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Home , Cetirizine, Channel blocker, Chlorzoxazone, Dexchlorpheniramine, Guanabenz, Melatonin

High Risk and Alternatives for Older Adults

MEDICATION PRESCRIBING CONCERN1-3 ALTERNATIVES3-5 (includes combinations)1-2 (excludes TCAs) First-generation properties, including CNS : , , , , depression, confusion, delirium, urinary : , chlorpheniramine, , retention, blurred vision, dry mouth, dry , , eyes, and constipation. , , , , , tripolidine Antiparkinson agents Anticholinergic properties, more effective /levodopa, ropinirole Benztropine (oral), agents available for treatment of Parkinson disease Antithrombotics Antithrombotics Increased risk of agranulocytosis, , clopidogrel , dipyridamole, oral short- dysfunction with ticlopidine acting (does not apply to the extended- Dipyridmole, short-acting may cause release combination with aspirin) orthostatic ; more effective alternatives available Anti-infectives Urinary Antibiotics Should not be used for UTI prophylaxis (risk UTI prophylaxis: TMP-SMX, trimethoprim, Nitrofurantoin (macrocrystal and of pulmonary and neurological toxicity, , cephalexin macrocrystal/monohydrate) chronic use nephrotoxicity) Short-term use for acute UTI is acceptable if CrCL is > 60 mL/min. Cardiovascular Alpha blockers, central High risk of adverse CNS effects; may cause ACEI/ARBs, beta-blockers, channel , , , bradycardia and orthostatic hypotension blockers, diuretics (>0.1 mg/day) blockers Hypotension, constipation, reflex Long acting or another calcium Nifedipine, short-acting channel blocker Cardiovascular, other is a potent negative inotrope failure : optimize ACEI, beta-blocker, Disopyramide, > 0.125 mg/day and therefore may induce in antagonist before using digoxin. older adults; strongly anticholinergic Atrial fibrillation : tartrate, Higher doses of digoxin in heart failure are CD associated with no additional benefit and may increase risk of toxicity. Renal impairment may increase risk of toxicity. Goal serum digoxin level 0.5-0.8 ng/mL. Central Nervous System Antianxiety Possible dependence and sedation for Anxiety: , , , meprobamate. Long-acting Long half life (up to several days) in elderly Sleep: trazodone, melatonin (, , ) patients; prolonged sedation and risk of Restless legs syndrome: pramipexole, falls/fractures ropinirole, levodopa, If benzodiazepines are required, use shorter acting agents at low doses. (typical) Sedation, seizures, extrapyramidal effects, Atypicals (increased risk of stroke and , hypotension, constipation, prolongs QT mortality when used to treat behavioral problems in elderly patients with ) (except when Highly addictive (risk for withdrawal Sleep: trazodone, melatonin used for seizures) reactions), long half lives cause more Anxiety: citalopram, sertraline, buspirone , , , sedation, CNS depression, risk of mephobarbital, falls/fractures, confusion, ataxia.

Last updated: 2/24/2014

Nonbenzodiazepine Increased risk of delirium, falls, fractures. Melatonin, trazodone , , Minimal improvement in sleep latency and duration Tertiary Highly anticholinergic, , orthostatic Depression: citalopram, sertraline, , , (>6 hypotension mg/day), , Sleep: trazodone, melatonin : gabapentin, , , , , topical , prophylaxis: beta-blocker, venlafaxine, , nortriptyline Vasodilators Limited efficacy, orthostatic hypotension, Stroke prevention: low-dose aspirin Short-acting dipyridamole, ergot dementia mesyloid, Endocrine Increased risk of stroke, VTE, breast Vasomotor symptoms: gabapentin, low-dose Conjugated estrogens, , esterified with long term use, not cardioprotective (Brisdelle), venlafaxine estrogens, estropipate Bone Density: calcium/Vit D, alendronate Megestrol Increases risk of thrombotic events and Vasomotor symptoms: gabapentin, low-dose possibly death in older adults paroxetine (Brisdelle), venlafaxine Androgens Prostatic hyperplasia, cardiac adverse None, use cautiously and sparingly based on methyltestosterone effects careful assessment of risks and benefits Sulfonylureas, long-duration Prolonged half life could cause prolonged , , metformin , glyburide hypoglycemia, chlorpropamide possibly causes SIADH , desiccated Cardiac adverse effects (tachyarrhythmia, palpitations) Gastrointestinal Antiemetics Can cause extrapyramidal adverse effects. Monitor closely and use low doses, Trimethobenzamide ondansetron Pain Medications Narcotics Limited efficacy with narcotic side effects APAP, short-acting NSAID (), topical , meperidine (confusion, constipation) creams (capsaicin, gel), other Meperidine can cause seizures in patients narcotics (APAP w/ , with renal impairment or , ) Non-COX-selective NSAIDs Increased risk of GI bleeding and peptic APAP, short-acting NSAID (ibuprofen), topical Indomethacin, ulcer disease creams (capsaicin, diclofenac gel) Skeletal Muscle Relaxants Skeletal Muscle Relaxants Most are poorly tolerated due to Monitor side effects, use low doses, consider , , anticholinergic effects, sedation, and lifestyle modifications (rest, stretching, heat, , , weakness. physical therapy) , Muscle spasms: ,

References: 1. Fick, Donna, et al. "American Geriatrics Society updated Beers Criteria for potentially inappropriate use in older adults." Journal of the American Geriatrics Society 60.4 (2012): 616-631. 2. PQA Use of High-Risk Medications in the Elderly (HRM). http://pqaalliance.org/images/uploads/files/HRM%20Measure%202013website.pdf. Updated 2013. Accessed 18 October 2013. 3. PL Detail-Document, Potentially Harmful in the Elderly: Beers List. Pharmacist’s Letter/Prescriber’s Letter. June 2012. 4. Christian, Jennifer B., Anne vanHaaren, Kathleen A. Cameron, and Kate L. Lapane. "Alternatives for potentially inappropriate medications in the elderly population: treatment algorithms for use in the Fleetwood Phase III study." The Consultant Pharmacist 19, no. 11 (2004): 1011-1028. 5. Natural Standard. (2013). Melatonin [Monograph]. Retrieved from http://www.naturalstandard.com.ezp3.lib.umn.edu/demo/demo- pro-melatonin.asp.

Last updated: 2/24/2014