Merck Manual

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Some Drugs Particularly Likely to Cause Problems in Older People

Some Drugs Particularly Likely to Cause Problems in Older People

Drug

Use

Problem

Alpha adrenergic blockers (such as doxazosin, prazosin, and terazosin)

These drugs should not be used to treat high blood pressure.

Use of these drugs increases the risk of orthostatic hypotension (sudden decrease in blood pressure when a person stands up).

These drugs can make it hard for women to hold their urine.

Alpha-adrenergic agonists (such as clonidine, guanabenz, guanfacine, methyldopa, and reserpine)

These drugs should usually not be used to treat high blood pressure unless other drugs have been ineffective.

Use of these drugs may cause orthostatic hypotension and an abnormally slow heart rate and may slow brain function.

Methyldopa and reserpine may contribute to depression.

Reserpine can contribute to erectile dysfunction (impotence).

Analgesics (some, such as meperidine and pentazocine)

To relieve pain

Meperidine, an opioid, often causes confusion and can sometimes cause seizures. Like all opioids, it may cause constipation, retention of urine, drowsiness, and confusion. When taken by mouth, meperidine is not very effective.

Pentazocine can cause confusion and hallucinations.

Amiodarone

Amiodarone usually should not be a first choice to treat atrial fibrillation (an abnormal heart rhythm) except in special circumstances.

Amiodarone may increase the risk of thyroid disorders, lung disorders, and long QT syndrome (which itself can contribute to serious abnormal heart rhythms).

Antidepressants (older ones, such as amitriptyline, amoxapine, clomipramine, desipramine, doxepin at high doses, imipramine, nortriptyline, paroxetine, protriptyline, and trimipramine)

To treat depression

These older antidepressants have strong anticholinergic effects.* They also increase risk of falls, constipation, dry mouth, excessive drowsiness, and abnormal heart rhythms.

Antihistamines (older ones) that have anticholinergic effects* (such as brompheniramine, carbinoxamine, chlorpheniramine, clemastine, cyproheptadine, dexbrompheniramine, dexchlorpheniramine, dimenhydrinate, diphenhydramine, doxylamine, hydroxyzine, meclizine, promethazine, and triprolidine)

To relieve allergy or cold symptoms, or to aid sleep

Many nonprescription (over-the-counter) and prescription antihistamines have strong anticholinergic effects.*

These antihistamines can cause drowsiness and confusion, and when used regularly, they can also cause constipation, dry mouth, and difficulty urinating.

Antihistamines are commonly included in cough and cold preparations and in pain relievers for use at bedtime.

When using these drugs as sleep aids, people may also develop a tolerance to their effects.

Antiparkinson drugs (benztropine and trihexyphenidyl)

More effective drugs are available.

Benztropine and trihexyphenidyl have strong anticholinergic effects.*

Antipsychotic drugs (such as chlorpromazine, haloperidol, thiothixene, risperidone, olanzapine, quetiapine, and aripiprazole) and metoclopramide

To treat loss of contact with reality (psychosis) or, somewhat controversially, to treat behavioral disturbances in people with dementia

Sometimes to treat nausea (generally chlorpromazine or metoclopramide only)

Antipsychotic drugs can cause drowsiness, movement disorders (that resemble Parkinson disease), and uncontrollable facial twitches. Some of these drugs also have anticholinergic effects.* Some other side effects are potentially fatal. Antipsychotic drugs should be used only when a psychotic disorder is present and require that a doctor closely monitors the person.

When given to people with dementia, antipsychotic drugs increase the risk of stroke and death.

Metoclopramide can cause drowsiness and movement disorders (that resemble Parkinson disease). In general, metoclopramide should not be used longer than 3 months.

Barbiturates (such as amobarbital, butabarbital, butalbital, mephobarbital, pentobarbital, phenobarbital, and secobarbital)

To calm, to relieve anxiety, or to aid sleep

People may become dependent on these drugs, the drugs may become ineffective in helping people sleep, and people can overdose by taking even low doses of these drugs.

Benzodiazepines (such as alprazolam, chlordiazepoxide, chlordiazepoxide with amitriptyline, clidinium with chlordiazepoxide, clonazepam, clorazepate, diazepam, estazolam, flurazepam, lorazepam, oxazepam, quazepam, temazepam, and triazolam)

To calm, to relieve anxiety, or to aid sleep

These drugs can cause drowsiness and loss of balance when a person is walking. The risk of falls and fractures is increased as is the risk of motor vehicle crashes.

The effects of some of these drugs last a very long time (often more than several days) in older people.

Certain hypnotic drugs (such as eszopiclone, zaleplon, and zolpidem)

To aid sleep

The side effects of these drugs are similar to those of benzodiazepines. It is best to use these drugs only for short periods of time.

Desmopressin

To help control nighttime urination

Desmopressin has a high risk of causing hyponatremia (low level of sodium in the blood). Desmopressin should not be used for treatment of excessive urination at night because there are safer alternatives.

To treat heart failure or abnormal heart rhythms(arrhythmias)

As people age, the kidneys are less able to remove digoxin from the body. Large doses of the drug can more easily reach harmful (toxic) levels. Side effects may include loss of appetite, nausea, and confusion.

Dipyridamole (immediate-release)

To reduce the risk of blood clots or to improve blood flow

Dipyridamole frequently causes low blood pressure when standing up in older people. It can also increase the risk of bleeding when it is taken with other drugs that make blood less likely to clot, such as aspirin or the anticoagulant warfarin.

Drugs that reduce or stop muscle spasms in the digestive tract (antispasmodic drugs, such as atropine [except for eye drops], belladonna alkaloids, clidinium/chlordiazepoxide, dicyclomine, hyoscyamine, propantheline, and scopolamine)

To relieve abdominal cramps and pain

These drugs have strong anticholinergic effects* and frequently cause side effects in older people. Their usefulness—especially at the low doses tolerated by older people—is questionable.

Ergot mesylate and isoxsuprine

To dilate blood vessels

These drugs are not effective for people of any age.

Estrogens with or without progestins

To treat osteoporosis and help relieve menopausal symptoms, such as hot flashes, night sweats, and vaginal dryness.

Estrogens increase the risk of breast and uterine (endometrial) cancer and may increase the risk of stroke, heart attack, and dementia in older women. Vaginal estrogen products seem to be safe and effective to treat painful intercourse, urinary tract infections, and other vaginal symptoms.

Histamine-2 (H2) blockers (such as cimetidine, famotidine, nizatidine, and ranitidine)

To treat heartburn (acid reflux), indigestion, or ulcers

Typical doses of cimetidine may have drug interactions and cause side effects, especially confusion.

To some extent, high doses of famotidine, nizatidine, and ranitidine may cause side effects, especially confusion.

These drugs may worsen memory and thinking problems in people with cognitive impairment.

Insulin given by a sliding scale

To treat diabetes

When given this way, insulin can cause dangerously low blood sugar and is not more effective at controlling diabetes than fixed doses of insulin given with meals.

Mineral oil

To treat constipation

When taken by mouth, mineral oil may be accidentally inhaled into the lungs, which can cause lung damage.

Male sex hormones (such as testosterone and methyltestosterone)

For low testosterone levels (called male hypogonadism)

These hormones should be used only if a man's testosterone levels are low and causing significant symptoms. Use of these hormones may contribute to heart disorders and worsen prostate disorders.

Megestrol

To increase appetite and help regain lost weight

Megestrol can cause blood clots and possibly increase the risk of death and is typically not very effective in helping people gain weight.

Muscle relaxants (such as carisoprodol, chlorzoxazone, cyclobenzaprine, metaxalone, methocarbamol, and orphenadrine)

To relieve muscle spasms

Most muscle relaxants have anticholinergic effects.* They also cause drowsiness and weakness and thus increase the risk of falls and fractures. The usefulness of all muscle relaxants at the low doses necessary to avoid side effects in older people is questionable. The risks likely outweigh the benefits.

Nifedipine (immediate release)

Nifedipine, if taken in immediate-release capsule form, may decrease blood pressure too much, sometimes causing symptoms similar to those of a heart attack (for example, chest pressure and chest pain).

With long-term use, nitrofurantoin can cause side effects (such as lung damage). When taken to treat a bladder infection, it may not be effective if kidney function is reduced.

NSAIDs (such as aspirin, diclofenac, diflunisal, etodolac, fenoprofen,ibuprofen, indomethacin, ketoprofen, meclofenamate, mefenamic acid, meloxicam, nabumetone, naproxen, oxaprozin, piroxicam, sulindac, and tolmetin)

COX-2 inhibitors (celecoxib)

To relieve pain and inflammation

Long-term use of NSAIDs may cause peptic ulcer disease, or bleeding from the stomach or intestine unless another drug is also given to protect the stomach. NSAIDs and celecoxib can also worsen kidney function and symptoms of heart failure.

Of all NSAIDs, indomethacin has the most side effects. It can also cause confusion or dizziness.

Proton-pump inhibitors

To reduce stomach acid production and treat acid reflux and ulcers

Long-term use of proton-pump inhibitors increases the risk of severe diarrhea caused by Clostridium difficile infection, bone loss and fractures, and vitamin B12 deficiency.

Sulfonylurea drugs (long-acting ones, such as chlorpropamide and glyburide)

To treat diabetes

The effects of chlorpropamide and glyburide last a long time. In older people, these drugs can cause low blood sugar levels (hypoglycemia) for many hours. Chlorpropamide can also cause the kidneys to retain too much water, lowering the sodium level in the blood.

Ticlopidine

To help prevent strokes

Ticlopidine can cause serious blood disorders. Safer and more effective drugs are available.

*Anticholinergic effects include confusion, blurred vision, constipation, dry mouth, light-headedness and loss of balance, and difficulty starting to urinate.

Dipyridamole is also available in an extended-release formulation with aspirin. This product, which is used to prevent strokes in people who have had a stroke, is not included in this list.

COX-2 inhibitors = coxibs; NSAIDs = nonsteroidal anti-inflammatory drugs.