| Problem: Indices or lists of
medications generally considered inappropriate for use in the
elderly are a great aid to drug regimen review, but I've seen
several different lists. Which is best?
Solution: Instead of relying on any one index, use all available tools in a complementary manner. |
"Any symptom in an elderly patient should be considered a
drug side effect until proved otherwise." That's how Brown
University pharmacoepidemiologist Jerry Avorn couches the paramount
importance of medication effects, side effects, and misadventures
as a driver of geriatric health problems.
Embracing this dictum wholeheartedly, long-term care pharmacists have moved in recent years to develop well-defined criteria, or indicators, for inappropriate drug use in elderly populations. Intended to assist pharmacists in targeting drug regimen review (DRR) activities, these indicators typically include a list of medications that should be avoided in the elderly unless there is clear evidence in each case that the potential benefits outweigh the potential risks. At the very least, use of any listed drug by a geriatric patient should put the pharmacist on the lookout for trouble.
Two such lists were recently published in this journal (Consult Pharm 1998;13:160-73). Developed by Brown University gerontologist Mark Beers, MD, one list is specific to nursing facility populations; the other is more broadly applicable to any person age 65 or older. "These two lists are great DRR aids-but they're not the only ones out there," says ASCP Director of Professional Affairs Tom Clark. "Other researchers have developed different lists with different formats, different references, and different approaches to explaining the need for special caution and characterizing the risk to patients."
ASCP's 1997-98 Professional Affairs Council has looked at several such lists over the past few months while working in response to a charge by ASCP President Jan Allen to develop DRR indicators for use in nursing facilities. One document the council will likely incorporate into its recommendations is presented here (see box on next page). Compiled by Clark, this list differs from those developed by Beers in several ways, he notes. "First, it includes additional references not cited by Beers. Second, it's broader, including several drugs not mentioned in the Beers documents. Third, this new lists cites a specific rationale for avoiding use of certain drugs in the elderly, rather than simply categorizing the severity of effects that can occur."
Consultant pharmacists may want to consider adding this document to their armamentarium of DRR tools, Clark says. "Rather than boxing yourself into using just one tool, why not use more than one? In this context, more is definitely better."
David K. Buerger
Senior Editor
Drugs Potentially Inappropriate for Geriatric Use
| Amitriptyline | 1, 3, 6 | A | Glutethimide* | 2 | B | ||
| Amobarbital* | 2, 3 | B | Hyoscyamine | 3, 6 | A | ||
| Belladonna alkaloids | 3, 6 | A | Indomethacin | 1, 3, 6 | G | ||
| Butabarbital* | 2, 3 | B | Isoxsuprine | 1, 6 | F | ||
| Carisoprodol | 1, 3, 6 | C | Meperidine (oral) | 3, 4 | G | ||
| Chlordiazepoxide* | 1, 3, 6 | D | Meprobamate* | 1, 2, 3, 6 | B,G | ||
| Chlorpropamide | 1, 3, 6 | E | Metaxalone | 3 | C | ||
| Chlorzoxazone | 3 | C | Methocarbamol | 1, 3, 4, 6 | C | ||
| Clidinium | 3, 6 | A | Methyldopa | 3 | G | ||
| Cyclandelate | 1, 3, 6 | F | Orphenadrine | 1, 6 | C | ||
| Cyclobenzaprine | 1, 3, 4, 6 | C | Oxybutynin | 3, 5 | A | ||
| Diazepam* | 1, 3, 6 | D | Pentazocine | 1, 3, 4, 6 | G | ||
| Dicyclomine | 3, 6 | A | Pentobarbital* | 1, 2, 3, 6 | B,G | ||
| Dipyridamole | 1, 4, 6 | F | Propantheline | 3 | A | ||
| Disopyramide | 3, 4 | A | Propoxyphene | 1, 3, 6 | G | ||
| Doxepin | 3 | A | Reserpine | 3, 4, 6 | G | ||
| Ergot mesyloids | 3 | F | Secobarbital* | 1, 2, 3, 6 | B,G | ||
| Ethchlorvynol* | 2 | B | Trimethobenzamide | 1, 3, 6 | F | ||
| Flurazepam* | 1, 3, 6 | D | |||||
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