The document summarizes the 2015 update of the American Geriatrics Society Beers Criteria, which provides a list of potentially inappropriate medications that should generally be avoided in older adults. Key points:
- The updated criteria include revisions to existing medications to avoid as well as new sections on medications requiring dose adjustments for kidney function and drug-drug interactions.
- A 13-member expert panel reviewed evidence and reached consensus on the criteria using a systematic, evidence-based process.
- The criteria are intended to improve medication safety for older adults by providing guidance to medical professionals, consumers, and health systems.
This document summarizes a presentation on clinical practice tools for identifying potential medication-related problems in the elderly. The presentation discusses several tools including the Beers List, Medication Appropriateness Index, IPET, Zhan-AHRQ, Medication Regimen Appropriateness Index, STOPP/START, IMAP, and NCQA-HEDIS. It provides definitions of related terms and describes each tool, how it was developed, its strengths and limitations. The presentation aims to help clinicians incorporate these tools into practice to improve medication management for elderly patients.
The document summarizes the 2019 update of the American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. An expert panel reviewed evidence published since the 2015 update and determined whether new criteria should be added or existing criteria removed or modified. The panel retained the five types of criteria from the 2015 update and incorporated new evidence. The goal is to improve care for older adults by reducing exposure to medications with unfavorable benefit-harm balances or safer alternatives.
The document summarizes an update to the American Geriatrics Society Beers Criteria, which lists potentially inappropriate medications for older adults. An expert panel conducted a systematic review and updated the criteria using evidence on drug-related problems and adverse drug events in older adults. The updated 2012 criteria include 53 medications or classes and are divided into three categories based on risks. The criteria are intended to improve care of older adults by reducing exposure to inappropriate medications and improving prescribing decisions.
The document discusses pharmacotherapy and adherence to Beers criteria in the elderly. It provides an overview of medication use challenges in older adults, including age-related changes to pharmacokinetics and pharmacodynamics. It also discusses tools to evaluate inappropriate medications like Beers criteria and STOPP/START criteria. Beers criteria lists potentially inappropriate medications or classes to avoid in older adults due to risks of adverse effects. STOPP/START criteria addresses medications that should be avoided as well as those that should be considered.
This document provides guidance on reviewing polypharmacy, which is the use of multiple medications. It is important to review polypharmacy because many elderly patients are on multiple drugs but around half may not be taken as prescribed and adverse drug reactions are common, especially with more comorbidities rather than age. The guidance aims to help practitioners review medications and potentially deprescribe those where risks outweigh benefits by providing tools and considerations. Key points are identifying high-risk patients for review, focusing on certain drug classes, and balancing multiple treatment guidelines for individual patient circumstances through comprehensive medication reviews.
2016: Considerations on Polypharmacy and Adverse Drug Events-WatanabeSDGWEP
The document discusses issues related to polypharmacy and adverse drug events in older adults. It notes that polypharmacy is common in seniors, putting them at higher risk for adverse drug events, hospitalizations, and costs. The document also reviews tools that can help reduce inappropriate polypharmacy and prescribing, such as Beers criteria, STOPP criteria, and comprehensive medication reviews.
This document discusses polypharmacy and medication errors. It begins by defining polypharmacy as the use of multiple medications where more are being used than clinically indicated. Polypharmacy can increase the risk of drug interactions and adverse events. Common risk factors for polypharmacy include the elderly, multiple comorbidities, recent hospitalization, and multiple physicians or pharmacies. Medication errors are also defined as any error in the medication use process and examples are provided. Reporting systems for medication errors and the most commonly implicated drug classes and individual drugs are outlined. Risk factors for errors and recommendations to reduce polypharmacy and errors are presented.
Polypharmacy resource_JAN 15_NINA BARNETTZeshan Ahmed
This document provides resources to support the management of polypharmacy and deprescribing. It begins with an overview of key terms such as polypharmacy, oligopharmacy, and deprescribing. It then discusses the increase in polypharmacy among older adults and some of the risks associated with inappropriate polypharmacy. The document is structured to provide background information on polypharmacy, tools and initiatives to support practice, and references. It aims to assist healthcare professionals with medication reviews and decisions around deprescribing for patients taking multiple medications.
This document summarizes a presentation on clinical practice tools for identifying potential medication-related problems in the elderly. The presentation discusses several tools including the Beers List, Medication Appropriateness Index, IPET, Zhan-AHRQ, Medication Regimen Appropriateness Index, STOPP/START, IMAP, and NCQA-HEDIS. It provides definitions of related terms and describes each tool, how it was developed, its strengths and limitations. The presentation aims to help clinicians incorporate these tools into practice to improve medication management for elderly patients.
The document summarizes the 2019 update of the American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. An expert panel reviewed evidence published since the 2015 update and determined whether new criteria should be added or existing criteria removed or modified. The panel retained the five types of criteria from the 2015 update and incorporated new evidence. The goal is to improve care for older adults by reducing exposure to medications with unfavorable benefit-harm balances or safer alternatives.
The document summarizes an update to the American Geriatrics Society Beers Criteria, which lists potentially inappropriate medications for older adults. An expert panel conducted a systematic review and updated the criteria using evidence on drug-related problems and adverse drug events in older adults. The updated 2012 criteria include 53 medications or classes and are divided into three categories based on risks. The criteria are intended to improve care of older adults by reducing exposure to inappropriate medications and improving prescribing decisions.
The document discusses pharmacotherapy and adherence to Beers criteria in the elderly. It provides an overview of medication use challenges in older adults, including age-related changes to pharmacokinetics and pharmacodynamics. It also discusses tools to evaluate inappropriate medications like Beers criteria and STOPP/START criteria. Beers criteria lists potentially inappropriate medications or classes to avoid in older adults due to risks of adverse effects. STOPP/START criteria addresses medications that should be avoided as well as those that should be considered.
This document provides guidance on reviewing polypharmacy, which is the use of multiple medications. It is important to review polypharmacy because many elderly patients are on multiple drugs but around half may not be taken as prescribed and adverse drug reactions are common, especially with more comorbidities rather than age. The guidance aims to help practitioners review medications and potentially deprescribe those where risks outweigh benefits by providing tools and considerations. Key points are identifying high-risk patients for review, focusing on certain drug classes, and balancing multiple treatment guidelines for individual patient circumstances through comprehensive medication reviews.
2016: Considerations on Polypharmacy and Adverse Drug Events-WatanabeSDGWEP
The document discusses issues related to polypharmacy and adverse drug events in older adults. It notes that polypharmacy is common in seniors, putting them at higher risk for adverse drug events, hospitalizations, and costs. The document also reviews tools that can help reduce inappropriate polypharmacy and prescribing, such as Beers criteria, STOPP criteria, and comprehensive medication reviews.
This document discusses polypharmacy and medication errors. It begins by defining polypharmacy as the use of multiple medications where more are being used than clinically indicated. Polypharmacy can increase the risk of drug interactions and adverse events. Common risk factors for polypharmacy include the elderly, multiple comorbidities, recent hospitalization, and multiple physicians or pharmacies. Medication errors are also defined as any error in the medication use process and examples are provided. Reporting systems for medication errors and the most commonly implicated drug classes and individual drugs are outlined. Risk factors for errors and recommendations to reduce polypharmacy and errors are presented.
Polypharmacy resource_JAN 15_NINA BARNETTZeshan Ahmed
This document provides resources to support the management of polypharmacy and deprescribing. It begins with an overview of key terms such as polypharmacy, oligopharmacy, and deprescribing. It then discusses the increase in polypharmacy among older adults and some of the risks associated with inappropriate polypharmacy. The document is structured to provide background information on polypharmacy, tools and initiatives to support practice, and references. It aims to assist healthcare professionals with medication reviews and decisions around deprescribing for patients taking multiple medications.
This document summarizes a study on polypharmacy among patients in South India. The study defined polypharmacy as using 2-4 drugs as minor polypharmacy and 5 or more drugs as major polypharmacy. It found that 59.82% of patients had major polypharmacy, occurring most in cardiovascular diseases. Polypharmacy was more prevalent in males and in ages 19-60 years. Hospital stays were longer for major polypharmacy. The study suggests simplifying treatment regimens by eliminating unnecessary drugs and dosages to reduce problems from polypharmacy.
This document discusses polypharmacy, which is defined as the administration of many drugs simultaneously or an excessive number of drugs. Polypharmacy is common in elderly patients with multiple chronic conditions. It can be appropriate if all drugs achieve therapeutic objectives and minimize adverse effects, but is often inappropriate if drugs are unnecessary or cause harm. Tools like Beers Criteria, STOPP, and START can help identify inappropriate polypharmacy and guide deprescribing. The document outlines factors contributing to polypharmacy and consequences like adverse drug reactions, providing strategies to assess medication benefit-harm and safely discontinue unnecessary drugs.
This webinar slide-set illustrates the stepwise process of engaging Scalable Architecture for Federated Translational Inquiries Network (SAFTINet) practice stakeholders in
selecting and adapting a measure of patient-reported medication adherence.
For more information on SAFTINet, please see http://www.ucdenver.edu/academics/colleges/medicalschool/programs/outcomes/COHO/saftinet/Pages/default.aspx
This document provides an introduction to pharmacoepidemiology. It defines pharmacoepidemiology as the study of drug use and effects in large populations. It discusses study designs used in pharmacoepidemiology including randomized trials, cohort studies, case-control studies, and case reports. Reasons for performing pharmacoepidemiology studies include fulfilling regulatory and legal obligations, assessing drug safety, and generating or testing hypotheses. Sources of data include spontaneous adverse event reporting, prescription databases, and electronic health records. The document also briefly discusses molecular pharmacoepidemiology, bioethics, pharmacoeconomics, and measuring quality of life outcomes.
Medication therapy is becoming increasingly more complex as new drugs are developed and more therapeutic targets are elucidated. In addition, polypharmacy (≥5 scheduled medications) has become exceedingly common in geriatric patients and in patients with chronic disease states. As the complexity of drug therapy and the number of medications increase, patients are at a high risk for medication errors and adverse drug events (ADEs), or injuries resulting from medication. The type of adverse events may be associated with professional practices, healthcare products, procedures, and systems including prescription, communication through instructions, drug labeling, packaging and nomenclature, reformulation, dissolution, distribution, administration, education, monitoring, and use. Classification and evaluation of medication errors according to their importance may constitute an important factor for process improvement in order to render the administration of medicines as safe as possible. In hospitals, medication errors occur at a rate of about one per patient per day. A dispensing error is one made by pharmacy staff when distributing medications to nursing units or directly to patients in an ambulatory-care pharmacy; the error rates for doses dispensed via the cart-filling process range from 0.87% to 2.9%. Technology has grown to be a constituent part of medicine these days. A few advantages that technology can supply are categorized as follows: the assisting of communication between clinicians; enhancing medication safety; decreasing potential medical errors and adverse events; rising access to medical information and encouraging patient-centered healthcare. The aim of this article is to provide a compendious literature review regarding Medication errors
Thesis_PhD_Improving medication safety in the elderlyHA VO THI
The document discusses medication safety issues for elderly patients, noting that physiological changes with aging increase their risk of adverse drug reactions and interactions from polypharmacy. Polypharmacy, defined as using multiple medications, is common in elderly patients due to multiple chronic conditions but can increase problems with adherence and side effects. Improving medication safety for elderly patients requires addressing polypharmacy issues through individualized treatment reviews that consider life expectancy, treatment goals and targets.
This document analyzes reporting of adverse drug reactions (ADRs) by pharmacists in the Pharmacovigilance Programme of India (PvPI) between July 2011 and December 2014. It finds that of 110,000 reports in the database, 16,646 (15%) were reported by pharmacists. Of these, 3,782 (22.7%) were serious reactions while 9,601 (57.7%) were non-serious. Reporting by pharmacists has increased over time. The document concludes that pharmacists can play an important role in pharmacovigilance by detecting, reporting, and assessing ADRs.
The document discusses pharmaceutical care, which aims to achieve the best possible outcomes for patients' quality of life through proper medication use. It defines pharmaceutical care as the responsible provision of drug therapy to achieve definite therapeutic outcomes that improve a patient's quality of life. Key aspects of pharmaceutical care include identifying and resolving actual and potential drug-related problems through monitoring medication appropriateness, effectiveness, and safety. The roles of pharmacists include collecting patient data, assessing medications, developing individualized care plans, implementing and monitoring care to evaluate outcomes and modify plans as needed.
The document discusses medication non-adherence, which is a major problem that impacts health and costs the healthcare system billions annually. It describes various technologies that have been developed to help patients better manage and adhere to their medication schedules, ranging from basic pillboxes and reminders to more advanced automated dispensers and sensors. The document recommends pilot studies be conducted to evaluate the real-world effectiveness of different medication adherence technologies in improving patient outcomes beyond standard discharge instructions alone.
Medication errors that occur during hospital admission can lead to preventable adverse drug events. This study uses a model to assess the costs and health effects of interventions aimed at reducing medication errors during admission reconciliation. The model estimates that all five interventions identified by a literature review are highly cost-effective compared to current practice. A pharmacist-led reconciliation intervention has the highest expected cost-effectiveness. The study concludes that medication reconciliation interventions provide a cost-effective use of healthcare resources to improve patient safety.
The Highs And Lows Of Opiate Managementguest2e3167
This document summarizes guidelines for prescribing opioids to manage chronic pain. It discusses the high prevalence and economic impact of chronic pain, as well as barriers physicians face in treating it. While opioids can provide pain relief, they carry risks of adverse effects, addiction, and overdose. The guidelines recommend developing a comprehensive treatment plan, trying non-opioid options first, carefully selecting and titrating opioid doses, monitoring patients for signs of misuse, and using treatment agreements to promote safe prescribing. The goal is to improve patients' function and quality of life while minimizing risks from long-term opioid therapy.
Knowledge and Perceptions Related to Hypertension, Lifestyle Behavior Modific...iosrjce
IOSR Journal of Nursing and health Science is ambitious to disseminate information and experience in education, practice and investigation between medicine, nursing and all the sciences involved in health care. Nursing & Health Sciences focuses on the international exchange of knowledge in nursing and health sciences. The journal publishes peer-reviewed papers on original research, education and clinical practice.
By encouraging scholars from around the world to share their knowledge and expertise, the journal aims to provide the reader with a deeper understanding of the lived experience of nursing and health sciences and the opportunity to enrich their own area of practice. The journal publishes original papers, reviews, special and general articles, case management etc.
Polypharmacy, defined as taking multiple medications, is common in the elderly population. Over half of people aged 65 and older take 5-9 medications, while 18% take 10 or more. The prevalence is higher in women due to longer lifespans and more frequent doctor visits. Polypharmacy can lead to adverse drug events, with risk exponentially increasing with more medications. Common signs include dizziness, confusion, and fatigue. Solutions include reducing unnecessary medications, simplifying dosing schedules, and increasing medication management support and provider education to curb this significant health issue in aging populations.
This document summarizes a study on the predictive characteristics of users of alternative medicine. The study found that 6.6% of patients surveyed had visited an alternative practitioner in the previous year. These patients tended to be of middle age, have chronic conditions, have a lower quality of life, greater anxiety and depression, and were heavier users of primary and secondary healthcare. Three factors - self-care and visiting specialists, changing primary doctors, and younger age - explained 66.2% of the variance in alternative medicine use. The conclusions indicate that seeking alternative medicine seems driven by patient characteristics but was not due to dissatisfaction with their primary doctor.
This document discusses medication errors, including their definition, causes, types, and strategies to prevent them. Some key points:
- Medication errors are preventable events that may cause harm and can occur at any stage from prescribing to administration. They are common but underreported.
- Errors are often due to look-alike or sound-alike drug names, miscommunication, lack of knowledge, and environmental factors like interruptions.
- Common types of errors include prescribing errors, dispensing errors, and administration errors. Analgesics, antibiotics, anticoagulants are high-risk drug classes.
- Prevention strategies include education, standardized processes, double checks, limiting distractions, clear
Medicamentos Potencialmente Inadecuados en personas mayoresSubDFarmacia
Este informe resume los hallazgos sobre la prescripción potencialmente inapropiada en ancianos. Identifica varios medicamentos potencialmente inapropiados como AINE, benzodiazepinas, antidepresivos y antihistamínicos anticolinérgicos. Además, analiza herramientas como los criterios Beers y STOPP/START para detectar este tipo de prescripciones y ofrece recomendaciones para mejorar la calidad de la atención a los ancianos.
The Patient Health Questionnaire (PHQ-9) is a 9-item instrument used to screen, diagnose, monitor, and measure the severity of depression. It asks how often over the last 2 weeks the patient has been bothered by 9 different problems, with response options ranging from "not at all" to "nearly every day." Scores of 5, 10, 15, and 20 represent cut-off points for mild, moderate, moderately severe, and severe depression, respectively. The PHQ-9 takes about 5 minutes to complete and can help providers determine appropriate treatment and monitor treatment response.
This document summarizes a study on polypharmacy among patients in South India. The study defined polypharmacy as using 2-4 drugs as minor polypharmacy and 5 or more drugs as major polypharmacy. It found that 59.82% of patients had major polypharmacy, occurring most in cardiovascular diseases. Polypharmacy was more prevalent in males and in ages 19-60 years. Hospital stays were longer for major polypharmacy. The study suggests simplifying treatment regimens by eliminating unnecessary drugs and dosages to reduce problems from polypharmacy.
This document discusses polypharmacy, which is defined as the administration of many drugs simultaneously or an excessive number of drugs. Polypharmacy is common in elderly patients with multiple chronic conditions. It can be appropriate if all drugs achieve therapeutic objectives and minimize adverse effects, but is often inappropriate if drugs are unnecessary or cause harm. Tools like Beers Criteria, STOPP, and START can help identify inappropriate polypharmacy and guide deprescribing. The document outlines factors contributing to polypharmacy and consequences like adverse drug reactions, providing strategies to assess medication benefit-harm and safely discontinue unnecessary drugs.
This webinar slide-set illustrates the stepwise process of engaging Scalable Architecture for Federated Translational Inquiries Network (SAFTINet) practice stakeholders in
selecting and adapting a measure of patient-reported medication adherence.
For more information on SAFTINet, please see http://www.ucdenver.edu/academics/colleges/medicalschool/programs/outcomes/COHO/saftinet/Pages/default.aspx
This document provides an introduction to pharmacoepidemiology. It defines pharmacoepidemiology as the study of drug use and effects in large populations. It discusses study designs used in pharmacoepidemiology including randomized trials, cohort studies, case-control studies, and case reports. Reasons for performing pharmacoepidemiology studies include fulfilling regulatory and legal obligations, assessing drug safety, and generating or testing hypotheses. Sources of data include spontaneous adverse event reporting, prescription databases, and electronic health records. The document also briefly discusses molecular pharmacoepidemiology, bioethics, pharmacoeconomics, and measuring quality of life outcomes.
Medication therapy is becoming increasingly more complex as new drugs are developed and more therapeutic targets are elucidated. In addition, polypharmacy (≥5 scheduled medications) has become exceedingly common in geriatric patients and in patients with chronic disease states. As the complexity of drug therapy and the number of medications increase, patients are at a high risk for medication errors and adverse drug events (ADEs), or injuries resulting from medication. The type of adverse events may be associated with professional practices, healthcare products, procedures, and systems including prescription, communication through instructions, drug labeling, packaging and nomenclature, reformulation, dissolution, distribution, administration, education, monitoring, and use. Classification and evaluation of medication errors according to their importance may constitute an important factor for process improvement in order to render the administration of medicines as safe as possible. In hospitals, medication errors occur at a rate of about one per patient per day. A dispensing error is one made by pharmacy staff when distributing medications to nursing units or directly to patients in an ambulatory-care pharmacy; the error rates for doses dispensed via the cart-filling process range from 0.87% to 2.9%. Technology has grown to be a constituent part of medicine these days. A few advantages that technology can supply are categorized as follows: the assisting of communication between clinicians; enhancing medication safety; decreasing potential medical errors and adverse events; rising access to medical information and encouraging patient-centered healthcare. The aim of this article is to provide a compendious literature review regarding Medication errors
Thesis_PhD_Improving medication safety in the elderlyHA VO THI
The document discusses medication safety issues for elderly patients, noting that physiological changes with aging increase their risk of adverse drug reactions and interactions from polypharmacy. Polypharmacy, defined as using multiple medications, is common in elderly patients due to multiple chronic conditions but can increase problems with adherence and side effects. Improving medication safety for elderly patients requires addressing polypharmacy issues through individualized treatment reviews that consider life expectancy, treatment goals and targets.
This document analyzes reporting of adverse drug reactions (ADRs) by pharmacists in the Pharmacovigilance Programme of India (PvPI) between July 2011 and December 2014. It finds that of 110,000 reports in the database, 16,646 (15%) were reported by pharmacists. Of these, 3,782 (22.7%) were serious reactions while 9,601 (57.7%) were non-serious. Reporting by pharmacists has increased over time. The document concludes that pharmacists can play an important role in pharmacovigilance by detecting, reporting, and assessing ADRs.
The document discusses pharmaceutical care, which aims to achieve the best possible outcomes for patients' quality of life through proper medication use. It defines pharmaceutical care as the responsible provision of drug therapy to achieve definite therapeutic outcomes that improve a patient's quality of life. Key aspects of pharmaceutical care include identifying and resolving actual and potential drug-related problems through monitoring medication appropriateness, effectiveness, and safety. The roles of pharmacists include collecting patient data, assessing medications, developing individualized care plans, implementing and monitoring care to evaluate outcomes and modify plans as needed.
The document discusses medication non-adherence, which is a major problem that impacts health and costs the healthcare system billions annually. It describes various technologies that have been developed to help patients better manage and adhere to their medication schedules, ranging from basic pillboxes and reminders to more advanced automated dispensers and sensors. The document recommends pilot studies be conducted to evaluate the real-world effectiveness of different medication adherence technologies in improving patient outcomes beyond standard discharge instructions alone.
Medication errors that occur during hospital admission can lead to preventable adverse drug events. This study uses a model to assess the costs and health effects of interventions aimed at reducing medication errors during admission reconciliation. The model estimates that all five interventions identified by a literature review are highly cost-effective compared to current practice. A pharmacist-led reconciliation intervention has the highest expected cost-effectiveness. The study concludes that medication reconciliation interventions provide a cost-effective use of healthcare resources to improve patient safety.
The Highs And Lows Of Opiate Managementguest2e3167
This document summarizes guidelines for prescribing opioids to manage chronic pain. It discusses the high prevalence and economic impact of chronic pain, as well as barriers physicians face in treating it. While opioids can provide pain relief, they carry risks of adverse effects, addiction, and overdose. The guidelines recommend developing a comprehensive treatment plan, trying non-opioid options first, carefully selecting and titrating opioid doses, monitoring patients for signs of misuse, and using treatment agreements to promote safe prescribing. The goal is to improve patients' function and quality of life while minimizing risks from long-term opioid therapy.
Knowledge and Perceptions Related to Hypertension, Lifestyle Behavior Modific...iosrjce
IOSR Journal of Nursing and health Science is ambitious to disseminate information and experience in education, practice and investigation between medicine, nursing and all the sciences involved in health care. Nursing & Health Sciences focuses on the international exchange of knowledge in nursing and health sciences. The journal publishes peer-reviewed papers on original research, education and clinical practice.
By encouraging scholars from around the world to share their knowledge and expertise, the journal aims to provide the reader with a deeper understanding of the lived experience of nursing and health sciences and the opportunity to enrich their own area of practice. The journal publishes original papers, reviews, special and general articles, case management etc.
Polypharmacy, defined as taking multiple medications, is common in the elderly population. Over half of people aged 65 and older take 5-9 medications, while 18% take 10 or more. The prevalence is higher in women due to longer lifespans and more frequent doctor visits. Polypharmacy can lead to adverse drug events, with risk exponentially increasing with more medications. Common signs include dizziness, confusion, and fatigue. Solutions include reducing unnecessary medications, simplifying dosing schedules, and increasing medication management support and provider education to curb this significant health issue in aging populations.
This document summarizes a study on the predictive characteristics of users of alternative medicine. The study found that 6.6% of patients surveyed had visited an alternative practitioner in the previous year. These patients tended to be of middle age, have chronic conditions, have a lower quality of life, greater anxiety and depression, and were heavier users of primary and secondary healthcare. Three factors - self-care and visiting specialists, changing primary doctors, and younger age - explained 66.2% of the variance in alternative medicine use. The conclusions indicate that seeking alternative medicine seems driven by patient characteristics but was not due to dissatisfaction with their primary doctor.
This document discusses medication errors, including their definition, causes, types, and strategies to prevent them. Some key points:
- Medication errors are preventable events that may cause harm and can occur at any stage from prescribing to administration. They are common but underreported.
- Errors are often due to look-alike or sound-alike drug names, miscommunication, lack of knowledge, and environmental factors like interruptions.
- Common types of errors include prescribing errors, dispensing errors, and administration errors. Analgesics, antibiotics, anticoagulants are high-risk drug classes.
- Prevention strategies include education, standardized processes, double checks, limiting distractions, clear
Medicamentos Potencialmente Inadecuados en personas mayoresSubDFarmacia
Este informe resume los hallazgos sobre la prescripción potencialmente inapropiada en ancianos. Identifica varios medicamentos potencialmente inapropiados como AINE, benzodiazepinas, antidepresivos y antihistamínicos anticolinérgicos. Además, analiza herramientas como los criterios Beers y STOPP/START para detectar este tipo de prescripciones y ofrece recomendaciones para mejorar la calidad de la atención a los ancianos.
The Patient Health Questionnaire (PHQ-9) is a 9-item instrument used to screen, diagnose, monitor, and measure the severity of depression. It asks how often over the last 2 weeks the patient has been bothered by 9 different problems, with response options ranging from "not at all" to "nearly every day." Scores of 5, 10, 15, and 20 represent cut-off points for mild, moderate, moderately severe, and severe depression, respectively. The PHQ-9 takes about 5 minutes to complete and can help providers determine appropriate treatment and monitor treatment response.
The PHQ-9 is a patient health questionnaire that consists of 9 questions to screen for depression. It asks how often over the last 2 weeks the patient has been bothered by problems such as little interest, feeling down, sleep issues, fatigue, appetite changes, feelings of failure, concentration difficulties, motor problems, and suicidal thoughts. The scores are added up to assess the severity of depression from minimal to severe. It can help diagnose major depressive disorder or other depressive disorder when answered in conjunction with a clinician's evaluation.
This document provides an overview of geriatrics and aging. It defines geriatrics as the care of aged people and notes it is a subspecialty of internal medicine focused on prevention and treatment of age-related disabilities. Key points include:
- Geriatrics aims to address common problems in old age like immobility, instability, intellectual impairment, incontinence, and multiple medical issues.
- Comprehensive Geriatric Assessment is a multidisciplinary approach to evaluate older patients' medical, psychological and functional status to maximize health and quality of life.
- Research seeks to understand aging processes to develop interventions that may slow or stop aging through approaches like modifying gene expression, repairing telomeres, or
The document discusses various topics related to geriatric pharmacology and medication use in elderly patients. It covers how aging affects drug absorption, distribution, metabolism, and excretion. It also discusses factors that can lead to polypharmacy in elderly patients and provides strategies to optimize pharmacotherapy and prevent inappropriate prescribing. Key criteria for evaluating potentially inappropriate medications in older adults, known as the Beers Criteria, are also summarized.
This document discusses polypharmacy in the elderly, defined as using more than 5 medications. It notes that polypharmacy prevalence increases with age, reaching 50% in those over 65. Consequences can include adverse drug reactions, reduced quality of life, and increased healthcare costs. Pharmacokinetic changes in aging like decreased liver and kidney function must be considered. The Beers Criteria provide guidance on inappropriate medications in elders. Interventions to reduce polypharmacy risk include regular medication reviews, educating patients, and using a personal health record.
U.S. Public Opinion on Health Care Reform, 2017KFF
The document summarizes polling data from the Kaiser Family Foundation on American priorities and opinions regarding health care:
- Lowering out-of-pocket costs for individuals is the top health care priority, followed by lowering prescription drug costs and dealing with opioid addiction. Priorities vary by political party.
- More of the public now views the Affordable Care Act (ACA) favorably compared to when it was signed in 2010, though opinions still differ by political party.
- Majority provisions of the ACA are viewed favorably by the public, though support differs between Democrats, independents, and Republicans.
- The public is divided on repealing the ACA, with a slight plurality supporting waiting until
CLINICAL INVESTIGATIONAmerican Geriatrics Society 2019 UpdWilheminaRossi174
CLINICAL INVESTIGATION
American Geriatrics Society 2019 Updated AGS Beers Criteria®
for Potentially Inappropriate Medication Use in Older Adults
By the 2019 American Geriatrics Society Beers Criteria® Update Expert Panel*
The American Geriatrics Society (AGS) Beers Criteria®
(AGS Beers Criteria®) for Potentially Inappropriate Medica-
tion (PIM) Use in Older Adults are widely used by clini-
cians, educators, researchers, healthcare administrators, and
regulators. Since 2011, the AGS has been the steward of the
criteria and has produced updates on a 3-year cycle. The
AGS Beers Criteria® is an explicit list of PIMs that are typi-
cally best avoided by older adults in most circumstances or
under specific situations, such as in certain diseases or con-
ditions. For the 2019 update, an interdisciplinary expert
panel reviewed the evidence published since the last update
(2015) to determine if new criteria should be added or if
existing criteria should be removed or undergo changes to
their recommendation, rationale, level of evidence, or
strength of recommendation. J Am Geriatr Soc 00:1–
21, 2019.
Key words: medications; drugs; older adults; Beers list;
Beers Criteria
The American Geriatrics Society (AGS) Beers Criteria
®
(AGS Beers Criteria®) for Potentially Inappropriate
Medication (PIM) Use in Older Adults are widely used by
clinicians, educators, researchers, healthcare administrators,
and regulators. Since 2011, the AGS has been the steward
of the criteria and has produced updates on a 3-year cycle
that began in 2012.1,2 The AGS Beers Criteria® are an
explicit list of PIMs that are typically best avoided by older
adults in most circumstances or under specific situations,
such as in certain diseases or conditions.
For the 2019 update, an interdisciplinary expert panel
reviewed the evidence published since the last update
(2015) to determine if new criteria should be added or if
existing criteria should be removed or undergo changes to
their recommendation, rationale, level of evidence, or
strength of recommendation. Each of the five types of cri-
teria in the 2015 update were retained in this 2019 update:
medications that are potentially inappropriate in most older
adults, those that should typically be avoided in older
adults with certain conditions, drugs to use with caution,
drug-drug interactions, and drug dose adjustment based on
kidney function.
OBJECTIVES
The specific aim was to update the 2015 AGS Beers Criteria®
using a comprehensive, systematic review and grading of the
evidence on drug-related problems and adverse events in
older adults. The strategies to achieve this aim were to:
• Incorporate new evidence on PIMs included in the 2015 AGS
Beers Criteria® and evidence regarding new criteria or modifi-
cations of existing criteria being considered for the 2019
update.
• Grade the strength and quality of each PIM statement based on
the level of evidence and strength of recommendation.
• Convene an interdisciplinary panel o ...
Ader et al (2015) The Medical Home and Integrated Behavioral Health Advancing...Ben Miller
This document discusses recommendations for advancing the integration of behavioral health and primary care. It recommends:
1. Building demonstration projects to test integrated care approaches and evaluate them using standardized measures.
2. Developing training programs for integrated care teams, which typically include the patient, primary care provider, behavioral health specialist, and care manager.
3. Implementing population-based strategies to improve behavioral health and strengthen relationships between practices and community resources.
FINAL MSmith_ Medn Measures that Matter_ AJPB_Jan-Feb 2015Marie Smith, PharmD
This document discusses the need for new quality measures that assess medication management across care settings and providers. It notes that while current measures address prescribing and adherence, they do not address optimization, coordination of medications prescribed by multiple providers, or medication management during care transitions. The document advocates developing measures that close these gaps, such as those assessing comprehensive medication reviews, reconciliation of medication lists during care transitions, and development of patient medication action plans. It provides examples of how measures could be organized into families and sets that cut across conditions and specialties to promote coordination and alignment of quality measurement.
The document discusses a report from the NGA that acknowledges pharmacists' scope of practice is restricted by state laws and encourages classifying pharmacists as health care providers to maximize pharmacy services. It summarizes that the report encourages states and private entities to expand what pharmacist services are covered by insurance, state employee health plans, health information exchanges, and Medicaid to allow pharmacists to practice at the full extent of their training.
What quality measures does the MCO have in placeSolutionManag.pdfformicreation
What quality measures does the MCO have in place?
Solution
Managed care organizations (MCOs) are responsible for ensuring that persons enrolled in their
plans receive quality health care. In addition, MCOs publicly funded through the Medicare and
Medicaid programs are required by State and Federal governments to meet certain quality
standards.
To fulfill their responsibilities, MCOs need ready access to a comprehensive array of evidence-
based clinical information and other clinical performance measures to enable them to evaluate
their providers\' performance and identify areas where improvement is needed. They also need to
know how their members feel about the care they receive and the way they are treated. Finally,
they need to ensure that both their providers and members are aware of the most recent
preventive care recommendations.
Valid, reliable, and cost-effective measurement tools must be available to make such
determinations, but these tools have not always been available. Furthermore, because the science
of performance measurement is relatively new, additional measures need to be developed and
those that have been developed can be improved. Therefore, to ensure that their enrollees in
MCOs receive high-quality care, MCOs need a reliable source to provide the most current and
scientifically sound tools.
In response to this need, the Agency for Healthcare Research and Quality (AHRQ) has funded
research to compile a database of evidence-based clinical guidelines and to develop clinical
performance measures, member satisfaction surveys, and preventive care recommendations that
can help MCOs meet their responsibilities. Additionally, AHRQ funds research and develops
performance measures and guidelines that MCOs, insurers, providers, and consumers can trust.
This report describes these tools and how they have been used and provides information on
where to learn more about them.
Background
Around one-half of insured Americans are enrolled in some form of managed care. However, as
the number of persons enrolled in MCOs increased in the 1990s, health care purchasers,
policymakers, and other stakeholders became concerned about the potential for health care
quality to diminish. In their view, the policies and practices imposed by MCOs to reduce what
MCOs define as unnecessary care might result in patients not receiving needed care. Therefore,
MCOs faced accreditation systems and other requirements to ensure that patients were receiving
the most appropriate care.
More recently, MCOs have had to address other emerging concerns such as: Rapid introduction
of new technologies, Data showing unexplained variations in the provision of care, Severe cost
pressures.
These factors have provided additional motivation to MCOs to develop systematic ways of
preserving and enhancing health care quality and cost-effectiveness.
Evidence-based practice guidelines and performance measures were developed to help ensure
that patients always receive the most appropri.
Diabetes Management Policy Proposal
Miatta Teasley
Capella University
NHS-FPX6004 Health Care Law and Policy
Professor Georgena Wiley
May 19, 2022
Click to edit Master title style
Click to edit Master title style
Hello and welcome to today's presentation on drug error regulatory policy proposals. This presentation is intended to provide you, your stakeholders, with all pertinent information regarding the need for an institutional policy to reduce medication errors in medical centers. We will also go over the scope of the recommendations, strategies for addressing medication errors, and stakeholder involvement in putting these strategies into action.
Policy Proposal
Diabetes Management
2
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Click to edit Master title style
This proposal revolves around creating and implementing strategies that will help Med’s caregivers be able to improve on patient care regarding diabetes.
Presentation Outline
Policy on Managing Medication Errors
Need for a Policy
Scope of Policy
Strategies to Resolve Mediation Errors
Role of the Hospital Staff
Positive impact on Working Conditions
Issues in the Application of Strategies
Alterative Perspectives on Mitigating Medication Errors
Stakeholder Participation
3
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Click to edit Master title style
The presentation highlights key functions in any policy implementation process. The steps this presentation takes appear in the order as indicated here. We will start y looking at
Policy on Managing Medication Errors then
Need for a Policy followed by
Strategies to Resolve Mediation Errors. Then the
Role of the Hospital Staff and the
Positive impact on Working Conditions. Also, we will look at
Issues in the Application of Strategies and the
Alterative Perspectives on Mitigating Medication Errors and finally,
Stakeholder Participation
Policy on Managing Medication Errors
4
Health practitioners should create and advance engaging policies
Many Healthcare departments require modernization
Healthcare policies should be adjusted to meet defined benchmarks
Key stakeholders are vital for successful implementation of proposed policies
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Click to edit Master title style
When advocating for organizational regulation changes about federal, state, or local health care guidelines or rules and regulations, healthcare practitioners should be able to create and advance an engaging and logical policy and guideline parameters that will provide a segment, a group, or an entire institution to correct and shed light on issues of accomplishment and execute developments in the quality and safety of medical management.
Despite being recognized as one of the greatest health insurance carriers for people over 65, several departments need to be modernized. The most pr.
The document discusses recommendations for comprehensive medical evaluation and assessment of comorbidities for diabetes care. It recommends that the initial evaluation confirm the diabetes diagnosis and classification, evaluate for complications and comorbidities, and engage the patient in care planning. Follow-up visits should assess treatment adherence, attainment of health targets, risk for complications, and self-management behaviors. Ongoing management is guided by assessing complications and setting therapeutic goals through shared decision-making.
Geriatric Assessment in Older Patients with Acute Myelogenous Leukemia: Treat...Carevive
Acute myelogenous leukemia (AML) primarily affects older adults with a median age of 67 years. Traditionally, older patients have not received intensive chemotherapy due to toxicity risks, but current research shows fit older patients who receive intensive chemotherapy have better outcomes than those who receive no treatment. Geriatric assessments are critical for determining treatment for older AML patients, as frailty is associated with poorer responses and survival. Assessments evaluate factors like activities of daily living, comorbidities, cognition, and quality of life. While comprehensive geriatric assessments are optimal, several screening tools can help hematologists evaluate fitness when determining AML treatment for older patients.
Clearing the Error: Patient Participation in Reducing Diagnostic ErrorJefferson Center
To generate new, patient-centered insights into diagnostic error, we convened diverse groups in public deliberation to recommend and evaluate actions that patients and/or their advocates would be willing and able to perform to improve diagnostic quality.
This study evaluated a comprehensive diabetes management program within a managed care organization that included risk stratification of patients and social marketing approaches. Over 12 months, the program resulted in improved glycemic control as measured by an increase in the number of patients in the low-risk HbA1c category. The majority of high-risk patients had changes made to their treatment regimens. Other clinical measures like blood pressure and LDL cholesterol also improved. Patients and providers reported greater satisfaction with the program. The risk stratification and intervention approach was successful in initiating recommended treatment changes and improving diabetes outcomes and satisfaction.
This study examined the effects of a pay-for-performance program implemented by a leading health insurer in Washington State between 2003 and 2007 that involved quality scorecards, public reporting, and financial incentives for medical groups. The researchers found that neither the scorecard nor the incentive program had a significant positive effect on clinical quality. Specifically, the addition of incentives to the scorecard was associated with a reduction in quality, contrary to the program's goals. The researchers believe the modest incentive amounts, use of rewards only with no penalties, and targeting of groups instead of individuals helped weaken the program's effects. The study contributes to understanding the challenges of achieving successful pay-for-performance.
Cpg management of type 2 diabetes mellitus (5th edition) special afes congres...Ibn Abdullah
This document provides a summary of the Clinical Practice Guidelines (CPG) on Management of Type 2 Diabetes Mellitus (5th Edition). It outlines the guideline development process, objectives, target population and groups. Key changes from previous editions include the addition of 11 new chapters covering topics such as use of A1c for screening/diagnosis and algorithms for patient follow-up and specific profiles. The document establishes A1c 6.5% or less as the main clinical indicator for quality management.
This document provides an overview of the process and methods used to develop recommendations for the testing, management, and treatment of hepatitis C virus (HCV) infection. A panel of HCV experts from various medical fields develops the guidance using an evidence-based approach. Recommendations are rated based on the strength of evidence. The guidance is intended to be a living document that is regularly updated as new treatments and information become available. Strict processes are in place to manage conflicts of interest among panel members.
The document discusses various topics related to physical therapy (PT) practice. It notes that in 2014, PTs can avoid PQRS penalties by reporting 3 quality measures for 50% of patients, and the number of measures required to receive bonuses will increase from 3 to 9. It also eliminates reporting via measures groups through claims. The document discusses focusing on developing quality measures for PT, payment models that promote value, and public policy initiatives to advance the role of PT in areas like disease management. It also discusses improving access, eliminating self-referral profits, and ensuring an adequate PT workforce.
This document discusses appropriate versus cost-driven approaches to utilization management of medications. It notes that cost-driven practices like prescription limits, therapeutic substitution, cost-sharing, and fail-first policies can negatively impact patients' health and increase overall costs. Alternatively, utilization management programs that promote high-value care through improved patient outcomes, like prescriber feedback, prescription case management, retrospective drug review, and value-based insurance design, can enhance quality of care while proving cost-effective. The summary concludes that for individuals with mental health conditions, appropriate pharmacy policies are important to support treatment and avoid risks to patient well-being.
The document discusses perceptions of value and relationships among biopharmaceutical stakeholders. It finds that key stakeholders have different definitions of "value" in healthcare, with outcomes being a more important part of biopharma executives' definitions compared to other groups. Physicians are widely perceived as adding the most value to healthcare. While stakeholders generally agree on the benefits of prescription medications, managed care executives are less convinced of patients' spending on medications being worth it. The document also examines stakeholders' perceptions of each other's effectiveness in areas like patient education and understanding needs. Most groups feel patients can do more to improve health behaviors and outcomes.
This document discusses prescription auditing as a way to promote rational drug use and improve patient care. It defines rational drug use as using the right drug, at the right dosage and cost to meet a patient's clinical needs. Prescription auditing involves collecting data on current prescribing practices and comparing it to standards to identify areas for improvement. The audit cycle involves defining standards, collecting data, identifying issues, implementing changes, and defining new standards. Prescription audits can help ensure appropriate drug therapy, control costs, prevent medication problems, evaluate effectiveness, and identify needs for practitioner education.
V O L U M E 3 4 - N U M B E R 4 - F A L L 2 0 1 6 187FEATURE ART.docxkdennis3
V O L U M E 3 4 , N U M B E R 4 , F A L L 2 0 1 6 187
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Nurse Practitioner Perceptions of a Diabetes Risk Assessment Tool in the Retail Clinic Setting Kristen L. Marjama, JoAnn S. Oliver, and Jennifer Hayes
Diabetes is the seventh leading cause of death in the United States, burdening society with
high costs for treatment and placing increased demand on the health care system (1). According to the 2014 National Diabetes Statistics Report, an estimated 29.1 million people in the United States have diabetes, and 8.1 million of them are undiagnosed (2). The lack of screening for early identification of patients at risk for type 2 diabetes is a significant clin- ical problem. Health care providers (HCPs) need to be aware of the in- creasing diabetes burden and to pri- oritize the screening of patients who may be at risk. Screening for risk can aid in both efforts to prevent the development of diabetes and early management of the disease to reduce complications. Clinical trials have demonstrated that type 2 diabetes can be delayed or prevented through life- style modification or pharmacother- apy for people at increased risk (3).
In order to reduce risk for those at risk of developing diabetes, screen- ing is a priority that will raise patient
awareness. Many patients are not aware of their risk for type 2 dia- betes until they receive a confirmed diagnosis from their HCP. There are numerous health care settings in which screenings can be imple- mented, including but not limited to primary care practices, urgent care centers, hospital emergency depart- ments, and retail health clinics.
Retail clinics are located in retail supermarket and pharmacy chains to provide high-quality, affordable, and easily accessible health care services for communities. A true measure of quality in retail clinics is their degree of adherence to several measures iden- tified in the Healthcare Effectiveness Data and Information Set (4). Services in this type of setting may include treatment of acute episodic conditions, physical examinations, vaccinations, health screenings, and prevention and management of chronic conditions (5). Retail clinics provide services to patients with or without insurance or a primary care “home.†Patients’ visits to a retail clinic afford the opportunity to assess
■IN BRIEF This article describes a study to gain insight into the utility and perceived feasibility of the American Diabetes Association’s Diabetes Risk Test (DRT) implemented by nurse practitioners (NPs) in the retail clinic setting. The DRT is intended for those without a known risk for diabetes. Researchers invited 1,097 NPs working in the retail clinics of a nationwide company to participate voluntarily in an online questionnaire. Of the 248 NPs who sent in complete responses, 114 (46%) indicated that they used the DRT in the clinic. Overall mean responses from these NPs indicated that they perceive the DRT as a feasible tool in the retail cli.
Best practices for cardiovascular disease prevention programs tssuser454af01
The document discusses 8 strategies for lowering blood pressure and cholesterol levels, including medication therapy management (MTM) provided by pharmacists. It provides examples of MTM programs in Ohio and Nebraska that led to improved hypertension control. MTM includes medication reviews, action plans, interventions, and follow-up. Clinical decision support systems (CDSS) provide prompts to help providers follow clinical guidelines and flag issues like uncontrolled hypertension. An example from a Nebraska clinic demonstrated improved workflow and quality measures through increased EHR and CDSS use.
Adhd Medication Shortage Uk - trinexpharmacy.comreignlana06
The UK is currently facing a Adhd Medication Shortage Uk, which has left many patients and their families grappling with uncertainty and frustration. ADHD, or Attention Deficit Hyperactivity Disorder, is a chronic condition that requires consistent medication to manage effectively. This shortage has highlighted the critical role these medications play in the daily lives of those affected by ADHD. Contact : +1 (747) 209 – 3649 E-mail : sales@trinexpharmacy.com
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
One health condition that is becoming more common day by day is diabetes.
According to research conducted by the National Family Health Survey of India, diabetic cases show a projection which might increase to 10.4% by 2030.
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Our backs are like superheroes, holding us up and helping us move around. But sometimes, even superheroes can get hurt. That’s where slip discs come in.
These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
2. grading to reach consensus on the updated 2015 AGS
Beers Criteria.
• Incorporate needed exceptions in the criteria as the
panel deemed clinically appropriate. These exceptions
would 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 is
practicing clinicians. The criteria are intended for use in all
ambulatory, acute, and institutionalized settings of care for
populations aged 65 and older in the United States, with the
exception of hospice and palliative care. Consumers,
researchers, pharmacy benefits managers, regulators, and
policymakers also widely use the AGS Beers Criteria. The
intentions of the criteria are to: improve medication selec-
tion; educate clinicians and patients; reduce adverse drug
events; 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 to
be improving the care of older adults by reducing their
exposure to PIMs. This is accomplished by using the criteria
as an educational tool and quality measure—two uses that
are not always in agreement. These criteria are not meant to
be applied in a punitive manner. Prescribing decisions are
not always clear-cut, and clinicians must consider multiple
factors, including discontinuation of medications no longer
indicated. Quality measures must be clearly defined, easily
applied, and measured with limited information and thus,
although useful, cannot perfectly distinguish appropriate
from inappropriate care. The panel considered and vigor-
ously discussed both roles during deliberations. The panel’s
review of evidence at times identified subgroups of individu-
als who should be exempt from a given criterion or to
whom a specific criterion should apply. Such a criterion
may not be easily applied as a quality measure, particularly
when such subgroups cannot be easily identified through
structured and readily accessible electronic health data. In
these cases, the panel felt that a criterion should not be
expanded to include all adults aged 65 and older when only
certain subgroups have an adverse balance of benefits versus
harms for the medication or conversely may be appropriate
candidates for a medication that is otherwise problematic.
Despite past and current efforts to translate the crite-
ria into practice, some controversy and myths about their
use in practice and policy continue to prevail. The panel
addressed these concerns and myths by writing a compan-
ion piece to the updated criteria to address the best way
for patients, providers, and health systems to use (and not
use) the 2015 AGS Beers Criteria. Alternative suggestions
to medications included in the current Use of High-Risk
Medications in the Elderly and Potentially Harmful Drug-
Disease Interactions in the Elderly quality measures are
presented in another companion paper. Both papers will
be published online in this journal.
METHODS
For this new update, the AGS employed a well-tested
framework that has long been used for development of
clinical practice guidelines.6,7
Specifically, the framework
involved the appointment of a 13-member interdisciplinary
expert panel with relevant clinical expertise and experience
and an understanding of how the criteria have been previ-
ously used. This framework also involved a development
process that included a systematic literature review and
evaluation 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 three
framework 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 new
members. Other factors that influenced selection of panel
members were the desire to have interdisciplinary represen-
tation, a range of medical expertise, and representation
from 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, representatives
from the Centers for Medicare and Medicaid Services,
National Committee for Quality Assurance, and Pharmacy
Quality Alliance were invited to serve as ex-officio mem-
bers.
Each expert panel member completed a disclosure
form at the beginning of the guideline process that was
shared with the entire panel at the start of each panel
meeting and call. Panel members who disclosed affiliations
or financial interests with commercial entities are listed in
the disclosures section of this article. Panel members were
asked to recuse themselves from discussions if they had a
potential 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 studies
that were relevant to the project. The initial literature
search was conducted on PubMed and the Cochrane
Library. The drugs, drug classes, and conditions included
in the 2012 criteria were used as initial search terms and
were generally focused on “adverse drug events” and “ad-
verse drug reactions.” Individual drugs, drug classes, and
conditions 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 included
for initial screening as potential background information
and for reference list review. The initial searches identified
20,748 citations, of which 6,719 were selected for prelimi-
nary abstract review. The panel co-chairs reviewed 3,387
citations and abstracts, of which 2,199 were excluded for
not meeting the study purpose or not containing primary
data. At the time of the panel’s face-to-face meeting, the
co-chairs had selected 1,188 unduplicated citations for the
full panel review. Subsequent searches (defined by panel
workgroups) were conducted until December 15, 2014;
2228 AGS 2015 BEERS CRITERIA UPDATE EXPERT PANEL NOVEMBER 2015–VOL. 63, NO. 11 JAGS
3. some of these searches included studies published in the
prior 10 years. The AGS also gave its members and mem-
bers of the public a chance to submit evidence they felt the
panel should consider. Any evidence submitted had to be
evidence based and published in a peer-reviewed journal.
Panel members reviewed abstracts, and evidence tables
were developed for 342 studies, including 60 systematic
reviews 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 group
to monitor the literature and to advise the 2015 expert
panel of any articles relevant to the 2012 criteria and
respond 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 other
expert members of AGS. The 2015 expert panel convened
for a 2-day in-person meeting on July 28–29, 2014, to
review the groups’ findings and the results of the litera-
ture search. Panel discussions were used to define terms
and to address questions of consistency, inclusion of infre-
quently used drugs, strategies for evaluating the evidence,
consolidation or expansion of individual criterion, and
development of renal dosage and drug–drug interaction
tables. The panel then split into four groups, with each
assigned a specific set of criteria for evaluation. Groups
were assigned as closely as possible according to specific
area of clinical expertise (e.g., cardiovascular, central ner-
vous system). Groups reviewed the literature search,
selected citations relevant to their assigned criteria, and
determined which citations they wanted to see the full-
text article for and which should be abstracted into an
evidence table. The groups then presented their findings
to the full panel for comment and consensus. After the
meeting, each group participated in a series of conference
calls to continue the literature selection process and
resolve any questions.
An independent researcher led the effort to prepare
evidence tables and relied on the assistance of one other
researcher for the initial drafts of evidence tables. The evi-
dence tables included a summary of the study, as well as a
quality rating and rating of the risk of bias for selected
articles. The quality rating system was based on the
Cochrane Risk of Bias8
and Jadad scoring system.9
The
ratings were based on six critical elements: evidence of bal-
anced allocation, allocation concealment, blinded outcome
assessment, completeness of outcome data, selective out-
come reporting, and other sources of bias. Following the
Cochrane approach, each article was assigned a quality
score (1–6 points) and a risk-of-bias rating. Low risk of
bias was indicated by a low risk of bias in all six domains,
unclear risk of bias was indicated by an unclear rating on
one or more domains (others low) or a high risk of bias
on one domain (others low or unclear), and high risk of
bias was indicated by a high risk of bias on two or more
domains. The independent researcher reviewed all evidence
tables and proposed quality and risk-of-bias ratings before
they were distributed to the expert panel to use for the
Grades of Recommendation Assessment, Development,
and Evaluation10
(GRADE) rating process.
Each panelist independently rated the quality of evi-
dence and strength of recommendation for each criterion
using the American College of Physicians’ Guideline Grad-
ing System11
(Table 1), which is based on the GRADE
scheme developed previously. AGS staff compiled the pan-
elist ratings for each group and returned them to that
group, 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 panel
reviewed the ratings and worked through any differences
until consensus was reached. The panel judged each crite-
rion as being a strong or weak recommendation on the
basis of the quality of supporting evidence, the frequency
and 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 harm
was substantial and safer or more-effective alternatives
were available.
After consensus was reached within the expert panel,
the updated guidelines were circulated for peer review to
relevant organizations and societies and posted to the AGS
website for public comment. Organizations that partici-
pated in peer review are listed in the Acknowledgments
section of this article. The panel reviewed and addressed
all comments.
Table 1. Designations of Quality of Evidence and
Strength of Recommendations
Quality of Evidence
High Evidence includes consistent results from well-
designed, well-conducted studies in representative
populations that directly assess effects on health
outcomes (≥2 consistent, higher-quality randomized
controlled trials or multiple, consistent observational
studies with no significant methodological flaws
showing large effects)
Moderate Evidence is sufficient to determine risks of adverse
outcomes, but the number, quality, size, or consistency
of included studies; generalizability to routine practice;
or indirect nature of the evidence on health outcomes
(≥1 higher-quality trial with >100 participants; ≥2
higher-quality trials with some inconsistency; ≥2
consistent, lower-quality trials; or multiple, consistent
observational studies with no significant
methodological flaws showing at least moderate
effects) limits the strength of the evidence
Low Evidence is insufficient to assess harms or risks in
health outcomes because of limited number or power
of studies, large and unexplained inconsistency
between higher-quality studies, important flaws in
study design or conduct, gaps in the chain of evidence,
or lack of information on important health outcomes
Strength of Recommendation
Strong Benefits clearly outweigh harms, adverse events, and
risks, or harms, adverse events, and risks clearly
outweigh benefits
Weak Benefits may not outweigh harms, adverse events,
and risks
Insufficient Evidence inadequate to determine net harms, adverse
events, and risks
Adapted from11
.
JAGS NOVEMBER 2015–VOL. 63, NO. 11 2015 AGS UPDATED BEERS CRITERIA 2229
4. 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 the
AGS website (www.americangeriatrics.org). Consistent
with the 2012 AGS Beers Criteria, Tables 2–4 list PIMS
for older adults outside the palliative care and hospice
setting, including medications to avoid for many or most
older adults (Table 2); medications for older adults with
specific diseases or syndromes to avoid (Table 3); and
medications to be used with caution (Table 4). New to
the AGS Beers Criteria are potentially clinically impor-
tant non-anti-infective drug–drug interactions (Table 5)
and non-anti-infective medications to avoid or the
dosage of which should be adjusted based on the indi-
vidual’s kidney function (Table 6). Tables 8-10 document
the differences between the 2012 and 2015 AGS Beers
Criteria.
Noteworthy Changes to PIMs and Older Adults
Based on two retrospective studies, the recommendation to
avoid the anti-infective nitrofurantoin in individuals with a
creatinine clearance of less than 60 mL/min has been
revised, given evidence that it can be used with relative
safety 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 because
of 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 outcomes
as 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 for
atrial fibrillation unless the individual has heart failure or
substantial left ventricular hypertrophy. Dronedarone is to
be avoided in individuals with permanent atrial fibrillation
or with severe or recently decompensated heart failure.
Disopyramide, a Class 1a antiarrhythmic drug, should also
be avoided because it is highly anticholinergic. Digoxin
should be avoided as first-line therapy for atrial fibrillation
or heart failure and should not be prescribed in daily doses
greater than 0.125 mg for any indication.
The nonbenzodiazepine, benzodiazepine receptor ago-
nist hypnotics (eszopiclone, zaleplon, zolpidem) are to be
avoided without consideration of duration of use because
of their association with harms balanced with their mini-
mal efficacy in treating insomnia. The recommendation to
avoid 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 use
of proton-pump inhibitors beyond 8 weeks without justifi-
cation. Multiple studies and five systematic reviews and
meta-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 addition
because of the high risk of hyponatremia.
Noteworthy Changes to Drug–Disease and Drug–
Syndrome PIMS
The nonbenzodiazepine, benzodiazepine receptor agonist
hypnotics have been added to the list of drugs to avoid in
individuals with dementia or cognitive impairment. Opi-
oids have been added to the list of central nervous system
(CNS) medications that should be avoided in individuals
with a history of falls or fractures. Antipsychotics are to
be avoided as first-line treatment of delirium because of
conflicting evidence on their effectiveness and the potential
for adverse drug effects (Table 3).
Drugs to Be Used with Caution
Table 4, medications to be used with caution in older
adults, has not been changed. The panel determined that
the medications listed in this table did not rise to the level
of meriting inclusion in Tables 2 and 3 and should not be
considered key elements of the criteria. Nevertheless, the
panel believed that there was sufficient uncertainty or con-
cern about the balance of benefits and harms for the listed
medications that clinicians should be aware of potential
problems 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 with
harmful outcomes in older adults.12
The list is selective,
and not comprehensive, and is not intended to diminish
the clinical importance of known drug–drug interactions
not listed. Examples of drug–drug interactions included in
this new section include peripheral alpha-1 blockers used
in combination with loop diuretics, which increases the
risk of urinary incontinence in women, and taking three or
more CNS-active drugs concomitantly, which increases the
risk of falls. Other interactions manifest as extensions of
both drugs’ known pharmacological effects (e.g., angioten-
sin-converting enzyme inhibitors (ACEIs) and potassium-
sparing diuretics without indications for use in systolic
heart failure (amiloride and triamterene), which together
increase risk of hyperkalemia). Other interactions increase
the risk of a drug’s toxicity (e.g., lithium in combination
with an ACEI or loop diuretics) (Table 5).
PIMs Based on Kidney Function
Also new for 2015 are drugs that should be avoided or for
which the dose should be adjusted in individuals with a
specific degree of kidney impairment to avoid harm. This
list was adapted from published consensus guidelines that
an expert group including two AGS Beers Criteria pan-
elists developed.13
The AGS Beers panel reviewed the evi-
dence and selected medications from these earlier
consensus guidelines for inclusion; added additional medi-
cations, including several anticoagulants; and included
spironolactone and triamterene, which in the 2012 criteria
had 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 on
clinical trial exclusion criteria and may not be the same as
2230 AGS 2015 BEERS CRITERIA UPDATE EXPERT PANEL NOVEMBER 2015–VOL. 63, NO. 11 JAGS
14. those in their labeling. As with the drug–drug interaction
table, this list is not meant to be comprehensive but to
highlight potentially important but sometimes overlooked
dose adjustments that are of particular concern for older
adults. Anti-infective drugs were not included because the
focus of the AGS Beers Criteria is on medications often
employed for chronic use and because such information is
available 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 draft
Table 7, which provides an updated list of drugs with
strong anticholinergic properties.14–17
Investigators who
developed the scales that the panel used in 2012 were asked
whether any changes had been made, and the panel consid-
ered those. The most notable drug to be removed from the
list was the second-generation antihistamine loratadine.
DISCUSSION
The 2015 AGS Beers Criteria for PIMs is the second such
update 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 first
published in 1991, making them the longest-running crite-
ria for PIMs in older adults. The process improves with
each update. The literature search has become more tar-
geted and refined, identifying new and important support-
ing evidence. The evidence review and grading
methodology has been adjusted according to best practices
and evolving approaches recommended by expert organi-
zations. As in 2012, this resulted in some changes to the
criteria in 2015, including drugs that were modified or
dropped and a few new additions. The 2015 update intro-
duced two new areas to improve drug safety in older
adults: 1) drugs for which dose adjustment is required
based on kidney impairment and 2) drug–drug interac-
tions. Rather than create numerous individual caveats for
each criterion excluding individuals in palliative care or
hospice settings, the panel chose to exclude individuals in
these settings from the criteria. The panel felt justified
making this decision because of the shift in benefit-to-harm
ratio 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 has
fewer changes and new medications, likely because of the
Table 4. 2015 American Geriatrics Society Beers Criteria for Potentially Inappropriate Medications to Be Used
with Caution in Older Adults
Drug(s) Rationale Recommendation
Quality of
Evidence
Strength of
Recommendation
Aspirin for primary prevention of
cardiac events
Lack of evidence of benefit versus
risk in adults aged ≥80
Use with caution in adults aged
≥80
Low Strong
Dabigatran Increased risk of gastrointestinal
bleeding compared with warfarin
and reported rates with other
target-specific oral anticoagulants
in adults aged ≥75; lack of
evidence of efficacy and safety in
individuals 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 older
adults; benefit in highest-risk older
adults (e.g., those with prior
myocardial infarction or diabetes
mellitus) may offset risk
Use with caution in adults aged
≥75
Moderate Weak
Antipsychotics
Diuretics
Carbamazepine
Carboplatin
Cyclophosphamide
Cisplatin
Mirtazapine
Oxcarbazepine
SNRIs
SSRIs
TCAs
Vincristine
May exacerbate or cause
syndrome of inappropriate
antidiuretic hormone secretion or
hyponatremia; monitor sodium
level closely when starting or
changing dosages in older adults
Use with caution Moderate Strong
Vasodilators May exacerbate episodes of
syncope in individuals with history
of 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.
2240 AGS 2015 BEERS CRITERIA UPDATE EXPERT PANEL NOVEMBER 2015–VOL. 63, NO. 11 JAGS
15. shorter time span since the criteria were last revised. Only
three new medications and two new drug classes were
added to Tables 2 or 3, although several were modified or
had some changes to the rationale and recommendation
statements. In a few instances, the level of evidence was
revised based on new literature and the improved modified
grading methodology. Some notable changes were the 90-
day-use caveat being removed from nonbenzodiazepine,
benzodiazepine receptor agonist hypnotics, resulting in an
unambiguous “avoid” statement (without caveats) because
of the increase in the evidence of harm in this area since
the 2012 update.22,23
In some cases, the rationale or word-
ing of an avoid statement was modified or clarified because
the panel and AGS had received comments regarding some
confusion about a medication in the criteria. For example,
the term “sliding scale” insulin was defined more clearly
when referred to in the criteria. Other changes included
lowering the creatinine clearance at which nitrofurantoin
should be avoided to less than 30 mL/min from less than
60 mL/min. Also, removing Classes 1a, 1c, and III (with
the exception of amiodarone) antiarrhythmic drugs as first-
line treatment for atrial fibrillation. Constipation was
removed as a drug–disease, drug–syndrome category,
because this condition is common across the age spectrum
and relevant drug–disease, drug–syndrome combinations to
avoid are not predominantly specific to older adults.
Some other important additions in the 2015 update
were the addition of long-term proton-pump inhibitor use
in the absence of a strong indication because of risk of
C. difficile infection, bone loss, and fractures and the addi-
tion of opioids in the diagnosis and condition table for
older adults with a history of falls and fractures. If opioids
must be used, it is recommended that reducing the use of
other CNS-active medications be considered.24,25
This
statement is in recognition of the need to have adequate
pain control while balancing the potential harms from opi-
oids and untreated pain. The panel balanced the difficulty
and challenges of poorly treated pain with the harms of
opioids and available alternatives in older adults. Another
critical change was to the language for use of antipsy-
Table 5. 2015 American Geriatrics Society Beers Criteria for Potentially Clinically Important Non-Anti-infective
Drug–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 or
triamterene
Increased risk of
Hyperkalemia
Avoid routine use; reserve for
patients with demonstrated
hypokalemia while taking an ACEI
Moderate Strong
Anticholinergic Anticholinergic Increased risk of
Cognitive decline
Avoid, minimize number of
anticholinergic drugs (Table 7)
Moderate Strong
Antidepressants (i.e.,
TCAs and SSRIs)
≥2 other CNS-active
drugsa
Increased risk of Falls Avoid total of ≥3 CNS-active
drugsa
; minimize number of CNS-
active drugs
Moderate Strong
Antipsychotics ≥2 other CNS-active
drugsa
Increased risk of Falls Avoid total of ≥3 CNS-active
drugsa
; minimize number of CNS-
active drugs
Moderate Strong
Benzodiazepines and
nonbenzodiazepine,
benzodiazepine receptor
agonist hypnotics
≥2 other CNS-active
drugsa
Increased risk of Falls
and fractures
Avoid total of ≥3 CNS-active
drugsa
; minimize number of CNS-
active drugs
High Strong
Corticosteroids, oral or
parenteral
NSAIDs Increased risk of Peptic
ulcer disease or
gastrointestinal bleeding
Avoid; if not possible, provide
gastrointestinal protection
Moderate Strong
Lithium ACEIs Increased risk of
Lithium toxicity
Avoid, monitor lithium
concentrations
Moderate Strong
Lithium Loop diuretics Increased risk of
Lithium toxicity
Avoid, monitor lithium
concentrations
Moderate Strong
Opioid receptor agonist
analgesics
≥2 other CNS-active
drugsa
Increased risk of Falls Avoid total of ≥3 CNS-active
drugsa
; minimize number of CNS
drugs
High Strong
Peripheral Alpha-1
blockers
Loop diuretics Increased risk of
Urinary incontinence in
older women
Avoid in older women, unless
conditions warrant both drugs
Moderate Strong
Theophylline Cimetidine Increased risk of
Theophylline toxicity
Avoid Moderate Strong
Warfarin Amiodarone Increased risk of
Bleeding
Avoid when possible; monitor
international normalized ratio
closely
Moderate Strong
Warfarin NSAIDs Increased risk of
Bleeding
Avoid when possible; if used
together, monitor for bleeding
closely
High Strong
a
Central 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.
JAGS NOVEMBER 2015–VOL. 63, NO. 11 2015 AGS UPDATED BEERS CRITERIA 2241
16. 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 effectiveness
in delirium and dementia, the rationale to avoid was modi-
fied to “avoid antipsychotics for behavioral problems
unless nonpharmacological options (e.g., behavioral inter-
ventions) have failed or are not possible, and the older
adult is threatening substantial harm to self or others.”7
The table of medications with strong anticholinergic
properties has been updated. Anticholinergic burden and
measurement is an area of literature that is continually
evolving. Use of anticholinergic medications remains a
concern because it is associated with impaired cognitive
and physical function and risk of dementia.29,30
These criteria continue to be useful and necessary as a
clinical and public health tool to improve medication
safety in older adults and to increase awareness of
polypharmacy and aid decision-making for choosing drugs
to 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, Health
Systems, and Payors, published online in this journal.
Recent work illustrates that prescription drug use has
increased in older adults over the past 20 years, with
poorer 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 in
2009–10 according to the 2012 AGS Beers Criteria. Even
though the rate of PIM use declined from 45.5% in 2006–
07 to 40.8% in 2009–10, almost half of older adults still
filled a PIM presecription.32
Despite their potential to
increase 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 to
avoid in older adults, but they are not meant to override
clinical judgment or an individual’s preferences, values,
and needs. There may be cases in which the healthcare
provider determines that a drug on the list is the only rea-
sonable alternative or the individual is at the end of life or
receiving palliative care. The criteria were developed in a
Table 6. 2015 American Geriatrics Society Beers Criteria for Non-Anti-Infective Medications That Should Be
Avoided 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 hemostasis
Amiloride <30 Increased potassium, and
decreased sodium
Avoid Moderate Strong
Apixaban <25 Increased risk of bleeding Avoid Moderate Strong
Dabigatran <30 Increased risk of bleeding Avoid Moderate Strong
Edoxaban 30–50 Increased risk of bleeding Reduce dose Moderate Strong
<30 or >95 Avoid
Enoxaparin <30 Increased risk of bleeding Reduce dose Moderate Strong
Fondaparinux <30 Increased risk of bleeding Avoid Moderate Strong
Rivaroxaban 30–50 Increased risk of bleeding Reduce dose Moderate Strong
<30 Avoid
Spironolactone <30 Increased potassium Avoid Moderate Strong
Triamterene <30 Increased potassium, and
decreased sodium
Avoid Moderate Strong
Central nervous system and analgesics
Duloxetine <30 Increased Gastrointestinal
adverse effects (nausea,
diarrhea)
Avoid Moderate Weak
Gabapentin <60 CNS adverse effects Reduce dose Moderate Strong
Levetiracetam ≤80 CNS adverse effects Reduce dose Moderate Strong
Pregabalin <60 CNS adverse effects Reduce dose Moderate Strong
Tramadol <30 CNS adverse effects Immediate release: reduce
dose
Extended release: avoid
Low Weak
Gastrointestinal
Cimetidine <50 Mental status changes Reduce dose Moderate Strong
Famotidine <50 Mental status changes Reduce dose Moderate Strong
Nizatidine <50 Mental status changes Reduce dose Moderate Strong
Ranitidine <50 Mental status changes Reduce dose Moderate Strong
Hyperuricemia
Colchicine <30 Gastrointestinal,
neuromuscular, bone marrow
toxicity
Reduce dose; monitor for
adverse effects
Moderate Strong
Probenecid <30 Loss of effectiveness Avoid Moderate Strong
CNS = central nervous system.
2242 AGS 2015 BEERS CRITERIA UPDATE EXPERT PANEL NOVEMBER 2015–VOL. 63, NO. 11 JAGS
17. way that facilitates a team approach (physicians, nurses,
pharmacists, therapists, and others) to prescribing and
monitoring adverse effects.
The 2015 AGS Beers Criteria encourage the use of non-
pharmacological approaches when needed to avoid drugs
that have a high risk of causing an adverse event. The evi-
dence base for specific nonpharmacological approaches
using a person-centered approach to care is growing, espe-
cially in older adults and in persons with dementia and
delirium.34-36
A nonpharmacological toolkit for reducing
antipsychotic use in older adults by promoting positive
behavioral health, developed by investigators at The Penn-
sylvania State University and the Polisher Research Insti-
tute, was recently released. This toolkit can be accessed
online (www.nursinghometoolkit.com). Nonpharmacologi-
cal strategies for hospitalized older adults and their
caregivers can also be accessed online (www.hospitalelder
lifeprogram.org). A 2015 systematic review and meta-analy-
sis of nonpharmacological strategies in older adults with
delirium found that 11 of 14 studies demonstrated
significant reductions in delirium incidence and a reduction
in the rate of falls.37
Several studies have also illustrated
effective interventions to improve sleep.38,39
The AGS Beers Criteria are one component of a com-
prehensive approach to medication use in older adults, and
they should be used in conjunction with other tools. The
Screening Tool of Older Persons’ potentially inappropriate
Prescriptions (STOPP) and Screening Tool to Alert doctors
to Right Treatment (START) criteria, first developed in
2008, are an explicit tool for assessing prescribing in older
adults in Europe. They were updated in 2015 to include
Table 7. Drugs with Strong Anticholinergic Properties
Antihistamines
Brompheniramine
Carbinoxamine
Chlorpheniramine
Clemastine
Cyproheptadine
Dexbrompheniramine
Dexchlorpheniramine
Dimenhydrinate
Diphenhydramine
(oral)
Doxylamine
Hydroxyzine
Meclizine
Triprolidine
Antiparkinsonian
agents
Benztropine
Trihexyphenidyl
Skeletal muscle
relaxants
Cyclobenzaprine
Orphenadrine
Antidepressants
Amitriptyline
Amoxapine
Clomipramine
Desipramine
Doxepin (>6 mg)
Imipramine
Nortriptyline
Paroxetine
Protriptyline
Trimipramine
Antipsychotics
Chlorpromazine
Clozapine
Loxapine
Olanzapine
Perphenazine
Thioridazine
Trifluoperazine
Antiarrhythmic
Disopyramide
Antimuscarinics
(urinary incontinence)
Darifenacin
Fesoterodine
Flavoxate
Oxybutynin
Solifenacin
Tolterodine
Trospium
Antispasmodics
Atropine (excludes
ophthalmic)
Belladonna
alkaloids
Clidinium-
chlordiazepoxide
Dicyclomine
Homatropine
(excludes
ophthalmic)
Hyoscyamine
Propantheline
Scopolamine
(excludes
ophthalmic)
Antiemetic
Prochlorperazine
Promethazine
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 (Class
1a, 1c, III except amiodarone)
as first-line treatment for atrial
fibrillation
Chronic constipation—entire
criterion
Trimethobenzamide Lower urinary tract—inhaled
anticholinergic drugs
Mesoridazine—no longer
marketed in United States
Chloral hydrate—no longer
marketed in United States
Table 8. Medications Moved to Another Category or
Modified Since 2012 Beers Criteria
Independent of Diagnoses or
Condition (Table 2)
Considering Disease or
Syndrome Interactions
(Table 3)
Nitrofurantoin—recommendation
and rationale modified
Heart failure—rationale and
quality of evidence modified
Dronedarone—recommendation
and rationale modified
Chronic seizures or epilepsy—
quality of evidence modified
Digoxin—recommendation and
rationale modified
Delirium—recommendation
and rationale modified
Benzodiazepines—
recommendation modified
Dementia or cognitive
impairment—recommendation
and rationale modified; new
drugs added
Nonbenzodiazepine,
benzodiazepine receptor agonist
hypnotics—recommendation
modified
History of falls or fractures—
recommendation and rationale
modified; new drugs added
Meperidine—recommendation
modified
Parkinson disease—
recommendation and rationale
modified
Indomethacin and ketorolac,
includes parenteral—rationale
modified
Chronic kidney disease Stage
IV or less (creatinine clearance
<30 mL/min)—triamterene
moved to Tables 5 and 6
Antipsychotics—recommendation
and rationale modified
Insomnia—new drugs added
Estrogen—recommendation
modified
Insulin, sliding scale—rationale
modified
JAGS NOVEMBER 2015–VOL. 63, NO. 11 2015 AGS UPDATED BEERS CRITERIA 2243
18. drugs affecting or being affected by renal function, similar
to this update of the AGS Beers Criteria.40
Similar tools
have been developed in Europe.41
The current update of
the AGS Beers Criteria confirms and extends this work
with a rigorous independent evidence grading process, an
open peer-review comment period consistent with Institute
of Medicine standards, and the addition of drug–drug
interactions and renal dose adjustment.
The 2015 AGS Beers Criteria have several important
limitations. Older adults are often underrepresented in drug
trials.11,42
Thus, using an evidence-based approach may
underestimate some drug-related problems or lead to
weaker evidence grading. The GRADE process was used for
evidence 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; for
instance, they do not comprehensively address the needs of
individuals receiving palliative and hospice care, in whom
the balance of benefits and harms for many drugs on the list
may differ from those of the general population of older
adults. Finally, the search strategies used might have missed
some studies published in languages other than English and
studies available in unpublished technical reports, white
papers, or other “gray literature” sources.
The process had many noteworthy strengths, including
the use of a 13-member, geographically diverse interdisci-
plinary panel with ex-officio members from the Centers
for Medicare and Medicaid Services, National Committee
for Quality Assurance, and Pharmacy Quality Alliance; the
use of an evidence-based approach using Institute of Medi-
cine standards and independent grading of the evidence by
panel members followed by a consensus approach; and the
continued development of a partnership with AGS to
update the criteria regularly.
In conclusion, the 2015 AGS Beers Criteria have several
important 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 is
required based on kidney impairment, and the addition of
selected drug–drug interactions. Careful application of the
criteria by healthcare professionals, consumers, payors, and
health 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, increased
reporting of drug-related problems, active patient and care-
giver engagement and communication regarding medication
use, targeted interventions to decrease adverse drug events
in older adults, and improved outcomes. Continued support
from the AGS will allow for the criteria methodology and
evidence for PIMs to be evaluated regularly and to remain
up to date, relevant and valuable.
PANEL MEMBERS AND AFFILIATIONS
The following individuals were members of the AGS Panel
to 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 Pharmacy
Benefits Management Services and Northwestern University
Feinberg School of Medicine, Chicago, IL (co-chair); Judith
Beizer, 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 Quality
Alliance, Inc., Baltimore, MD (nonvoting member); Jerome
J. 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 Geriatric
Research, Education and Clinical Center, Veterans Affairs
Healthcare (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, Skaggs
School of Pharmacy and Pharmaceutical Sciences, Univer-
sity of Colorado, Aurora, CO; Satinderpal Sandhu, MD,
Summa Health Care System and Northeast Ohio Medical
University, Akron, OH; Michael Steinman, MD, University
of California at San Francisco and San Francisco Veterans
Affairs Medical Center, San Francisco, CA.
ACKNOWLEDGMENTS
The decisions and content of the 2015 AGS Beers Criteria
are those of the AGS and the panel members and are not
necessarily 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 Gina
Rocco 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. And
as always, the late Mark H. Beers, MD.
The following organizations with special interest and
expertise in the appropriate use of medications in older
adults provided peer review of a preliminary draft of this
guideline: American Medical Directors Association—The
Society 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
Syndrome Interactions
(Table 3)
Proton-pump inhibitors Falls and fractures—opioids
Desmopressin Insomnia—armodafinil and
modafinil
Anticholinergics, first-generation
antihistamines—meclizine
Dementia or cognitive impairment
—eszopiclone and zaleplon
Delirium—antipsychotics
2244 AGS 2015 BEERS CRITERIA UPDATE EXPERT PANEL NOVEMBER 2015–VOL. 63, NO. 11 JAGS
19. emy of Geriatric Psychiatry, American Academy of Neu-
rology, American Association of Clinical Endocrinologists,
American Association of Diabetes Educators, American
College of Clinical Pharmacy, American College of Obstet-
rics and Gynecology, American College of Physicians,
American College of Surgeons, American Osteopathic
Association, American Pharmacists Association, American
Society of Consultant Pharmacists, American Society of
Health-System Pharmacists, American Urological Society,
the Endocrine Society, Gerontological Advanced Practice
Nurses Association, Gerontological Society of America,
National Committee for Quality Assurance, National
Gerontological Nursing Association, NICHE, Pharmacy
Quality Alliance, Society for Women’s Health Research,
and Society of General Internal Medicine.
Conflict of Interest: Dr. Beizer is an author and editor
for LexiComp, Inc. Dr. Brandt is a consultant for Omni-
care, Centers for Medicare and Medicaid Services, and
University of Pittsburgh and a Section Editor for the Jour-
nal of Gerontological Nursing and received a grant from
Econometrica. Dr. Fick is a paid consultant for SLACK
Inc., 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 Nursing
Research. Dr. Linnebur is a consultant for Colorado
Access and Kindred Healthcare. Dr. Semla serves on the
AARP Caregiver Advisory Panel, is an editor for Lexi-
Comp, and is a consultant for Omnicare. Dr. Semla’s wife
holds commercial interest in AbbVie (at which she is also
an employee), Abbott, and Hospira. Dr. Semla receives
honoraria from the AGS for his contribution as an author
of 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 of
Directors. Dr. Steinman is a consult for Iodine.com, a web
start-up company.
Author Contributions: All panel members contributed
to the concept, design, and preparation of the manuscript.
Sponsor’s Role: AGS staff participated in the final
technical preparation and submission of the manuscript.
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