Geriatrics

 Summary
o Geriatrics is the branch of medicine concerned with the health and care of older adults, defined by
the American Geriatrics Society (AGS) as those aged 65 years or older.
o Normal aging changes (e.g., stiffening of arteries, osteoporosis, decline in cognitive function)
predispose older adults to multiple chronic conditions, disability, adverse pharmacological
reactions, and decreased quality of life.
o A comprehensive geriatric assessment, usually performed by a primary care physician, can help
identify older adults' health care needs and develop management plans that improve their well-
being.
 This assessment involves
 Evaluating functional status
 Screening for geriatric syndromes (e.g., frailty, cognitive impairment, and malnutrition)
 Providing appropriate preventive care
 Assessing medications, and
 Establishing treatment goals and advance directives.
o Polypharmacy is common in older adults, and evaluating its effects becomes more important as they
age.
 Conservative prescribing practices (assessing appropriateness before starting new medications,
performing regular medication reviews, and stopping medications that are no longer indicated)
can help reduce pill burden and consequences of polypharmacy (e.g., adverse events due
to drug interactions).
o Older adults with significant impairment or complex care needs may require referral to a
geriatrician.
o Depending on their current functional status and care needs, the appropriate care setting for an
older adult may be a private home, a short-term post-acute care facility (an acute inpatient
rehabilitation facility or a skilled nursing facility), or a long-term care facility (an assisted living
facility, nursing home, or long-term acute care hospital).
 Geriatric assessment
o General principles
 Usually a multidisciplinary assessment led by a primary care physician or geriatrician
 Includes typical elements of a clinical examination with additional emphasis on assessing
functional and cognitive abilities
 Explores social and environmental factors impacting a patient's functional status
o Geriatric assessments allow for the early identification and management of conditions that can
impact functional status and quality of life.
 Therefore, they are usually inappropriate for patients with end-stage disease (e.g.,
advanced dementia, terminal cancer) or complete functional dependence.
o Indications
 At the start of any hospital admission for older adults
 Consider outpatient geriatric assessment if patients present with any of the following:
 Multimorbidity
 Functional impairment
 Geriatric syndromes
 Polypharmacy
 Transitions in care settings (e.g., entering a nursing home)
 Concerns about social support and/or safety
o Components
 Perform a functional status assessment.
  Screen for geriatric syndromes.
 Assess social factors.
 Provide appropriate preventive care.
 Establish a care plan according to the patient's needs and preferences.
 Discuss the importance of establishing timely advance directives regarding:
 Preferences for future medical care and interventions
 A surrogate decision-maker
o Functional status assessment
 Functional status assessments are used to evaluate an individual's ability to perform tasks of
daily living in order to determine their care needs.
 E.g., the most suitable living arrangements, the need for a permanent or temporary
caregiver
 Basic activities of daily living (ADLs)
 Definition: six basic self-care tasks performed daily (Other tasks such as grooming and
ambulating may also be considered ADLs).
 Bathing
 Dressing
 Toileting
 Transferring (getting in or out of bed or standing up from a chair)
 Continence
 Eating
 Example screening tools
 Katz index of independence in activities of daily living
 Barthel index
 Standard physical examination: Look for features suggesting difficulties with ADLs.
 Grooming and hygiene
 E.g., uncut toenails may suggest impaired grooming ability.
 Signs of injuries suggestive of unsteadiness/falls
 Ability to dress/undress (e.g., button shirt, take off shoes)
 Ability to move from a chair to the examination table
 Instrumental activities of daily living (IADLs)
 Definition: eight standard activities required to live independently
 Grocery shopping
 Doing laundry
 Using the telephone
 Preparing meals
 Housekeeping
 Managing:
 Finances
 Transportation
 Medications
 Example screening tool: Lawton IADL scale
o Screening for geriatric sydromes
 Geriatric syndromes
 A group of complex health conditions that may result from multiple risk factors and
organ system impairments
 Makes individuals vulnerable to additional physical stressors or insults
 Risk factors increase with age and may include:
 Functional impairment (i.e., in ADLs and/or IADLs)
 Impaired mobility
 Cognitive impairment
 Note that cognitive impairment is also considered a geriatric syndrome itself.
 Screening for geriatric syndromes
Syndrome Indications for screening Example screening methods
 Consider in all older adults.
 Especially important in:  Canadian Study of Health and
 Older adults at increased risk (E.g., multiple Aging (CSHA) clinical frailty
comorbidities, adversely affected by social scale [17]
Frailty
determinants of health)  FRAIL questionnaire
 Hospitalized older adults, to help establish  Edmonton frail scale
prognosis and care goals

 Annually or if presenting after a fall  CDC STEADI algorithm for falls

Falls

 Mini-Cog
 If impairment is suspected
 Montreal Cognitive
Cognitive  The USPSTF states that there is insufficient
Assessment (MoCA)
impairment evidence to recommend screening asymptomatic
 Mini-Mental State
and dementia older adults.
Examination (MMSE)

 Patient Health Questionnaire-

2 (PHQ-2) or Patient Health
Depression in  Annually (if systems for follow-up are in place) Questionnaire-9 (PHQ-9)
older adults  Geriatric Depression Scale-
15 (GDS-15)

 Monitor weight and/or ask the

patient if they have lost weight in
Malnutrition in  Consider annually. the last 6–12 months.
older adults  Alternative: Mini nutritional
assessment (MNA)

 Patients with any of the following :  First-line: audiometry

 Reported hearing loss  Alternatives: whispered voice
 Cognitive or mood conditions test at 2 ft (60 cm) or asking the
Hearing loss
patient if they feel they
The USPSTF states that there is insufficient evidence to have hearing loss
recommend screening asymptomatic adults > 50 years of age.
 Consider annually.

The USPSTF states that there is insufficient evidence to  Snellen chart

Vision loss recommend screening asymptomatic older adults, although the  Referral to ophthalmologist
American Academy of Ophthalmology recommends
a comprehensive eye examination at least every 1–2 years for all
adults > 65 years of age.
Screen for osteoporosis in women:
 Dual-energy x-ray
absorptiometry (DXA) of the
Osteoporosis  ≥ 65 years of age
femoral neck
 < 65 years of age at increased risk of osteoporosis

Ask the patient if they have

experienced urinary incontinence in the
past year; if the answer is yes, ask if this
Urinary  Annually has occurred on at least six separate days.
incontinence
 A (+) response to both questions
should prompt further evaluation.

Decubitus ulcers  No clear recommendation; identify risk factors (E.g., low  Norton scale
body weight, cognitive or physical impairment, conditions
 Screening for geriatric syndromes
Syndrome Indications for screening Example screening methods
that impact skin integrity and healing)  Braden scale

 Frailty assessment
 Frailty is a geriatric syndrome that encompasses variable impairments in multiple
domains (e.g., mobility, strength, cognition), increasing the risk of morbidity and
mortality.
 The definitions and measures of frailty are varied.
 Multiple geriatric syndromes → ↑ risk of frailty → ↑ risk of further geriatric syndromes → ↑ risk of
disability, institutionalization, and death.
 Indications
 Consider for all older adults.
 Outpatient screening is particularly important for patients at increased risk, e.g.:
 Current or former smokers
 Individuals negatively impacted by social determinants of health
 E.g., individuals who are single, experiencing social
isolation, and with a low socioeconomic status
 Patients with specific comorbidities
 Diabetes, COPD or respiratory
disease, stroke, dementia, multiple sclerosis, connective
tissue disease, osteoarthritis, or chronic fatigue syndrome
 Screen older adults on admission to hospital to help establish prognosis and care goals.
 Example screening tools
 CSHA clinical frailty scale
 FRAIL questionnaire
 Edmonton frail scale
 Management of frailty
 Refer for a multicomponent physical activity program that includes resistance and balance training.
 Address contributors, e.g., polypharmacy, weight loss, fatigue.
 Consider the need for social support.
 Falls in older adults
 The following guidance is based on the current CDC STEADI algorithm for falls.
 Screening
 Ask all older adults annually: Have you fallen in the past year? Ask how many falls have occurred and
whether the fall resulted in an injury.
 If yes: What were the circumstances of the fall(s)?
 If no, ask:
 Do you feel unsteady when standing or walking?
 Are you worried about falling?
 If yes to any question: at risk for falls; perform a fall risk assessment.
 If no to all questions: Recommend general fall prevention strategies.
o Fall risk assessment
 This should be performed for patients who screen positive for fall risk or who present after an acute
fall.
 Identify risk factors, including:
  Underlying medical conditions (e.g., depression, osteoporosis)
 Medications associated with increased fall risk,
e.g., benzodiazepines, antidepressants ( “Beers Criteria”)
 Environmental hazards at home (e.g., floor surface, inadequate lighting,
furniture location)
 Perform a physical examination, including:
 Postural vital signs (to identify orthostatic hypotension)
 Musculoskeletal tests to evaluate gait, strength, and balance, e.g.:
 Get up and go test
 Ask the patient to get up from a straight-backed
chair, walk 3 m (10 ft), turn around, walk back, and
sit down again.
 The result is abnormal if patients have qualitative
impairments (E.g., excessive slowness, abnormal
movements, staggering or stumbling) or the test
takes > 12 seconds.
 Performance-oriented mobility assessment (Tinetti test)
 Visual acuity testing
 Feet and footwear assessment
 Shoes should fit well, have low and unworn heels, and
have a high amount of surface contact area with the floor.
 Consider:
 A cognitive assessment [30]
 Laboratory studies, e.g.:
 CBC (to rule out anemia)
 BMP (to rule out electrolyte abnormalities)
 Serum vitamin B12 level
 Serum vitamin D level
 Fall prevention in older adults
 Falls are the leading cause of injury-related death in adults aged ≥ 65 years
 The aim of preventive measures is to maximize the patient's independence and safety in line with
their values and preferences.
 All patients
 Provide general education, e.g., on medication interaction risks, appropriate
footwear, home hazards (E.g., loose carpeting, clutter on the floor)
 Recommend regular exercise (including aerobic, balance, and strength training).
 Refer to a community exercise program or fall prevention
program if available.
 Ask about vitamin D intake (from diet, supplements, sunlight) and risk factors
for vitamin D deficiency; consider recommending a supplement.
 As indicated according to risk assessment
 Optimize the management of comorbidities, including medication adjustments.
 Minimize the number of medications that may contribute to falls ( “Beers
Criteria”).
 Refer to occupational therapy for a home hazard assessment and modification.
 Evidence of poor gait, strength, or balance: Refer for physical therapy.
 Consult additional specialists as required (e.g., ophthalmologist, podiatrist).
 For hospitalized patients, consider additional measures.
 Falls in older adults
 Leading cause of injury, morbidity, mortality
o Can result in trauma (eg, hip fracture), prolonged immobilization, prolonged length of stay at
Overview
hospital, increased institutional liability and functional decline.

 History of fall
 Sensory & cognitive disturbance
 Incontinence
Risk factors
 Chronic disease (eg, T2DM, arthritis, CVD)
 Medications (eg, neuroleptics, antidepressants, vasodilators)

Outpatient  Screening:
prevention o Musculoskeletal eg,
 "Get up & go" test
 Ask the patient to rise from a chair & walk briskly to the end of the room. Time
& patient difficulty in this test (eg, difficulty in rising from chair, impaired gait)
predict the risk of falling.
o Vision
 Age-related declines in proprioception affect balance, leaving patients with increased
reliance on visual input.
o As a result, diminished visual acuity can substantially elevate overall fall risk.
 In addition, age-related eye conditions (eg, macular degeneration, cataracts) can reduce dark
adaptation, increasing risk for falls in low-light conditions.
 Therefore, all patients who sustain a fall should have visual acuity screening with a
dilated eye examination and receive appropriate corrective eyewear or prevention
interventions (eg, surgical treatment of cataracts, nutritional supplementation for
macular degeneration).
o Hearing
o Bone density
 Osteoporosis screening and management (eg, optimization of bone density) have
demonstrated effectiveness in preventing secondary fall complications (eg, hip fracture)
 Screening measures should include a clinical risk factor assessment (eg, Fracture Risk
Assessment Tool [FRAX]) and bone density measurement (eg, dual-energy x-ray
absorptiometry).
 Treatment (eg, bisphosphonate therapy) is recommended when 10-year fracture risk
exceeds 2.5%

FRAX assessment tool

The FRAX risk calculator is an online assessment tool used to estimate the 10-year risk of fracture in
patients with osteopenia/osteoporosis. It is available at http://www.shef.ac.uk/FRAX/tool.jsp
The following variables are included in estimating fracture risk:
 Age
 Sex
 Weight
 Height
 Previous fracture history
 Smoking status
 Glucocorticoid use
 Rheumatoid arthritis history
 Secondary causes of osteoporosis
 Alcohol use
 Bone mineral density at the femoral neck

Orthostasis
o
 Medication & home safety review
 Correction of vitamin D deficiency (in select patients)
o Vitamin D supplementation is recommended to prevent falls only for individuals
 Who are known to have vitamin D insufficiency (<10 ng/mL) or
 Who have had previous fall
 Home safety assessment (typically performed by an occupational therapist)
  Supervised exercise program
o Has been shown to significantly reduce fall risk and should be recommended for all elderly patients
who are at high risk for falls (or who have sustained a fall previously).
o The program should include strength, balance (eg, Tai Chi), and cardiovascular components (eg,
walking).

Inpatient  Assess fall risk & customize strategies to patient's specific risk factors
prevention o Fall risk assessment
 Hospitals should have a fall prevention strategy that includes a standardized process to
screen for fall risk.
 In populations with a high pretest probability of falling (eg, geriatric population of
hospital), scoring tools that classify patient risk as "high" or "low" have low
clinical utility because most patients will be classified as high risk. The screening
process is more likely to show
 Low positive predictive value (PPV) for actual falls (ie, the likelihood of
falling in those with a positive/high-risk screening result). I.e the tool
rates most of patients as having a high risk for falling, but the actual fall
rate is much lower
 The low PPV of the screening tool reduces the tool's ability to
accurately identify patients who are at highest risk and most
likely to benefit from targeted fall risk mitigation interventions
(eg, sitter, 1:1 supervision).
 It may also contribute to alert fatigue (eg, staff are less likely to
pay attention to a high fall risk score because it is very common
and not accurate in predicting a fall).
 Low specificity (ie, percentage of patients who will not fall who are
classified as low risk), leading to a high false-positive rate
 Possible changes to better assess fall risk include incorporating a multifactorial,
qualitative risk assessment (rather than just quantitative "high/low" score) and adding
multidisciplinary (eg, nursing, medicine, pharmacy) input.
o Tailored (ie,customized) fall prevention approach
 Fall risk is multifactorial (eg, increased by diverse factors); therefore, prevention of falls
in hospital settings requires a tailored (eg, customized) approach.
 After performing a multidisciplinary and comprehensive fall risk assessment using
qualitative and quantitative approaches, staff (eg, nurses, physicians) should select fall
prevention interventions based on the patient's identified risk factors because optimal
fall prevention strategies vary widely depending on the risk factor.
 For example, a patient with a history of nighttime delirium may require a
dedicated sitter or increased staff supervision whereas a patient with lower
extremity weakness or gait disturbance may require orders for regular physical
therapy and a room with a low bed.
 In most inpatient settings, the approach of tailoring fall prevention strategies to the
patient's specific situation is superior to approaches that automatically allocate
interventions based on a quantitative fall risk score (which is likely to be high in most
patients at hospitals serving a primarily geriatric population)

 Optimize environment (eg, minimize furniture, lower the bed, place in direct view of nurses if high risk)
o Careful placement of furniture and proper selection of equipment (eg, low bed).
o Lights should be bright during the day and dimmed at night for patients with delirium because
increased lighting at night can alter the sleep-wake cycle and increase agitation
 Increasing direct supervision, which may include
o 1:1 patient supervision with a sitter
o Rooming the patient within direct line of sight of nurses (eg, in front of the nursing station with
open door)
 Perform frequent checks on high-risk patients (eg, every 15 minutes).
 Frequent supervised toileting for patients with incontinence (eg, hourly toileting)
o Patients with high fall risk should not be encouraged to use a bedside commode without
supervision.
 Avoid restraints (eg, wrist restraints) & overreliance on fall alert systems
o Call alarm systems are not effective in reducing fall complications, likely because
 Patients with more serious injuries are unable to access their devices (eg, loss of
consciousness, limb injury)
  Bed alarms are not associated with a reduced incidence of falls
 Evidence suggests alarms may be overly sensitive to patient movement and fail
to adequately signal impending fall risk (which can contribute to alert
fatigue [ie, alarms generate many false-positive signals, leading to staff
inattentiveness]). Moreover, after the alarm sounds, patients have typically
already fallen by the time staff arrive at bedside.

*Ask the patient to rise from a chair & walk briskly to the end of the room. Time & patient difficulty in this test predict the risk of
falling.

CVD = cardiovascular disease; T2DM = type 2 diabetes mellitus.

Neuropsychological assessment in older adults

 Cognitive assessment
 Indications
 Suspected mild cognitive impairment (MCI) or dementia
 Concerns may have been raised by the patient, family
members, or caregivers, or changes observed by the
provider.
 As part of a Medicare Annual Wellness Visit
 Example screening tests:
 Patient: Mini-Cog, MoCA, or MMSE
 Mini-Cog is usually preferred in primary care settings
 MoCA now requires clinicians to pay for training and
certification prior to use, and
 MMSE is copyrighted and may not be available in all
settings.
 The accuracy of all screening tests is higher
for dementia than for MCI.
 Carer: Informant questionnaire on cognitive decline in the elderly
 Management considerations:
 Consider a diagnosis of delirium (instead of or in addition to dementia),
especially in patients with acute or fluctuating symptoms.
 Early diagnosis of MCI is important, as interventions such as aerobic exercise
may help prevent progression to dementia
 For patients who drive and have a diagnosis of MCI or dementia, check state
laws to determine if:
 Patients are required to take an annual test to maintain
their driver's license.
 Physicians are mandated to report MCI diagnoses to the
Department of Motor Vehicles.
 Dementia affects 30% of adults aged > 85 years, but it is not part of the normal aging process (the
term “senile dementia” is a misnomer) and always requires management.
o Mood assessment
 Overview
 Clinically significant depressive symptoms affect 10–15% of older adults.
 Depression can present in atypical ways in older adults
(e.g., pseudodementia, apathy, weight loss).
 Ask the patient about sleep quality.
 Cognitive impairment, decreased functional status, and suicide are more
common in older adults with depression than younger adults with depression.
 Indication: Screen all patients annually.
 Example screening tests
 PHQ-2 (followed by PHQ-9 if score is ≥ 3) or PHQ-9
 GDS-15
o Assessment of social situation
 Evaluate for:
 Social support, e.g., by asking about:
 Who the patient lives with
 The frequency of visits from friends and/or family
 The number of close friends available for emotional support
 Availability of help in case of sickness or disability
 Financial difficulties, e.g., ability to pay for food, medication, and rent
 Risk factors for older adult abuse, e.g. :
 Isolation and lack of social support
 Social isolation, both objective and perceived, increases the risk of mortality in
older adults.
 Functional impairment
 Decreased physical health
 Lower income
 Living in a shared space with many household members
 Contact Adult Protective Services if older adult abuse is suspected.
 If concerns are identified:
 Refer to social work or contact Social Services.
 For patients experiencing loneliness or social isolation, consider:
 Addressing existing sensory impairments that might contribute to isolation, e.g., with hearing
aids and vision aids
 Treating underlying depression
 Depression can both lead to and result from social isolation.
 Referral to community support groups or encouraging group activities (e.g., lunch clubs, dance class)
o Opportunities for preventive care
 Chronic conditions
 Take into consideration life expectancy and goals of care when forming management
plans.
 In older adults with diabetes, for example, tight glycemic control to minimize complications may be
appropriate for a fit and healthy patient, but for a frail patient with limited life expectancy, more
relaxed glycemic targets to avoid adverse effects such as hypoglycemia may be more appropriate.
 Ensure patients understand their diagnosis and how to manage their condition
 Immunizations:
 Determine if vaccinations are up-to-date according to the adult immunization schedule,
including
 Tdap vaccination
 60% of tetanus cases are adults aged over 60 years.
 Pneumococcal vaccination
 Herpes zoster vaccination
 Influenza vaccination
 Lifestyle factors:
 If remaining life expectancy is ≥ 5 years, ask about these factors regularly and provide
necessary counseling.
 Every visit:
 Smoking
 Annually
 Sexual function
 Physical activity

Unhealthy alcohol use; consider using a specialized screening tool, e.g., Short

Michigan alcoholism screening test-geriatric version.
 Driving assessment:
 Assess older adults with risk factors, e.g. :
 Conditions, medications, or symptoms that could impact driving
 E.g., recent events such as syncope, stroke, or seizure
 Chronic conditions such as dementia, cardiovascular disease, or OSA
 Medications such as anticholinergics, opioids, or sedative-hypnotics
 Symptoms such as dizziness or fatigue
 New functional impairment
 Concerns from caregiver(s)
o Principles of pharmacotherapy for older adults

Medication prescribing in elderly patients

 Increased susceptibility to ADEs
Major  Increased polypharmacy risk due to multiple chronic conditions
considerations  Susceptibility to harms from overtreatment & undertreatment

 Limit the number of prescribers

o Having a high number of prescribers is associated with an increased risk for adverse drug
events (ADEs), likely due to reconciliation errors, incomplete documentation, and suboptimal
communication between providers.
o Patients often require specialist referral for optimal management of chronic conditions.
However, primary care providers should work closely with specialists and can often prescribe
the majority of the patient's medications, ensuring that medication records are updated and
complete.

 Review criteria for geriatric populations (eg, Beers,* START**)

 Consider time to benefit for drug
o Prescriptions for elderly patients should consider the medication's magnitude of effect and
Principles
time to therapeutic benefit, in addition to the patient's goals of care and health status (eg,
of prescribing
life expectancy).
 For example, treatment of a systolic blood pressure of 140-159 mm Hg is associated
with a 2% absolute risk reduction in coronary events over 4-5 years.
 This information may support starting antihypertensive therapy in some
patients (eg, patient has therapeutic goals, good health status, longer life
expectancy) but not others (eg, frail, elderly patient with primarily palliative
goals of care and short life expectancy).
 Tailor regimen to the patient's goals & life expectancy
o Clinicians should individualize drug therapy to each patient's context and therapeutic
priorities.
 Frequently reassess appropriateness of medication

*Beers criteria: list of medications considered potentially inappropriate or to be used with caution in the elderly.
**START criteria: used to identify potential harm of withholding specific drug in older patients.
ADEs = adverse drug events; START = Screening Tool to Alert to Right Treatment.

 The impact of aging on pharmacokinetics (E.g., ↓ hepatic metabolism, ↓ tubular

secretion and GFR) increases the likelihood of adverse drug effects and drug interactions in
older adults
 Polypharmacy in older adults is common (especially in those living in long-term care facilities)
because of multiple comorbidities.
 Older age, polypharmacy, and limited health literacy all contribute to an increased risk
of medication errors.
  Follow principles of prescribing for older adults.
 Consider whether new medications are appropriate .
 Use low starting doses and titrate slowly while assessing for adverse effects.
 Perform regular medication reviews to determine if any need to be adjusted or stopped
 Initiation of new medications
 Approach
 Determine necessity.
 Consider if nonpharmacological alternatives, e.g., diet or exercise, are more
appropriate.
 Check if existing medications may be causing the current symptoms (i.e., avoid
the prescribing cascade).
 Determine appropriateness.
 Consult the Beers Criteria to determine if the medication is suitable in older
adults.
 Review existing medications for potential interactions .
 Use shared decision-making with the patient and/or their carer, considering the
following patient factors:
 Life expectancy
 A patient with limited life expectancy is unlikely to
benefit from a medication such as a statin that
requires several years to have an impact.
 Goals of care
 Patients whose goal is maximum longevity may be
willing to tolerate more adverse effects than a
patient whose focus is maximum quality of life.
 Severity of disease symptoms and impact on the patient's
life
 Burden of treatment (e.g., adverse effects, intensity of
treatment regimen)
 Select the correct dosage
 Check renal and liver function; adjusted doses or different medications may be
necessary.
 Liver size declines with age and may be further impacted
by chronic disease.
 Start at a low dose; follow recommended starting doses for older adults when
available.
 Titrate medications up slowly; before increasing the dosage, assess for risk
factors affecting adherence.
 Select the correct formulation:
 Consider difficulties with swallowing.
 The dosage and speed of absorption can be affected by
crushing tablets and/or opening capsules and mixing them
with food or thickening fluids. If a patient cannot swallow
tablets or capsules, avoid modified release preparations
and select liquid formulations if available.
 Provide clear instructions.
 Explain what the medication is for and how it works .
 Support dosage information with written instructions.
 Advise patients on common adverse effects and what to do if they occur .
 For patients requiring multiple medications, consider strategies to help patients
take them correctly (e.g., use of pillboxes, written instructions).
 Beers Criteria
 The AGS Beers Criteria are recommendations for pharmacological care in older adults to:
 Improve medication selection
 Reduce adverse events
 Recommendations are divided into the following categories:
 Medications to avoid in most older adults
 Medications to avoid in older adults with specific conditions (e.g., heart failure, history of falls)
 Medications to avoid in older adults with impaired kidney function
 Medications to be used with caution in older adults
 Drug interactions

2019 AGS Beers Criteria: selected medication recommendations

Potentially problematic
Drug class Effects Recommendations
medications
 Opioids
 Antiepileptics
 Avoid prescribing:
 SSRIs
 ≥ 3 CNS-active drugs in
 SNRIs
 Can cause sedation, combination
 Benzodiazepines
cognitive impairment,  Opioids, antiepileptics, SN
 Nonbenzodiazepine
and/or delirium → ↑ RIs,
hypnotics
risk of falls and fractures and benzodiazepines to
 Barbiturates
 Opioids and drugs with a patients with a history of
 Drugs with antimuscari
ntimuscarinic effects can falls or fractures
nic effects
CNS-active dr also cause urinary  Benzodiazepines for older
 Muscarinic
ugs retention and constipatio adults with delirium, dem
antagonists
n. entia, or cognitive
 TCAs
 Antipsychotics, SSRIs, SN impairment
 Paroxetine
RIs, and TCAs can  When possible, any of the
 Antipsychotics
cause SIADH and/or hypo listed agents
 First-
natremia.  Monitor serum sodium in patients
generation
taking antipsychotics or antidepres
antihistamines
sants.
 Muscle
relaxants

 Sliding-scale insulin
regimens (I.e., regimens
of short or rapid-acting
insulin without
concurrent use of basal  Increased risk
 Avoid prescribing.
Antidiabetics or long-acting insulin) of hypoglycemia
 Long-acting sulfonylure
as
 Glimepiride
 Glyburide

 Nonselective
peripheral α-blockers
 May elevate the risk
 Doxazosin
Antihyperten of orthostatic  Avoid prescribing.
 Prazosin
sives hypotension
 Terazosin
 Clonidine

Other drugs  NSAIDs  Risk of GI bleeding  Avoid chronic use of NSAIDs,

 Risk of acute kidney especially in combination with
injury anticoagulation and antiplatelet
 May increase blood therapy.
pressure  Use caution in
prescribing aspirin for primary
prevention of ASCVD or colorectal
 2019 AGS Beers Criteria: selected medication recommendations
Potentially problematic
Drug class Effects Recommendations
medications
cancer in adults aged ≥ 70 years.
 Avoid aspirin dosages > 325
mg/day in patients with a history
of gastric or duodenal ulcers.

 Avoid use for > 8 weeks except in

specific situations. (For example,
 May increase the risk high-risk patients (e.g., on
 Proton-pump inhibitors of C. difficile infection, oral glucocorticoids or
bone loss, and fractures chronic NSAIDs) and those not
responsive to alternative
treatment)

 Many commonly prescribed drugs (e.g., NSAIDs, proton pump

inhibitors, opioids, benzodiazepines) may be harmful in older adults
 Management of existing medications
 Approach
 Ensure patients receive recommended monitoring.
 Monitoring may involve laboratory studies, e.g., INR for warfarin, drug levels, or
assessment of organ function, or it may be symptom-based. If patients are
unable to attend regular follow-ups, consider discontinuing the medication.
 Perform regular medication reviews.
 Be aware of the risks of polypharmacy, and consider deprescribing when possible.
 Medication reviews
 Ask the patient to bring in all the medications they take, including over-the-counter, complementary,
and alternative medications (a brown bag medication review).
 Review the indications for each prescribed medication, and ensure proper documentation.
 E.g., review medical records, obtain a comprehensive medical and surgical
history
 Determine if all medications are still being taken and, if so, at what dosage.
 Assess if prescribed medications:
 Are still appropriate for the patient's:
 Age (e.g., using the Beers Criteria).
 Other methods include the screening tool of older
persons' prescriptions (STOPP) to identify
potentially inappropriate medications and the
screening tool to alert doctors to the right
treatment (START) to identify appropriate
medications that have not been prescribed.
However, no single tool provides a comprehensive
evaluation of potentially harmful polypharmacy.
 Condition
 Medications may no longer be required
(e.g., pain medications for an arthritic hip after
a joint replacement) or appropriate if a
patient's goals of care have changed.
 Require dosage adjustments (e.g., renal dosing)
 Could cause or are causing drug interactions
 Have benefits that outweigh the potential harms of continued use
 Could be replaced with a more affordable formulation
 A comprehensive medication review should be conducted at each health maintenance visit and
considered for each patient visit
 Polypharmacy
 Polypharmacy is the routine and concurrent use of multiple medications (usually defined as ≥ 5
medications).
 There is no consensus definition of polypharmacy, and some researchers argue
that a distinction should be made between appropriate and inappropriate use of
multiple medications. Examples of inappropriate polympharmacy include the use
of medications that are unnecessary or not indicated, or that duplicate the effects
of other drugs.
 Polypharmacy is associated with increased health care spending and poor patient outcomes
including:
 Falls, frailty, disability, and death
 Adverse drug events (e.g., due to drug interactions or medication errors)
 Drug-induced cognitive impairment causing toxic encephalopathy
 Taking medications incorrectly (e.g., missing doses, taking additional doses)
 Factors that contribute to polypharmacy
 Patient factors
 Age > 62 years
 Cognitive impairment, mental health conditions, or
developmental disability
 Complex care needs
 E.g., multiple chronic conditions or care involving
multiple specialists
 No primary care physician
 Living in a long-term care facility
 Systemic factors
 Substandard medical documentation and/or transition of
care
 Physicians may be unclear why a medication was
started or whether it should be continued long-
term.
 Use of automatic medication refills
 Prioritization of quality metrics that are condition-specific
 In order to meet health care system-mandated
measurements, clinicians may feel pressured to
prescribe medications that are not beneficial to the
patient but meet the expectations for standard of
care (e.g., statin for CAD prevention in a patient
with metastatic breast cancer).
 Polypharmacy in older adults is associated with an increased risk of adverse drug events, delirium, falls,
and cognitive and functional decline