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Drugs to avoid Elderly

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Version Jan 2023

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Class	Drug	Prescribing Concern
first generation (sedating) antihistamines	diphenhydramine chlorpheniramine promethazine cyproheptadine clemastine hydroxyzine doxylamine (and others)	sedating and strongly anticholinergic; promote delirium, falls, urinary retention, dry mouth, constipation; use of diphenhydramine may be appropriate for acute treatment of severe allergic reactions
antispasmodic	dicyclomine hyocyamine propantheline oxybutynin (immediate release) scopolamine belladonna alkaloids clinidinium	sedating and strong anticholinergic properties; promote delirium, falls, urinary retention, dry mouth, constipation; use of hyoscyamine, scopolamine, and belladonna alkaloids to dry secretions in palliative medical care may be appropriate
Tricyclic antidepressants	amitriptylinebr doxepin imipramine nortriptyline (and others)	avoid in the elderly; sedating and strong anticholinergic properties promote delirium, falls, urinary retention, constipation, and orthostatic hypotension
Anti-cholinergic antiparkinson agent	benztropine trihexyphenidyl	avoid due to sedation, anti-cholinergic properties; not recommended for prevention of antipyramidal side effects from antipsychotic medications and better medications available for Parkinson
muscle relaxants	cyclobenzaprine methocarbamol carisoprodol metaxalone (and others)	avoid in the elderly due to sedation and anti-cholinergic properties; questionable effectiveness in tolerable doses, and promotes delirium, sedation, and falls
benzodiazepines	alprazolam lorazepam diazepam chlordiazepoxide chlorazepate (and others)	avoid in the elderly for control of delirium, sleep disorders, or agitation; elders are more sensitive to the delirium promoting and fall promoting side effects of these medications; may be appropriate for some conditions such as alcohol withdrawal, or benzodiazepine withdrawal
Non-benzodiazepine hypnotics	Zolpidem (and others)	Avoid due to sedation; promotes delirium, falls, and fractures in the elderly like the benzodiazepines do
Antipsychotic agents (atypical and conventional)	Haloperidol Thioridazine Chlorpromazine Olanzapine Quetiapine Risperidone (and others)	Because of increased risk of stroke and death, avoid for behavioral problems in the elderly unless non-pharmacologic measures have failed and the patient is a risk to themselves or others
Alpha 1 blockers	doxazosin prazosin terazosin	avoid use as antihypertensive due to high risk of orthostatic hypotension and better agents are available
CNS acting alpha agonist hypotensive agents	clonidine methyldopa	associated with bradycardia, orthostatic hypotension, sedation, delirium, depression; avoid methyldopa and clonidine should not be first-line for hypertension
cardiac glycoside	Digoxin over 0.125mg daily	Higher doses used in heart failure increases risk of toxicity without adding benefit; reduced renal function may increase risk of toxicity
antiarrhythmic drugs	amiodarone flecainide procainamide sotalol quinidine disopyramide (and others)	risk - benefit analysis favours rate control over rhythm control in most older adults; amiodarone associated with thyroid problems, pulmonary problems and QT prolongation; disopyramide may have a negative inotropic effect and may precipitate heart failure, it is also anticholinergic
Non-COX selective NSAIDS	Aspirin > 325mg/day Ibuprofen Naproxen Piroxicam Indomethacin (and others)	Avoid chronic use unless other measures fail and can use PPI with it; risk of GI bleeding, reduced renal function, exacerbation of heart failure
Long acting sulfonylureas	Chlorpropamide glyburide	Avoid in the elderly because of increased risk of prolonged hypoglycemia
a urinary anti-infective agent	nitrofurantoin	contraindicated in those with creatinine clearances below 60ml/min because of failure to reach therapeutic concentrations in the urine and increased risk of nerve and liver toxicity

PLEASE NOTE LEGAL ADVICE: The contents are under continuing development and improvements and may contain errors of omission or fact. The official launch will be at the end of 2018. Feedback vital and always welcome at drokane at gmail.com. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice. It is only for educational purposes. Please adhere to your local protocols. If you are unwell please seek healthcare advice from your doctor. This does not replace senior or specialist advice. If you do not accept this then please do not use the website. If you need medical advice, please consult a doctor or other appropriate medical professional. If you are a medical professional and you need advice then speak to your senior or colleagues.

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