Defining inappropriate practices in prescribing for elderly people

Table 2: Inappropriate practices in prescribing psychotropic drugs for elderly people
Practice	Mean clinical significance rating	Risk to patient	Alternative therapy	% of panel members who agreed with alternative
Long-term prescription of long-half-life benzodiazepine to treat insomnia	3.72	May cause falls, fractures, confusion, dependence and withdrawal	Nondrug therapy or short-half-life benzodiazepine	97
Prescription of tricyclic antidepressant to treat depression for patients with a history of glaucoma, BPH* or heart block	3.63	May aggravate glaucoma, cause urinary retention in patients with BPH or worsen heart block	SSRI	94
Long-term prescription of barbiturate to treat insomnia	3.59	May cause falls, fractures, confusion, dependence and withdrawal	Nondrug therapy or low dosage of short-half-life benzodiazepine	94
Prescription of SSRI† for patients already receiving an MAO‡ inhibitor to treat depression	3.56	May extend adverse effects of SSRI	Avoid combining; ensure a wash-out period of at least 7 days if switching from an MAO inhibitor to an SSRI	81
Long-term prescription of long-half-life benzodiazepine to treat anxiety	3.55	May cause falls, fractures, confusion, dependence and withdrawal	Nondrug therapy or short-half-life benzodiazepine	88
Long-term prescription of long-half-life benzodiazepine to treat agitation in dementia	3.52	May cause falls, fractures, confusion, dependence and withdrawal	Loxapine or haloperidol Short-half-life benzodiazepine	88 56
Prescription of tricyclic antidepressant to treat depression for patients with a history of postural hypotension	3.26	May worsen postural hypotension and cause falls	SSRI, with monitoring of blood pressure	94
Long-term prescription of triazolam to treat insomnia	3.23	May cause cognitive and behavioural abnormalities	Nondrug therapy or low dosage of short-half-life benzodiazepine	91
Prescription of chlorpromazine to treat psychosis for patients with a history of postural hypotension	3.22	May worsen postural hypotension and cause falls	High-potency neuroleptic such as haloperidol, with blood-pressure monitoring	94
Prescription of nylidrin, niacin or pentoxifylline to treat dementia	3.16	Ineffective treatment for dementia and moderate risk of side effects	Discontinue	81
Prescription of tricyclic antidepressant with active metabolites (e.g., imipramine or amitriptyline) to treat depression	3.12	May cause anticholinergic side effects	Tricyclic antidepressant without active metabolites or SSRI	91
Prescription of methylphenidate to treat depression	3.11	May cause agitation, stimulation of central nervous system and seizures	SSRI or short-half-life tricyclic antidepressant without active metabolites	81
*BPH = benign prostatic hyperplasia. †SSRI = selective serotonin reuptake inhibitor. ‡MAO = monamine oxidase.

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