· All speakers have indicated they have nothing to disclose except for the following: Jennifer...

34th Annual Winter Refresher in Albuquerque

Saturday, February 20, 2016Hotel Albuquerque, Old Town

Scientific Program ChairJohn Andazola, MD

This program has been approved for 7 Prescribed Credits by the AAFP

All speakers have indicated they have nothing to disclose except for the following:Jennifer Hettema, PhD - Research grants, NIAAA; Ownership, Land of Enchantment Productions; Consultant, NIDA grant; Motivational interviewing training, Health Trust Foundation; Steering Committee member, FASD

Mission StatementThe New Mexico Academy of Family Physicians exists to improve the health of the people of New Mexico by supporting and advancing the specialty of Family Medicine and serving the needs of our members.

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Please contact us if you have questions or concerns about the chapter or your membership.

New Mexico Chapter American Academy of Family Physicians2400 Louisiana Blvd. NE, Bldg. 2, Suite 101Albuquerque, NM 87110Phone: (505) 292-3113Fax: (505) [email protected]

7:00 am – 8:00 am Past President’s BreakfastRendering Room

7:00 am – 8:00 am Registration/Exhibits OpenBreakfast - Exhibit Hall

7:55 am – 8:00 am Introduction & WelcomeJohn Andazola, MD, Scientific Program Chair

8:00 am – 9:00 am “Screening and Brief Intervention for Risky Alcohol Use in Primary Care” Jennifer Hettema, Ph.D.

9:00 am – 10:00 am “Key Articles & Clinical Developments of 2015 in Family Medicine” Dan Waldman, MD

10:00 am – 10:30 am Break - Exhibit Hall

10:30 am – 11:30 am “Evidence Based Parenting” Heather Kovich, MD

11:30 am – 12:30 pm “Quality Improvement in Your Practice” Darrick Nelson, MD

12:30 pm – 1:30 pm Lunch - Exhibit Hall

1:30 pm – 2:30 pm “Patient Rights Versus Public Social Needs in a Measles Outbreak” Nina Ahmad, MD

2:30 pm - 3:00 pm Poster Session - Lecture Hall

3:00 pm - 3:30 pm Break - Exhibit Hall

3:30 pm – 4:30 pm “Medication Issues in the Elderly” Patrick Leung, PharmD, BCPS, PhC & Davena Norris, PharmD, BCPS, PhC

4:30 pm - 5:30 pm “Upstream Medicine” Stephanie Benson, MD, Stephen Colmant, Ph.D., Iván A. de la Rosa, Ph.D.

5:30 pm Drawing for Door Prizes (Must be registered for the conference and present to win)

Schedule of Events and Lectures

1

“Screening and Brief Intervention for Risky Alcohol Use in Primary Care” Jennifer Hettema, Ph.D. .......................................................................................................3

“Key Articles & Clinical Developments of 2015 in Family Medicine” Dan Waldman, MD ..........................................................................................................26

“Evidence Based Parenting” Heather Kovich, MD ...........................................................................................................45

“Quality Improvement in Your Practice” Darrick Nelson, MD ...........................................................................................................68

“Patient Rights Versus Public Social Needs in a Measles Outbreak” Nina Ahmad, MD ..............................................................................................................78

“Medication Issues in the Elderly” Patrick Leung, PharmD, BCPS, PhC & Davena Norris, PharmD, BCPS, PhC ..................93

“Upstream Medicine” Stephanie Benson, MD, Stephen Colmant, Ph.D., and Iván A. de la Rosa, Ph.D. .........143

Table of Contents

2

“Screening and Brief Intervention for Risky Alcohol Use

in Primary Care”

by

Jennifer Hettema, Ph.D.

Jennifer Hettema, Ph.D., is a clinical psychologist and Associate Research Professor in the

Department of Family and Community Medicine at the University of New Mexico. She

completed her undergraduate and graduate studies at the University of New Mexico, completed a

two-year NIDA-funded postdoctoral fellowship at the University of California San Francisco,

and served on the faculty at the University of Virginia before returning home to New Mexico.

Dr. Hettema conducts research on brief behavioral interventions in medical settings and is a

member of the Motivational Interviewing Network of Trainers.

Email: [email protected]

Learning Objectives

At the end of this presentation, the attendee will be able to:

1. Describe the rationale and evidence-base for screening and brief intervention for risky

alcohol use in primary care

2. Apply and interpret the NIAAA single question alcohol screening test

3. Demonstrate several effective brief intervention strategies

3

SCREENING AND BRIEF INTERVENTION FOR RISKY ALCOHOL USE IN PRIMARY CAREJennifer Hettema, Ph.D.University of New MexicoDepartment of Family and Community Medicine

Agenda• Rationale for screening and brief intervention• Evidence for screening and brief intervention• Screening and brief intervention protocol• Practice• Discussion

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GOALS OF MEDICINE

prolong life

fight and prevent disease

reduce pain and suffering

promote health

avoid premature death

*Sijay – onebeyond metamedia

4

“Modifiable behavioral risk factors are leading causes of mortality in the United States.”

5

BEHAVIORAL CHANGE

• Most, if not all, medical issues reduce to the need forbehavioral change

• Whether or notand the way in which providers interact with patients around issues ofbehavioral change can dramatically influence theprobability that change will occur

85,000 deathsannually

• Think of a patient that you have workedwith for whom alcohol was a problem.

6

Continuum of Alcohol Problems

2-3 Criteria

4-5Criteria

6+Criteria

Alcohol Use Disorders

Exceeds Recommended

LimitsDrinks Within

LimitsAbstinent

Continuum of Alcohol Problems

2-3 Criteria

4-5Criteria

6+Criteria

Alcohol Use Disorders

Exceeds Recommended

LimitsDrinks Within

LimitsAbstinent

Targeting Risky Use

• On a population level, most alcohol-relatedharm is not due to drinkers with severealcohol dependence but attributable to amuch larger group of hazardous or harmfuldrinkers whose consumption exceedsrecommended drinking levels and whoexperience a wide range of physical,psychological or social problems (Kaner,2009)

7

• >50% of health consequences of alcohol occur in risky and problem drinkers (not dependent drinkers).

• A large number of people at small risk contribute morecases than a smaller number of people who are individually at greater risk.

The Prevention Paradox

Continuum of Intervention

AUD(mod or severe)

Risky Use orMild AUD

No / Low Risk

Primary Prevention

Brief Intervention

SpecializedTreatment

Continuum of Intervention

AUD(mod or severe)

Risky Use orMild AUD

No / Low Risk

Primary Prevention

Brief Intervention

SpecializedTreatment

8

SBIRT

creening

• Quickly assess theseverity ofalcohol use and identify the appropriate level oftreatment.

rief

ntervention

• Increase insight andawareness ofalcohol use; motivation toward behavioral change.

eferral to

reatment

• Provide those identified asneeding more extensive treatment with access to specialty care.

Oregon SBIRT, 2011

SBIRT Benefits: Primary Care Settings

• Meta-analyses & reviews-More than 34 randomized controlled trials

-Focused primarily on risky drinkers in medicalsettings-Result: 10-30% reduction in alcohol consumptionat 12 months

Oregon, 2012; Moyer et al, 2002; Whitlock et al, 2004; Bertholet et al, 2005


Oregon, 2012; Moyer et al, 2002; Whitlock et al, 2004; Bertholet et al, 2005

If you see on average, 40 patients per

week.

Four to eight of these

patients are at risk

(10-20%).

With brief intervention, 1-3 patientsweekly are

likely to lower their

risk.

9

SBIRT Benefits: Primary Care Settings*

0% 10% 20% 30% 40% 50%

Drinks Per Week

BingeDrinking

ER Visits

Nonfatal Injuries

Hospitalizations

Arrests

*SAMHSA, 20122/9/201619

10


• Clinically preventable burden: total quality adjusted yearsof life gained if a clinical preventive service is delivered at recommended intervals

-4• Cost effectiveness: average net cost per quality adjusted

year of life gained by offering the clinical preventive service

-5• Combined score-9

*Maciosek, 2006

11






*Maciosek, 2006






*Maciosek, 2006






*Maciosek, 2006

12






*Maciosek, 2006

“These results make alcohol screening and counseling services one of the highest-ranking preventive services …evaluated using standardized methods.”

“Similar to screening for colorectal cancer, hypertension, vision (in adults over 65).”

13

“Similar to influenza or pneumococcal immunization.”

SBIRT Protocol

14

SBIRT Protocol• Mechanics + Interpersonal Style

SBIRT• Screening quickly assesses substance use severity and

identifies the appropriate level of treatment

• Brief Intervention focuses on increasing patient awareness of own substance use and motivation tochange

• Referral to Treatment provides those needing moreextensive treatment with access to specialty care

SBIRT

• Screening quickly assesses substance use severity andidentifies the appropriate level of treatment

• Brief Intervention focuses on increasing patient awareness of own substance use and motivation tochange

• Referral to Treatment provides those needing moreextensive treatment with access to specialty care

15

Screening• Ask Permission

Screening• Ask Permission• Agenda Set• Normalize

How Much is Too Much?*

• For healthy adults age 65 and under:

*SAMHSA, 2012

• For people over 65, exceeding 3 drinks a day or 7drinks a week is not recommended.

• Women who are pregnant or may becomepregnant should not drink.

16

Single Question Alcohol ScreenHow many times in the past year have you had 5 (4 for women or men > 65) or more drinks in a day?

Positive Screen = 1 or more

• 82% sensitive, 79% specific for any unhealthy use• 84% sensitive, 78% specific for risky use• 88% sensitive, 67% specific for a current alcohol use

disorder

• Nearly three-fourths of U.S. adults never exceed theselimits

Source: Smith (2009) J Gen Intern Med 24(7):783–8

Physiological Consequences of Risky Drinking

*SAMHSA, 2012

Negative Screen• Affirm • Advise• Open Door• Rescreen Annually

17

Positive Screen• Assess further

• Quantity, frequency, max (explain standard

drink)

• Open-ended vs. Closed-ended

Assess for Severity

Assess for AUDs

18

DSM-5 Criteria for Substance Use Disorders Recommendations and Rationale

Source: Am J Psychiatry. 2013;170(8):834-851.

a One or more abuse criteria within a 12-month period and no dependence diagnosis; applicable to all substances except nicotine, for which DSM-IV abuse criteria were not given.b Three or more dependence criteria within a 12-month period.c Two or more substance use disorder criteria within a 12-month period.d Withdrawal not included for cannabis, inhalant, and hallucinogen disorders in DSM-IV. Cannabis withdrawal added in DSM-5.

Assess for AUDs• Open-ended vs. Closed-ended

2 Item ScaleRecurrent drinking in hazardous situationsIn the last 12 months, have you been intoxicated on alcohol (or drugs) where you could have hurt yourself or others?

Drinking more than intendedIn the last 12 months, how often did you drink (or use more) than you intended?

19

2-Item test characteristics for current AUD in positive screensSample N Sensitivity Specificity

Acute injury in ED, 1998-2000 959 95% 77%

Random digit dialing 494 94% 62%

Five family medicine practices in

Georgia, 2004-05

280 95% 66%

National Epidemiologic Survey on

Alcohol and Related Conditions, 2001-

02

7,890 77% 86%

18-20 year olds in ED 181 88% 90%

Sources: Vinson D, Kruse RL, Seale JP. Alcohol Clin Exp Res. 2007;31(8):1392–1398. Kelly TM, et

al. Addict Behav. 2009;34(8):668-774.

Decision Rule• Risky Use / Mild AUD >>> Brief Intervention

• Moderate or Severe AUD >>> Brief Intervention with Goal of Medical Management and/or Referral to Treatment

Feedback: How• #1: Summarize results of screening and assessment

20

Feedback: How• Decide what might be the most helpful piece of feedback-Severity level (risky, AUD)-Safe drinking limits-Health implications-Relationship to medical issues-Others?

Feedback: How• Ask permission: Can I share some informationwith you about…?

Feedback: How• Elicit (open-ended question): what patient already knows

about topic

• Provide: information, recommendation

• Elicit (open-ended question): reaction, what patient planson doing with information

21

Feedback: How• Elicit (open-ended question): what patient already knows

about topic-Reflect• Provide: information, recommendation

• Elicit (open-ended question): reaction, what patient planson doing with information

-Reflect

Assess Readiness for Change


Brief Intervention

22


Develop Action Plan

Build Motivation for Change• Brief intervention can be used to build motivation

• Use of effective communication skills can enhance briefinterventions (OARS)

• Brief intervention should seek to evoke the patients ownmotivation (change talk)

Build Motivation - HowOption A: Pros and Cons

• Drinking: • What are the good things about drinking beer? What are some of

the not so good things about it?

How might things be better or different if you cut back? If you continue at this level what are some of the worst things that might happen? If you cut back what are some of the best things that might happen?

23

Building Motivation – HowOption B: Ruler• You can use a ruler to determine the patient’s perceived

importance, confidence, or readiness to change behavior. • The actual number that the patient gives you isn’t the

important part. The goal is to evoke change talk, usingfollow-up questions.

Building Motivation – HowOption C: Values Clarification• Identify and explore values or goals that thepatients finds important.

• Use OARS to draw out and explore discrepancies(if any) between these values and the patient’salcohol or drug use.

Practice• Form pairs• Practice using the role play scenarios

24

Discussion / Questions

Contact• Jennifer Hettema – [email protected]

25

“Key Articles & Clinical Developments of 2015 in

Family Medicine”

by

Dan Waldman, MD

Dan Waldman, MD, graduated from the University of Massachusetts Medical School and

completed his residency training here at the University of New Mexico. He is an Assistant

Professor in the Department of Family & Community Medicine, and board certified in Family

Medicine. Dr. Waldman is the Residency Program Director, medical director of the inpatient

service and the Family Medicine Inpatient Unit. His interests include diagnostic reasoning,

inpatient care, and procedural training.


Learning Objectives


1. Cite the more important and clinically relevant research articles of the past year for the

field of Family Medicine

2. Describe methods for staying current in clinical medicine

26

W H A T W A S I M P O R T A N T …

… A T L E A S T T O S O M E O F U S

D A N W A L D M A N , M D

U N M F A M I L Y A N D C O M M U N I T Y M E D I C I N E

Key Articles & Clinical Developments of 2015 in Family Medicine

What This Talk is About…

27

How Did I Choose What I Chose?

� Our faculty

� Essential Evidence

� Journal Watch

� “Top of 2015” Lists

� Prioritized:� key areas of FM practice

� might directly change clinical practice

� might be leading to paradigm changes

� Fun

The Blood Pressure Saga Continues

Reminder: JNC8 BP Goals

Diastolic Systolic

All pts

90

Age 18-59,Diabetes,

CKD

140 150

Age≥60

(JNC8 was based largely on RCT data)

28

SPRINT Trial

� ACCORD (2010): treating pts with DM2 and hypertension to systolic goal of <120 wasn’t better than <140 (4,733 patients enrolled)

� Now SPRINT: same <140 vs <120 systolic

comparison

� 9361 high risk, non diabetic patients

� Trial stopped after 3.3 years (early)

� Nonfatal + fatal adverse CV events lower in 120 group

� Adverse events higher in 120 group

� Mean # of BP meds 1.8 in 140 systolic group, 2.8 in 120

SPRINT Outcomes

� Reduction in all cause mortality

� 3.3% vs 4.5%, NNT 83 over 3 years

� Reduction in CV mortality

� 0.8% vs 1.4%, NNT 167 over 3.3 years

� Reduction in heart failure development

� 1.3% vs 2.1%, NNT 125 over 3.3 years

The Sprint Research Group: N Engl J Med 2015;

373:2103-2116

29

Some Thoughts…

� Was ACCORD underpowered?

� High risk group

� <1/2 of the 120 systolic target group met target

� BP measurements were done carefully…they let people sit and equilibrate

� Excluded:� resistant hypertension

� Diabtes

� Stroke history

� Institutionalized Elderly

� Increased complications: syncope, electrolyte abnormalities, AKI

What now?

� Well…it’s unclear

� Very challenging to implement <120 goal

� A reasonable editorial suggested <130 systolic for those over 50 without DM or stroke

� Some felt the rush to make the data public felt “rushed”

Spironolactone for Resistant Hypertension

� “Resistant Hypertension” = uncontrolled BP despite treatment with meds from 3 classes

� Interesting study design (rotated meds)

� Spironolactone lowered systolic~9mmHg, others ~4

� Don’t use if GFR <45

Williams B et al. Spironolactone versus placebo, bisoprolol, and

doxazosin to determine the optimal treatment for drug-resistant

hypertension (PATHWAY-2): A randomised, double-blind,

crossover trial. Lancet 2015 Sep 20; [e-pub]

30

The Cholesterol Story Also Continues

ACC/AHA Guidelines

HIGH POTENCY STATIN HIGH POTENCY STATIN

MODERATE TO HIGH POTENCY STATIN

START WITH MODERATEPOTENCY STATIN

Issues with the ACC/AHA Risk Calculator?

Challenge to risk calculator: ACC/AHA calculator may overestimate 10 year risk, causing more people to need statins

DeFilippis AP et al. An analysis of calibration and discrimination among multiple cardiovascular

risk scores in a modern multiethnic cohort. Ann Intern Med 2015 Feb 17; 162:266

ACC/AHA 10 year risk

Observed in Data

9.16% 5.16%

31

Steroids for Community-Acquired Pneumonia (CAP)

Background

� As many as 20% of patients with CAP worsen despite guideline-adherent antimicrobial therapy

� When a pathogen is identified (only 38% of the time), most commonly it’s a virus (about 60% of

identified pathogens)

Jain S, Self WH, Wunderink RG, et al, for the CDC EPIC Study Team.

Community-acquired pneumonia requiring hospitalization among US

adults. N Engl J Med 2015;373(5):1415-1427.

Small RCT

Spanish RCT: 120 patients with severe CAP

� Steroid group less likely to experience a multicomponent treatment-failure endpoint (3% vs 14%, P = 0.04)

� Mechanical ventilation

� Shock

� Death

� Also less radiographic progression (13% vs. 31%)

Torres A, Sibila O, Ferrer M, et al. Effect of corticosteroids on treatment

failure among hospitalized patients with severe community-acquired

pneumonia and high inflammatory response. JAMA 2015;313(7):677-

686.

32

Larger RCT

Swiss trial of 785 patients

� Included patients with less-severe CAP

� Results: steroids significantly shortened time to clinical stability from 4.4 days to 3.0 days

Blum CA, Nigro N, Briel M, et al. Adjunct prednisone therapy for

patients with community-acquired pneumonia: a multicentre, double-

blind, randomised, placebo-controlled trial. Lancet

2015;385(9977):1511-1518

Larger RCT

Swiss trial of 785 patients

� LOS reduced by 1 day

� No significant increase in complications associated with community-acquired pneumonia

Blum CA, Nigro N, Briel M, et al. Adjunct prednisone therapy for

patients with community-acquired pneumonia: a multicentre, double-

blind, randomised, placebo-controlled trial. Lancet

2015;385(9977):1511-1518

33

Meta-analysis

Meta-analysis: 13 RCT’s (including the two 2015 trials)� Results: moderate systemic corticosteroid doses (20–60 mg of prednisone or equivalent total daily dose) significantly lowered incidences of :� ARDS (0.4% vs. 3.0%; number needed to treat, 38) � mechanical ventilation (3.1% vs. 5.7%; NNT, 38) � shortened hospital length of stay (by 2.9 days) � Hyperglycemia requiring treatment more common in corticosteroid

group� other adverse events were similar in corticosteroid and placebo groups

� Mortality Rates� Lower all-cause mortality with steroids was of borderline significance in

the entire treatment population (5.3% vs. 7.9%; NNT, 38)� significant mortality benefit occurred in patients with severe pneumonia

(7.4% vs. 22.0%; NNT, 7)

Meta-analysis

� More research ongoing

� Notably in a Spanish H1N1 study pts did worse

� Consider 5-7 days of 20-60mg daily prednisone (40-50mg?) Siemieniuk RAC, Meade MO, Alonso-Coello P, et al. Corticosteroid

therapy for patients hospitalized with community-acquired pneumonia.

Ann Intern Med 2015;163(7):519-528.

HIV Pre-Exposure Prophylaxis

34

Background: HIV Pre-Exposure Prophylaxis

� HIV infections continue, example: 1 new HIV infection per day in the city of San Francisco

� Tenofovir/emtricitabine (Truvada): FDA Approved in 2012 for HIV Pre-exposure prophylaxis

� Cochrane review 2012

� TDF-FTC versus placebo showed a reduction in the risk of acquiring HIV infection (RR 0.49; 95% CI 0.28 to 0.85; 8918 participants)

New Study this year: “On Demand” Truvada

RCT (government funded)

� 400 HIV negative men with unprotected anal intercourse with ≥ 2 men in previous 6 months

� Excluded: impaired renal function, hepatitis B/C

� Intervention:

� 2 pills between 2 and 24 hours before intercourse

� 3rd pill at 24 hrs

� 4th at 48 hrs after first 2 taken

� Followed for median 9.3 months

PrEP

� Intervention group less likely to develop HIV (14 vs 2 infections)

� 6.6 vs 0.91 per 100 person-years of follow up

� NNT = 17 per yearMolina JM, Capitant C, Spire B, et al, for the ANRS IPERGAY

Study Group. On-demand preexposure prophylaxis in men at

high risk for HIV-1 infection. N Engl J Med 2015;373(23):2237-

2246.

35

Long Term ASA after VTE

Long Term ASA for DVT

� Meta-analysis (of 2 trials total ~1200 patients)

� Nonpregnant adults with a first unprovoked DVT or PE

� Aspirin 100mg QD vs matching placebo

Simes J, Becattini C, Agnelli G, et al, for the INSPIRE Study

Investigators (International Collaboration of Aspirin Trials for

Recurrent Venous Thromboembolism). Aspirin for the prevention

of recurrent venous thromboembolism: The INSPIRE

collaboration. Circulation 2014;130(14):1062-1071.

36

Long term ASA for DVT

� Rate of recurrent VTE ~ 1/3 lower in the aspirin group (5.1% vs 7.5% per year; P = .008; NNT = 42 per year)

� Similar reduction for DVT or PE

� no difference in major bleeding

Out-of-Hospital Births

Out-of-Hospital Births

� Rate of out-of-hospital birth in the U.S. increasing, data on safety/outcomes is evolving

� Rate of C-sections in hospitals is more than double 1970, yet no change in intrapartum fetal mortality

� Data problem: misclassification of transfers as

“hospital births”

� Recent addition to field in the Oregon birth certificate: “intended delivery location”

37

New Study

� Data

� 75,923 planned and completed hospital births in OR

� 1968 completed home births

� 1235 completed birth-center deliveries

� Excluded unplanned home births

� No difference in statistics based on “actual place of birth”

� When births reclassified based on intended site: higher perinatal mortality out of hospital (3.9 vs 1.8 per 1000 births)

� More data:

� Higher rate of poor Apgar scores out of hospital

� More neonatal seizures

� More neonatal ventilator support

� More maternal blood transfusions

� Lower NICU admissions

� Lower OB interventions

Snowden et al. Planned Out-of-Hospital Birth

and Birth Outcomes. N Engl J Med 2015 Dec 31;373(27):2642-5

Should all babies be born in a hospital?

� Other national systems: integrated out-of-hospital delivery infrastructure, training regulation and transfer protocols

� Example: Canadian article this year showing no

difference in outcomes for planned place of birth

� Is Oregon a “worst case scenario?”

38

Considerations for Out-of-Hospital Birth

� How close is the hospital?

� Is there a relationship with an OB unit?

� Is the midwife skilled?

� Avoid high risk births out of hospital

VBAC at Home?

� Maternal/neotnatal outcomes for planned VBAC at home

� 12,092 women without prior cesarean

� 1,052 women with a prior cesarean

� Transfer rates 18% for women with prior cesarean, 7% for others

� 4.75 neonatal deaths per 1000 in prior cesarean group vs 1.24/1000 in control group

� Higher rates of some other complications

� Consider avoiding VBAC at homeCox KJ, Bovbjerg ML, CheyneyM, Leeman LM. Planned Home

VBAC in the United States, 2004-2009: Outcomes, Maternity

Care Practices, and Implications for Shared Decision Making.

Birth 2015 Dec;42(4):299-308. doi: 10.1111/birt.12188

Quicker Summaries

39

More Questions About A1C

� No reduction in CV or all-cause mortality at 10 years for T2DM in “intensive” glycemic control

� A1C 6.9% vs 8.4% in “usual care”

� VA study, largely in men (97%)

� Small improvement in the morbidity outcome (combo of MI, CVA or new/worsening HF)

Hayward RA, Reaven PD, Wiitala WL, et al, for the VADT

Investigators. Follow-up of glycemic control and

cardiovascular outcomes in type 2 diabetes. N Engl J Med

2015;372(23):2197-2206.

Pediatrics: Get Rid of Your Dishwasher?

Swedish study: parents of 1,209 7-8 year olds were sent a survey

� Hand washing dishes: associated with lower rate of allergic disease development

� 12% hand-washed dishes

� Odds ratio 0.57 (0.37-0.85)

Hesselmar B, Hicke-Roberts A, Wennergren G.

Allergy in children in hand versus machine

dishwashing. Pediatrics 2015;135;e590

Pediatrics: Backup Strep Culture?

� Back up Cx not needed for Neg rapid strep in a country with low incidence of rheumatic fever (like the U.S.)

� Using confirmatory cultures to back up “RADT’s”

costs >$8 million per additional case of rheumatic heart disease prevented

Lean WL, Arnup S, Canchin M, Steer AC. Rapid

diagnostic tests for group A streptococcal

pharyngitis: a meta-analysis. Pediatrics

2014;134(4);771-781.

40

Behavioral Health

� Giving patients financial incentives helps them quit smoking

� Drug therapy for PTSD works but doesn’t work great (meta-analysis). Paxil may be slightly better than

others

Halpern SD, French B, Small DS, et al. Randomized

trial of four financial-incentive programs for

smoking cessation. N Engl J Med

2015;372(22):2108-2117

Hoskins M, Pearce J, Bethell A, et al.

Pharmacotherapy for post-traumatic stress

disorder: systematic review and meta-analysis. Br

J Psychiatry 2015;206(2):93-100.

Musculoskeletal/Procedures

� Platelet-rich plasma injections aren’t better than hyaluronic acid for knee DJD

� Sterile gloves aren’t needed for minor skin procedures

Filardo G, Di Matteo B, Di Martino A, et al.

Platelet-rich plasma intra-articular knee injections

show no superiority versus viscosupplementation:

a randomized controlled trial. Am J Sports Med

2015l;43(7):1575-1582.

Heal C, Sriharan S, Buttner PG, Kimber D.

Comparing non-sterile with sterile gloves for minor

surgery: a prospective randomised controlled non-

inferiority trial. Med J Aust 2015;202(1):27-32.

Adult Medicine

� USPSTF says there isn’t evidence for screening for thyroid disease

� ACP releases a practice guideline that says don’t screen low-risk adults for cardiac disease

Chou R, for the High Value Care Task Force of the American College of

Physicians. Cardiac screening with electrocardiography, stress

echocardiography, or myocardial perfusion imaging: advice for high-

value care from the American College of Physicians. Ann Intern Med

2015;162(6):438-447.

LeFevre ML, on behalf of the U.S. Preventive Services Task Force

Screening for thyroid dysfunction: U.S. Preventive Services Task Force

recommendation statement. Ann Intern Med 2015;162(9):641-650.

41

Graduate Medical Education

� The latest duty hour reforms haven’t had a measurable effect on mortality or hospital readmissions

� Prevalence of depression and depressive symptoms

among residents is…depressingly high (28.8%)Mata D et al. Prevalence of Depression and Depressive Symptoms Among

Resident PhysiciansA Systematic Review and Meta-analysis

JAMA. 2015;314(22):2373-2383

Patel MS, Volpp KG, Small DS, et al. Association of the 2011

ACGME resident duty hour reforms with mortality and

readmissions among hospitalized Medicare patients. JAMA

2014;312(22):2364-2373.

Other Inpatient Medicine

� Patient navigators slightly decrease (4%) readmission rates for older patients, and increase (12%) readmissions in younger patients

Balaban RB, Galbraith AA, Burns ME, Vialle-

Valentin CE, Larochelle MR, Ross-Degnan D. A

patient navigator intervention to reduce hospital

readmissions among high-risk safety-net patients: a

randomized controlled trial. J Gen Intern Med

2015;30(7):907-915

Bridging Therapy

� Bridging therapy, more harm in both:

� Atrial fibrillation

� Low risk VTE patients who need warfarin interrupted

Steinberg BA, Peterson ED, Kim S, et al, for the Outcomes Registry for Better

Informed Treatment of Atrial Fibrillation Investigators and Patients. Use and

outcomes associated with bridging during anticoagulation interruptions in patients

with atrial fibrillation: findings from the Outcomes Registry for Better Informed

Treatment of Atrial Fibrillation (ORBIT-AF). Circulation 2015;131(5):488-494.

Clark NP, Witt DM, Davies LE, et al. Bleeding, recurrent

venous thromboembolism and mortality risks

during warfarin interruption for invasive procedures.

JAMA Intern Med 2015;175(7):1163-1168.

42

and Finally…

Health Advice on TV Medical Talk Shows

� TV docs: 54% of recs had some evidence support

� “The Doctors” 53%

� Dr. Oz: 33% Korownyk C, Kolber MR, McCormack J, et al. Televised medical

talk shows--what they recommend and the evidence to support

their recommendations: a prospective observational study.

BMJ 2014;349:g7346.

Spicy Foods…

Chinese Population based prospective cohort study

� 199,293 men and 288,082 women aged 30 to 79

� Spicy food consumption: inverse associations with total mortality in both men & women (after adjustment for other risk factors)

Jun LV Consumption of spicy foods and total and cause specific

mortality: population based cohort study. BMJ 2015;351:h3942

43

Spicy Food…

THANKS!

44

“Evidence Based Parenting”

by

Heather Kovich, MD

Heather Kovich, MD, is a Family Physician and the Chief of Staff at the Northern Navajo

Medical Center in Shiprock, New Mexico. She attended Temple University School of Medicine

and the University of Washington Family Medicine Residency. She has two sons, ages two and

four, who generally refuse to follow evidence based guidelines.


Learning Objectives


1. Understand the current infant sleep recommendations

2. Understand screen time limits for children

3. Understand car and booster seat recommendations

45

Evidence Based Parenting

Common Anticipatory Guidance from Physicians

Heather Kovich, MDNorthern Navajo Medical Center

Shiprock, NM

Objectives

IntroAnticipatory Guidance

Infant Sleep

Car Seats

Screen Time

• To understand The impact of anticipatory guidance

from physicians

Evidence behind sleep training for infants

The importance of car seats, booster seats, and seatbelt laws

The controversy about young children and screen time

Anticipatory Guidance

http://www.someecards.com/usercards/viewcard/thank-you-so-much-for-your-unsolicited-advice-on-how-to-be-a-good-parent-30-years-ago-but-if-you-dont-mind-ill-listen-to-my-doctor--21f55

IntroAnticipatory Guidance

Infant Sleep

Car Seats

Screen Time

Future

46

Parents Like It

• More topics (up to 6) increaseparental satisfaction

• 1/3 of parents would be willing topay more to get more anticipatoryguidance Arch Pediatr Adolesc Med. 2000 Dec;154(12):1191-8.

25 min telephone survey of 2k parents of 0-3 yo in 1995-96

Intro

Anticipatory GuidanceInfant Sleep

Car Seats

Screen Time

Does It Work?

Maybe, but outcomes are intermediate Curr Opin Pediatr. 2003 Dec;15(6):630-5.

Systematic review.

Parents know more about developmentbut no change in development

Better safety behavior, no change in major injuries or trips to the ED• More seat belt use

Lots of data for “Reach Out and Read”• Improves language development in

children

Intro


Car Seats

Screen Time

Does It Work?

Fewer well child visits = no health impact 2 trials with 700 randomized children, half

as many well child visits: no difference in health, parental satisfaction, parental anxiety

Additional nurse visits for vaccinations

BMJ. 2001 Oct 13;323(7317):846-9.

Intro


Car Seats

Screen Time

47

Parents Forget Advice

http://www.someecards.com/usercards/viewcard/MjAxMy1hNWNlNTMwYjgzOWYyODcw

Intro


Car Seats

Screen Time

Parents Forget Advice

• More than 8 topics per visit –parents start to forget When asked by phone 1 month later Ambul Pediatr. 2005 Nov-Dec;5(6):372-6.

Intro


Car Seats

Screen Time

Lots of Recommended Topics

• 8 might seem like a lot, but BrightFutures recommends 21 topics to be discussed at first

newborn visit https://brightfutures.aap.org/Bright%20Futures%20D

ocuments/CoreTools2-5DayVisit.pdf

16 different topics at next visit https://brightfutures.aap.org/Bright%20Futures%20D

ocuments/CoreTools1MonthVisit.pdf

Intro


Car Seats

Screen Time

48

We’re not counseling on all topics

Survey of 900 pediatricians 11% were counseling on all 6 topics in the

survey.

Less than half regularly counseled on more than 2 topics. • Pediatrics. 2002 May;109(5):E83-3.

2 medical students observed 500 well child visits Clinicians addressed 42% of BF

anticipatory guidance topics, took 8.6 min of a 20 min visit (mean)• Acad Pediatr. 2011 Jan-Feb;11(1):18-26.

Intro


Car Seats

Screen Time

Future

The Take-Home

• Parents like it.

• There are too many things forus to talk about or for them toremember.

• It doesn’t have a large impacton child health, but it canimpact knowledge andbehaviors.

Intro


Car Seats

Screen Time

Sleeping

http://www.someecards.com/usercards/unsubmitted/MjAxMy01OTgxMTMzNWI2M2UxODdm

Intro


Infant SleepCar Seats

Screen Time

49

Sleep: Normal or Problem?

42% of 9 month olds awaken regularly at night J Adv Nurs. 1996 Nov;24(5):938-42.

Up to 46% of parents report infant sleep problems Med J Aust. 2005 Mar 7;182(5):215-8.

Bedtime problems and frequent night waking are highly prevalent… occurring in approximately 20-30% of infants, toddlers, and preschoolers Sleep. 2006 Oct;29(10):1263-76.

For infants and toddlers, night wakings are one of the most common sleep problems, with 25% to 50% of children over the age of 6 months continuing to awaken during the night. Sleep. 2006 Oct;29(10):1263-76.

Intro



Screen Time

Drowsy But Awake

• Placing your baby in the crib whenhe is drowsy but not asleep willhelp your baby learn that he cango to sleep on his own. Then,when he awakens at night, he willbe more likely to be able to goback to sleep without your help. https://brightfutures.aap.org/Bright%20Futures%2

0Documents/15-Infancy.pdf

• Recommended guidance at 1, 4,and 6 month visit

Intro



Screen Time

Internet forums

http://www.whattoexpect.com/forums/july-2011-babies/topic/putting-down-drowsy-but-awake-yeah-right.html

Intro



Screen Time

50

Internet Forums

http://community.babycenter.com/post/a9055075/put_baby_down_drowsy_but_awake....wtf

Intro



Screen Time

Drowsy But Awake: Evidence?

• Never studied alone

• Part of many multi-componentsleep interventions

• Studies generally involve• Initial face-to-face intervention

• Printed information (book/handout)

• Regularly scheduled supportive visits or phone calls

• Parents keep detailed diaries

• Full time caregiver at home for first 12 weeks.

Intro



Screen Time

Sleep Counseling: Evidence?

• Studies usually limited by• Small size (n=11 to n=200)• difficult recruiting subjects (¼-⅓ of

recruited families actually enroll)• short follow up periods• don’t evaluate for sleeping vs

feeding difficulties• The printed information is not

published or freely available

Intro



Screen Time

51

Systematic Review

• 43 studies (1993-2013); infants<6mo

• 2 larger RCT showed smallincrease in sleep duration, but nodecrease in crying time

J Dev Behav Pediatr. 2013 Sep;34(7):497-507.

• Overall, no significant benefit tosleep programs.

Intro



Screen Time

Metaanalysis

• Subject: postnatal parental education

• Measurable outcome = sleep

• 4 studies met their inclusion criteria

• 2 studies showed benefit; 90% weightedresults from one study

• Showed 29 min more nighttime sleep at 6 weeks

• No difference in crying time• 20% attrition

• 1 study with no benefit showed morematernal anxiety in intervention group

• Cochrane Database Syst Rev. 2013 Nov 28;11:CD004068.

Intro



Screen Time

Recent Evidence

• RCT; n=123

• Actigraph for objective maternal/infantsleep measurement

• Intervention similar to other studies

• No statistically significant difference Amount of maternal/infant sleep at 6, 12 wks

Number of nighttime awakenings

Subjective morning fatigue

Depressive symptoms on Edinburgh scale

• BMJ. 2013 Mar 20;346:f1164.

Intro



Screen Time

52

Recent Evidence

• 60% in both groups soughtinformation from other sources: 41% books

35% internet

35% other mothers

14% physician

BMJ. 2013 Mar 20;346:f1164.

Intro



Screen Time

Good news: It Gets Better

• 483 first-borns; prospective trial 2 wks through 24 months.

• Prevalence of sleep problems at 8, 12, 18, and 24 months was

21, 16, 10, and 12%, respectively

• 6.4% had a problem at > or =3 ofthese ages. Pediatrics. 2006 Mar;117(3):836-42.

Intro



Screen Time

The Take-Home

• No data to support drowsy-but-awake or other sleep hygienecounseling for infants

• It’s normal, but it gets better

Intro



Screen Time

53

Car Seats

• “If I had to choose the single worstaspect of parenting in the first year of ababy’s life, I have a very simple answer:the f***ing car seat. Every aspect of it—choosing one, buying it, installing it,removing it, putting it into another car,strapping a screaming baby into it—istotally maddening and utterlyexhausting.”

Intro


Infant Sleep

Car SeatsScreen Time

http://www.theawl.com/2015/03/the-car-seat

Rear Facing Until Age 2

• “Parents wrestle with rear facingcar seat advice” The Washington Post, Sept 24, 2011

“Do any of the folks who studied this have small children?”

“Have they tried to keep a squirrelly, anxious and frustrated 18-month-old rear-facing?”

“This is silly...It would also increase safety to wrap kids in bubble wrap.”

Intro


Infant Sleep


Car Accidents = Common Cause of Death in Children

Intro


Infant Sleep


Rank* Age <1 Ages 1–4 Ages 5–9 Ages 10–14 Ages 15–19

1 Suffocation907 (77%)

Drowning450 (31%)

Motor Vehicle (MV) Traffic378 (49%)

MV Traffic491 (68%)

MV Traffic3,242 (67%)

2 MV Traffic91 (8%)

MV Traffic363 (25%)

Drowning119 (15%)

Transportation – Other117 (15%)

Poisoning715 (15%)

3 Drowning45 (4%)

Fire/Burns169 (12%)

Fire/Burns88 (11%)

Drowning90 (10%)

Drowning279 (6%)

4 Fire/Burns25 (2%)



Fire/Burns53 (6%)


5 Poisoning22 (2%)

Suffocation125 (9%)

Suffocation26 (3%)

Suffocation41 (5%)

Fall58 (1%)

http://www.cdc.gov/safechild/NAP/background.html

Causes of Unintentional Injury Death in Children, 2009

54

Common but Declining

• In children < 16 yo 1500 deaths/yr

>50% are completely unrestrained

1998-2008 deaths declined 45%

• For each fatality 18 children hospitalized

300 receive medical treatment

http://pediatrics.aappublications.org/content/pediatrics/early/2011/03/21/peds.2011-0215.full.pdf

Intro


Infant Sleep


Restraint Use Increasing Since 1995

• Restraint use for adults was 60%; now 87%

• Also increasing for children:Intro


Infant Sleep


http://www.childtrends.org/?indicators=seat-belt-use

Patterns of restraint use

• We’re good about putting kids inrestraints 99% restraint use among infants<1y

92% 1-3 yo

89% 4-7 yo

• Restraint use children driven by belted driver = 92%

Unbelted = 54%

Intro


Infant Sleep


http://pediatrics.aappublications.org/content/early/2011/03/21/peds.2011-0215

55

We’re Good At Wearing Seatbelts

Intro


Infant Sleep


http://www-nrd.nhtsa.dot.gov/Pubs/812113.pdf

Primary Enforcement Works

• Non-use of restraints by 13–15year olds 10.8% in secondary enforcement

states

3.6% in primary enforcement states Accid Anal Prev. 2007 May;39(3):524-9.

Intro


Infant Sleep


Primary Laws vs Secondary Laws

Intro


Infant Sleep


http://www.iihs.org/iihs/topics/laws/safetybeltuse/mapbeltenforcement

56

Car Seats Help

• Compared with no restraints: Car seats reduce the risk of death by 71% for infants

54% for toddlers ages 1-4 years.

Booster seats reduce the risk for serious injury by 45% for children ages 4-8 years.

• https://www.aap.org/en-us/advocacy-and-policy/state-advocacy/Documents/CPS.pdf

Intro


Infant Sleep


Rear Facing Until Age ___

• BMJ: 4 yo BMJ. 2009 Jun 11;338

• Sweden: 4 yo Don’t actually have forward facing car

seats, only FF booster seats BMJ. 2009 Jun 11;338

• AAP: 2 yo Pediatrics. 2011 Apr;127(4):788-93.

• US State Laws: 1 yo Except NJ, OK; CA 1/2017 http://www.ghsa.org/html/stateinfo/laws/ch

ildsafety laws.html

Intro


Infant Sleep


Rear Facing - Theory

• Most car accidents = forwardcollisions

• Rear facing seats distribute forceover greater surface area

• Support head and neck better

• Children have relatively biggerheads, weaker necks Annu Proc Assoc Adv Automot

Med. 2007;51:169-80.

Intro


Infant Sleep


57

Crash Test Dummies

• 12mo, 18mo, 36mo size dummies US and Euro forward and rear facing car seats,

forward collision at 30 mph

• RF Euro seats: lowest risk of injury

• US designs: RF US seats had the worst head and chest injury

measures, but only significant compared to Euro RF seats

FF US seats worse for neck measures, but this has been shown to be inconsistent btn dummies and real bodies

Huge discrepancy between US designs• Annu Proc Assoc Adv Automot Med. 2007;51:169-80.

Intro


Infant Sleep


Europe vs US Car Seats

Intro


Infant Sleep


Pictures of a RF US design with flexible lower webbing, and a RF European design with rigid ISOFIX connectors and support leg.

Europe vs US Car Seats

• US: 2 point belt attachment (LATCH); European = 3 point rigid (ISOFIX)

• European RF seats have a floor prop, US seatsoptional: have to pass crash tests without it

• Some European countries and Canada require a tether to limit rebounding, US does not

• US car seats go through testing for front end collisions at 30 mph (NHSTA considering side-impact testing)

• European seats are tested for front, rear, and overturning

• US car seats have to “pass” testing, but resultsdo not have to be posted.

Intro


Infant Sleep


58

Rear Facing

• “A 2007 article in Injury Preventionshowed that 1-2 year olds were 5TIMES SAFER riding rear facingthan forward facing.” www.thecarseatlady.com

Intro


Infant Sleep


Rear Facing Evidence

• Inj Prev. 2007 Dec;13(6):398-402. Retrospective cohort chart review – NHTSA

representative sample 1988-2003

Accident victims: <1 yo or 1-2 yo; rear or front facing

Injury severity score (iss) </> 9 (moderate injury)

N = 60 kids 1-2 yo RF

Weighted data = RF 86% vs FF 69% effective forpreventing ISS >9 compared with no restraints (OR 1.7) in 1-2 yo; benefit was from side crashes, not significant when looking at frontal crashes

weighted data showed more likely to have very serious/life threatening injury with rear facing, although this is most likely an artifact of the small dataset

Intro


Infant Sleep


Rear Facing - Crash Dummies

• 6m infant: LATCH v seat beltinstallation with rear collisions

• LATCH installation had highermeasures of head injury risk

• Seat belt installation more stable

• Convertible seat was okay Traffic Inj Prev. 2015 Oct 8;16 Suppl

2:S16-23.

Intro


Infant Sleep


59

Rear Facing – Crash Dummies

Intro


Infant Sleep


Car Seats

• Take home: Everyone in the vehicle should wear

restraints. Laws correlate with increased restraint

use.

Lots of room for improvement in car seat design

car seat testing and regulations

Rear facing might be safest

Move to Sweden

Intro


Infant Sleep


Screen Time

Intro


Infant Sleep

Car Seats

Screen Time

http://www.art.com/products/p16818055335-sa-i6990093/emily-flake-she-thinks-it-s-a-touchscreen-new-yorker-cartoon.htm

60

Screen Time – AAP Recs

• 1999, 2011, and 2013 AAPrecommendations discourage any screen use for

children <2 yo

limit entertainment screen time to <1-2 hours per day for older children

www.pediatrics.org/cgi/doi/10.1542/peds.2011-1753

Intro


Infant Sleep

Car Seats

Screen Time

Screen Time

Intro


Infant Sleep

Car Seats

Screen Time

http://www.someecards.com/usercards/viewcard/MjAxNC1iMGQwMTVlNWUxMTk1MmQz

Screen Time

• 2011: 10% of children under 2 hadused a smartphone or tablet

• 2013: 38% https://www.commonsensemedia.org/sites/d

efault/files/research/zero-to-eight-2013.pdf

Intro


Infant Sleep

Car Seats

Screen Time

61

2007 Survey TV/DVDs <2 yo

• Random phone survey 1000 English speaking parents in MN and WA. Response rate = 20%

Intro


Infant Sleep

Car Seats

Screen Time

Arch Pediatr Adolesc Med. 2007;161(5):473-479. doi:10.1001/archpedi.161.5.473

2007 Survey: TV/DVD <2 yo

Intro


Infant Sleep

Car Seats

Screen Time

Arch Pediatr Adolesc Med. 2007;161(5):473-479. doi:10.1001/archpedi.161.5.473

Television is Terrible?

• Infants and toddlers who watchlots of TV are potentially at risk inlater childhood for deficits in attention

poorer language development

diminished cognitive achievements

• The following 3 studies were allcited by the AAP in their 2011guidelines.

Intro


Infant Sleep

Car Seats

Screen Time

62

Television and Attention Deficits

• Longitudinal survey 1300 children

• Average TV viewing/day: 1 yo = 2.2 hours (SD: 2.91)

3 yo = 3.6 hours (SD: 2.94)

• 10% had attention ‘problems’ at age 7 >1.2 SD >mean on hyperactivity questions

Not diagnostic of ADHD but similar prevalence

• Regression analysis: hours of televisionper day at ages 1 and 3 were associatedwith attention probs at age 7(OR 1.09).

Pediatrics. 2004 Apr;113(4):708-13

Intro


Infant Sleep

Car Seats

Screen Time

BUT…

• Maternal depression when child young was also correlated with attention problems (OR 1.03)

• Low maternal self-esteem prior to birth of child was more strongly assd than TV (OR 1.36).

Pediatrics. 2004 Apr;113(4):708-13

• 2010 reanalysis original data

Adding 2 covariates eliminated any effect maternal skills/achievement

early poverty status• Child Dev. 2010 Jan-Feb;81(1):368-75

• Retesting in Danish cohort: no effect Danes watch less TV overall

Only had data for 3 yo and 7 yo (no 1 yo data) Pediatrics. 2004 Nov;114(5):1372-3

Intro


Infant Sleep

Car Seats

Screen Time

Television and Reading/Memory

• Longitudinal survey 1800 children

• Outcome = math, reading, short termmemory test scores at age 6

• Modest decrease in reading/memoryscores at age 6 correlated with eachhour television watched <3 yo.

• BUT…each hour of television in the 3-5yo age range was associated withmodest increase in reading scores.

Arch Pediatr Adolesc Med. 2005;159(7):619-625.

Intro


Infant Sleep

Car Seats

Screen Time

63

Television and Language Development

• Telephone survey of 1000 parents whoalso completed a survey of languagedevelopment

• In children 8-16mo each daily hour ofbaby DVDs was associated with asignificant decrease in languagedevelopment

• No effect of other educational or non-educational television viewing.

• 17-24mo no effect for any media. J Pediatr. 2007 Oct;151(4):364-8

Intro


Infant Sleep

Car Seats

Screen Time

BUT…

• Reanalysis did not confirm findings

• Raw data did not show statisticalsignificance, only when 20 covariateswere added. Unclear rationale for all covariates

Nonnormal distribution for most variables (a few extreme outliers in baby videos)

• Dev Psychol. 2014 Jan;50(1):129-37.

Intro


Infant Sleep

Car Seats

Screen Time

TV and Adolescent Test Scores

• 6-12th grade test scores in 300k children who had/didn’t have access to TV when they were young (in the 1940s-1950s) Variable television roll-out to different markets e.g.

Seattle had TV before Denver

• Compared children in different markets

• Compared children in same market, differentyears (before/after TV)

• Test scores from Coleman Report: Study of educational opportunity commissioned by

Civil Rights Act.

Gentzkow et al The Quarterly Journal of Economics, Feb 2008 http://www.brown.edu/Research/Shapiro/pdfs/tv.pdf

Intro


Infant Sleep

Car Seats

Screen Time

64

TV and Adolescent Test Scores

• Gentzkow et al, contd. By 1950s kids in houses with TV

were watching 4 hours/day Data are for school aged kids. Scant data for

younger kids. Small surveys = 30-60 min for 3 yo, no data for <2 yo.

Showed a slight benefit to having television during pre-school years

Intro


Infant Sleep

Car Seats

Screen Time

TV and Language/Motor Skills

• 872 children in MA

• Mothers reported TV use at 6, 12,24 months.

• At 3 years no difference in averbal/language test nor a finemotor/spacial skills test.

• Kids watched less TV than in otherstudies. Mean: 0-2y was 1.2 h

Pediatrics. 2009 Mar;123(3):e370-5.

Intro


Infant Sleep

Car Seats

Screen Time

What We Know About Screen Time

• Toddlers and pre-schoolers can learnfrom TV Infant Behav Dev. 2008 Dec;31(4):696-703.

Pecora, N., Murray, J. P., & Wartella, E. A. (2007). Children and television: Fifty years of research. Mahwah, NJ: Erlbaum.

• Babies <2y learn more from people Child Dev. 1999 Sep-Oct;70(5):1067-81.

Child Dev. 1998 Aug;69(4):950-65.

Psychol Sci. 2010 Nov;21(11):1570-4

Developmental Review 30 (2010) 101–115 (Review)

• Background TV makes adults and kidstalk less Infant Behav Dev. 2010 Apr;33(2):176-88.

Arch Pediatr Adolesc Med. 2009 Jun;163(6):554-8.

http://www.newyorker.com/magazine/2015/01/12/talking-cure

Intro


Infant Sleep

Car Seats

Screen Time

65

What We Know About Screen Time

• Childhood obesity is positivelyassociated with amount of TV

• Interventions can reduce screen timeand obesity School or community-based

Involve parental support

Technology to track screen time and turn offscreens http://www.thecommunityguide.org/obesity/behavioral.html

• Physician anticipatory guidance notshown to be effective for reducingscreen time Curr Opin Pediatr. 2003 Dec;15(6):630-5.

Intro


Infant Sleep

Car Seats

Screen Time

Beyond “Turn It Off”

• 2015: Beyond “Turn It Off”: How toAdvise Families on Media Use

• Lots of recommendations, no hardnumbers

Intro


Infant Sleep

Car Seats

Screen Time

Beyond “Turn It Off”

• Media is just another environment

• Parenting has not changed

• Role modeling is critical

• We learn from each other

• Content matters

• Curation helps

• Co-engagement counts

• Playtime is important

• Set limits

• It’s okay for your teen to be online

• Create tech-free zones

• Kids will be kids

Intro


Infant Sleep

Car Seats

Screen Time

http://www.aappublications.org/content/36/10/54

66

Screen Time – Take Home

• Screens are here to stay

• There may be risks and benefits – Conflicting data for TV

Less data for newer technologies

Kids < 2yo learn better from people

More screen time correlates withmore obesity

• New AAP rules More nuanced

Counseling may take longer

Intro


Infant Sleep

Car Seats

Screen Time

Conclusion

• Anticipatory Guidance: Don’t do it all pick a few high yield topics

• Consider “Reach Out and Read” and seat belts

consider your population

• Infant Sleep: No data for any particular method

• Car Seats: Counsel about use of car seats and seat belts

• Screen Time: Impact on cognition/behavior not clear

Adverse impact on childhood weight

The end!

Special thanks to:

Bennett, Russell, and Andrew Weber

Northern Navajo Medical Center Medical Staff

Contact:

[email protected]

67

“Quality Improvement in Your Practice”

by

Darrick Nelson, MD

Darrick Nelson, MD, is originally from a small mining town in Arizona and a U. S. Army

Veteran. Dr. Nelson obtained his medical degree from the University of Texas Health Science

Center at San Antonio. He graduated Magna Cum Laude from the University of Texas at Dallas

with a Bachelor of Science degree in biology. Prior to joining Hidalgo Medical Services (HMS),

Dr. Nelson was a professor and a core faculty member at Texas A&M University Health Science

Center, Department of Family and Community Medicine, Corpus Christi Family Medicine

Residency Program where he was responsible for the teaching and supervision of residents in

outpatient clinics, inpatient hospital, intensive care unit, newborn nursery, labor and delivery,

including C-sections, high risk obstetrics, and indigent care. Dr. Nelson is a Fellow in medical

informatics and was physician liaison for implementation of electronic clinical documentation

system with CHRISTUS Spohn Shoreline Hospital.

Dr. Nelson serves as the Chief Medical Officer of HMS, a non-profit, Federally Qualified Health

Center with a total of 12 locations in Grant and Hidalgo Counties of southwest New Mexico. Dr.

Nelson directs the delivery of patient centered primary care services for HMS as well as

leadership and innovation on projects and programs to improve clinical and overall health

outcomes for the residents of Southwest New Mexico. In addition to providing direction in all

aspects of patient-centered, high quality healthcare, Dr. Nelson is one of the founders of the

FORWARD NM – Pathways to Health Careers workforce program at HMS. This 5-stage

program reaches students from secondary education throughout graduate degrees and includes

accreditation of the HMS Family Medicine Residency Program, the first Teaching Health Center

designation in New Mexico. This is a 1-2 model in partnership with the University of New

Mexico.

In 2012 Dr. Nelson was named the New Mexico Primary Care Association's "Community Health

Center Medical Provider for the Year." Dr. Nelson currently directs and is the Chairman of

Hidalgo Medical Services’ Quality Improvement Committee. In 2013, through Dr. Nelson’s

vision and leadership, Hidalgo Medical Services received a “Small Healthcare Provider Quality

Improvement” grant from the Federal Office of Rural Healthcare Policy. Dr. Nelson is a Fellow

of the National Institute for Program Director Development and served on the Board of Trustees

for Gila Regional Medical Center and served as the Chairman of Gila Regional Medical Center's

Quality Improvement Committee. Dr. Nelson recently joined the Board of Directors for The

National Rural Training Track Campus Collaborative (“The RTT Collaborative” or “RTTCC”), a

newly established 501(c) (3) organized to sustain medical education in rural places.


68

Learning Objectives


1. Define the role of Quality Improvement in practice

2. Understand the Model for improvement

3. Define the use of PDSA cycles that can help quantify improvement

4. Demonstrate the use of PDSA cycles to guide improvement

69

Quality Improvement In Your

Practice

Darrick P. Nelson, MD

Hidalgo Medical Services

ICEO, CMO, HMSFMRP Program Director

[email protected]

Learning Objectives

• Define the role of Quality Improvement in

practice

• Understand the Model for improvement

• Define the use of PDSA cycles that can help

guide quality improvement

• Demonstrate the use of PDSA cycles to guide

improvement

What is Quality Improvement?

• Quality Assurance?

– A term used in manufacturing and generally after-the-fact assurance of item quality

• Quality Improvement

– Quality improvement (QI) consists of systematic and continuous actions that lead to measurable improvement in health care services and the health status of targeted patient groups. The Institute of Medicine's (IOM) which is a recognized leader and advisor on improving the Nation's health care, defines quality in health care as a direct correlation between the level of improved health services and the desired health outcomes of individuals and populations (1).

1. The Institute of Medicine of the National Academics

70

The value of continuously considering

quality

Why conduct continuous quality

improvement in your practice?

• It’s Fun

• It can help improve reimbursement in a pay forperformance environment

• It can help meet ABFM MOC part IV requirements

• It can contribute to decreasing the cost of care to

the healthcare system

• It can reduce medical errors

• Most importantly, it can improve the quality ofcare that we deliver to our patients

The Model for Improvement

• The Model for Improvement,* developed by Associatesin Process Improvement, is a simple yet powerful tool for accelerating improvement

• The model is not meant to replace change models that organizations may already be using, but rather to accelerate improvement

• This model has been used very successfully by hundreds of health care organizations in many countries to improve many different health careprocesses and outcomes.

Sources:

*Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd edition). San Francisco: Jossey-Bass Publishers; 2009.

71

The Model Includes Two Parts

1. Three fundamental questions, which can be

addressed in any order.

2. The Plan-Do-Study-Act (PDSA) cycle** to test

changes in real work settings. The PDSA cycle

guides the test of a change to determine if

the change is an improvement.

**The Plan-Do-Study-Act (PDSA) cycle was originally developed by Walter A. Shewhart as the Plan-Do-Check-Act (PDCA) cycle. W.

Edwards Deming modified Shewhart's cycle to PDSA, replacing "Check" with "Study." [See Deming WE. The New Economics for

Industry, Government, and Education. Cambridge, MA: The MIT Press; 2000.]

The Three Fundamental Questions

Setting Aims

Improvement requires setting aims. The aim

should be time-specific and measurable; it should

also define the specific population of patients or

other system that will be affected

Establishing Measures

Teams use quantitative measures to determine if

a specific change actually leads to an

improvement

Selecting Changes

Ideas for change may come from the insights of

those who work in the system, from change

concepts or other creative thinking techniques, or

by borrowing from the experience of others who

have successfully improved

Setting Aims, Establishing Measures,

Selecting Changes

72

Constructing an Aim Statement

We will

_[verb]___[noun]___________________ by

_[number]_____ [units] by __[date]___.

Thoughts for Improvement

• Before you try to solve a problem, define it.

• Before you try to control a process,

understand it.

• Before trying to control everything, find out

what is important.

Neuhauser, D., PhD, Myhre, S., MBA, & Alemi, F., PhD. (2004). Personal Continous Quality Improvement Work Book (7th ed.).

Helpful Hints

• Clearly define your goal for each cycle – Put it

in writing!

• Keep a log or diary of your progress.

• Data collection should be on a frequent basis

– start immediately!

• Assemble data graphically


73

Testing ChangesThe Plan-Do-Study-Act (PDSA) cycle is shorthand for testing a change in the real work setting — by planning it, trying it, observing the results, and acting on what is learned. This is the scientific method adapted for action-oriented learning.

The PDSA Cycle

coachingandleading.wordpress.com-

The Scientific Method of Improvement

the PDSA Cycle


HMS PDSA Tracking Sheet

74

HMS PDSA #1

Data from NM Primary Care Association October 2013 Patient Experience

Survey

HMS PDSA #1

Aim: Increase the percentage of patients getting

pre visit reminders

Measure: Annual Patient satisfaction survey

change

Selecting the Change: Enabling automatic voice,

text and e-mail reminders through our EHR

HMS PDSA #1

Data from NM Primary Care Association October 2014 Patient Experience

Survey

75

HMS PDSA #1

Results from cycle #1

• We saw a modest increase, 84% to 86% ofpatients indicating that they got pre-clinicreminders

• We realized that our system of collectingpatient contact information neededimprovement

• The disposition on PDSA#1 was “ADAPT”

– The adaptation was to improve our mechanism for collecting patient contact information

HMS PDSA #2

Aim: Increase the percentage of senior patients

receiving pneumococcal and influenza

vaccinations

Measure: Percent increase in senior patients

who received pneumococcal and influenza

immunizations

Selecting the Change: “Red Cards” and outreach

76

The power of PDSA (influenza)

Questions?

Thank You

77

“Patient Rights Versus Public Social Needs in

a Measles Outbreak – New York, 2012”

by

Nina Ahmad, MD

Nina Ahmad, MD, is a Vaccine Science Fellow with the AAFP and works as the Medical

Director and Director of Emergency Preparedness and Response at the Center for Environmental

Health at New York State Department of Health in Albany, NY. From 2012 to 2014 she worked

as an Epidemic Intelligence Service Officer at the CDC where her job included investigating

outbreaks of disease. She graduated from Chicago Medical School and completed a Residency in

Family Medicine at the University of Medicine and Dentistry of New Jersey.


Learning Objectives


1. List signs and symptoms of measles

2. Describe the epidemiology of measles in the US

3. Explain the role of the CDC investigators and primary care providers in a disease

outbreak

4. List reasons why patients and their families might be reluctant to cooperate with medical

authorizes in an out break

5. Identify steps to take to prevent the spread of measles and other communicable diseases

in a community

6. Describe the process for contacting infection control experts

78

Nina Ahmad, MD

Director of Emergency Preparedness and Response

New York State Department of Health

Patient Rights Versus Public Social

Needs in a Measles Outbreak —

New York, 2012

September 4, 2012:

Unvaccinated male aged 9

years returned home from

London

Timeline of Symptom Development

79

September 4, 2012:



London

September 5, 2012:

Returned to private

school (School A)


September 4, 2012:



London

September 5, 2012:

Returned to private

school (School A)

September 12, 2012:

Symptom development


September 4, 2012:



London

September 5, 2012:

Returned to private

school (School A)

September 12, 2012:

Symptom development

September 16, 2012:

Rash development


80

Koplik’s Spots

81

Conjunctivitis

Rash

Measles Patient

� Unvaccinated male aged 9 years

� September 4- Returned from family vacation in

London

� September 14- Attended School A while contagious

� September 16- Rash onset

� Physician diagnosed via telephone (without testing)

82

States Without Religious Exemption

Mississippi West Virginia

States with Philosophical Exemption

Arizona

Arkansas

California

Colorado

Idaho

Louisiana

Maine

Michigan

Minnesota

North Dakota

Ohio

Oklahoma

Texas

Utah

Vermont

Washington

Wisconsin

School A

� Small building housing highly unvaccinated population

� 3 different counties between nursery age to 18

� All 182 students and staff who attended School A on

September 14, 2012 potentially exposed

� Course of illness

� Movement throughout school

� Practiced routines and rituals (group hand washing, singing, playing

and sharing of musical instruments)

85

Determination of Those Susceptible

School A (N=182)

Staff N= 33 (18%)

Students N=149(82%)

Evidence

of Immunity or

Born Before 1957

N= 16 (48%)

Evidence

of Immunity

N= 59 (40%)

No

Evidence

N= 17 (52%)

No

Evidence

N= 90 (60%)

Containment Efforts at School A

� 107 (59%) people had no evidence of immunity

� 17 staff

� 90 students

� 34 (32%) chose vaccination

� 17 staff

� 17 students

� 104 (68%) excluded

� All were students

Suspect Secondary Case

� Unvaccinated male aged 2 years

� 93 total exposed contacts

� Seen at Clinic A

� Tested at Laboratory X

86

Potential Exposures to the Suspect Measles Patient

Total Potential

Exposures to Suspect

Case

N= 93

Clinic A

N= 62 (67%)

Laboratory X

N=31 (33%)

3 Pregnant woman and 8 children < 12 months

Results of Case Finding

� 275 potential exposures identified

� No secondary cases were identified

Objective

� What was the economic impact of the health

departments attempts to prevent spread of measles in

this community from the public health perspective?

87

Methods

� Evaluation period: September 18 - October 15, 2012

� Identified involved personnel

� Identified response efforts

� Used standardized economic response surveys

� Interviewed fiscal personnel at each health department

� Salary, fringe, and overhead

Identification of Involved Personnel

� Key contacts used to assist in identification of involved

personnel

� Review of emails and record keeping during response

Identification of Response Activities

� Review of meeting notes and emails

� Standardized Economic Survey

88

Respondents to Standardized Economic Survey

� 31 public health officers from 5 public health

departments

� 4 staff members from one public health laboratory

� Survey completion rate

� Part 1: 91%

� Part 2: 74%

Time and Costs of Response Efforts

� 688 person-hours (44 overtime hours)

� $46,028 was expended

Public Health Measles Response Costs in Dollars (N= $46,028)

Dollars

Types of Costs

89

Hours

Hours Spent in Measles Response Efforts (N=688)

0

10

20

30

40

50

60

70

80

90

Daily Public Health Hours Expended During Measles Response

Hours

Dates

First day of measles case

containment efforts

First day of suspect measles

case containment efforts

Conclusions

� Response was initiated due to importation of measles

by an unvaccinated child

� No healthcare provider involved reported to public

health

� 34 people at School A chose to vaccinate

� No secondary measles cases identified

� 688 hours and $46,028 expended

� Similar to response in Iowa to a measles case

90

Office of Surveillance, Epidemiology, and Laboratory Services

Scientific Education and Professional Development Program Office

Acknowledgments

� NYS and Local Health Departments� Eleanor Adams

� Julius Ade

� Sarah Ali

� Deborah Blog

� Bryan Cherry

� Donna Demeter

� Jane Grenko

� Bradley Hutton

� Julian Isaacs

� Heidi Iyok

� Daniel Kuhles

� Philip Kurpiel

� Jacklyn Lawler

� Vincent Martello

� Angela Maxted

� James Nerone

� Alexandra Newman

� Ellen Parrinelli

� Bibi Raouf

� Elizabeth Rausch-Phung

� Russell Rockwell

� Andrew Rotans

� Cynthia R Schulte

� Gloria Seise

� Carol Smith

� Linda Squires

� Joan Whitehouse

� Wadsworth laboratories� Meghan Fuschino

� Daryl Lamson

� Michael Popwich

� Kirsten St. George

� CDC

� Preeta Kutty

� Julie Magri

� Ismael Ortega-Sanchez

Standardized Economic Survey

� Two part survey designed and used in previous New

York state response efforts

� Part 1

� Personnel hours

� Associated direct costs

� Resources utilized

� Activities conducted

� Salaries

� Part 2

� Hours expended each day of study period

91

Financial Costs

� Worked with CDC economist

� Only looked at direct costs to public health

� Obtained salary for each employee

� Used fringe rate at each department to calculate fringe

benefits

� Social Security and Medicare

� Federal Unemployment Taxes/Insurance

� State Unemployment Taxes/Insurance

� On-the-job accident insurance

� Medical insurance and paid sick leave

Financial Costs

� Used overhead rate at each department to calculate

overhead costs

� Rent

� Utilities

� Telephone

� Postage

� Building use allowance

Results

� Response efforts

� Costs

92

“Medication Issues in the Elderly”

by

Patrick Leung, Pharm.D., BCPS, PhC &

Davena Norris, Pharm.D., BCPS, PhC

Patrick Leung, PharmD, has been a Clinical Pharmacy Specialist at Memorial Medical Center

and a faculty member at Southern New Mexico Family Medicine Residency since 2002. He is a

pharmacist clinician at Memorial Medical Center Anticoagulation Management Service. Besides

his teaching responsibilities at the Southern New Mexico Family Medicine Residency, he has

been a preceptor for UNM pharmacy students since 2004 and is the Pharmacy Residency

Program Director at Memorial Medical Center. Dr. Leung is a Board Certified Pharmacotherapy

Specialist. He received his Bachelor of Pharmacy and Doctor of Pharmacy degrees from

Washington State University. His areas of interest are medication safety, infectious diseases,

cardiovascular diseases, anticoagulation, and diabetes.

Davena Norris, PharmD, is a Clinical Pharmacist at Memorial Medical Center (MMC) in Las

Cruces, New Mexico. Upon graduating from the University of New Mexico College of

Pharmacy in 2012, she has completed a PGY1 pharmacy residency at the Southern Arizona VA

healthcare System (SAVAHCS) in Tucson. In her current position at MMC, Dr. Norris works

collaboratively with Family Medicine Residents and faculty to manage medication therapy in

both inpatient and ambulatory settings. A few of her greatest practice interests include diabetes

management and prevention, the care of older adults, and infectious disease. She has many

teaching roles, including serving as a faculty member for the Southern NM Family Medicine

Residency Program (SNMFMRP), Program Coordinator for the MMC PGY1 Pharmacy

Residency Program, and a preceptor for the UNM College of Pharmacy.

Email: [email protected], [email protected]

Learning Objectives


1. Identify age-related pharmacokinetic and pharmacodynamics changes in older adults

2. Utilize the START/STOPP and Beer’s criteria to recognize appropriate and inappropriate

medication prescribing in older adults

3. Explain the importance of and strategies for managing polypharmacy in older adults

93

Patrick Leung, Pharm.D., BCPS, PhCDavena Norris, Pharm.D., BCPS, PhC

2/20/2016

Learning Objectives Identify age-related pharmacokinetic and

pharmacodynamic changes in older adults.

Utilization the START/STOPP and Beer’s criteria to recognize appropriate and inappropriate medication prescribing in older adults.

Explain the importance of and strategies for managing polypharmacy in older adults.

Patrick Leung, Pharm.D., BCPS, PhC

94

Medication issues in Older Adults Over 1/3 of the prescription medications are taken by

patients over 65 years old, although elderly makes up only 15% of the US population.

Hutchison LC, Sleeper RB. Geriatric Pharmacotherapy. P57-76

Population Aged 65 and Over for the United States

http://www.census.gov/prod/2014pubs/p25-1140.pdf

Medication issues in Older Adults Up to 35% of elderly outpatients experience ADEs

annually Up to 30% of hospital admission in elderly are

related to ADEs Elderly are seven times more likely than young

adults to have adverse events that requiredhospitalizations Age-related physiological changes A larger number of co-existing conditions Polypharmacy

Hutchison LC, Sleeper RB. Geriatric Pharmacotherapy. P57-76 Hamilton et al. BMC Geriatrics 2009;9(5):1-4

Age-related ChangesOlder patients respond to medications

differently than younger patientsbecause of physiologic changes inaging:Pharmacokinetic changesPharmacodynamic changes

95

Drug ResponsePharmacokinetics: Drug concentrations at the site ofaction

Pharmacodynamics: End-organ responsiveness to a givendrug concentration

Which one of the following changes in an elderly patient’s body composition compared with a younger patient may affect the pharmacokinetics of drugs that he/she is taking?

A. Increased bonemass

B. Increased musclemass

C. Decreased adipose mass

D. Decreased totalbody water

30

Age-dependent changes in body Composition

Klotz U. Drug Metab Rev 2009;41(2):67-76

96

Which one of the following changes in liver function would be expected in an older adult?

A. Increased liverdiameter

B. Reduced hepaticblood flow

C. Reducedcytochrome P450enzyme function

D. Increased hepaticmetabolism

Physiologic Changes in AgingBody composition ↓ Total body water

↓ Lean body mass

↑ Body fat

GI system Delayed gastric emptying

↑ Gastric PH

↓ GI blood flow

Liver ↓ Liver size

↓ Hepatic blood flow

Renal System ↓ Renal mass & blood flow

↓ glomerular filtration rate

ELDesoky ES. Am J Ther 2007(14):488-98 Klotz U. Drug Metab Rev 2009;41(2):67-76

Physiologic Changes in AgingCardiovascular system ↓ myocardial β-receptor

sensitivity

↓ Baroreceptor activity

↓ Cardiac output

↑ Total peripheral resistance

Central Nervous System ↓ weight and volume of the

brain

↓ ACH receptors in the brain

↓ opioid receptor function

Klotz U. Drug Metab Rev 2009;41(2):67-76ELDesoky ES. Am J Ther 2007(14):488-98

97

Pharmacokinetic Changes Absorption

Distribution

Metabolism

Renal Excretion

Pharmacokinetic ChangesAbsorption

Physiologic changes of aging Clinical Significance

Delayed gastric emptying

↑ Gastric PH

↓ GI blood flow

No clinical significant change in absorption with age


Pharmacokinetic ChangesDistribution

Physiologic Changes of Aging

Clinical Significance

●↓ Total body water

●↓ Lean body mass

●↑ Body fat

● ↓ serum albumin

● ↑ volume of distribution of lipid-soluble drugs (e.g. diazepam)

● ↓ volume of distribution ofwater-soluble drugs (e.g.digoxin, gentamicin)

● ↑ free fraction in plasma ofhighly protein-bound acidicdrugs (e.g. warfarin, phenytoin)

ELDesoky ES. Am J Ther 2007(14):488-98 Klotz U. Drug Metab Rev 2009;41(2):67-76

98

Pharmacokinetic Changes Metabolism

Physiologic Changes of Aging

Clinical Significance

● ↓ Liver size

(-20 to 30%)

● ↓ Hepatic blood flow

(-20 to 50%)

● ↓ First-pass metabolism (e.g.propranolol, MS, statins)

● ↓ rate of activation of someprodrugs (e.g. enalapril)

● Marked inter-individual variationin the rate of hepatic metabolism

● Illness and drug interactions aremore important in reducing theactivity of CYP enzyme systemthan aging


Which one of the following is the likely reason that elderly patients may have a decreased diuretic response to a given dose of furosemide?

A. Reducedabsorption rate

B. Reduced serumprotein binding

C. Reduced delivery to its site of action

D. Reduced vascular homeostaticmechanisms

:30

Pharmacokinetic ChangesRenal Excretion

Physiologic Changes of Aging Clinical Significance

● ↓ Renal mass

(up to 30%)

● ↓ Renal blood flow

● ↓ glomerular filtration

rate (by 1% every

year of age after 20)

● ↓ renal elimination (e.g.gentamicin, enalapril, digoxin,lithium, diuretic)

● Marked inter-individual variation

● Frail elderly patients with littlemuscle mass may have normalSrCr despite having experienceda decline in GFR by >50%.

ELDesoky ES. Am J Ther 2007(14):488-98

99

Which one of the following drugs would have no increased risk of adverse effects as a result of age-related changes in pharmacokinetics or pharmacodynamics?

A. DigoxinB. EnalaprilC. MetoprololD. Isosorbide

mononitrate

30

Pharmacodynamic ChangesChanges in drug pharmacodynamics

can result from changes in receptornumber, receptor affinity, or post-receptor effects (including secondmessenger systems).Pharmacodynamic changes inAutonomic and central nervous system

Pharmacodynamic ChangesAutonomic Nervous SystemAge-related changes

in ElderlyPharmacodynamic

Effects● ↓ β-adrenergic receptorsin CV and respiratory tract

● Impaired baroreceptorreflex activity

● ↓ Cholinergic transmissionand number of muscarinicACH receptors

● Less responsive to β-agonistsand β-antagonists

● Elderly are much more likely tohave an exaggerated posturalhypotension

● ↑ sensitivity to antagonism ofcholinergic receptors


100

Pharmacodynamic ChangesCentral Nervous System

Age-related changes in Elderly

Pharmacodynamic Effects

● ↓ Functional reserve inmemory and other functionsof CNS

● ↑ sensitivity to sedationdrugs and drugs withanticholinergic effects in theCNS


Case 1AB is a 68-year old man who presents to your clinic with complaints of new onset urinary urgency, frequency, and reduction of stream flow. His wife accompanies him to the clinic visit because she is concerned about his recent onset of disorientation. He has been using an OTC medication for allergy symptoms.

Case (cont.)His current medications:• Hydrochlorothiazide 12.5 mg daily (4 yrs)• Amlodipine 5 mg daily (6 months)• Amitriptylline 50 mg at bedtime for back pain (2

years)• Diphenhydramine 25 mg 3 times/day prn (2 weeks)• Atorvastatin 10 mg at bedtime (2 yrs)• Temazepam 15 mg at bedtime (6 months)Vital sign: BP 159/95, P 75Lab: Na 143, K 4.9, BUN 22, Cr 1.5

101

Which of the following is the most appropriate intervention for AB?

A. Tamsulosin (Flomax)0.4 mg at bedtime

B. Discontinuediphenhydramine

C. Discontinuehydrochlorothiazide

D. No change

30

Which one of the following is the most likely cause of the change in AB’s cognitive function?

A. Sleep deprivationB. Long-term

temazepam useC. Age-related cognitive

dysfunctionD. Accumulated

anticholinergic activity

30

Patrick Leung, Pharm.D., BCPS, PhC

102

What percentage of adults 65 or older taking 5-9 medicationsA. 20%B. 40%C. 60%D. 80%

30

Polypharmacy in Older AdultsPolypharmacy: 5 medicationsAdults 65 years of age or older:40% take 5-9 medications18% take 10 medications

http://www.bu.edu/slone/files/2012/11/SloneSurveyReport2006.pdf

Trends in any Rx drug use and Polypharmacy (5 Rx drugs) in the US from 1999-2012

Kantor et al. JAMA 2015;314(17):1818-31

24

39

84 90

103

Polypharmacy in Older AdultsPolypharmacy is more commonin elderly because they havemore chronic disease conditionsand are taking more medications

http://www.bu.edu/slone/files/2012/11/SloneSurveyReport2006.pdf

CMS: Chronic Conditions Among Medicare Beneficiaries, 2000

Polypharmacy in Older Adults Can be appropriate or inappropriate Multiple medications are often required to treat

clinically complex older adults. Challenge to match the complex needs of older

patients with those of disease specific clinical practice guidelines.

Example: An older patient with a myocardial infarction, history of diabetes mellitus type II, andCOPD.

104

Polypharmacy Increases the risk of adverse drug reactions, drug-

drug interactions, drug-disease interactions anddrug-food interactions.

Increases the possibility of “prescribing cascades”. Increases healthcare costs

Emergency Hospitalizations for AdverseDrug Events in Older Americans Adverse drug reactions were responsible for about

100,000 hospitalizations among older Americans each year.

Almost half of these admissions were elderly 80 years or above

Nearly two thirds of these hospitalizations were due to unintentional overdose

The estimated cost of ADEs in 2006 was 3.5 billion US dollars

Budnitz DS et al. N Engl J Med 2011;365(21):2002-12.

Budnitz DS et al. N Engl J Med 2011;365:2002-2012.

Estimated Rates of Emergency Hospitalizations for Adverse Drug Events in Older U.S. Adults, 2007–2009.

105

Risk Factors for Adverse Drug Effects 6 or more concurrent chronic conditions 12 or more doses of drug/day 9 more medications Prior adverse drug reaction Low body weight or body mass index Age 85 or older Estimated CrCl < 50 ml/min Inappropriate Prescribing

Inappropriate Prescribing in ElderlyMedications that pose more harm than

benefit Inappropriate dose or durationMedications with clinically significant drug-

drug, and drug-disease interactionsUnderuse of potentially beneficial

medicationsHamilton et al. BMC Geriatrics 2009;9(5):1-4

Inappropriate Prescribing in Elderly Up to 24% of elderly outpatients and 40% of nursing

home residents receiving at least one inappropriate medication according to Beers’ criteria

58% of elderly do not receive one or more clinically indicated medications according to START criteria

Inappropriate prescribing is associated with increased morbidity, mortality and healthcare cost, primarily due to an increased prevalence of ADEs

Hamilton et al. BMC Geriatrics 2009;9(5):1-4

106

References Hutchison LC, and Sleeper RB. Fundamental of Geriatric Pharmacotherapy. Bethesda:

American Society of Health-System Pharmacists, 2015. Print. Jennifer M. Ortman, Victoria A. Velkoff, and Howard Hogan. An Aging Nation: The Older

Population in the United States, May 2014. http://www.census.gov/prod/2014pubs/p25-1140.pdf.Accessed 1/21/2016.

Hamilton et al. Inappropriate prescribing and adverse drug events in older people. BMC Geriatrics 2009;9(5):1-4

Klotz U. Pharmacokinetics and drug metabolish in the elderly. Drug Metab Rev 2009;41(2):67-76

ELDesoky ES. Pharmacokinetic-Pharmacodynamic Crisis in the Elderly. Am J Ther2007(14):488-98

Slone Epidemiology Center. PATTERNS OF MEDICATION USE IN THE UNITED STATES 2006. http://www.bu.edu/slone/files/2012/11/SloneSurveyReport2006.pdf. Accessed 7/12/2015. Kantor et al. Trends in Prescription Drug Use Among Adults in the United States From 1999-

2012. JAMA 2015;314(17):1818-31 Budnitz DS et al. Emergency Hospitalizations for Adverse Drug Events in Older Americans. N

Engl J Med 2011;365:2002-2012 Centers for Medicare and Medicaid Services. Chronic Conditions among Medicare

Beneficiaries, Chartbook, 2012 Edition. Baltimore, MD. 2012. http://www.cms.gov/Research-Statistics- Data-and-Systems/Statistics-Trends-and-Reports/Chronic-Conditions/Downloads/2012ChartBook.pdf. Accessed 7/13/2015.

Davena, Pharm.D., BCPS, PhC

American Geriatrics Society (AGS)

2015 Updated Beers Criteria Purpose

To identify potential inappropriate medications (PIM) that should be avoided in many older adults

To reduce ADEs and drug related problems Improve medication selection and use in older adults Designed for use in any clinical setting

http://geriatricscareonline.org

AGS. 2015. http://geriatricscareonline.org

107


2015 Updated Beers Criteria Key principles

Potentially inappropriate, not definitely inappropriate Understand why medications are on the Beers Criteria Optimal application involves offering safer non-

pharmacologic and pharmacologic therapies. Access to medications in the Beers Criteria should not

be excessively restricted by health plans

Consider Beers Criteria to be a “Warning Light”



2015 Updated Beers CriteriaTable 2* PIM use in older adults

Table 3* PIM due to drug-disease or drug-syndrome interactions

Table 4 PIM to be used with caution in older adults

Table 5* Drug-drug interactions to avoid in older adults

Table 6* Avoid/dose reduce with renal dysfunction

Table 7 Drugs with strong anticholinergic properties

Table 8 Changes since 2012 Beers Criteria

Table 9 Medications removed since 2012 Beers Criteria


2015 AGS Updated Beers Criteria

Table 2PIM Use in Older Adults

108

Table 2: PIM in Older Adults

Patient Case (JP) CC: “Altered mental status”

HPI: 79 y/o man brought to your clinic by his wife after he was found difficult to arouse this morning. He has increased intermittent periods of confusion and is more “sleepy” reporting up to 16 hours of sleep per day. He started a new medication for neuropathy a week ago. Patient also reports dizziness and two falls in the past month.


Patient Case (JP) PMH

Diabetes, type 2 with neuropathy, no nephropathy Hypertension Depression Osteoarthritis GERD


Patient Case (JP) Home Medications

Metformin 1000 mg BID Glyburide 10 mg daily Lisinopril 20 mg daily Gabapentin 300 mg TID Amitriptyline 50 mg at bedtime Doxazosin 4 mg at bedtime Diphenhydramine 25 mg BID prn allergies Pantoprazole 40 mg daily Acetaminophen 500 mg every 6 hours prn pain

109

Patient Case (JP): Which new medication could explain his worsened confusion and sedation?

A. MetforminB. AmitriptylineC. DoxazosinD. DiphenhydramineE. Lisinopril

30

Patient Case (JP): JP is taking how many PIM according to the Beers Criteria?A. 1B. 2C. 3D. 4E. 5

30


Patient Case (JP) Home Medications – 5 PIM

Metformin 1000 mg BID Glyburide 10 mg daily Lisinopril 20 mg daily Gabapentin 300 mg TID Amitriptyline 50 mg at bedtime Doxazosin 4 mg at bedtime Diphenhydramine 25 mg BID prn nausea Pantoprazole 40 mg daily Acetaminophen 500 mg every 6 hours prn pain

110

Drugs Rationale Recomm-endation

Quality of Evidence

Strength of Rec

Sulfonylureas(Long duration)- Chlorpropamide- Glyburide

Chlorpropamide: prolonged half-lifein older adults; can cause prolonged hypoglycemia; causes SIADH

Glyburide: higher risk of severeprolonged hypoglycemia

Avoid High Strong

Insulin, slidingscale

Higher risk of hypoglycemiawithout improvement inhyperglycemia managementregardless of care setting; refersto sole use of short- or rapid-actinginsulins to manage oravoid hyperglycemia in absenceof basal or long-acting insulin;does not apply to titration ofbasal insulin or use of additionalshort- or rapid-acting insulin inconjunction with scheduledinsulin (ie, “correction insulin”)

Avoid Moderate Strong


Diabetes Medications


Quality of Evidence

Strength of Rec

Antidepressants, alone or in combination

TCAsAmitriptylineAmoxapineClomipramineDesipramineDoxepin >6 mg/dImipramineNortriptylineParoxetineProtriptyline

Highly anticholinergic, sedating,and cause orthostatichypotension; safety profile oflow-dose doxepin (≤6 mg/d)comparable with that of placebo

Avoid High Strong


CNS – Antidepressants



Quality of Evidence

Strength of Rec

Benzodiazepines

Short- andIntermediate acting:- Alprazolam- Lorazepam- Temazepam- Triazolam

Long-acting:- Chlordiazepoxide- Clonazepam- Diazepam

Older adults have increased sensitivity to benzodiazepines and decreased metabolism of long-acting agents; in general, all benzodiazepines increase risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes in older adults. May be appropriate for seizure disorders, rapid eye movement, sleep disorders, benzo/ethanol withdrawal, severe GAD, and periprocedural anesthesia


Nonbenzodiazepine,benzo receptor agonist hypnotics

- Eszopiclone- Zolpidem- Zaleplon

Benzodiazepine-receptor agonists have adverse events similar to those ofbenzodiazepines in older adults(e.g., delirium, falls, fractures);increased emergency roomvisits/hospitalizations; motorvehicle crashes; minimal improvement in sleep latency and duration



CNS – Benzos and Hypnotics

111


Quality of Evidence

Strength of Rec

First-generationantihistamines:

- Chlorpheniramine- Cyproheptadine- Dimenhydrinate- Diphenhydramine- Doxylamine- Hydroxyzine- Meclizine- Promethazine

Highly anticholinergic; clearancereduced with advanced age, andtolerance develops when used ashypnotic; risk of confusion, drymouth, constipation, and otheranticholinergic effects or toxicityUse of diphenhydramine insituations such as acute treatmentof severe allergic reaction maybe appropriate.



Anticholinergic Medications



Quality of Evidence

Strength of Rec

Peripheral alpha-1blockers

- Doxazosin- Prazosin- Terazosin

High risk of orthostatichypotension; not recommendedas routine treatment forhypertension; alternative agentshave superior risk/benefit profile

Avoid use as an anti-hypertensive

Moderate Strong

Proton-pumpinhibitors

Risk of C difficile infection andbone loss and fractures

Avoid scheduled use for >8 weeksunless for high risk patients (e.g., oralcorticosteroids or chronic NSAIDuse), erosive esophagitis, Barrett’sesophagitis, pathologicalhypersecretory condition, ordemonstrated need for maintenancetreatment (e.g., due to failure of drugdiscontinuation trial or H2 blockers)

See rationale High Strong


Cardiovascular/Gastrointestinal


Table 3PIM due to Drug-Disease /Drug-Syndrome Interactions

112

Table 3: PIM due to Drug-Disease /Drug-Syndrome Interactions

Patient Case (MB) 68 y/o woman PMH

Parkinson’s disease Heart failure (LVEF = 30%) Atrial fibrillation Insomnia Seasonal allergies


Patient Case (MB) Medications

Carbidopa/levodopa 25/100 mg 1 tablet 4 times daily Diltiazem ER 180 mg daily Apixaban 5 mg BID Metoclopramide 5 mg AC/HS for nausea Claritin D 1 tablet at bedtime for allergies

Patient Case: MB is taking how many PIM according to the Beers Criteria based on her medical history?

A. NoneB. 1C. 2D. 3E. 4

30

113


Patient Case (MB) Medications

Carbidopa/levodopa 25/100 mg 1 tablet 4 times daily Diltiazem ER 180 mg daily Apixaban 5 mg BID Metoclopramide 5 mg AC/HS for nausea Claritin D 1 tablet at bedtime for allergies


Quality of Evidence

Strength of Rec

NSAIDs and COX-2inhibitors

NondihydropyridineCCBs (diltiazem,verapamil)—avoidonly for HFrEF

Thiazolidinediones(pioglitazone, rosiglitazone)

Cilostazol

Dronedarone(severe or recentlydecompensated heart failure)

Potential to promote fluid retention and/or exacerbateheart failure

Avoid NSAIDs: moderateCCBs: moderate

TZDs: highCilostazol: low

Dronedarone:high

Strong

Table 3: PIM due to Drug-Disease /Drug-Syndrome InteractionsHeart Failure



Quality of Evidence

Strength of Rec

All antipsychotics(except aripiprazole,quetiapine, clozapine)

Antiemetics- Metoclopramide- Prochlorperazine- Promethazine

Dopamine-receptorantagonists with potential to worsen parkinsoniansymptoms. Quetiapine,aripiprazole, clozapineappear to be less likely toprecipitate worsening ofParkinson disease


Table 3: PIM due to Drug-Disease /Drug-Syndrome InteractionsParkinson Disease


114


Quality of Evidence

Strength of Rec

Oral decongestants- Pseudoephedrine- Phenylephrine

Stimulants- Amphetamine- Armodafinil- Methylphenidate- Modafinil- Theobromines- Theophylline- Caffeine

CNS stimulanteffects


Table 3: PIM due to Drug-Disease /Drug-Syndrome InteractionsInsomnia



Table 5Drug-Drug Interactions to be Avoided in Older Adults

What does the Beers Criteria say about the use of opioid analgesics as a class?A. Opioids are PIM for use in

all older adultsB. Avoid in patients with a

history of falls or fractures (excludes pain management due to a recent fracture or joint replacement)

C. Avoid using with > 2 other CNS-active drugs

D. Both B and C

30

115


Table 6Avoid or Dose Reduce with Varying Levels of Kidney Function in Older Adults

Table 6: Avoid or Dose Reduce with Renal Dysfunction

Patient Case (TH) HPI

Ms. TH is a 71 y/o woman with a history of DM2, HTN, and CKD stage 4. She comes to your clinic stating she can feel her heart “fluttering” since 1 week ago. An EKG shows Afib. Her vitals are HR 105, BP 143/90. She denies chest pain and her troponins are negative. The decision is made to start a beta blocker for rate control and anticoagulation for stroke prevention.

Patient Case (TH): Using the Beers criteria as a guide, which anticoagulant would be most appropriate for TH?

A. Dabigatran (Pradaxa)75 mg BID

B. Warfarin 5 mg daily (adjust per INR)

C. Rivaroxaban 15 mg daily

D. Enoxaparin 1 mg/kg BID

30

116

START and STOPP Criteria

START and STOPP Criteria Published 2008

START (Screening Tool to Alert doctors to Right Treatment)

STOPP (Screening Tool of Older Persons’ potentially inappropriate

Prescriptions)

http://www.ngna.org/_resources/documentation/chapter/carolina_mountain/STARTandSTOPP.pdf

Pharmacists Letter. 2011.

Contents of STOPPPhysiological System Number of Criteria

Cardiovascular system 17

Central nervous system 13

Gastrointestinal system 5

Musculoskeletal system 8

Respiratory system 3

Urogenital system 6

Endocrine system 4

Drugs that adversely affect fallers 5

Analgesics 3

Duplicate drug classes 1


117

STOPP Criteria

Patient Case (LB) LB is a 67 y/o man with CAD, DVT (first uncomplicated

1 year ago), HTN, and gout (last attack 2 months ago)

CC: Need medication refills

Medications Aspirin 325 mg daily Warfarin 6 mg daily Carvedilol 6.25 mg BID Hydrochlorothiazide 12.5 mg daily

Patient Case: Which of LB’s medications may be potentially inappropriate based on the STOPP criteria?

A. Aspirin 325 mg dailyB. Warfarin 6 mg dailyC. Carvedilol 6.25 mg

BIDD. Hydrochlorothiazide

12.5 mg daily

30

STOPP Criteria – CV System

118

Contents of STARTPhysiological System Number of Criteria

Cardiovascular system 8

Central nervous system 2

Gastrointestinal system 2

Musculoskeletal system 3

Respiratory system 3

Endocrine system 4


START Criteria

Davena Norris, Pharm.D., BCPS, PhC

119

Strategies for Managing Polypharmacy1. Use screening tools as “Warning light”2. Determine if medication is truly need

Medication Appropriateness Index (MAI)3. Are there safer, more effective alternatives?

AGS Alternative Medications List4. Prudent prescribing decisions to avoid polypharmacy

Avoid prescribing cascade5. Medication Therapy Management

Medication Appropriateness Index (MAI) Is there an indication for the drug? Is the medication effective for the conditions? Is the dosage correct? Are the directions correct? Are the directions practical? Are there clinically significant drug-drug interactions? Are there clinically significant drug-disease/condition interactions? Is there unnecessary duplication with other drugs? Is the duration of therapy acceptable? Is this drug the least expensive alternative compared with others of

equal usefulness?

Hanlon et al. J Clin Epidemiol 1992;45:1045

Safer, more effective alternatives? AGS Alternatives List Consider non-pharmacologic first

Patient Case #1: JP’s PIM

Glyburide 10 mg daily

Amitriptyline 50 mg HS

Doxazosin 4 mg HS

Diphenhydramine 25 mg BID prn

Pantoprazole 40 mg daily

Alternatives/Management

Short-acting SU (glipizide), metformin

Increase gabapentin, SNRI

Alternative antihypertensive (CCB?)

Second-generation antihistamine, intranasal saline or corticosteroid

Evaluate duration and if had a trial of an alternative (H2 blocker)

Hanlon et al. JAGS. 2015.

120

The Basics: Principles of Prescribing for Older Adults Start with a low dose Titrate upward slowly, as tolerated Avoid starting 2 drugs at the same time Avoid the “prescribing cascade”

AKA: starting a new drug to treat side effect of another Assess adherence and barriers to adherence Stop potentially unnecessary, ineffective therapy

Medication Therapy Management (MTM)

Use pharmacists as members of the TEAM

Complete comprehensive medication reviews

Minimize polypharmacy

Address barriers to adherence

Optimize drug therapy and improve patient outcomes

MTM at the Family Medicine Clinic

Results from November 2014 – July 2015

18

13

7

2 21

0

5

10

15

20

Num

ber

of P

atie

nts

Figure 1: Primary Reason for Consult

Medications at initial visit: 0 – 32, 13 (median)

Medical conditions addressed: 1 – 14, 7 (median)

Age: 23 – 91, 44% over 65 years of age

Gender: 67% female

121

MTM at the Family Medicine Clinic

Results from November 2014 – July 2015

20

15

0

5

10

15

20

25

Initial visit Most recent visit

Number of Medications (Median)

7.6

14.2

11.4

9.4 9.3

7.57.3 7.1

10.9

7.68.5 9

0

2

4

6

8

10

12

14

16

Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6

Change in HbA1c

Initial HbA1c Most Recent HbA1c

References American Geriatrics Society. AGS 2015 Updated Beers criteria for potentially

inappropriate medication use in older adults. JAGS. Available at http://geriatricscareonline.org.

Hanlon JT, Semla TP, Schmader KE. Alternative medications for medications in the use ofhigh-risk medications in the elderly and potentially harmful drug-disease interactions in the elderly quality measures. JAGS.

START and STOPP criteria. Pharmacist Letter. September 2011. Wooten JM. Rules for improving pharmacotherapy in older adults, part 1. Southern

Medical Journal. 2015 Feb; 108(2): 97-104. Wooten JM. Rules for improving pharmacotherapy in older adults, part 2. Southern

Medical Journal. 2015 Mar; 108(3): 145-150.

122

CLINICAL INVESTIGATIONS

American Geriatrics Society 2015 Updated Beers Criteria forPotentially Inappropriate Medication Use in Older Adults

By the American Geriatrics Society 2015 Beers Criteria Update Expert Panel

The 2015 American Geriatrics Society (AGS) Beers Criteriaare presented. Like the 2012 AGS Beers Criteria, theyinclude lists of potentially inappropriate medications to beavoided in older adults. New to the criteria are lists ofselect drugs that should be avoided or have their doseadjusted based on the individual’s kidney function andselect drug–drug interactions documented to be associatedwith harms in older adults. The specific aim was to have a13-member interdisciplinary panel of experts in geriatriccare and pharmacotherapy update the 2012 AGS BeersCriteria using a modified Delphi method to systematicallyreview and grade the evidence and reach a consensus oneach existing and new criterion. The process followed anevidence-based approach using Institute of Medicine stan-dards. The 2015 AGS Beers Criteria are applicable to allolder adults with the exclusion of those in palliative andhospice care. Careful application of the criteria by healthprofessionals, consumers, payors, and health systemsshould lead to closer monitoring of drug use in olderadults. J Am Geriatr Soc 2015.

Key words: Beers List; medications; Beers Criteria;drugs; older adults; polypharmacy

The American Geriatrics Society (AGS) Beers Criteriafor Potentially Inappropriate Medication (PIM) Use in

Older Adults is an explicit list of PIMs best avoided inolder adults in general and in those with certain diseasesor syndromes, prescribed at reduced dosage or with cau-tion or carefully monitored. Beers Criteria PIMs have beenfound to be associated with poor health outcomes, includ-ing confusion, falls, and mortality.1,2 Avoiding PIMs in

older adults is one strategy to decrease the risk of adverseevents. Interventions using explicit criteria have beenfound to be an important component of strategies forreducing inappropriate medication usage.3–5

The AGS Beers Criteria for PIM Use in Older Adultsare one of the most frequently consulted sources about thesafety of prescribing medications for older adults. TheAGS Beers Criteria are used widely in geriatric clinicalcare, education, and research and in development of qual-ity indicators. In 2011, the AGS assumed the responsibilityof updating and maintaining the Beers Criteria and, in2012, released the first update of the criteria since 2003.The AGS has made a commitment to update the criteriaregularly. The changes in the 2015 update are not asextensive as those of the previous update, but in additionto updating existing criteria, two major components havebeen added: 1) drugs for which dose adjustment isrequired based on kidney function and 2) drug–drug inter-actions. Neither of these new additions is intended to becomprehensive, because such lists would be too extensive.An interdisciplinary expert panel focused on those drugsand drug–drug interactions for which there is evidence inolder adults that they are at risk of serious harm if thedose is not adjusted or the drug interaction is overlooked.

OBJECTIVES

The specific aim was to update the 2012 AGS Beers Crite-ria using a comprehensive, systematic review and gradingof the evidence on drug-related problems and adverse drugevents in older adults. The strategies to achieve this aimwere to:

• Incorporate new evidence on currently listed PIMs andevidence from new medications or conditions notaddressed in the 2012 update.

• Incorporate two new areas of evidence on drug–druginteractions and dose adjustments based on kidney func-tion for select medications.

• Grade the strength and quality of each PIM statementbased on the level of evidence and strength of recom-mendation.

• Convene an interdisciplinary panel of 13 experts in geri-atric care and pharmacotherapy who would apply amodified Delphi method to the systematic review and

From the Special Projects & Governance, American Geriatrics Society,New York, New York.

Address correspondence to Mary Jordan Samuel, Manager, Special Projects& Governance, American Geriatrics Society, 40 Fulton Street, 18th Floor,New York, NY 10038. E-mail: [email protected]

DOI: 10.1111/jgs.13702

JAGS 2015

© 2015, Copyright the Authors

Journal compilation © 2015, The American Geriatrics Society 0002-8614/15/$15.00

123

grading to reach consensus on the updated 2015 AGSBeers Criteria.

• Incorporate needed exceptions in the criteria as thepanel deemed clinically appropriate. These exceptionswould be designed to make the criteria more individual-ized to clinical practice and be more relevant across set-tings of care.

INTENT OF CRITERIA

The primary target audience for the AGS Beers Criteria ispracticing clinicians. The criteria are intended for use in allambulatory, acute, and institutionalized settings of care forpopulations aged 65 and older in the United States, with theexception of hospice and palliative care. Consumers,researchers, pharmacy benefits managers, regulators, andpolicymakers also widely use the AGS Beers Criteria. Theintentions of the criteria are to: improve medication selec-tion; educate clinicians and patients; reduce adverse drugevents; and serve as a tool for evaluating quality of care,cost, and patterns of drug use of older adults.

The goal of the 2015 AGS Beers Criteria continues tobe improving the care of older adults by reducing theirexposure to PIMs. This is accomplished by using the criteriaas an educational tool and quality measure—two uses thatare not always in agreement. These criteria are not meant tobe applied in a punitive manner. Prescribing decisions arenot always clear-cut, and clinicians must consider multiplefactors, including discontinuation of medications no longerindicated. Quality measures must be clearly defined, easilyapplied, and measured with limited information and thus,although useful, cannot perfectly distinguish appropriatefrom inappropriate care. The panel considered and vigor-ously discussed both roles during deliberations. The panel’sreview of evidence at times identified subgroups of individu-als who should be exempt from a given criterion or towhom a specific criterion should apply. Such a criterionmay not be easily applied as a quality measure, particularlywhen such subgroups cannot be easily identified throughstructured and readily accessible electronic health data. Inthese cases, the panel felt that a criterion should not beexpanded to include all adults aged 65 and older when onlycertain subgroups have an adverse balance of benefits versusharms for the medication or conversely may be appropriatecandidates for a medication that is otherwise problematic.

Despite past and current efforts to translate the crite-ria into practice, some controversy and myths about theiruse in practice and policy continue to prevail. The paneladdressed these concerns and myths by writing a compan-ion piece to the updated criteria to address the best wayfor patients, providers, and health systems to use (and notuse) the 2015 AGS Beers Criteria. Alternative suggestionsto medications included in the current Use of High-RiskMedications in the Elderly and Potentially Harmful Drug-Disease Interactions in the Elderly quality measures arepresented in another companion paper. Both papers willbe published online in this journal.

METHODS

For this new update, the AGS employed a well-testedframework that has long been used for development of

clinical practice guidelines.6,7 Specifically, the frameworkinvolved the appointment of a 13-member interdisciplinaryexpert panel with relevant clinical expertise and experienceand an understanding of how the criteria have been previ-ously used. This framework also involved a developmentprocess that included a systematic literature review andevaluation of the evidence base by the expert panel.Finally, the Institute of Medicine’s 2011 report on devel-oping practice guidelines, which included a period for pub-lic comments, guided the framework. These threeframework principles are described in greater detail below.

PANEL SELECTION

A panel with expertise in geriatric medicine, nursing, phar-macy practice, research, and quality measures was con-vened comprising members of the previous panel and newmembers. Other factors that influenced selection of panelmembers were the desire to have interdisciplinary represen-tation, a range of medical expertise, and representationfrom different practice settings (e.g., long-term care, ambu-latory care, geriatric mental health, palliative care and hos-pice). In addition to the 13-member panel, representativesfrom the Centers for Medicare and Medicaid Services,National Committee for Quality Assurance, and PharmacyQuality Alliance were invited to serve as ex-officio mem-bers.

Each expert panel member completed a disclosureform at the beginning of the guideline process that wasshared with the entire panel at the start of each panelmeeting and call. Panel members who disclosed affiliationsor financial interests with commercial entities are listed inthe disclosures section of this article. Panel members wereasked to recuse themselves from discussions if they had apotential conflict of interest.

LITERATURE SEARCH

The literature from August 1, 2011 (the end of the previ-ous panel’s search) to July 1, 2014, was searched to iden-tify published systematic reviews, meta-analyses,randomized controlled trials, and observational studiesthat were relevant to the project. The initial literaturesearch was conducted on PubMed and the CochraneLibrary. The drugs, drug classes, and conditions includedin the 2012 criteria were used as initial search terms andwere generally focused on “adverse drug events” and “ad-verse drug reactions.” Individual drugs, drug classes, andconditions were searched individually and in combination.Search filters included human subjects, English language,and aged 65 and older. Case reports, case series, editorials,and letters were excluded. Clinical reviews were includedfor initial screening as potential background informationand for reference list review. The initial searches identified20,748 citations, of which 6,719 were selected for prelimi-nary abstract review. The panel co-chairs reviewed 3,387citations and abstracts, of which 2,199 were excluded fornot meeting the study purpose or not containing primarydata. At the time of the panel’s face-to-face meeting, theco-chairs had selected 1,188 unduplicated citations for thefull panel review. Subsequent searches (defined by panelworkgroups) were conducted until December 15, 2014;

2 AGS 2015 BEERS CRITERIA UPDATE EXPERT PANEL 2015 JAGS

124

some of these searches included studies published in theprior 10 years. The AGS also gave its members and mem-bers of the public a chance to submit evidence they felt thepanel should consider. Any evidence submitted had to beevidence based and published in a peer-reviewed journal.Panel members reviewed abstracts, and evidence tableswere developed for 342 studies, including 60 systematicreviews and meta-analyses, 49 randomized controlled tri-als, and 233 observational and other types of publications.

DEVELOPMENT PROCESS

Since the previous update, the AGS had created a groupto monitor the literature and to advise the 2015 expertpanel of any articles relevant to the 2012 criteria andrespond accordingly. Two members of the expert panel(MS, SL) led this group, which was composed of mem-bers of the AGS Clinical Practice Committee and otherexpert members of AGS. The 2015 expert panel convenedfor a 2-day in-person meeting on July 28–29, 2014, toreview the groups’ findings and the results of the litera-ture search. Panel discussions were used to define termsand to address questions of consistency, inclusion of infre-quently used drugs, strategies for evaluating the evidence,consolidation or expansion of individual criterion, anddevelopment of renal dosage and drug–drug interactiontables. The panel then split into four groups, with eachassigned a specific set of criteria for evaluation. Groupswere assigned as closely as possible according to specificarea of clinical expertise (e.g., cardiovascular, central ner-vous system). Groups reviewed the literature search,selected citations relevant to their assigned criteria, anddetermined which citations they wanted to see the full-text article for and which should be abstracted into anevidence table. The groups then presented their findingsto the full panel for comment and consensus. After themeeting, each group participated in a series of conferencecalls to continue the literature selection process andresolve any questions.

An independent researcher led the effort to prepareevidence tables and relied on the assistance of one otherresearcher for the initial drafts of evidence tables. The evi-dence tables included a summary of the study, as well as aquality rating and rating of the risk of bias for selectedarticles. The quality rating system was based on theCochrane Risk of Bias8 and Jadad scoring system.9 Theratings were based on six critical elements: evidence of bal-anced allocation, allocation concealment, blinded outcomeassessment, completeness of outcome data, selective out-come reporting, and other sources of bias. Following theCochrane approach, each article was assigned a qualityscore (1–6 points) and a risk-of-bias rating. Low risk ofbias was indicated by a low risk of bias in all six domains,unclear risk of bias was indicated by an unclear rating onone or more domains (others low) or a high risk of biason one domain (others low or unclear), and high risk ofbias was indicated by a high risk of bias on two or moredomains. The independent researcher reviewed all evidencetables and proposed quality and risk-of-bias ratings beforethey were distributed to the expert panel to use for theGrades of Recommendation Assessment, Development,and Evaluation10 (GRADE) rating process.

Each panelist independently rated the quality of evi-dence and strength of recommendation for each criterionusing the American College of Physicians’ Guideline Grad-ing System11 (Table 1), which is based on the GRADEscheme developed previously. AGS staff compiled the pan-elist ratings for each group and returned them to thatgroup, which then reached consensus in a conference call.Additional literature was obtained and included as needed.When group consensus could not be reached, the full panelreviewed the ratings and worked through any differencesuntil consensus was reached. The panel judged each crite-rion as being a strong or weak recommendation on thebasis of the quality of supporting evidence, the frequencyand severity of harms, and the availability of better treat-ment alternatives. For some criteria, the panel provided a“strong” recommendation, even though the quality of evi-dence was low or moderate, when the potential for harmwas substantial and safer or more-effective alternativeswere available.

After consensus was reached within the expert panel,the updated guidelines were circulated for peer review torelevant organizations and societies and posted to the AGSwebsite for public comment. Organizations that partici-pated in peer review are listed in the Acknowledgmentssection of this article. The panel reviewed and addressedall comments.

Table 1. Designations of Quality of Evidence andStrength of Recommendations

Quality of EvidenceHigh Evidence includes consistent results from well-

designed, well-conducted studies in representativepopulations that directly assess effects on healthoutcomes (≥2 consistent, higher-quality randomizedcontrolled trials or multiple, consistent observationalstudies with no significant methodological flawsshowing large effects)

Moderate Evidence is sufficient to determine risks of adverseoutcomes, but the number, quality, size, or consistencyof included studies; generalizability to routine practice;or indirect nature of the evidence on health outcomes(≥1 higher-quality trial with >100 participants; ≥2higher-quality trials with some inconsistency; ≥2consistent, lower-quality trials; or multiple, consistentobservational studies with no significantmethodological flaws showing at least moderateeffects) limits the strength of the evidence

Low Evidence is insufficient to assess harms or risks inhealth outcomes because of limited number or powerof studies, large and unexplained inconsistencybetween higher-quality studies, important flaws instudy design or conduct, gaps in the chain of evidence,or lack of information on important health outcomes

Strength of RecommendationStrong Benefits clearly outweigh harms, adverse events, and

risks, or harms, adverse events, and risks clearlyoutweigh benefits

Weak Benefits may not outweigh harms, adverse events,and risks

Insufficient Evidence inadequate to determine net harms, adverseevents, and risks

Adapted from11.

JAGS 2015 2015 AGS UPDATED BEERS CRITERIA 3

125

RESULTS

The panel’s recommendations are presented in Tables 2–7. References, as evidence tables, supporting the recom-mendations appear in the online appendix posted on theAGS website (www.americangeriatrics.org). Consistentwith the 2012 AGS Beers Criteria, Tables 2–4 list PIMSfor older adults outside the palliative care and hospicesetting, including medications to avoid for many or mostolder adults (Table 2); medications for older adults withspecific diseases or syndromes to avoid (Table 3); andmedications to be used with caution (Table 4). New tothe AGS Beers Criteria are potentially clinically impor-tant non-anti-infective drug–drug interactions (Table 5)and non-anti-infective medications to avoid or thedosage of which should be adjusted based on the indi-vidual’s kidney function (Table 6). Tables 8-10 documentthe differences between the 2012 and 2015 AGS BeersCriteria.

Noteworthy Changes to PIMs and Older Adults

Based on two retrospective studies, the recommendation toavoid the anti-infective nitrofurantoin in individuals with acreatinine clearance of less than 60 mL/min has beenrevised, given evidence that it can be used with relativesafety and efficacy in individuals with a creatinine clear-ance of 30 mL/min or greater. The long-term use of nitro-furantoin for suppression should still be avoided becauseof concerns of irreversible pulmonary fibrosis, liver toxic-ity, and peripheral neuropathy (Table 2).

The recommendation to avoid antiarrhythmic drugs(Classes 1a, 1c, III) as first-line treatment for atrial fibrilla-tion has been removed in light of new evidence and guide-lines that suggest that rhythm control can have outcomesas good as or better than those with rate control. Never-theless, certain antiarrhythmics remain in the criteria.Amiodarone is still to be avoided as first-line therapy foratrial fibrillation unless the individual has heart failure orsubstantial left ventricular hypertrophy. Dronedarone is tobe avoided in individuals with permanent atrial fibrillationor with severe or recently decompensated heart failure.Disopyramide, a Class 1a antiarrhythmic drug, should alsobe avoided because it is highly anticholinergic. Digoxinshould be avoided as first-line therapy for atrial fibrillationor heart failure and should not be prescribed in daily dosesgreater than 0.125 mg for any indication.

The nonbenzodiazepine, benzodiazepine receptor ago-nist hypnotics (eszopiclone, zaleplon, zolpidem) are to beavoided without consideration of duration of use becauseof their association with harms balanced with their mini-mal efficacy in treating insomnia. The recommendation toavoid sliding-scale insulin is retained, and further clarifica-tion of what constitutes a sliding-scale regimen is pro-vided. An addition to Table 2 is the avoidance of the useof proton-pump inhibitors beyond 8 weeks without justifi-cation. Multiple studies and five systematic reviews andmeta-analyses support an association between proton-pump inhibitor exposure and Clostridium difficile infec-tion, bone loss, and fractures. Desmopressin for the treat-ment of nocturia or nocturnal polyuria is another additionbecause of the high risk of hyponatremia.

Noteworthy Changes to Drug–Disease and Drug–Syndrome PIMS

The nonbenzodiazepine, benzodiazepine receptor agonisthypnotics have been added to the list of drugs to avoid inindividuals with dementia or cognitive impairment. Opi-oids have been added to the list of central nervous system(CNS) medications that should be avoided in individualswith a history of falls or fractures. Antipsychotics are tobe avoided as first-line treatment of delirium because ofconflicting evidence on their effectiveness and the potentialfor adverse drug effects (Table 3).

Drugs to Be Used with Caution

Table 4, medications to be used with caution in olderadults, has not been changed. The panel determined thatthe medications listed in this table did not rise to the levelof meriting inclusion in Tables 2 and 3 and should not beconsidered key elements of the criteria. Nevertheless, thepanel believed that there was sufficient uncertainty or con-cern about the balance of benefits and harms for the listedmedications that clinicians should be aware of potentialproblems and exercise caution when considering their use.

Drug–Drug Interactions

New to the AGS Beers Criteria are drug–drug interactions(excluding anti-infectives) that are highly associated withharmful outcomes in older adults.12 The list is selective,and not comprehensive, and is not intended to diminishthe clinical importance of known drug–drug interactionsnot listed. Examples of drug–drug interactions included inthis new section include peripheral alpha-1 blockers usedin combination with loop diuretics, which increases therisk of urinary incontinence in women, and taking three ormore CNS-active drugs concomitantly, which increases therisk of falls. Other interactions manifest as extensions ofboth drugs’ known pharmacological effects (e.g., angioten-sin-converting enzyme inhibitors (ACEIs) and potassium-sparing diuretics without indications for use in systolicheart failure (amiloride and triamterene), which togetherincrease risk of hyperkalemia). Other interactions increasethe risk of a drug’s toxicity (e.g., lithium in combinationwith an ACEI or loop diuretics) (Table 5).

PIMs Based on Kidney Function

Also new for 2015 are drugs that should be avoided or forwhich the dose should be adjusted in individuals with aspecific degree of kidney impairment to avoid harm. Thislist was adapted from published consensus guidelines thatan expert group including two AGS Beers Criteria pan-elists developed.13 The AGS Beers panel reviewed the evi-dence and selected medications from these earlierconsensus guidelines for inclusion; added additional medi-cations, including several anticoagulants; and includedspironolactone and triamterene, which in the 2012 criteriahad been listed in Tables 2 and 3, respectively. The crea-tinine clearance thresholds below which use of apixaban,edoxaban, and rivaroxaban are to be avoided are based onclinical trial exclusion criteria and may not be the same as


126

Table

2.

2015AmericanGeriatricsSocietyBeers

CriteriaforPotentiallyInappropriate

MedicationUse

inOlder

Adults

OrganSystem,

Therapeutic

Category,Drugs

Rationale

Recommendation

Quality

of

Evidence

Strength

of

Recommendation

Anticho

linergics

First-generationantihistamines

Bromph

eniram

ine

Carbino

xamine

Chlorph

eniram

ine

Clemastine

Cyproheptadine

Dexbrom

pheniram

ine

Dexchlorpheniramine

Dimenhydrinate

Diphenh

ydramine(oral)

Doxylam

ine

Hydroxyzine

Meclizine

Promethazine

Triprolidine

Highlyanticho

linergic;

clearanceredu

cedwith

advanced

age,

andtolerancedevelops

when

used

ashypn

otic;risk

ofconfusion,

drymou

th,

constipation,

andotheranticho

linergiceffectsor

toxicity

Use

ofdiph

enhydram

inein

situations

such

asacutetreatm

entof

severe

allergic

reactionmay

beapprop

riate

Avoid

Mod

erate

Stron

g

Antiparkinson

ianagents

Benztropine

(oral)

Trihexyphenidyl

Not

recommendedforpreventionof

extrapyram

idal

symptom

swith

antipsychotics;

more-effectiveagents

availablefortreatm

entof

Parkinson

disease

Avoid

Mod

erate

Stron

g

Antispasm

odics

Atrop

ine(excludesop

hthalmic)

Bellado

nnaalkaloids

Clidinium-Chlordiazepoxide

Dicyclomine

Hyoscyamine

Propantheline

Scopo

lamine

Highlyanticho

linergic,

uncertaineffectiveness

Avoid

Mod

erate

Stron

g

Antithrombo

tics

Dipyridam

ole,

oral

short-acting

(doesno

tapplyto

theextend

ed-

releasecombinationwith

aspirin)

May

causeorthostatic

hypo

tension;

more

effectivealternatives

available;

intravenou

sform

acceptable

forusein

cardiacstress

testing

Avoid

Mod

erate

Stron

g

Ticlop

idine

Safer,effectivealternatives

available

Avoid

Mod

erate

Stron

gAnti-infective

Nitrofurantoin

Potentialforpu

lmon

arytoxicity,hepatoxicity,

andperiph

eral

neurop

athy,especially

with

long

-term

use;

saferalternatives

available

Avoid

inindividu

alswith

creatinine

clearance<30

mL/min

orforlong

-term

supp

ressionof

bacteria

Low

Stron

g

Cardiovascular

Peripheralalph

a-1blockers

Doxazosin

Prazosin

Terazosin

Highrisk

oforthostatic

hypo

tension;

not

recommendedas

routinetreatm

entfor

hypertension

;alternativeagents

have

superior

risk–b

enefitprofi

le

Avoid

useas

anantihypertensive

Mod

erate

Stron

g

(Continued)


127

Table

2(C

ontd.)

OrganSystem,

Therapeutic

Category,Drugs

Rationale

Recommendation

Quality

of

Evidence

Strength

of

Recommendation

Central

alph

ablockers

Clonidine

Guanabenz

Guanfacine

Methyldop

aReserpine

(>0.1mg/d)

Highrisk

ofadverseCNSeffects;

may

cause

bradycardiaandorthostatic

hypo

tension;

not

recommendedas

routinetreatm

entfor

hypertension

Avoid

clon

idineas

first-line

antihypertensive

Avoid

others

aslisted

Low

Stron

g

Disop

yram

ide

Disop

yram

ideisapo

tent

negativeinotrope

and

thereforemay

indu

ceheartfailure

inolder

adults;strong

lyanticho

linergic;

other

antiarrhythmic

drug

spreferred

Avoid

Low

Stron

g

Dronedarone

Worse

outcom

eshave

been

repo

rted

inpatients

taking

dron

edaron

ewho

have

perm

anentatrial

fibrillationor

severe

orrecently

decompensated

heartfailure

Avoid

inindividu

alswith

perm

anentatrial

fibrillationor

severe

orrecently

decompensated

heartfailure

High

Stron

g

Digoxin

Use

inatrial

fibrillation:

shou

ldno

tbe

used

asa

first-lineagentin

atrialfib

rillation,

because

more-effectivealternatives

existanditmay

beassociated

with

increasedmortality

Avoid

asfirst-linetherapyforatrial

fibrillation

Atrialfib

rillation:

mod

erate

Atrialfib

rillation:

strong

Use

inheartfailure:qu

estionableeffectson

risk

ofho

spitalizationandmay

beassociated

with

increasedmortalityin

olderadults

with

heart

failure;in

heartfailure,high

erdo

sagesno

tassociated

with

additionalbenefit

andmay

increase

risk

oftoxicity

Avoid

asfirst-linetherapyforheartfailure

Heartfailure:low

Heartfailure:strong

Decreased

renalclearanceof

digo

xinmay

lead

toincreasedrisk

oftoxiceffects;

furtherdo

seredu

ctionmay

benecessaryin

patientswith

Stage

4or

5chronickidn

eydisease

Ifused

foratrial

fibrillationor

heart

failure,avoiddo

sages>0.12

5mg/d

Dosage>0.12

5mg/d:

mod

erate

Dosage>0.12

5mg/d:

strong

Nifedipine,immediate

release

Potentialforhypo

tension;

risk

ofprecipitating

myocardialischem

iaAvoid

High

Stron

g

Amiodarone

Amiodarone

iseffectiveformaintaining

sinu

srhythm

buthasgreatertoxicitiesthan

other

antiarrhythmicsused

inatrial

fibrillation;

itmay

bereason

able

first-linetherapyin

patientswith

concom

itant

heartfailure

orsubstantialleft

ventricularhypertroph

yifrhythm

controlis

preferredover

rate

control

Avoid

amiodarone

asfirst-linetherapyfor

atrial

fibrillationun

less

patient

hasheart

failure

orsubstantialleftventricular

hypertroph

y

High

Stron

g

Central

nervou

ssystem

(Continued)


128

Table

2(C

ontd.)

OrganSystem,

Therapeutic

Category,Drugs

Rationale

Recommendation

Quality

of

Evidence

Strength

of

Recommendation

Antidepressants,alon

eor

incombination

Amitriptyline

Amoxapine

Clomipramine

Desipramine

Doxepin

>6mg/d

Imipramine

Nortriptyline

Paroxetine

Protriptyline

Trimipramine

Highlyanticho

linergic,

sedating,

andcause

orthostatic

hypo

tension;

safety

profi

leof

low-

dose

doxepin(≤6mg/d)

comparablewith

that

ofplacebo

Avoid

High

Stron

g

Antipsychotics,

first-(con

ventional)

andsecond

-(atypical)generation

Increasedrisk

ofcerebrovascularaccident

(stroke)

andgreaterrate

ofcogn

itive

decline

andmortalityin

person

swith

dementia

Avoid

antipsychoticsforbehavioral

prob

lemsof

dementia

ordelirium

unless

nonp

harm

acolog

ical

options

(e.g.,behavioral

interventions)have

failedor

areno

tpo

ssible

andtheolderadultis

threateningsubstantialharm

toselfor

others

Avoid,except

forschizoph

renia,

bipo

lar

disorder,or

short-term

useas

antiemetic

during

chem

otherapy

Mod

erate

Stron

g

Barbiturates

Amob

arbital

Butabarbital

Butalbital

Mepho

barbital

Pentobarbital

Pheno

barbital

Secob

arbital

Highrate

ofph

ysical

depend

ence,toleranceto

sleepbenefits,

greaterrisk

ofoverdo

seat

low

dosages

Avoid

High

Stron

g

Benzodiazepines

Sho

rt-andinterm

ediate-acting

Alprazolam

Estazolam

Lorazepam

Oxazepam

Temazepam

Triazolam

Older

adults

have

increasedsensitivity

tobenzod

iazepinesanddecreasedmetabolism

oflong

-actingagents;in

general,all

benzod

iazepinesincrease

risk

ofcogn

itive

impairment,delirium,falls,fractures,

andmotor

vehiclecrashesin

olderadults

Avoid

Mod

erate

Stron

g

(Continued)


129

Table

2(C

ontd.)

OrganSystem,

Therapeutic

Category,Drugs

Rationale

Recommendation

Quality

of

Evidence

Strength

of

Recommendation

Long

-acting

Clorazepate

Chlordiazepoxide(alone

orin

combinationwith

amitriptylineor

clidinium)

Clonazepam

Diazepam

Flurazepam

Quazepam

May

beapprop

riateforseizuredisorders,

rapid

eyemovem

entsleepdisorders,

benzod

iazepine

withdraw

al,ethano

lwithdraw

al,severe

generalized

anxietydisorder,andperiprocedural

anesthesia

Meprobamate

Highrate

ofph

ysical

depend

ence;very

sedating

Avoid

Mod

erate

Stron

gNon

benzod

iazepine,benzod

iazepine

receptor

agon

isthypn

otics

Eszopiclon

eZo

lpidem

Zaleplon

Benzodiazepine-receptor

agon

ists

have

adverse

events

similarto

thoseof

benzod

iazepinesin

olderadults

(e.g.,delirium,falls,fractures);

increasedem

ergencydepartmentvisits

and

hospitalizations;motor

vehiclecrashes;

minimal

improvem

entin

sleeplatencyanddu

ration

Avoid

Mod

erate

Stron

g

Ergo

loid

mesylates

(dehydrogenatedergo

talkaloids)

Isoxsuprine

Lack

ofefficacy

Avoid

High

Stron

g

Endo

crine

And

rogens

Methyltestosterone

Testosterone

Potentialforcardiacprob

lems;

contraindicated

inmen

with

prostate

cancer

Avoid

unless

indicatedforconfi

rmed

hypo

gonadism

with

clinical

symptom

sMod

erate

Weak

Desiccatedthyroid

Con

cernsabou

tcardiaceffects;

safer

alternatives

available

Avoid

Low

Stron

g

Estrog

enswith

orwithou

tprog

estins

Evidence

ofcarcinog

enic

potential(breastand

endo

metrium

);lack

ofcardioprotectiveeffect

andcogn

itive

protectionin

olderwom

enEvidence

indicatesthat

vaginalestrog

ensforthe

treatm

entof

vaginaldrynessaresafe

and

effective;

wom

enwith

ahistoryof

breast

cancer

who

dono

trespon

dto

nonh

ormon

altherapies

areadvisedto

discusstherisk

andbenefitsof

low-dosevaginalestrog

en(dosages

ofestradiol

<25

lgtwiceweekly)

with

theirhealthcare

provider

Avoid

oral

andtopicalpatch

Vaginal

cream

ortablets:

acceptable

touselow-doseintravaginal

estrog

enfor

managem

entof

dyspareunia,

lower

urinarytractinfections,andothervaginal

symptom

s

Oralandpatch:

high

Vaginalcream

ortablets:

mod

erate

Oralandpatch:

strong

Topicalvaginalcream

ortablets:

weak

Growth

horm

one

Impact

onbo

dycompo

sitionissm

alland

associated

with

edem

a,arthralgia,carpaltunn

elsynd

rome,

gynecomastia,impaired

fasting

glucose

Avoid,except

asho

rmon

ereplacem

ent

afterpituitary

glandremoval

High

Stron

g

(Continued)


130

Table

2(C

ontd.)

OrganSystem,

Therapeutic

Category,Drugs

Rationale

Recommendation

Quality

of

Evidence

Strength

of

Recommendation

Insulin,slidingscale

Higherrisk

ofhypo

glycem

iawithou

timprovem

entin

hyperglycemia

managem

ent

regardless

ofcare

setting;

refers

tosole

useof

short-or

rapid-actinginsulinsto

manageor

avoidhyperglycemia

inabsenceof

basalor

long

-actinginsulin;do

esno

tapplyto

titrationof

basalinsulin

oruseof

additionalshort-or

rapid-

actinginsulin

inconjun

ctionwith

schedu

led

insulin

(i.e.,correctioninsulin)

Avoid

Mod

erate

Stron

g

Megestrol

Minimal

effect

onweigh

t;increasesrisk

ofthrombo

ticevents

andpo

ssibly

deathin

older

adults

Avoid

Mod

erate

Stron

g

Sulfonylureas,long

-duration

Chlorprop

amide

Chlorprop

amide:

prolon

gedhalf-lifein

older

adults;cancauseprolon

gedhypo

glycem

ia;

causes

synd

romeof

inapprop

riateantidiuretic

horm

onesecretion

Avoid

High

Stron

g

Glybu

ride

Glybu

ride:high

errisk

ofsevere

prolon

ged

hypo

glycem

iain

olderadults

Gastrointestinal

Metoclopram

ide

Can

causeextrapyram

idal

effects,

includ

ing

tardivedyskinesia;risk

may

begreaterin

frail

olderadults

Avoid,un

less

forgastroparesis

Mod

erate

Stron

g

Mineral

oil,givenorally

Potentialforaspirationandadverseeffects;

saferalternatives

available

Avoid

Mod

erate

Stron

g

Proton-pu

mpinhibitors

Riskof

Clostridium

difficile

infectionandbo

neloss

andfractures

Avoid

schedu

ledusefor>8weeks

unless

forhigh

-riskpatients(e.g.,oral

corticosteroidsor

chronicNSAID

use),

erosiveesop

hagitis,Barrett’s

esop

hagitis,

patholog

ical

hypersecretory

cond

ition

,or

demon

stratedneed

formaintenance

treatm

ent(e.g.,du

eto

failure

ofdrug

discon

tinuationtrialor

H2blockers)

High

Stron

g

Painmedications

Meperidine

Not

effectiveoral

analgesicin

dosages

common

lyused;may

have

high

errisk

ofneurotoxicity,includ

ingdelirium,than

other

opioids;

saferalternatives

available

Avoid,especially

inindividu

alswith

chronickidn

eydisease

Mod

erate

Stron

g

(Continued)


131

Table

2(C

ontd.)

OrganSystem,

Therapeutic

Category,Drugs

Rationale

Recommendation

Quality

of

Evidence

Strength

of

Recommendation

Non

-cyclooxygenase-selective

NSAIDs,

oral:

Aspirin

>32

5mg/dDiclofenac

Diflun

isal

Etod

olac

Feno

profen

Ibup

rofen

Ketop

rofen

Meclofenamate

Mefenam

icacid

Meloxicam

Nabum

eton

eNaproxen

Oxaprozin

Piroxicam

Sulindac

Tolmetin

Increasedrisk

ofgastrointestinal

bleeding

orpepticulcerdiseasein

high

-riskgrou

ps,

includ

ingthoseaged

>75

ortaking

oral

orparenteral

corticosteroids,

anticoagu

lants,

orantiplateletagents;useof

proton

-pum

pinhibitor

ormisop

rostol

redu

cesbu

tdo

esno

teliminate

risk.Upp

ergastrointestinal

ulcers,gross

bleeding

,or

perforationcaused

byNSAIDs

occurin

approximately1%

ofpatientstreated

for3–6mon

thsandin

~2–4

%of

patients

treatedfor1year;thesetrends

continue

with

long

erdu

rationof

use

Avoid

chronicuse,

unless

other

alternatives

areno

teffectiveandpatient

cantake

gastroprotectiveagent(proton-

pumpinhibitoror

misop

rostol)

Mod

erate

Stron

g

Indo

methacin

Indo

methacinis

morelikelythan

otherNSAIDs

tohave

adverseCNSeffects.

OfalltheNSAIDs,

indo

methacinhasthemostadverseeffects.

Avoid

Mod

erate

Stron

g

Ketorolac,includ

esparenteral

Increasedrisk

ofgastrointestinal

bleeding

,pepticulcerdisease,

andacutekidn

eyinjury

inolderadults

Pentazocine

Opioidanalgesicthat

causes

CNSadverse

effects,

includ

ingconfusionandhallucinations,

morecommon

lythan

otherop

ioid

analgesic

drug

s;isalso

amixed

agon

istandantago

nist;

saferalternatives

available

Avoid

Low

Stron

g

Skeletalmusclerelaxants

Carisop

rodo

lChlorzoxazone

Cyclobenzaprine

Metaxalon

eMetho

carbam

olOrphenadrine

Mostmusclerelaxantspo

orlytoleratedby

older

adults

becausesomehave

anticho

linergic

adverseeffects,

sedation,

increasedrisk

offractures;

effectivenessat

dosagestoleratedby

olderadults

questionable

Avoid

Mod

erate

Stron

g

Genitourinary

Desmop

ressin

Highrisk

ofhypo

natrem

ia;saferalternative

treatm

ents

Avoid

fortreatm

entof

nocturia

orno

cturnalpo

lyuria

Mod

erate

Stron

g

Theprimary

target

audience

ispracticingclinicians.

Theintentionsofthecriteria

are

toim

provetheselectionofprescriptiondrugsbycliniciansandpatients;evaluate

patternsofdruguse

within

populations;

educate

cliniciansandpatients

onproper

drugusage;

andevaluate

health-outcome,

quality-of-care,cost,andutilizationdata.

CNS=centralnervoussystem

;NSAID

s=nonsteroidalanti-inflammatory

drugs.


132

Table

3.

2015AmericanGeriatricsSocietyBeers

CriteriaforPotentiallyInappropriate

MedicationUse

inOlder

AdultsDueto

Drug–D

isease

orDrug–S

yn-

dromeInteractionsThatMayExacerbate

theDisease

orSyndrome

DiseaseorSyndrome

Drug(s)

Rationale

Recommendation

Quality

ofEvidence

Strength

of

Recommendation

Cardiovascular

Heartfailure

NSAIDsandCOX-2

inhibitors

Non

dihydrop

yridineCCBs(diltiazem,verapamil)

—avoidon

lyforheartfailure

with

redu

ced

ejectionfraction

Thiazolidinediones(pioglitazone,rosiglitazone)

Cilostazol

Dronedarone

(severeor

recently

decompensated

heartfailure)

Potentialto

prom

oteflu

idretentionandexacerbate

heart

failure

Avoid

NSAIDs:

mod

erate

CCBs:

mod

erate

Thiazolidinediones:

high

Cilostazol:low

Dronedarone:high

Stron

g

Syncope

AChE

IsPeripheralalph

a-1blockers

Doxazosin

Prazosin

Terazosin

Tertiary

TCAs

Chlorprom

azine

Thioridazine

Olanzapine

Increasesrisk

oforthostatic

hypo

tensionor

bradycardia

Avoid

Peripheralalph

a-1

blockers:high

TCAs,

AChE

Is,

antipsychotics:

mod

erate

AChE

Is,TC

As:

strong

Peripheralalph

a-1

blockers,antipsychotics:

weak

Central

nervou

ssystem

Chron

icseizures

orepilepsy

Bup

ropion

Chlorprom

azine

Clozapine

Maprotiline

Olanzapine

Thioridazine

Thiothixene

Tram

adol

Lowersseizurethreshold;

may

beacceptable

inindividu

alswith

well-

controlledseizures

inwho

malternativeagents

have

notbeen

effective

Avoid

Low

Stron

g

Delirium

Anticho

linergics

(see

Table7forfulllist)

Antipsychotics

Benzodiazepines

Chlorprom

azine

Corticosteroidsa

H2-receptorantago

nists

Cimetidine

Famotidine

Nizatidine

Ranitidine

Meperidine

Sedativehypn

otics

Avoid

inolderadults

with

orat

high

risk

ofdelirium

becauseof

thepo

tentialof

indu

cing

orworsening

delirium

Avoidantipsychoticsforbehavioral

prob

lemsof

dementia

ordelirium

unless

nonp

harm

acolog

icalop

tions

(e.g.,behavioralinterventions)

have

failedor

areno

tpo

ssiblean

dtheolderadultisthreatening

substantialharm

toselfor

others

Antipsychoticsareassociated

with

greaterrisk

ofcerebrovascular

accident

(stroke)

andmortalityin

person

swith

dementia

Avoid

Mod

erate

Stron

g

(Continued)


133

Table

3(C

ontd.)

DiseaseorSyndrome

Drug(s)

Rationale

Recommendation

Quality

ofEvidence

Strength

of

Recommendation

Dem

entia

orcogn

itive

impairment

Anticho

linergics

(see

Table7forfulllist)

Benzodiazepines

H2-receptorantago

nists

Non

benzod

iazepine,benzod

iazepine

receptor

agon

isthypn

otics

Eszopiclon

eZo

lpidem

Zaleplon

Antipsychotics,

chronicandas-neededuse

Avoid

becauseof

adverseCNS

effects

Avoid

antipsychoticsforbehavioral

prob

lemsof

dementia

ordelirium

unless

nonp

harm

acolog

ical

options

(e.g.,behavioral

interventions)have

failedor

are

notpo

ssiblean

dtheolderadultis

threateningsubstantialharm

toselfor

others.Antipsychoticsare

associated

with

greaterrisk

ofcerebrovascularaccident

(stroke)

andmortalityin

person

swith

dementia

Avoid

Mod

erate

Stron

g

History

offalls

orfractures

Anticon

vulsants

Antipsychotics

Benzodiazepines

Non

benzod

iazepine,benzod

iazepine

receptor

agon

isthypn

otics

Eszopiclon

eZaleplon

Zolpidem

TCAs

SSRIs

Opioids

May

causeataxia,impaired

psycho

motor

function,

syncop

e,additionalfalls;shorter-acting

benzod

iazepines

areno

tsafer

than

long

-actingon

es

Ifon

eof

thedrug

smustbe

used,

consider

redu

cing

useof

other

CNS-activemedications

that

increase

risk

offalls

andfractures

(i.e.,anticon

vulsants,op

ioid-

receptor

agon

ists,antipsychotics,

antidepressants,benzod

iazepine-

receptor

agon

ists,othersedatives

andhypn

otics)

andimplem

ent

otherstrategies

toredu

cefallrisk

Avoid

unless

safer

alternatives

areno

tavailable;

avoid

anticon

vulsants

except

for

seizureandmoo

ddisorders

Opioids:avoid,

exclud

espain

managem

entdu

eto

recent

fracturesor

joint

replacem

ent

High

Opioids:mod

erate

Stron

g

Opioids:strong

Insomnia

Oraldecong

estants

Pseud

oeph

edrine

Phenyleph

rine

Stim

ulants

Amph

etam

ine

Arm

odafinil

Methylphenidate

Mod

afinil

Theobrom

ines

Theoph

ylline

Caffeine

CNSstimulanteffects

Avoid

Mod

erate

Stron

g

(Continued)


134

Table

3(C

ontd.)

DiseaseorSyndrome

Drug(s)

Rationale

Recommendation

Quality

ofEvidence

Strength

of

Recommendation

Parkinson

disease

Allantipsychotics(exceptaripiprazole,

quetiapine,clozapine)

Antiemetics

Metoclopram

ide

Prochlorperazine

Promethazine

Dop

amine-receptor

antago

nists

with

potentialto

worsen

parkinsonian

symptom

sQuetiapine,aripiprazole,clozapine

appear

tobe

less

likelyto

precipitate

worsening

ofParkinson

disease

Avoid

Mod

erate

Stron

g

Gastrointestinal

History

ofgastricor

duod

enal

ulcers

Aspirin

(>32

5mg/d)

Non

-COX-2

selectiveNSAIDs

May

exacerbate

existingulcers

orcausenew

oradditionalulcers

Avoid

unless

other

alternatives

areno

teffectiveandpatient

can

take

gastroprotectiveagent

(i.e.,proton

-pum

pinhibitor

ormisop

rostol)

Mod

erate

Stron

g

Kidneyandurinarytract

Chron

ickidn

eydisease

StagesIV

orless

(creatinineclearance

<30

mL/min)

NSAIDs(non

-COXandCOX-selective,

oral

and

parenteral)

May

increase

risk

ofacutekidn

eyinjury

andfurtherdeclineof

renal

function

Avoid

Mod

erate

Stron

g

Urinary

incontinence

(alltypes)

inwom

enEstrog

enoral

andtransdermal(excludes

intravaginal

estrog

en)

Peripheralalph

a-1blockers

Doxazosin

Prazosin

Terazosin

Agg

ravationof

incontinence

Avoid

inwom

enEstrog

en:high

Peripheralalph

a-1

blockers:mod

erate

Estrog

en:strong

Peripheralalph

a-1

blockers:strong

Lower

urinarytract

symptom

s,benign

prostatic

hyperplasia

Stron

glyanticho

linergicdrug

s,except

antim

uscarinics

forurinaryincontinence

(see

Table7forcompletelist)

May

decrease

urinaryflo

wand

causeurinaryretention

Avoid

inmen

Mod

erate

Stron

g

Theprimary

target

audience

isthepracticingclinician.Theintentionsofthecriteria

are

toim

proveselectionofprescriptiondrugsbycliniciansandpatients;evaluate

patternsofdruguse

within

populations;

educate

cliniciansandpatients

onproper

drugusage;

andevaluate

health-outcome,

quality-of-care,cost,andutilizationdata.

aExcludes

inhaledandtopicalform

s.Oralandparenteralcorticosteroidsmayberequired

forconditionssuch

asexacerbationsofchronic

obstructivepulm

onary

disease

butshould

beprescribed

inthelowest

effectivedose

andfortheshortestpossible

duration.

CCB=calcium

channel

blocker;AChEI=acetylcholinesterase

inhibitor;

CNS=centralnervoussystem

;COX

=cyclooxygenase;NSAID

=nonsteroidalanti-inflammatory

drug;SSRIs

=selectiveserotonin

reup-

takeinhibitors;TCA

=tricyclic

antidepressant.


135

those in their labeling. As with the drug–drug interactiontable, this list is not meant to be comprehensive but tohighlight potentially important but sometimes overlookeddose adjustments that are of particular concern for olderadults. Anti-infective drugs were not included because thefocus of the AGS Beers Criteria is on medications oftenemployed for chronic use and because such information isavailable from multiple other sources (Table 6).

Drugs with Strong Anticholinergic Properties

Numerous scales are available to rank anticholinergic activ-ity. The panel used a composite of several scales to draftTable 7, which provides an updated list of drugs withstrong anticholinergic properties.14–17 Investigators whodeveloped the scales that the panel used in 2012 were askedwhether any changes had been made, and the panel consid-ered those. The most notable drug to be removed from thelist was the second-generation antihistamine loratadine.

DISCUSSION

The 2015 AGS Beers Criteria for PIMs is the second suchupdate by the American Geriatrics Society of medications

to avoid in older adults and the fourth update of the crite-ria since their original release.18–21 The criteria were firstpublished in 1991, making them the longest-running crite-ria for PIMs in older adults. The process improves witheach update. The literature search has become more tar-geted and refined, identifying new and important support-ing evidence. The evidence review and gradingmethodology has been adjusted according to best practicesand evolving approaches recommended by expert organi-zations. As in 2012, this resulted in some changes to thecriteria in 2015, including drugs that were modified ordropped and a few new additions. The 2015 update intro-duced two new areas to improve drug safety in olderadults: 1) drugs for which dose adjustment is requiredbased on kidney impairment and 2) drug–drug interac-tions. Rather than create numerous individual caveats foreach criterion excluding individuals in palliative care orhospice settings, the panel chose to exclude individuals inthese settings from the criteria. The panel felt justifiedmaking this decision because of the shift in benefit-to-harmratio in end-of-life decisions and paucity of evidence avail-able for avoiding drugs in these populations.

Compared with the 2012 update, the 2015 update hasfewer changes and new medications, likely because of the

Table 4. 2015 American Geriatrics Society Beers Criteria for Potentially Inappropriate Medications to Be Usedwith Caution in Older Adults

Drug(s) Rationale Recommendation

Quality of

Evidence

Strength of

Recommendation

Aspirin for primary prevention ofcardiac events

Lack of evidence of benefit versusrisk in adults aged ≥80

Use with caution in adults aged≥80

Low Strong

Dabigatran Increased risk of gastrointestinalbleeding compared with warfarinand reported rates with othertarget-specific oral anticoagulantsin adults aged ≥75; lack ofevidence of efficacy and safety inindividuals with CrCl <30 mL/min

Use with caution in in adults aged≥75 and in patients with CrCl<30 mL/min

Moderate Strong

Prasugrel Increased risk of bleeding in olderadults; benefit in highest-risk olderadults (e.g., those with priormyocardial infarction or diabetesmellitus) may offset risk

Use with caution in adults aged≥75

Moderate Weak

AntipsychoticsDiureticsCarbamazepineCarboplatinCyclophosphamideCisplatinMirtazapineOxcarbazepineSNRIsSSRIsTCAsVincristine

May exacerbate or causesyndrome of inappropriateantidiuretic hormone secretion orhyponatremia; monitor sodiumlevel closely when starting orchanging dosages in older adults

Use with caution Moderate Strong

Vasodilators May exacerbate episodes ofsyncope in individuals with historyof syncope

Use with caution Moderate Weak

The primary target audience is the practicing clinician. The intentions of the criteria are to improve selection of prescription drugs by clinicians and

patients; evaluate patterns of drug use within populations; educate clinicians and patients on proper drug usage; and evaluate health-outcome, quality-of-

care, cost, and utilization data.

CrCl = creatinine clearance; SNRIs = serotonin-norepinephrine reuptake inhibitors; SSRIs = selective serotonin reuptake inhibitors; TCAs = tricyclic anti-

depressants.


136

shorter time span since the criteria were last revised. Onlythree new medications and two new drug classes wereadded to Tables 2 or 3, although several were modified orhad some changes to the rationale and recommendationstatements. In a few instances, the level of evidence wasrevised based on new literature and the improved modifiedgrading methodology. Some notable changes were the 90-day-use caveat being removed from nonbenzodiazepine,benzodiazepine receptor agonist hypnotics, resulting in anunambiguous “avoid” statement (without caveats) becauseof the increase in the evidence of harm in this area sincethe 2012 update.22,23 In some cases, the rationale or word-ing of an avoid statement was modified or clarified becausethe panel and AGS had received comments regarding someconfusion about a medication in the criteria. For example,the term “sliding scale” insulin was defined more clearlywhen referred to in the criteria. Other changes includedlowering the creatinine clearance at which nitrofurantoinshould be avoided to less than 30 mL/min from less than60 mL/min. Also, removing Classes 1a, 1c, and III (with

the exception of amiodarone) antiarrhythmic drugs as first-line treatment for atrial fibrillation. Constipation wasremoved as a drug–disease, drug–syndrome category,because this condition is common across the age spectrumand relevant drug–disease, drug–syndrome combinations toavoid are not predominantly specific to older adults.

Some other important additions in the 2015 updatewere the addition of long-term proton-pump inhibitor usein the absence of a strong indication because of risk ofC. difficile infection, bone loss, and fractures and the addi-tion of opioids in the diagnosis and condition table forolder adults with a history of falls and fractures. If opioidsmust be used, it is recommended that reducing the use ofother CNS-active medications be considered.24,25 Thisstatement is in recognition of the need to have adequatepain control while balancing the potential harms from opi-oids and untreated pain. The panel balanced the difficultyand challenges of poorly treated pain with the harms ofopioids and available alternatives in older adults. Anothercritical change was to the language for use of antipsy-

Table 5. 2015 American Geriatrics Society Beers Criteria for Potentially Clinically Important Non-Anti-infectiveDrug–Drug Interactions That Should Be Avoided in Older Adults

Object Drug and

Class

Interacting Drug

and Class Risk Rationale Recommendation

Quality of

Evidence

Strength of

Recommendation

ACEIs Amiloride ortriamterene

Increased risk ofHyperkalemia

Avoid routine use; reserve forpatients with demonstratedhypokalemia while taking an ACEI

Moderate Strong

Anticholinergic Anticholinergic Increased risk ofCognitive decline

Avoid, minimize number ofanticholinergic drugs (Table 7)

Moderate Strong

Antidepressants (i.e.,TCAs and SSRIs)

≥2 other CNS-activedrugsa

Increased risk of Falls Avoid total of ≥3 CNS-activedrugsa; minimize number of CNS-active drugs

Moderate Strong

Antipsychotics ≥2 other CNS-activedrugsa

Increased risk of Falls Avoid total of ≥3 CNS-activedrugsa; minimize number of CNS-active drugs

Moderate Strong

Benzodiazepines andnonbenzodiazepine,benzodiazepine receptoragonist hypnotics


Increased risk of Fallsand fractures

Avoid total of ≥3 CNS-activedrugsa; minimize number of CNS-active drugs

High Strong

Corticosteroids, oral orparenteral

NSAIDs Increased risk of Pepticulcer disease orgastrointestinal bleeding

Avoid; if not possible, providegastrointestinal protection

Moderate Strong

Lithium ACEIs Increased risk ofLithium toxicity

Avoid, monitor lithiumconcentrations

Moderate Strong

Lithium Loop diuretics Increased risk ofLithium toxicity

Avoid, monitor lithiumconcentrations

Moderate Strong

Opioid receptor agonistanalgesics


Increased risk of Falls Avoid total of ≥3 CNS-activedrugsa; minimize number of CNSdrugs

High Strong

Peripheral Alpha-1blockers

Loop diuretics Increased risk ofUrinary incontinence inolder women

Avoid in older women, unlessconditions warrant both drugs

Moderate Strong

Theophylline Cimetidine Increased risk ofTheophylline toxicity


Warfarin Amiodarone Increased risk ofBleeding

Avoid when possible; monitorinternational normalized ratioclosely

Moderate Strong

Warfarin NSAIDs Increased risk ofBleeding

Avoid when possible; if usedtogether, monitor for bleedingclosely

High Strong

aCentral nervous system (CNS)-active drugs: antipsychotics; benzodiazepines; nonbenzodiazepine, benzodiazepine receptor agonist hypnotics; tricyclic

antidepressants (TCAs); selective serotonin reuptake inhibitors (SSRIs); and opioids.

ACEI = angiotensin-converting enzyme inhibitor; NSAID = nonsteroidal anti-inflammatory drug.


137

chotics26 in the dementia and delirium drug–disease, drug–syndrome category and the addition of avoiding antipsy-chotics in persons with delirium as first-line treatment.With increasing evidence of harm associated with antipsy-chotics27,28 and conflicting evidence on their effectivenessin delirium and dementia, the rationale to avoid was modi-fied to “avoid antipsychotics for behavioral problemsunless nonpharmacological options (e.g., behavioral inter-ventions) have failed or are not possible, and the olderadult is threatening substantial harm to self or others.”7

The table of medications with strong anticholinergicproperties has been updated. Anticholinergic burden andmeasurement is an area of literature that is continuallyevolving. Use of anticholinergic medications remains aconcern because it is associated with impaired cognitiveand physical function and risk of dementia.29,30

These criteria continue to be useful and necessary as aclinical and public health tool to improve medicationsafety in older adults and to increase awareness ofpolypharmacy and aid decision-making for choosing drugsto avoid in older adults. The AGS is publishing a compan-ion piece to this update Beers Criteria; How to Use the

Beers Criteria—A Guide for Patients, Clinicians, HealthSystems, and Payors, published online in this journal.Recent work illustrates that prescription drug use hasincreased in older adults over the past 20 years, withpoorer health in older adults associated with being on mul-tiple medications.31 Using data from the Medical Expendi-ture Panel Survey (MEPS), it was found that at least 41%of older adults still filled a prescription for a PIM in2009–10 according to the 2012 AGS Beers Criteria. Eventhough the rate of PIM use declined from 45.5% in 2006–07 to 40.8% in 2009–10, almost half of older adults stillfilled a PIM presecription.32 Despite their potential toincrease the risk of falls, fractures, and cognitive impair-ment, the use of benzodiazepines remains high (~9%).32,33

The 2015 AGS Beers Criteria are an essential evi-dence-based tool to use in decision-making for drugs toavoid in older adults, but they are not meant to overrideclinical judgment or an individual’s preferences, values,and needs. There may be cases in which the healthcareprovider determines that a drug on the list is the only rea-sonable alternative or the individual is at the end of life orreceiving palliative care. The criteria were developed in a

Table 6. 2015 American Geriatrics Society Beers Criteria for Non-Anti-Infective Medications That Should BeAvoided or Have Their Dosage Reduced with Varying Levels of Kidney Function in Older Adults

Medication Class

and Medication

Creatinine Clearance,

mL/min, at Which

Action Required Rationale Recommendation

Quality of

Evidence

Strength of

Recommendation

Cardiovascular or hemostasisAmiloride <30 Increased potassium, and

decreased sodiumAvoid Moderate Strong

Apixaban <25 Increased risk of bleeding Avoid Moderate StrongDabigatran <30 Increased risk of bleeding Avoid Moderate StrongEdoxaban 30–50 Increased risk of bleeding Reduce dose Moderate Strong

<30 or >95 AvoidEnoxaparin <30 Increased risk of bleeding Reduce dose Moderate StrongFondaparinux <30 Increased risk of bleeding Avoid Moderate StrongRivaroxaban 30–50 Increased risk of bleeding Reduce dose Moderate Strong

<30 AvoidSpironolactone <30 Increased potassium Avoid Moderate StrongTriamterene <30 Increased potassium, and

decreased sodiumAvoid Moderate Strong

Central nervous system and analgesicsDuloxetine <30 Increased Gastrointestinal

adverse effects (nausea,diarrhea)

Avoid Moderate Weak

Gabapentin <60 CNS adverse effects Reduce dose Moderate StrongLevetiracetam ≤80 CNS adverse effects Reduce dose Moderate StrongPregabalin <60 CNS adverse effects Reduce dose Moderate StrongTramadol <30 CNS adverse effects Immediate release: reduce

doseExtended release: avoid

Low Weak

GastrointestinalCimetidine <50 Mental status changes Reduce dose Moderate StrongFamotidine <50 Mental status changes Reduce dose Moderate StrongNizatidine <50 Mental status changes Reduce dose Moderate StrongRanitidine <50 Mental status changes Reduce dose Moderate Strong

HyperuricemiaColchicine <30 Gastrointestinal,

neuromuscular, bone marrowtoxicity

Reduce dose; monitor foradverse effects

Moderate Strong

Probenecid <30 Loss of effectiveness Avoid Moderate Strong

CNS = central nervous system.


138

way that facilitates a team approach (physicians, nurses,pharmacists, therapists, and others) to prescribing andmonitoring adverse effects.

The 2015 AGS Beers Criteria encourage the use of non-pharmacological approaches when needed to avoid drugsthat have a high risk of causing an adverse event. The evi-dence base for specific nonpharmacological approachesusing a person-centered approach to care is growing, espe-cially in older adults and in persons with dementia anddelirium.34-36 A nonpharmacological toolkit for reducingantipsychotic use in older adults by promoting positivebehavioral health, developed by investigators at The Penn-sylvania State University and the Polisher Research Insti-tute, was recently released. This toolkit can be accessedonline (www.nursinghometoolkit.com). Nonpharmacologi-cal strategies for hospitalized older adults and theircaregivers can also be accessed online (www.hospitalelderlifeprogram.org). A 2015 systematic review and meta-analy-sis of nonpharmacological strategies in older adults withdelirium found that 11 of 14 studies demonstrated

significant reductions in delirium incidence and a reductionin the rate of falls.37 Several studies have also illustratedeffective interventions to improve sleep.38,39

The AGS Beers Criteria are one component of a com-prehensive approach to medication use in older adults, andthey should be used in conjunction with other tools. TheScreening Tool of Older Persons’ potentially inappropriatePrescriptions (STOPP) and Screening Tool to Alert doctorsto Right Treatment (START) criteria, first developed in2008, are an explicit tool for assessing prescribing in olderadults in Europe. They were updated in 2015 to include

Table 7. Drugs with Strong Anticholinergic Properties

AntihistaminesBrompheniramineCarbinoxamineChlorpheniramineClemastineCyproheptadineDexbrompheniramineDexchlorpheniramineDimenhydrinateDiphenhydramine(oral)DoxylamineHydroxyzineMeclizineTriprolidine

Antiparkinsonianagents

BenztropineTrihexyphenidyl

Skeletal musclerelaxantsCyclobenzaprineOrphenadrine

AntidepressantsAmitriptylineAmoxapineClomipramineDesipramineDoxepin (>6 mg)ImipramineNortriptylineParoxetineProtriptylineTrimipramine

AntipsychoticsChlorpromazineClozapineLoxapineOlanzapinePerphenazineThioridazineTrifluoperazine

AntiarrhythmicDisopyramide

Antimuscarinics(urinary incontinence)DarifenacinFesoterodineFlavoxateOxybutyninSolifenacinTolterodineTrospium

AntispasmodicsAtropine (excludesophthalmic)BelladonnaalkaloidsClidinium-chlordiazepoxideDicyclomineHomatropine(excludesophthalmic)HyoscyaminePropanthelineScopolamine(excludesophthalmic)

AntiemeticProchlorperazinePromethazine

Table 9. Medications Removed Since 2012 Beers Crite-ria

Independent of Diagnoses

or Condition (Table 2)

Considering Disease and

Syndrome Interactions

(Table 3)

Antiarrhythmic drugs (Class1a, 1c, III except amiodarone)as first-line treatment for atrialfibrillation

Chronic constipation—entirecriterion

Trimethobenzamide Lower urinary tract—inhaledanticholinergic drugs

Mesoridazine—no longermarketed in United StatesChloral hydrate—no longermarketed in United States

Table 8. Medications Moved to Another Category orModified Since 2012 Beers Criteria

Independent of Diagnoses or

Condition (Table 2)

Considering Disease or


(Table 3)

Nitrofurantoin—recommendationand rationale modified

Heart failure—rationale andquality of evidence modified

Dronedarone—recommendationand rationale modified

Chronic seizures or epilepsy—quality of evidence modified

Digoxin—recommendation andrationale modified

Delirium—recommendationand rationale modified

Benzodiazepines—recommendation modified

Dementia or cognitiveimpairment—recommendationand rationale modified; newdrugs added

Nonbenzodiazepine,benzodiazepine receptor agonisthypnotics—recommendationmodified

History of falls or fractures—recommendation and rationalemodified; new drugs added

Meperidine—recommendationmodified

Parkinson disease—recommendation and rationalemodified

Indomethacin and ketorolac,includes parenteral—rationalemodified

Chronic kidney disease StageIV or less (creatinine clearance<30 mL/min)—triamterenemoved to Tables 5 and 6

Antipsychotics—recommendationand rationale modified

Insomnia—new drugs added

Estrogen—recommendationmodifiedInsulin, sliding scale—rationalemodified


139

drugs affecting or being affected by renal function, similarto this update of the AGS Beers Criteria.40 Similar toolshave been developed in Europe.41 The current update ofthe AGS Beers Criteria confirms and extends this workwith a rigorous independent evidence grading process, anopen peer-review comment period consistent with Instituteof Medicine standards, and the addition of drug–druginteractions and renal dose adjustment.

The 2015 AGS Beers Criteria have several importantlimitations. Older adults are often underrepresented in drugtrials.11,42 Thus, using an evidence-based approach mayunderestimate some drug-related problems or lead toweaker evidence grading. The GRADE process was used forevidence grading, which allowed for rigor and greater trans-parency in the evidence grading process.10 The criteria can-not account for all individuals and special populations; forinstance, they do not comprehensively address the needs ofindividuals receiving palliative and hospice care, in whomthe balance of benefits and harms for many drugs on the listmay differ from those of the general population of olderadults. Finally, the search strategies used might have missedsome studies published in languages other than English andstudies available in unpublished technical reports, whitepapers, or other “gray literature” sources.

The process had many noteworthy strengths, includingthe use of a 13-member, geographically diverse interdisci-plinary panel with ex-officio members from the Centersfor Medicare and Medicaid Services, National Committeefor Quality Assurance, and Pharmacy Quality Alliance; theuse of an evidence-based approach using Institute of Medi-cine standards and independent grading of the evidence bypanel members followed by a consensus approach; and thecontinued development of a partnership with AGS toupdate the criteria regularly.

In conclusion, the 2015 AGS Beers Criteria have severalimportant updates, including the addition of new medica-tions, clarification of some of the 2012 criteria language,the addition of selected drugs for which dose adjustment isrequired based on kidney impairment, and the addition ofselected drug–drug interactions. Careful application of thecriteria by healthcare professionals, consumers, payors, andhealth systems should lead to closer monitoring of drug use.Dissemination of the criteria should lead to increased edu-cation and awareness of drug-related problems, increasedreporting of drug-related problems, active patient and care-giver engagement and communication regarding medicationuse, targeted interventions to decrease adverse drug eventsin older adults, and improved outcomes. Continued support

from the AGS will allow for the criteria methodology andevidence for PIMs to be evaluated regularly and to remainup to date, relevant and valuable.

PANEL MEMBERS AND AFFILIATIONS

The following individuals were members of the AGS Panelto update the 2015 AGS Beers Criteria: Donna M. Fick,PhD, RN, FGSA, FAAN, College of Nursing and Medicine,The Pennsylvania State University, University Park, PA (co-chair); Todd P. Semla, PharmD, MS, BCPS, FCCP, AGSF,U.S. Department of Veterans Affairs National PharmacyBenefits Management Services and Northwestern UniversityFeinberg School of Medicine, Chicago, IL (co-chair); JudithBeizer, PharmD, CGP, FASCP, AGSF, St. Johns University,New York, NY; Nicole Brandt, PharmD, BCPP, CGP,University of Maryland, Baltimore, MD; Robert Dom-browski, PharmD, Centers for Medicare and Medicaid Ser-vices, Baltimore, MD (nonvoting member); Catherine E.DuBeau, MD, University of Massachusetts Medical School,Worcester, MA; Woody Eisenberg, MD, Pharmacy QualityAlliance, Inc., Baltimore, MD (nonvoting member); JeromeJ. Epplin, MD, AGSF, Litchfield Family Practice Center,Litchfield, IL; Nina Flanagan, PhD, GNP-BC, APHM-BC,Decker School of Nursing, Binghamton University, Dun-more, PA; Erin Giovannetti, National Committee for Qual-ity Assurance, Washington, DC (nonvoting member);Joseph Hanlon, PharmD, MS, BCPS, FASHP, FASCP,FGSA, AGSF, Department of Medicine (Geriatric Medicine)School of Medicine, University of Pittsburgh and GeriatricResearch, Education and Clinical Center, Veterans AffairsHealthcare (GRECC) System, Pittsburgh, PA; Peter Holl-mann, MD, AGSF, Alpert Medical School, Brown Univer-sity, Providence, RI; Rosemary Laird, MD, MHSA, AGSF,Geriatric Medical Leader for Florida Hospital, Winter Park,FL; Sunny Linnebur, PharmD, FCCP, BCPS, CGP, SkaggsSchool of Pharmacy and Pharmaceutical Sciences, Univer-sity of Colorado, Aurora, CO; Satinderpal Sandhu, MD,Summa Health Care System and Northeast Ohio MedicalUniversity, Akron, OH; Michael Steinman, MD, Universityof California at San Francisco and San Francisco VeteransAffairs Medical Center, San Francisco, CA.

ACKNOWLEDGMENTS

The decisions and content of the 2015 AGS Beers Criteriaare those of the AGS and the panel members and are notnecessarily those of the U.S. government or U.S. Depart-ment of Veterans Affairs.

Sue Radcliff, Independent Researcher, Denver, Color-ado, provided research services. Jirong Yue and GinaRocco provided additional research services. Susan E.Aiello, DVM, ELS, provided editorial services. Elvy Ickow-icz, MPH, Zhenya Hurd, and Mary Jordan Samuel pro-vided additional research and administrative support. Andas always, the late Mark H. Beers, MD.

The following organizations with special interest andexpertise in the appropriate use of medications in olderadults provided peer review of a preliminary draft of thisguideline: American Medical Directors Association—TheSociety for Post-Acute and Long-Term Care Medicine,American Academy of Family Physicians, American Acad-

Table 10. Medications Added Since 2012 Beers Crite-ria

Independent of Diagnoses

or Condition (Table 2)

Considering Disease and


(Table 3)

Proton-pump inhibitors Falls and fractures—opioidsDesmopressin Insomnia—armodafinil and

modafinilAnticholinergics, first-generationantihistamines—meclizine

Dementia or cognitive impairment—eszopiclone and zaleplonDelirium—antipsychotics


140

emy of Geriatric Psychiatry, American Academy of Neu-rology, American Association of Clinical Endocrinologists,American Association of Diabetes Educators, AmericanCollege of Clinical Pharmacy, American College of Obstet-rics and Gynecology, American College of Physicians,American College of Surgeons, American OsteopathicAssociation, American Pharmacists Association, AmericanSociety of Consultant Pharmacists, American Society ofHealth-System Pharmacists, American Urological Society,the Endocrine Society, Gerontological Advanced PracticeNurses Association, Gerontological Society of America,National Committee for Quality Assurance, NationalGerontological Nursing Association, NICHE, PharmacyQuality Alliance, Society for Women’s Health Research,and Society of General Internal Medicine.

Conflict of Interest: Dr. Beizer is an author and editorfor LexiComp, Inc. Dr. Brandt is a consultant for Omni-care, Centers for Medicare and Medicaid Services, andUniversity of Pittsburgh and a Section Editor for the Jour-nal of Gerontological Nursing and received a grant fromEconometrica. Dr. Fick is a paid consultant for SLACKInc., is an editor for the Journal of Gerontological Nurs-ing, and has current R01 funding from the National Insti-tutes of Health and the National Institute of NursingResearch. Dr. Linnebur is a consultant for ColoradoAccess and Kindred Healthcare. Dr. Semla serves on theAARP Caregiver Advisory Panel, is an editor for Lexi-Comp, and is a consultant for Omnicare. Dr. Semla’s wifeholds commercial interest in AbbVie (at which she is alsoan employee), Abbott, and Hospira. Dr. Semla receiveshonoraria from the AGS for his contribution as an authorof Geriatrics at Your Fingertips and for serving as a sec-tion editor for the Journal of the American Geriatrics Soci-ety and is a past president and chair of the AGS Board ofDirectors. Dr. Steinman is a consult for Iodine.com, a webstart-up company.

Author Contributions: All panel members contributedto the concept, design, and preparation of the manuscript.

Sponsor’s Role: AGS staff participated in the finaltechnical preparation and submission of the manuscript.

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“Upstream Medicine”

by

Stephanie Benson, MD, Stephen Colmant, Ph.D., &

Iván A. de la Rosa, Ph.D.

Stephanie Benson, MD, is currently a Faculty Physician at the Southern New Mexico Family

Medicine Residency Program in Las Cruces, New Mexico. She graduated medical school in

2003 from West Virginia University School of Medicine and then entered residency at WVU in

the Department of Family Medicine. In 2007 she transferred to New Mexico and then completed

Family Medicine residency training in 2009 at the Southern New Mexico Family Medicine

Residency Program in Las Cruces, New Mexico. In 2013, she completed a Faculty Development

Fellowship at University of North Carolina-Chapel Hill, Department of Family Medicine. She

has served on the Board of Directors of the New Mexico Chapter of the American Academy of

Family Physicians (NMAFP) since 2008, where she had been elected as President and Board

Chair and continues to serve as Alternate Delegate to the National AAFP Congress of Delegates.

She is a Fellow of the AAFP and currently serves on the board of two local charity organizations,

including St. Luke’s Healthcare Clinic where she also serves as Medical Director. Her interests

include academic medicine, health care policy, indigent care, and global health.

Stephen A. Colmant, Ph.D., is a licensed psychologist with the Southern New Mexico Family

Medicine Residency Program at Memorial Medical Center. He is completing a two-year

fellowship in clinical psychopharmacology. Dr. Colmant earned his Ph.D. in counseling

psychology from Oklahoma State University in 2005. He is the author of “Sweat Therapy: A

guide to greater well-being”. He, his wife, and his daughter live in Las Cruces, NM.

Iván A. de la Rosa, Ph.D., is an experienced program evaluator in the areas of maternal and

child health, and intimate partner violence. As a researcher, Dr. de la Rosa is particularly

interested in the identification of risk and protective factors relevant to the well-being of

borderland women and children. Currently, he is involved on the development and evaluation of

innovative programs that address social determinants of health in primary care settings. Previous

research initiatives emphasized family resilient capacities and substance abuse. Dr. de la Rosa is

an associate professor at the School of Social Work at New Mexico State University and adjunct

research faculty at Southern New Mexico Family Medicine Residency Program.

Email: [email protected], [email protected], [email protected]

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Learning Objectives


1. Review the history and current status of the Annual Check-Up

2. Discuss the relationship between Well-Being and Mental Health with each other and with

Physical Health

3. Describe the development of a Well-Being Check-Up procedure that includes both a

physician and a Behavioral Health Provider that occurs in a Family Medicine practice

setting. The procedure includes measures of physical health, psychological health, and

well-being.

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Upstream MedicineDr. Stephanie Benson

Dr. Stephen Colmant

Dr. Ivan A. de la Rosa

February 20, 2016

145

What is Prevention?

1. Stops (prevents) a problem behavior from ever occurring.

2. Delays the onset of a problem behavior.

3. Reduces the impact of an existing problem behavior.

4. Strengthens knowledge, attitudes, and behaviors that promoteemotional and physical well-being.

5. Supports institutional, community, and government policies that promote physical and emotional well-being.

The Problem

• Poverty is the single largest determinant of health.

• Some Americans will die 20 years earlier than others who live just a few miles away because of differences in education, income, race, ethnicity and where and how they live.

• Your zip code may be a bigger determinant of your health than your genetic code!

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Mental Health & Primary Care are Inseparable

• 43-60% of all MH care is provided by PCP.

• Up to 30% of primary care Pts have a mental disorder.

• Identification & Treatment is poor.

• Pharmacology is the most common treatment.

• The provision of primary care and MH Tx is mostly segregated.

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The problem

• New Mexico ranks 33rd in overall health status among U.S. states

• Health indicators demonstrate significant health disparities related tosocial determinants of health

• Need for better training of medical residents to address social determinants of health in primary care setting

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What we know

• Life expectancy for Latinos

• US: 82.8

• NM: 78.8

• Teen death rate (per 100,000 residents)

• US: 49

• NM: 62

What we know

• Diabetes death rate (per 100,000 residents)

• US: 21.2

• NM: 27.6

• Percent of Native Americans with overweight/obesity

• US: 68.1%

• NM: 77.5%

What we know

• Basic conditions necessary for health include:• access to and quality of health care

• education

• the environment

• income

• employment

• housing

• safety

• But, focus of medical education is on medical/biological aspect of health

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Basic conditions necessary for health include:

• access to and quality of health care

• education

• income

• the environment

• employment

• housing

• safety

Project Activities

1. Develop integrated multidisciplinary team

2. Develop a social and behavioral determinants of healthscreening tool

3. Develop social/behavioral determinants of health curriculum in family medicine residency in line withBeyond Flexner developments

Project Activities

4. Develop operating procedures to utilize the screening tool toidentify the upstream health needs of patients

5. Train NMSU undergraduate and graduate students to work inmultidisciplinary teams to address health disparities

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Social/behavioral health surveillance system

• Conducted literature review of social/behavioral determinants of health

• Surveyed rapid assessment instruments used in other medical facilities across the country

• Conducted power analyses to sample current patient population

Social/behavioral health surveillance system

• I was able to follow the treatment plan my provider and I agreed on at mylast appointment.

• I take all of my medications the way I am told to take them.

• I need to increase my exercise.

• I need to change my eating habits.

• I use illegal drugs (or drugs prescribed for others) so I need to cut down or stop.

• In the past 30 days, I had to cut the size of my meals or skip meals because there wasn’t enough money or food.

• There is someone in my life I’m afraid of or who hurts me.

• I’m having trouble paying for gas or electricity bills.

• There are legal issues that I am having trouble addressing.

• I want to talk with someone today about the change I need to make.

Decision Tree

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Well-Being Check-Ups:Beyond Depression Screening

Stephen A. Colmant, Ph.D.

DEFINING WELL-BEING

• Subjective Well-Being, Wellness, Quality of Life, Happiness, andLife Satisfaction are often used interchangeably.

• WB – Life Satisfaction, Emotional Vitality, & Optimism.

• Wellness refers to diverse and interconnected dimensions of physical, mental, and social well-being that extend beyond the traditional definition of health. It includes choices and activities aimed at achieving physical vitality, mental alacrity, social satisfaction, a senseof accomplishment, and personal fulfillment, (Huseyin & Ioannidis, 2015) .

Perception of QUALITY OF LIFE

• Health

• Self-Esteem

• Goals and Values

• Money

• Work

• Play

• Learning

• Creativity

• Helping

• Love

• Friends

• Children

• Relatives

• Home

• Neighborhood

• Community

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The Wheel of Wellness

REASONS TO INVEST IN WELL-BEING

• As many as two-thirds of all premature deaths inthe U.S. are due to lifestyle factors that can be modified.

• Increased use of preventative care.

• Better workplace and academic functioning

• High well-being associated with health andlongevity.

PROCEDURE

1. Patient completes intake paperwork and questionnaires.

2. Examination by Physician and Behavioral Health Provider.

3. Physician and Behavioral Health Provider consult with one another on the patient’s strengths, needs, and recommendations.

4. The two health providers provide the patient feedback.

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TOOLSPsychological Symptoms

CHILDREN

• Achenbach

• Connors

ADULT

• Brief Symptom Inventory

Well-Being

CHILDREN

• Check on parent wellness

• Behavioral and Emotional Rating Scale

ADULT

• Wellness Evaluation of Lifestyles

• Quality of Life Inventory

BILLING

• 96127 Brief emotional/behavioral assessment - $5.37

• 96110 Developmental screening - $8.96

• 96111 Developmental testing - $130.77

• 96101 Psych Testing - Molina Healthcare - $174.60 NM Centennial Care - $87.94

• 90791 PSYCH Diagnostic Interview - $144.07

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59th Annual Family Medicine Seminar

Taos, New Mexico

SAve The DATeJuly 28-31, 2016

Thank you for attending!

· All speakers have indicated they have nothing to disclose except for the following: Jennifer...

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