High Risk Medications in the Elderly

Medications are a classic two-edged sword.  Used appropriately and monitored carefully, they can be live saving, life extending or symptom limiting.  Unfortunately, there is no medication which is completely risk or side effect free; therefore prescribing is always a balance of risk versus benefit. Nowhere is this more of a challenge than in the elderly.  Normal age related declines in the body’s ability to metabolize drugs, limited reserve to balance against side effects that would have been minimal at younger ages, and the frequent use of multiple medications all combine to make drug treatment in the elderly a sophisticated therapeutic intervention.  The National Committee for Quality Assurance has identified a group of medications that are associated with an increased risk of harm in the elderly.  These so called “high risk medications” (HRMs) are to be used with caution because of their potential risk of harm, and “should generally be avoided in people 65 years or older because they are either ineffective or they pose unnecessarily high risk for older people and a safer alternative is available”. The list (www.ncqa.org/Portals/0/newsroom/.../Drugs_Avoided_Elderly.pdf) includes drugs within numerous categories of medications: antianxiety, antiemetic, analgesic, antihistamine, antipsychotic, amphetamine, barbiturate, benzodiazepine, calcium channel blocker, gastrointestinal antispasmodic, belladonna alkaloids, muscle relaxant, estrogen, hypoglycemic, narcotic and vasodilator.  This is not to say that none of these medications should ever be used—many are quite effective in the correct clinical situation. However, if you are taking a medication on the list and are 65 and older, you should review the benefits, risks and alternatives with your doctor.A new study in the Journal of Internal Medicine took a look at how often these medications are prescribed. Reviewing the Medicare data base for over six million patients 65 and older, authors analyzed HRM prescribing trends in the United States. A little more than 1 out of 5 patients (21%) received at least one HRM in the last year, and 4.8% received at least two. Higher rates were seen in women, low income patients and those living in southern states.Be a smart consumer and an engaged patient. Know about your medications, the indication for their use, and side effects to be watched for. Most patients take most medications with no adverse effects—and an open communication with your primary care physician is the key to safety.