How to Review Medications for Safety & Appropriateness in Aging

By now you’ve probably heard that older adults are often taking “too many” medications.

You also hopefully know that older people are often prescribed medications that may be harmful, or no longer necessary. The CDC has estimated that adverse drug events send older adults to the emergency room 450,000 times per year.

Why does this happen? Research has shown that “inappropriate prescribing” is common in older adults. Meaning that, when patient charts are carefully reviewed, experts often find that older adults are receiving medications that are ineffective, duplicate the effect of another medication, or otherwise lack a basis for being prescribed.

So what can you do?

To reduce the chance of being harmed by inappropriate medications, the answer is not to look for a super doctor. The answer is to regularly conduct a methodical medication review, in which all medications are reviewed for appropriateness and safety. This is part of a process called “deprescribing.”

Scheduling such regular medication reviews is becoming more common in well-run primary care clinics. But if your  doctor’s office doesn’t yet offer this service, you can ask for it.

Geriatricians are trained to do this, but if you can’t find a geriatrician, you should be able to get a decent review from the primary care doctor.

But before you go in, it pays to do a little homework on your own. That’s because the input of a patient and her caregivers is actually crucial to determining whether each medication is appropriate for her.

To help you complete this background preparation for a medication review, just follow the 5-Step process I describe below. This will free up some time when you’re actually seeing the doctor — which might mean more time for questions or discussion — and can help you spot safety issues that a non-geriatrician might otherwise not notice.

5 Steps to Prepare for a Medication Review

Before going in for your medication review, here are five things you should do:

1. List all medications you’re taking, along with the intended purpose of each medication.

If you aren’t sure of why a medication is prescribed, make a note to ask the doctor. Pharmacists can usually help as well. You may also find that some medications are serving more than one purpose. For instance, for someone diagnosed with both atrial fibrillation and hypertension — a common combination —  the cardiovascular medication diltiazem can be used to lower blood pressure, as well as to keep the heart from racing.

Clarifying the purpose of a medication will make it easier for you and the doctor to then figure out if the medication is still necessary.

2. Know the purpose of a prescribed medication and symptom and take note of when the symptom was last checked on.

This is especially important for medications prescribed for bothersome symptoms, such as depressed mood, incontinence or pain. If the symptom isn’t better, that is often a sign that the treatment plan needs to be reassessed, either by stopping the medication and trying something else or by changing the dose.

If the symptom is better, this might be a sign that it’s time to try tapering the medication. Or it might mean the current treatment is just right and should be continued. Which it is will depend on what condition is being treated. High blood pressure, for instance, usually requires indefinite treatment. But for other conditions, it might be quite appropriate to try reducing the medication to see if it’s still absolutely necessary.

What you don’t want is for a medication to remain at the same dose simply because things are on “auto-pilot.” Keeping a medication at the same dose should be an actively considered choice made by the patient and doctor together, rather than the consequence of inertia.

3. Know which of your medications are on the Beer’s list.

Every few years, the American Geriatrics Society (AGS) updates its list of medications that older adults should avoid or use with caution. If you are taking one of these medications, it’s important to be aware of this, and the related risks of the medication. You can learn more here: Medications Older Adults Should Avoid or Use with Caution: The American Geriatrics Society Beers Criteria (2019 Update).

Sadly, the AGS doesn’t currently make the list easily available to the public and their published article listing the medications is behind a paywall. But, if you dig around online, you may be able to find a PDF posted of the article, like here. You can also ask a pharmacist to help you spot these drugs.

If you do find that you (or your older parent) is taking a medication on the Beer’s list, this doesn’t mean the doctor has prescribed inappropriately. It does mean, however, that it’s extra important to review the benefits and burdens of this medication. It’s also extra important to ask about non-drug alternatives for treating whatever problem the Beer’s list medication is intended to treat.

For instance, it’s fairly common for older adults to be prescribed medication for overactive bladder, because urinary leaks are common among older adults. But most of these drugs are anticholinergics, which means they affect the brain along with the bladder. Anticholinergics are on the Beer’s list because they can cause confusion in older adults; they’ve also been linked with developing dementia. Fortunately, for older adults, it’s often possible to improve bladder issues using non-drug techniques, such as bladder training, pelvic strengthening exercises, or timed toileting. This may not be right for every older person, but by spotting any Beer’s list medications, you can give yourself an opportunity to consider potentially safer treatment options.

Along with anticholinergic drugs, the Beer’s list medications I see prescribed most often to older adults are sedatives and tranquilizers for sleep or anxiety, antipsychotics for dementia, and non-steroidal anti-inflammatory drugs (such as ibuprofen or naproxen, which are also available over-the-counter) for arthritis.

4. Check for signs of over-treatment, especially for diabetes and high blood pressure.

Did you know that it’s fairly common for aging adults to be receiving higher doses of medication than is actually necessary? This can create safety issues, especially when it comes to diabetes and high blood pressure.

Over-treatment of hypertension, for example, can cause an older adult’s blood pressure to be low, especially with standing. (A drop in blood pressure with standing is sometimes called orthostatic hypotension.) This can cause dizziness or light-headedness. It can increase the risk of falls; a study found that older adults taking high blood pressure medication had a higher chance of bone-breaking falls.

Similarly, high doses of diabetes medication can cause a senior to experience episodes of hypoglycemia or low blood sugar. Studies have found that insulin, in particular, is linked to hospitalizations and emergency room visits.

To help your doctor spot over-treatment, you’ll want to familiarize yourself with what the “goal” is for your treatment. For blood pressure, this means finding out what range your blood pressure should be in. (See my update on blood pressure guidelines here.)  For diabetes, you’ll want to find out what is a good range for your random blood sugar, as well as the ideal range for your hemoglobin A1C. You can learn about expert recommendations for diabetes control in older adults here.

You can also learn more about the overtreatment of hypertension and diabetes in this NY Times article: Some Older Patients Are Treated Not Wisely, but Too Much.

5. Check for drug interactions.

You may also be concerned about the possibility of drug interactions, especially if you (or your parent) is taking several prescription medications.

If that’s the case, you can try entering yourmedications in a free online drug interaction checker. (I have tried this one and it seems relatively easy to use.) If any concerning interactions crop up, make a note to ask the doctor. You can also print the webpage showing the interactions and bring it to the next doctor’s visit.

Risky drug interactions are certainly a serious issue in geriatric health care. That said, I find it’s much more common for older adults to be suffering from other forms of “inappropriate” drug prescribing, such as being given medications that are on the Beer’s list, or being aggressively treated for high blood pressure.

To recap, the five steps are:

1. List all medications you or your older relative is taking, along with the intended purpose of each medication.
2. If the purpose of a medication is to control a sign or symptom, take note of when the symptom was last checked on, and how it’s been doing.
3. Check to see if any of the medications are on the Beer’s list.
4. Check for signs of over-treatment, especially for high blood pressure and diabetes.
5. Check for drug interactions.

Why You Should Be Proactive About Medications in Aging

You may be asking why shouldn’t we expect doctors and pharmacists to make sure an older person’s medications are safe and appropriate, particularly with technology and modern conveniences?

The answer is that we are constantly working within healthcare to make things better and safer for aging adults. But reviews of healthcare quality show that older patients often don’t get recommended care, and it will probably be a while before it’s safe to assume that an older person’s healthcare is optimal without double-checking on things.

The fact remains that older adults and families who actively participate in optimizing their health care often do better. By working with your doctor, you’ll not only help catch oversights, but you’ll also ensure that symptoms are properly addressed and that the medical care is better tailored to you as an individual.

Healthcare works best when it’s a partnership between patients, family caregivers and doctors. By learning to request and prepare for a medication review, you’ll be making sure an important aspect of aging healthcare is better handled.

Last but not least: try our podcast episode on deprescribing (featuring the wonderful deprescribing expert Dr. Cara Tannenbaum), plus we have a related article here: Deprescribing: How to Be on Less Medication for Healthier Aging.

Questions? Comments? Let me know below!