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:

http://www.americangeriatrics.org/files/documents/beers/PrintableBeersPocketCard.pdf

References:

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.