PPRNet Practice Guidelines
Practice guidelines:
|
Avoid use of medications considered always inappropriate for patients 65 years of age or older: |
|
| Barbiturates | Meperidine (DemerolÒ) |
| Belladonna alkaloids (DonnatalÒ,others) | Meprobamate (MiltownÒ, EquanilÒ) |
| Chlorpropamide (DiabineseÒ) | Pentazocine (TalwinÒ) |
| Dicyclomine (BentylÒ) | Propantheline (Pro-BanthineÒ) |
| Flurazepam (DalmaneÒ) | Trimethobenzamide (TiganÒ) |
| Hyoscyamine (LevsinÒ, LevsinexÒ) | |
|
Avoid use of medications considered rarely appropriate in patients 65 years of age or older |
|
| Carisoprodol (SomaÒ) | Metaxalone (SkelaxinÒ) |
| Chlordiazopoxide (LibriumÒ) | Methocarbamol (RobaxinÒ) |
| Chlorzoxazone (ParaflexÒ) | Propoxyphene (Darvon®, DarvocetÒ, others) |
| Cyclobenzaprine (FlexerilÒ) | Diazepam (ValiumÒ) |
Inappropriate medication use is a major
patient safety concern, particularly in older patients, with the estimated
prevalence of potentially inappropriate use ranging from 12 to 40%.
In 1991 Beers and colleagues developed explicit criteria identifying
inappropriate medication use in the elderly based upon a consensus of nationally
recognized experts as supported by published literature, and this criteria was
subsequently updated in 1997, incorporating more recent scientific information.
In a 2001 study, an expert panel was convened to further categorize
inappropriate medications into drugs (1) that should always be avoided, (2) are
rarely appropriate, and (3) have some indications but are often misused.
These potentially inappropriate drugs and their side effects are
presented below.
Benzodiazepines
with longer half-lives, including flurazepam
(Dalmane), chlordiazopoxide (Librium), and
diazepam (Valium) produce prolonged sedation and increase the incidence
of falls and fractures. Medium
or short-acting benzodiazepines are preferable.
Meprobamate
(Miltown, Equanil)
is a highly addictive and sedating anxiolytic.
Chlorpropamide
(Diabinese) has a prolonged half-life in the elderly and can cause
prolonged and serious hypoglycemia. Additionally,
it is the only oral hypoglycemic agent that causes SIADH.
Pentazocine
(Talwin) is a narcotic analgesic that causes more CNS side effects,
including confusion and hallucinations, more commonly than other narcotic
drugs. Additionally, it is a
mixed agonist and antagonist. For
both reasons, its use should generally be avoided in the elderly.
Trimethobenzamide
(Tigan) is one of the least effective antiemetic drugs, yet it can cause
extrapyramidal side effects.
Gastrointestinal
antispasmodic drugs such as belladonna
alkaloids (Donnatal and others),
dicyclomine (Bentyl), hyocyamine (Levsin, Levsinex), and
propantheline (Pro-Banthine) are highly anti-cholinergic and generally
produce substantial toxic effects in the elderly.
Additionally, their effectiveness at doses tolerated by the elderly
is questionable.
Propoxyphene
should generally be avoided in the elderly. It offers few analgesic
advantages over acetaminophen, yet has the side effects of other narcotic
drugs.
Most muscle relaxants and antispasmodic drugs, including carisoprodol (Soma), chlorzoxazone (Paraflex), cyclobenzaprine (Flexiril), metaxalone (Skelaxin), and methocarbamol (Robaxin), are poorly tolerated by the elderly, leading to anticholinergic side effects, sedation, and weakness. Additionally, their effectiveness at doses tolerated by the elderly is questionable.
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