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86 Substance Use in Older Adults
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rnatives for AUD in a large, national study: differences
CHAPTER 4
Safe Prescribing Practices
for Older Adults
Badr Ratnakaran, M.B.B.S.
Rajdip Barman, M.D.
Older adults are more vulnerable to side effects of medications than
their younger counterparts. Thus, to reduce the risk of adverse drug
events and drug–drug interactions, physiological changes related to aging should be taken into consideration when prescribing medications to
older adults. In addition, polypharmacy is a public health concern that
can contribute to adverse drug events, geriatric syndromes, hospitalizations, and mortality in older adults. When prescribing medications for
older adults, care should be taken that inappropriate medications are
avoided and safe practices are adopted. Health care providers should
also assess for nonadherence and that medications are managed safely
by older adults at home. During transitions of care, medication reconciliation is recommended to avoid medication discrepancies during
87
88 Substance Use in Older Adults
care. Medications in older adults should be reviewed periodically by
health care providers for appropriateness and to avoid polypharmacy.
When inappropriate medications are identified, or when there is a concern that medications are being abused, deprescribing should be undertaken promptly to avoid further negative outcomes.
PHYSIOLOGICAL CHANGES IN
OLDER ADULTS
The aging process results in physiological changes that affect the safety
of medications. Changes in hepatic and renal function, body fat, lean
body mass, and total body water volume lead to altered pharmacodynamics and pharmacokinetics of drugs. Physiological changes with aging and pharmacological considerations are summarized in Table 4–1
(Kaiser 2015; Slattum et al. 2017).
SAFELY PRESCRIBING PSYCHOTROPIC
MEDICATIONS TO OLDER ADULTS
Careful review of risks and benefits is essential prior to recommending
any new medication to older adults. While the efficacy of most medications is comparable in older adults and younger adults, tolerability is
not. If you r
psychiatry mantra, “start low, go slow”—in other words, start with
doses lower than customary in younger adults and titrate more slowly
than you would in younger adults. Monitor very carefully for side effects and regularly reassess the risks and benefits of each medication.
Minimizing the use of medications that are potentially inappropriate for older adults is essential. Several assessment tools have been
developed
older adults. Examples include the American Geriatrics Society Beers
Criteria (2023), Screening Tool to Alert Doctors to Right Treatment
(START) or Screening Tool of Older People’s Prescriptions (STOPP)
(O’Mahony et al. 2015), and Medication Appropriateness Index (Hanlon et al. 1992). These instruments have reduced inappropriate prescribing, but their impact on clinical practices has been questionable (Rankin
et al. 2018
ate medications and potential prescription omissions. Corsonello et al.
(2012) r
ecommend a medication, make sure to follow the geriatric
to assess the appropriateness of prescribing medications to
). STOPP and START consist of a list of potentially inappropri-
eported that the STOPP/START criteria have higher reliability
Table 4–1. Physiological changes in older adults and pharmacological implications
Property Physiological changes Consequence Importance in older adults
Safe Prescribing Practices for Older Adults 89
Absorption Decreased GI motility and
blood flow
Increased gastric pH
Decreased digestive enzyme
activity
Distribution Decreased lean muscle mass
and total body water
Increased total body fat
percentage
Renal Decreased renal mass
Decreased renal blood flow
Liver Decreased liver mass
Decreased hepatic blood flow
Decreased hepatic CYP450
enzymes
Decreased protein synthesis
Increased transit time of
medications
Altered drug absorption
Increased risk of constipation
Increased plasma concentration of
hydrophilic drugs
Increased distribution of lipophilic
drugs (e.g., morphine, fentanyl,
benzodiazepines)
Decreased glomerular filtration
rate and clearance
Increased elimination half-life of
drugs metabolized by the liver
Alteration in the metabolism of
dr
ugs metabolized by CYP450
enzymes
Decreased serum albumin
Alteration in bioavailability of drugs
Increased risk of opioid-induced constipation
Delay in medication elimination and onset of action
Increased risk of medication side effects
Required dose adjustment of hydrophilic drugs (e.g.,
gabapentin) due to slower renal excretion
Potential for accumulation of toxic metabolites of
hydrophilic drugs
Adverse interactions between drugs that influence
or are metabolized by CYP450 enzymes (e.g.,
methadone)
Increase in free concentration of drugs strongly bound
to albumin (
concentration is in normal range
Increase in active metabolites of drugs metabolized by
the li
e.g., diazepam) even when total
ver (desmethyldiazepam from diazepam)
Table 4–1. Physiological changes in older adults and pharmacological implications (continued)
Property Physiological changes Consequence Importance in older adults
90 Substance Use in Older Adults
Cardiac Decreased cardiac index
Increased thickness of blood
vessels
Decreased cardiovascular
sensitivity of
β-adrenoreceptors
Brain Decline in cognitive function,
cessing speed, working
pro
memory, and executive
function
Increased sensitivity to
benzodiazepines, opioids,
dopaminergic medications,
H1-antihistamines, and
psychotropic medications
GI= gastrointestinal.
Source. Kaiser 2015; Slattum et al. 2017.
Increased risk of cardiac ischemia
Increased risk of hypertension
Increased risk of cardiac
conduction disturbances
Impairment of reflex tachycardia
Increased risk of cognitive side
effects of medications
Increased risk of sedation from
medications
Increased risk of other neurological
side effects of medications
Decrease in response to agonists and antagonists of
β-adrenoreceptors (e.g., propranolol)
Increased risk of orthostatic hypotension with
antihypertensive medications (e.g., clonidine)
Increased risk of cardiac conduction disturbances
(e.g., QTc prolongation by tricyclic antidepressants)
Increased risk of cognitive dysfunction, including
memory problems and confusion from
benzodiazepines, opioids, anticholinergic
medications, and psychotropic medications
like antipsychotics
Dose reduction in medications causing sedation
Increased risk of neurological side effects such
as falls, tremors, serotonin syndrome, and
extrapyramidal symptoms from psychotropic
medications
Safe Prescribing Practices for Older Adults 91
and greater ability to predict adverse drug reactions and prevent potentially inappropriate prescriptions than the Beers criteria. In several
coun
tries, STOPP/START criteria have been incorporated in prescrip-
tion software to minimize risks (Corsonello et al. 2012).
Older adults should be encouraged to always bring a list of their
cribed medications, over-the-counter (OTC) medications, and sup-
pres
plements to appointments to share with health care providers. Clinicians should regularly evaluate medication adherence, effectiveness,
and adverse effects, perhaps in collaboration with family members or
other caregivers. Educating patients about the appropriate use of medications, explaining the consequences of prescription drug misuse or
abuse, and monitoring refills (ideally, with the participation of family
members) can minimize adverse drug interactions and inappropriate
prescriptions as well (Simoni-Wastila and Yang 2006).
An important strategy is called “Brown Bag Medicine Review.”
r adults are asked to bring in all prescribed medications, OTC med-
Olde
ications, and dietary supplements in a brown bag to their appointments, especially if there is concern that they are incorrectly using or
misusing medications. This strategy can improve client reporting of
medication use and clinician-patient discussion of medication use
(Weiss et al. 2016).
Regular use of state prescription drug monitoring programs
DMPs) is essential and increasingly required when prescribing con-
(P
trolled substances. In order to detect possible misuse, clinicians should
corroborat
with reports provided by prescription drug plans. Clinicians should
regularly screen for substance use disorders (as described in Chapter 2)
and should also screen for cognitive impairment, a possible cause of
nonadherence or misuse of medications. In summary, clinicians should
pay close attention to signs of nonadherence or misuse, should keep in
mind drug–drug interactions, and should regularly evaluate appropriateness of medications and their dosages in the context of medical comorbidit
We present a summary of safe prescribing practices in Figure 4–1.
e patients’ refill requests with the PDMP query results and
ies and the aging process.
Medication Reconciliation and Review
During transitions of care, proper management of medications is essential for high-quality care and patient safety. Preventing medication errors during transitions of care is essential. A Cochrane Review of 20
studies found
rors during transitions of care (Redmond et al. 2018). These errors can
that 559 of 1,000 patients were at risk of one or more er-
Screening
strategies
Treatment
approach
92 Substance Use in Older Adults
• Maintain up-to-date list of prescribed medications, over-the-counter medications,
and dietary supplements
• Brown-bag medicine review
• Ensure medication adherence: pill count; communicate with family members and
other health care providers
• Contact the pharmacy and review the state prescription drug monitoring program
• If indicated, screen for substance use disorders
• Assess medical comorbidities; consider liver and renal function when selecting
and adjusting dosages
• Consider drug–drug interaction
• Avoid long-acting benzodiazepines
• Explore nonpharmacological and therapeutic interventions
• If patient meets criteria for substance use disorder: SBIRT (screening,
brief intervention, and referral to treatment)
Figure 4–1. Safe practices in prescribing controlled substances.
Safe Prescribing Practices for Older Adults 93
occur at any point of transitions of care of a patient: during hospital discharge to home, admission to the hospital, emergency room visits, and
transfer from one
risk of adverse events due to medication errors during transitions of
care, as many of them have complex medication regimens and high-risk
treatments, including the use of anticoagulants, opioid medications,
and benzodiazepines. Medication reconciliation (MedRec) and medication review (MedRev) are two important processes done during transitions of care to ensure appropriate medications are prescribed for
patients and
The Institute for Healthcare Improvement defines MedRec as “a
proce
ss of identifying the most accurate list of all medications a patient
is taking—including name, dosage, frequency, and route—and using
this list to provide correct medications for patients anywhere within the
health care system.” It is part of the National Patient Safety Goals of the
Joint Commission (2022) in the United States and the Required Organizational Practices of Accreditation Canada (2020). MedRec can be a labor-intensive process and can require the teamwork of the hospital
pharmacist, the physician, and the patient. Various guidelines for MedRec have been created by organizations including national pharmaceutical societies, the World Health Organization, and the Institute for
Healthcare
MedRec should be done at all care transitions to avoid medication
discre
pancies (Beuscart et al. 2021). The steps of MedRec are as follows:
hospital to another. Older adults are vulnerable to the
adverse events from medication errors are avoided.
Improvement (Beuscart et al. 2021).
1. Obtain the best possible medication history (BPMH);
2. Compare the information from BPMH with the current or planned
prescription of medications;
3. Identify and resolve discrepancies in medications;
4. Communicate to patient, caregivers, and other health care providers
the list of medications after the discrepancies have been resolved
and further clinical decisions have been made.
BPMH should ideally be obtained by collecting information from at
least three different sources, including patients, caregivers, medical records, pharmacists, long-term care facilities, and from the contents of
ents’ medicine bottles. Information on OTC medications and
pati
herbal/nutritional supplements should also be obtained from patients
and caregivers. Once a BPMH is obtained, it is compared with the existing medication list. Medication adherence by patients is assessed and
screpancies rectified. An illustrated summary of steps is provided in
di
Figure 4–2.
94 Substance Use in Older Adults
Obtain BPMH
Compare medication list from
BPMH with current/planned
prescriptions and resolve
medication discrepancies
Communicate with
appropriate
caregivers
Initiate relevant
clinical decisions
Figure 4–2. Steps in medication reconciliation.
BPMH=best possible medication history.
Safe Prescribing Practices for Older Adults 95
Health care providers should take care to avoid errors during the
MedRec process (Sponsler et al. 2015). Some of these errors include
1. Errors of omission: omitting a medication from the orders (e.g., fail-
ure of ordering an important medication taken by the patient at
home during hosp
2. Errors of commission: prescribing a medication with no indication
for continua
tion of stress ulcer during hospitalization is continued after discharge even when there is no indication for it);
3. Therapeutic duplication: a patient’s home medication might be sub-
stituted during hospitalization due to the unavailability of the medication in the hospital’s formulary or due to the need for a substitute
cation with different pharmacokinetic properties (e.g., using an
medi
immediate-release formulation in place of sustained-release formulation). Because of inappropriate MedRec, the patient might continue to take both the hospital and home medications on discharge.
Once the MedRec is completed, the corrected medication list should
be r
eviewed (MedRev) by health care providers for the appropriateness
of the medications. MedRev should be done considering the whole clinical picture of the patient. The patient’s current medical conditions, appropriateness of the medications, potential drug–drug interactions, and
current evid
be considered while doing the MedRev (Beuscart et al. 2021; Sponsler et
al. 2015). Factors in older adults to be considered in MedRev include
polypharmacy, risk of falls, frailty, cognitive dysfunction, and ability to
adhere to complex medication regimens. If inappropriate medications
are identified, the risks versus benefits of continuing the medications
should be communicated with the health care providers, patients, and
caregivers before discontinuing the medications. The final medication
list after MedRec and MedRev is then used for continued clinical decisions for the patient after the transition of care.
In Case Example 4–1, we illustrate many of the above principles.
ence-based management of the medical conditions should
italization);
tion (e.g., a proton-pump inhibitor started for preven-
Case Example 4–1: “Six Medications and a
Fall. So, What Next?”
Ms. McGraw is a 68-year-old cisgender woman who was admitted to
the hospital after falling and sustaining a fracture to her right radius and
ulna. She described generalized weakness and ataxia for the week leading to the fall. She did not report any fever, confusion, cough, chest pain,
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