The Age Friendly Hospital measure assesses hospital commitment to improving care for patients 65 years or older receiving services in the hospital, operating room, or emergency department. This structural measure seeks to ensure that hospitals are reliably implementing the “4 M’s,” and thus providing evidence-based elements of high-quality care for all older adults. The elements in the Age Friendly Hospital measure align with IHI’s and the John A. Hartford Foundation’s national initiative for Age Friendly Systems, in which many hospitals already participate. This measure consists of five domains that address essential aspects of clinical care for older patients.
The five domains for hospital attestation and key elements for each domain include:
Domain 1: Eliciting Patient Healthcare Goals – This domain focuses on obtaining patients’ health-related goals and treatment preferences, which will inform shared decision making and goal-concordant care.
Domain 2: Responsible Medication Management -This domain aims to optimize medication management by monitoring the pharmacological record for drugs that may be considered inappropriate in older adults due to increased risk of harm.
Domain 3: Frailty Screening and Intervention – This domain aims to screen patients for geriatric issues related to frailty, including cognitive impairment/delirium, physical function/mobility, and malnutrition, for the purpose of early detection and intervention where appropriate.
Domain 4: Social Vulnerability – This domain seeks to ensure that hospitals recognize the importance of social vulnerability screening of older adults and have systems in place to ensure that social issues are identified and addressed as part of the care plan.
Domain 5: Age-Friendly Care Leadership – This domain seeks to ensure consistent quality of care for older adults through the identification of an age friendly champion and/or interprofessional committee tasked with ensuring compliance with all components of this measure.
Hospitals or health systems would need to evaluate and determine whether they can affirmatively attest to each domain, some of which have multiple attestation statements.
For a hospital or a health system to affirmatively attest to domain 2, they would evaluate and determine whether it engaged in each of the elements that comprise the domain.
The measure requires hospitals to attest to the following: Our hospital reviews medications for the purpose of identifying potentially inappropriate medications (PIMs) for older adults as defined by standard evidence-based guidelines, criteria, or protocols. Review should be undertaken upon admission, before major procedures, and/or upon significant changes in clinical status. Once identified, PIMs should be considered for discontinuation and/or dose adjustment as indicated.
Tip: Focus more than just polypharmacy of 5 or greater medication (since many older adults with chronic conditions would meet this threshold) but rather presence of PIMs or high-risk drugs (appropriate but these drugs have a narrow therapeutic index e.g. anticoagulant)
Identify High Risk Psychotropics and Other Medications in Older Adults
For a complete list of high-risk medications for older adults you can consult the Beers list. The medications below are a set that are seen frequently in the emergency department and also impact the other 4M’s – mobility (these are all fall risk drugs); mentation (many of these drugs increase delirium risk).
Benzodiazepines
Cause CNS sedation and withdrawal. Associated with delirium in hospitalized patients; if patient is already taking, maintain or lower dose, but do not discontinue abruptly.
Instead: Use nonpharmacologic sleep strategies
Opioids
Cause anticholinergic toxicity, CNS sedation, and fecal impaction. Consider risks versus benefits, since uncontrolled pain can also cause delirium; patients with renal insufficiency are at elevated risk for adverse effects; naloxone can be used for severe overdoses.
Instead: Use local and regional analgesic measures; non-psychoactive pain medications (e.g., acetaminophen and NSAIDs) around the clock; reserve opioids for breakthrough and severe pain.
Nonbenzodiazepine sedative hypnotics
(e.g. zolpidem, eszopiclone)
Cause CNS sedation and withdrawal. Like other sedatives, these agents can cause delirium.
Instead: Use nonpharmacologic sleep strategies
Antihistamines
especially first-generation sedating agents (e.g., doxylamine diphenhydramine, dimenhydrinate)
Cause anticholinergic toxicity. Patients should be asked about the use of over-the-counter medications; many patients do not realize that drugs with names ending in “PM” contain diphenhydramine or other sedating antihistamines.
Instead: Use nonpharmacologic sleep strategies, pseudoephedrine for upper respiratory congestion, and nonsedating antihistamines for allergies.
Alcohol
Causes CNS sedation and withdrawal. The history taking must include questions about alcohol intake.
Instead: If patient has a history of heavy intake, monitor closely and use benzodiazepines for withdrawal symptoms.
Antimuscarinics
(e.g. Overactive bladder medications such as oxybutynin and benztropine)
Causes anticholinergic toxicity. Though delirium is unusual at low doses.
Instead: Lower the dose or use behavioral approaches for urinary incontinence (e.g., scheduled toileting)
Anticonvulsants
(e.g. primidone, phenobarbital, and phenytoin)
Causes CNS sedation. Delirium can occur despite therapeutic drug concentrations.
Instead: Use an alternative agent or consider stopping if patient is at low risk for seizures and has no recent history of them.
Tricyclic antidepressants
(especially tertiary)
Causes Anticholinergic toxicity. Newer agents (e.g., duloxetine) are as effective as tertiary amines for adjuvant treatment of chronic pain.
Instead: Use serotonin-reuptake inhibitors or serotonin–norepinephrine reuptake inhibitors
This list is adapted from Adapted from Marcantonio ER. Delirium in hospitalized older adults. N Engl J Med. 2017. DOI: 10.1056/NEJMcp1605501;
Dose Adjustment for Older Adults
Physicians need to appreciate the age-related physiological changes, as well as the presence of other medications that necessitate dose adjustment in older adults. Lower doses may be more appropriate.
The Beers list provides a list of potentially inappropriate medications, but includes a lot of nuance so not every drug listed will require a BPA. Instead as you approach a process improvement for dose adjustment consider 5-10 commonly prescribed medications on the Beers list. These can be removed from EMR ordering panels with a rationale for education and suggestions for alternatives.
The goal is to identify the right patients, the right meds/doses, and provide rationale and alternatives to prescribing physicians.
Top 5 Meds to consider removing from ordering panels:
- Diphenhydramine– for itching with opioids, for sleep
- Dimenhydrinate – for nausea and vomiting
- Benzodiazepines – for agitation, can increase delirium risk (can use Beers or Choosing Wisely warning)
- Opioid dosages in older pts. Tailor ordering panels for this pt population and use decreased doses
- NSAIDS – although on Beers, short term use with lower dosages is reasonable in pts with good renal function and low risk of GI adverse events; can minimize opioid use and decrease delirium risk
References
American Geriatrics Society 2023 updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023. DOI:10.1111/jgs.18372
Marcantonio ER. Delirium in hospitalized older adults. N Engl J Med. 2017. DOI: 10.1056/NEJMcp1605501;
ED Programs to Support Geriatric Medication Safety SR/MA in JAMA Network Open: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2831215
Contributors
