Alternatives to Potentially Inappropriate Medications in the Elderly

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In 2015, the American Geriatrics Society released an update to the Beer’s Criteria for Potentially Inappropriate Medications in the Elderly.   An article appearing in the November 2015 edition of JAGS, highlights possible alternatives to some of the medications included in the 2015 update.  This article focuses on two areas: High-Risk Medications and Harmful Drug-Disease Interactions in the Elderly.  Specific drug classes discussed include drugs with high anticholinergic activity, non-steroidal anti-inflammatory drugs (NSAIDs), and drugs with significant CNS activity.

First generation antihistamines such as diphenhydramine (Benadryl, Tylenol-PM) are both highly anticholinergic and sedating.  Safer alternatives include intranasal saline flushes, intranasal corticosteroids such as fluticasone (Flonase), and second-generation or less sedating antihistamines such as loratadine (Claritin).

Chronic use of oral NSAIDs such as ibuprofen or naproxen increases the risk of gastric bleeding, and acute kidney injury especially in older adults with a history of peptic ulcer disease, chronic kidney disease, hypertension, or heart failure.  Possible alternatives may include topical NSAIDS such as diclofenac

(Voltaren gel and Flector patch) and topical lidocaine (lidocaine gel).

Medication classes with significant CNS activity in older adults include antipsychotics and benzodiazepines especially at higher doses for longer duration.  Risks include falls, cognitive impairment, and sedation.  It is important to limit the dose and duration of antipsychotics when used for delirium or for the behavioral complications of dementia.

Alternatives for High-Risk Medications in the Elderly

  1. First-generation antihistamines (Benadryl, ChlorTrimeton). Avoid using for sleep.  For allergic symptoms, consider second-generation antihistamines (Claritin, Zyrtec) or nasal corticosteroids (Flonase) or saline flushes.
  2. Long-acting antidiabetics (glyburide, chlorpropamide). Consider glipizide, metformin.

Alternatives for Harmful Drug-Disease Interactions in the Elderly

  1. Avoid benzodiazepines (Valium, Ativan, Xanax) and nonbenzodiazepine hypnotics (Ambien, Sonata). Consider Buspar or an antidepressant such as Cymbalta, Effexor, or Remeron especially if anxiety, insomnia, or symptoms of depression.
  2. Avoid drugs with significant anticholinergic activity such as chlorpromazine, loxapine, olanzapine, and trifluoperazine.  Consider haloperidol, risperidone, or quetiapine, but only for short duration at the lowest effective dose.

Chronic Kidney Disease or Chronic Renal Failure (eGFR < 30 mL/min)

  1. Avoid all NSAIDs including ibuprofen, naproxen, and celecoxib (Celebrex). Consider acetaminophen, Cymbalta (arthritis, neuropathic pain), topical NSAIDS (Flector patch, Voltaren gel), Lidocaine gel and patch


References:   1. Hanlon JT et al Alternative Medications for Medications in the Use of High-Risk Medications in the Elderly and Potentially Harmful Drug–Disease Interactions in the Elderly Quality Measures JAGS November 2015 Vol. 63 No. 11 pp. e8-818

This article was originally published in our monthly issue of From the Front Lines – a monthly publication that shares best practices and medication-related challenges faced by “front line” staff in long-term care and post-acute (LTCPAC) facilities.

>>> From the Front Lines – February 2016 <<<