References

Andrade C Sedative Hypnotics and the Risk of Falls and Fractures in the Elderly. J Clin Psychiatry. 2018; 79:(3) https://doi.org/10.4088/JCP.18f12340

Coleman JJ, Pontefract SK Adverse drug reactions. Clin Med (Lond). 2016; 16:(5)481-485 https://doi.org/10.7861/clinmedicine.16-5-481

Curtin D, Gallagher P, O'Mahony D Deprescribing in older people approaching end-of-life: development and validation of STOPPFrail version 2. Age Ageing. 2021; 50:(2)465-471 https://doi.org/10.1093/ageing/afaa159

Davies LE, Spiers G, Kingston A, Todd A, Adamson J, Hanratty B Adverse Outcomes of Polypharmacy in Older People: Systematic Review of Reviews. J Am Med Dir Assoc. 2020; 21:(2)181-187 https://doi.org/10.1016/j.jamda.2019.10.022

Distefano G, Goodpaster BH Effects of Exercise and Aging on Skeletal Muscle. Cold Spring Harbor Perspectives in Medicine. 2018; 8:(3) https://doi.org/10.1101/cshperspect.a029785

Dumic I, Nordin T, Jecmenica M, Stojkovic Lalosevic M, Milosavljevic T, Milovanovic T Gastrointestinal Tract Disorders in Older Age. Can J Gastroenterol Hepatol. 2019; 2019 https://doi.org/10.1155/2019/6757524

Fisher H, Zabar S, Chodosh J, Langford A, Trinh-Shevrin C, Sherman S, Altshuler L A novel simulation-based approach to training for recruitment of older adults to clinical trials. BMC Med Res Methodol. 2022; 22:(1) https://doi.org/10.1186/s12874-022-01643-4

Gao L, Maidment I, Matthews FE, Robinson L, Brayne C Medication usage change in older people (65+) in England over 20 years: findings from CFAS I and CFAS II. Age Ageing. 2018; 47:(2)220-225 https://doi.org/10.1093/ageing/afx158

Garza AZ, Park SB, Kocz R Drug Elimination.Treasure Island (FL): StatPearls Publishing; 2022

Kim IH, Kisseleva T, Brenner DA Aging and liver disease. Curr Opin Gastroenterol. 2015; 31:(3)184-91 https://doi.org/10.1097/MOG.0000000000000176

Maes ML, Fixen DR, Linnebur SA Adverse effects of proton-pump inhibitor use in older adults: a review of the evidence. Ther Adv Drug Saf. 2017; 8:(9)273-297 https://doi.org/10.1177/2042098617715381

NHS. Vitamin D. 2024. https//www.nhs.uk/conditions/vitamins-and-minerals/vitamin-d (accessed 9 April 2024)

National Institute for Health and Care Excellence. British National Formulary. Gastro-oesophageal reflux disease. 2019. https//bnf.nice.org.uk/treatment-summaries/gastro-oesophageal-reflux-disease (accessed 9 April 2024)

National Institute for Health and Care Excellence. Calcium carbonate. 2024. https//bnf.nice.org.uk/drugs/calcium-carbonate/ (accessed 9 April 2024)

Nazarko L Understanding and managing constipation in older adults. Practice Nursing. 2017; 28

O'Mahony D, O'Sullivan D, Byrne S, O'Connor MN, Ryan C, Gallagher P STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015; 44:(2)213-8 https://doi.org/10.1093/ageing/afu145

Pezeshkian S, Conway SE Proton Pump Inhibitor Use in Older Adults: Long-Term Risks and Steps for Deprescribing. Consult Pharm. 2018; 33:(9)497-503 https://doi.org/10.4140/TCP.n.2018.497

Ryba N, Rainess R Z-drugs and Falls: A Focused Review of the Literature. Sr Care Pharm. 2020; 35:(12)549-554 https://doi.org/10.4140/TCP.n.2020.549

Shanah L, Kabashneh S, Alkassis S, Ali H, Mir T Use of Anticoagulants in Patients With Non-Valvular Atrial Fibrillation Who Are at Risk of Falls. Cureus. 2020; 12:(9) https://doi.org/10.7759/cureus.10336

Sönnerstam E, Sjölander M, Gustafsson M Inappropriate Prescription and Renal Function Among Older Patients with Cognitive Impairment. Drugs Aging. 2016; 33:(12)889-899 https://doi.org/10.1007/s40266-016-0408-8

World Health Organization. Promoting rational use of medicines. 2022. https//www.who.int/activities/promoting-rational-use-of-medicines (accessed 9 April 2024)

Conducting a medication review in older adults

02 May 2024
Volume 6 · Issue 5

Abstract

Once prescribers have initiated medication regimens, there can be a reluctance to review and discontinue them. Over the past two decades in the UK, the percentage of individuals aged 65 and above on polypharmacy (five or more medications) has risen from 12–49% (Gao et al, 2018). Medication can harm as well as heal, and the need for medication reviews grows as our population ages. This article is one of a series, written by a consultant nurse and a pharmacist, and aims to help readers further develop their skills in medication management.

Older people are more likely to be prescribed medication than younger people; however, unfortunately medication is not always prescribed appropriately, and age-related changes increase a person's vulnerability to adverse effects. According to the World Health Organization (WHO, 2022):

‘Rational use of medicines requires that patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements, for an adequate period of time, and at the lowest cost to them and their community.’

Irrational use of medicines is a major problem worldwide. The WHO estimates that more than half of all medicines are prescribed, dispensed or sold inappropriately, and that half of all patients fail to take them correctly. The over-use, under-use or misuse of medicines results in wastage of scarce resources and widespread health hazards.

Age-related changes and adverse medication effects

Older adults (people aged 65 or over) and those ethnic minority and low-income communities are under-represented in clinical trials. This means that prescribers have limited information about the efficacy of a drug and any side effects in these groups (Fisher et al, 2022).

Drugs given orally are normally absorbed in the small intestine, metabolised in the liver and excreted by the kidneys (Garza et, al, 2022). Age-related changes affect the ability to absorb and excrete drugs. Ageing affects the rate of stomach emptying and the speed with which food and medicines travel through the gastrointestinal tract. Blood flow is also reduced, affecting the absorption of medication (Dumic et al, 2019). Ageing leads to a decline in muscle mass and an increase in fat, which has an impact on the way medicines are absorbed (Distefano and Goodpaster, 2018). The size of the liver reduces by 20% in older age and blood flow to the liver is reduced by 40%, these changes reduce the ability to metabolise drugs (Kim et al, 2015).

Renal function declines with age and decline in renal function can impair the ability to excrete medication (Sönnerstam et al, 2016). Age-related changes at molecular level can alter the way drugs bind to specific receptors, and this can increase or decrease the effect of a medicine in an older person (Davies et al, 2020). Age-related changes affect the way an older person's body reacts to medication, and a medicine that was suitable for a person when younger may be inappropriate as the person ages. Older people and their families can find this difficult to understand and can resist changes to medication,

Age-related changes increase the risk of a person suffering adverse drug reactions (ADRs). Adverse drug reactions are ‘unintended, harmful events attributed to the use of medicines’ (Coleman and Pontefract, 2016). ADRs can have a major effect on a person's health and quality of life. The following case study outlines a medication review of a patient admitted to an inpatient ward caring for older people. We were able to check previous medical history, test results and medication history on our electronic patient record

‘Despite health professionals' awareness of the risks associated with polypharmacy and sedative use in older people, inappropriate prescribing still occurs’

Case history

Mr Jones (a pseudonym) is an 83-year-old Caucasian male. His medical records indicate that he has prostatic hypertrophy, atrial fibrillation and bipolar affective disease in remission. He has had two falls since admission to the ward (Table 1 provides details of his medication and indications) and was admitted originally for depression.


Table 1. Medication and indications
Medication Dose Frequency Indication Comments
Tamsulosin 400 microgram modified-release capsules One daily Prostatic hypertrophy Drops blood pressure, give at night
Finasteride tablets 5 mg One daily Prostatic hypertrophy  
Chewable vitamin tablets 500 mg/400 unit One daily Not indicatedLow calcium? Calcium can cause dyspepsia
Antacid liquid peppermint 10 ml Three times daily as required Dyspepsia Calcium can cause dyspepsia
Lansoprazole gastro-resistant capsules 15 mg One daily No indication peptic ulceration or gastro-oesophageal reflux Calcium can cause dyspepsia
Lactulose oral solution 15 ml Twice daily Constipation Calcium can cause constipation
Quetiapine modified release 50 mg Each night Antipsychotic to treat bipolar disease Increases risk of falls
Simvastatin 40 mg Each night Elevated cholesterol  
Felodipine modified release 10 mg One daily Hypertension  
Buspirone 5 mg Twice daily Generalised anxiety disorder  
Mirtazapine orodispersible tablets 45 mg One daily Depression Can cause sedation
Zopiclone 3.75 mg Each night as required   New prescription
Promethazine hydrochloride tablets 25 mg One each night Long-acting antihistamine used as night sedation  
Promethazine hydrochloride 25 mg Each night as required   New prescription

Initially, there was some reluctance from the ward consultant for the pharmacist and consultant nurse to conduct medication reviews. The consultant was responsible for patient care on the ward and may have considered that the reviews would infringe on the medical domain. However, it was agreed that the recommendations would be considered. Table 2 outlines the rationale for these.


Table 2. Medication changes and rationale
Medication Issue Recommendation and rationale
Zopiclone 3.75 mg once each night as required New sedatives should not be initiated in hospital as they increase risk of falls and factures. Patient has fallen twice since admission New prescription on admission Discontinue
Promethazine hydrochloride tablets 25 mg one at night This long-acting antihistamine can cause daytime sedation and increase the risk of falls Discontinue
Promethazine hydrochloride tablets 25 mg one at night as required Dose of long-acting antihistamine doubled on admission. Increased risk of daytime sedation and falls Only as a last resortUse sleep hygiene measures
Chewable vitamin tablets 500 mg/400 unit one daily It was considered that this was causing dyspepsia and possibly constipation DiscontinueIf calcium required in the future prescribe calcium citrate better tolerated in older people
Lansoprazole gastro-resistant capsules 15 mg one daily Multiple risks with long-term use. It is thought this might have been given because calcium carbonate was causing dyspepsia Discontinue
Antacid liquid peppermint 10 ml three times daily as required Not indicated for long-term use For review in 1 week
Lactulose oral solution 15 ml twice a day Unclear if required, monitor bowel actions using Bristol stool chart For review in 1 week

The review identified medications with three effects that needed consideration: drugs with sedative properties; drugs with the potential to cause hypotension; and medication affecting the gastrointestinal tract.

Medication with sedative properties

Mr Jones had suffered two falls in the inpatient unit. These affected his confidence and he required persuasion to remain active, especially after the second fall. The pharmacist and consultant nurse (review team) noted the new prescription of zopiclone and the increase in promethazine. Evidence-based guidance states that prescribers should not normally initiate new sedatives in hospital (O'Mahoney et al, 2015: Curtin et al, 2021). Z-drugs, such as zopiclone, increase risk of falls, and all sedatives and hypnotics increase fracture risk in older people (Anrade, 2018: Ryba and Rainess, 2020). The review team recommended that the as required zopiclone and the regular promethazine were discontinued. The as required promethazine could be retained, but nursing staff were encouraged to promote sleep hygiene and to use this a last resort. The consultant agreed to implement the recommended changes.

Medication that can cause hypotension

The review team asked nursing staff to check lying and standing blood pressure to establish whether Mr Jones had a postural drop. This was not noted, although he did complain of dizziness and said he moved around less than he used to because of this. The review team considered the increased risks secondary to the use of tamsulosin and quetiapine. It recommended that tamsulosin was prescribed at night to reduce the risks of hypotension.

Medication affecting the gastrointestinal tract

Mr Jones was taking 500 mg/400 unit chewable vitamin tablets, comprising a combination of calcium carbonate and vitamin D. The indication for this was unclear. Some individuals who take calcium supplements experience gastrointestinal side effects, including dyspepsia, bloating and constipation. Calcium carbonate appears to cause more of these side effects than calcium citrate, especially in older adults who have lower levels of stomach acid. Symptoms can be alleviated by changing to a different type of calcium, taking smaller calcium doses more often during the day, or taking the supplement with meals (National Institute for Health and Care Excellence (NICE), 2023). We checked all blood results and they were normal. There were some age-related changes to renal function.

The team could find no record of an indication for the use of lansoprazole, a proton pump inhibitor (PPI). Mr Jones reported a history of dyspepsia of several years' duration. NICE (2023) guidance recommends that if there is an endoscopy confirmed diagnosis of gastro-oesophageal reflux disease (GORD), a PPI should be offered for 4 or 8 weeks.

‘The review team recommended that the as required zopiclone and the regular promethazine were discontinued. The as required promethazine could be retained, but nursing staff were encouraged to promote sleep hygiene and to use this a last resort’

There is growing evidence of the adverse effects of PPIs, especially in older people. These include hypomagnesia, interstitial nephritis, fractures and Clostridium difficile-associated diarrhoea (Pezeshkian and Conway, 2018). Older adults are also at increased risk of pneumonia, B12 deficiency and dementia, and it is important to review the need for PPI treatment, especially in older people (Maes et al, 2017). Prescribers should ensure that PPIs are prescribed for recognised indications and appropriate durations to minimise PPI over-use and the associated increased risk of harm (All Wales, Medicines Strategy Group, 2018).

The team noted that Mr Jones was prescribed an antacid. NICE (2023) advises that this is not used long term; therefore, it was recommended that the medications affecting the gastrointestinal system were addressed at the same time. It was recommended that the 500 mg/400 unit chewable tablets were discontinued, and for Mr Jones to commence vitamin D supplements. The NHS (NHS, 2023) advises 10 micrograms a day for older people who are housebound. The review team recommended that the omeprazole was discontinued and that nursing staff commence monitoring bowel actions using the Bristol stool chart. This would be reviewed in 7 days (Nazarko, 2017). It was agreed to review the antacid in 7 days. The consultant accepted all of the recommendations.

Conclusion

Despite health professionals' awareness of the risks associated with polypharmacy and sedative use in older people, inappropriate prescribing still occurs. Some junior doctors can get into the habit of prescribing sedatives such as Z-drugs ‘just in case’. This practice can cause catastrophic harm to vulnerable individuals.

Sometimes a medication such as a PPI is prescribed without an awareness of the long-term adverse effects. As the evidence base grows, we may learn that a medication that appeared not to have side effects can be harmful in certain circumstances. All prescribers need to be alert to the dangers of polypharmacy and to review medication. The number of older people who are vulnerable to the adverse effects of medication is set to grow in line with an ageing population with multiple comorbidities.

Key Points

  • Ageing affects the ability to absorb and excrete medicines
  • Older adults are especially vulnerable to the adverse effects of medication
  • The number of older adults prescribed five or more medications has quadrupled in the last 20 years
  • Whilst clinicians are happy to initiate medication there is less appetite to review
  • Ensuring the older person is only taking medicines that are clinically indicated reduces adverse effects and enhances quality of life

CPD reflective questions

  • Why do you think the number of people prescribed five or more medicines has quadrupled?
  • Ageing and hospital admission can affect quality of sleep. What measures, other than medication, could be introduced in a hospital ward to promote sleep?
  • Medication review can reduce the risk of falls and adverse medication. How can you incorporate medication review into your day-to-day practice?
  • Why do you think clinicians are reluctant to review medication? How can we overcome these barriers?