Kenneth Koncilja, MD

Medications started for appropriate indications in middle age may need to be monitored more closely as the patient ages. Some drugs may become unnecessary or even dangerous as the patient ages, functional status and renal function decline, and goals of care change.

See related editorial

Older adults tend to have multiple illnesses and therefore take more drugs, and polypharmacy increases the risk of poor outcomes. The number of medications a person uses is a risk factor for adverse drug reactions, nonadherence, financial burden, drug-drug interactions, and worse outcomes.¹

The prevalence of polypharmacy increased from an estimated 8.2% to 15% from 1999 to 2011 based on the National Health and Nutrition Examination Survey.² Guideline-based therapy for specific diseases may lead to the addition of more medications to reach disease targets.³ Most older adults in the United States compound the risk of prescribed medications by also taking over-the-counter medications and dietary supplements.⁴

In addition, medications are often used in older adults based on studies of younger persons without significant comorbidities. Applying clinical guidelines based on these studies to older adults with comorbidity and functional impairment is challenging.⁵ Age-related pharmacokinetic and pharmacodynamic changes increase the risk of adverse drug reactions.⁶

In this article, we review commonly used medications that are potentially inappropriate based on clinical practice. We also review tools to evaluate appropriate drug therapy in older adults.

DRUGS THAT ARE COMMONLY USED, BUT POTENTIALLY INAPPROPRIATE

Statins

Statins are effective when used as secondary prevention in older adults,⁷ but their efficacy when used as primary prevention of atherosclerotic cardiovascular disease in people age 75 and older is questionable.⁸ Nevertheless, they are widely used for this purpose. For example, before the 2013 joint guidelines of the American College of Cardiology and the American Heart Association (ACC/AHA) were released, 22% of patients age 80 and older in the Geisinger health system were taking a statin for primary prevention.⁹

The 2013 ACC/AHA guidelines included a limited recommendation for statins for primary prevention of atherosclerotic cardiovascular disease in adults age 75 and older.¹⁰ The guideline noted, however, that few data were available to support this recommendation.¹⁰

In a systematic review of 18 randomized clinical trials of statins for primary prevention of atherosclerotic cardiovascular disease, the mean age was 57, yet conclusions were extrapolated to an older patient population.¹¹ The estimated 10-year risk of atherosclerotic cardiovascular disease based on pooled cohort risk equations of adults age 75 and older always exceeds the 7.5% treatment threshold recommended by the guidelines.⁸

Myopathy is a common adverse effect of statins. In addition, statins interact with other drugs that inhibit the cytochrome P450 3A4 isoenzyme, such as amlodipine, amiodarone, and diltiazem.^8,12 If statin therapy caused no functional limitation due to muscle pain or weakness, statins for primary prevention would be cost-effective, but even a small increase in adverse effects in an elderly patient can offset the cardiovascular benefit.¹³ A recent post hoc secondary analysis found no benefit of pravastatin for primary prevention in adults age 75 and older.¹⁴

Thus, statin treatment for primary prevention in older patients should be individualized, based on life expectancy, function, and cardiovascular risk. Statin therapy does not replace modification of other risk factors.

Anticholinergics

Drugs with anticholinergic properties are commonly prescribed in the elderly for conditions such as muscle spasm, overactive bladder, psychiatric disorders, insomnia, extrapyramidal symptoms, vertigo, pruritus, peptic ulcer disease, seasonal allergies, and even the common cold,¹⁵ and many of the drugs often prescribed have strong anticholinergic properties (Table 1). Taking multiple medications with anticholinergic properties results in a high “anticholinergic burden,” which is associated with falls, impulsive behavior, poor physical performance, loss of independence, dementia, delirium, and brain atrophy.^15–18

The 2014 American College of Physicians guideline on nonsurgical management of urinary incontinence in women recommends pharmacologic treatment for urgency and stress urinary incontinence after failure of nonpharmacologic therapy,¹⁹ and many drugs for these urinary symptoms have anticholinergic properties. If an anticholinergic is necessary, an agent that results in a lower anticholinergic burden should be considered in older patients.

A pharmacist-initiated medication review and intervention may be another way to adjust medications to reduce the patient’s anticholinergic burden.^20,21 The common use of anticholinergic drugs in older adults reminds us to monitor their use closely.²²

Benzodiazepines are among the most commonly prescribed psychotropics in developed countries and are prescribed mainly by primary care physicians rather than psychiatrists.²³

In 2008, 5.2% of US adults ages 18 to 80 used a benzodiazepine, and long-term use was more prevalent in older patients (ages 65–80).²³

Benzodiazepines are prescribed for anxiety,²⁴ insomnia,²⁵ and agitation. They can cause withdrawal²⁶ and have potential for abuse.²⁷ Benzodiazepines are associated with cognitive decline,²⁸ impaired driving,²⁹ falls,³⁰ and hip fractures³¹ in older adults.

In addition, use of nonbenzodiazepine hypnotics (eg, zolpidem) is on the rise,³² and these drugs are known to increase the risk of hip fracture in nursing home residents.³³

The American Geriatrics Society, through the American Board of Internal Medicine’s Choosing Wisely campaign, recommends avoiding benzodiazepines as a first-line treatment for insomnia, agitation, or delirium in older adults.³⁴ Yet prescribing practices with these drugs in primary care settings conflict with guidelines, partly due to lack of training in constructive strategies regarding appropriate use of benzodiazepines.³⁵ Educating patients on the risks and benefits of benzodiazepine treatment, especially long-term use, has been shown to reduce the rate of benzodiazepine-associated secondary events.³⁶

Antipsychotics

Off-label use of antipsychotics is common and is increasing in the United States. In 2008, off-label use of antipsychotic drugs accounted for an estimated $6 billion.³⁷ A common off-label use is to manage behavioral symptoms of dementia, despite a black-box warning about an increased risk of death in patients with dementia who are treated with antipsychotics.^38,39 The Choosing Wisely campaign recommends against prescribing antipsychotics as a first-line treatment of behavioral and psychological symptoms of dementia.³⁴

Antipsychotic drugs are associated with risk of acute kidney injury,⁴⁰ as well as increased risk of falls and fractures (eg, a 52% higher risk of a serious fall, and a 50% higher risk of a nonvertebral osteoporotic fracture).⁴¹

Patients with dementia often exhibit aggression, resistance to care, and other challenging or disruptive behaviors. In such instances, antipsychotic drugs are often prescribed, but they provide limited and inconsistent benefits, while causing oversedation and worsening of cognitive function and increasing the likelihood of falling, stroke, and death.^38,39,41

Because pharmacologic treatments for dementia are only modestly effective, have notable risks, and do not treat some of the behaviors that family members and caregivers find most distressing, nonpharmacologic measures are recommended as first-line treatment.⁴² These include caregiver education and support, training in problem-solving, and targeted therapy directed at the underlying causes of specific behaviors (eg, implementing nighttime routines to address sleep disturbances).⁴² Nonpharmacologic management of behavioral symptoms in dementia can significantly improve quality of life for patients and caregivers.⁴² Use of antipsychotic drugs in patients with dementia should be limited to cases in which nonpharmacologic measures have failed and patients pose an imminent threat to themselves or others.⁴³

Proton pump inhibitors

Proton pump inhibitors are among the most commonly prescribed medications in the United States, and their use has increased significantly over the decade. It has been estimated that between 25% and 70% of these prescriptions have no appropriate indication.⁴⁴

There is considerable excess use of acid suppressants in both inpatient and outpatient settings.^45,46 In one study, at discharge from an internal medicine service, almost half of patients were taking a proton pump inhibitor.⁴⁷

Evidence-based guidelines recommend these drugs to treat gastroesophageal reflux disease, nonerosive reflux disease, erosive esophagitis, dyspepsia, and peptic ulcer disease. However, long-term use (ie, beyond 8 weeks) is recommended only for patients with erosive esophagitis, Barrett esophagus, a pathologic hypersecretory condition, or a demonstrated need for maintenance treatment for reflux disease.⁴⁸

Although proton pump inhibitors are highly effective and have low toxicity, there are reports of an association with Clostridium difficile infection,⁴⁹ community-acquired pneumonia,⁵⁰ hip fracture,⁵¹ vitamin B₁₂ deficiency,⁵² atrophic gastritis,⁵³ kidney disease,⁵⁴ and dementia.⁵⁵

Nondrug therapies such as weight loss and elevation of the head of the bed may improve esophageal pH levels and reflux symptoms.⁵⁶

Deprescribing.org has practical advice for healthcare providers, patients, and caregivers on how to discontinue proton pump inhibitors, including videos, algorithms, and guidelines.

TOOLS TO EVALUATE APPROPRIATE DRUG THERAPY

Beers criteria

The Beers criteria (Table 2), developed in 1991 by a geriatrician as an approach to safer, more effective drug therapy in frail elderly nursing home patients,⁵⁷ were updated by the American Geriatrics Society in 2015 for use in any clinical setting.⁵⁸ (The criteria are also available as a smartphone application through the American Geriatrics Society at www.americangeriatrics.org.)

The Beers criteria offer evidence-based recommendations on drugs to avoid in the elderly, along with the rationale for use, the quality of evidence behind the recommendation, and the graded strength of the recommendation. The Beers criteria should be viewed through the lens of clinical judgment to offer safer nonpharmacologic and pharmacologic treatments.

The Joint Commission recommends medication reconciliation at every transition of care.⁵⁹ The Beers criteria are a good starting point for a comprehensive medication review.

STOPP/START criteria

Another tool to aid safe prescribing in older adults is the Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions (STOPP), used in conjuction with the Screening Tool to Alert Doctors to Right Treatment (START). The STOPP/START criteria^60,61 are based on an up-to-date literature review and consensus (Table 3).

THE BOTTOM LINE

Physicians caring for older adults need to diligently weigh the benefits of drug therapy and consider the patient’s care goals, current level of functioning, life expectancy, values, and preferences. Statin therapy for primary prevention, anticholinergics, benzodiazepines, antipsychotics, and proton pump inhibitors are widely used without proper indications, pointing to the need for a periodic comprehensive review of medications to reevaluate the risks vs the benefits of the patient’s medications. The Beers criteria and the STOPP/ START criteria can be useful tools for this purpose.

Medications started for appropriate indications in middle age may need to be monitored more closely as the patient ages. Some drugs may become unnecessary or even dangerous as the patient ages, functional status and renal function decline, and goals of care change.

See related editorial

Older adults tend to have multiple illnesses and therefore take more drugs, and polypharmacy increases the risk of poor outcomes. The number of medications a person uses is a risk factor for adverse drug reactions, nonadherence, financial burden, drug-drug interactions, and worse outcomes.¹

The prevalence of polypharmacy increased from an estimated 8.2% to 15% from 1999 to 2011 based on the National Health and Nutrition Examination Survey.² Guideline-based therapy for specific diseases may lead to the addition of more medications to reach disease targets.³ Most older adults in the United States compound the risk of prescribed medications by also taking over-the-counter medications and dietary supplements.⁴

In addition, medications are often used in older adults based on studies of younger persons without significant comorbidities. Applying clinical guidelines based on these studies to older adults with comorbidity and functional impairment is challenging.⁵ Age-related pharmacokinetic and pharmacodynamic changes increase the risk of adverse drug reactions.⁶

In this article, we review commonly used medications that are potentially inappropriate based on clinical practice. We also review tools to evaluate appropriate drug therapy in older adults.

DRUGS THAT ARE COMMONLY USED, BUT POTENTIALLY INAPPROPRIATE

Statins

Statins are effective when used as secondary prevention in older adults,⁷ but their efficacy when used as primary prevention of atherosclerotic cardiovascular disease in people age 75 and older is questionable.⁸ Nevertheless, they are widely used for this purpose. For example, before the 2013 joint guidelines of the American College of Cardiology and the American Heart Association (ACC/AHA) were released, 22% of patients age 80 and older in the Geisinger health system were taking a statin for primary prevention.⁹

The 2013 ACC/AHA guidelines included a limited recommendation for statins for primary prevention of atherosclerotic cardiovascular disease in adults age 75 and older.¹⁰ The guideline noted, however, that few data were available to support this recommendation.¹⁰

In a systematic review of 18 randomized clinical trials of statins for primary prevention of atherosclerotic cardiovascular disease, the mean age was 57, yet conclusions were extrapolated to an older patient population.¹¹ The estimated 10-year risk of atherosclerotic cardiovascular disease based on pooled cohort risk equations of adults age 75 and older always exceeds the 7.5% treatment threshold recommended by the guidelines.⁸

Myopathy is a common adverse effect of statins. In addition, statins interact with other drugs that inhibit the cytochrome P450 3A4 isoenzyme, such as amlodipine, amiodarone, and diltiazem.^8,12 If statin therapy caused no functional limitation due to muscle pain or weakness, statins for primary prevention would be cost-effective, but even a small increase in adverse effects in an elderly patient can offset the cardiovascular benefit.¹³ A recent post hoc secondary analysis found no benefit of pravastatin for primary prevention in adults age 75 and older.¹⁴

Thus, statin treatment for primary prevention in older patients should be individualized, based on life expectancy, function, and cardiovascular risk. Statin therapy does not replace modification of other risk factors.

Anticholinergics

Drugs with anticholinergic properties are commonly prescribed in the elderly for conditions such as muscle spasm, overactive bladder, psychiatric disorders, insomnia, extrapyramidal symptoms, vertigo, pruritus, peptic ulcer disease, seasonal allergies, and even the common cold,¹⁵ and many of the drugs often prescribed have strong anticholinergic properties (Table 1). Taking multiple medications with anticholinergic properties results in a high “anticholinergic burden,” which is associated with falls, impulsive behavior, poor physical performance, loss of independence, dementia, delirium, and brain atrophy.^15–18

The 2014 American College of Physicians guideline on nonsurgical management of urinary incontinence in women recommends pharmacologic treatment for urgency and stress urinary incontinence after failure of nonpharmacologic therapy,¹⁹ and many drugs for these urinary symptoms have anticholinergic properties. If an anticholinergic is necessary, an agent that results in a lower anticholinergic burden should be considered in older patients.

A pharmacist-initiated medication review and intervention may be another way to adjust medications to reduce the patient’s anticholinergic burden.^20,21 The common use of anticholinergic drugs in older adults reminds us to monitor their use closely.²²

Benzodiazepines are among the most commonly prescribed psychotropics in developed countries and are prescribed mainly by primary care physicians rather than psychiatrists.²³

In 2008, 5.2% of US adults ages 18 to 80 used a benzodiazepine, and long-term use was more prevalent in older patients (ages 65–80).²³

Benzodiazepines are prescribed for anxiety,²⁴ insomnia,²⁵ and agitation. They can cause withdrawal²⁶ and have potential for abuse.²⁷ Benzodiazepines are associated with cognitive decline,²⁸ impaired driving,²⁹ falls,³⁰ and hip fractures³¹ in older adults.

In addition, use of nonbenzodiazepine hypnotics (eg, zolpidem) is on the rise,³² and these drugs are known to increase the risk of hip fracture in nursing home residents.³³

The American Geriatrics Society, through the American Board of Internal Medicine’s Choosing Wisely campaign, recommends avoiding benzodiazepines as a first-line treatment for insomnia, agitation, or delirium in older adults.³⁴ Yet prescribing practices with these drugs in primary care settings conflict with guidelines, partly due to lack of training in constructive strategies regarding appropriate use of benzodiazepines.³⁵ Educating patients on the risks and benefits of benzodiazepine treatment, especially long-term use, has been shown to reduce the rate of benzodiazepine-associated secondary events.³⁶

Antipsychotics

Off-label use of antipsychotics is common and is increasing in the United States. In 2008, off-label use of antipsychotic drugs accounted for an estimated $6 billion.³⁷ A common off-label use is to manage behavioral symptoms of dementia, despite a black-box warning about an increased risk of death in patients with dementia who are treated with antipsychotics.^38,39 The Choosing Wisely campaign recommends against prescribing antipsychotics as a first-line treatment of behavioral and psychological symptoms of dementia.³⁴

Antipsychotic drugs are associated with risk of acute kidney injury,⁴⁰ as well as increased risk of falls and fractures (eg, a 52% higher risk of a serious fall, and a 50% higher risk of a nonvertebral osteoporotic fracture).⁴¹

Patients with dementia often exhibit aggression, resistance to care, and other challenging or disruptive behaviors. In such instances, antipsychotic drugs are often prescribed, but they provide limited and inconsistent benefits, while causing oversedation and worsening of cognitive function and increasing the likelihood of falling, stroke, and death.^38,39,41

Because pharmacologic treatments for dementia are only modestly effective, have notable risks, and do not treat some of the behaviors that family members and caregivers find most distressing, nonpharmacologic measures are recommended as first-line treatment.⁴² These include caregiver education and support, training in problem-solving, and targeted therapy directed at the underlying causes of specific behaviors (eg, implementing nighttime routines to address sleep disturbances).⁴² Nonpharmacologic management of behavioral symptoms in dementia can significantly improve quality of life for patients and caregivers.⁴² Use of antipsychotic drugs in patients with dementia should be limited to cases in which nonpharmacologic measures have failed and patients pose an imminent threat to themselves or others.⁴³

Proton pump inhibitors

Proton pump inhibitors are among the most commonly prescribed medications in the United States, and their use has increased significantly over the decade. It has been estimated that between 25% and 70% of these prescriptions have no appropriate indication.⁴⁴

There is considerable excess use of acid suppressants in both inpatient and outpatient settings.^45,46 In one study, at discharge from an internal medicine service, almost half of patients were taking a proton pump inhibitor.⁴⁷

Evidence-based guidelines recommend these drugs to treat gastroesophageal reflux disease, nonerosive reflux disease, erosive esophagitis, dyspepsia, and peptic ulcer disease. However, long-term use (ie, beyond 8 weeks) is recommended only for patients with erosive esophagitis, Barrett esophagus, a pathologic hypersecretory condition, or a demonstrated need for maintenance treatment for reflux disease.⁴⁸

Although proton pump inhibitors are highly effective and have low toxicity, there are reports of an association with Clostridium difficile infection,⁴⁹ community-acquired pneumonia,⁵⁰ hip fracture,⁵¹ vitamin B₁₂ deficiency,⁵² atrophic gastritis,⁵³ kidney disease,⁵⁴ and dementia.⁵⁵

Nondrug therapies such as weight loss and elevation of the head of the bed may improve esophageal pH levels and reflux symptoms.⁵⁶

Deprescribing.org has practical advice for healthcare providers, patients, and caregivers on how to discontinue proton pump inhibitors, including videos, algorithms, and guidelines.

TOOLS TO EVALUATE APPROPRIATE DRUG THERAPY

Beers criteria

The Beers criteria (Table 2), developed in 1991 by a geriatrician as an approach to safer, more effective drug therapy in frail elderly nursing home patients,⁵⁷ were updated by the American Geriatrics Society in 2015 for use in any clinical setting.⁵⁸ (The criteria are also available as a smartphone application through the American Geriatrics Society at www.americangeriatrics.org.)

The Beers criteria offer evidence-based recommendations on drugs to avoid in the elderly, along with the rationale for use, the quality of evidence behind the recommendation, and the graded strength of the recommendation. The Beers criteria should be viewed through the lens of clinical judgment to offer safer nonpharmacologic and pharmacologic treatments.

The Joint Commission recommends medication reconciliation at every transition of care.⁵⁹ The Beers criteria are a good starting point for a comprehensive medication review.

STOPP/START criteria

Another tool to aid safe prescribing in older adults is the Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions (STOPP), used in conjuction with the Screening Tool to Alert Doctors to Right Treatment (START). The STOPP/START criteria^60,61 are based on an up-to-date literature review and consensus (Table 3).

THE BOTTOM LINE

Physicians caring for older adults need to diligently weigh the benefits of drug therapy and consider the patient’s care goals, current level of functioning, life expectancy, values, and preferences. Statin therapy for primary prevention, anticholinergics, benzodiazepines, antipsychotics, and proton pump inhibitors are widely used without proper indications, pointing to the need for a periodic comprehensive review of medications to reevaluate the risks vs the benefits of the patient’s medications. The Beers criteria and the STOPP/ START criteria can be useful tools for this purpose.

Medications started for appropriate indications in middle age may need to be monitored more closely as the patient ages. Some drugs may become unnecessary or even dangerous as the patient ages, functional status and renal function decline, and goals of care change.

See related editorial

Older adults tend to have multiple illnesses and therefore take more drugs, and polypharmacy increases the risk of poor outcomes. The number of medications a person uses is a risk factor for adverse drug reactions, nonadherence, financial burden, drug-drug interactions, and worse outcomes.¹

The prevalence of polypharmacy increased from an estimated 8.2% to 15% from 1999 to 2011 based on the National Health and Nutrition Examination Survey.² Guideline-based therapy for specific diseases may lead to the addition of more medications to reach disease targets.³ Most older adults in the United States compound the risk of prescribed medications by also taking over-the-counter medications and dietary supplements.⁴

In addition, medications are often used in older adults based on studies of younger persons without significant comorbidities. Applying clinical guidelines based on these studies to older adults with comorbidity and functional impairment is challenging.⁵ Age-related pharmacokinetic and pharmacodynamic changes increase the risk of adverse drug reactions.⁶

In this article, we review commonly used medications that are potentially inappropriate based on clinical practice. We also review tools to evaluate appropriate drug therapy in older adults.

DRUGS THAT ARE COMMONLY USED, BUT POTENTIALLY INAPPROPRIATE

Statins

Statins are effective when used as secondary prevention in older adults,⁷ but their efficacy when used as primary prevention of atherosclerotic cardiovascular disease in people age 75 and older is questionable.⁸ Nevertheless, they are widely used for this purpose. For example, before the 2013 joint guidelines of the American College of Cardiology and the American Heart Association (ACC/AHA) were released, 22% of patients age 80 and older in the Geisinger health system were taking a statin for primary prevention.⁹

The 2013 ACC/AHA guidelines included a limited recommendation for statins for primary prevention of atherosclerotic cardiovascular disease in adults age 75 and older.¹⁰ The guideline noted, however, that few data were available to support this recommendation.¹⁰

In a systematic review of 18 randomized clinical trials of statins for primary prevention of atherosclerotic cardiovascular disease, the mean age was 57, yet conclusions were extrapolated to an older patient population.¹¹ The estimated 10-year risk of atherosclerotic cardiovascular disease based on pooled cohort risk equations of adults age 75 and older always exceeds the 7.5% treatment threshold recommended by the guidelines.⁸

Myopathy is a common adverse effect of statins. In addition, statins interact with other drugs that inhibit the cytochrome P450 3A4 isoenzyme, such as amlodipine, amiodarone, and diltiazem.^8,12 If statin therapy caused no functional limitation due to muscle pain or weakness, statins for primary prevention would be cost-effective, but even a small increase in adverse effects in an elderly patient can offset the cardiovascular benefit.¹³ A recent post hoc secondary analysis found no benefit of pravastatin for primary prevention in adults age 75 and older.¹⁴

Thus, statin treatment for primary prevention in older patients should be individualized, based on life expectancy, function, and cardiovascular risk. Statin therapy does not replace modification of other risk factors.

Anticholinergics

Drugs with anticholinergic properties are commonly prescribed in the elderly for conditions such as muscle spasm, overactive bladder, psychiatric disorders, insomnia, extrapyramidal symptoms, vertigo, pruritus, peptic ulcer disease, seasonal allergies, and even the common cold,¹⁵ and many of the drugs often prescribed have strong anticholinergic properties (Table 1). Taking multiple medications with anticholinergic properties results in a high “anticholinergic burden,” which is associated with falls, impulsive behavior, poor physical performance, loss of independence, dementia, delirium, and brain atrophy.^15–18

The 2014 American College of Physicians guideline on nonsurgical management of urinary incontinence in women recommends pharmacologic treatment for urgency and stress urinary incontinence after failure of nonpharmacologic therapy,¹⁹ and many drugs for these urinary symptoms have anticholinergic properties. If an anticholinergic is necessary, an agent that results in a lower anticholinergic burden should be considered in older patients.

A pharmacist-initiated medication review and intervention may be another way to adjust medications to reduce the patient’s anticholinergic burden.^20,21 The common use of anticholinergic drugs in older adults reminds us to monitor their use closely.²²

Benzodiazepines are among the most commonly prescribed psychotropics in developed countries and are prescribed mainly by primary care physicians rather than psychiatrists.²³

In 2008, 5.2% of US adults ages 18 to 80 used a benzodiazepine, and long-term use was more prevalent in older patients (ages 65–80).²³

Benzodiazepines are prescribed for anxiety,²⁴ insomnia,²⁵ and agitation. They can cause withdrawal²⁶ and have potential for abuse.²⁷ Benzodiazepines are associated with cognitive decline,²⁸ impaired driving,²⁹ falls,³⁰ and hip fractures³¹ in older adults.

In addition, use of nonbenzodiazepine hypnotics (eg, zolpidem) is on the rise,³² and these drugs are known to increase the risk of hip fracture in nursing home residents.³³

The American Geriatrics Society, through the American Board of Internal Medicine’s Choosing Wisely campaign, recommends avoiding benzodiazepines as a first-line treatment for insomnia, agitation, or delirium in older adults.³⁴ Yet prescribing practices with these drugs in primary care settings conflict with guidelines, partly due to lack of training in constructive strategies regarding appropriate use of benzodiazepines.³⁵ Educating patients on the risks and benefits of benzodiazepine treatment, especially long-term use, has been shown to reduce the rate of benzodiazepine-associated secondary events.³⁶

Antipsychotics

Off-label use of antipsychotics is common and is increasing in the United States. In 2008, off-label use of antipsychotic drugs accounted for an estimated $6 billion.³⁷ A common off-label use is to manage behavioral symptoms of dementia, despite a black-box warning about an increased risk of death in patients with dementia who are treated with antipsychotics.^38,39 The Choosing Wisely campaign recommends against prescribing antipsychotics as a first-line treatment of behavioral and psychological symptoms of dementia.³⁴

Antipsychotic drugs are associated with risk of acute kidney injury,⁴⁰ as well as increased risk of falls and fractures (eg, a 52% higher risk of a serious fall, and a 50% higher risk of a nonvertebral osteoporotic fracture).⁴¹

Patients with dementia often exhibit aggression, resistance to care, and other challenging or disruptive behaviors. In such instances, antipsychotic drugs are often prescribed, but they provide limited and inconsistent benefits, while causing oversedation and worsening of cognitive function and increasing the likelihood of falling, stroke, and death.^38,39,41

Because pharmacologic treatments for dementia are only modestly effective, have notable risks, and do not treat some of the behaviors that family members and caregivers find most distressing, nonpharmacologic measures are recommended as first-line treatment.⁴² These include caregiver education and support, training in problem-solving, and targeted therapy directed at the underlying causes of specific behaviors (eg, implementing nighttime routines to address sleep disturbances).⁴² Nonpharmacologic management of behavioral symptoms in dementia can significantly improve quality of life for patients and caregivers.⁴² Use of antipsychotic drugs in patients with dementia should be limited to cases in which nonpharmacologic measures have failed and patients pose an imminent threat to themselves or others.⁴³

Proton pump inhibitors

Proton pump inhibitors are among the most commonly prescribed medications in the United States, and their use has increased significantly over the decade. It has been estimated that between 25% and 70% of these prescriptions have no appropriate indication.⁴⁴

There is considerable excess use of acid suppressants in both inpatient and outpatient settings.^45,46 In one study, at discharge from an internal medicine service, almost half of patients were taking a proton pump inhibitor.⁴⁷

Evidence-based guidelines recommend these drugs to treat gastroesophageal reflux disease, nonerosive reflux disease, erosive esophagitis, dyspepsia, and peptic ulcer disease. However, long-term use (ie, beyond 8 weeks) is recommended only for patients with erosive esophagitis, Barrett esophagus, a pathologic hypersecretory condition, or a demonstrated need for maintenance treatment for reflux disease.⁴⁸

Although proton pump inhibitors are highly effective and have low toxicity, there are reports of an association with Clostridium difficile infection,⁴⁹ community-acquired pneumonia,⁵⁰ hip fracture,⁵¹ vitamin B₁₂ deficiency,⁵² atrophic gastritis,⁵³ kidney disease,⁵⁴ and dementia.⁵⁵

Nondrug therapies such as weight loss and elevation of the head of the bed may improve esophageal pH levels and reflux symptoms.⁵⁶

Deprescribing.org has practical advice for healthcare providers, patients, and caregivers on how to discontinue proton pump inhibitors, including videos, algorithms, and guidelines.

TOOLS TO EVALUATE APPROPRIATE DRUG THERAPY

Beers criteria

The Beers criteria (Table 2), developed in 1991 by a geriatrician as an approach to safer, more effective drug therapy in frail elderly nursing home patients,⁵⁷ were updated by the American Geriatrics Society in 2015 for use in any clinical setting.⁵⁸ (The criteria are also available as a smartphone application through the American Geriatrics Society at www.americangeriatrics.org.)

The Beers criteria offer evidence-based recommendations on drugs to avoid in the elderly, along with the rationale for use, the quality of evidence behind the recommendation, and the graded strength of the recommendation. The Beers criteria should be viewed through the lens of clinical judgment to offer safer nonpharmacologic and pharmacologic treatments.

The Joint Commission recommends medication reconciliation at every transition of care.⁵⁹ The Beers criteria are a good starting point for a comprehensive medication review.

STOPP/START criteria

Another tool to aid safe prescribing in older adults is the Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions (STOPP), used in conjuction with the Screening Tool to Alert Doctors to Right Treatment (START). The STOPP/START criteria^60,61 are based on an up-to-date literature review and consensus (Table 3).

THE BOTTOM LINE

Physicians caring for older adults need to diligently weigh the benefits of drug therapy and consider the patient’s care goals, current level of functioning, life expectancy, values, and preferences. Statin therapy for primary prevention, anticholinergics, benzodiazepines, antipsychotics, and proton pump inhibitors are widely used without proper indications, pointing to the need for a periodic comprehensive review of medications to reevaluate the risks vs the benefits of the patient’s medications. The Beers criteria and the STOPP/ START criteria can be useful tools for this purpose.

Most older drivers are safe drivers and are less likely than younger people to drive recklessly, at high speeds, or under the influence of alcohol.¹ However, motor vehicle injuries are the second leading cause of injury-related deaths among older adults. Very old adults (80 years and over) have higher rates of fatality and injury in motor vehicle crashes per million miles driven than any other age group except for teenagers.¹ Therefore, consider safety screening of all very old drivers plus any older adult with certain high-risk medical conditions, including the following.

NEUROCOGNITIVE DISORDERS

Drivers with Alzheimer disease—the most common type of major neurocognitive disorder (dementia) in older adults in the United States—are at high risk for adverse driving events due to impaired memory, attentiveness, problem-solving skills, multitasking, orientation, judgment, and reaction speed. Even in amnesic mild cognitive impairment—a mild neurocognitive disorder without functional decline—driving skills such as lane control may be impaired.²

Frontotemporal dementia, a less common cause of dementia in older adults, is associated with profound impairments in reasoning, task flexibility, planning, and execution. Persons with frontotemporal dementia are more likely to speed, run stop signs, and suffer more off-road crashes and collisions.³

Discuss driving safety with any patient age 80 or older or one with specific conditions

The diagnosis of dementia, however, is less predictive of driving risk than the stage of dementia. The American Academy of Neurology recommends that health care providers clinically “stage” all demented individuals using a validated tool at diagnosis and periodically afterwards. The Clinical Dementia Rating (CDR) scale is appropriate for staging dementia in the office. The CDR has also been shown to identify people with dementia who are at an increased risk of unsafe driving, with strong  evidence (level of evidence A) relating dementia stage to driving risk.⁴ The CDR assigns a score of 1 for mild dementia (function impaired in at least one complex activity); 2 for moderate dementia (function impaired in at least one basic activity); and 3 for severe dementia. Individuals with a CDR score of 2 or higher are considered to be at very high risk if still driving. These persons should be encouraged to surrender their driving privileges.⁴ Even with mild dementia (CDR score of 1), as few as 41% of drivers may drive safely.⁴ Most persons with mild cognitive impairment (CDR score of 0.5) are safe drivers.

Patients often have poor insight into their driving safety. However, a caregiver’s rating of driving skills as marginal or unsafe is useful in identifying unsafe drivers (level of evidence B) and can be considered a red flag.⁴ Predictors with less support in the literature (level of evidence C) include recent traffic citations, motor vehicle accidents, and self-reported situational avoidance, such as limiting driving to familiar roadways. Additional predictors include Mini-Mental State Examination scores of 24 or less, and/or the emergence of an aggressive or impulsive personality (Table 1). A driver evaluation is helpful when there is mild cognitive impairment or mild dementia with at least one red flag.

Clinicians who are not comfortable with staging dementia as mild, moderate, or severe may consider referring to a neurologist or geriatrician.

There is no evidence to support or refute the benefit of interventional strategies such as driver rehabilitation for drivers with dementia.

PARKINSON DISEASE

Individuals with mild motor disability from Parkinson disease may be fit drivers. As the disease progresses, drivers with Parkinson disease may make more errors than healthy elders in visual scanning, signaling, vehicle positioning, and velocity regulation (eg, traveling so slowly that it may be unsafe).⁵ Clinicians can consider referring a patient with Parkinson disease for a baseline driving evaluation upon diagnosis, and then every 1 to 2 years for reassessment. Alternate transportation should be arranged as the disease progresses.

EPISODIC INCAPACITATION

Approximately 1% to 3% of all motor vehicle accidents are due to sudden incapacitation of an otherwise safe driver.

Syncope. Neurally mediated (vasovagal) syncope accounts for 30% to 35% of syncopal episodes while driving.⁶ Cardiac arrhythmias are the next most common cause and include bradyarrhythmias (7%), supraventricular tachyarrhythmias (2%–15%), and ventricular tachyarrhythmias (5%–17%). Because neurocardiogenic syncope often recurs, consider restricting driving for those with recurrent or severe neurocardiogenic syncopal episodes until symptoms are controlled.

Arrhythmias. Driving recommendations for various arrhythmias^7,8 are listed in Table 2.

Many patients who have an implantable cardioverter-defibrillator (ICD) device experience an unexpected shock. For individuals with a history of ventricular tachycardia or fibrillation, the 5-year actuarial incidence of appropriate ICD shocks ranges between 55% and 70%. However, data indicate that 90% to 100% of drivers who received ICD discharges while driving continued to drive without causing motor vehicle accidents.^9,10

Seizures. States differ in their rules for reporting drivers who have epilepsy or breakthrough seizures. Physicians should refer to their state regulations when counseling these patients.

POLYPHARMACY

Polypharmacy is common in older adults. Many take psychoactive drugs that can impair tracking, alertness, coordination, and reaction time. With the “Roadwise Rx” tool  (www.roadwiserx.com), health care providers and patients can enter the names of medicines to check if they affect driving ability. Nonproprietary on-line tools such as “START” (Screening Tool to Alert doctors to Right Treatment) and “STOPP” (Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions) can be used to prune medication lists.

DRIVING EVALUATION

America is a nation of highways overflowing with cars. Cars provide transportation but also reflect wealth and personality, particularly for men. Practically, the ability to drive a car allows older men and women to socialize in the community, shop for essentials, and take care of themselves without being a burden. Driving cessation can cause social isolation and depressive symptoms and can strain caregiver resources.

Patients’ self-rating of driving correlates poorly with caregivers’ ratings

It is therefore understandable for health care providers to feel reluctant or uncomfortable counseling older adults to give up their driving privileges. A health care provider who identifies driving safety concerns can refer a patient to a geriatrician for further risk  assessment or to a certified driver rehabilitation specialist (CDRS) for a driving evaluation. A CDRS will also offer the patient and caregiver information on local resources for transportation alternatives. A list of local CDRSs can be found on the Association for Driver Rehabilitation Specialists website (www.aded.net). Many hospitals have occupational therapists who are CDRSs.

The evaluation typically involves an assessment of the driver’s knowledge of traffic signs and laws, a cognitive assessment, possibly a simulation, and finally an on-road driving evaluation if deemed appropriate. Medicare coverage depends on diagnosis and the state carrier.

Most older drivers are safe drivers and are less likely than younger people to drive recklessly, at high speeds, or under the influence of alcohol.¹ However, motor vehicle injuries are the second leading cause of injury-related deaths among older adults. Very old adults (80 years and over) have higher rates of fatality and injury in motor vehicle crashes per million miles driven than any other age group except for teenagers.¹ Therefore, consider safety screening of all very old drivers plus any older adult with certain high-risk medical conditions, including the following.

NEUROCOGNITIVE DISORDERS

Drivers with Alzheimer disease—the most common type of major neurocognitive disorder (dementia) in older adults in the United States—are at high risk for adverse driving events due to impaired memory, attentiveness, problem-solving skills, multitasking, orientation, judgment, and reaction speed. Even in amnesic mild cognitive impairment—a mild neurocognitive disorder without functional decline—driving skills such as lane control may be impaired.²

Frontotemporal dementia, a less common cause of dementia in older adults, is associated with profound impairments in reasoning, task flexibility, planning, and execution. Persons with frontotemporal dementia are more likely to speed, run stop signs, and suffer more off-road crashes and collisions.³

Discuss driving safety with any patient age 80 or older or one with specific conditions

The diagnosis of dementia, however, is less predictive of driving risk than the stage of dementia. The American Academy of Neurology recommends that health care providers clinically “stage” all demented individuals using a validated tool at diagnosis and periodically afterwards. The Clinical Dementia Rating (CDR) scale is appropriate for staging dementia in the office. The CDR has also been shown to identify people with dementia who are at an increased risk of unsafe driving, with strong  evidence (level of evidence A) relating dementia stage to driving risk.⁴ The CDR assigns a score of 1 for mild dementia (function impaired in at least one complex activity); 2 for moderate dementia (function impaired in at least one basic activity); and 3 for severe dementia. Individuals with a CDR score of 2 or higher are considered to be at very high risk if still driving. These persons should be encouraged to surrender their driving privileges.⁴ Even with mild dementia (CDR score of 1), as few as 41% of drivers may drive safely.⁴ Most persons with mild cognitive impairment (CDR score of 0.5) are safe drivers.

Patients often have poor insight into their driving safety. However, a caregiver’s rating of driving skills as marginal or unsafe is useful in identifying unsafe drivers (level of evidence B) and can be considered a red flag.⁴ Predictors with less support in the literature (level of evidence C) include recent traffic citations, motor vehicle accidents, and self-reported situational avoidance, such as limiting driving to familiar roadways. Additional predictors include Mini-Mental State Examination scores of 24 or less, and/or the emergence of an aggressive or impulsive personality (Table 1). A driver evaluation is helpful when there is mild cognitive impairment or mild dementia with at least one red flag.

Clinicians who are not comfortable with staging dementia as mild, moderate, or severe may consider referring to a neurologist or geriatrician.

There is no evidence to support or refute the benefit of interventional strategies such as driver rehabilitation for drivers with dementia.

PARKINSON DISEASE

Individuals with mild motor disability from Parkinson disease may be fit drivers. As the disease progresses, drivers with Parkinson disease may make more errors than healthy elders in visual scanning, signaling, vehicle positioning, and velocity regulation (eg, traveling so slowly that it may be unsafe).⁵ Clinicians can consider referring a patient with Parkinson disease for a baseline driving evaluation upon diagnosis, and then every 1 to 2 years for reassessment. Alternate transportation should be arranged as the disease progresses.

EPISODIC INCAPACITATION

Approximately 1% to 3% of all motor vehicle accidents are due to sudden incapacitation of an otherwise safe driver.

Syncope. Neurally mediated (vasovagal) syncope accounts for 30% to 35% of syncopal episodes while driving.⁶ Cardiac arrhythmias are the next most common cause and include bradyarrhythmias (7%), supraventricular tachyarrhythmias (2%–15%), and ventricular tachyarrhythmias (5%–17%). Because neurocardiogenic syncope often recurs, consider restricting driving for those with recurrent or severe neurocardiogenic syncopal episodes until symptoms are controlled.

Arrhythmias. Driving recommendations for various arrhythmias^7,8 are listed in Table 2.

Many patients who have an implantable cardioverter-defibrillator (ICD) device experience an unexpected shock. For individuals with a history of ventricular tachycardia or fibrillation, the 5-year actuarial incidence of appropriate ICD shocks ranges between 55% and 70%. However, data indicate that 90% to 100% of drivers who received ICD discharges while driving continued to drive without causing motor vehicle accidents.^9,10

Seizures. States differ in their rules for reporting drivers who have epilepsy or breakthrough seizures. Physicians should refer to their state regulations when counseling these patients.

POLYPHARMACY

Polypharmacy is common in older adults. Many take psychoactive drugs that can impair tracking, alertness, coordination, and reaction time. With the “Roadwise Rx” tool  (www.roadwiserx.com), health care providers and patients can enter the names of medicines to check if they affect driving ability. Nonproprietary on-line tools such as “START” (Screening Tool to Alert doctors to Right Treatment) and “STOPP” (Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions) can be used to prune medication lists.

DRIVING EVALUATION

America is a nation of highways overflowing with cars. Cars provide transportation but also reflect wealth and personality, particularly for men. Practically, the ability to drive a car allows older men and women to socialize in the community, shop for essentials, and take care of themselves without being a burden. Driving cessation can cause social isolation and depressive symptoms and can strain caregiver resources.

Patients’ self-rating of driving correlates poorly with caregivers’ ratings

It is therefore understandable for health care providers to feel reluctant or uncomfortable counseling older adults to give up their driving privileges. A health care provider who identifies driving safety concerns can refer a patient to a geriatrician for further risk  assessment or to a certified driver rehabilitation specialist (CDRS) for a driving evaluation. A CDRS will also offer the patient and caregiver information on local resources for transportation alternatives. A list of local CDRSs can be found on the Association for Driver Rehabilitation Specialists website (www.aded.net). Many hospitals have occupational therapists who are CDRSs.

The evaluation typically involves an assessment of the driver’s knowledge of traffic signs and laws, a cognitive assessment, possibly a simulation, and finally an on-road driving evaluation if deemed appropriate. Medicare coverage depends on diagnosis and the state carrier.

Most older drivers are safe drivers and are less likely than younger people to drive recklessly, at high speeds, or under the influence of alcohol.¹ However, motor vehicle injuries are the second leading cause of injury-related deaths among older adults. Very old adults (80 years and over) have higher rates of fatality and injury in motor vehicle crashes per million miles driven than any other age group except for teenagers.¹ Therefore, consider safety screening of all very old drivers plus any older adult with certain high-risk medical conditions, including the following.

NEUROCOGNITIVE DISORDERS

Drivers with Alzheimer disease—the most common type of major neurocognitive disorder (dementia) in older adults in the United States—are at high risk for adverse driving events due to impaired memory, attentiveness, problem-solving skills, multitasking, orientation, judgment, and reaction speed. Even in amnesic mild cognitive impairment—a mild neurocognitive disorder without functional decline—driving skills such as lane control may be impaired.²

Frontotemporal dementia, a less common cause of dementia in older adults, is associated with profound impairments in reasoning, task flexibility, planning, and execution. Persons with frontotemporal dementia are more likely to speed, run stop signs, and suffer more off-road crashes and collisions.³

Discuss driving safety with any patient age 80 or older or one with specific conditions

The diagnosis of dementia, however, is less predictive of driving risk than the stage of dementia. The American Academy of Neurology recommends that health care providers clinically “stage” all demented individuals using a validated tool at diagnosis and periodically afterwards. The Clinical Dementia Rating (CDR) scale is appropriate for staging dementia in the office. The CDR has also been shown to identify people with dementia who are at an increased risk of unsafe driving, with strong  evidence (level of evidence A) relating dementia stage to driving risk.⁴ The CDR assigns a score of 1 for mild dementia (function impaired in at least one complex activity); 2 for moderate dementia (function impaired in at least one basic activity); and 3 for severe dementia. Individuals with a CDR score of 2 or higher are considered to be at very high risk if still driving. These persons should be encouraged to surrender their driving privileges.⁴ Even with mild dementia (CDR score of 1), as few as 41% of drivers may drive safely.⁴ Most persons with mild cognitive impairment (CDR score of 0.5) are safe drivers.

Patients often have poor insight into their driving safety. However, a caregiver’s rating of driving skills as marginal or unsafe is useful in identifying unsafe drivers (level of evidence B) and can be considered a red flag.⁴ Predictors with less support in the literature (level of evidence C) include recent traffic citations, motor vehicle accidents, and self-reported situational avoidance, such as limiting driving to familiar roadways. Additional predictors include Mini-Mental State Examination scores of 24 or less, and/or the emergence of an aggressive or impulsive personality (Table 1). A driver evaluation is helpful when there is mild cognitive impairment or mild dementia with at least one red flag.

Clinicians who are not comfortable with staging dementia as mild, moderate, or severe may consider referring to a neurologist or geriatrician.

There is no evidence to support or refute the benefit of interventional strategies such as driver rehabilitation for drivers with dementia.

PARKINSON DISEASE

Individuals with mild motor disability from Parkinson disease may be fit drivers. As the disease progresses, drivers with Parkinson disease may make more errors than healthy elders in visual scanning, signaling, vehicle positioning, and velocity regulation (eg, traveling so slowly that it may be unsafe).⁵ Clinicians can consider referring a patient with Parkinson disease for a baseline driving evaluation upon diagnosis, and then every 1 to 2 years for reassessment. Alternate transportation should be arranged as the disease progresses.

EPISODIC INCAPACITATION

Approximately 1% to 3% of all motor vehicle accidents are due to sudden incapacitation of an otherwise safe driver.

Syncope. Neurally mediated (vasovagal) syncope accounts for 30% to 35% of syncopal episodes while driving.⁶ Cardiac arrhythmias are the next most common cause and include bradyarrhythmias (7%), supraventricular tachyarrhythmias (2%–15%), and ventricular tachyarrhythmias (5%–17%). Because neurocardiogenic syncope often recurs, consider restricting driving for those with recurrent or severe neurocardiogenic syncopal episodes until symptoms are controlled.

Arrhythmias. Driving recommendations for various arrhythmias^7,8 are listed in Table 2.

Many patients who have an implantable cardioverter-defibrillator (ICD) device experience an unexpected shock. For individuals with a history of ventricular tachycardia or fibrillation, the 5-year actuarial incidence of appropriate ICD shocks ranges between 55% and 70%. However, data indicate that 90% to 100% of drivers who received ICD discharges while driving continued to drive without causing motor vehicle accidents.^9,10

Seizures. States differ in their rules for reporting drivers who have epilepsy or breakthrough seizures. Physicians should refer to their state regulations when counseling these patients.

POLYPHARMACY

Polypharmacy is common in older adults. Many take psychoactive drugs that can impair tracking, alertness, coordination, and reaction time. With the “Roadwise Rx” tool  (www.roadwiserx.com), health care providers and patients can enter the names of medicines to check if they affect driving ability. Nonproprietary on-line tools such as “START” (Screening Tool to Alert doctors to Right Treatment) and “STOPP” (Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions) can be used to prune medication lists.

DRIVING EVALUATION

America is a nation of highways overflowing with cars. Cars provide transportation but also reflect wealth and personality, particularly for men. Practically, the ability to drive a car allows older men and women to socialize in the community, shop for essentials, and take care of themselves without being a burden. Driving cessation can cause social isolation and depressive symptoms and can strain caregiver resources.

Patients’ self-rating of driving correlates poorly with caregivers’ ratings

It is therefore understandable for health care providers to feel reluctant or uncomfortable counseling older adults to give up their driving privileges. A health care provider who identifies driving safety concerns can refer a patient to a geriatrician for further risk  assessment or to a certified driver rehabilitation specialist (CDRS) for a driving evaluation. A CDRS will also offer the patient and caregiver information on local resources for transportation alternatives. A list of local CDRSs can be found on the Association for Driver Rehabilitation Specialists website (www.aded.net). Many hospitals have occupational therapists who are CDRSs.

The evaluation typically involves an assessment of the driver’s knowledge of traffic signs and laws, a cognitive assessment, possibly a simulation, and finally an on-road driving evaluation if deemed appropriate. Medicare coverage depends on diagnosis and the state carrier.