Potentially Inappropriate Medicines in Older Adults

Potentially inappropriate medicines are those whose risk probably outweighs benefit in older adults, usually because a safer alternative exists or because dose or duration is excessive. They are flags for review rather than absolute prohibitions, and each decision needs the indication, the person’s goals and the alternatives. Explicit criteria lists identify them quickly, but no list replaces clinical judgement.

Why risk rises. Reduced renal and hepatic clearance, higher brain sensitivity, postural hypotension and multiple drugs combine to produce falls, delirium, bleeding, hypoglycaemia and acute kidney injury.

Recognition. Review for these drugs at every medication review, on admission and on discharge. Ask first whether the indication is still valid.

Pethidine and high-dose tramadol. Pethidine produces a neurotoxic metabolite and should not be prescribed. Tramadol carries seizure, hyponatraemia and serotonin toxicity risk.

Special groups. Chronic kidney disease, dementia, Parkinson disease and prior falls each convert some borderline drugs into drugs to avoid. In East Africa, over-the-counter NSAIDs and traditional herbal products are common, so ask about them directly.

Dose. If a flagged drug is justified, use the lowest dose for the shortest time with a written stop date.

Monitoring. Check creatinine and potassium within 1 to 2 weeks of any NSAID, sodium 2 weeks after SSRI starts, QTc before ondansetron or antipsychotics, and digoxin level when renal function changes or a new interacting drug is added.

Common errors. Continuing hospital-initiated sedatives at discharge, repeat prescribing without review, and combining an NSAID with an anticoagulant or antiplatelet drug.

Stopping. Taper benzodiazepines, Z-drugs, tricyclic antidepressants and antipsychotics rather than stopping suddenly; reductions of 10% to 25% every 2 to 4 weeks are usual.

Referral and escalation. Seek pharmacist or geriatrician review when a flagged drug is justified by a specialist but harm has occurred, when several flagged drugs coexist, or when withdrawal symptoms recur.