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discontinuingthemedicationshouldbeconsidered.Benefitsbeyondayearhavenotbeeninvestigatedand
therisksandbenefitsoflong-termtherapyhavenotbeenwellestablished,resultinginaneedforongoing
assessment.
Regarding other treatments for agitation and delirium, two items were raised regarding the use of
chemical and physical restraints. Both the AGS and AMDA called out the use of antipsychotic
medicationsbecauseoftheir adverseeffectsandconsiderationaschemicalrestraints;theyspecifically
recommendednottouseantipsychoticmedicationsforBPSDinindividualswithdementiaasfirstchoice
or without anassessment for an underlying cause of the behavior.People with dementia often exhibit
aggression, resistance to care, and other challenging or disruptive behaviors. In such instances,
antipsychoticmedicinesareoftenprescribed,buttheyoftenprovidelimitedbenefitandcancauseserious
harm, including stroke and premature death. Use of these drugs should be limited to cases where
nonpharmacologic measures have failedandpatientspose animminentthreat to themselves or others.
Identifyingandaddressingcausesofbehaviorchangecanmakedrugtreatmentunnecessary.
Careful differentiation of cause of the symptoms (physical or neurological vs. psychiatric or
psychological)mayhelpbetter defineappropriatetreatmentoptions.Thetherapeutic goaloftheuseof
antipsychoticmedicationsistotreatpatientswhopresentanimminentthreatofharmtoselforothersor
areinextremedistress—nottotreatnonspecificagitationorotherformsoflesserdistress.Treatmentof
BPSDinassociationwiththelikelihoodofimminentharmto self or others includesassessingfor and
identifyingandtreatingunderlyingcauses(includingpain,constipation,andenvironmentalfactorssuchas
noise and being too cold or warm), ensuring safety, reducing distress, and supporting the patient’s
functioning.IftreatmentofotherpotentialcausesoftheBPSDisunsuccessful,antipsychoticmedications
canbe considered, taking intoaccounttheir significant riskscompared to potential benefits. When an
antipsychoticisusedforBPSD,itisadvisabletoobtaininformedconsent.
Alsoregardingchemicalrestraintsinolderadults,usingbenzodiazepinesorothersedative–hypnotics
as the first choice for insomnia,agitation,or delirium is discouraged. Large-scalestudies consistently
showthattheriskforfallsandhipfracturesleadingtohospitalizationanddeathcanmorethandoublein
older adultstakingbenzodiazepinesandothersedative– hypnotics.Olderpatients,theircaregivers, and
their providers should recognize these potential harms when considering treatment strategies for
insomnia, agitation, or delirium. Use of benzodiazepines should be reserved for alcohol withdrawal
symptoms/deliriumtremensorseveregeneralizedanxietydisorderunresponsivetoothertherapies.
Andlastly, avoidingphysical restraintstomanagebehavioralsymptomsofhospitalized olderadults
withdeliriumwas calledout.Personswithdelirium maydisplaybehaviors thatriskinjuryorinterfere
with treatment. There is little evidence to support the effectiveness of physical restraints in these
situations.Physicalrestraintscanleadtoseriousinjuryordeathandmayworsenagitationanddelirium.
Effectivealternativesincludestrategies topreventandtreatdelirium, identificationandmanagementof
conditionscausingpatientdiscomfort,environmentalmodificationstopromoteorientationandeffective
sleep–wakecycles,frequentfamilycontact,andsupportiveinteractionwithstaff.Educationalinitiatives
and innovative models of practice have been shown to be effective in implementing a restraint-free
approachtopatientswithdelirium.Thisapproachincludescontinuousobservation;tryingreorientation
once and if not effective not continuing; observing behavior to obtain clues about patients’ needs;
discontinuingand/or hiding unnecessary medical monitoring devices or intravenous (IV) devices; and
avoiding short-term memory questions to limit patient agitation. Pharmacologic interventions are
occasionallyutilizedafterevaluationbyamedicalprovideratthebedside,ifapatientpresentsharmto
himselforherselforothers.Physical restraintsshouldonlybeusedas averylastresortandshouldbe
discontinuedattheearliestpossibletime.
ScreeningandMedicationManagement
Considerthetruebenefitsforeachandeveryindividualresidentbeforerecommendingascreeningtestor
medication. All too often, treatments are ordered based on an overestimate of the benefits and
undervaluation of the risks. This includes such actions as not recommending screening for breast or
colorectalcancerorprostatecancer(withthePSAtest)withoutconsideringlifeexpectancyandtherisks
of testing, overdiagnosis, and overtreatment. Cancer screening is associated with short-term risks,
includingcomplicationsfrom testing,overdiagnosis,andtreatmentoftumorsthatwouldnothaveledto
symptoms.Forprostatecancer(ChoosingWisely,2013),1,055menwouldneedtobescreenedand37
wouldneedtobetreatedtoavoid1deathin11years.For breastandcolorectal cancer,1,000 patients
wouldneedtobescreenedtoprevent1deathin10years.Forpatientswitha lifeexpectancyunder10
years,screeningforthesethreecancersexposesthemtoimmediateharmswithlittlechanceofbenefit.
Inaddition,aresident’slifeexpectancyshouldbetakenintoaccountsuchthatthereisnoroutineuseof
lipid-lowering medications in individuals with a limited life expectancy. There is no evidence that
hypercholesterolemia,orlowHDL-C,isanimportantriskfactorforall-causemortality,coronaryheart
diseasemortality,orhospitalizationformyocardialinfarctionorunstableanginainpersonsolderthan70
years.Infact,studiesshowthatolderpatientswiththelowestcholesterolhavethehighestmortalityafter
adjustingforotherriskfactors.Inaddition,a lessfavorable risk–benefitratiomaybe seenforpatients
older than 85, where benefits may be more diminished and risks from statin drugs more increased
(cognitiveimpairment,falls,neuropathy,andmuscledamage).
Drugregimenreviewsaredonemonthlybyaconsultantpharmacistwithinthenursinghome,andthese
assessments are critical to assuring appropriate medication use. Older patients disproportionately use
moreprescriptionandnonprescriptiondrugsthanotherpopulations,increasingtheriskforsideeffects
andinappropriate prescribing.Polypharmacymayleadtodiminishedadherence,ADRs,andincreased
risk of cognitive impairment, falls, and functional decline. Medication review identifies high-risk
medications, drug interactions, and medications continued beyond their indication. Additionally,
medication review elucidates unnecessary medications and underuse of medications and may reduce
medicationburden.
AntibioticUse
TheCDCandotherorganizationsareincreasinglysensitivetotheoveruseofantibiotics.Thisoverusehas
led to dangerous drug-resistant organisms. As a result, both the AGS and AMDA have made
recommendationstonotuseantimicrobialstotreatbacteriuriainolderadultsunlessspecificurinarytract
symptoms are present. Cohort studies have found no adverse outcomes for older men or women
associatedwithasymptomaticbacteriuria. Antimicrobialtreatmentstudiesfor asymptomaticbacteriuria
in older adults demonstrate no benefits and show increased adverse antimicrobial effects. Consensus
criteriahavebeendevelopedtocharacterizethespecific clinicalsymptomsthat,whenassociatedwith
bacteriuria,defineUTI.
Theinappropriatetreatmentof positive urinecultures starts withaninappropriateurine analysis; as
such, it is recommended not to obtain a urine culture unless there are clear signs and symptoms that
localize to the urinary tract. Chronic asymptomatic bacteriuria is frequent in the LTC setting, with
prevalence as high as 50%. A positive urine culture in the absence of localized UTI symptoms (i.e.,
dysuria,frequency,urgency)isoflimitedvalueinidentifyingwhetherapatient’ssymptomsarecausedby
a UTI. Colonization(a positive bacterial culture without signs or symptoms of a localized UTI) is a
commonproblem inLTCfacilities, whichcontributestotheoveruseofantibiotictherapy, leadingtoan
increasedriskfordiarrhea,resistantorganisms,andinfectionduetoClostridiumdifficile.Anadditional
concernisthatthefindingofasymptomaticbacteriuriamayleadtoanerroneousassumptionthataUTIis
thecauseofanacutechangeofstatus,whichleadstofailureindetectingoradelayinthedetectionofa
patient’spossiblymoreseriousunderlyingproblem.Apatientwithadvanceddementiamaybeunableto
reporturinarysymptoms.Inthissituation,itis reasonabletoobtainaurinecultureiftherearesignsof
systemicinfectionsuchasfever(anincreaseintemperatureofequaltoorgreaterthan2°F[1.1°C]from
baseline),leukocytosis,oraleftshiftorchillsintheabsenceofadditionalsymptoms(e.g.,newcough)to
suggestanalternativesourceofinfection.Remember,itoftenstartswithcliniciansbelievingapatient’s
changeinconditionandrequestingaurineanalysisdespitetherenotbeinganysignsofaurinaryinfection.
Thoughtfulrecommendationsinthisareacangoalongwayinassuringappropriateantibioticuse.
DiabetesManagement
Diabetes management was another area where both the AGS and AMDA found common ground. The
inappropriatetreatmentofresidentswithdiabetescanresultinfallsfromhypoglycemiaaswellaspainful
frequent fingersticks and injections from the overuse of sliding scale insulin (SSI). As a result, it is
recommendedtoavoidusingmedicationstoachievehemoglobinA1clessthan7.5%inmostadultsaged
65andolder;moderatecontrolisgenerallybetter.Thereisnoevidencethatusingmedicationstoachieve
tightglycemiccontrolinolderadultswithtype2diabetesisbeneficial.Amongnon-olderadults,except
for long-term reductions in myocardial infarction and mortality with metformin, using medications to
achieve glycatedhemoglobinlevels lessthan7% is associated withharms, includinghigher mortality
rates.Tightcontrolhasbeenconsistentlyshowntoproducehigherratesofhypoglycemiainolderadults.
Giventhelong timeframetoachievetheorizedmicrovascularbenefitsoftightcontrol,glycemictargets
shouldreflectpatientgoals,healthstatus,andlifeexpectancy.Reasonableglycemictargetswouldbe7%
to7.5%inhealthyolderadultswithlonglifeexpectancy,7.5%to8%inthosewithmoderatecomorbidity
andalifeexpectancylessthan10years,and8%to9%inthosewithmultiplemorbiditiesandshorterlife
expectancy.
SSIwascalledoutasatermtobeavoidedforlong-termdiabetesmanagementforindividualsresiding
inthenursing home. SSI is a reactive way of treatinghyperglycemia after it has occurred rather than
preventingit.GoodevidenceexiststhatneitherisSSIeffectiveinmeetingthebody’sinsulinneedsnoris
itefficientintheLTCsetting.UseofSSIleadstogreaterpatientdiscomfortandincreased nursingtime
becausepatients’bloodglucoselevelsareusuallymonitoredmorefrequentlythanmaybenecessaryand
moreinsulininjectionsmaybegiven.WithSSIregimens,patientsmaybeatriskfromprolongedperiods
ofhyperglycemia.Inaddition,theriskofhypoglycemiais asignificantconcernbecauseinsulinmaybe
administeredwithoutregardtomealintake.Basalinsulin,orbasalplusrapid-actinginsulinwithoneor
moremeals (oftencalled basal/bolus insulintherapy), mostcloselymimics normalphysiologic insulin
productionandcontrolsbloodglucosemoreeffectively.Clinicianscanraiseawarenessofinappropriate
SSIwithrecommendationsforchangestoscheduleddosingororalorinsulintreatments.
NutritionalSupport
Lastly, appropriate nutritional support is often critical at the end of life. This involves avoiding
inappropriatenutritionalinterventions.Onesuchinterventionispercutaneousfeedingtubes.Assuch,itis
recommendednottousepercutaneousfeedingtubesinindividualswithadvanceddementia.Instead,oral-
assistedfeedingsmaybeoffered.Strongevidenceexiststhatartificialnutritiondoesnotprolonglifeor
improvequalityoflifeinpatientswithadvanceddementia.Substantialfunctionaldeclineandrecurrentor
progressive medical illnesses may indicate that a patient who is not eating is unlikely to obtain any
significant or long-term benefit from artificial nutrition. Feeding tubes are often placed after
hospitalization, frequently withconcernsfor aspirations andfor thosewhoare noteating.Contrary to
whatmanypeoplethink,tubefeedingdoes notensurethepatient’scomfortor reducesuffering;itmay
causefluidoverload,diarrhea,abdominalpain,localcomplications,andlesshumaninteractionandmay
increasetheriskforaspiration.Assistancewithoralfeedingisanevidence-basedapproachtoprovide
nutritionforpatientswithadvanceddementiaandfeedingproblems.
Carefulhand-feedingforpatientswithseveredementiaisatleastasgoodastubefeedingforimproving
theoutcomesofdeath,aspirationpneumonia,functionalstatus,andpatientcomfort.Foodisthepreferred
nutrient.Tubefeedingisassociatedwithagitation,increaseduseofphysicalandchemicalrestraints,and
worseningpressureulcers.
Alsocalledoutregardingnutritionalsupportwasavoidingtheuseofprescriptionappetitestimulants
orhigh-caloriesupplementsfortreatmentofanorexiaorcachexiainolderadults;instead,socialsupports
maybeoptimized,feedingassistanceprovided,andpatientgoalsandexpectationsclarified.Unintentional
weight loss is a common problem for medically ill or frail older adults. Although high-calorie
supplementsincreaseweightinolderpeople,thereisnoevidencethattheyaffectotherimportantclinical
outcomes,suchasqualityoflife,mood,functionalstatus,orsurvival.Useofmegestrolacetateresultsin
minimal improvements inappetiteandweightgain,noimprovement inqualityoflife orsurvival,and
increasedriskforthromboticevents,fluidretention,anddeath.Inpatientswhotakemegestrolacetate,1
in12willhaveanincreaseinweightand1in23willdie.TheAGSBeersCriterialistsmegestrolacetate
and cyproheptadine as medications to avoid in older adults (AGS, 2019). Systematic reviews of
cannabinoids,dietarypolyunsaturatedfattyacids(DHA)andeicosapentaenoicacid(EPA),thalidomide,
andanabolicsteroidshavenotidentifiedadequateevidencefortheefficacyandsafetyoftheseagentsfor
weight gain. Mirtazapine is likely to cause weight gain or increased appetite when used to treat
depression, but there is little evidence to support its use to promote appetite and weight gain in the
absenceofdepression.Intheend,clinicianscanassistbyincreasingfamilyinvolvementinfeedingand
promotingthisoralfeedingactivitytopreventthepotentialinappropriateuseofpharmacotherapy.
ExecutingonTheseFive
These five areas—dementia andBPSD management,screening and medicationmanagement, antibiotic
use, diabetes management,andnutritionalmanagement—arecritical toimprovingoutcomes for nursing
homeresidents.AcommonthreadrunningthroughtheseChoosingWiselyinitiativesisthattheprudentuse
ofservicesinvolvesapatientcenteredapproach,takingintoaccountthebenefitsandrisks.Thisrequires
thoughtfulassessmentstoassurethatinterventionsarenotencouragedthataretrulynotofbenefitforthat
particular patient.Intheend,all clinicianscanplaya keyrole inassuringthateachresidentreceives
appropriatecare.Anditisthiscarethatwillassistinimprovingthequalityoflifeanddeathforolder
adults(Box5.5).
ExploringAlternativestoMedication
Thehealthcareprovidermustevaluatenewproblemsanddetermineifamedicationisnecessaryaspart
ofthetreatmentplan.Iftherearealternativestomedications,suchasdiet,exercise,andweightlossfor
borderlinehypertensionorantiembolismstockingsinsteadofa diureticforpedaledema,theseoptions
shouldbeexploredfirst.Onlyafternonpharmacologictreatmentsfailshouldamedicationbeinitiated.In
knowingthepatient’soverallsituation—physically,mentally,andsocially—theproviderhasabaseline
fromwhichtoconsidertherisksandbenefitsofmedicationtherapy.Table5.6lists20medicationsthat
shouldnotbeprescribedtoanyolderpatients.Allofthedrugsinthistablearealsopresentinthe2019
BeersCriteria.
Box5.5 GuidelinesforSafePrescribinginDementiaandBehavioralandPsychological
SymptomsofDementia
1. Assure that dementia and BPSD are properly managed through use of physical and chemical
restraintssuchasantipsychoticsandbenzodiazepinesaswellascholinesteraseinhibitors.
2.Assistinthereductionofinappropriatescreeningandmedicationsthatarenotbeneficialbecauseof
limitedeffectivenessanddangerousadverseeffects.
3. Do not request a urine analysis or order for an antibiotic unless there is clear indicationof a
bacterialinfection.
4.AssureappropriatediabetesmanagementthroughareasonablehemoglobinA1ctargetanduseof
regularlyscheduledantidiabeticmedications,thusavoidingSSI.
5.Assistinthepromotionoforalfeedingsuchthatpercutaneousfeedingtubeandappetitestimulants
areonlyusedinraresituations.
BPSD,behavioralandpsychologicalsymptomsofdementia;SSI,slidingscaleinsulin.
When deciding on a medication for an older adult, assisting with that decision, or evaluating a
selection, a drug that treats two coexisting conditions should be considered. For example, a calcium
channel blocker might be selected for the patient with angina and hypertension. An older man with
hyperplasiaoftheprostateandhypertensionmaybenefitfromanalpha-adrenergicblockingagentsuchas
terazosin (Hytrin). Treating two conditions with one medication reduces cost, cuts down on dosing
schedules,andimprovesadherenceandpatientsatisfaction.
SimplifyingtheRegimen
Simplifyingthe medicationplan is a key to therapeutic adherenceand safety. Drugs are started at the
lowestdosepossibleandthedosageincreasedasneeded.Lowerdosesareofteneffectiveandreducethe
riskoftoxicity.Dosingschedulesmustbeeasytofollowandremember.Iftwodrugsareequallysuitable
totreatthesamecondition,itisdesirabletoprescribetheonethatrequiresthelessfrequentdosing.
Another importantconcernis thecostofthedrug,especiallyif thedrugis for long-termuse.Many
olderadultsareonfixedincomesandfindthecostofprescriptiondrugsunaffordable.Ifthemostsuitable
medication for the condition is expensive, this is explained to the patient before purchase to prevent
“sticker shock,” or the embarrassment of not having enough money to pay for the prescription.
Understanding the impact of a patient’s out-of-pocket expenses on adherence is important. As Dr. C.
EverettKoop, former U.S.surgeongeneral, hasbeenquoted, “A medicationonlyworksif the patient
takesit.”
TABLE5.6
TwentyDrugstoAvoidinOlderAdults
PrescriptionDrug Use ReasonforAvoiding
Amitriptyline Totreatdepression Otherantidepressantmedicationscausefewersideeffects.
Carisoprodol Torelieveseverepaincaused
bysprainsandbackpain
Minimallyeffectivewhilecausingtoxicity.Potentialfortoxic
reactionisgreaterthanpotentialbenefit.
Chlordiazepoxide Totranquilizeortorelieve
anxiety
Shorter-actingbenzodiazepinesaresaferalternatives.
Chlorpropamide Totreatdiabetes Otheroralhypoglycemicmedicationshaveshorterhalf-lives
anddonotcauseinappropriateantidiuretichormonesecretion.
Cyclandelate Toimprovebloodcirculation Effectivenessisindoubt.Thisdrugisnolongeravailableinthe
UnitedStates.
Cyclobenzaprine Torelieveseverepaincaused
bysprainsandbackpain
Minimallyeffectivewhilecausingtoxicity.Potentialfortoxic
reactionisgreaterthanpotentialbenefit.
Diazepam Totranquilizeortorelieve
anxiety
Shorter-actingbenzodiazepinesaresaferalternatives.
Dipyridamole Toreducebloodclot
formation
Effectivenessatlowdosageisindoubt.Toxicreactionishighat
higherdosages.Saferalternativesexist.
Flurazepam Toinducesleep Shorter-actingbenzodiazepinesaresaferalternatives.
Indomethacin Torelievethepainand
inflammationofrheumatoid
arthritis
OtherNSAIDscausefewertoxicreactions.
Isoxsuprine Toimprovebloodcirculation Effectivenessisindoubt.
Meprobamate Totranquilize Shorter-actingbenzodiazepinesaresaferalternatives.
Methocarbamol Torelieveseverepaincaused
bysprainsandbackpain
Minimallyeffectivewhilecausingtoxicity.Potentialfortoxic
reactionisgreaterthanpotentialbenefit.
Orphenadrine Torelieveseverepaincaused
bysprainsandbackpain
Minimallyeffectivewhilecausingtoxicity.Potentialfortoxic
reactionisgreaterthanpotentialbenefit.
Pentazocine Torelievemoderatetosevere
pain
Othernarcoticmedicationsaresaferandmoreeffective.
Pentobarbital Toinducesleepandreduce
anxiety
Safersedative–hypnoticsareavailable.
Phenylbutazone Torelievethepainand
inflammationofrheumatoid
arthritis
OtherNSAIDscausefewertoxicreactions.
Propoxyphene Torelievemildtomoderate
pain
ThisdrugisnolongeravailableintheUnitedStates.
Secobarbital Toinducesleepandreduce
anxiety
Safersedative–hypnoticsareavailable.
Trimethobenzamide Torelievenauseaand
vomiting
Leasteffectiveoftheavailableantiemetics
NSAIDs,nonsteroidalanti-inflammatorydrugs.
EducatingAdultsandCaregivers
Potential side effects need to be discussed in a nonthreatening way to prevent needless fear or
anticipationwhenstartinga newmedication.Manyolderadultsforgostartinga medicationforfear of
potential side effects that may occur. The media are powerful in alarming adults about potentially
undesirable or dangerous adverse effects, proven or not. Many older adults stop taking essential
medicationsafterreadingorhearingsomethinginthemediapertainingtothatparticulardrug.
ReviewingMedications
Theproviderworkingwithageriatricpatientshouldhavethepatientbringinallofhisorhermedications
toeachofficevisitorreviewacurrentmedicationcardifthepatientcarriesone.Thecurrentmedications
takenbythepatientarerecordedateachofficevisitaspartoftheprogressnote.Thisreviewalertsthe
providertoimproperdosinganddrugadministration,misunderstandingofmedications,andchangesmade
byspecialistsandotherprofessionals.ThespecialistisnotalwaysawareofallthemedicationsorOTC
drugsthepatienttakesandmayprescribeadrugthatplacesthepatientatriskforinteractions.Aspartof
the review, the health care provider should ask about topical creams, vitamins, eye drops, and OTC
products that may interact with prescription drugs. Adults do not always view these products as
medications.
Theprovider shouldreview all drugsperiodicallytodetermineifthedosagecanbe reducedorthe
drugdiscontinued.Thegoalshouldalwaysbetouseaslittlemedicationaspossibletotreatthemultiple
illnessesthatchallengetheolderadult.
Attheendofeachofficevisit,theproviderneedstogivethemedicationlisttothepatient.Dosesand
timestotakethemedicationsandanyspecialinstructionsneedtobeclearlystatedandcommunicatedin
writing as appropriate. New medications should be listed by brand and generic name so there is no
confusion.Clearwritingwithlargeletteringshouldbeused,particularlyifthepatienthascommonvision
impairments,suchascataracts,glaucoma,ormaculardegeneration.
Thecapsofthemedicationbottlesthatthepatientbringstotheofficecanbelabeledwiththereasonfor
thedrug(e.g.,“bloodpressure,”“waterpill,”or“diabetes”).Thishelpstoensurethatthepatienthasa
basicunderstandingoftheimportanceofeachdrug.Ifthecaregiverofanolderpatientisavailable,the
providershould explainanynew medicationchanges or special instructions,especiallyfor the patient
withcognitiveimpairmentorotherchangesinmentalstatus.
THERAPEUTICMONITORING
Whenmemoryproblemsareanissue,amedicationplannerhelps.Labeledwiththedaysoftheweekand
fourdosingtimesperday,theplannerisausefuldeviceforpreparingmedicationsforaweek.Apatient
whofailstotakethemedicationsdespitevisualcuesandcarefullabelingmaybesendingasignalthatthe
familyorotherresponsiblecaregiversneedtoinvestigateadditionalinterventions,homecareservices,or
futureplacementinassistedlivingorLTCfacilities.
Itisimportantroutinelytoscheduleandmonitortheresultsoflaboratorytestswhenthepatientistaking
medicationsthatmayresultinfluctuatingdrugbloodlevels.Forexample,olderadultstakingsuchdrugs
aswarfarin,theophylline(Theo-Dur),digoxin,andquinidine(Quinaglute)needcarefulmonitoring,asdo
adultstakinganticonvulsantmedications,suchasphenytoin,carbamazepine(Tegretol),andvalproicacid
(Depakote),forseizuredisorders.
Adultstakingdiureticsorangiotensin-convertingenzyme(ACE)inhibitorsrequireperiodicevaluation
with a renal profile todetectelectrolyte imbalances, as well as renal insufficiency (as evidenced by
rising blood urea nitrogen[BUN]andcreatinine levels). AdultsstartingACEinhibitor therapyshould
have a baselineBUN/creatinine level documentedwith a follow-up testin2 weeks to alertfor renal
arterystenosis(evidencedbyariseintheBUN/creatininelevels).Becauseofthepotentialforelevations
inserumpotassiumconcentrationwithACEinhibitortherapy,theolderadultneedsroutinerenalprofiles
todetectsuchchanges,especiallywhendrugtherapyalsoincludesdiureticsanddigoxin(Lanoxin).(Box
5.4presentsguidelinesforprescribingdrugssafelyforolderadults.)
SUMMARY
Threequotesthatsummarizebestpracticesinpharmacotherapyprinciplesinolderadultsfollow:
1.“Anysymptominanelderlypatientshouldbeconsideredadrugsideeffectuntilprovedotherwise.”
2.“Startlow,goslowbutgetthere(thetherapeuticdose).”
3.“Amedicationonlyworksifthepatienttakesit.”
Itbeginswithdeterminationoftherighttreatmentinthefaceofnewsymptomsorissues.Thismaynot
always mean beginning a new medication but rather may mean instead reducing a dose of a current
medication,discontinuingatherapy,orstartinganonpharmacologictreatment.ThequotefromLeslieFine
shouldberememberedandpracticed,that“anysymptominanelderlypatientshouldbeconsideredadrug
side effectuntil proved otherwise.” This is importantto preventpolypharmacy issues in older adults.
Also,whendeterminingifanewmedicationshouldbestarted,carefulassessmentofthebenefitsversus
thecostsshould be undertakensuch thatonly those treatments thatoffer benefits over costs should be
started.Assessing costsincludesnotonlyfinancial costs butalsopotential sideeffects,while benefits
analysesneedtotakeintoaccountbenefitsgiventhelifeexpectancyandotherconcernsintheolderadult.
Thesecondquotedealswithstartinga newmedication.Itbeginswithastandardgeriatric quotebut
withanewaddition.Thequoteisthatmedicationsinolderadultsshould“startlowandgoslow”but,to
becomplete,shouldinclude“butgetthere.”Thistranslatestoinitiatingmedicationsatalowstartingdose
andtitratingslowlybutgettingtothetherapeuticdose.Thisisnotonlytopreventadverseeventsfromtoo
quick a titration at too high a dose but also to caution against therapies that are not being used at a
therapeuticlevel.
ThefinalquotecomesfromC.EverettKoopdescribingtheimportanceofadherence—“Amedication
only works if the patient takes it”: for after a careful determination and initiation of the “right”
medication,attherightdosefortherightduration,hasbeenmade,assuranceofadherenceisthefinalstep
in producing optimum outcomes. Of course, there is no final step; pharmacotherapy management,
especially in older adults, requires educated clinicians’ ongoing evaluation and support to assure
optimumoutcomes.
CASESTUDY1
R.S.isan85-year-old femalewhohascongestiveheartfailure.Overthepast3months,shehashad
four hospitalizations. Like many older adults, R.S. is experiencing difficulty swallowing and
psychologicchangesaffectinghermedicationabsorption.
1. Whichof the following would be anappropriate startingpoint for identifyingcauses for R.S.’s
frequencyofhospitalizations?
a.Simplyaskifsheistakinghermedicationsasdirected.
b.Assumethatherfrequenthospitalizationsaresecondarytoexpectedchanges,whicharenormal
featuresofaging.
c. Examine all of R.S.’s medication vials to complete an assessment including pill count for
adherence.
d.Assumethatherfrequenthospitalizationsaretheresultofundertreatingherconditions.
Answer:c.
2. In determining themostappropriate course of treatmentfor R.S., assessing her life expectancy
shouldneverbetakenintoaccount.Rather,thesamecourseoftreatmentshouldbepursuedwithout
regardforlifeexpectancyorheruniquegoalsofcare.
a.True
b.False
Answer:b.
3.WhichofthefollowingbestdescribesaconcernthatR.S.istakingnonprescribeddrugs,whichmay
impacthercardiacfunction?
a. Assume thatalthoughR.S.likelyhasnotdiscussed hertakingnonprescribed drugswithher
healthcareprovidersthatthisismostlikelynotanissue.
b.Assumebecauseolderadultstypicallydonottakenonprescribeddrugsthatthisisnotanissue
withR.S.
c.Becauseolderadultstakeasignificantnumberofnonprescribeddrugswithoutknowledgeof
their physicians, R.S.’s use is best assessed through a home visitandthe asking of open-ended
questions.
Answer:c.
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