What's Appropriate and What's Not: Determining the Right Medication for Your Older Patient

Regardless of pharmacy practice setting/type, it is likely safe to say that all pharmacists are seeing their patient population age. According to statistics from the Administration on Aging, the population that is 65 years and older increased from 35 million in 2000 to 40 million by 2010—a 15% increase—and it is predicted to further increase to 55 million in 2020.1 As pharmacists, patients and medical providers will continue to seek our counsel on the most appropriate medication choices. We should all be aware of the safest medication options to advise them on, whether the questions are about OTC or prescription agents.

Various tools published in the literature can help determine medication appropriateness (Medication Appropriateness Index, ACOVE Quality Indicators, Beers Criteria), but these tools are not always comprehensive and may not take into account the unique characteristics of your older patient. Pharmacists should possess the inherent knowledge and skills to treat common disease states in older adults and assist in choosing the safest agent possible to reach treatment goals. This article outlines key treatment pearls for common disease states encountered when caring for older adults.

Osteoarthritis

Osteoarthritis (OA) is the most common joint disease encountered in older adults. Acetaminophen remains the first-line agent for management of OA pain. Doses should be tailored to the severity/duration of symptoms and frequent enough to maintain control over the course of the day. Suggest initial regimens of 1000 mg twice daily, increasing to 1000 mg 3 times daily after 4 to 6 weeks if additional pain relief is needed. Monitor liver function tests at least annually while on long-term acetaminophen regimens. Discourage long-term use of 4000 mg/day acetaminophen regimens due to concerns over liver function abnormalities and risk for acetaminophen toxicity due to the availability of other products containing acetaminophen.

OTC Cough and Cold

OTC cough/cold products are some of the most accessible products available to the general public, and older adults are often large consumers. Cough/cold products are generally thought to be safe and harmless and patients like the thought of treating symptoms without having to seek a physician’s counsel. Older adults become complicated to treat, however, given the high burden of their daily medication load, comorbidities, and basic physiologic changes.

Avoid decongestant-containing products, if possible, given effects on blood pressure. Avoid sedating/highly anticholinergic antihistamines (diphenhydramine, chlorpheniramine), as these can worsen or cause cognitive impairment, falls, constipation, urinary retention, and dry mouth and dry eyes. Table 1 presents some safe alternatives for the common cough/cold symptoms in an older adult.

Mood

Mood disorders, most commonly depression, are extremely prevalent in older adults. Biochemical changes in the brain contribute to a neurotransmitter imbalance that increases risk for mood changes, as well as changes in the brain due to other illnesses (eg, stroke, dementia, Parkinson’s). Assisting patients and prescribers in choosing the right antidepressant agent is extremely important to avoid potentially dangerous adverse effects. All antidepressant classes (eg, tricyclic antidepressants [TCAs], monoamine oxidase inhibitors [MAO-Is], selective serotonin reuptake inhibitors [SSRIs]) have been shown to be equally effective in treating depression and helping patients achieve remission.

When treating older adults, the differences lie in the safety profile of the drugs. Tricyclic antidepressants (eg, amitriptyline, imipramine) are extremely anticholinergic, contribute to orthostasis/falls, and can cause cardiac conduction disturbances. Rarely should these agents be used firstline, if at all. With the availability of safer options, MAO-Is have also fallen out of favor due to their interaction with tyramine- containing foods/drinks precipitating a hypertensive crisis. SSRIs (eg, citalopram, sertraline) have become the cornerstone of depression treatment in older adults due to their safety profile, minimal drug-interaction potential, and low potential for overdose.

Currently, sertraline and citalopram are considered initial options, keeping in mind the new concerns for higher citalopram doses (>20 mg/day in older adults) and QTc prolongation. The risk appears minimal based on available literature, but should be weighed when choosing agents. Serotonin norepinephrine reuptake inhibitors (eg, venlafaxine, duloxetine) and “atypical” antidepressants (eg, mirtazapine, bupropion) remain second- or third-line options, or agents that may be added to “augment” the response of an existing antidepressant. Remember, push doses high enough to achieve a desired response, titrate slowly, and monitor for side effects along the way.

Insomnia

Sleep disturbances are very common as people age due to a multitude of factors, including medication side effects, complex comorbidities, poor sleep hygiene, and changes in the sleep cycle with aging. The first approach should always be ruling out medical causes and educating the patient about practicing good sleep hygiene. Watch out, as seniors are often out to self-medicate for insomnia with remedies like diphenhydramine, doxylamine, or other sedating OTC agents. None of these are safe for any period of time and their use should be highly discouraged. Patients should always be advised to discuss their concerns with their physicians before medicating.

If any OTC treatment is recommended after a thorough medical workup, suggest melatonin at doses starting at 1 mg up to 5 mg just prior to bed. The efficacy of melatonin is conflicting and stronger for sleep cycle disorders, but it is fairly void of any significant adverse effects (watch INR upon starting if on warfarin). As far as prescription agents go, none are void of significant side effects and patients should always be educated and warned about possible risks when discussing options with them. Data concerning the use of trazodone at low doses (25-100 mg) are poor and often side effects of orthostasis/hypotension limit its use. However, in certain patients, trazodone may actually be one of the “safer” options and may be used with close monitoring and follow-up.

Mirtazapine is a helpful antidepressant agent that can help with insomnia that is complicated by depression. Mirtazapine is most sedating at lower doses, so just be aware that as you titrate up, the sedating effect may lessen. Recommend starting with 7.5 to 15 mg prior to bedtime. The other sedative/hypnotics (eg, zolpidem, zaleplon) may be used if all other interventions have failed and inadequate sleep is truly affecting daily function and quality of life. Avoid controlled release products, as they have pharmacologic profiles similar to the immediate release options and have a higher potential for accumulation and toxicity, and they are more expensive. Zolpidem, 2.5 to 5 mg prior to bedtime, may be tried with close monitoring, follow- up, and patient education. Emphasize using sleep agents for the shortest duration necessary to treat the problem and try to decrease the dose periodically to see if total drug discontinuation may be possible. Also encourage using good sleep hygiene practices with any therapies tried. A patient education handout on sleep hygiene for your patient population is available from Pharmacist’s Letter.2 Pharmacy Times has also recently published a patient guide in The Educated Patient on insomnia (www.pharmacytimes.com/publications/ issue/2011/October2011/Sweet-Dreams-AGuide- to-Overcoming-Insomnia).

Caring for the Hospitalized Older Adult

Upon hospitalization of an older adult, several standard measures should be taken by the health-system pharmacist to prevent errors and further acute health complications. First and foremost, an accurate medication history should be taken to ensure that no home medications are omitted that could adversely affect the patient’s health. If the patient is not a reliable source of information for the history or not in the condition to provide information, a caregiver or other family member should be sought out to collect this information. If all else fails, the pharmacist can contact the patient’s pharmacy via phone to ascertain the prescription profile for the patient.

Pharmacists should be very cautious about adding new medications that may precipitate delirium in the older adult during hospitalization, and always weigh the risks/benefits of adding drugs; for example, benzodiazepenes, narcotics, antipsychotics, or certain antibiotics (eg, quinolones) can precipitate delirium. Ensuring that pain is adequately controlled is key in the inpatient setting as uncontrolled pain can lead to delirium, impaired healing, and may lengthen or complicate hospital stays. Use scheduled pain regimens (eg, Tylenol) rather than as-needed regimens, when needed, to prevent and control chronic, moderate-tosevere pain on a long-term basis. Assessing renal function on an ongoing basis and ensuring that all medications are renally dosed are key to preventing medication toxicity and drug-induced renal impairment.

Finally, pharmacists play an integral role in the discharge planning process to ensure that all medications are appropriately placed on discharge instructions, whether the patient is returning home or to a nursing facility. It is also pertinent to make sure that inpatient medications (PPIs, heparin, antibiotics) that are no longer needed on an outpatient basis do not get placed on discharge summaries and complicate medication regimens. Inpatient pharmacists are poised to play an integral role in the admission and discharge medication reconciliation process and are vital to ensuring that these transitions are smooth and accurate for our older patients. PTHS

Dr. Burkhart received her doctor of pharmacy in 2004 from the Eshelman School of Pharmacy at the University of North Carolina (UNC) at Chapel Hill and in 2005 completed a 1-year geriatric specialty residency with the school and UNC hospitals. She is currently a clinical assistant professor in the division of pharmacy practice and experiential education at the UNC Eshelman School of Pharmacy and clinical assistant professor in the division of geriatrics at the UNC School of Medicine. Dr. Burkhart teaches in both the didactic and experiential settings at UNC-Chapel Hill. Her clinical practice includes working in the UNC Division of Geriatric Medicine’s Interdisciplinary Geriatric Evaluation Clinic and in the local community where she offers medication management services to older adults in their home and at a local senior center. Dr. Burkhart is actively involved in research, serving as the lead study pharmacist on 2 federally funded grants to improve the quality of medication use in older adults.