Login
Subscribe
Adults aged 65 or older are at high risk of experiencing drug interactions and adverse events.[1] There are several reasons for this; for instance, older adults are more likely than younger adults to have multiple health conditions that occur at the same time, for which they often need to take several prescription medications.[2] Older adults also frequently take over-the-counter drugs as well as dietary and herbal supplements.[3] Many medications and supplements have adverse effects, and...
Adults aged 65 or older are at high risk of experiencing drug interactions and adverse events.[1] There are several reasons for this; for instance, older adults are more likely than younger adults to have multiple health conditions that occur at the same time, for which they often need to take several prescription medications.[2] Older adults also frequently take over-the-counter drugs as well as dietary and herbal supplements.[3] Many medications and supplements have adverse effects, and taking several drugs at the same time increases the risk of drug interactions.
As people get older, their bodies undergo changes that contribute to medication risk.[4] These include changes in the digestive system, circulation and body weight, as well as reductions in organ and muscle mass and decreased efficiency of the kidneys and liver.[5] These age-related changes can alter how quickly drugs are absorbed and enter the bloodstream, as well as how drugs are broken down and removed from the body. As the metabolism of some drugs slows, their concentration in the blood increases; some patients may need lower doses. Even drugs that previously caused no problems may need to have their doses adjusted or be replaced with another medicine.[6]
Drug classes that older adults should avoid
Despite the increased risks of drug interactions and adverse events, older adults are not adequately represented in many clinical trials. Thus, information about the safety and effectiveness of drugs in the elderly may be inadequate or unavailable.[7] However, some studies specifically assess which drugs may be especially risky and potentially inappropriate in older people.[8],[9] In 2023 the American Geriatrics Society updated a list (called the Beers Criteria) of medications that older adults should avoid, if possible.[10] This article highlights five drug classes that are associated with increased risks for older adults.
Benzodiazepines and Z-drugs
Benzodiazepines, such as alprazolam (XANAX and generics), chlordiazepoxide (LIBRIUM and generics) and diazepam (DIAZEPAM INTENSOL, VALIUM and generics), are sedative hypnotics that are used to induce or maintain sleep and to treat acute anxiety.[11] Another class of hypnotics — often called Z-drugs — includes eszopiclone (LUNESTA and generics), zaleplon (SONATA and generics) and zolpidem (AMBIEN, EDLUAR and generics). Z-drugs are approved for short-term relief of insomnia and have similar but shorter-acting effects than benzodiazepines. Because of the serious risks associated with these drugs, including abuse and addiction, Public Citizen’s Health Research Group classifies all benzodiazepines (except for alprazolam, which can be used to treat panic disorder) and Z-drugs as Do Not Use for people of any age. Although benzodiazepines and Z-drugs are widely prescribed for older adults, they are associated with serious adverse events, including an increased risk of falls and fractures, cognitive impairment and delirium.[12],[13]
Anticholinergic medications
Anticholinergic drugs interfere with the neurotransmitter acetylcholine, which transmits signals between nerve cells.[14] These drugs are prescribed for asthma, Parkinson’s disease, certain psychiatric disorders, cardiovascular disease, allergies and other conditions. However, blocking or impeding the effects of acetylcholine can also cause serious problems including memory impairment, confusion, hallucinations, blurred vision, dry mouth, nausea, constipation and tachycardia (rapid heart rate).[15] In older adults, some anticholinergic drugs, including first-generation antihistamines (such as diphenhydramine [BENADRYL and generics]), tricyclic antidepressants (including amitriptyline [generic only]) and medications to treat overactive bladder (such as fesoterodine [TOVIAZ and generics]), also are associated with an increased risk of delirium, cognitive decline, dementia and falls.[16] If a person is taking several anticholinergic medications concomitantly, these dangerous effects can increase. Examples of oral anticholinergic drugs are shown in the Table below.
Examples of Oral Anticholinergic Drugs
| Drug Class | Generic Name | Brand Name(s)† |
|---|---|---|
| Antihistamines | chlorpheniramine* | generic only |
| cyproheptadine | generic only | |
| hydroxyzine | VISTARIL and generics | |
| meclizine | ANTIVERT and generics | |
| Antipsychotics | chlorpromazine** | generic only |
| clozapine** | CLOZARIL, VERSACLOZ and generics | |
| Antispasmodics | atropine*** | generic only |
| dicyclomine*** | generic only | |
| Drugs for overactive bladder | oxybutynin** | generic only |
| tolterodine** | DETROL and generics | |
| Muscle relaxants | orphenadrine*** | generic only |
| Tricyclic antidepressants | desipramine** | NORPRAMIN and generics |
| doxepin*** | SILENOR and generics | |
| imipramine*** | generic only | |
| nortriptyline** | PAMELOR and generics |
†Brand-name combination products that contain other active ingredients are not included.
*Designated as Do Not Use for allergic rhinitis or urticaria by Public Citizen’s Health Research Group
**Designated as Limited Use by Public Citizen’s Health Research Group
***Designated as Do Not Use by Public Citizen’s Health Research Group
Cardiovascular and antithrombotic medications
In older adults, certain drugs that are prescribed to reduce the risk of myocardial infarction (heart attack) and stroke and to prevent a second or subsequent heart attack can also increase the risk of major bleeding, for instance in the brain or gastrointestinal tract.[17] Importantly, an increased risk of bleeding is associated with the anticoagulants (blood thinners) rivaroxaban (XARELTO) and warfarin (JANTOVEN and generics) and with aspirin (BAYER and generics), which is sometimes prescribed for people who already had a heart attack or stroke to prevent another one from occurring.[18] Some herbal supplements can further increase this risk. For example, people have a higher risk of bleeding when they are taking the herbal supplement ginkgo biloba at the same time as warfarin.[19]
Sulfonylureas
Sulfonylureas stimulate the pancreas to produce more insulin. This class of drugs is prescribed for people with type 2 diabetes to lower glucose levels in the blood.[20],[21] In older adults, several second- or third-generation sulfonylureas, including glyburide (DIABETA, GLYNASE and generics), glipizide (GLUCOTROL XL and generics) or glimepiride (AMARYL and generics), are associated with higher risks of hypoglycemia (low blood glucose), cardiovascular events such as stroke, and all-cause mortality.
Antipsychotics in older adults with dementia
Antipsychotics, such as aripiprazole (ABILIFY and generics), brexpiprazole (REXULTI and generics), haloperidol (generic only), olanzapine (ZYPREXA and generics), quetiapine (SEROQUEL and generics) and risperidone (RISPERDAL and generics), are frequently prescribed to address behavioral problems in older adults with dementia.[22],[23] Because the limited benefits of these drugs in older adults with dementia do not outweigh the serious risks, Public Citizen’s Health Research Group recommends that antipsychotics not be used in older adults with dementia. The serious risks include higher rates of cognitive decline and stroke and an increased risk of death. The June 2024 issue of Worst Pills, Best Pills News highlighted a large observational study from the United Kingdom that adds to the evidence of the risks of antipsychotic use in people with dementia.[24],[25] Compared with people who were not prescribed antipsychotics, those who were prescribed an antipsychotic had an increased risk of many adverse outcomes including stroke, heart attack, heart failure, venous thromboembolism, fractures, acute kidney injury and pneumonia.
What You Can Do
Tell your clinician about all medications and supplements you are taking, including all prescription and over-the-counter drugs, dietary and herbal supplements, eye drops and topical ointments and creams. Regularly discuss with your clinician whether you still need to take all these medications and whether the doses should be reduced, especially if you are aged 65 or older.
Ask your clinician to review all your medications to see if there is a risk of drug interactions. Do not stop taking any drug without talking to your clinician first.
References
[1] Błeszyńska E, Wierucki Ł, Zdrojewski T, Renke M. Pharmacological interactions in the elderly. Medicina (Kaunas). 2020;56(7):320.
[2] Davies EA, O'mahony MS. Adverse drug reactions in special populations–the elderly. Br J Clin Pharmacol. 2015 Oct;80(4):796-807.
[3] Rochon, PA. Drug prescribing for older adults. UpToDate. Updated September 12, 2023.
[4] Food and Drug Administration. As you age: you and your medicines. February 19, 2019. https://www.fda.gov/drugs/information-consumers-and-patients-drugs/you-age-you-and-your-medicines. Accessed May 7, 2024.
[5] Błeszyńska E, Wierucki Ł, Zdrojewski T, Renke M. Pharmacological interactions in the elderly. Medicina (Kaunas). 2020;56(7):320.
[6] Food and Drug Administration. 5 medication safety tips for older adults. February 15, 2024. https://www.fda.gov/consumers/consumer-updates/5-medication-safety-tips-older-adults. Accessed May 7, 2024.
[7] Lau SJ, Huang Y, Hsieh J, et al. Participation of older adults in clinical trials for new drug applications and biologics license applications from 2010 through 2019. JAMA Netw Open. 2022;5(10):e2236149.
[8] Davies EA, O'mahony MS. Adverse drug reactions in special populations–the elderly. Br J Clin Pharmacol. 2015 Oct;80(4):796-807.
[9] Błeszyńska E, Wierucki Ł, Zdrojewski T, Renke M. Pharmacological interactions in the elderly. Medicina (Kaunas). 2020;56(7):320.
[10] 2023 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023;71(7):2052-2081.
[11] FDA belatedly requires abuse-related black-box warnings for benzodiazepines. Worst Pills, Best Pills News. May 2021. https://www.worstpills.org/newsletters/view/1399. Accessed May 7, 2024.
[12] Davies EA, O'mahony MS. Adverse drug reactions in special populations–the elderly. Br J Clin Pharmacol. 2015 Oct;80(4):796-807.
[13] 2023 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023;71(7):2052-2081.
[14] Ghossein N, Kang M, Lakhkar AD. Anticholinergic Medications. [Updated 2023 May 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan.
[15] Rochon, PA. Drug prescribing for older adults. UpToDate. Updated September 12, 2023.
[16] 2023 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023;71(7):2052-2081.
[17] 2023 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023;71(7):2052-2081
[18] New analysis: Daily low-dose aspirin not beneficial for preventing a first stroke in healthy older adults. Worst Pills, Best Pills News. February 2024. https://www.worstpills.org/newsletters/view/1582. Accessed May 8, 2024.
[19] Davies EA, O'mahony MS. Adverse drug reactions in special populations–the elderly. Br J Clin Pharmacol. 2015 Oct;80(4):796-807.
[20] 2023 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023;71(7):2052-2081.
[21] Drug profile. Worst Pills, Best Pills News. Last reviewed December 31, 2023. https://www.worstpills.org/monographs/view/43. Accessed May 8, 2024.
[22] 2023 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023;71(7):2052-2081.
[23] Brexpiprazole: Do Not Use for agitation due to Alzheimer’s dementia. Worst Pills, Best Pills News. October 2023. https://www.worstpills.org/newsletters/view/1559. Accessed May 2, 2024.
[24] Mok PLH, Carr MJ, Guthrie B, et al. Multiple adverse outcomes associated with antipsychotic use in people with dementia: population based matched cohort study. BMJ. 2024;385:e076268.
[25] New study: more evidence of the risks of antipsychotic use in people with dementia. Worst Pills, Best Pills News. June 2024. https://www.worstpills.org/newsletters/view/1605. Accessed June 3, 2024.
