Potentially inappropriate medicines for older people

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Hi, and welcome to this Australian Prescriber Podcast. I'm Dr Justin Coleman, a GP in Inala Indigenous Health, where I prescribe quite a few medications to quite a few older people, which is what we're talking about today. With me, I have Dr Alex Choo, who's a geriatrician and pharmacologist at the Northern Adelaide Local Health Network. Welcome, Alex.

Hi, Justin.

We're going to be talking about the article you wrote in Australian Prescriber called Potentially inappropriate medicines for older people: consensus-based lists. And to me, it's a vitally important article. When I teach registrars, I find that registrars and younger doctors feel far more confident in starting a medication than stopping a medication. And it's a bit like game theory in a way, because we know that for older people in particular, they lose the game if they're prescribed multiple, multiple medications. So, once you get above 5 and even above 10 medications, the effects, the benefits start to become less and less certain. And if someone else comes along and prescribes yet another medication, in general it's not a great thing for the older person. But game theory dictates that the person prescribing the individual, actually feels more confident prescribing one more medication. Because for them it's all about, well, a person has a pain and they want to treat it, so they prescribe one more tablet.

And it's easy for lots of individuals, in particular new doctors they see, or a specialist they see, to prescribe just one more medication. And in that way, the medications just tend to build up and up. The question is, what can we do about it? Well, the answer is to some extent being very careful with our prescriptions and also having some form of active de-prescribing or rationalisation process. And one thing that makes that a lot easier to do, particularly for doctors who are a bit more junior and a bit less confident, is having some sort of guideline. So, Alex Choo, what I'd like to do today is talk about a new Australian guideline, which was just developed and published last year in 2024, which is looking at potentially inappropriate medicines. Alex, how do you see the problem and how do you see the guideline as being some sort of help for that problem?

Yeah. Thanks, Justin. The issue with polypharmacy and multiple medications being used in the elderly is a growing one. We know that people who age are multi-morbid and have multiple chronic medical conditions that require more medications. And as a result, people are living with a high burden of medications. And with that comes many adverse effects, risk of drug-drug interactions, higher risk of falls. And all of this contribute to the burden on the health system and for an individual, the negative outcomes with polypharmacy. And so, one of the ways that we can help to address this is probably increasing awareness of certain drug classes that contribute more to harm in the older population. And that's where the medication lists that have recently been published can be helpful in raising awareness of some of these drug classes that may potentially cause more harm.

You mentioned in the article that adverse drug reactions actually account for a fifth of all unplanned hospital admissions. And of course, the majority of those may potentially be preventable. And it's lists like the potentially inappropriate medication list, which we'll call in this podcast the PIM list, which will help prevent some of those things. How do we describe inappropriate prescribing? When does a prescription become inappropriate for the individual?

I see it as an individualised evaluation of the appropriateness of prescribing. There are certain situations where someone requires those medications. The pendulum swings to inappropriate when they have more harm associated with the prescription, rather than any benefit from it. And again, that's the nuance with prescribing. Every individual has different needs and needs to be evaluated on an individual basis.

As a geriatrician, no doubt you must see that there are plenty of people who would come into hospital or in a GP's case, come up for their annual health check or prescription renewal, where the individual drug prescribed for them probably made sense at the time. It was prescribed in good faith. The doctor prescribing it felt that it was doing more good than harm, because it was treating something. And yet, if they stack up over time, there does come a point as they get older, maybe their organs start to fail, where suddenly the balance between harm and good tips the other way.

Yeah. That's right. As you age, your physiology changes as well. Body composition, for example, changes. And you have high fat mass and lower muscle mass, and that results in changes to the pharmacokinetics. We know that the brain is more vulnerable to sedative medications and anticholinergic medications, for example. And that speaks towards the pharmacodynamics. And as you age, liver function, kidney function, all of those change as well. And so, I think the learning point here is that as someone ages, it's always important to reevaluate the medication list. And I think it can be quite terrifying for some people, prescribers in particular, when you have a monster list of 10 to 20 medications. How do you pick that apart? And the process itself is time-consuming, but one that is very valuable because it can significantly reduce someone's morbidity or mortality.

Yeah. And I guess another point to note is that the pharmaceutical trials, which showed the benefit of that drug, generally don't enrol 75, 80 year olds on 10 different other medications. They tend to be more a pure thing. Is this medication good for pain or good for high blood pressure? And the people in the trial and where the evidence is gathered do tend to exclude a lot of the people whom we're talking about adding an 11th chemical into their bloodstream. In the article you describe implicit and explicit reviews of medications, and I thought that was really interesting. I gather what I tend to do in my day-to-day life tends to be more an implicit review; is that right? Tell us about those 2.

Yeah. So, an implicit review is where a prescriber may sit in front of an individual and evaluate a particular medication or a list of medications. And that really is very much reliant on the clinical judgement of the prescriber. And that takes into account multiple things like the person's frailty, for example, the relative burden of the comorbidities that the person is dealing with. And conversely, explicit evaluation with the medication would be where we rely on a clinical guideline. But as you've touched on before, it's quite linear in the sense that the guideline for diabetes is written specifically for managing diabetes. And so, that doesn't take into account necessarily the new ones, particularly of the older person where they're not dealing with just one medical problem, but multiple.

I guess, we ideally have a combination of both. So, you have explicit guidelines and we're going to talk about one in the moment. But then I guess you have that patient-centred approach, where it's up to the individual practitioner to apply that guideline to the individual sitting in the chair opposite them. So, let's talk about these explicit guidelines. First, I thought we'll briefly mention a couple which listeners may well have heard of. And that's the Beers Criteria and the European-based screening tool of older people's prescriptions, which is the STOPP guideline, S-T-O-P-P [Screening Tool of Older Persons' Prescriptions]. Just very briefly, could you tell us about those 2?

Yeah, sure. So, the criterias that you've mentioned, the Beers and the STOPP Criteria, are what we would call PIMs lists or potentially inappropriate medication lists. I would say probably the most commonly referenced list is the Beers Criteria, as you've highlighted before. It was created in the United States, initially developed for people living in a nursing home, but over time has expanded. And it's currently in its seventh version now, last published in 2023. And that gives essentially a list of medications that the prescribers should pay attention to as medications that may be potentially inappropriate.

Well, we Aussies, of course, never like to borrow too much from our US counterparts, particularly arguably in the recent times. And we've come up with our own list. What was the method for coming up with that and why is that required in Australia?

I think local lists are important. A lot of the drugs that are listed in the United States list, the Beers Criteria, are not relevant within our context. We don't prescribe a lot of those drugs. Prescription is a lot more linear in Australia because of the PBS [Pharmaceutical Benefits Scheme], which means that there's a smaller group of drugs that we would use. So, there is probably a lack of familiarity with some of the drugs that are published on the Beers Criteria. The PIMs [Potentially Inappropriate Medicines] list was developed in Australia. That was developed by Dr. Wang and her group, and they were looking at really providing that localised context. How they did it was not too different from the Beers Criteria. And that all of these lists generally are developed through the Delphi method, where an expert panel has a discussion and agrees or disagrees about whether a particular drug class causes greater risk of harm than benefit to the older person.

It's time to jump to some examples within this list. There are 2 ways of using the list. One way is looking by a specific clinical condition. And in your article you use as an example, an individual with constipation who's an older person. And the PIMs list recommends avoiding tricyclics, and the opioids, codeine and hydromorphone, and giving some alternative medications instead. Physiotherapy, paracetamol opioids with lower risk of toxicities, such as oxycodone or buprenorphine. So, that's one way of using the list. The other way... And I thought we'd just go through some of the classes now. There are 15 different classes of drugs in the list. We won't go through them. All listeners can, of course, look them up in your article. First of all, we have the antipsychotics, the first-generation ones, and also Olanzapine.

Yeah. So, I think antipsychotics are traditionally prescribed for primary psychiatric conditions, but I think over time the uses have extended a little bit. Think Olanzapine, for example, can be used potentially for depression. And certainly, in the age group and the cohort that I care for, behavioural and psychological disturbances and dementia. And you'd probably want to be evaluating the need for that. Are there other alternatives? For example, if you're using it for depression or together with sleep, for example, are there other alternatives that you could consider, like the more sort of sedative type antidepressant, like Mirtazapine, for example?

Sure. So, I guess being cautious to start in the first place and also vigilant each time you're represcribing about whether they still need it. Not surprisingly the benzos make the list. How do you see the use of benzos in older people?

Yeah. I think problematic and challenging one. In the older person, the most common use for benzos would be insomnia. We know that insomnia is a big problem in the older age group. Particularly the concern here and what's been highlighted, you'll see a representation of more of the medium acting and long-acting benzodiazepines. I touched on earlier before that there are changes to the physiology and therefore the pharmacokinetics. And that probably results in generally a longer duration of action of the benzos. And so, that results in more persistent sedative effects and that's probably where the risk of harms.

And who am I to mention benzodiazepines without going straight onto opioids? Opioids, of course, we should all be aware, have their problems, but tell us about those in older people specifically.

Yeah. So, again, much like the insomnia issue, chronic pain is something that creeps up quite a bit. The wear and tear of joints and osteoarthritis results in chronic pain and really debilitating pain. Perception of pain is, as we know, quite subjective. And while there are risk with the medications, the impact on someone's life is quite significant and often can be underappreciated. And so, there's often this tension to try and do something at least with pharmacotherapy. In this list that's published by Dr. Wang and her group, one of the examples of using alternatives when treating pain is actually things like physical therapy, physiotherapy, and opioids with lower toxicity, like oxycodone and buprenorphine, compared to say hydromorphone and pethidine.

And then getting back to looking at the patient in front of you, I guess the harm benefit pendulum perhaps swings again once you enter palliative care phase. And the person in fact has a fairly low quality of life and limited lifespan for the opioids.

Yes, that's right. And so, again, the risk-benefit ratio changes depending on the stage of life. That's why these lists are there as a guide and as a tool to be aware of, but it doesn't necessarily mean that any of these medications on that list are completely inappropriate and should not be prescribed.

Yeah. The NSAIDs [non-steroidal anti-inflammatory drugs]. When I was training in medicine, there were a lot of people on NSAIDs. And I remember the non-steroidals, the newer classes came in about 10 years into my career and suddenly everyone who was older was switching to those, things like meloxicam. But even that, of course, has its problems. So, where do you see the use of non-steroidals?

So, non-steroidals, in general, I think short-term use. The risks are certainly a lot lower than if you were to use it long-term. The changes with NSAIDs these days is that we're using it for chronic pain conditions. There are COX-2 inhibitors now that have a lower side effect burden. That's not to say that there's no space for NSAIDs either in short-term practise. One of the conditions that often have this to and fro about in my mind is gout, for example, which we know responds really well to NSAIDs. The flip side, using something like prednisolone is not without its risks either. It's got a whole host of other associated complications. And so, it's just that evaluation of what the patient's condition is.

Yeah. I agree. Gout's a fine clinical example. Just a couple more classes. The tricyclic antidepressants; so, I gather the SSRIs [selective serotonin reuptake inhibitors] are really much preferred in older people compared to doxepin and dothiepin (dosulepin).

Yeah, that's correct. In general, tricyclic antidepressants have multiple sites of target, so they not only affect the serotonin pathways, but can also have anticholinergic effects. And so, they are associated with higher risks of cognitive impairment, confusion, and also urinary incontinence [or retention], for example. And so, particularly, I think tricyclics are a good one to talk about, because at the moment there's so many other alternatives for antidepressants. It's one of those drug classes where you do sometimes think about its space currently. And if multiple alternatives exist, it probably should spark some thinking if you see someone being prescribed a tricyclic, whether an alternative is probably a better option.

Yeah. And then the last one I thought we'd mentioned, the sulfonylureas, which I must say I have been prescribing less and less over the last 5 to 10 years, just because better alternatives have come up, but in older people they have particular problems?

Yeah. So, sulfonylureas were probably second line a few iterations ago with your type 2 diabetes treatment algorithms. These days they've probably been replaced by SGLT2 inhibitors, for example. So, again, one of those situations where there are alternatives and probably better alternatives as well in this case. The risk with sulfonylureas is really that they can precipitate hypoglycaemia. And I'd argue that in the older person and management of type 2 diabetes, it's the risk of hypoglycaemia, rather than necessarily the hyperglycaemia, that probably causes more harm. And that's what the risk is there.

Yeah. That's right. And certainly, there've been calls to not chase down that HbA1c as aggressively as time goes by, and the person becomes more prone to hypos. And not only hypos, but also hypos they don't know about. Alex Choo, that's been a great walk through the PIMs list. What's your take-home message for prescribers as to how they might use this PIMs list once they look it up?

Firstly, I think have a look into it and see if there's anything that you would commonly prescribe. Think about it as a way to spark some thinking about reconsidering it in the other [older] people that you prescribe [for]. Are there any on the list that you've used more often than others? It might be a good starting point to then have a look at the evidence behind it. Are there alternatives, for example? The other practical thing that I could probably think about is to have it on the wall within the wards, for example. It's a good marketer, just have a look as a primer really. And I think probably thirdly is use it as an aid when you're evaluating someone's long medication list. And use it as a marker for reevaluating that for the individual person that you're seeing there.

Wonderful. I now wish it had a little photo of you, Dr Alex Choo, next to the list, so when people pin it up on the wall, there you are. Thank you very much for the article. Thanks for coming along and helping explain it.

Thanks, Justin.

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My guest's views are their own and don't represent Australian Prescriber. And my views are certainly all mine.