Prescribing for Older Patients

  • Paul GallagherEmail author
  • Amanda Lavan
  • Denis O’Mahony


Prescribing for older patients presents numerous pharmacological and practical challenges, particularly in a busy emergency department where physicians have limited resources to comprehensively appraise the quality, safety and appropriateness of medication use in this heterogeneous patient group. Though the majority of older people are physically and cognitively well, emergency departments (EDs) worldwide are treating ever-increasing numbers of older patients who present with complex co-morbid illnesses, multiple concurrent medications, cognitive impairments and functional dependence, all of which increase the risk of adverse drug events (ADEs) [1–4]. Indeed, ADEs are a frequent cause of presentation to emergency departments amongst older people, common examples being falls (± injury such as hip fracture) because of sedative hypnotic drugs, gastrointestinal or intracranial haemorrhage because of anticoagulant or antiplatelet drugs, acute confusional states because of drugs with anticholinergic properties, hypoglycaemia because of antidiabetic medications and drug toxicity because of drugs with narrow therapeutic indices, e.g. digoxin [5, 6]. Most ADEs are predictable through age-related changes in pharmacokinetic (absorption, distribution, metabolism and excretion) and pharmacodynamic response to commonly prescribed drugs [7]. Physicians who assess and treat older patients in the emergency department must be mindful of these age-related physiological changes in addition to the influence of pathological processes and polypharmacy on the risk of drug-disease and drug-drug interactions, inappropriate prescribing and suboptimal adherence.


  1. 1.
    George G, Jell C, Todd BS (2006) Effect of population ageing on emergency department speed and efficiency: a historical perspective from a district general hospital in the UK. Emerg Med J 23:379–383CrossRefGoogle Scholar
  2. 2.
    Strange GR, Chen EH, Sanders AB (1992) Use of emergency departments by elderly patients: projections from a multicentre data base. Ann Emerg Med 21:819–824CrossRefGoogle Scholar
  3. 3.
    Aminzadeh F, Dalziel WB (2002) Older adults in the emergency department: a systematic review of patterns of use, adverse outcomes, and effectiveness of interventions. Ann Emerg Med 39:238–247CrossRefGoogle Scholar
  4. 4.
    Salvi F, Morichi V, Grilli A, Giorgi R et al (2007) The elderly in the emergency department: a critical review of problems and solutions. Intern Emerg Med 2:292–301CrossRefGoogle Scholar
  5. 5.
    Budnitz DS, Shehab N, Kegler SR, Richards CL (2007) Medication use leading to emergency department visits for adverse drug events in older adults. Ann Intern Med 147:755–765CrossRefGoogle Scholar
  6. 6.
    Piromohamed M, James S, Meakin S et al (2004) Adverse drug reactions as a cause of admission to hospital: prospective analysis of 18820 patients. BMJ 329:15CrossRefGoogle Scholar
  7. 7.
    Mangoni AA, Jackson SHD (2004) Age-related changes in pharmacokinetics and pharmacodynamics: basic principles and practical applications. Br J Clin Pharmacol 57(1):6–14CrossRefGoogle Scholar
  8. 8.
    Qato DM, Alexander GC, Conti RM et al (2008) Use of prescription and over-the-counter medications and dietary supplements among older adults in the united states. JAMA 300:2867–2878CrossRefGoogle Scholar
  9. 9.
    Department of Health (2004) Prescriptions dispensed in the community: statistics for 1993–2003. Department of Health, LondonGoogle Scholar
  10. 10.
    Patterns of medication use in the United States (2006) A report from the Slone survey. Slone Epidemiology Centre at Boston University, BostonGoogle Scholar
  11. 11.
    Doshi JA, Shaffer T, Briesacher BA (2005) National Estimates of medication use in nursing homes: findings from the 1997 medicare current beneficiary survey and the 1996 medical expenditure survey. J Am Geriatr Soc 53:438–443CrossRefGoogle Scholar
  12. 12.
    Rousseau A, Rybarczyk-Vigouret MC, Vogel T, Lang PO, Michel B (2016) Inappropriate prescription and administration of medications in 10 nursing homes in Alsace, France. Rev Epidemiol Sante Publique 64(2):95–101Google Scholar
  13. 13.
    Cockcroft DW, Gault MH (1976) Prediction of creatinine clearance from serum creatinine. Nephron 16:31–41CrossRefGoogle Scholar
  14. 14.
    Levey AS, Bosch JP, Lewis JB et al (1999) A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of diet in renal disease study group. Ann Intern Med 130:461–470CrossRefGoogle Scholar
  15. 15.
    British National Formulary Mar 2015–Sept 2015.
  16. 16.
    World Health Organisation (1972) Technical Report number 498Google Scholar
  17. 17.
    Goldberg RM, Mabee J, Chan L, Wong S (1996) Drug – drug and drug – disease interactions in the ED: analysis of a high risk population. Am J Emerg Med 14:447–450CrossRefGoogle Scholar
  18. 18.
    Spinewine A, Schmader KE, Barber N et al (2007) Appropriate prescribing in elderly people: how well can it be measured and optimised? Lancet 370:173–184CrossRefGoogle Scholar
  19. 19.
    Gallagher P, O’Mahony D (2008) STOPP (screening tool of older persons’ potentially inappropriate prescriptions): application to acutely ill elderly patients and comparison with beers’ criteria. Age Ageing 37:673–679CrossRefGoogle Scholar
  20. 20.
    Ryan C, O’Mahony D, Kennedy J et al (2013) Potentially inappropriate prescribing in older residents in Irish nursing homes. Age Ageing 42(1):116–120CrossRefGoogle Scholar
  21. 21.
    Hamilton H, Gallagher P, Ryan C, Byrne S, O’Mahony D (2011) Potentially inappropriate medications defined by STOPP criteria and the risk of adverse drug events in older hospitalized patients. Arch Intern Med 171(11):1013–1019CrossRefGoogle Scholar
  22. 22.
    Maher RL, Hanlon J, Hajjar ER (2014) Clinical consequences of polypharmacy in elderly. Expert Opin Drug Saf 13:57–65CrossRefGoogle Scholar
  23. 23.
    Frank C, Godwin M, Verma S et al (2001) What drugs are our frail elderly patients taking? Do drugs they take or fail to take put them at increased risk of interactions and inappropriate medication use? Can Fam Physician 47:1198–1204PubMedPubMedCentralGoogle Scholar
  24. 24.
    Lau DT, Kasper JD, Potter DE, Lyles A, Bennett RG (2005) Hospitalization and death associated with potentially inappropriate medication prescriptions among elderly nursing home residents. Arch Intern Med 165:68–74CrossRefGoogle Scholar
  25. 25.
    Lindley CM, Tully MP, Paramsothy V, Tallis RC (1992) Inappropriate medication is a major cause of adverse drug reactions in elderly patients. Age Ageing 21:294–300CrossRefGoogle Scholar
  26. 26.
    IMS Institute for Healthcare Economics (2013) Available costs in U.S. Healthcare. The $200 billion opportunity from using medicines more responsiblyGoogle Scholar
  27. 27.
    Beers MH, Ouslander JG, Rollingher I et al (1991) Explicit criteria for determining inappropriate medication use in nursing home residents. UCLA division of geriatric medicine. Arch Intern Med 151:1825–1832CrossRefGoogle Scholar
  28. 28.
    Beers MH (1997) Explicit criteria for determining potentially inappropriate medication use by the elderly. An update. Arch Intern Med 157:1531–1536CrossRefGoogle Scholar
  29. 29.
    Fick DM, Cooper JW, Wade WE et al (2003) Updating the beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med 163:2716–2724CrossRefGoogle Scholar
  30. 30.
    American Geriatrics Society 2012 Beers Criteria Update Expert Panel (2012) American Geriatrics Society updated beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 60:616–631CrossRefGoogle Scholar
  31. 31.
    Gallagher P, Ryan C, Byrne S, Kennedy J, O’Mahony D (2008) STOPP (screening tool of older Person’s prescriptions) and START (screening tool to alert doctors to right treatment). Consensus validation. Int J Clin Pharmacol Ther 46:72–83CrossRefGoogle Scholar
  32. 32.
    O’Mahony D, O’Sullivan D, Byrne S et al (2015) STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing 44:213–218CrossRefGoogle Scholar
  33. 33.
    Gallagher PF, O’Connor MN, O’Mahony D (2011) Prevention of potentially inappropriate prescribing for elderly patients: a randomized controlled trial using STOPP/START criteria. Clin Pharmacol Ther 89:845–854CrossRefGoogle Scholar
  34. 34.
    O’Connor MN (2014) Adverse drug reactions in older people during hospitalisation: prevalence, risk factors and recognition. MD thesis. University College Cork, CorkGoogle Scholar
  35. 35.
    Samaras N, Chevalley T, Samaras D, Gold G (2010) Older patients in the emergency department: a review. Ann Emerg Med 56:261–269CrossRefGoogle Scholar
  36. 36.
    Hohl CM, Dankoff J, Colacone A, Afilalo M (2001) Polypharmacy, adverse drug-related events, and potential adverse drug interactions in elderly patients presenting to an emergency department. Ann Emerg Med 38:666–671CrossRefGoogle Scholar
  37. 37.
    Budnitz DS, Lovegrove MC, Shehab N, Richards CL (2011) Emergency hospitalisations for adverse drug events in older Americans. N Engl J Med 365:2002–2012CrossRefGoogle Scholar
  38. 38.
    Stang AS, Wingert AS, Hartling L, Plint AC (2013) Adverse events related to emergency department care: a systematic review. PLoS One 8:e74241CrossRefGoogle Scholar
  39. 39.
    Lehnbom EC, Stewart MJ, Manias E, Westbrook JI (2014) Impact of medication reconciliation and review on clinical outcomes. Ann Pharmacother 48:1298–1312CrossRefGoogle Scholar
  40. 40.
    Graf CE, Zekry D, Giannelli S, Michel JP, Chevalley T (2011) Efficiency and applicability of comprehensive geriatric assessment in the emergency department: a systematic review. Aging Clin Exp Res 23:244–254CrossRefGoogle Scholar
  41. 41.
    Alassaad A, Bertilsson M, Gillespie U et al (2014) The effects of pharmacist intervention on emergency department visits in patients 80 years and older: subgroup analyses by number of prescribed drugs and appropriate prescribing. PLoS One 9:e111797CrossRefGoogle Scholar
  42. 42.
    Ross S, Loke YK (2009) Do educational interventions improve prescribing by medical students and junior doctors? A systematic review. Br J Clin Pharmacol 67:662–670CrossRefGoogle Scholar
  43. 43.
    Terrell K, Perkins A, Dexter P et al (2009) Computerized decision support to reduce potentially inappropriate prescribing to older emergency department patients: a randomized, controlled trial. J Am Geriatr Soc 57:1388–1394CrossRefGoogle Scholar
  44. 44.
    Bayoumi I, Al Balas M, Handler SM, Holbrook A et al (2014) The effectiveness of computerized drug-lab alerts: a systematic review and meta-analysis. Int J Med Inform 83:406–415CrossRefGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2018

Authors and Affiliations

  • Paul Gallagher
    • 1
    Email author
  • Amanda Lavan
    • 1
  • Denis O’Mahony
    • 1
  1. 1.Department of Geriatric MedicineCork University HospitalWiltonIreland

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