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 the 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.
Responsible Medication Management is the second domain of the CMS measure that aims to optimize medication management by monitoring medication use that may be potentially inappropriate in older adults due to increased risk of harm. 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 on 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 AGS 2023 Beers criteria and the Geriatric Emergency Medication Safety Recommendations (GEMS-Rx). For clinicians working in the ED, the medications most frequently seen and for which the ED can intervene are listed below. These medications also impact the other 4M’s such as mobility (these are ALL fall risk drugs) and mentation (many of these drugs are also deliriogenic).
Benzodiazepines
e.g. Alprazolam (XANAX), Clonazepam (KLONOPIN), Lorazepam (ATIVAN), Diazepam (VALIUM), Temazepam (RESTORIL).
Cause CNS sedation and withdrawal. Increase delirium risk, increase fall risk, and are not generally effective in reducing agitation. If patient is already taking, maintain or lower dose, but do not discontinue abruptly.
Benzodiazepines are acceptable to use for seizure disorders, benzodiazepine or ethanol withdrawal, severe generalized anxiety disorder, and end of life.
Instead: Use nonpharmacologic sleep strategies. For epilepsy, use other anticonvulsants (eg, lamotrigine (LAMICTAL), levetiracetam (KEPPRA)). For agitation, treat pain first with acetaminophen (TYLENOL), then low-dose opioid. For severe agitation, use low-dose antipsychotic (eg, olanzapine (ZYPREXA), risperidone (RISPERDAL), quetiapine(SEROQUEL) [Lewy body dementia]).
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. Eszopiclone (LUNESTA), Zaleplon (SONATA), Zolpidem (AMBIEN).
Cause CNS sedation and withdrawal. Like other sedatives, these agents can cause delirium.
Instead: Use nonpharmacologic sleep strategies. For insomnia, use melatonin, ramelteon (ROZEREM), low-dose doxepin (SILENOR). For anxiety, use mirtazapine (REMERON), buspirone (BUCAPSOL), serotonin–norepinephrine reuptake inhibitors (eg, duloxetine (CYMBALTA), venlafaxine (EFFEXOR), desvenlafaxine (PRISTIQ)).
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. For allergies, consider using intranasal saline, steroids or second-generation antihistamines (eg, cetirizine (ZYRTEC), loratadine (CLARITIN)). For vertigo, use short-term steroids and canalith repositioning maneuvers.
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)
Barbiturates
e.g. Primidone, Phenobarbital.
Causes CNS sedation. Delirium can occur despite therapeutic drug concentrations.
Instead: For epilepsy, use other anticonvulsants (eg, lamotrigine (LAMICTAL), levetiracetam (KEPPRA)). For agitation, treat pain first with acetaminophen (TYLENOL), then low-dose opioid. For severe agitation, use low-dose antipsychotic (eg, olanzapine (ZYPREXA), risperidone (RISPERDAL), quetiapine(SEROQUEL) [Lewy body dementia])
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
Skeletal Muscle Relaxants
e.g. Carisoprodol (SOMA), Chlorzoxazone (LORZONE), Cyclobenzaprine (AMRIX, FLEXERIL), Metaxalone (SKELAXIN), Methocarbamol (ROBAXIN), Orphenadrine.
Causes anticholinergic toxicity, sedation, and increased risk of falls and fractures. for the management of spasticity, baclofen (and tizanidine) may be appropriate but these drugs can also cause substantial adverse effects in older adults.”
Instead: Musculoskeletal pain can be managed first with nonpharmacologic agents (e.g. heat, ice, massage) then with acetaminophen (TYLENOL), short-course NSAIDs, lidocaine patch, diclofenac gel.
Antipsychotics
e.g. Aripiprazole, Haloperidol, Olanzapine, Quetiapine, Risperidone, others.
Causes greater rate of cognitive decline, increased risk of stroke and mortality in persons with dementia. Antipsychotics may be appropriate in patients treated for schizophrenia, bipolar disorder, Parkinson disease psychosis, adjunctive treatment of major depressive disorder, or for short-term use as an antiemetic.
Instead: Avoid antipsychotics for behavioral problems of dementia unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others.
This list is adapted from 1. Marcantonio ER. Delirium in hospitalized older adults. N Engl J Med 2017 and 2. Skains RM et al. Geriatric Emergency Medication Safety Recommendations (GEMS-Rx): Modified Delphi Development of a High-Risk Prescription List for Older Emergency Department Patients. Ann Emerg Med 2024.
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 – all benzodiazepines increase delirium risk, increase fall risk, and are not generally effective in reducing agitation (can use Beers or Choosing Wisely warning).
- Opioid dosages in older patients. Tailor ordering panels for this patient population and use decreased doses.
- NSAIDS – although on Beers, short term use with lower dosages is reasonable in patients 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
