Appropriate prescribing in the elderly: Current perspectives

Abstract

Advances in medical therapeutics have undoubtedly contributed to health gains and increases in life expectancy over the last century. However, there is growing evidence to suggest that therapeutic decisions in older patients are frequently suboptimal or potentially inappropriate and often result in negative outcomes such as adverse drug events, hospitalisation and increased healthcare resource utilisation. Several factors influence the appropriateness of medication selection in older patients including age-related changes in pharmacokinetics and pharmacodynamics, high numbers of concurrent medications, functional status and burden of co-morbid illness. With ever-increasing therapeutic options, escalating proportions of older patients worldwide, and varying degrees of prescriber education in geriatric pharmacotherapy, strategies to assist physicians in choosing appropriate pharmacotherapy for older patients may be helpful. In this paper, we describe important age-related pharmacological changes as well as the principal domains of prescribing appropriateness in older people. We highlight common examples of drug-drug and drug-disease interactions in older people. We present a clinical case in which the appropriateness of prescription medications is reviewed and corrective strategies suggested. We also discuss various approaches to optimising prescribing appropriateness in this population including the use of explicit and implicit prescribing appropriateness criteria, comprehensive geriatric assessment, clinical pharmacist review, prescriber education and computerized decision support tools.

Keywords: Elderly; Inappropriate prescribing; Polypharmacy; Beers criteria; Screening Tool of Older Person’s potentially inappropriate Prescriptions/Screening Tool to Alert to Right Treatment; Adverse drug reactions

Core tip: In this paper we discuss the challenges and complexities of prescribing for older people. We describe the important age-related changes in pharmacokinetics and pharmacodynamics that influence prescribing decisions and we highlight commonly encountered examples of drug-drug and drug-disease interactions. We present a detailed analysis of a complex clinical case in which several instances of potentially inappropriate prescribing exist and we suggest corrective actions. We explore a range of strategies aimed at optimizing prescribing appropriateness for older people including prescribing criteria, comprehensive geriatric assessment, clinical pharmacy interventions and computerized decision supports.