Pathy's Principles and Practice of Geriatric Medicine. Группа авторов

      Research showed that the routine use of the Pill Pruner tool safely limits the number of medications taken by older patients on admission to the hospital, reduces the number of medications on hospital discharge, and reminds about the need to communicate medication changes to the patient’s primary practitioner by ensuring that the hospital discharge summary accurately reflects the medications changes made in the hospital.³⁰ In the original study, patients were followed up at 90 days post‐hospital discharge, and the changes made while in the hospital were maintained as an outpatient.

      The Drug Burden Index (DBI) was introduced in 2007³¹ and is designed to measure cumulative exposure to anticholinergic and sedative medications, including its impact on physical and cognitive function.^32,33 Despite its limitations (see Table 10.3), the DBI is useful for predicting the risk of ADRs, as a high DBI has been correlated with an increased risk for functional decline in community‐dwelling older adults and an increased risk of falls in residents of long‐term care facilities.^33‐35

The Tool to Reduce Inappropriate Medications (TRIM) was developed in 2016 at the US Veterans Affairs (VA) Medical Center.³⁶ TRIM uses a computer algorithm based on Beers and STOPP criteria to identify PIMs and provide recommendations for medication discontinuation. The computer programme extracts information from the electronic health record related to age, medications, and chronic medical conditions, identifying high‐risk patients and providing feedback reports to clinicians for evaluating the medication regimen. These algorithms identify medication regimen discrepancies, poor treatment adherence, potential overtreatment of diabetes and hypertension, inappropriate drug renal dosing, and a list of patient‐reported medication‐related adverse reactions.³⁶ While TRIM has only been validated in the US VA system, the potential for this tool to have widespread applicability and positively impact the care of older adults on a population health level in the era of electronic health record use is significant.

      The Fit fOR The Aged (FORTA) tool was introduced in 2008 as a classification system to help prescribers screen for PIMS and PPOs in older adults.^37,38 It is the first to combine both positive and negative labelling into one tool and has been validated in various settings and countries. The FORTA system classifies each medication into one of the following four categories:

      Initial studies have shown improvement in medication management and fall reduction with the use of FORTA.³⁹

Principles of appropriate prescribing

      The prescribing and management of medications is a clinical procedure that takes time, expertise, and accuracy to improve patient outcomes. Appropriate prescribing for patients of any age balances a particular medication’s potential benefits against the known risks for that individual. Appropriate prescribing avoids clinical inertia but limits the medication list to what is absolutely necessary to prevent disease or decline, manage chronic diseases, and improve quality of life. While extreme polypharmacy (taking 10 or more medications) has been associated with increased adverse events, including death,^40‐44 there is no known ‘appropriate polypharmacy threshold’ for people with multimorbidity. Appropriate prescribing will always consider the patient’s age, goals of care, functional status, and life expectancy.

      With patients’ increasing age, prescribers need to heed the principle of the happy medium for chronic disease management. That is, as we age, the benefit of tight disease control decreases and the risk of overtreatment increases. For many chronic diseases, the clinical targets shift to become more liberalized depending on the individual person’s age and functional status. As an example, people over the age of 70 with hypertension have a U‐shaped mortality curve with increased risk with very high blood pressure and low blood pressure. This curve becomes sharper with each decade of life.⁴⁵ However, recent clinical trials suggest that the individual’s functional status is just as important, if not more so, than age alone. Robust patients over age 80 may benefit from stricter blood pressure control, while frail or disabled patients will have worse outcomes with stricter blood pressure control.^46‐48

      Medications used for primary prevention of diseases, such as cardiovascular disease, become less effective as patients near the end of life. If certain drugs take years to show benefit, then the risk of side effects may outweigh benefits in those with less than 5‐ to 10‐year life expectancy. Life expectancy tables based on age and gender exist to help guide decision‐making.^49,50 Caution should be taken not to underestimate life expectancy, especially in healthy older people. Prognostication is more accurate if you combine clinical judgment with life tables, functional status assessment, and severity of comorbid conditions. Appropriate prescribing, therefore, needs to include a good geriatric assessment that evaluates for frailty, physical function, physical fitness, and life expectancy. For evaluation of these, please see Chapters 7 (‘Physical Fitness and Exercise’), 95 (‘Maintaining Functional Status’), 97 (‘Frailty’), and 120 (‘End‐of‐Life and Palliative Care’).

      When prescribing medications for older adults, remember the following basic principles: