Polypharmacy in Older Adults Nursing CE Course

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The Assessment and Management of Polypharmacy in Older Adults

Disclosure Statement

The purpose of this course is to familiarize the learner with an assessment of polypharmacy amongst older adult patients and the evidence-based strategies to address this concern.

At the conclusion of this course, APRNs will be prepared to:

• recognize the importance of assessing for polypharmacy in older adult patients
• describe the process of deprescribing
• outline various other pharmacology considerations unique to older adult patients

When caring for older adults (aged 65+), various unique considerations should be taken into account. The population of Americans over the age of 65 is expected to more than more than 80 million by 2040 (Centers for Disease Control and Prevention, 2022). Best-practice and evidence-based protocols should be developed and utilized in hospitals, rehabilitation centers, long-term care (LTC) facilities, home-care agencies, and community clinics. These same protocols should be introduced in nursing education programs to enhance familiarity during training. Advanced practice registered nurses (APRNs) must function in tandem with the interdisciplinary team, as the Institute of Medicine (now the National Academy of Medicine) highlights collaboration as vital to the care of the aging in their Retooling for an Aging America: Building the Health Care Workforce report in 2008.

Polypharmacy

The National Center for Health Statistics found that 83% of older adults (ages 60-79) in the United States used at least one prescription medication in the last 30 days, and 34% used at least five medications (Hales et al., 2019). National treatment guidelines may dictate that patients be prescribed several medications to reduce their risk of long-term complications from chronic conditions, such as diabetes mellitus (DM) and coronary artery disease. However, polypharmacy (the simultaneous use of multiple medications) becomes an issue if it contributes to negative outcomes, such as adverse drug events (ADEs), hospital admissions, drug interactions, nonadherence, and increased cost. Polypharmacy is established as an independent risk factor for hip fractures in older adults (National Institute on Aging, 2021; Rochon, 2023). Being prescribed various medications by multiple providers increases the risk of ADEs and drug-drug interactions in older adult patients (Ward & Reuben, 2022). Risk factors for polypharmacy include advancing age, lack of education, ethnicity, health status, and access to a pharmacy (Nguyen et al., 2020). The risk of a drug-drug interaction increases as the number of medications increases. A patient taking 5-9 different medications has a 50% chance of experiencing a drug interaction, and that probability increases to 100% in a patient taking 20 or more medications. While polypharmacy increases the risk of poor adherence, older adult patients may also have other issues specific to their population that affect adherence. These include cognitive impairment, visual impairment, limited financial resources, and limited access to a pharmacy/transportation to a pharmacy, all of which may reduce medication adherence. Patients may also elect to reduce the dose or stop a medication if they experience an unpleasant side effect that they believe is being caused by the medication (Rochon, 2023; Saljoughian, 2019). Additionally, prescriptions that are not being consistently filled or taken as ordered may indicate neglect (Agarwal, 2023). A common phenomenon amongst older adults with multiple prescribed medications, a prescribing cascade, occurs when additional medications are prescribed due to the misdiagnosis of an ADE as a new medical condition. For example, many antipsychotic medications may lead to parkinsonism (symptoms that mimic Parkinson's disease in patients without the underlying diagnosis), prompting the prescription of an antiparkinson medication, which then causes orthostatic hypotension and delirium. Similarly, an anticholinergic drug may be prescribed to manage incontinence that is being caused by a cholinesterase inhibitor being administered to manage dementia (Rochon, 2023).

Prescribing for the Older Adult Patient

The Physiology of Aging

The known physiological changes that occur alongside advancing age should be considered when prescribing medications for older adults. While most medications' absorption rate does not change with age, common medications can alter the absorption of other medications. Additionally, certain conditions may reduce the acidity of the gastrointestinal (GI) tract or the availability of intrinsic factors and affect medication absorption. Furthermore, the percentage of body fat typically increases with age while the amount of total body water decreases. This simple and gradual change can lead to longer half-lives for fat-soluble medications (increased volume of distribution) and an increase in the concentration of water-soluble medications. Hepatic blood flow tends to decrease with age (along with size/mass), which is important because the liver is responsible for metabolizing many of the medications used in modern Western medicine, altering the body's ability to process and clear those drugs. This hepatic impairment may further increase a medication's half-life and alter how frequently it should be dosed. Evaluating for these changes is especially crucial in patients taking medications that are processed via cytochrome P450. Patients with decreased hepatic function who are taking medications processed via cytochrome P450 may experience higher circulating levels of medications or adverse drug reactions (ADRs), especially warfarin (Coumadin) and phenytoin (Dilantin). Older adults may also be more sensitive to the effects of certain medications, such as benzodiazepines (Rochon, 2023; Saljoughian, 2019).

Similarly, drug elimination (clearance) can be impacted by a gradual decline in renal function typically seen in older adults, related to diminished renal blood flow, reduced number of functioning nephrons, decreased glomerular filtration rate (GFR), and tubular secretion. This is typical in patients without renal disease. Decreased elimination increases a medication's half-life, thereby altering how frequently it should be dosed. Reduced lean muscle mass, which is common in older patients, may alter the creatinine clearance (CrCl), rendering this an inaccurate indicator of medication elimination. Medications that rely heavily on renal excretion include histamine-2 receptor antagonists (H2 blockers such as famotidine [Pepcid]), digoxin (Lanoxin), and ciprofloxacin (Cipro). See Table 1 for additional information regarding renal function considerations in prescribing. Increasing levels of unbound or free medication may result from a reduction in serum albumin levels related to malnutrition in a geriatric patient experiencing feeding or eating problems. Decreased cardiac output may lead to inadequate drug distribution. Due to changes in pharmacodynamics in older adults, many patients will also develop a heightened sensitivity to certain drugs. All of this can lead to a lower dosage of most medications required to achieve the same plasma concentration and, therefore, the same therapeutic effects (Rochon, 2023; Saljoughian, 2019).

Table 1

Medications to Avoid/Modify in Older Adults with Impaired Renal Function

(American Geriatric Society [AGS] Beers Criteria Update Expert Panel, 2023, Table 6)

Safe Prescribing

Education and communication may help avoid many of the adverse effects of polypharmacy in the older adult population. Patients should be encouraged to maintain an accurate medication list; they should update it regularly, bring it with them to all medical appointments (or keep a digital copy on their phone), and share it with all of their medical providers to ensure accuracy and awareness across disciplines and specialists. This list should include the medication name, dosage, frequency, and the indication/rationale for prescribing. Providers should review each patient's medication list at each clinic visit and update it as needed. At predetermined intervals, the provider should compare the list with the patient's medication bottles, which the patient should bring with them for corroboration. This reconciliation should also include any supplements or over-the-counter (OTC) medications that they take. Since herbal medicines can also be ingested or infused into teas, patients should be asked specifically about any additional (non-pill) supplements, herbs, or vitamins (Saljoughian, 2019; Ward & Reuben, 2022).

Prescribers should note that while the use of electronic health records (EHRs) has improved prescribing safety overall by alerting the user when a medication incompatibility is detected, an overabundance of these reminders can lead to reminder fatigue (also referred to as alert or alarm fatigue). These computer programs are also not failsafe and should not be relied upon to replace provider judgment and knowledge. Patient education regarding any new medications should include the name, dosage, frequency, and indication/rationale, as well as potential side effects, any dietary restrictions, and any look-alike or sound-alike medications. Patients should be encouraged not to stop or change how they take a medication without discussing it with their prescriber first, and patients should be verbally and directly asked about medication adherence at each visit. Education about medication safety can also prevent mishaps, including the importance of not saving or sharing medications and safe medication storage in a secure location (Saljoughian, 2019; Ward & Reuben, 2022).

Patients with memory deficits should be encouraged to explore various solutions available, including pill dispensers, color-coded pillboxes, prepackaged pill packets, or technology aids offering reminder features, such as smartphone applications. A simple alternative is to consistently link the medication dose with a routine daily activity, such as brushing their teeth, shaving, or drinking coffee. From a system standpoint, providers must ensure that they are consistently and accurately communicating any medication changes to the other members of the interdisciplinary healthcare team, including pharmacists, intensivists, specialists, and primary care providers (Saljoughian, 2019).

The Assessing Care of Vulnerable Elders (ACOVE) project endorses many of the above helpful tips when prescribing for older adults. The ACOVE project also encourages prescribers to document any response to therapy, either expected and positive or unexpected and adverse (Rochon, 2023).

Deprescribing

Many common geriatric syndromes (e.g., falls, incontinence, cognitive impairment, poor nutrition) may be related to an ADR. For example, polypharmacy in older adults is associated with a reduced intake of fiber, vitamins (especially fat-soluble and B vitamins), minerals, and an increased intake of cholesterol, glucose, and sodium (Saljoughian, 2019). Deprescribing is the process of systematically reviewing a patient's medication list to determine if certain medications are causing more harm than good or are no longer indicated. The ACOVE project recommends that prescribers review the ongoing need for a particular drug annually (Rochon, 2023). The process should involve shared decision-making, planning, and robust communication with the patient and family regarding the underlying rationale. Medications should be tapered safely while the patient and family observe for any effects (Saljoughian, 2019; Steinman & Reeve, 2023). As a process, proponents describe deprescribing as proactive and systematic because it allows the provider to prevent ADEs and side effects before they occur, as opposed to reactively tapering a medication after an ADE has been identified. Reducing the medication burden may improve the patient's adherence to their remaining medications. Deprescribing can also reduce the risk of falls, hospitalization, and death and improve cognitive function. The process may be especially beneficial when targeted for patients with the following characteristics:

• numerous prescribed medications
• the presence of multiple comorbidities/chronic medical conditions
• a history of renal impairment
• the existence of multiple prescribers and transitions of care
• a history of medication nonadherence
• a limited life expectancy
• a history of cognitive impairment and/or dementia
• older, frail patients (Steinman & Reeve, 2023)

The deprescribing process is more impactful if targeted at specific medications or classes of medications, such as potentially inappropriate medications (PIMs) and other high-risk medications. High-risk medications may include insulin (due to the risk of hypoglycemia and related sequelae) or aspirin (due to the risk of bleeding events). Medications with no known indication, those causing or contributing to an ADR/ADE, those associated with extreme treatment burden, or ineffective medications are also often targeted for deprescribing. Preventative medications in a patient with a life-limiting condition are also frequently targeted (Steinman & Reeve, 2023). Certain drug classes are known to be associated with an increased risk of ADE/ADRs, including anticoagulants, NSAIDs, cardiovascular medications, diuretics, antibiotics, antiepileptic drugs (AEDs), benzodiazepines, and hypoglycemic agents (Saljoughian, 2019). Anticholinergic medications may cause dizziness, memory loss, confusion, hallucinations, dry mouth, and/or cognitive impairment (Rochon, 2023).

A stepwise approach to deprescribing may help simplify the process. The first stage should include discussing medications and their usage with the patient, caregivers, and any other care providers (including pharmacists). This should include documenting a list of all medicines prescribed (and OTC) and how they are being taken (dose, frequency, duration, indication, patient's experience, and adherence patterns). This information should also include a clear picture of the patient's treatment goals and any problems that they believe are related to their medication(s). Stage two should consist of identifying drugs that could/should be deprescribed based on the criteria discussed above (lack of indication/effectiveness, high risk, known ADE, component of prescribing cascade, or unacceptable treatment burden). Finally, a gradual process to implement the planned changes should be outlined, with consistent monitoring and follow-up during and after. Most experts recommend stopping one drug at a time and considering each step of the process a trial that may or may not be successful (e.g., an increase in heartburn after deprescribing a proton pump inhibitor [PPI]). Occasionally, two medications can be simultaneously discontinued if they are causing ADE/ADRs and there is minimal risk of withdrawal. Tapering medications (e.g., decrease dose by 50% every 2-4 weeks) may be safer than stopping them abruptly, as this reduces the risk of withdrawal effects. Tapering is especially helpful when deprescribing beta-blockers, corticosteroids, benzodiazepines, PPIs, antipsychotics, antidepressants, and AEDs. The patient should be monitored at each dose reduction and again 2-4 weeks after cessation. A list of symptoms to monitor for may help patients and caregivers feel prepared and well-informed. The deprescribing plan should be documented in the EHR and communicated clearly to the patient, the family/caregivers, other healthcare team members, and the patient's pharmacy/pharmacist (Steinman & Reeve, 2023).

Prescriber Tools

Various tools have been developed to help providers identify PIMs. The AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (The Beers Criteria, or BC) was last updated in 2023 and includes six categories: PIMs are listed in Table 2, medications that are potentially inappropriate with certain conditions are included in Table 3, medications that should be used with caution due to risk of ADEs can be found in Table 4, drug-drug interactions that should be avoided are included in Table 5, medications that should be avoided or reduced in patients with kidney dysfunction are listed in Table 6, and medications with strong anticholinergic properties are included in Table 7. The BC includes dozens of medications or classes of medications. Critics point out that the BC does not typically include information on underused or alternative medications and focuses solely on medication available in the US (AGS Beers Criteria Update Expert Panel, 2023; Nguyen et al., 2020).

A handful of changes are made to the BC with each update based on recent evidence. Medications are removed from the list if they are no longer available in the US market. For some medicines, such as metoclopramide (Reglan), the AGS specifies a maximum duration of acceptable use (12 weeks) in older adults with gastroparesis due to the risk of extrapyramidal effects (EPS), including tardive dyskinesia. Meperidine (Demerol) should be avoided due to the risk of neurotoxicity and delirium, especially in those with chronic kidney dysfunction. Aspirin should be avoided for the primary prevention of cardiovascular disease. Nonselective peripheral alpha-blockers (e.g., terazosin [Hytrin]) and central alpha agonists (e.g., clonidine [Catapres]) should be avoided as antihypertensives due to the risk of orthostatic hypotension. Digoxin (Lanoxin) should be avoided as a first-line treatment for atrial fibrillation (a-fib) or heart failure in older adults. Sulfonylureas (e.g., glipizide [Glucotrol] and glyburide [DiaBeta]) should be avoided in older adults due to an increased risk for cardiovascular events, mortality, and hypoglycemia. If necessary, a short-acting agent is preferred (e.g., glipizide [Glucotrol]). Systemic (oral or transdermal) estrogen should be avoided in women 60 and older due to the risk of cancer (breast and endometrial), heart disease, stroke, venous thromboembolism (VTE), and dementia, as well as a lack of cardioprotective or cognitive benefit. Vaginal (topical) estrogen products are safe and effective for the treatment of vaginal dryness, dyspareunia, recurrent urinary tract infections, and other vaginal symptoms (AGS Beers Criteria Update Expert Panel, 2023, Table 2; Rochon, 2023).

The AGS outlines medications that may affect or negatively impact certain diseases or syndromes. It is broken down into four groups: cardiovascular, CNS, GI, and kidney/urinary tract conditions. This section includes medications to avoid in older adults with a history of heart failure, syncope, delirium, dementia/cognitive impairment, falls/fractures, Parkinson's disease, gastric or duodenal ulcers, urinary incontinence, and lower urinary tract symptoms (AGS Beers Criteria Update Expert Panel, 2023, Table 3).

The BC cautions against combining certain medications in older patients, such as opioids with benzodiazepines due to the risk of overdose, opioids with AEDs (gabapentin [Neurontin] and pregabalin [Lyrica]) due to the risk of sedation, and multiple anticholinergic medications due to the risk of cognitive decline. No more than two CNS-active drugs should be prescribed concurrently due to the risk of falls and fractures. They also explicitly warn against combining loop diuretics with alpha-1 blockers in older patients due to the increased risk of incontinence. Toxicity is also a risk with older patients on certain medications. For example, the BC warns that lithium (Lithobid) toxicity can result if combined with an angiotensin-converting enzyme (ACE) inhibitor or loop diuretic, phenytoin (Dilantin) toxicity may result if combined with TMP-SMX (Bactrim), and theophylline (Theo-24, Uniphyl) toxicity may result if combined with cimetidine (Tagamet) or ciprofloxacin (Cipro). Similarly, warfarin (Coumadin) may lead to an increased risk of bleeding if combined with amiodarone (Cordarone), ciprofloxacin (Cipro), most macrolides (except azithromycin [Zithromax]), TMP-SMX (Bactrim), or SSRIs (AGS Beers Criteria Update Expert Panel, 2023, Table 5).

Several medications should be avoided due to their anticholinergic effects, such as first-generation antihistamines (e.g., diphenhydramine [Benadryl]), certain antidepressants (e.g., tricyclic antidepressants, paroxetine [Paxil]), GI antispasmodics (e.g., scopolamine), and skeletal muscle relaxants (e.g., carisoprodol [Soma]). This list also includes antiemetics (e.g., promethazine [Phenergan]), antimuscarinics used for urinary incontinence (e.g., oxybutynin [Ditropan]), antiparkinsonian medications (e.g., benztropine [Cogentin]) and antipsychotics (e.g., clozapine [Clozaril] and olanzapine [Zyprexa]; AGS Beers Criteria Update Expert Panel, 2023, Table 7).

Other prescribing tools include the Screening Tool of Older Person's Prescriptions (STOPP, last updated in 2023) and the Screening Tool to Alert Doctors to Right Treatments (START). The STOPP/START tools contain criteria for stopping and starting medications. The tool is organized by organ system, adverse events, and drug class. A greater percentage of the PIMs included in the STOPP list were associated with an ADE as compared to the BC, but critics point out that the STOPP/START tools do not suggest alternative medications or renal dosing adjustments. Studies also indicate that these tools may reduce the cost of medicines and improve activities of daily living (ADLs) but may not decrease the length of hospital stay. Fit FOR The Aged (FORTA) was originally developed in Germany. The expanded EURO-FORTA list is organized by organ system. All 264 medications/drug classes are given a grade of A (indispensable/clear benefit), B (beneficial/proven but limited efficacy or safety concerns), C (questionable efficacy or safety profile, consider alternative), or D (clearly avoid, find alternative). FORTA includes minimal information regarding the rationale for their recommendations and no information regarding drug-drug interactions, drug-disease interactions, or renal dosing adjustments. Lexicomp Online and IBM Micromedex are drug-drug interaction tools available online and often incorporated into EHR prescribing modules. Alternatives include clinical decision algorithms or questionnaires, such as the Good Palliative-Geriatric Practice Algorithm Medication Appropriateness Index or the 10-Step Drug Minimization Guide. These require more clinical judgment from the prescriber as they include no drug-specific information. The Centers for Medicare and Medicaid Services drug utilization review recommends against the use of eight drugs/drug classes in older adults: digoxin (Lanoxin), calcium channel blockers (CCBs), ACE inhibitors, H2 blockers, NSAIDs, benzodiazepines, antipsychotics, and antidepressants (Nguyen et al., 2020; Rochon, 2023).

Anticoagulation in Older Adults. While research indicates that the benefit of anticoagulant use in older patients with a-fib far outweighs the risk of subdural hematoma related to head trauma suffered during a fall, even in patients at high risk of falling, this is a complex clinical decision (Kiel, 2023). The 2023 AGS BC now suggests avoiding rivaroxaban (Xarelto) for the long-term treatment of VTE or nonvalvular a-fib due to an increased risk of bleeding. The anticoagulant warfarin (Coumadin) should also be avoided for the treatment of VTE or nonvalvular a-fib if alternative direct-acting oral anticoagulants [DOACs]) can be used. Dabigatran (Pradaxa) should be used with caution in older adults due to the increased risk of bleeding. The patient's renal function should also be evaluated before initiating edoxaban (Savaysa), rivaroxaban (Xarelto), or dabigatran (Pradaxa), as detailed in Table 1 (AGS Beers Criteria Update Expert Panel, 2023, Table 2).

A consensus project regarding the use of anticoagulants in older adults attempted to decipher preferences among a panel of 79 experts, entitled the ACONVENIENCE study. They found that advanced age alone should not determine the anticoagulation decision. Apixaban (Eliquis) was the highest-rated DOAC. The only slight disadvantage of apixaban (Eliquis) is its requirement for twice-daily dosing, while edoxaban (Savaysa) and rivaroxaban (Xarelto) can often be dosed once-daily. Warfarin (Coumadin) appears to be less safe (i.e., a higher rate of major bleeding) and less convenient (i.e., the requirement for therapeutic monitoring) than the DOACs in general unless contraindicated based on drug-drug interactions or renal function. Those with mechanical valves or severe mitral stenosis might consider the use of a vitamin-K antagonist (VKA). Prescribers should also avoid combining anticoagulants with antiplatelets and NSAIDs (including aspirin) unless necessary based on cardiac history, as these compound the bleeding risk. Uncontrolled HTN should also be avoided to reduce the hemorrhagic stroke risk, and patients should be cautioned to limit their alcohol intake. A PPI can be added to reduce the risk of GI bleeding. Anticoagulants should be held in those with a platelet count below 50,000/mL (Bonanad et al., 2022).

The ACONVENIENCE study experts all agreed that rivaroxaban (Xarelto), edoxaban (Savaysa), and apixaban (Eliquis) could be used in those with CrCl 15-30 mL/min, but dabigatran (Pradaxa) was contraindicated (Bonanad et al., 2022). By contrast, the AGS found that edoxaban (Savaysa) and rivaroxaban (Xarelto) dosages should be reduced in those with a CrCl < 50 mL/min and avoided in those with a CrCl < 15 mL/min. They agreed that dabigatran (Pradax) should be avoided in those with a CrCl < 30 mL/min but did not feel that apixaban (Eliquis) needed to be reduced or avoided in those with limited renal function (AGS Beers Criteria Update Expert Panel, 2023, Table 6).

The American Academy of Family Physicians (AAFP, Roth et al., 2020) suggests a risk stratification strategy using the CHADSVASc or similar tool to identify those with a-fib that may benefit from anticoagulation. This should be combined with the patient's functional status (to help identify any risk for falls), bleeding risk (e.g., HAS-BLED tool or similar), all comorbidities, and other medications used. A shared decision-making process with the patient and family is always recommended (Roth et al., 2020). A cohort study using adults age 75 and older with a-fib found the net clinical benefit from oral anticoagulation continued despite advanced age until at least 87 (based on warfarin [Coumadin]) or 92 (based on apixaban [Eliquis]; Shah et al., 2019).

Expect Challenges

Certain medications may be more difficult to deprescribe, such as benzodiazepines, which may require a 25% dose reduction every 2 weeks, as well as an alternate nonpharmacological or pharmacological therapy to replace its effects. Withdrawal symptoms, such as insomnia, anxiety, irritability, and GI symptoms, are common, especially once the dose has been reduced to 25% of the original dose. PPIs are commonly targeted to deprescribe/taper as they are often started during hospitalization or other acute periods of stress and unintentionally continued indefinitely. The dose can be cut in half for 2 weeks and then discontinued altogether in most cases, with monitoring for symptom recurrence for 4-12 weeks after cessation. Those with occasional symptoms can be directed to utilize a chewable antacid or H2 blocker as needed. Antipsychotics are often prescribed for patients with dementia to manage behavioral or psychological symptoms or insomnia, despite warnings regarding the mortality risk in this patient population. Antipsychotic dosages can typically be reduced by 25%, then 50%, then 75% every week or two while monitoring closely for symptoms of withdrawal (i.e., psychosis, aggression, or hallucinations). Caregivers should be trained in behavioral and environmental treatment strategies. Glucose-lowering medications may be deprescribed safely, especially in those with multiple medical comorbidities, renal impairment, dementia, limited life expectancy, a history of hypoglycemia, or an impaired ability to sense or respond to hypoglycemia. Sulfonylureas or insulin are the most likely to cause episodes of hypoglycemia. The American Diabetes Association offers a suggested algorithm for switching patients from a complex to a simple regimen. Patients with end-stage dementia or those with substantial worsening of their cognitive function despite treatment with a cholinesterase inhibitor or memantine (Namenda) should be evaluated for discontinuation of these agents. The dose should be decreased by no more than 50% every 4 weeks, as reports of severe withdrawal symptoms have been reported in patients who abruptly discontinue these medications. If agitation, aggression, or hallucinations occur within the first week after a dose reduction, the previous dose should be promptly restarted. If symptoms worsen within 2-6 weeks of a dosage adjustment, this may indicate that the medication was providing significant benefit. The provider should engage the patient and caregiver(s) in a discussion about restarting the medication at that prior dose level. Antidepressant discontinuation can cause withdrawal symptoms of insomnia, dizziness, fatigue, headache, nausea, anxiety, and flu-like symptoms. These symptoms may be more prominent after stopping some antidepressants (paroxetine [Paxil] or fluvoxamine [Luvox]) in comparison to others (fluoxetine [Prozac]). As in the early phases and planning, shared decision-making with the patient and caregiver(s) should continue throughout the monitoring and follow-up phases (Steinman & Reeve, 2023).

References

Agarwal, K. (2023). Failure to thrive in older adults: Evaluation. UpToDate. Retrieved December 11, 2023, from https://www.uptodate.com/contents/failure-to-thrive-in-older-adults-evaluation

American Geriatrics Society Beers Criteria Update Expert Panel. (2023). American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 71(7), 2052–2081. https://doi.org/10.1111/jgs.18372

Bonanad, C., Formiga, F., Anguita, M., Petidier, R., & Gullón, A. (2022). Oral anticoagulant use and appropriateness in elderly patients with atrial fibrillation in complex clinical conditions: ACONVENIENCE Study. Journal of Clinical Medicine, 11(24). https://doi.org/10.3390/jcm11247423

Centers for Disease Control and Prevention. (2022). Promoting health for older adults. https://www.cdc.gov/chronicdisease/resources/publications/factsheets/promoting-health-for-older-adults.htm

Hales, C. M., Servais, J., Martin, C. B., & Kohen, D. (2019). Prescription drug use among adults aged 40-79 in the United States and Canada. NCHS Data Brief, (347), 1–8. https://www.cdc.gov/nchs/products/databriefs/db347.htm

Institute of Medicine (US) Committee on the Future Health Care Workforce for Older Americans. (2008). Retooling for an aging America: Building the health care workforce. National Academies Press (US). https://doi.org/10.17226/12089

Kiel, D. P. (2023). Falls: Prevention in community-dwelling older persons. UpToDate. Retrieved December 11, 2023, from https://www.uptodate.com/contents/falls-prevention-in-community-dwelling-older-persons

National Institute on Aging. (2021). The dangers of polypharmacy and the case for deprescribing in older adults. https://www.nia.nih.gov/news/dangers-polypharmacy-and-case-deprescribing-older-adults

Nguyen, T., Wong, E., & Ciummo, F. (2020). Polypharmacy in older adults: Practical applications alongside a patient case. The Journal for Nurse Practitioners, 16(3), 205–209. https://doi.org/10.1016/j.nurpra.2019.11.017

Rochon, P. A. (2023). Drug prescribing for older adults. UpToDate. Retrieved December 11, 2023, from https://www.uptodate.com/contents/drug-prescribing-for-older-adults

Roth, A. R., Lazris, A., Haskell, H., & James, J. (2020). Anticoagulation in older adults. American Family Physician, 101(12), 748–750. https://www.aafp.org/pubs/afp/issues/2020/0615/p748.html

Saljoughian, M. (2019). Polypharmacy and drug adherence in elderly patients. US Pharmacist, 44(7), 33-36. https://www.uspharmacist.com/article/polypharmacy-and-drug-adherence-in-elderly-patients

Shah, S. J., Singer, D. E., Fang, M. C., Reynolds, K., Go, A. S., & Eckman, M. H. (2019). Net clinical benefit of oral anticoagulation among older adults with atrial fibrillation. Circulation. Cardiovascular Quality and Outcomes, 12(11), e006212. https://doi.org/10.1161/CIRCOUTCOMES.119.006212

Steinman, M., & Reeve, E. (2023). Deprescribing. UpToDate. Retrieved December 11, 2023, from https://www.uptodate.com/contents/deprescribing

Ward, K. T., & Reuben, D. B. (2022). Comprehensive geriatric assessment. UpToDate. Retrieved December 11, 2023, from www.uptodate.com/contents/comprehensive-geriatric-assessment