If you've been taking a certain medication for many years, you might assume it's fine to continue it as you get older. But physicians say that many people may be ingesting what they refer to as “potentially inappropriate medications”—drugs that may no longer be safe because of advancing age or the onset of new medical conditions.
A study in an August 2023 issue of JAMA Network showed 37 percent of adults 65 and older worldwide have been using potentially inappropriate medications (PIMs). Taking the wrong drugs can lead to an increase in adverse reactions, emergency department visits, and a decline in quality of life. How? By increasing the risk of falls, delirium, depression, dizziness, confusion, balance problems, dementia, hallucinations, bleeding (in the stomach or elsewhere), heart rhythm abnormalities, bone loss, and urinary retention complications.
“If a medication worked for you when you were in your 40s or 50s, it could be fine as you get into your 60s or 70s—but it could also do more harm than good at that point,” says Ambar Kulshreshtha, a physician epidemiologist and an associate professor in the department of family and preventive medicine at the Emory University School of Medicine in Atlanta. “Many patients are not aware that this could become a problem.”
Some doctors aren’t, either. In fact, a study in a 2022 issue of Frontiers in Pharmacology found that 55 percent of the nearly 600 participating physicians in China had never heard of a screening tool for PIM use in older patients. Similarly, a study in a 2016 issue of PLOS One found that among nearly 400,000 patients ages 65 years or older in Germany, 58 percent had PIM prescriptions from pharmacies.
It can also lead to post-operative complications. A study in a 2022 issue of the journal Anesthesia and Analgesia examined the use of potentially inappropriate medications among 1,627 adults ages 65 and older who underwent elective inpatient surgery: The researchers found that 69 percent of the patients received at least one PIM—and it was associated with a longer hospital stay after surgery.
In other words, with PIM use, older people can end up trading one medical problem for another. In these instances, says Jason Karlawish, a geriatrician and professor of medicine at the University of Pennsylvania, “what started as an appropriate medication can become inappropriate over time.”
Categories of PIMs
Every few years, the American Geriatrics Society updates its Beers Criteria, an explicit list of potentially inappropriate medications, in older adults; the list is widely used by doctors, researchers, and other health professionals.
The 2023 update includes five categories—medications that are considered potentially inappropriate in people 65 and older; drugs that may be inappropriate in people with certain medical conditions such as heart failure, dementia, or Parkinson’s; medications that should be used with caution in older adults; potentially problematic drug-drug interactions; and drugs where the dosages should be adjusted based on the person’s kidney function.
More than 200 commonly taken drugs are on the 2023 Beers Criteria list of PIMs in older adults. These include various first-generation antihistamines (such as oral diphenhydramine, or Benadryl), benzodiazepines (sedatives such as alprazolam, clonazepam, and diazepam), some cardiovascular drugs (such as digoxin for atrial fibrillation and clonidine for hypertension), some antidepressants (including amitriptyline and paroxetine), certain anti-psychotic drugs (which are often used in an off-label capacity for sleep problems), proton-pump inhibitors for treating acid reflux, some muscle relaxants, chronic use of non-steroidal anti-inflammatory drugs (including ibuprofen and naproxen) and other pain medications, among others.
PIM use varies across the globe. Africa and South America have the highest prevalence of PIM use—47 percent—while in Europe it is 35 percent and in North America, it’s 29 percent.
Compounding the PIM problem is the issue of polypharmacy, which is defined as the concurrent use of five or more prescription drugs—something that’s prevalent among older adults. “The two problems tend to go together,” says Karlawish.
In a study in a 2021 issue of the Archives of Gerontology and Geriatrics, researchers examined the use of PIMS among more than 61,000 adults, ages 65 and older, who had at least two chronic medical conditions (such as hypertension, diabetes, or depression) and used prescription drugs from at least five pharmaceutical classes over a seven-year period: They found that 69 percent of them used at least one PIM and the odds were higher for women.
As people get older and develop various medical conditions, they also may become susceptible to “prescribing cascades,” says Austin Armstrong, a geriatrician with Medstar Washington Hospital Center in Washington, D.C. If someone has hypertension, for example, and they’re taking a medication to lower it, it’s worth noting that some blood pressure medications can cause leg swelling (edema) as a side effect, in which case the person may be given a diuretic to reduce the fluid accumulation. Prescribing cascades like this often contribute to polypharmacy.
“When you are on multiple medications, even if they are safe when they’re taken individually, when they’re taken together they may cause more harm than good,” Kulshreshtha says. And if a PIM is added to the mix in an older adult, the potential for unfortunate effects increases even more.
Why certain drugs become problematic
There are many reasons why certain drugs may cause harm as people get older, but the most common explanation has to do with age-related physiological changes.
It’s widely known that as people get older, their metabolic rate slows down, which is why people often gain weight as the decades pass. Something that’s less well recognized among patients: Older adults also experience slowing of motility through the gastrointestinal tract, a reduction in body water, and changes in kidney and liver function that affect how they absorb, process, and excrete drugs. “This creates a web of vulnerability for having adverse events,” explains Armstrong.
Meanwhile, age-related changes to vision, hearing, and bone density can make older adults more susceptible to certain adverse effects from drugs. And the process of aging leads to a decrease in neurons (brain cells) and neural connections, says George T. Grossberg, a professor in the department of psychiatry and behavioral neuroscience and director of geriatric psychiatry at the Saint Louis School of Medicine. “As a result, the aging brain becomes more sensitive to mood- or mind-altering side effects” from some medications.
Anticholinergic drugs that block transmission of the neurotransmitter acetylcholine—including some medications used to treat allergies, depression, respiratory disorders (such as asthma), overactive bladder, cardiovascular disease, and Parkinson’s—“are precipitators of confusion, even delirium, in older adults,” Grossberg says.
The trouble is, many doctors have a see-a-disease, give-a-drug mindset to treating patients, Grossberg says, and some physicians may not be aware of the potential risks of using certain drugs in older adults. To some extent, this may be because these medications were studied in younger populations and only later were some of them found to be problematic in older adults, notes Karlawish. “There’s a lag of uptake of this information.”
Legacy prescriptions
Complicating matters, “older adults are likely to see multiple physicians—this reflects the specialization of medical care and the fact that older adults often have multiple medical conditions,” Karlawish says.
Another factor contributing to PIM use: People and doctors often become attached to using certain drugs because they work well, and believe there’s no need to make a change, just because the person is now older. This is called legacy prescribing, and it’s particularly common with antidepressants and proton pump inhibitors, research has found.
“Prescribers are hesitant to stop prescribing a medicine if the patient has been taking it for a while,” Armstrong says. “But your 80-year-old self is not the same as your 40-year-old self so it may no longer be an appropriate drug.”
Talking with your doctor about PIMs
It’s important for older adults, and perhaps their family members, to periodically review their medications with their physicians during appointments. If you notice any symptoms of PIM use that may correspond to a drug you’re taking, mention them to your doctor. Even if you don’t, Kulshreshtha recommends reviewing your current meds and asking: Why do I need this particular medication? What is it doing for me? And is it safe for me to take at my age even if I’ve been taking it for a while?
“That is enough to trigger the doctor to be more thoughtful about medications as you get older,” Kulshreshtha adds.
The goal is to look at all the drugs and gauge which ones may no longer be necessary.
“We should be paying more attention to the concept of deprescribing in older adults,” says Grossberg. In a nutshell, deprescribing describes the process of gradually discontinuing or reducing the dosage of drugs that could be harmful or that are no longer required; it’s considered especially important in older people.
“By taking people off potentially deleterious medications, we can see what their baseline looks like,” Grossberg says. “Often they get a whole lot better.”
In other instances, an adjustment in dosage may be in order. “As people get older, dosages might need to be adjusted or tapered down to avoid PIM effects,” Armstrong says. “It’s an ever-shifting landscape. We have to treat the patient as a whole in the moment they present to us.”
