Physicians know that some drugs used in younger patients act differently in older populations. To guide the safe prescription of drugs in patients who are aged 65 years or older, the American Geriatrics Society (AGS) publishes guidelines about potentially inappropriate medications (PIMs) for older adults in ambulatory, acute, and institutionalized care settings.

American Geriatrics Society. American Geriatrics Society 2023 Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatrics Soc. 2023;71(7):2052–2081.

 

These guidelines aim to reduce adverse events and evaluate the quality of care, cost, and patterns of drug use in this population. 

 

 

Growth hormones

 

Growth hormone replacement therapy aims at ameliorating lean/fat mass ratio, bone metabolism, blood pressure, and quality of life.

Ricci Bitti S, Franco M, Albertelli M, et al. GH replacement in the elderly: Is it worth it? Front Endocrinol (Lausanne). 2021;12:680579.

 

Growth hormones offer minimal benefit to elderly patients, says the AGS. Instead, this therapy leads to edema, impaired fasting glucose levels, gynecomastia, and more. These drugs should be avoided in all patients except those with verified growth hormone deficiency. 

 

Nifedipine

 

In older patients, calcium-channel blockers are used to treat hypertension, angina pectoris, isolated systolic hypertension, and coronary vasospasm.

Lee EM. Calcium channel blockers for hypertension: old, but still useful. Cardiovasc Prev Pharmacother. 2023;5(4):113–125.

 

 

 

Amiodarone

 

Although effective at maintaining sinus rhythm, this drug should be avoided in elderly patients. One exception is first-line treatment of atrial fibrillation in patients presenting with heart failure or substantial left ventricular hypertrophy.

 

Warfarin

 

In cases of atrial fibrillation or venous thromboembolism, direct oral anticoagulants (DOACs) are preferred to warfarin as a means of anticoagulation in older populations. Warfarin increases the risk of intracranial and other bleeds.

Despite an elevated risk of bleeding, oral anticoagulation is correlated with net clinical benefit in older patients.

Rutherford OCW, Jonasson C, Ghanima W, et al. Effectiveness and safety of oral anticoagulants in elderly patients with atrial fibrillation. Heart. 2022;108(5):345–352.

 

 

Amitriptyline 

 

This and other antidepressants with high anticholinergic activity, such as clomipramine or paroxetine, should be avoided by elderly patients. The AGS warns that these drugs can lead to sedation and orthostatic hypotension. 

 

Sulfonylureas

 

 

According to the results of one meta-analysis, sulfonylureas could compound the risk of fractures in elderly patients with diabetes.

 

Proton pump inhibitors

 

Proton pump inhibitors (PPIs) heighten the risk of C. difficile infection, GI malignancies, pneumonia, bone loss, and fractures. The AGS recommends not prescribing scheduled dosages for more than 8 weeks, except for high-risk populations—like those taking corticosteroids or chronic NSAID users. 

If an elderly patient is taking a PPI but without a medical indication for them, this treatment should be tapered and discontinued. The patient should then self-monitor for relapse of symptoms once they have discontinued the PPIs. If heartburn, indigestion, or chest pain recur, the patient can be placed on a trial period of the lowest possible PPI dosage or started on an H2-receptor antagonist, with an eye toward discontinuation.

Hawthorne J. Proton-pump inhibitors as potentially inappropriate medications in older adults. Arkansas Geriatric Education Collaborative. University of Arkansas for Medical Sciences. February 12, 2016.