Chapter e23: Prescribing in the Older Adult

Emily R. Hajjar; Lauren R. Hersh; Shelly L. Gray

KEY CONCEPTS

Improving and maintaining functional status is a cornerstone of care for older adults.
Adverse drug reactions in older adults are common and cause considerable morbidity.
Inappropriate prescribing is a major concern and is guided by the Beer’s criteria.
Polypharmacy can be defined in various ways and is a common occurrence in older adults.
Underutilization of medications also occurs and can be improved by using the START criteria.
Pharmacists can play a major role in optimizing drug therapy and preventing adverse consequences of medications in older adults.
Deprescribing should be considered to reduce medications in older adults.
Practitioners may consider targeting high-risk older adults to implement comprehensive management strategies.

PRECLASS ACTIVITY

Preclass Engaged Learning Activity

Read the current American Geriatrics Society Beers Criteria®¹⁶ and discuss the impact of the recommendations on medication use in older adults.

INTRODUCTION

Pharmacotherapy for older adults can cure or palliate disease as well as enhance health-related quality of life (HRQOL). HRQOL considerations for older adults include focusing on improvements in physical functioning (eg, activities of daily living), psychological functioning (eg, cognition, depression), social functioning (eg, social activities, support systems), and overall health (eg, general health perception).¹ Despite the benefits of pharmacotherapy, HRQOL can be compromised by drug-related problems. The clinical response to a medication in an older adult is the result of the interaction of a number of complex processes, including pharmacokinetics, pharmacodynamics, concurrent medications, comorbidities, and frailty. Age-related changes in physiology can affect drug pharmacokinetics and pharmacodynamics.² When applying general knowledge of pharmacokinetic and pharmacodynamic alterations in an older adult in the clinical setting, it is necessary to consider the patient’s overall condition, age, diseases, frailty status, and concurrent medications. Prevention of drug-related problems in older adults requires that health professionals become knowledgeable about a number of age-specific issues. To address these knowledge needs, this chapter discusses the epidemiology of adverse consequences of medications in older adults and an approach to optimizing medication use through the provision of a comprehensive geriatric assessment.

ADVERSE CONSEQUENCES OF MEDICATION USE

Although medications used by older adults can lead to improvement in HRQOL, adverse outcomes caused by drug-related problems are considerable.³ Adverse drug reactions (ADRs) and negative consequences of drug therapy are major threats to the HRQOL of outpatient older adults and account for a significant portion of healthcare expenditures.⁴ Estimates are that more than $520 billion was spent in 2016 for prescription-associated morbidity and mortality from nonoptimized medications.⁴

ADVERSE DRUG REACTIONS

ADRs are a major public health problem for older adults in all settings.⁵ ADRs are defined as “a response to a drug that is noxious and unintended and occurs at doses normally used in man for the prophylaxis, diagnosis or therapy of disease, or for modification ...