An 83-year-old woman is brought to the office by her son as a new patient. The patient feels well and has no health concerns. Review of medical records from her previous physician indicates that she has osteoporosis and mild cognitive impairment. The patient takes no medications, lives with her son and grandchildren, and is independent with activities of daily living. She prepares meals for the family and plays outside with the family dog and her grandchildren for 20 minutes daily. Blood pressure is 152/75 mm Hg and pulse is 77/min. BMI is 20 kg/m2. The patient is alert, conversant, and oriented to time, self, and place. Examinations of the heart, lungs, and abdomen are within normal limits. Results of laboratory testing include an LDL of 170 mg/dL, triglycerides of 220 mg/dL, and a hemoglobin A1c of 7.3%. The physician diagnoses hyperlipidemia and type 2 diabetes mellitus, and home monitoring of blood pressure is arranged. When discussing medication options for this patient, which of the following actions is most recommended to improve health care outcomes and quality?
Medication prescribing in elderly patients | |
Major considerations |
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Principles |
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*Beers criteria: list of medications considered potentially inappropriate or to be used with caution in the elderly. | |
When working with elderly patients, clinicians often must manage multiple chronic conditions (eg, cognitive impairment, hyperlipidemia, diabetes mellitus) in patients who are at increased risk of adverse drug events (ADEs). To appropriately manage these conditions while minimizing ADEs, clinicians should individualize drug therapy to each patient's context and therapeutic priorities.
Prescriptions for elderly patients should consider the medication's magnitude of effect and time to therapeutic benefit, in addition to the patient's goals of care and health status (eg, life expectancy). For example, treatment of a systolic blood pressure of 140-159 mm Hg is associated with a 2% absolute risk reduction in coronary events over 4-5 years. This information may support starting antihypertensive therapy in some patients (eg, patient has therapeutic goals, good health status, longer life expectancy) but not others (eg, frail, elderly patient with primarily palliative goals of care and short life expectancy).
Similar factors should be discussed with this patient when recommending the optimal treatment for hyperlipidemia and osteoporosis.
(Choices A and D) Clinicians should avoid specific medications (eg, benzodiazepines) with increased risks in elderly patients, but some degree of ADE risk may be acceptable (and unavoidable) to achieve desired therapeutic benefits aligned with patient goals. Likewise, dosing in elderly patients should generally be conservative, but the risks associated with dose escalation are often justified if needed to achieve desired effects. Both medication choice and dosing should be individualized, which may require modifications from standard guidelines (eg, using second-line agent).
(Choice C) Involving family members can be useful in the care of elderly patients, but active education approaches (eg, teach-back) are preferred to passive information distribution (eg, printed instructions). Moreover, tailoring medical decisions to the patient's context (eg, expected time to benefit vs life expectancy) is more likely to optimize outcomes.
Educational objective:
Elderly patients are vulnerable to both overprescribing and underprescribing of medications and have increased susceptibility to adverse drug events. Clinicians should tailor therapeutic decisions to each patient's individual context, considering factors such as the medication's time to benefit and absolute treatment effects as well as the patient's health status (eg, life expectancy) and goals of care.