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Medication-Related Problems in Older Adults

ByJ. Mark Ruscin, PharmD, FCCP, BCPS, Southern Illinois University Edwardsville School of Pharmacy;
Sunny A. Linnebur, PharmD, BCPS, BCGP, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado
Reviewed/Revised Apr 2025
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Topic Resources

Medication-related problems are common in older adults and include drug ineffectiveness, adverse drug effects, overdosage, underdosage, inappropriate treatment, inadequate monitoring, nonadherence, and drug-drug or drug-disease interactions. (See also Overview of Pharmacologic Therapy in Older Adults.)

Medications may be ineffective in older adults because clinicians under-dose or do not titrate the dose over time (eg, because of increased concern about adverse effects) or because adherence is poor (eg, because of financial or cognitive limitations).

Adverse drug effects are effects that are unwanted, uncomfortable, or dangerous. Common examples are oversedation, confusion, hallucinations, falls, diarrhea, constipation, and bleeding. Among ambulatory people 65, adverse drug effects occur at a rate of about 50 events per 1000 person-years (1). Hospitalization rates due to adverse drug effects are 4 to 7 times higher in older patients than in younger patients; these hospitalizations in older patients are most commonly due to anticoagulants, antibiotics, diabetes agents, opioid analgesics, and antipsychotics (2, 3).

References

  1. 1. Gurwitz JH, Field TS, Harrold LR, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA. 2003;289(9):1107-1116. doi:10.1001/jama.289.9.1107

  2. 2. Salvi F, Marchetti A, D'Angelo F, Boemi M, Lattanzio F, Cherubini A. Adverse drug events as a cause of hospitalization in older adults. Drug Saf. 2012;35 Suppl 1:29-45. doi:10.1007/BF03319101

  3. 3. Shehab N, Lovegrove MC, Geller AI, Rose KO, Weidle NJ, Budnitz DS. US Emergency Department Visits for Outpatient Adverse Drug Events, 2013-2014. JAMA. 2016;316(20):2115-2125. doi:10.1001/jama.2016.16201

Prevention

Before starting a new medication

To reduce the risk of adverse drug effects in older adults, clinicians should do the following before starting a new medication:

  • Consider that new symptoms or medical problems may be related to existing pharmacologic therapy

  • Consider nonpharmacologic treatment

  • Discuss goals of care with the patient and/or caregivers and establish a timeframe in which benefit from the pharmacologic therapy is expected

  • Evaluate the indication for each new medication (to avoid using unnecessary medications)

  • Consider age-related changes in pharmacokinetics or pharmacodynamics and their effect on dosing requirements

  • Choose the safest possible pharmacologic agent for the indication (eg, for noninflammatory arthritis, acetaminophen instead of an oral nonsteroidal anti-inflammatory drug [NSAID])Choose the safest possible pharmacologic agent for the indication (eg, for noninflammatory arthritis, acetaminophen instead of an oral nonsteroidal anti-inflammatory drug [NSAID])

  • Check for potential drug-disease and drug-drug interactions

  • Start with the lowest effective dose

  • Use the fewest medications necessary

  • Note coexisting disorders and their likelihood of contributing to adverse drug effects

  • Explain the uses and adverse effects of each medication

  • Provide clear instructions to patients about how to take their medications (including generic and brand names, spelling of each drug name, indication for each medication, and explanation of formulations that contain more than one medication) and for how long the medication will likely be necessary

  • Anticipate confusion due to sound-alike medication names and pointing out any names that could be confused (eg, Glucophage® and Glucovance®)

After starting a medication

The following should be done after starting a medication:

  • Assume a new symptom may be medication-related until proven otherwise (to prevent a prescribing cascade).

  • Monitor patients for signs of adverse drug effects, including measuring drug levels and doing other laboratory tests as necessary.

  • Document the response to therapy and increase doses as necessary to achieve the desired effect.

  • Regularly reevaluate the need to continue pharmacologic therapy and stop medications that are no longer necessary or medications with greater potential risk than benefit.

Ongoing

The following should be ongoing:

Medication reconciliation is a process that helps ensure transfer of information about medication regimens at any transition point in the health care system. The process includes identifying and listing all medications patients are taking (name, dose, frequency, route) and comparing the resulting list with the physician’s orders at a transition point. Medication reconciliation should occur at each move (admission, transfer, and discharge).

Computerized physician ordering programs and electronic medical record systems can incorporate prescribing alerts to warn clinicians to potential problems (eg, allergy, need for reduced dosage in patients with impaired renal function, drug-drug interactions). These programs can also cue clinicians to monitor certain patients closely for adverse drug effects.

Drugs Mentioned In This Article

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