Joseph T. Hanlon

Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

Background Inappropriate polypharmacy, prevalent among older patients, is associated with substantial harms. Objective To develop measures of high-risk polypharmacy and pilot test novel electronic health record (EHR)-based nudges grounded in behavioral science to promote deprescribing. Design We developed and validated seven measures, then conducted a three-arm pilot from February to May 2019. Participants Validation used data from 78,880 patients from a single large health system. Six physicians were pre-pilot test environment users. Sixty-nine physicians participated in the pilot. Main Measures Rate of high-risk polypharmacy among patients aged 65 years or older. High-risk polypharmacy was defined as being prescribed ≥5 medications and satisfying ≥1 of the following high-risk criteria: drugs that increase fall risk among patients with fall history; drug-drug interactions that increase fall risk; thiazolidinedione, NSAID, or non-dihydropyridine calcium channel blocker in heart failure; and glyburide, glimepiride, or NSAID in chronic kidney disease. Interventions Physicians received EHR alerts when renewing or prescribing certain high-risk medications when criteria were met. One practice received a “commitment nudge” that offered a chance to commit to addressing high-risk polypharmacy at the next visit. One practice received a “justification nudge” that asked for a reason when high-risk polypharmacy was present. One practice received both. Key Results Among 55,107 patients 65 and older prescribed 5 or more medications, 6256 (7.9%) had one or more high-risk criteria. During the pilot, the mean (SD) number of nudges per physician per week was 1.7 (0.4) for commitment, 0.8 (0.5) for justification, and 1.9 (0.5) for both interventions. Physicians requested to be reminded to address high-risk polypharmacy for 236/833 (28.3%) of the commitment nudges and acknowledged 441 of 460 (95.9%) of justification nudges, providing a text response for 187 (40.7%). Conclusions EHR-based measures and nudges addressing high-risk polypharmacy were feasible to develop and implement, and warrant further testing.

Objective To provide clinicians with information about avoiding adverse drug withdrawal events (ADWEs) when discontinuing unnecessary medications as per the STOPPFrail criteria. Data Sources Searches of MEDLINE (1970-June 2020), the Cochrane Database of Systematic Reviews (through June 2020), Google Scholar (through June 2020). Study Selection Reviews and original studies of ADWEs. Data Extraction Tapering protocols for specific drugs/ classes from randomized controlled deprescribing trials. Data Synthesis Six drug classes were identified as being high risk for physiological ADWEs. Conclusion The occurrence of ADWEs is rare in comparison to adverse drug reactions in older adults. Few drugs/classes have been reported to have physiological ADWEs with abrupt discontinuation. For these we provide information about tapering protocols and symptom monitoring to avoid ADWEs.

OBJECTIVE: To establish consensus recommendations for empirical treatment of uncomplicated cystitis with anti‐infectives in noncatheterized older nursing home residents to be implemented in the Improving Outcomes of UTI Management in Long‐Term Care Project (IOU) funded by the Agency for Healthcare Research and Quality. DESIGN: Two‐round modified Delphi survey. PARTICIPANTS: Expert panel of 19 clinical pharmacists. MEASUREMENTS: Comprehensive literature search and development/review/edit of draft survey by the investigative group (one geriatric clinical pharmacist, two geriatric medicine physicians, and one infectious disease physician). The expert panel members rated their agreement with each of 31 recommendations for drugs of choice, dosing medications at various levels of renal function, drug‐drug interactions to avoid, and duration of therapy by sex on a 5‐point Likert scale (1 = strongly disagree to 5 = strongly agree). Consensus agreement was defined as a lower 95% confidence limit of 4.0 or higher for the recommendation‐specific mean score. RESULTS: The response rate was 95% for the first round, and three recommendations achieved consensus (dosing for nitrofurantoin and trimethoprim/sulfamethoxazole in those without chronic kidney disease, and drug‐drug interaction between trimethoprim/sulfamethoxazole and warfarin). In the second round, 90% responded and reached consensus on an additional eight recommendations (two for nitrofurantoin or trimethoprim/sulfamethoxazole as initial drugs of choice, three for dosing ciprofloxacin, nitrofurantoin, and trimethoprim/sulfamethoxazole at various levels of chronic kidney disease, and three drug‐drug interactions to avoid: trimethoprim/sulfamethoxazole with phenytoin and ciprofloxacin with theophylline or with tizanidine). CONCLUSION: An expert panel of clinical pharmacists was able to reach consensus on a set of recommendations for the empirical treatment of cystitis with oral anti‐infective medications in older nursing home residents. The recommendations were incorporated into a treatment algorithm for uncomplicated cystitis in noncatheterized nursing home residents and used in educational materials for health professionals in an ongoing controlled intervention study. J Am Geriatr Soc 67:539–545, 2019.

Medications can pose considerable risk in older adults. This article annotates four articles addressing this concern from 2016. The first provides national data on the use of specific prescription, over‐the‐counter and dietary supplements in older adults and their change over time. The second discusses the opportunity of deprescribing ineffective/unnecessary stool softeners (i.e., docusate) routinely given to older hospital patients. The third national study examines common adverse drug events in older emergency room patients. Finally, a study published demonstrating a potential association between melatonin and fractures is discussed. This manuscript is intended to provide a narrative review of key publications in medication safety for clinicians and researchers committed to improving medication safety in older adults.

Objectives: To examine the association between CNS medication burden and serious falls in those with a recent fall history. Design: Nested‐case control study; cases matched to four controls by age, gender, and date. Setting: US nursing homes. Participants: 5,556 residents age ≥65 with a recent fall history admitted to a nursing home between 1/1‐9/30/2010 and followed until discharge, death, or December 31, 2010. Measurements: Outcome was serious falls as per Medicare Part A and B ICD / CPT codes. CNS burden, from Medicare Part D data, was calculated by dividing the daily dose of each CNS agent (i.e., specific antidepressants, antiepileptic, antipsychotic, benzodiazepine and opioid receptor agonists) received during the 6 days prior to the index (outcome) date by the minimum effective geriatric daily dose and summing the results across medications. Results: There were 367 cases and 1,468 matched controls. Those taking 3 + CNS standardized daily doses were more likely to have a serious fall than those not taking any CNS medications (Adjusted Odds Ratio 1.83; 95% confidence interval 1.35–2.48). There was no significant difference in fall risk for residents taking >0 to <3 CNS standardized daily doses compared to residents taking no CNS medications (Adjusted Odds Ratio 0.85; 95% CI 0.63–1.15). Conclusion: CNS medication burden, approximately 3 + standardized daily doses, was associated with an increased risk of serious falls in nursing home residents with recent fall. Clinicians should be vigilant for opportunities to discontinue or decrease the doses of individual CNS medications and/or consider non‐pharmacological alternatives. Such interventions that reduce use of CNS medications in nursing homes could reduce fall rates but further research is needed to confirm this.

What is known and objective There are few studies examining both drug–drug and drug–disease interactions in older adults. Therefore, the objective of this study was to describe the prevalence of potential drug–drug and drug–disease interactions and associated factors in community‐dwelling older adults. Methods This cross‐sectional study included 3055 adults aged 70–79 without mobility limitations at their baseline visit in the Health Aging and Body Composition Study conducted in the communities of Pittsburgh PA and Memphis TN, USA. The outcome factors were potential drug–drug and drug–disease interactions as per the application of explicit criteria drawn from a number of sources to self‐reported prescription and non‐prescription medication use. Results Over one‐third of participants had at least one type of interaction. Approximately one quarter (25·1%) had evidence of had one or more drug–drug interactions. Nearly 10·7% of the participants had a drug–drug interaction that involved a non‐prescription medication. % The most common drug–drug interaction was non‐steroidal anti‐inflammatory drugs (NSAIDs) affecting antihypertensives. Additionally, 16·0% had a potential drug–disease interaction with 3·7% participants having one involving non‐prescription medications. The most common drug–disease interaction was aspirin/NSAID use in those with history of peptic ulcer disease without gastroprotection. Over one‐third (34·0%) had at least one type of drug interaction. Each prescription medication increased the odds of having at least one type of drug interaction by 35–40% [drug–drug interaction adjusted odds ratio (AOR) = 1·35, 95% confidence interval (CI) = 1·27–1·42; drug–disease interaction AOR = 1·30; CI = 1·21–1·40; and both AOR = 1·45; CI = 1·34–1·57]. A prior hospitalization increased the odds of having at least one type of drug interaction by 49–84% compared with those not hospitalized (drug–drug interaction AOR = 1·49, 95% CI = 1·11–2·01; drug–disease interaction AOR = 1·69, CI = 1·15–2·49; and both AOR = 1·84, CI = 1·20–2·84). What is new and conclusion Drug interactions are common among community‐dwelling older adults and are associated with the number of medications and hospitalization in the previous year. Longitudinal studies are needed to evaluate the impact of drug interactions on health‐related outcomes.