As emergency physicians, we have all noticed that the number of geriatrics patients that visit the emergency department continues to increase over time. It is projected that by 2013, 20% of the population will be age 65 or older. One important issue with respect to geriatrics patients is inappropriate prescription/use of medications. Data shows that 30% of patients in the emergency department have a potential adverse drug event amongst their medications. Furthermore, approximately 5% of older patients discharged from the emergency department with a prescription for a potentially inappropriate medication. There exists a compository of medications referred to as PIMs (potentially inappropriate medications) – Beers Criteria. This criteria was initially developed for nursing home patients, and has since been expanded to multiple settings that provide health care to geriatrics patients.
Here is a list of some of the medications on this list relevant to us as ED physicians:
- Benzodiazepines: older patients metabolize benzodiazepines less well than younger patients, secondary to such, patients are at increased risk of delirium and falls; as an alternative, consider low dose haldol
- Antihistamines: decreased clearance in older adults; patients are at increased risk of confusion and constipation; as an alternative for diphenhydramine, you can consider loratidine or certirizine
- Tricyclic antidpressants: can cause orthostatic hypotension, sedation, and also has anticholinergic effects; as an alternative, consider mirtazepine or sertaline
- Muscle relaxants (i.e. carisoprodol, cyclobenzaprine, methocarbamol): cause sedation, patients are at increased fall risk, as with tricyclics, they have anticholinergic effects; as an alternative use acetominophen, and in appropriate patients, low dose NSAIDs
- Antibiotics, specifically, Macrobid: Macrobid is ineffective in patients with creatinine clearance < 60 ml/min, it can also worsen renal impairment and cause pulmonary toxicity; instead, use cephalosporins
- Diabetic medications, particularly, insulin, sulfonylureas: increased risk of hypoglycemia without improvement in hyperglycemia management
For a expanded list:
American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, J Am Geriatr Soc, 60(4): 616-631, 2012.
Hohl CM, Dankoff J, Colacone A, Afilalo, Polypharmacy, Adverse Drug-Related Events, and Potential Adverse Drug Interactions in Elderly Patients Presenting to an Emergency Department. Annals of Emergency Medicine, 38(6) 666-671, 2001.
Hwang U, Platts-Mills TF. Acute Pain Management in Older Adults in the Emergency Department. Clin Geriatr Med, 29(1) 151-164, 2013.