Live Well, Live Long : Optimal Medications Use: Wise Choices for Healthy Aging

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Appendix A (Cont'd)

High-risk and Potentially Inappropriate Medications for Older Adults

(Adapted with permission from Table I in Cameron, K.A., and Richardson, A.W. (2001) "A Guide to Medication and Aging." Generations 24:14-20)

* Asterisks indicate medications for which the risk of severity for older adults is highest

Medications	Reason That Use Is a Problem
propoxyphene and combination products (Darvon, Darvocet N-100)	Used to control pain. Propoxyphene offers little pain-relief advantage over acetaminophen, yet has the side effects of other narcotics.
indomethacin (Indocin, Indocin SR)	Used to control pain and inflammation. Of all available nonsteroidal anti-inflammatory drugs, indomethacin produces the most central-nervous-system side effects - especially confusion and agitation.
pentazocine (Talwin)*	Used to control pain. Pentazocine is a narcotic painkiller that causes more central-nervous-system side effects, including confusion and hallucinations, more commonly than other narcotics. Additionally, it is a mixed agonist/antagonist and thus may interfere with the painkilling effects of other narcotics.
trimethobenzamide (Tigan)	Used to control nausea. Trimethobenzamide is one of the least effective of the drugs used to control nausea and vomiting, yet it can cause extrapyramidal side effects, such as stiffness, shuffling gait, difficulty swallowing and tremor.
methocarbamol (Robaxin), carisoprodol (Soma) chlorzoxazone (Paraflex) metaxalone (Skelaxin) cyclobenzaprine (Flexeril)	Used to ease muscles in spasm. Most drugs used to relax muscles and reduce muscle spasms 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.
amitriptyline (Elavil)* chlordiazepoxide/amitriptyline (Limbitrol)* perphenazine/amitriptyline (Triavil)*	Used to treat depression. Because of its strong anticholinergic and sedating properties, amitriptyline is rarely the best antidepressant for older adults.
doxepin (Sinequan)*	Used to treat depression. Because of its strong anticholinergic and sedating properties, doxepin is rarely the best antidepressant for older adults.
flurazepam (Dalmane)*	Used to treat insomnia. This benzodiazepine hypnotic has an extremely long half-life in the elderly, producing prolonged sedation (often lasting for days and worsening for days if the drug is taken daily) and increasing the incidence of falls and fractures.
meprobamate (Miltown, Equanil)	Used to treat anxiety. Meprobamate is a highly addictive and sedating antianxiety drug. Those who have been using it for prolonged periods may be addicted and may need to be withdrawn slowly.
lorazepam (Ativan) 3 mg oxazepam (Serax) 60 mg alprazolam (Xanax)² 2 mg temazepam (Restoril) 15 mg triazolam (Halcion) 0.25mg	Used to treat insomnia and anxiety. Because of increased sensitivity to benzodiazepines in older adults, smaller doses may be effective as well as safer. Total daily doses should rarely exceed the suggested maximums at left.
chlordiazepoxide (Librium)* chlordiazepoxide/amitriptyline (Limbitrol)* clidinium/chlordiazepoxide (Librax)* diazepam (Valium)flurazepam (Dalmane)	Used to treat insomnia and anxiety. Chlordiazepoxide and diazepam have a long half-life in older adults, producing prolonged sedation (often lasting several days and continuing to worsen if the drug is taken daily) and increasing the risk of falls and fractures. Short- and intermediate-acting benzodiazepines are preferred if a benzodiazepine is required.
disopyramide (Norpace, Norpace CR)*	Used to treat abnormal heart rhythms. Disopyramide, of all drugs used to treat arrhythmias, is the most potent negative inotrope (that is, it decreases the pumping action of the heart) and therefore may induce heart failure in older adults. It is also strongly anticholinergic. When appropriate, other antiarrhythmics should be used.
digoxin (Lanoxin)* Doses above 0.125 mg	Used to treat abnormal heart rhythms and heart failure. Because of decreased clearance of digoxin by the kidney, doses in the elderly should rarely exceed 0.125 mg daily, except when treating atrial arrhythmias.
dipyridamole (Persantine)	Used to help stop blood from clotting in people who have experienced strokes, heart attacks, and other conditions. Dipyridamole frequently causes orthostatic hypotension (lightheadedness upon standing) in older adults. It has been proven beneficial only in patients with artificial heart valves. Whenever possible, its use with older adults should be avoided.
methyldopa (Aldomet) methyldopa/HCTZ (Aldoril) **High severity if recently started	Used to treat high blood pressure. Methyldopa may cause bradycardia (a slowed heart beat) and exacerbate depression in older adults. Alternate treatments for hypertension are generally preferred.
reserpine (Serpasil) reserpine/HCTZ (Hydropres)	Used to treat high blood pressure. Reserpine imposes unnecessary risk for older adults, inducing depression, impotence, sedation, and orthostatic hypotension (light-headedness upon standing). Safer alternatives exist.
chlorpropamide (Diabinese)*	Used to control blood sugar in people with diabetes. Chlorpropamide has a prolonged half-life in the elderly and can cause prolonged and serious hypoglycemia (low blood sugar). Additionally, it is the only oral hypoglycemic agent that causes SIADH, which can lead to abnormally low levels of sodium in the blood. Avoid for older adults.
dicyclomine (Bentyl)* hyoscyamine (Levsin, Levsinex)* propantheline (Pro-Banthine)* belladonna alkaloids (Donnatal & others)* clidinium/chlordiazepoxide (Librax)*	Used to treat stomach and intestinal cramps. GI antispasmodics are highly anticholinergic and generally produce substantial toxicity in older adults. Additionally, their effectiveness at doses tolerated by the elderly is questionable. All of these drugs are best avoided in this age group, especially for chronic use.
chlorpheniramine (Chlor-Trimeton) diphenhydramine (Benadryl) hydroxyzine (Vistaril, Atarax) cyproheptadine (Periactin) promethazine (Phenergan) tripelennamine (PBZ) dexchlorpheniramine (Polaramine) Actifed C Poly-Histine CS Bromfed DM Ambenyl Novahistine DH Phenergan with Codeine Phenergan VC with Codeine Histussin HC Polyhistine DM Tussionex Phenergan DM	Used to treat the runny nose of the common cold. All nonprescription and many prescription antihistamines have potent anticholinergic properties. Many cough and cold preparations are available without antihistamines, and these are safer substitutes for older adults.
diphenhydramine (Benadryl)	Used to treat allergies and insomnia. Diphenhydramine is potently anticholinergic and usually should not be used as a drug to induce sleep in the elderly. When used to treat or prevent allergic reactions, it should be used in the smallest possible dose and with great caution.
ergot mesyloids (Hydergine) cyclospasmol	Used to treat dementia. Hydergine (ergot mesyloids) and the cerebral vasodilators have not been shown to be effective, in the doses studied, for the treatment of dementia or any other condition.
Iron supplements Doses above 325 mg	Used to treat iron deficiency anemia but frequently given to older people with other types of anemia, which they do not remedy. Iron supplements rarely need to be given in doses exceeding 325 mg of ferrous sulfate daily. When doses are higher, total absorption is not substantially increased, but constipation is more likely to occur.
All barbiturates except phenobarbital*	Used to treat insomnia and anxiety. Barbiturates cause more side effects than most other drugs used for sedation or to induce sleep in the elderly and are highly addictive. They should not be started as new therapy in the elderly except when used to control seizures; patients who have used barbiturates for a prolonged period may be addicted.
meperidine*	Used to treat pain. Meperidine is not an effective oral painkiller and has many disadvantages compared to other narcotics. Avoid for older adults.
ticlopidine*	Used to help prevent blood from clotting in people who have had strokes, heart attacks and other conditions. Ticlopidine has been shown to be no better than aspirin in preventing clotting (except in a few specific conditions, such as after use of a coronary artery stent) and is considerably more toxic. Avoid for older adults.

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