1. 1 Arch Intern Med.2003;163:2716-2724. 2 JAMA.2006;296:1858-1866. The Most Common Cause of Adverse Medication Events that Result in Emergency Department use in the Elderly: Hypoglycemic agents: Decreased renal clearance leads to drug accumulation and hypoglycemic episodes. Ask patients about signs and symptoms of hypoglycemia. Digoxin (Lanoxin): Accumulates in the elderly population can lead to toxicity (nausea, anorexia, vomiting, and rarely yellow vision). Digoxin should be dosed at ≤ 0.125mg/day unless treating atrial arrhythmias. Ask patients about nausea, anorexia, vomiting and, if present, check a digoxin level. Warfarin (Coumadin): Make sure all patients on warfarin are enrolled in pharmaco- therapy clinic. Amiodarone (Cordarone): A major CYP-3A4 inhibitor resulting in multiple drug-drug interactions. Dose reductions are necessary for many medications including: Warfarin- 35-65% dose reduction, Digoxin- 50% dose reduction and Simvastatin- maximum dose of 20 mg. NSAIDs: Increase incidence of GI bleed, acute renal failure and HTN in the elderly with Risk factors for GI bleed: >75 years of age, previous GI bleed, concomitant use of warfarin, long term glucocorticoid use, history of PUD. Risk factors warrant therapy with misoprostol or PPI. Herbal products: Not regulated by FDA, many have the potential to be dangerous. Rarely considered by patients as medications and their use is often not discussed with a physician. Garlic and Gingko Biloba: Increase bleeding time St John’s Wort: Increased clearance of medications metabolized through CYP3A4 Chromium, Gingko Biloba, Nettle: Hypoglycemia Know what your patients are taking and evaluate for potential harm. Other agents commonly associated with ED visits and hospitalizations in the elderly: 2 Opioid and non-opioid analagesics Antibiotics ACE Inhibitors/ARBs Antihistamines Decongestants/Cold remedies Medication Use and Safety in the Elderly Americans aged 65 and over consume 30% of all prescriptions and 40% of all OTC medications. They are at higher risk for adverse drug events, drug-drug interactions, and therapeutic duplication. Potentially Unsafe Medications in the Elderly 1 : Pain Relievers: Propoxyphene and combination products(Darvon®, Darvocet N-100®, Meperidine (Demerol®) Muscle Relaxants: Carisoprodol (Soma®), cyclobenzapine (Flexeril®), metaxalone (Skelaxin®) Antidepressants: Tricyclic Antidepressants (TCAs): ie, amitriptyline,(Elavil®), Fluoxetine (Prozac®) Sleeping Pills and Antianxiety Medications: Benzodiazepines: ie, Alprazolam (Xanax®), lorazepam (Ativan®), zolpidem (Ambien®) Heart Medications: Digoxin (Lanoxin®) doses above 0.125 mg Dipyridamole (Persantine®), Methyldopa (Aldomet®), Amiodarone (Cordarone®) Diabetes Medications: Glipizide (Glucotrol®), glyburide (Diabeta®), glimiperide (Amaryl®), insulin Stomach and Intestinal Medications: Dicyclomine (Bentyl®),hyoscyamine (Levsin®), promethazine (Phenergan®) Antihistamines: Chlorpheniramine (Chlor-Trimeton®), diphenhydramine (Benadryl®), hydroxyzine (Vistaril®, Atarax®), cyproheptadine (Periactin®) Potentially Unsafe Medications Given Disease States 1 : Constipation: Calcium channel blockers Cognitive Impairment: Anticholinergics, antispasmodics, muscle relaxants Parkinson’s Disease: Metoclopramide (Reglan®), Antipsychotics SIADH/ Hyponetrenia: SSRIs Bladder Outflow Obstruction: Anticholinergics, antihistamines, antispasmodics Syncope/Falls: Tricyclic antidepressants, Benzodiazepines Challenges in Prescribing for the Elderly: Multiple chronic medical problems Multiple medications and prescribers Different metabolism and responses Supplements, herbals and OTC drugs are commonly used Physiologic changes associated with normal aging: Less body water More body fat Less muscle mass Slowed hepatic metabolism Decreased renal excretion Decreased responsiveness and sensitivity of the baroreceptor reflex Dangers of Multiple Medications “Polypharmacy”: Adverse effects Drug-drug interactions Duplication of drug therapy Poor adherence Cost Decreased quality of life Adverse Drug Events (ADEs): Adverse symptoms Adverse patient outcomes leading to: ED visits and hospitalizations Falls Functional decline Changes in cognition Death Risk Factors for ADEs: >6 disease states >12 doses/day >9 medications BMI <22 kg/m 2 Creatinine clearance <50 mL/min Female Funded by: DW Reynolds Foundation