High Risk Medications
- Medications are necessary.
- In this age of chronic disease management many patients are on many medications: this is inevitable and health-promoting.
- All medication prescribing requires an analysis of risk vs. benefit.
- The main medications we want to be most aware of are the high-risk but low-benefit group.
High-Risk, Low-Benefit
Click on a medication group below to learn more.
1. Benzodiazepines
Probably not a great class for older people: in the ED, most agitation in older patients is not about anxiety but rather about untreated pain or undiagnosed delirium. It makes more sense to treat the pain or to look for the cause of the delirium. BNZs have a significant frontal lobe effect so treating an agitated person with lorazepam will merely produce a drowsy disinhibited agitated person! And since they’re mostly lipophilic, they stay around for a long time.
2. Codeine
A weak analgesic (10:1 with morphine) with a strong side effect profile (nausea/constipation) for which 10% of the population does not have the enzyme to convert this pro-drug to morphine. And yet everyone gets the adverse effects! Why are we using it when much more elder-friendly analgesia exists?
3. Non-steroidal anti-inflammatory drugs
All members of this class have deleterious effects on renal blood flow through their anti-prostaglandin effect. It is occasionally enough to tip over the stable renal impairment of old age into acute renal failure. They exacerbate hypertension. Their gastritis-causing effects are worsened in a population that has decreased gastric emptying and lower gastric pH. In general they are probably best avoided unless: the cause of the pain is clearly inflammatory AND there are no other options for analgesia – two conditions that are rarely met.
4. Any medication with anti-cholinergic effects
In a population which is naturally acetycholine deficient, blocking acetylcholine– ©Gravol, ©Benadryl, ©Indocid, even ©Zantac – can tip the vulnerable brain into delirium.
High-Risk, High-Benefit
Click on a medication group below to learn more.
1. Anti-coagulants
There are more admissions to hospital and more adverse drug effects from warfarin than from all other drugs combined –and yet it is clearly a beneficial essential medication for many older people. Approximately 2/3 of all commonly prescribed medications interact with warfarin, usually by increasing anti-coagulation, usually by competing with scarce hepatic enzymes for metabolism. If you are making any medication change (adding, deleting, or dose-adjusting a medication) be aware the change will likely have an effect on the INR.
2. Hypo-glycemics
Insulin can be challenging to adjust and administer, especially for a person with mild cognitive impairment and decreased fine motor dexterity. Glyburide and other sulfonylureas can precipitate sudden drops in blood sugar. Keep this in mind in assessing “weak and dizzy,” new falls, or even apparent CNS events (it might be just an episode of hypoglycemia.)
3. Opioids
Clearly the main stay of analgesia if acetaminophen has been ineffective. Also clearly need close attention to dosing and adjustment. Hydromorphone is the most potent, and least renally excreted so least likely to accumulate.
To learn more about effective dosing of opioids visit the Symptom Management module.
To learn more about effective dosing of opioids visit the Symptom Management module.
Important Note
When using high-risk medications:
- Start low, go slow. Because of the physiologic changes of aging MUCH smaller doses may be effective in the older patient. This applies not only to opioids but to antibiotics, hypo-glycemics, haloperidol.
- Think about and talk about expected effects with patients and their care-givers – especially with “dizzy-making” or “constipation-making” or “drowsy-making.” If patients know these effects are normal they can take action (have someone around to help, start laxatives early, decrease the second dose) to prevent a need for return to ED.
- Notify all principal care-givers of any medication changes that occurred in the ED. This means not only the family doctor (send a copy of the chart with the patient, fax a copy of chart to the doc) but also nursing home staff and care-givers and family members at home.
Discussion: High Risk Medications
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ok
good notice
ok
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interesting re:starting at lower amounts of antibiotics. Good to know!
caution should always be used on the elderly when prescribing medications.
great info
I get pharmacy involved as soon as possible.
…
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prescribing and reviewing medications for old people frequently is vital to make sure they ae taking the right meds in the right doses
okay
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has a clue
Start slow and go low. I will remember that.
interesting
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great
it’s important to assess the risk vs benefit to medications
PolyPharm
good consideration
I would like to post your important note so everyone can see. Great highlights.
great material
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Metformin can also be used for PCOS
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ok
good information
sure thing
good informatoin
excellent points to consider
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seadtion last choice in elderly
great info
good inforamtion
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start low go slow – to avoid dangerous SE
start low go slow has served many of my patients well
nice tips
Muy bueno para seguimiento y control de los pacientes así como elevar su calidad de vida
very important to know risks and benefits for geriatrics patients
Logical
good to know when it comes to high risk meds
its good to have a good idea of what might be high risk medications becuase this increased awareness i hope will help prevent medication errors in the future as a HCP
Education is an important factor it Is important the patient knows the side effects for each med, along with MD reviewing interactions of what the patient is on.
good ideas
good
agreed
agreed
The nausea is much more likely to be caused by the pain so high-quality analgesia may well function as an anti-nauseant! However it’s good to remember the vomiting centre is dopamine- and serotonin-mediated so other choices are more reasonable — metoclopramide, ondansetron (now off patent and very cheap) or even haloperidol (strongly anti-dopaminergic) at 0.5 mg iv. Reserving dimenhydrinate (Gravol)for true cholinergic-mediated nausea (i.e. vestibula
low and slow
thanks
Communication with patients about risk/benefit is very important.
metformin does NOT cause hypoglycaemia – error in text
good list of risk/benefit meds
interesting
Med rec is VERY important
Lots of info but great.
good info, especially wrt benzo
Geriatric pharmacists can be a big help in the ER
yes agreed
good information
Good lesson pertaining anti-coagulant and med interaction
Beers list should be readily available and frequently referenced.
yes
I never knew gravol could be so bad for the elderly. I noticed we use more Zofran now.
It is so crucial to see how the patient responds to the medicaiton, what side effects they have in ED, before sending them off on their way, have seen patients being discharged with a script e.g. for Tylenol #3 or Hydromorphone right after patient took the medication.
The breakdown of high risk / low benefit and high risk / high benefit very helpful
good point
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understood
roger
understood
fairly common OTC medications so deadly for the weak and frail elderly
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who knew 2/3 of meds interact with Warfarin
yep
Agreed!
interesting note re INR. I didn’t realize that many patients are on warfarin
Knowing which drugs are likely to cause trouble is useful. Also, ‘start low, go slow’ is a really good motto.
it is important to communicate with all those involved in the care of the elder patient
try to use a list of interactions
do list of the medicines consumed reamente also review the side effects with patients
take into account polypharmacy
Las interacciones medicamentosas deben de tenerse muy en cuenta
Great amount of patients taking warfarin with inadequate combinations.
🙂
Interesting to know Gravol has so much potential for adverse effects but yet very commonly used
like the tips, especially to start slowly and work your way up
Medications review specially in elderly is very important……
I am still using gravol IV to prevent nausea in patients receiving IV narcotics. Is this necessary or should a different drug be used?
MANY patients receiving opioids (especially the elderly and especially with hydromorphone) do NOT develop nausea. The nausea is much more likely to be caused by the pain so high-quality analgesia may well function as an anti-nauseant! However it’s good to remember the vomiting centre is dopamine- and serotonin-mediated so other choices are more reasonable — metoclopramide, ondansetron (now off patent and very cheap) or even haloperidol (strongly anti-dopaminergic) at 0.5 mg iv. Reserving dimenhydrinate (Gravol)for true cholinergic-mediated nausea (i.e. vestibular) is reasonable.
Need to be careful not to prescrible metoclopramide to the patient with Parkinsons/Parkinsonism as it is a dopamine receptor antagonists so can really worsend the parkinsonian symptoms.
Metoclopramide is also not not for the frail elderly in general as it can also cause extrapyramidal effects (Beers Criteria)