Table 1:

Summary of effects and recommendations for management of specific PIMs (Adapted with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Guideline Older Adult Oncology V2.2015. ©2017 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines® and illustrations herein may not be reproduced in any form for any purpose without the express written permission of NCCN. To view the most recent and complete version of the NCCN Guidelines, go online to NCCN.org [13])

Therapeutic class/medication	Negative effects	Condition the drug may adversely affect	Recommendation
First-generation antihistamines: diphenhydramine	Highly anticholinergic; increased risk of confusion, dry mouth, constipation, and other anticholinergic toxicities. Clearance reduced with advanced age.	Delirium Cognitive impairment Urinary retention	Use only for supportive care when convincing benefit exists, and use the lowest dose possible Appropriate for acute treatment of severe allergic reactions For pruritus, use second generation antihistamines
Benzodiazepines: lorazepam	Older adults have increased sensitivity to benzodiazepines and slower metabolism of benzodiazepines Can increase the risk of falls, cognitive impairment, and motor vehicle accidents	Falls Fractures Cognitive impairment Delirium	Reduce dose and/or lengthen the dosing interval when using for supportive care during chemotherapy administration For nausea, consider alternative antiemetics (for example, serotonin antagonists or aprepitant)
Corticosteroids (oral): dexamethasone	Can result in weight gain, muscle weakness, agitation, hyperglycemia, Cushing syndrome. Increases risk of gastrointestinal bleeding, fractures, infections, and thromboembolism.	Delirium Diabetes Osteoporosis Insomnia	When used for supportive care, carefully consider the dose and duration of therapy. Use the lowest possible dose ideally for shortterm therapy (1–3 weeks) For nausea, consider alternative antiemetics (for example, serotonin antagonists or aprepitant)
Histamine-2 receptor blockers: Famotidine ranitidine cimetidine	Can induce or worsen delirium in older adults	Delirium Cognitive impairment Dementia	Avoid in patients at risk for delirium
Antiemetic, prokinetic: metoclopramide	May cause extrapyramidal effects; risk greater in frail older adults	Parkinson’s disease	Avoid, unless use for patients with gastroparesis If benefit outweighs risk, use the lowest dose possible, and avoid exceeding 5 mg For nausea, consider alternative antiemetics (for example, serotonin antagonists or aprepitant)
Antipsychotics: olanzapine	Olanzapine has high anticholinergic effects. Increases the risk of cerebrovascular accident. Increased mortality risk in patients with dementia. Can cause hyperglycemia. Increases the risk of falls and fractures, especially in patients with baseline high risk. Concern for QT prolongation, especially in combination with serotonin antagonists, antidepressants, and in patients with underlying cardiac diseases.	Dementia (black box FDA warning for increased mortality risk) Falls Fractures	May be appropriate for short duration treatment of refractory chemotherapy-induced nausea and vomiting If using an antipsychotic, attempt to reduce, taper, or stop other antipsychotics and/or drugs acting on the central nervous system that can worsen the risk of falls or cognitive decline With concern for QT prolongation, start at the lowest dose with slow uptitration. Consider baseline ECG before initiation of therapy. For nausea, could consider other antiemetics (serotonin antagonists or aprepitant for example) if risk outweighs the benefit of using an antipsychotic. Monitor for extrapyramidal symptoms; tools such as the AIMS are useful.

Abbreviations: PIMs = potentially inappropriate medications, NCCN = National Comprehensive Cancer Network, FDA = Food and Drug Administration, ECG = Electrocardiography, AIMS = Abnormal Involuntary Movements Scale

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