ANSWER
It is difficult to prescribe for the elderly.
Older people are frequently prescribed unnecessary drugs, drugs that are contraindicated in their age group, or the incorrect dose for their age.
Age misconceptions may prevent them from receiving drugs with specific indications and evidence bases.

Inappropriate prescribing can be reduced by conducting regular drug reviews, using electronic prescribing, conducting regular audits, and limiting the number of prescribers.
Even though one-fifth of the UK population is 60 or older1, people in this age group receive 59% of dispensed prescriptions and account for more than half of NHS drug costs.
2 Older people frequently have multiple medical problems and take multiple medications. Because aging causes changes in pharmacokinetics and pharmacodynamics, prescribing in this age group can be difficult. 3
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Many randomized controlled trials involving older patients focus on managing a single disease state, such as hypertension or osteoporosis. However, people in this age group frequently have many interacting conditions. They are taking many drugs, so treatment guidance must often be based on consensus and involves extrapolating data from healthier patients. This review highlights some of the challenges in prescribing to older patients and provides recommendations for appropriate prescribing.

Go to: Sources and criteria for selection.
We used the keywords “elderly” and “prescribing” in the National Library of Medicine, PubMed, and Embase databases, as well as synonyms by MeSH or major descriptor headings. Our search was restricted to human studies published in English in the previous five years. Before obtaining the full text of articles of interest, we displayed abstracts of interest using Abstract Plus. We also looked through the Cochrane Library and our reference files.

Visit: What physiological changes occur as we age?
Changes in pharmacokinetics and pharmacodynamics
The body changes as it ages, affecting drug distribution, metabolism, and excretion. These modifications included decreased renal clearance, liver size, and lean body mass. 4 Chronic disease may also reduce hepatic enzyme activity and serum albumin levels. The most clinically significant of these changes is a decrease in renal clearance, which leads to decreased excretion of water-soluble drugs. This is especially important for drugs like digoxin, lithium, and gentamicin, which have a narrow therapeutic window (the ratio of desired effect to toxic effect).

In addition to pharmacokinetic changes, older people are more sensitive to the effects of some drugs, particularly those that act on the central nervous system, such as benzodiazepines, which are associated with increased postural sway and the risk of falling.

Polypharmacy and multiple pathologies
Polypharmacy is expected in the elderly; approximately 20% of people over 70 take five or more medications.
5 Over the last decade, the average number of items prescribed to people aged 60 and up has nearly doubled, rising from 21.2 to 40.8 per person per year. 6 Polypharmacy was previously associated with inappropriate prescribing, but this is no longer the case because all prescribed drugs may have an appropriate indication.

Polypharmacy is linked to increased negative outcomes, including drug interactions, adverse drug reactions, falls, hospital admissions, length of stay, readmission rate soon after discharge, and mortality rate.

5 7 8 These effects may be due to polypharmacy acting as a marker of multiple pathology or frailty rather than being an independent risk factor.

Visit: What Is Inappropriate Prescription?
Inappropriate prescribing for older patients includes all standard indicators of inappropriate prescribing for adults. Still, the problem is especially acute for older patients due to their frequent use of multiple medications. This not only increases their risk of an adverse event but also means that unnecessary drugs may be obscured by a large number of necessary ones. Dose, formulation, and delivery must be adjusted according to the patient’s age and frailty, and some drugs should be avoided entirely. This is familiar territory for general practitioners, who see very young patients and routinely adjust drug doses based on the British National Formulary for Children—perhaps we need an equivalent publication for older patients to emphasize the importance of age consideration. Problems arise when older patients are assumed to respond to drugs the same way that an average adult does, problems arise. 9 Furthermore, as patients age, it is easy to forget to adjust drug doses appropriately. A review by someone other than the usual prescriber can be especially beneficial in this situation.

Visit: Which medications should we avoid in elderly patients?
Some adverse drug reactions, such as cough caused by angiotensin-converting enzyme inhibitors, occur at a similar rate regardless of age. However, the pharmacokinetic or pharmacodynamic changes seen with aging may result in a higher prevalence of adverse drug reactions. The Beers criteria, an American consensus guideline first published in 1991 and last updated in 2003, provides a list of drugs that a panel of experts thought were particularly problematic for older patients. 10 The table provides examples from this list that are particularly pertinent to prescribing in the United Kingdom.

Drugs that are especially dangerous for the elderly10

Drug

Adverse drug effects
Nonsteroidal anti-inflammatory drugs used for a long time
Gastrointestinal bleeding, renal impairment, and hypertension
Benzodiazepines
Falls caused by a loss of balance
Anticholinergic medications
Alzheimer’s disease and urinary retention
Antidepressants tricyclic
Sedation and orthostatic hypotension
Chlorpropamide
Hypoglycaemia
Doxazosin
Orthostatic hypotension, dry mouth, and urinary difficulties
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Go to:
What medications should we consider routinely in elderly patients?
Although older people have been under-represented in clinical trials of new drugs, there is solid evidence that some newer treatments work well in this population. Warfarin reduces strokes in patients with atrial fibrillation while having no significant increase in the risk of bleeding, and it is recommended for most atrial fibrillation patients over the age of 75. 11 12

Recent reviews also provide compelling evidence for the use of angiotensin converting enzyme inhibitors and blockers in the treatment of left ventricular systolic dysfunction, statins in the treatment of hypercholesterolemia, and bisphosphonates in the treatment of osteoporosis in the elderly.

13 14 15 16 These medications were well tolerated in the elderly, but few studies included patients taking multiple medications simultaneously. 11 13 14 15 16. As a result, we recommend carefully monitoring the introduction of new agents, often starting with low doses and titrating upwards.

Go to: How can we reduce inappropriate prescribing in the elderly?
Good prescribing technique
Box 1 contains some guidelines for prescribing in elderly patients. Some guidelines, such as using as few prescribers as possible, are evidence-based17, but most are consensus opinions due to a lack of evidence in this area.

Box 1: Prescription Guidelines for Elderly Patients
Conduct a systematic medication review and discuss and agree on changes with the patient.
Stop taking any current medications that are not prescribed.
Prescribe new drugs with clear indications.
Avoid drugs known to be harmful to elderly patients, such as benzodiazepines, and recommend dosage reduction when necessary.
For elderly patients, use the recommended dosages.
Use simple drug regimens and administration systems.
When possible, use once-daily or once-weekly formulations and fixed-dose combinations.
If appropriate, consider non-pharmacological treatments.
Limit the number of people who can prescribe for each patient.
Avoid treating adverse drug reactions with additional drugs whenever possible.
Medication evaluation
Regular medication reviews are recommended by the national service framework for older people, with patients taking four or more drugs being reviewed every six months and those taking fewer drugs being reviewed annually.
18 General practitioners, who do most of the prescribing, can authorize repeat prescriptions for a fixed period or several repeats, and their clinical software will automatically generate a recall. The National Prescribing Centre has issued detailed guidance on conducting a medication review for all patients prescribed four or more repeat medicines as part of the quality and outcomes framework of the general practitioner contract. 19 However, the government has recently threatened to withdraw funding for this goal in favor of more extended hours.

The medication review not only examines the indication for taking existing drugs and checks their dosage but also allows for identifying and treating new conditions, such as atrial fibrillation, cardiac failure, or Alzheimer’s disease, which become more familiar with age. Geriatricians should refer older people with complex medication or medical needs for a specialist review. 18

Only 14 trials met the inclusion criteria for a systematic review of the effects of pharmacist-led interventions on reducing polypharmacy, and these tended to report cost savings rather than patient benefits.

20 A recent randomized controlled trial found that regular telephone counseling by a hospital pharmacist increased concordance and reduced all-cause mortality without changing the total number of drugs taken,21 but implementing this intervention in the larger community would be difficult. A drug use review was included as the first advanced level service to be implemented under the 2005 contract for community pharmacists,22 23. Still, the goal of this review is to ensure that drugs are taken and taken correctly. Pharmacists cannot review treatment indications without clinical records. Even though there is no evidence that community pharmacists reduce mortality or emergency admissions, they play an essential role in detecting adverse drug reactions, drug interactions, and concordance issues. 24

Using the fewest number of prescribers possible
In the United Kingdom, most prescribing is done by the patient’s primary care physician, but it is frequently started or adjusted in secondary care, so good communication is essential. Unintentional medication discrepancies are discovered in half of older patients after they leave the hospital. This error rate can be reduced if the community pharmacist receives a copy of the discharge summary. 25

A recent study in the United States discovered that the number of doctors who prescribe for a patient is directly related to the incidence of adverse drug reactions.

17 Non-medical prescribing by nurses and other health care providers has not been studied. It produces a similar number of prescriptions as physician prescribing26, but it increases the potential number of prescribers (though independent nurse prescribers work closely with the patient’s primary care physician).

Education
According to a Cochrane review, educational outreach visits are a promising way to change the behavior of health professionals, particularly prescribing behavior.
27 In a UK study of 75 randomly selected general practices, those who received educational outreach improved their prescribing practice slightly. 28 Smaller practices (two or fewer full-time equivalent practitioners) improved by 13.5%, while larger practices did not significantly improve. This could be due to a higher proportion of doctors from smaller practices attending the outreach meetings. A randomized controlled trial revealed that similar interventions could influence prescribing in hospital settings. 29

Prescriptions can now be filled electronically.
Electronic prescribing (ePrescribing) aims to reduce prescribing and administration errors by eliminating the possibility of mistakes when generating or reading paper prescriptions.
30 This is one step toward the overall goal of integrating the entire patient record across the healthcare system to reduce errors or delays in communication between service providers. This structure can accommodate prescribing advice software. This has the potential to be especially beneficial for older patients with multiple morbidities who are taking multiple medications, but setting up is only half the battle—patients may need assistance and encouragement to use it at first. 31

Before and after studies in a surgical ward of a London teaching hospital show an early benefit. The implementation of closed-loop electronic prescribing resulted in fewer prescribing errors, medication administration errors, and prescription endorsements by a pharmacist. 32 33

Audit
Prescription auditing is essential to providing exemplary clinical care. Still, the traditional audit loop of data collection, interpretation, and feedback creates a long delay between an action and its feedback, reducing any effect on behavior. Furthermore, merged data distances the prescriber from specific errors and makes it more challenging to identify obvious ways to improve. Auditing does not always change behavior34, but prescribing indicators for older patients35, 36, 37 have been developed and could provide immediate feedback when integrated into electronic prescribing systems. The types of indicators used to assess prescribing quality are shown in Box 2.

Box 2: Prescription Quality Indicators

35
Indicators quantitative
Such as the average number of drugs prescribed or drugs classified as “black triangle” or “less suitable for prescribing” in the British National Formulary.
11 These indicators work best when combined with others.

Indicators of quality
These are drug-specific indicators of unnecessary or ineffective prescribing (for example, prescribing an H2 receptor blocker and a proton pump inhibitor at the same time) or potentially harmful drugs (such as long-acting hypoglycaemic agents)

Indicators based on evidence
These assess the extent to which research evidence is implemented in practice, such as the use of antithrombotic therapy in atrial fibrillation, while also allowing the prescriber to identify reasons why the evidence base should not be followed, such as because a palliative care pathway is being followed or the patient has a history of an adverse reaction.

Go to: What future improvements can we expect?
Unified medical records, electronic prescribing with decision support, and real-time prescribing feedback have the potential to reduce prescribing errors and improve patient care. Even when older people are included in clinical trials for new treatments, the results are not easily generalizable to a frail elderly population with multiple comorbidities. Such randomized controlled trials ideally include representative samples of frail older patients, but the practical challenges are significant.

Proceed to: Conclusions
Many challenges exist when prescribing for elderly patients, most of which have not changed in the last 20 years.
38 Because of changes in pharmacodynamics and pharmacokinetics, these patients frequently require lower doses. The presence of multiple medical problems and subsequent polypharmacy increases the likelihood of adverse drug reactions and interactions.

The evidence base for specific treatments in older people is increasing. Still, even when the evidence base does not extend to a particular age group, effective treatments should not be withheld purely based on age, just as treatments would not be denied to specific ethnic groups under-represented in clinical studies.

Tips for non-specialists
Older people’s drugs should be reviewed regularly. People taking fewer than four drugs should be reviewed at least annually. People taking four or more should be reviewed at least every six months.
Patients taking several drugs with multiple comorbidities may benefit from a specialist review by a geriatrician. The referral should include a history of adverse events or intolerances and a list of drugs currently being taken.
QUESTION
Only scholarly reviewed resources are required