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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2939_Библиотеки_им_академика_М_И_Перельмана
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350
K. A. Swanson et al.
The START (Screening Tool to Alert Doctors to Right Treatment) (see Table3),
is a tool to help identify potentially benecial medications that may have been omitted from a LTCF resident’s treatment regimen. The START tool is similar to the
STOPP criteria in that both have been validated in the elderly, derived from
evidence- based prescribing practice, and arranged by physiological systems; but
Table 3 START: Screening Tool to Alert doctors to Right Treatments
These medications should be considered for people ≥65years of age based on other clinical
conditions and no contraindication to the recommendation
Cardiovascular conditions
• Initiate anticoagulation to reduce stroke/thrombosis risk in chronic atrial brillation—
direct acting anticoagulant (ex. apixaban, others), warfarin, aspirin (when DOAC or
warfarin is contraindicated)
• Aspirin or clopidogrel in documented history of atherosclerotic coronary, cerebral, or
peripheral vascular disease in patients with sinus rhythm
• Antihypertensive therapy when systolic blood pressure is consistently >160 mmHg
• Lipid lowering therapy (statin) with documented history of coronary, cerebral, or
peripheral vascular disease, where the patient’s functional status remains independent for
ADLs and life expectancy is greater than 5years
• Initiate or optimize treatment for chronic heart failure according to current guidelines
when not contraindicated by current clinical conditions or status [which may include:
ACEi indicates angiotensin-converting enzyme inhibitor(ACEi), angiotensin receptor
blocker (ARB), angiotensin receptor-neprilysin inhibitor (ARNi), hydralazine, isosorbide
dinitrate, mineralocorticoid receptor antagonist (MRA), sodium-glucose cotransporter 2
inhibitor (SGLT2i), or diuretics]
• Initiate or optimize treatment according to current guidelines for acute myocardial
infarction (e.g., ACEi) or chronic stable angina (e.g., beta-blocker)
Respiratory system
• Initiate or optimize treatment for moderate to severe symptoms of COPD and/or frequent
emergency room visits or hospitalization (which may include: inhaled beta2 agonist,
anticholinergics, inhaled corticosteroids, others)
• Initiate or optimize treatment for moderate to severe symptoms of asthma (which may
include: inhaled corticosteroids, inhaled beta2 agonist, others)
• Initiate or optimize oxygen therapy for documented chronic respiratory failure
Central nervous system
• Initiate or optimize treatment for Parkinson’s disease with functional impairment and
disability (which may include: -DOPA, COMT inhibitors, MAO-B inhibitors, dopamine
receptor agonists, others)
• Initiate or optimize treatment for moderate to severe depressive symptoms with or without
anxiety [which may include: selective serotonin reuptake inhibitors (SSRIs), serotonin and
norepinephrine reuptake inhibitors (SNRIs), norepinephrine and dopamine reuptake
inhibitors (NDRIs), mixed serotonin effect agents, serotonin and α2-adrenergic
antagonists, others]
• Initiate or optimize treatment for cognitive impairment/dementia in individuals where the
patient’s functional status remains independent for ADLs and life expectancy is greater
than 5years and treatment is appropriate according to the individual’s goals of care [which
may include: acetylcholinesterase inhibitor (AChI) or n-methyl--aspartate antagonists
(NMDA)]
Medication Management inLong-Term Care
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Table 3
(continued)
Gastrointestinal system
• Initiate or optimize treatment for moderate to severe gastroesophageal reux disease
(GERD) especially with history of erosive esophagitis and/or strictures [which may
include: daily doses of proton pump inhibitor (PPI) or high dose histamine-2 receptor
antagonist (H2RA)]
• Initiate or optimize treatment for prevention of peptic ulcers due to nonsteroidal antiinammatory drugs (NSAIDs) when use is absolutely necessary strictures [which may
include: daily doses of proton pump inhibitor (PPI) or high dose histamine-2 receptor
antagonist (H2RA)]
• Initiate or optimize ber supplementation for chronic, symptomatic diverticular disease
with constipation
Musculoskeletal system
• Initiate or optimize treatment for active moderate to severe rheumatoid arthritis strictures
[which may include: disease-modifying anti-rheumatic drugs (DMARDs), immune
modulating agents such as monoclonal antibodies against TNF-α, leukocyte adhesion and
migration inhibitors, interleukin inhibitors, JAK inhibitors, others]
• Initiate or optimize treatment for osteoporosis or individuals requiring maintenance
corticosteroids (therapy may include: bisphosphonates, calcium, and vitamin D, others)
Endocrine system
• Initiate or optimize treatment for diabetes and or metabolic syndrome (therapy may
include: metformin, others)
• Initiate or optimize therapy to reduce risk of nephropathy associated with diabetes
(therapy may include ACEI or ARB)
• Initiate or optimize therapy to reduce major cardiovascular risk in individuals with
diabetes [therapy may include: antiplatelet agents, lipid-lowering agents (e.g., statins),
others]
(Adapted from Ref. [16])
351
unlike STOPP, START identies possible prescribing omissions in older adults as
opposed to medication overuse by STOPP.These tools can enable practitioners to
better evaluate an older person’s “prescription” drug regimen in the context of current clinical diagnoses [16].
Issues inMedication Management
Anticholinergic Burden
Medications that block cholinergic neurons are considered potentially harmful in
older individual due to adverse effects that include dry mouth, constipation, urinary retention, precipitation of glaucoma, and altered mental status or cognition.
Highly anticholinergic medications have also been associated with increased risk
of hospitalization and mortality, dementia, and pneumonia. Several tools have been
developed to determine the cumulative risk for anticholinergic effects, such as the
Anticholinergic Cognitive Burden List (ACB), the Anticholinergic Drug Scale
352
K. A. Swanson et al.
(ADS), and the Anticholinergic Risk Scale (ARS). These tools categorize medications as Highly Anticholinergic (Score = 3), Moderately Anticholinergic
(Score=2), and Mildly Anticholinergic (Score=1). The use of multiple drugs with
anticholinergic activity will result in a cumulative anticholinergic burden that in
turn increase the risk of delirium, worsening dementia, hospitalization, and mortality [21–23].
“Deprescribing” andGradual Dose Reduction (GDR)
Known as deprescribing, many initiatives have been undertaken to identify the
risks and benets to reducing medication burden via systematic evaluation and discontinuation of potentially unnecessary medication. Prescribers are often hesitant to
deprescribe due to concerns that this may cause patient decompensation in clinical
and functional status. Cautious and gradual discontinuation of medication through
a process termed by CMS as Gradual Dose Reduction (GDR), often causes little if
any detrimental effects in older and/or frail adults [24]. In 2021, AMDA-The Society
for Post-Acute Care and Long-Term Care Medicine launched an initiative titled
“Drive to Deprescribe” (D2D). This program addresses the issue of polypharmacy
and inappropriate medication use in post-acute and long-term care (PALTC) with
the goal to reduce (unnecessary) medication use by 25% [24]. Federal nursing facility regulation require that gradual dose reductions (GDR) be attempted at least quarterly for all sedative/hypnotics and psychotropics that are prescribed on a scheduled
basis and continued beyond the manufacturer’s recommended duration of use.
Current practice extends GDR to all medication. Any medication should be determined as whether necessary in order to lessen the risk of a potentially harmful
outcome.
However, a consultant pharmacist’s recommendation for a GDR can be
declined on clinical grounds if
1. Continued use of the medication is in accordance with the current standard of
practice and a GDR would likely impair the patient’s function or cause psychiatric or instability by either exacerbating an underlying medical condition or psychiatric disorder.
or
2. Patient’s target symptoms for which the medication had been prescribed either
returned or worsened after the most recent GDR, and further GDR attempts
would likely impair the patient’s function or psychiatric stability.
Practitioners should note that current State Operations Manual (SOM) guidelines
to surveyors state that medication should be prescribed only when necessary and in
the lowest effective dose and that each resident’s drug regimen be free from
Medication Management inLong-Term Care
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353
unnecessary drugs (F-Tag 757). Once symptoms have resolved or stabilized, these
guidelines recommend that attempts be made to either discontinue the medication
or reduce the dose through GDR.Previous efforts to reduce unnecessary medication
focused solely on antipsychotics, benzodiazepines, and centrally acting drugs. The
current guidelines encourage GDR be attempted for all medications unless the
patient’s current condition would be adversely affected. Refer to Appendix A for
more detailed information on what denes an unnecessary medication and the intent
of the federal regulation.
Transitions inCare andMedication Errors
Transitions in care portend signicant risk for patients with changes inlocation,
level of care, and/or providers. Such transitions can result in unrecognized medica-
tion errors and adverse patient outcomes. Medication-related adverse events are
common after discharge from the hospital [25]. For this reason, one of the National
Patient Safety goals of the Joint Commission on Accreditation of Hospital
Organizations (JCAHO) continues to be medication reconciliation and the transmission of accurate up-to-date medication information between care settings.
Risk factors for medication-related adverse events during a care transition
include:
• Polypharmacy (>4 medications)
• Inadequate monitoring of high-risk medications such as insulin, warfarin
• Chronic complex illness: stroke, cancer, diabetes, COPD, heart disease
• Hurried transfers during nonstandard times of day/night/weekend
• Inadequate patient support post-discharge from one care setting to another
Hand-off communication must include comprehensive and up-to-date records to
accompany the patient through any care transition and ensure a timely evaluation of
the patient upon admission to their new residence. This can help alleviate medication errors, diagnose new problems, and prevent the occurrence of deteriorating
conditions. Use of a universally accessible electronic health care records (EHR)
across all care settings is essential to meet this goal [26].
Use ofPsychoactive Medication
Older adults are especially vulnerable to adverse effects from psychoactive medication especially the atypical antipsychotics that can cause delirium, extrapyramidal
symptoms, postural hypotension, falls (with/without fractures), and cardiac
354
K. A. Swanson et al.
arrhythmias. Although these medications have been used off-label to manage behavioral and psychological symptoms of dementia (BPSD), safety concerns have been
raised and well documented [17, 27]. Other adverse outcomes include hospitalization [28] and acute kidney injury [18].
In 2014, the American Geriatrics Society (AGS) recommended Choosing
Wisely® guidelines that staff and physicians should initiate non-pharmacologic
strategies as rst-line treatment for aggression and disruptive behaviors associated
with dementia. Identifying and addressing the underlying cause of the behavior
(the antecedent) may preclude the use of psychoactive medication. If these
approaches fail and the clinician decides that there is a need to prescribe an antipsychotic medication, patients and their families should be informed on the drug’s
potential adverse effects. Many facilities now require the family to sign informed
consent prior to their use. Proactive monitoring of blood pressure, as well as serum
lipid, glucose, and creatinine levels should be part of the treatment plan for any
patient prescribed an antipsychotic medication. Additionally, recent meta-analysis
studies have shown (though of low quality) that antipsychotics may be successfully
discontinued in older adults with dementia and other neuropsychiatric symptoms
who have been on antipsychotics for 3months. The discontinuation of these medications had little or no rebound effect on behavioral and psychological symptoms [29].
Overprescribing ofAntibiotics
The over-prescribing of antibiotics continues to be a concern in the older aged
population, specically those who reside in a nursing home setting. Antibiotic
stewardship is an integral component of quality assurance and performance
improvement in LTCFs. Antibiotic overuse has been linked to multiple risks including antibiotic drug–drug interactions, colonization with multiresistant organisms,
and creation of “super-bugs” in which no antibiotic will be effective. Preventive
use of antibiotics is an ongoing concern in long-term care facilities [30]. Research
questions the evidence for prescribing antibiotics to prevent recurrent urinary tract
infections, to treating acute bronchitis (often viral) to prevent bacterial pneumonia,
to treat acute sinusitis to prevent bacterial superinfection, to ongoing antibiotic
treatment in persons with COPD to prevent exacerbations or hospitalizations, to
prevent soft tissue skin infections in a patient with frequent cellulitis (often overdiagnosed), and for treatment at the time of dental procedures to prevent endocarditis in patients with heart disease or to prevent joint infection in those patients with
articial joints.
Medication Management inLong-Term Care
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355
Overprescribing ofProton Pump Inhibitors
Proton pump inhibitors (PPIs) are gastric acid suppressive medications that are used
to treat gastrointestinal disorders such as Gastroesophageal Reux Disease (GERD)
and Peptic Ulcer Disease (PUD). Since their approval for use in the United States
over 30years ago, they have expanded to worldwide use, are deemed low risk medications in most countries, and often obtained without a prescription. However more
recent studies regarding PPIs have reported adverse effects when prescribed long
term. PPIs have been linked to an increased risk of Clostridium difcile infection,
increased infection risk in cirrhotic patients, acute interstitial nephritis, prevention
of clopidegrol conversion to its active metabolite, increased risk of hip fracture,
increased risk of chronic kidney disease, increased risk of community acquired
pneumonia, decreased iron, B12, and magnesium absorption leading to deciencies, and rebound gastric acid hypersecretion after discontinuation of use.
Given these multiple risk factors, cautious prescribing and regular monitoring of
PPI use is essential in older adults who may be at higher risk of those adverse reactions mentioned above. Deprescribing should be considered and entails decreasing
dosage, switching to as needed use, or stopping altogether and starting a different
medication for symptom management. Histamine 2 receptor blockers are an appropriate alternative, and have been associated with less C difcile, and fracture risk
[31, 32]. Patients should be educated on non-pharmacologic lifestyle modications
to reduce the need for acid suppressive therapy. These include weight loss, elevated
head of bed, limiting bedtime meals, and avoiding high-fat greasy meals.
Selection ofDiabetic Medication
Several studies have suggested that older adults with diabetes and high comorbidity
have diminished cardiovascular benet from intensive blood glucose control (Hgb
A1C less than 6.5–7%), and an increased risk for hypoglycemia. These patients
would benet more from improved control of other risk factors including serum
lipids, dietary consumption of sodium, and blood pressure [33, 34]. Current treatment options for diabetes have increased with multiple medications now available.
Each has its own mode of action and risk. Renal status should always be considered
when prescribing. Some of these medications have been shown to have cardiovascular benets as well. Table4 provides a summary of these medications as to route
of administration, risk of hypoglycemia, weight loss or gain, cardiovascular effect,
renal effect, and side effect risk and contraindications [35]. For more detailed information on the management of diabetes in PALTC refer to the chapter on “Common
Clinical Conditions in Long-Term Care.”
356
• Potential for B12 deciency
• Lactic acidosis
• Fluid retention/edema-CHF
• Benet in NASH
• Risk of bone fracture
• Bladder cancer (Pioglitazone)
• ↑ LDL (Rosiglitazone)
Not recommender in renal
impairment—can cause uid
retention
population
(Liraglutide, Exenatide,
• Glipizide preferred in older
impaired
Caution if GFR <30 • Risk of thyroid C cell tumors
Dulaglutide, Albiglutide)
emptying → n/v, diarrhea)—care
in elderly/frail/malnourished
• GI side effects (delayed gastric
• Injection site reactions
• ↑ Risk of pancreatitis
• Risk of amputation
• (Canagiozin)
Cangiozin (Cl in GFR <45)
Dapigaozin [caution in GFR
K. A. Swanson et al.
2 DM)
hypotension
• DKA risk (all agents, rare in type
• GU infection (bacterial/fungal)
• Risk of volume depletion/
• ↑ LDL
<60, Cl GFR <30
Empagiozin (Cl GFR <30)]
(Black cox warning:
Rosiglitazone and
Pioglitazone)
Common diabetic medications in older patients
Class/drug Route Hypoglycemia Weight CV effect Renal effect Contraindications/side effects
Table 4 Commonly used diabetic medication in older adults
Metformin Oral NO Loss Potential benet Contraindicated if GFP <30 • GI side common
Thiazolidinediones Oral NO Gain Increased risk of CHF
Sulfonylurea Oral YES Gain Neutral Avoid glyburide in renal
semaglutide)
GLP 1 analogs Subq NO Loss Benet (Liraglutide and
Empagiozin)
SGLT-2 inhibitors Oral NO Loss Benet (Canagiozin,
Medication Management inLong-Term Care
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• Risk of pancreatitis
• Joint pain
• Well tolerated in elderly
• Injection site reactions
• Hypoglycemia
Dose adjustment required if
renal impaired
impaired
357
Alogliptin)
Common diabetic medications in older patients
Class/drug Route Hypoglycemia Weight CV effect Renal effect Contraindications/side effects
DPP-4 inhibitors Oral NO Neutral CHF risk (Saxogliptin,
Insulin Subq YES Gain Neutral Lower doses for renal
Adapted from: https://professional.diabetes.org/sites/professional.diabetes.org/les/media/mendez_how_to_use_the_type_2_diabetes_treatment_algo-
rithm.pdf
358
K. A. Swanson et al.
Choice andUse ofAnalgesics
Guidelines published by the American Geriatric Society (AGS ) caution against the use
of nonselective NSAIDs (especially those with a long half-life such as naproxen and
piroxicam) and COX-2 selective inhibitors due to their potential cardiac (uid and
sodium retention), gastrointestinal (inammation, bleeding), CNS (altered mental status, psychosis), and renal effects (altered blood ow) [36]. Both these classes of medication have signicant drug interactions with ACE inhibitors (potential for hyperkalemia),
diuretics (diminished diuresis due to changes in renal blood ow), methotrexate
(decreased clearance), anticoagulants (potentiated effects), and lithium (decreased renal
clearance and increase risk of lithium toxicity). Additionally, there is concern that concomitant use of a NSAID (especially ibuprofen) or a COX-2 inhibitor with a once daily
cardio-preventive dose of aspirin will negate aspirin’s cardio-preventive effect [37].
An FDA Advisory Panel has recommended sweeping safety restrictions on the
use of acetaminophen alone and in combination with opioids such as hydrocodone/
acetaminophen and oxycodone/acetaminophen due to reports of increased cases of
liver damage and acute liver failure associated with acetaminophen overuse. This
risk increases with current and chronic use of alcohol. The panel advised that combination opioid/acetaminophen analgesics increase the possibility of accidental
overdose and acute liver failure, especially when taken with over-the-counter formulations of acetaminophen. The panel also recommended that the maximal amount
per unit dose of acetaminophen be a lowered to 325 mg tablet in lieu of the current
500 and 650mg tablets currently available over the counter. And that the maximum
daily dosage for osteoarthritis be less than 4 g per day [38], i.e., 2–3 g per day.
Useful medication guidelines for many drugs can be downloaded from the FDA
website. These guidelines provide specic information for patients and caregivers
and may help prevent ADEs [39]. Current national initiatives focus on reducing the
overuse of opioid analgesics due to the risk of accidental overdose and death. The
diversion of controlled substances continues to be major concern. This can also
occur in LTC facilities! Every patient visit should include a review of current analgesic utilization (both scheduled and as needed) with a goal to discontinue any
unused, unnecessary, or ineffective drugs.
Medication Treatment Goals forHypertension
The elderly are at high risk for cardiovascular events, thus blood pressure should be
monitored and hypertension treated. Recommendations from the Joint National
Commission 8 (JNC-8) published in 2014 set BP goals for persons over the age of
60years at <150/90. This goal has been controversial as many clinicians advocate a
lower blood pressure goal of 140/90in persons under the age of 80 and a higher goal
of 150/90 for those over the age of 80. There also has been a change in the recommended BP goals for patients with chronic kidney disease (CKD) and diabetes from
<130/80 to <140/90. The Joint National Commission also recommended that clinicians investigate for secondary causes/contributors to hypertension (see Table 5),
Medication Management inLong-Term Care
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Table 5 Secondary causes of hypertension
Cause How to identify
Medication Medication reconciliation: check for nonsteroidal anti-inammatory (NSAIDS),
steroids, venlafaxine, estrogen-containing preparations (found in herbals,
over-the-counter meds)
Alcohol abuse AUDIT-C
Obstructive SAEpworth sleepiness scale, sleep study, snoring history
Lifestyle High sodium diet, increased body mass index (BMI), lack of exercise
Primary renal Basic metabolic prole (BMP), urine sediment, urine for microalbumin/
creatinine
Renovascular Clinical atherosclerosis: PVD, CAD, CVD
Acute onset/exacerbation of hypertension; +abdominal bruit, deterioration of
renal function after angiotensin-converting enzyme inhibitor (ACEI) or
angiotensin receptor blocker (ARB)
Aldosteronism Electrolytes (low potassium)
Adapted from reference [40]
359
assess for end organ damage, and better monitor for side effects of antihypertensive
medication (including postural hypotension) [40].
Newer recommendations from ACC/AHA in 2017 call for stricter control of
blood pressure [41]. These recommendations dene elderly as individuals >65years
of age and recommend starting pharmacotherapy with BPs >130/80. It is important
to note that the American College of Physicians (ACP) and the American Academy
of Family Physicians (AAFP) did not support the ACC/AHA recommendations and
continue to recommend the original JNC-8 guidelines with BP goals for individuals
over 60years of age at <150/90. Additionally, in 2018 the European Society of
Cardiology (ECS) and European Society of Hypertension (ESH) stratied patients
further to a “very old” category, dening those 80 years of age. In these patients,
they recommended starting pharmacotherapy at BPs >160/90. A lower BP target of
130–139/70–79 could be considered in those over 65years old, but not the very
old (>85).
Although the ACC/AHA and the ECS/ESH guidelines differ in denitions and
thresholds, both agree that treatment of high blood pressure in the elderly is pivotal
to reduce atherosclerotic cardiovascular risk, and recommend caution and close
monitoring.
If clinically appropriate, it is particularly important in geriatric patients to optimize antihypertensive therapy with lifestyle modications, including the implementation of the Dietary Approaches to Stop Hypertension (DASH) diet with a sodium
restriction of 1500 mg/day (4 g or two-thirds of a teaspoon of table salt) [42].
Restrictive diets are not recommended in the frail elderly because of the potential to
cause weight loss. If, however, dietary intervention is insufcient to control blood
pressure, a low-dose thiazide diuretic and long-acting calcium channel blocker can
be prescribed unless comorbidities merit the choice of other drugs. See chapter:
“Common Clinical Conditions in Long-Term Care” for further discussion on the
treatment of hypertension.
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