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Rules for Improving Pharmacotherapy in

Older Adult Patients: Part 2 (Rules 6-10).
ARTICLE FEBRUARY 2015
DOI: 10.14423/SMJ.0000000000000243 Source: PubMed

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Review Article

Rules for Improving Pharmacotherapy in Older

Adult Patients: Part 2 (Rules 6Y10)
James M. Wooten,

PharmD

Abstract: The population of older adult patients in the United States

is growing each year. Appropriate pharmacotherapy has allowed many
older patients to live longer and maintain healthy lives. Unfortunately,
the inappropriate utilization of medications can be harmful to older
adult patients. Inappropriate pharmacotherapy may lead to overusing
medications and polypharmacy. Polypharmacy can contribute to a higher
incidence of adverse effects, increase the risk of dangerous drug interactions, cause noncompliance with appropriate medication use, and
signicantly increase the cost of health care. The polypharmacy issue
with geriatric patients has been described as an epidemic and this issue
must be addressed. This review provides objective rules that may help
prevent polypharmacy. Consideration of these rules when prescribing,
dispensing, and caring for older adult patients will improve the overall
pharmacotherapy regimens instituted by healthcare providers.
Key Words: Gerontology, pharmacodynamics, pharmacokinetics, pharmacology, pharmacotherapy

n Part 1, which appeared in the February issue, polypharmacy was dened as taking multiple unnecessary medications.1Y4 Because of the variety of medications taken by the
growing older adult population of the United States, as well as
an ever-increasing armamentarium of medications to treat almost all diseases, polypharmacy has become a major healthcare
issue for older patients. Polypharmacy increases the risk of drugrelated adverse effects and harmful drug interactions, reduces
compliance to appropriate pharmacotherapy, and signicantly
increases the level of morbidity and mortality in the geriatric
population.
Rules/guidelines should be established and adhered to by
all healthcare providers so that the polypharmacy epidemic can
be stopped and older adult patients can lead better lives. This
article provides practitioners with specic rules/guidelines that
From the Department of Internal Medicine-Clinical Pharmacology, University
of Missouri-Kansas City School of Medicine; Kansas City.
Reprint requests to Dr James M Wooten, University of Missouri-Kansas City
School of Medicine, 2411 Holmes St, Kansas City, MO 64108.
E-mail: wootenj@umkc.edu
The author has no nancial relationships to disclose and no conicts of interest
to report.
Accepted September 22, 2014.
Copyright * 2015 by The Southern Medical Association

they can use when prescribing medications for their older adult
patients. These rules/guidelines could be printed and posted
where prescribers could easily and readily be reminded of these
important objective concerns. Following these rules greatly
enhances the pharmacotherapy plan for all older patients, prevent potential adverse drug effects, reduce healthcare costs, and
allow patients to lead happier and healthier, productive lives.
Part 2 enumerates the nal ve, rules 6 through 10.

Rule 6: Prescribe and Recommend Only

Those Medications/Drug Classes for Which
You Have a Thorough Understanding
of the Pharmacology
Rule 6 appears obvious, but some medication choices are
better than others. For instance, a patient who is hypertensive
and has systolic heart failure can be treated with an angiotensinconverting enzyme inhibitor, which treats both problems.
Thoroughly assessing the patients medical issues and judiciously prescribing specic medications is an effective way to
approach this rule. Practitioners must realize that if more than
one healthcare provider is managing the patients medication
prole, a consultation with the other providers may be necessary to ensure that the proper pharmacotherapy is prescribed.2,3
Important aspects of a medications pharmacologic prole include the drugs indications for use, mechanism of action, pharmacokinetics, appropriate dosage for most patients,
adverse effects/contraindications; and monitoring parameters.
Because of the extensive number of medications on the market,
it is impossible to know everything about every drug; however,
intimate knowledge of medications commonly prescribed to
older adults can assist practitioners in making safe and effective
pharmacologic decisions for these patients.

Key Points
& Polypharmacy in the geriatric population is an important issue.
& Older adult patients undergo physiologic changes that can
alter a drugs pharmacokinetics and pharmacodynamics.
& Practitioners must take great care when prescribing medications to older adult patients to ensure that every drug prescribed is appropriately assessed and monitored.

0038-4348/0Y2000/108-145
DOI: 10.14423/SMJ.0000000000000257

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& Rules for Improving Pharmacotherapy in Elderly Patients

Dosage
Most older adult patients need lower doses of medications
than do other patient populations. This dosing information is
available in some tertiary pharmacotherapy texts (eg, Physicians
Desk Reference) or medical applications for various electronic
devices (Epocrates). The majority of the data were not discovered
during clinical trials. (The Food and Drug Administration does
not mandate that a specic number of older adult subjects be
enrolled in Phase I, II, or III trials before drug approval. Because
older adults have a large number of comorbidities and take many
medications, they are not ideal subjects for trials.5) In general,
postmarketing surveillance is the primary method by which
specic dosing recommendations in older adults is obtained.3Y8
Practitioners should note the following important considerations regarding drug doses in older adults:
& Assess the patients renal function, hepatic function, and nutritional
status (eg, weight, albumin) before any dose is prescribed. Each of
these parameters has a signicant inuence on the precise dosage
for a patient.
& Be aware that changing from one dosage form to another may inuence the bioavailability of the drug, which may affect the dosage.
& Realize that liquid preparations to be delivered via a feeding tube
may interact with various nutrients.
& Understand that controlled-release preparations cannot be crushed,
and the number of doses per day may need to be altered.
& Contact a pharmacist if there is a question regarding a dose or
dosage form.
& Start with lower doses of a drug and titrate to efcacy and tolerability whenever possible.

Adverse Drug Reactions

The older adult population experiences more adverse drug
events (ADEs) than do other patient groups because of the physiologic effects of aging (eg, reduced renal and hepatic function).
One could describe ADEs in older patients as a perfect storm
of issues that come together to make older people extremely
susceptible to ADEs. Because of this, a thorough understanding
of the adverse effect prole of each drug prescribed and the
potential risk involved in using a particular drug in a specic patient are critical. Every drug has associated ADEs. The following
provides suggestions for reducing ADEs in older adults3,4,8Y11:
& Provide proper medication counseling.
& Ensure that the patient receives adequate tutelage in taking medications with exact/complex instructions for use (eg, inhalers, subcutaneous insulin injection).
& Provide written materials or brochures (if available) on the disease(s) being treated and for medications.
& Try to improve patient compliance.
& Use correct dosage based on patients renal and/or hepatic function
and titrate doses up slowly, if possible.
& Know and anticipate the ADEs of all drugs prescribed and monitor
patient (eg, obtain blood levels, international normalized ratio if
patient takes warfarin) for those ADEs.
& Ensure that the pharmacy also counsels the patient.
& Always assess for potential drugYdrug, drugYdisease, drugYfood
interactions and choose drugs/drug classes with reduced interaction risk (see Table 3).
& Train the patients family or caregiver to monitor for ADEs.

146

There are several tools that enumerate the most appropriate

and the least appropriate/most unsafe drugs/drug classes to use
and/or avoid in the geriatric population. The Beers criteria is
a list of medications that details the drugs/drug classes that
have the potential to be dangerous to older adult patients based
on pharmacology (ie, mechanism of action, pharmacokinetics,
ADEs).12 The Beers criteria do not preclude practitioners from
prescribing any of the drugs on the list, but it is an excellent tool
to help guide practitioners in selecting the best and safest medications for their older adult patients.
Similar to, but much more comprehensive than the Beers
criteria, is the STOPP (Screening Tool of Older Persons potentially inappropriate Prescriptions) criteria.13 These criteria were
developed to reduce ADEs in older people with acute illnesses.
STOPP assesses potential adverse drugYdrug interactions and/or
duplicate drug class prescriptions. The STOPP and the Beers
criteria overlap in several areas.
Using various tools can improve the drug selection process
for practitioners prescribing for older adult patients. Whichever
tools are used, there is no substitute for thorough knowledge
regarding the patients history and medical issues.

Rule 7: Identify, Anticipate, and Monitor

Potential Drug Interactions Before They
Become a Problem
It has been estimated that 90% of all individuals 65 years
or older take at least 1 medication per week, 40% use Q5, and
12% use Q10/week. Because of the sheer number of medications that some individuals receive, the risk for drugYdrug
interactions is extremely high. DrugYdrug interactions can be
categorized as either pharmacodynamic or pharmacokinetic
interactions.14,15

Pharmacodynamic Interactions
Pharmacodynamic interactions occur when prescribing
drugs with synergistic actions. These interactions are common
and can occur when a patient has more than one healthcare
provider or the prescriber does not thoroughly understand the
pharmacology of the drugs being prescribed. This can be confusing and dangerous, especially when drugs from completely
different drug classes are prescribed. The presentation in patients
can be insidious as the drugs are added one on top of the other
(drug stacking), until the synergistic effects merge and the
syndrome presents itself; thus, medication reviews by pharmacology experts should be recommended for patients who are
taking several different medications. Two specic examples of
this problem are presented in Table 1.15Y18

Pharmacokinetic Interactions
Because of the physiologic changes associated with aging,
these patients are at greater risk for drugYdrug interactions.
Hepatic metabolism may be signicantly altered for some
drugs. The reasons for various drugYdrug interactions in older
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Review Article

Table 1. Pharmacodynamic drugYdrug interactions

Drug-induced problem/syndrome Drugs/drug classes contributing to problem
Serotonin syndrome

Symptomatology

SSRIs (eg, paroxetine, sertraline, uoxetine)

Spontaneous clonus

Levodopa, carbidopa-levodopa
(indirectly causes release of serotonin)

Inducible clonus and agitation or diaphoresis

SNRIs (eg, desvenlafaxine, duloxetine,

milnacipran, venlafaxine)

Ocular clonus and agitation or diaphoresis

Direct serotonin receptor agonists: tryptans

(eg, sumatriptan, rizatriptan)
Hypertonia

Tremor and hyperreexia

Fentanyl

Temperature above 38-C and ocular clonus

or inducible clonus

Tramadol
Buspirone
Meperidine
Cyclobenzaprine
Cocaine
St Johns wort (hypericum perforatum)
Anticholinergic syndrome

Antihistamines (eg, chlorpheniramine,

cyproheptadine, doxylamine, hydroxyzine,
diphenhydramine, meclizine, promethazine)

Flushing caused by cutaneous vasodilation

(red as a beet)
Anhydrosis (dry as a bone)
Hyperthermia caused by loss of sweat
(hot as a hare)
Blurry vision caused by nonreactive mydriasis
and paralysis of accommodation (blind as a bat)
Agitated delirium (mad as a hatter)
Urinary retention (full as a ask)
Decreased bowel sounds
Tachycardia

SNRIs, serotonin-norepinephrine reuptake inhibitors; SSRIs, selective serotonin reuptake inhibitors.

adult patients include changes in drug absorption and distribution, reduced hepatic clearance and reduced renal function,
polypharmacy, and the high number of comorbidities in these
individuals.15Y18
DrugYdrug interactions cannot always be avoided. Practitioners must be able to anticipate these interactions and create
a monitoring plan to minimize the risk to the patient. Ways
to mitigate these interactions in older adults, beyond those
mentioned earlier in the article, include close monitoring of
drugs with a narrow therapeutic range or index (Table 2) and

Table 2. Common drugs/drug classes with a narrow

therapeutic range
Class

Drug

Anticoagulants

Warfarin

Anticonvulsants

Phenytoin

Antiarrhythmics
Immunosuppressants

Southern Medical Journal

Amiodarone
Cyclosporine

knowledge of the common inducer and inhibitor drugs

(Table 3).14Y18
Another type of interaction prevalent in the geriatric population is drugYdisease interactions, wherein a particular drug
may worsen a specic medical condition (Table 4). Understanding the pharmacologic prole of each drug prescribed to
an older adult patient can reduce the incidence of these types of
interactions.14Y18
Other interaction types occur in older people, including
drugYfood interactions and drugYnutrient interactions. Practitioners must be observant with all drugs prescribed to avoid
these common interaction issues.

Rule 8: Establish a Monitoring Plan for

Each Medication Prescribed for Both
Efcacy and Toxicity
Patient monitoring for a drugs efcacy and toxicity is
critical. Practitioners should address the monitoring plan at the
time a drug is prescribed. A monitoring plan for each medication on the patients prole should be a part of the patients

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& Rules for Improving Pharmacotherapy in Elderly Patients

Table 3. Common inducer and inhibitor drugs for

cytochrome P450 drugYdrug interactions
Enzyme

Inhibitors

Inducers

CYP1A2

Ciprooxacin, uvoxamine

Phenytoin, rifampin

CYP2C9

Fluconazole

Carbamazepine, rifampin

CYP2D6

Bupropion, uoxetine,
paroxetine

CYP3A

Macrolides (eg, erythromycin,

clarithromycin)

Carbamazepine, modanil,
phenytoin, phenobarbitone,
rifabutin, rifampicin,
St Johns wort

Azole antifungals
(eg, voriconazole, itraconazole,
ketoconazole, uconazole)

and monitor their therapy and take an active role in improving

their health; however, this is challenging for some patients, especially if there are unique barriers that limit effective counseling, such as the following21Y24:
&
&
&
&
&
&
&
&
&
&

Limited cognitive function

Limited education
Literacy issues
Hearing difculties
Vision limitations
Limited nancial resources
Polypharmacy (can complicate medication instruction)
Language barriers
Limited time
Cultural differences

To overcome these barriers, the rst step is identifying which

of them may limit communication and then structuring an effective counseling session with the patient or patients caregiver.
The following provides suggestions to improve communication
with geriatric patients:

Protease inhibitors (eg, indinavir,

ritonavir, saquinavir)
Grapefruit juice
Cimetidine
Ciprooxacin

medical record. Suggestions regarding monitoring include the

following19Y22:
& Understand the pharmacologic prole of every drug prescribed.
& Understand that monitoring for efcacy may be as simple as taking
blood pressure measures (eg, for antihypertensive agents) or as complicated as assessing a chest x-ray for pneumonia (eg, for antibiotics).
& Know which drugs have a narrow therapeutic index; slight changes
in concentration can yield ADEs.
& Know the adverse effect prole for every drug prescribed so that
the patient can be assessed for these effects.
& Double-check doses based on renal or hepatic function using an
appropriate resource. Contact a pharmacist if necessary.
& Individualize doses for each individual patientVone size does not
t all.

Rule 9: Properly Counsel Patients/Caregivers

on All of the Patients Medications and
Ensure That the Patient Understands the
Pharmacotherapy Plan
Effective patient counseling and instruction is an important part of the healthcare plan. Patients who are informed and
understand their own healthcare issues will be able to assess

& Counsel the patient/caregiver in a quiet, well-lighted environment

where the patient/caregiver is comfortable.
& Do not rush.
& Attempt to identify any barriers that may exist with the patient that
will limit communication. Try to correct the issues that are identied (eg, if patient has limited hearing, provide written materials).
& Provide patient/caregiver with an up-to-date medication list and
make sure all parties have the same list.
& Assess language barriers and use interpreters if necessary.
& Use language that is appropriate for patients educational background.
& Use written instruction aides whenever possible.
& Identify and correct any cultural barriers that may exist.
& Identify potential nancial difculties that may limit compliance.
& Maintain a positive attitude and try to motivate the patient to take
an active role.
& Be respectful and refer to patient in an appropriate way (eg, Mrs
Lopez, rather than Fulgenica or Dear).
& Do not be judgmental.
& Use any teaching aides that are available.
& Answer all of the patients/caregivers/familys questions. If certain
questions cannot be answered, then help them nd someone who
can answer the questions.
& Ask the patient to repeat instructions.
& Ensure that the patient knows the possible limitations of treatment
(eg, adverse effects, potential interactions).
& Instruct patient about over-the-counter medications, vitamins, nutritionals, and herbal therapies.

Table 4. DrugYdisease state interactions

Drug/drug class
A-Adrenergic antagonists (eg, propranolol,
metoprolol, carvedilol)

Disease state

Pharmacologic interaction

Asthma/COPD

Blocking the A-2 receptors in the lungs may induce bronchoconstriction,

which may worsen asthma or COPD

Aminoglycosides (eg, gentamicin, tobramycin)

Chronic kidney disease

Aminoglycosides are nephrotoxic and may worsen renal function

NSAIDs (eg, ibuprofen, naproxen)

Nondihydropyridine calcium-channel blockers
(eg, verapamil, diltiazem)

Peptic ulcer disease

Congestive heart failure

NSAIDs can cause peptic ulcers

Verapamil or diltiazem can reduce the inotropic action of the heart

COPD, chronic obstructive pulmonary disease; NSAIDs, nonsteroidal anti-inammatory drugs.

148

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Review Article

The practitioner must ensure that the patient/caregiver

clearly understands that all pharmacotherapy treatment will be
monitored for both efcacy and potential toxicity (include in
the medication list if possible). Objective and specic goals for
the treatment regimens should be set, and the patient/caregiver
should understand the goals and objectives of pharmacotherapy. Ensure that patient clearly understands the plan if a specic
treatment is not successful or proves to be harmful. Follow-up
appointments should be arranged and reminders (eg, telephone
calls, e-mails, texts) provided. Compliance should be assessed
at every visit. All questions should be answered to the patients
satisfaction.21Y24

Rule 10: Assess and Address

Compliance Issues
Compliance can be a major problem in providing effective
health care to older adult patients. There are several reasons for
their poor compliance, including the following25Y29:
& Lack of appropriate discharge planning
& Adverse effects of medication
& Lack of trust in the healthcare provider(s) and/or the treatment plan

&
&
&
&
&
&
&

Poor understanding of illness(es)

Poor patientYprovider relationship
Complexity of treatment regimen
Financial difculties
Cognitive issues (eg, Alzheimer disease)
Psychological problems (eg, psychosis, depression)
Polypharmacy

Compliance should be addressed with the patient/caregiver at the time each drug is prescribed (Table 5).

Conclusions
This article and its predecessor present 10 rules for improving pharmacotherapy in older adults. Rules like these are
necessary because older patients use a higher percentage of
medications than other patient populations and they are extremely vulnerable to drug-related issues that could cause great
harm. Practitioners must be cognizant of the challenges that are
encountered when prescribing drugs to older patients, and
these rules provide a constant reminder to promote safe and
effective pharmacotherapy. These rules help ensure that patients
are aware that their healthcare providers are considering and
implementing the most appropriate pharmacology plan that ts

Table 5. Potential compliance barriers and strategies to improve compliance

Barriers

Strategies

Patient-related issues
Forgetting to take medication

Use pill boxes, medication calendars, smartphone apps

Difculty taking so many medications

Structure times to take medications around daily activities (eg, meals)

Lack of understanding of disease

Reduce number of medications, if possible; address polypharmacy issue

Denial

Ensure patient understands disease being treated and why

Low expectations

Set specic goals for patient (eg, blood pressure goals, blood sugar goals)

Depression
Physical barriers

Find devices to patient overcome physical barriers to compliance (eg, special inhaler)
Sort out nancial barriers and attempt to help patient in whatever way possible

Financial difculties

Use translator

Language literacy issues

Ask patient to write down all questions

Medication-related issues
Complex pharmacotherapy regimen

Review pharmacotherapy plan at each visit

Adverse effects

Check patients medication list and make sure it is appropriate

Change to drug with fewer/different adverse effect prole, if possible
Assess all medication adverse effects
Reduce polypharmacy as much as possible
Discontinue medications that are not useful to patients current regimen

Prescriber-related issues
Prescriber does not explain treatment plan

Use multidisciplinary team to help care for patient

Prescriber does not take time with patient/patients family

Provide verbal and written instructions

Prescriber does not listen to patient

Prescriber provides information that patient/patients family
does not understand

Use training aides

Ensure that patient/caregiver has easy access to provider so that questions are answered

Prescriber will not answer questions

Prescriber does not follow-up with patient/family

Southern Medical Journal

Encourage patient to write down all questions

Ensure that patients medication list is identical to practitioners list

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& Rules for Improving Pharmacotherapy in Elderly Patients

with their age, comorbidities, and other treatment regimens.

Practitioners should avoid the seven deadly sins of prescribing29:
1. A drug is prescribed to treat a disease or ailment that is actually
caused by an adverse reaction to another drug. Example: Prescribing a drug for a patient who has constipation caused by
overprescribing drugs with anticholinergic properties.
2. A drug is prescribed to treat a problem that should be treated
initially with nonpharmacologic therapy. Example: Prescribing
a sedative for insomnia to a patient who regularly ingests caffeinated products right before bedtime.
3. Attempt to treat a medical problem that may be either self-limited
or unresponsive to pharmacologic treatment. Example: Prescribing
an antibiotic to a patient who has a viral infection.
4. A drug is prescribed for a problem, but instead of the safest, most
effective treatment, the healthcare provider recommends an agent
that is inappropriate for a geriatric patient. Example: Prescribing
diazepam (long-acting benzodiazepine on the Beers list) as a sedative when a mild sedative (trazodone) would be more appropriate.
5. Two drugs are prescribed appropriately, but they interact to cause
serious injury or death, and there was no monitoring plan in place
for the interaction. Example: Prescribing warfarin (for deep vein
thrombosis) along with trimethoprim/sulfamethoxazole (for urinary tract infection). This combination slows the metabolism of
warfarin, which leads to over-anticoagulation and possibly a severe
bleeding episode.
6. Two or more drugs in the same drug class are used to treat separate
problems. The drugs do not improve efcacy, but rather have
additive effects that could harm the patient. Example: Prescribing
a beta-blocker (carvedilol) to slow heart rate, but the patient is
already taking propranolol (prescribed by psychiatrist) to treat
anxiety; this in turn leads to profound bradycardia.
7. The correct drug is selected to treat a problem, but the dosage is
much too high for the patient. Example: Prescribing levooxacin
750 mg/day to treat a urinary tract infection in a patient with renal
insufciency. This occurs often in older adults; typical dosages
are prescribed when older adults should be receiving a lower dose
because of reduced renal or hepatic function.

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