Dangerous Drugs: These 12 Medications Are Inappropriate for Older Folks

Dr. Sharon Orrange
Dr. Orrange is an Associate Professor of Clinical Medicine in the Division of Geriatric, Hospitalist and General Internal Medicine at the Keck School of Medicine of USC.
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In studies, “elderly” is defined as 65 years or older. Now, criteria established by the American Geriatrics Society and several recent studies have solidified a list medications that pose the greatest risk to the elderly.

With extra caution, some risks may be worth it—but which medications pose the greatest risk, and are there better alternatives?

1. Older antihistamines. Available over the counter and commonly used for allergy and cold symptoms, many folks also take advantage of the sedating effect and use them for sleep. Benadryl (diphenhydramine) and hydroxyzine are common examples of anticholinergic medications that are not cleared as well from the system in older people. This can lead to confusion, dry mouth, and constipation. Other examples in this class older folks should try and avoid include brompheniramine (Dimetapp, Benadryl Allergy), chlorpheniramine (Chlor-Trimeton), clemastine (Tavist), dexbrompheniramine (Drixoral), and dimenhydrinate (Dramamine).

Better options: For allergy symptoms and nasal congestion, turn instead to non-sedating antihistamines like Claritin (loratadine), Allegra (fexofenadine), Zyrtec (cetirizine) or intranasal steroid sprays like Flonase (fluticasone).

2. Prostate medications. Several medications used for urinary symptoms due to enlarged prostate are not recommended in people over 65 due to the high risk of hypotension (low blood pressure) upon standing. These include Cardura (doxazosin), Minipress (prazosin) and Hytrin (terazosin). Low blood pressure when you stand may result in a syncopal (fainting) episode and broken bones as a result. Not a small deal.

Better options: To treat symptoms due to large prostate (urinary frequency, hesitancy, urgency) there are much safer options: Flomax (tamsulosin), Uroxatral (alfuzosin), and Rapaflo (silodosin) work well and don’t carry the risk of low blood pressure.

3. Clonidine carries a higher risk of low blood pressure and low heart rate in older folks. Stay away if you can.

Better options: Thiazide diuretics (hydrochlorothiazide and chlorthalidone); amlodipine; angiotensin receptor blockers (ARBs) like losartan and valsartan; and ACE Inhibitors like lisinopril will not cause these problems and they work well.

4. Multaq (dronedarone) and amiodarone have been identified as potentially inappropriate medications that should be avoided in patients 65 years and older with atrial fibrillation or heart failure that is severe. Reports show worse outcomes in those taking them.

Better options: First, discuss with your cardiologist the possibility of rate control only (slowing the heart rate down) with beta blockers or calcium channel blockers rather than rhythm control with Dronedarone and Amiodarone. This is a time when the benefits of these two medications may outweigh the risks.

5. Digoxin (Digitek, Lanoxin) is to be avoided in folks over 65 for the treatment of atrial fibrillation and heart failure because.. simply put…it is associated with increased mortality.

Better options: Beta blockers (metoprolol, atenolol) and/or calcium channel blockers (diltiazem) work better for rate control than digoxin and don’t carry the potential risk of higher mortality.

6. Older antidepressants: Some antidepressants are anticholinergic and cause sleepiness and low blood pressure upon standing in older people. Amitriptyline, Nortriptyline (Pamelor), Desipramine (Norpramin), Doxepin (Prudoxin, Zonalon) and Paroxetine (Paxil) have been identified as posing risk in the elderly.

Better options: First line treatment is psychotherapy (no medications) but if you need meds Celexa (citalopram), Lexapro (escitalopram), Cymbalta (duloxetine), and Prozac (fluoxetine) are safer options.

7. Benzodiazepines/anxiety meds. These include lorazepam (Ativan), alprazolam (Niravam, Xanax), and temazepam (Restoril). Older adults have increased sensitivity to benzodiazepines and don’t metabolize these long-acting agents well. It is important to know that all benzodiazepines increase the risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes in older adults. Yipes.

Better options: For anxiety or insomnia try a referral to a cognitive-behavioral therapist or a safer SSRI (selective serotonin reuptake inhibitor) antidepressant like citalopram (Celexa) or escitalopram (Lexapro).

8. Dementia medications and antipsychotics. Zyprexa (olanzapine), Risperdal (risperidone), Abilify (aripiprazole), and Seroquel (quetiapine) are atypical neuroleptics which are the drugs of choice for treating psychotic symptoms and agitation in patients with dementia. These drugs may increase mortality and should not be used routinely to treat neuropsychiatric symptoms of dementia.

Better options: Nonpharmacologic methods are effective in reducing agitation and psychotic symptoms in folks with dementia including exercise, music training, aromatherapy, massage and touch therapy.

9. Insomnia medications. Ambien (zolpidem), Sonata (zaleplon), and Lunesta (eszopiclone) may cause problems similar to those listed in #7 including delirium, falls, and fractures. Increased emergency department visits, hospitalizations, and motor vehicle crashes also make these bad for the elderly. Plus they don’t work well for insomnia in the elderly—studies have shown only minimal improvement in sleep latency and duration when taking these.

Better options: Though not a quick fix, non-pharmacologic treatment of insomnia is more effective: cognitive behavioral therapy, improved sleep hygiene, regular exercise and mindfulness techniques.

10. Micronase (glyburide). Diabetes medications that lower blood sugar like glyburide pose a higher risk of severe prolonged low blood sugars in older adults.

Better options: Glucophage (metformin), Januvia (sitagliptin) and Tradjenta (linagliptin) don’t lower blood sugar to the same degree and thus don’t pose the risk.

11. NSAIDS. Especially true for those with kidney problems (renal insufficiency) using NSAIDS like ibuprofen (Motrin) or naproxen (Aleve) results in an increased risk of gastrointestinal (GI) bleed in those 75 years or older. Short term use at the lowest doses is ok because its longer term (3-6 months) use where problems are seen.

Better options: Meloxicam (Mobic) carries a slightly lower risk and Tylenol (acetaminophen) does not result in GI bleed.

12. Muscle relaxants. Soma (carisoprodol) and Flexeril (cyclobenzaprine) are poorly tolerated by older adults because of the anticholinergic adverse effects including sedation and increased risk of fractures. Effectiveness at the lower doses that can be taken by older adults is questionable, so the risks may not be worth it.

Better options: Pick a less sedating muscle relaxant like Skelaxin (metaxalone) or Robaxin (methocarbamol), or skip it all together.

Hope this helps.

Dr O.

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