Version May 2024
| Indicator title | Description | Rationale |
| Medication list | An up-to-date medication list that includes over-the-counter medications should be accessible to all health care providers in the medical record. | Enables identification of potential drug-related causes of new symptoms, eliminates inappropriate duplications, allows review for drug-drug interactions, and allows streamlining of regimen to improve adherence. |
| Annual drug regimen review | All vulnerable older adults should have an annual drug regimen review. | Allows an opportunity for discontinuing unnecessary medications, or addition of necessary drugs that are not currently prescribed. |
| Drug indication | All drugs prescribed for vulnerable older adults should have a clearly defined indication. | Allows discontinuing medications that may have been prescribed for unclear or transient indications. |
| Patient education | All vulnerable older adults (or caregivers) should receive appropriate education about the use of any prescribed drug. | Education may improve adherence and clinical outcomes; also can alert patients or caregivers to potential adverse effects. |
| Response to therapy | Response to therapy should be documented for all ongoing medical conditions. | Documenting response will help clarify whether a drug is meeting the therapeutic goal for which it was prescribed and provides a basis for continuation, modification, or discontinuation. |
| Education for warfarin therapy | Patients newly prescribed warfarin should receive education about diet, drug interactions, and risk of bleeding, or should be referred to an anticoagulation clinic. | Awareness of drugs and dietary substances that interact with warfarin can decrease the risk of bleeding complications. |
| Monitoring warfarin therapy | When warfarin is prescribed, INR should be determined within 4 days of initiation of therapy and at least every 6 weeks therafter.* | Older adults are at high risk for drug toxicity, and close monitoring can help maintain the INR within the therapeutic range. |
| Monitoring ACE inhibitor therapy | When ACE inhibitor therapy is prescribed, a serum creatinine and potassium should be monitored within 2 weeks after initiation of therapy and at least yearly thereafter. | Older adults are at increased risk of renal insufficiency and hyperkalemia. |
| Monitoring loop diuretic therapy | When loop diuretic therapy is prescribed, electrolytes should be checked within 2 weeks after initiation and at least annually. | Risk of hypokalemia due to diuretic therapy. |
| Avoid propoxyphene | Do not prescribe propoxyphene as an analgesic agent. | Propoxyphene is inferior to, or at best equivalent to, acetaminophen or other analgesics with better safety profiles. |
| Avoid chronic or high-dose benzodiazepine use | If a benzodiazepine is taken for more than 1 month, there should be documentation of discussion of risks and attempt to taper or discontinue. | Benzodiazepines increase the risk of falls, hip fracture, and confusion. |
| Avoid drugs with strong anticholinergic properties | Do not prescribe drug therapies with a strong anticholinergic effect if alternative therapies are available. | These therapies are associated with adverse events such as confusion, urinary retention, constipation, visual disturbance, and hypotension. |
| Avoid barbiturates | If an older adult does require the therapy for control of seizures, do not use barbiturates. | These therapies are potent central nervous system depressants, have a low therapeutic index, are highly addictive, cause drug interactions, and are associated with an increased risk for falls and hip fracture. |
| Avoid meperidine as an opioid analgesic | When analgesia is required, avoid use of meperidine. | This therapy is associated with an increased risk for delirium and may be associated with the development of seizures. |
| Avoid chronic use of ketorolac | Ketorolac should not be prescribed for more than 5 days. | This therapy is associated with a high risk of GI side effects, including bleeding, and other analgesics are safer in older patients. |
| Avoid skeletal muscle relaxants | Skeletal muscle relaxants (cyclobenzaprine, methocarbamol, carisoprodol, chlorzoxazone, orphenadrine, tizanidine, metaxalone) should not be prescribed for more than 1 week. | These medications can cause anticholinergic adverse effects, sedation, confusion, and data of efficacy are limited. |
| Avoid ticlopidine | Clopidogrel should be prescribed rather than ticlopidine for patients who require antiplatelet therapy (eg, recent stroke, myocardial infarction, acute coronary syndrome, percutaneous angioplasty). | Ticlopidine may be less effective than clopidogrel and is associated with a higher risk of hematological disorders than clopidogrel. |
| Treat iron deficiency anemia with low-dose oral iron therapy | Vulnerable older adults with iron deficiency anemia should take no more than 1 low-dose oral iron tablet daily. | Low-dose therapy is equally effective with fewer adverse effects than high-dose oral iron therapy. |
| Antipsychotic medication response | An assessment of response should be documented within 1 month for older adults started on an antipsychotic drug. | The use of antipsychotic drugs increases mortality in older adults, and behavioral modification is an effective alternative. |
| Acetaminophen | Older adults prescribed high-dose (≥3 g per day) acetaminophen, or those with liver disease taking acetaminophen chronically, should be advised of the risk of liver toxicity. | The risk of liver toxicity is greater with use of acetaminophen. |
| NSAIDs and aspirin | The risk of GI bleeding should be discussed and documented. Individuals at increased risk for GI bleeding (age >75 years, peptic ulcer disease, history of GI bleeding, warfarin use, chronic glucocorticoid use) should be treated concomitantly with misoprostol or a proton pump inhibitor when treated with a nonselective NSAID. | Risks of GI bleeding are increased in older adults taking NSAIDs or daily aspirin. |
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