Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Pharmacol. Jun 9, 2015; 4(2): 193-209
Published online Jun 9, 2015. doi: 10.5497/wjp.v4.i2.193
Appropriate prescribing in the elderly: Current perspectives
Amanda Hanora Lavan, John O’Grady, Paul Francis Gallagher
Amanda Hanora Lavan, John O’Grady, Paul Francis Gallagher, Department of Geriatric Medicine, Cork University Hospital, Cork, Ireland
Author contributions: All the authors contributed to this work.
Conflict-of-interest: None.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Dr. Paul Francis Gallagher, PhD, FRCPI, Consultant Physician, Department of Geriatric Medicine, Cork University Hospital, Cork, Wilton, Co., Cork, Ireland.
Telephone: +353-21-4921302 Fax: +353-21-4922829
Received: July 27, 2014
Peer-review started: July 28, 2014
First decision: September 16, 2014
Revised: March 20, 2015
Accepted: May 8, 2015
Article in press: May 11, 2015
Published online: June 9, 2015

Advances in medical therapeutics have undoubtedly contributed to health gains and increases in life expectancy over the last century. However, there is growing evidence to suggest that therapeutic decisions in older patients are frequently suboptimal or potentially inappropriate and often result in negative outcomes such as adverse drug events, hospitalisation and increased healthcare resource utilisation. Several factors influence the appropriateness of medication selection in older patients including age-related changes in pharmacokinetics and pharmacodynamics, high numbers of concurrent medications, functional status and burden of co-morbid illness. With ever-increasing therapeutic options, escalating proportions of older patients worldwide, and varying degrees of prescriber education in geriatric pharmacotherapy, strategies to assist physicians in choosing appropriate pharmacotherapy for older patients may be helpful. In this paper, we describe important age-related pharmacological changes as well as the principal domains of prescribing appropriateness in older people. We highlight common examples of drug-drug and drug-disease interactions in older people. We present a clinical case in which the appropriateness of prescription medications is reviewed and corrective strategies suggested. We also discuss various approaches to optimising prescribing appropriateness in this population including the use of explicit and implicit prescribing appropriateness criteria, comprehensive geriatric assessment, clinical pharmacist review, prescriber education and computerized decision support tools.

Keywords: Elderly, Inappropriate prescribing, Polypharmacy, Beers criteria, Screening Tool of Older Person’s potentially inappropriate Prescriptions/Screening Tool to Alert to Right Treatment, Adverse drug reactions

Core tip: In this paper we discuss the challenges and complexities of prescribing for older people. We describe the important age-related changes in pharmacokinetics and pharmacodynamics that influence prescribing decisions and we highlight commonly encountered examples of drug-drug and drug-disease interactions. We present a detailed analysis of a complex clinical case in which several instances of potentially inappropriate prescribing exist and we suggest corrective actions. We explore a range of strategies aimed at optimizing prescribing appropriateness for older people including prescribing criteria, comprehensive geriatric assessment, clinical pharmacy interventions and computerized decision supports.