Pitfalls in Prescribing for the Elderly

An acute hospitalization or trip to the ED provides a good opportunity for another physician to take a critical look at an older patient’s medications.

"I used to get cranky when a hospitalist would take one of my patients who I’ve been taking care of for 10 years and say, ‘Gee, Wallace – this is a dumb drug for this patient; I’m stopping the Fosamax.’ I’d reply, ‘I know the patient; don’t mess with him.’ But more and more, as I look at the literature, I’m thinking that when a patient is in the hospital or the ED, it’s a great time to cut back. I would urge those of you who are hospitalists to do that for reasons of adherence and safety. The data are out there to support you. Just let us know what you’ve done," the geriatrician said.

One of the key means of reducing polypharmacy in the elderly involves avoidance of what’s been called "the prescribing cascade." This cascade occurs when an adverse effect of one drug gets misinterpreted as a new medical condition, for which a second drug is dutifully prescribed.

"This happens all the time," according to Dr. Wallace.

Examples: A patient on hydrochlorothiazide experiences rising uric acid levels, is diagnosed with gout, and put on allopurinol; had he simply been switched to another antihypertensive agent, he’d still be on one drug instead of two for two diseases. Or a patient on chronic daily NSAID therapy develops rising blood pressure as a drug side effect, gets labeled hypertensive, and goes on antihypertensive medications. Or a patient on donepezil or another cholesterase inhibitor reports an increased frequency of urination because of the drug’s effects on the bladder; in response, tolterodine is prescribed.

Three years ago, the cholinesterase inhibitors used in treating dementia were linked to a previously unrecognized increased risk of bradycardia. In a large Canadian study, these medications were associated with a 69% increased rate of emergency department visits for symptomatic bradycardia, a 76% increase in syncope, a 49% greater likelihood of permanent pacemaker implantation, and an 18% increased risk of hip fracture (Arch. Intern. Med. 169: 867-73).

"We didn’t know about this until 2009. I grew up using donepezil in the 1990s when I was a fellow. We were using it all the time and no one thought about bradycardia. It wasn’t in our differential," Dr. Wallace recalled. "I’m sure patients passed out and got pacemakers as an unrecognized drug side effect. My question is this: We think we’re smart, but what else do we not know, especially with newer agents coming along?"

Dr. Wallace reported having no financial conflicts.