzamide (Tigan®) Can cause extrapyramidal side effects, sedation
  • Alternative: prochlorperazine (Compazine®), ondansetron (Zofran®)

The Beers List, however, is only one tool for reducing adverse drug events such as falls in the elderly. There are many medications not on the Beers List that may also contribute to falls. It is recommended to complete a medication review in geriatric patients who are at high risk or have already experienced a fall. Although not always contraindicated, medications on the list should be used cautiously and if alternatives are available, they should be considered. Pharmacotherapy decisions should be made based on the whole patient, considering medical, social and psychological conditions, prognosis and quality of life. 

References available upon request from the MPA office.

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