Medication management in older adults

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Medication management in older adults

Medications started for appropriate indications in middle age may need to be monitored more closely as the patient ages. Some drugs may become unnecessary or even dangerous as the patient ages, functional status and renal function decline, and goals of care change.

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Older adults tend to have multiple illnesses and therefore take more drugs, and polypharmacy increases the risk of poor outcomes. The number of medications a person uses is a risk factor for adverse drug reactions, nonadherence, financial burden, drug-drug interactions, and worse outcomes.1

The prevalence of polypharmacy increased from an estimated 8.2% to 15% from 1999 to 2011 based on the National Health and Nutrition Examination Survey.2 Guideline-based therapy for specific diseases may lead to the addition of more medications to reach disease targets.3 Most older adults in the United States compound the risk of prescribed medications by also taking over-the-counter medications and dietary supplements.4

In addition, medications are often used in older adults based on studies of younger persons without significant comorbidities. Applying clinical guidelines based on these studies to older adults with comorbidity and functional impairment is challenging.5 Age-related pharmacokinetic and pharmacodynamic changes increase the risk of adverse drug reactions.6

In this article, we review commonly used medications that are potentially inappropriate based on clinical practice. We also review tools to evaluate appropriate drug therapy in older adults.

DRUGS THAT ARE COMMONLY USED, BUT POTENTIALLY INAPPROPRIATE

Statins

Statins are effective when used as secondary prevention in older adults,7 but their efficacy when used as primary prevention of atherosclerotic cardiovascular disease in people age 75 and older is questionable.8 Nevertheless, they are widely used for this purpose. For example, before the 2013 joint guidelines of the American College of Cardiology and the American Heart Association (ACC/AHA) were released, 22% of patients age 80 and older in the Geisinger health system were taking a statin for primary prevention.9

The 2013 ACC/AHA guidelines included a limited recommendation for statins for primary prevention of atherosclerotic cardiovascular disease in adults age 75 and older.10 The guideline noted, however, that few data were available to support this recommendation.10

In a systematic review of 18 randomized clinical trials of statins for primary prevention of atherosclerotic cardiovascular disease, the mean age was 57, yet conclusions were extrapolated to an older patient population.11 The estimated 10-year risk of atherosclerotic cardiovascular disease based on pooled cohort risk equations of adults age 75 and older always exceeds the 7.5% treatment threshold recommended by the guidelines.8

Myopathy is a common adverse effect of statins. In addition, statins interact with other drugs that inhibit the cytochrome P450 3A4 isoenzyme, such as amlodipine, amiodarone, and diltiazem.8,12 If statin therapy caused no functional limitation due to muscle pain or weakness, statins for primary prevention would be cost-effective, but even a small increase in adverse effects in an elderly patient can offset the cardiovascular benefit.13 A recent post hoc secondary analysis found no benefit of pravastatin for primary prevention in adults age 75 and older.14

Thus, statin treatment for primary prevention in older patients should be individualized, based on life expectancy, function, and cardiovascular risk. Statin therapy does not replace modification of other risk factors.

Anticholinergics

Drugs with strong anticholinergic properties

Drugs with anticholinergic properties are commonly prescribed in the elderly for conditions such as muscle spasm, overactive bladder, psychiatric disorders, insomnia, extrapyramidal symptoms, vertigo, pruritus, peptic ulcer disease, seasonal allergies, and even the common cold,15 and many of the drugs often prescribed have strong anticholinergic properties (Table 1). Taking multiple medications with anticholinergic properties results in a high “anticholinergic burden,” which is associated with falls, impulsive behavior, poor physical performance, loss of independence, dementia, delirium, and brain atrophy.15–18

The 2014 American College of Physicians guideline on nonsurgical management of urinary incontinence in women recommends pharmacologic treatment for urgency and stress urinary incontinence after failure of nonpharmacologic therapy,19 and many drugs for these urinary symptoms have anticholinergic properties. If an anticholinergic is necessary, an agent that results in a lower anticholinergic burden should be considered in older patients.

A pharmacist-initiated medication review and intervention may be another way to adjust medications to reduce the patient’s anticholinergic burden.20,21 The common use of anticholinergic drugs in older adults reminds us to monitor their use closely.22

 

 

Benzodiazepines and nonbenzodiazepines

Benzodiazepines are among the most commonly prescribed psychotropics in developed countries and are prescribed mainly by primary care physicians rather than psychiatrists.23

In 2008, 5.2% of US adults ages 18 to 80 used a benzodiazepine, and long-term use was more prevalent in older patients (ages 65–80).23

Benzodiazepines are prescribed for anxiety,24 insomnia,25 and agitation. They can cause withdrawal26 and have potential for abuse.27 Benzodiazepines are associated with cognitive decline,28 impaired driving,29 falls,30 and hip fractures31 in older adults.

In addition, use of nonbenzodiazepine hypnotics (eg, zolpidem) is on the rise,32 and these drugs are known to increase the risk of hip fracture in nursing home residents.33

The American Geriatrics Society, through the American Board of Internal Medicine’s Choosing Wisely campaign, recommends avoiding benzodiazepines as a first-line treatment for insomnia, agitation, or delirium in older adults.34 Yet prescribing practices with these drugs in primary care settings conflict with guidelines, partly due to lack of training in constructive strategies regarding appropriate use of benzodiazepines.35 Educating patients on the risks and benefits of benzodiazepine treatment, especially long-term use, has been shown to reduce the rate of benzodiazepine-associated secondary events.36

Antipsychotics

Off-label use of antipsychotics is common and is increasing in the United States. In 2008, off-label use of antipsychotic drugs accounted for an estimated $6 billion.37 A common off-label use is to manage behavioral symptoms of dementia, despite a black-box warning about an increased risk of death in patients with dementia who are treated with antipsychotics.38,39 The Choosing Wisely campaign recommends against prescribing antipsychotics as a first-line treatment of behavioral and psychological symptoms of dementia.34

Antipsychotic drugs are associated with risk of acute kidney injury,40 as well as increased risk of falls and fractures (eg, a 52% higher risk of a serious fall, and a 50% higher risk of a nonvertebral osteoporotic fracture).41

Patients with dementia often exhibit aggression, resistance to care, and other challenging or disruptive behaviors. In such instances, antipsychotic drugs are often prescribed, but they provide limited and inconsistent benefits, while causing oversedation and worsening of cognitive function and increasing the likelihood of falling, stroke, and death.38,39,41

Because pharmacologic treatments for dementia are only modestly effective, have notable risks, and do not treat some of the behaviors that family members and caregivers find most distressing, nonpharmacologic measures are recommended as first-line treatment.42 These include caregiver education and support, training in problem-solving, and targeted therapy directed at the underlying causes of specific behaviors (eg, implementing nighttime routines to address sleep disturbances).42 Nonpharmacologic management of behavioral symptoms in dementia can significantly improve quality of life for patients and caregivers.42 Use of antipsychotic drugs in patients with dementia should be limited to cases in which nonpharmacologic measures have failed and patients pose an imminent threat to themselves or others.43

Proton pump inhibitors

Proton pump inhibitors are among the most commonly prescribed medications in the United States, and their use has increased significantly over the decade. It has been estimated that between 25% and 70% of these prescriptions have no appropriate indication.44

There is considerable excess use of acid suppressants in both inpatient and outpatient settings.45,46 In one study, at discharge from an internal medicine service, almost half of patients were taking a proton pump inhibitor.47

Evidence-based guidelines recommend these drugs to treat gastroesophageal reflux disease, nonerosive reflux disease, erosive esophagitis, dyspepsia, and peptic ulcer disease. However, long-term use (ie, beyond 8 weeks) is recommended only for patients with erosive esophagitis, Barrett esophagus, a pathologic hypersecretory condition, or a demonstrated need for maintenance treatment for reflux disease.48

Although proton pump inhibitors are highly effective and have low toxicity, there are reports of an association with Clostridium difficile infection,49 community-acquired pneumonia,50 hip fracture,51 vitamin B12 deficiency,52 atrophic gastritis,53 kidney disease,54 and dementia.55

Nondrug therapies such as weight loss and elevation of the head of the bed may improve esophageal pH levels and reflux symptoms.56

Deprescribing.org has practical advice for healthcare providers, patients, and caregivers on how to discontinue proton pump inhibitors, including videos, algorithms, and guidelines.

TOOLS TO EVALUATE APPROPRIATE DRUG THERAPY

Beers criteria

The 2015 Beers criteria: Selected drugs to avoid in older adults

The Beers criteria (Table 2), developed in 1991 by a geriatrician as an approach to safer, more effective drug therapy in frail elderly nursing home patients,57 were updated by the American Geriatrics Society in 2015 for use in any clinical setting.58 (The criteria are also available as a smartphone application through the American Geriatrics Society at www.americangeriatrics.org.)

The Beers criteria offer evidence-based recommendations on drugs to avoid in the elderly, along with the rationale for use, the quality of evidence behind the recommendation, and the graded strength of the recommendation. The Beers criteria should be viewed through the lens of clinical judgment to offer safer nonpharmacologic and pharmacologic treatments.

The Joint Commission recommends medication reconciliation at every transition of care.59 The Beers criteria are a good starting point for a comprehensive medication review.

STOPP/START criteria

STOPP: Selected warnings and recommendations

Another tool to aid safe prescribing in older adults is the Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions (STOPP), used in conjuction with the Screening Tool to Alert Doctors to Right Treatment (START). The STOPP/START criteria60,61 are based on an up-to-date literature review and consensus (Table 3).

THE BOTTOM LINE

Physicians caring for older adults need to diligently weigh the benefits of drug therapy and consider the patient’s care goals, current level of functioning, life expectancy, values, and preferences. Statin therapy for primary prevention, anticholinergics, benzodiazepines, antipsychotics, and proton pump inhibitors are widely used without proper indications, pointing to the need for a periodic comprehensive review of medications to reevaluate the risks vs the benefits of the patient’s medications. The Beers criteria and the STOPP/ START criteria can be useful tools for this purpose.

References
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  2. Kantor ED, Rehm CD, Haas JS, Chan AT, Giovannucci EL. Trends in prescription drug use among adults in the United States from 1999–2012. JAMA 2015; 314:1818–1831.
  3. Tinetti ME, Bogardus ST Jr, Agostini JV. Potential pitfalls of disease-specific guidelines for patients with multiple conditions. N Engl J Med 2004; 351:2870–2874.
  4. Qato DM, Wilder J, Schumm LP, Gillet V, Alexander GC. Changes in prescription and over-the-counter medication and dietary supplement use among older adults in the United States, 2005 vs 2011. JAMA Intern Med 2016; 176:473–482.
  5. Boyd CM, Darer J, Boult C, et al. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA 2005; 294:716–724.
  6. Atkin PA, Veitch PC, Veitch EM, Ogle SJ. The epidemiology of serious adverse drug reactions among the elderly. Drugs Aging 1999; 14:141–152.
  7. Collins R, Reith C, Emberson J, et al. Interpretation of the evidence for the efficacy and safety of statin therapy. Lancet 2016; 338:2532–2561.
  8. Gurwitz JH, Go AS, Fortman SP. Statins for primary prevention in older adults: uncertainty and the need for more evidence. JAMA 2016; 316:1971–1972.
  9. Chokshi NP, Messerli FH, Sutin D, Supariwala AA, Shah NR. Appropriateness of statins in patients aged ≥ 80 years and comparison to other age groups. Am J Cardiol 2012; 110:1477–1481.
  10. Stone NJ, Robinson J, Lichtenstein AH, et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 129(suppl 2):S1–S45.
  11. Taylor F, Huffman MD, Macedo AF, et al. Statins for the primary prevention of cardiovascular disease. Cochrane Database Syst Rev 2013; 1:CD004816.
  12. Chatzizisis YS, Koskinas KC, Misirli G, Vaklavas C, Hatzitolios A, Giannoglou GD. Risk factors and drug interactions predisposing to statin-induced myopathy: implications for risk assessment, prevention and treatment. Drug Saf 2010; 33:171–187.
  13. Odden MC, Pletcher MJ, Coxson PG, et al. Cost-effectiveness and population impact of statins for primary prevention in adults aged 75 years or older in the United States. Ann Intern Med 2015; 162:533–541.
  14. Han BH, Sutin D, Williamson JD, et al. Effect of statin treatment vs usual care on primary cardiovascular prevention among older adults. The ALLHAT-LLT randomized clinical trial. JAMA Intern Med 2017; 177:955–965.
  15. Gray SL, Anderson ML, Dublin S, et al. Cumulative use of strong anticholinergics and incident dementia: a prospective cohort study. JAMA Intern Med 2015; 175:401–407.
  16. Rudolph JL, Salow MJ, Angelini MC, McGlinchey RE. The anticholinergic risk scale and anticholinergic adverse effects in older persons. Arch Intern Med 2008; 168:508–513.
  17. Hilmer SN, Mager DE, Simonsick EM, et al. A drug burden index to define the functional burden of medications in older people. Arch Intern Med 2007; 167:781–787.
  18. Risacher SL, McDonald BC, Tallman EF, et al; Alzheimer’s Disease Neuroimaging Initiative. Association between anticholinergic medication use and cognition, brain metabolism, and brain atrophy in cognitively normal older adults. JAMA Neurol 2016; 73:721–732.
  19. Qaseem A, Dallas P, Forciea MA, Starkey M, Denberg TD, Shekelle P; Clinical Guidelines Committee of the American College of Physicians. Nonsurgical management of urinary incontinence in women: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2014; 161:429–440.
  20. Efjestad AS, Molden E, Oksengard AR. Pharmacist-initiated management of antagonistic interactions between anticholinergic drugs and acetyl cholinesterase inhibitors in individuals with dementia. J Am Geriatr Soc 2013; 61:1624–1625.
  21. Kersten H, Molden E, Tolo IK, Skovlund E, Engedal K, Wyller TB. Cognitive effects of reducing anticholinergic drug burden in a frail elderly population: a randomized controlled trial. J Gerontol A Biol Sci Med Sci 2013; 68:271–278.
  22. Curtis LH, Østbye T, Sendersky V, et al. Inappropriate prescribing for elderly Americans in a large outpatient population. Arch Intern Med 2004; 164:1621–1625.
  23. Olfson M, King M, Schoenbaum M. Benzodiazepine use in the United States. JAMA Psychiatry 2015; 72:136–142.
  24. Martin JL, Sainz-Pardo M, Furukawa TA, Martín-Sánchez E, Seoane T, Galán C. Benzodiazepines in generalized anxiety disorder: heterogeneity of outcomes based on a systematic review and meta-analysis of clinical trials. J Psychopharmacol 2007; 21:774–782.
  25. Buscemi N, Vandermeer B, Friesen C, et al. The efficacy and safety of drug treatments for chronic insomnia in adults: a meta-analysis of RCTs. J Gen Intern Med 2007; 22:1335–1350.
  26. Rickels K, Schweizer E, Case WG, Greenblatt DJ. Long-term therapeutic use of benzodiazepines, I. Effects of abrupt discontinuation. Arch Gen Psychiatry 1990; 47:899–907.
  27. Fenton MC, Keyes KM, Martins SS, Hasin DS. The role of a prescription in anxiety medication use, abuse, and dependence. Am J Psychiatry 2010; 167:1247–1253.
  28. Billoti de Gage S, Moride Y, Ducruet T, et al. Benzodiazepine use and risk of Alzheimer’s disease: case-control study. BMJ 2014; 349:g5205.
  29. Smink BE, Egberts AC, Lusthof KJ, Uges DR, de Gier JJ. The relationship between benzodiazepine use and traffic accidents: a systemic literature review. CNS Drugs 2010; 24:639–653.
  30. Tinett, ME, Speechley M, Ginter S. Risk factors for falls among elderly persons living in the community. N Engl J Med 1988; 319:1701–1707.
  31. Zint K, Haefeli WE, Glynn RJ, Mogun H, Avorn J, Stürmer T. Impact of drug interactions, dosage, and duration of therapy on the risk of hip fracture associated with benzodiazepine use in older adults. Pharmacoepidemiol Drug Saf 2010; 19:1248–1255.
  32. Briesacher BA, Soumerai SB, Field TS, Fouayzi H, Gurwitz JH. Medicare Part D’s exclusion of benzodiazepines and fracture risk in nursing homes. Arch Intern Med 2010; 170:693–698.
  33. Berry SD, Lee Y, Cai S, Dore DD. Nonbenzodiazepine sleep medication use and hip fractures in nursing home residents. JAMA Intern Med 2013; 173:754–761.
  34. American Geriatrics Society. Choosing Wisely. Ten things clinicians and patients should question. www.choosingwisely.org/societies/american-geriatrics-society/. Accessed December 3, 2017.
  35. Cook JM, Marshall R, Masci C, Coyne JC. Physicians’ perspectives on prescribing benzodiazepines for older adults: a qualitative study. J Gen Intern Med 2007; 22:303–307.
  36. Tannenbaum C, Martin P, Tamblyn R, Benedetti A, Ahmed S. Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial. JAMA Intern Med 2014; 174:890–898.
  37. Alexander GC, Gallagher SA, Mascola A, Moloney RM, Stafford RS. Increasing off-label use of antipsychotic medications in the United States, 1995–2008. Phamacoepidemiol Drug Saf 2011; 20:177–184.
  38. Gill SS, Bronskill SE, Normand SL, et al. Antipsychotic drug use and mortality in older adults with dementia. Ann Intern Med 2007; 146:775–786.
  39. US Food and Drug Administration (FDA). Public health advisory: deaths with antipsychotics in elderly patients with behavioral disturbances. www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm053171.htm. Accessed December 4, 2017.
  40. Hwang YJ, Dixon SN, Reiss JP, et al. Atypical antipsychotic drugs and the risk for acute kidney injury and other adverse outcomes in older adults. Ann Intern Med 2014; 161:242–248.
  41. Fraser L, Liu K, Naylor KL, et al. Falls and fractures with atypical antipsychotic medication use: a population-based cohort study. JAMA Intern Med 2015; 175:450–452.
  42. Gitlin LN, Kales HC, Lyketsos CG. Nonpharmacologic management of behavioral symptoms in dementia. JAMA 2012; 308:2020–2029.
  43. Schneider LS, Tariot PN, Dagerman KS, et al; CATIE-AD Study Group. Effectiveness of atypical antipsychotic drugs in patients with Alzheimer’s disease. N Engl J Med 2006; 355:1525–1538.
  44. Forgacs I, Loganayagam A. Overprescribing proton pump inhibitors. BMJ 2008; 336:2–3.
  45. Mazer-Amirshahi M, Mullins PM, van den Anker J, Meltzer A, Pines JM. Rising rates of proton pump inhibitor prescribing in US emergency departments. Am J Emerg Med 2014; 32:618–622.
  46. Heidelbaugh JJ, Goldberg KL, Inadomi JM. Magnitude and economic effect of overuse of antisecretory therapy in the ambulatory care setting. Am J Manag Care 2010; 16:e228–e324.
  47. Pham CQ, Regal RE, Bostwich TR, Knauf KS. Acid suppressive therapy used on an inpatient internal medicine service. Ann Pharmacother 2006; 40:1261–1266.
  48. Kahrilas PJ, Shaheen NJ, Vaezi MF, et al; American Gastroenterological Association. American Gastroenterological Association medical position statement on the management of gastroesophageal reflux disease. Gastroenterology 2008; 135:1383–1391.e1–e5.
  49. Howell MD, Novack V, Grgurich P, et al. Iatrogenic gastric acid suppression and the risk of nosocomial Clostridium difficile infection. Arch Intern Med 2010; 170:784–790.
  50. Gulmez SE, Holm A, Frederiksen H, Jensen TG, Pedersen C, Hallas J. Use of proton pump inhibitors and the risk of community-acquired pneumonia: a population-based case-control study. Arch Intern Med 2007; 167:950–955.
  51. Yang YX, Lewis JD, Epstein S, Metz DC. Long-term proton pump inhibitor therapy and risk of hip fracture. JAMA 2006; 296:2947–2953.
  52. Lam JR, Schneider JL, Zhao W, Corley DA. Proton pump inhibitor and histamine 2 receptor antagonist use and vitamin B12 deficiency. JAMA 2013; 310:2435–2442.
  53. Kuipers EJ, Lundell L, Klinkenberg-Knol EC, et al. Atrophic gastritis and Helicobacter pylori infection in patients with reflux esophagitis treated with omeprazole or fundoplication. N Engl J Med 1996; 334:1018–1022.
  54. Lazarus B, Chen Y, Wilson FP, et al. Proton pump inhibitor use and the risk of chronic kidney disease. JAMA Intern Med 2016; 176:238–246.
  55. Gomm W, von Holt K, Thomé F, et al. Association of proton pump inhibitors with risk of dementia: a pharmacoepidemiological claims data analysis. JAMA Neurol 2016; 73:410–416.
  56. Kaltenbach T, Crockett S, Gerson LB. Are lifestyle measures effective in patients with gastroesophageal reflux disease? An evidence-based approach. Arch Intern Med 2006; 166:965–971.
  57. Beers MH, Ouslander JG, Rollingher I, Reuben DB, Brooks J, Beck JC. Explicit criteria for determining inappropriate medication use in nursing home residents. Arch Intern Med 1991; 151:1825–1832.
  58. American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2015; 63:2227–2246.
  59. Joint Commission. Sentinel event alert, Issue 35: using medication reconciliation to prevent errors. www.jointcommission.org/sentinel_event_alert_issue_35_using_medication_reconciliation_to_prevent_errors/. Accessed August 18, 2017.
  60. Gallagher P, Ryan C, Byrne S, Kennedy J, O’Mahony D. STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation. Int J Clin Pharmacol Ther 2008; 46:72–83.
  61. O’Mahony D, O’Sullivan D, Byrne S, O’Connor MN, Ryan C, Gallagher P. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing 2015; 44:213–218.
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Luke D. Kim, MD, FACP, CMD
Assistant Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University; Center for Geriatric Medicine, Medicine Institute, Cleveland Clinic

Kenneth Koncilja, MD
Geriatric Medicine Fellow, University of California San Francisco, Division of Geriatrics, Department of Medicine

Craig Nielsen, MD, FACP
Associate Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University; Vice Chairman, Department of Internal Medicine, Medicine Institute, Cleveland Clinic; Deputy Editor, Cleveland Clinic Journal of Medicine

Address: Luke D. Kim, MD, Center for Geriatric Medicine, Medicine Institute, X10, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195; kiml2@ccf.org

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polypharmacy, side effects, adverse effects, medication reconciliation, anticholinergic, antihistamines, antiparkinsonian, muscle relaxants, antidepressants, antipsychotics, antiarrhythmics, antimuscarinics, antiemetics, antispasmodic, statins, diphenhydramine, lorazepam, amitriptyline, benzodiazepines, STOPP/START criteria, proton pump inhibitors, Beers criteria, Luke Kim, Kenneth Koncilja, Craig Nielsen
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Luke D. Kim, MD, FACP, CMD
Assistant Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University; Center for Geriatric Medicine, Medicine Institute, Cleveland Clinic

Kenneth Koncilja, MD
Geriatric Medicine Fellow, University of California San Francisco, Division of Geriatrics, Department of Medicine

Craig Nielsen, MD, FACP
Associate Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University; Vice Chairman, Department of Internal Medicine, Medicine Institute, Cleveland Clinic; Deputy Editor, Cleveland Clinic Journal of Medicine

Address: Luke D. Kim, MD, Center for Geriatric Medicine, Medicine Institute, X10, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195; kiml2@ccf.org

Author and Disclosure Information

Luke D. Kim, MD, FACP, CMD
Assistant Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University; Center for Geriatric Medicine, Medicine Institute, Cleveland Clinic

Kenneth Koncilja, MD
Geriatric Medicine Fellow, University of California San Francisco, Division of Geriatrics, Department of Medicine

Craig Nielsen, MD, FACP
Associate Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University; Vice Chairman, Department of Internal Medicine, Medicine Institute, Cleveland Clinic; Deputy Editor, Cleveland Clinic Journal of Medicine

Address: Luke D. Kim, MD, Center for Geriatric Medicine, Medicine Institute, X10, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195; kiml2@ccf.org

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Related Articles

Medications started for appropriate indications in middle age may need to be monitored more closely as the patient ages. Some drugs may become unnecessary or even dangerous as the patient ages, functional status and renal function decline, and goals of care change.

See related editorial

Older adults tend to have multiple illnesses and therefore take more drugs, and polypharmacy increases the risk of poor outcomes. The number of medications a person uses is a risk factor for adverse drug reactions, nonadherence, financial burden, drug-drug interactions, and worse outcomes.1

The prevalence of polypharmacy increased from an estimated 8.2% to 15% from 1999 to 2011 based on the National Health and Nutrition Examination Survey.2 Guideline-based therapy for specific diseases may lead to the addition of more medications to reach disease targets.3 Most older adults in the United States compound the risk of prescribed medications by also taking over-the-counter medications and dietary supplements.4

In addition, medications are often used in older adults based on studies of younger persons without significant comorbidities. Applying clinical guidelines based on these studies to older adults with comorbidity and functional impairment is challenging.5 Age-related pharmacokinetic and pharmacodynamic changes increase the risk of adverse drug reactions.6

In this article, we review commonly used medications that are potentially inappropriate based on clinical practice. We also review tools to evaluate appropriate drug therapy in older adults.

DRUGS THAT ARE COMMONLY USED, BUT POTENTIALLY INAPPROPRIATE

Statins

Statins are effective when used as secondary prevention in older adults,7 but their efficacy when used as primary prevention of atherosclerotic cardiovascular disease in people age 75 and older is questionable.8 Nevertheless, they are widely used for this purpose. For example, before the 2013 joint guidelines of the American College of Cardiology and the American Heart Association (ACC/AHA) were released, 22% of patients age 80 and older in the Geisinger health system were taking a statin for primary prevention.9

The 2013 ACC/AHA guidelines included a limited recommendation for statins for primary prevention of atherosclerotic cardiovascular disease in adults age 75 and older.10 The guideline noted, however, that few data were available to support this recommendation.10

In a systematic review of 18 randomized clinical trials of statins for primary prevention of atherosclerotic cardiovascular disease, the mean age was 57, yet conclusions were extrapolated to an older patient population.11 The estimated 10-year risk of atherosclerotic cardiovascular disease based on pooled cohort risk equations of adults age 75 and older always exceeds the 7.5% treatment threshold recommended by the guidelines.8

Myopathy is a common adverse effect of statins. In addition, statins interact with other drugs that inhibit the cytochrome P450 3A4 isoenzyme, such as amlodipine, amiodarone, and diltiazem.8,12 If statin therapy caused no functional limitation due to muscle pain or weakness, statins for primary prevention would be cost-effective, but even a small increase in adverse effects in an elderly patient can offset the cardiovascular benefit.13 A recent post hoc secondary analysis found no benefit of pravastatin for primary prevention in adults age 75 and older.14

Thus, statin treatment for primary prevention in older patients should be individualized, based on life expectancy, function, and cardiovascular risk. Statin therapy does not replace modification of other risk factors.

Anticholinergics

Drugs with strong anticholinergic properties

Drugs with anticholinergic properties are commonly prescribed in the elderly for conditions such as muscle spasm, overactive bladder, psychiatric disorders, insomnia, extrapyramidal symptoms, vertigo, pruritus, peptic ulcer disease, seasonal allergies, and even the common cold,15 and many of the drugs often prescribed have strong anticholinergic properties (Table 1). Taking multiple medications with anticholinergic properties results in a high “anticholinergic burden,” which is associated with falls, impulsive behavior, poor physical performance, loss of independence, dementia, delirium, and brain atrophy.15–18

The 2014 American College of Physicians guideline on nonsurgical management of urinary incontinence in women recommends pharmacologic treatment for urgency and stress urinary incontinence after failure of nonpharmacologic therapy,19 and many drugs for these urinary symptoms have anticholinergic properties. If an anticholinergic is necessary, an agent that results in a lower anticholinergic burden should be considered in older patients.

A pharmacist-initiated medication review and intervention may be another way to adjust medications to reduce the patient’s anticholinergic burden.20,21 The common use of anticholinergic drugs in older adults reminds us to monitor their use closely.22

 

 

Benzodiazepines and nonbenzodiazepines

Benzodiazepines are among the most commonly prescribed psychotropics in developed countries and are prescribed mainly by primary care physicians rather than psychiatrists.23

In 2008, 5.2% of US adults ages 18 to 80 used a benzodiazepine, and long-term use was more prevalent in older patients (ages 65–80).23

Benzodiazepines are prescribed for anxiety,24 insomnia,25 and agitation. They can cause withdrawal26 and have potential for abuse.27 Benzodiazepines are associated with cognitive decline,28 impaired driving,29 falls,30 and hip fractures31 in older adults.

In addition, use of nonbenzodiazepine hypnotics (eg, zolpidem) is on the rise,32 and these drugs are known to increase the risk of hip fracture in nursing home residents.33

The American Geriatrics Society, through the American Board of Internal Medicine’s Choosing Wisely campaign, recommends avoiding benzodiazepines as a first-line treatment for insomnia, agitation, or delirium in older adults.34 Yet prescribing practices with these drugs in primary care settings conflict with guidelines, partly due to lack of training in constructive strategies regarding appropriate use of benzodiazepines.35 Educating patients on the risks and benefits of benzodiazepine treatment, especially long-term use, has been shown to reduce the rate of benzodiazepine-associated secondary events.36

Antipsychotics

Off-label use of antipsychotics is common and is increasing in the United States. In 2008, off-label use of antipsychotic drugs accounted for an estimated $6 billion.37 A common off-label use is to manage behavioral symptoms of dementia, despite a black-box warning about an increased risk of death in patients with dementia who are treated with antipsychotics.38,39 The Choosing Wisely campaign recommends against prescribing antipsychotics as a first-line treatment of behavioral and psychological symptoms of dementia.34

Antipsychotic drugs are associated with risk of acute kidney injury,40 as well as increased risk of falls and fractures (eg, a 52% higher risk of a serious fall, and a 50% higher risk of a nonvertebral osteoporotic fracture).41

Patients with dementia often exhibit aggression, resistance to care, and other challenging or disruptive behaviors. In such instances, antipsychotic drugs are often prescribed, but they provide limited and inconsistent benefits, while causing oversedation and worsening of cognitive function and increasing the likelihood of falling, stroke, and death.38,39,41

Because pharmacologic treatments for dementia are only modestly effective, have notable risks, and do not treat some of the behaviors that family members and caregivers find most distressing, nonpharmacologic measures are recommended as first-line treatment.42 These include caregiver education and support, training in problem-solving, and targeted therapy directed at the underlying causes of specific behaviors (eg, implementing nighttime routines to address sleep disturbances).42 Nonpharmacologic management of behavioral symptoms in dementia can significantly improve quality of life for patients and caregivers.42 Use of antipsychotic drugs in patients with dementia should be limited to cases in which nonpharmacologic measures have failed and patients pose an imminent threat to themselves or others.43

Proton pump inhibitors

Proton pump inhibitors are among the most commonly prescribed medications in the United States, and their use has increased significantly over the decade. It has been estimated that between 25% and 70% of these prescriptions have no appropriate indication.44

There is considerable excess use of acid suppressants in both inpatient and outpatient settings.45,46 In one study, at discharge from an internal medicine service, almost half of patients were taking a proton pump inhibitor.47

Evidence-based guidelines recommend these drugs to treat gastroesophageal reflux disease, nonerosive reflux disease, erosive esophagitis, dyspepsia, and peptic ulcer disease. However, long-term use (ie, beyond 8 weeks) is recommended only for patients with erosive esophagitis, Barrett esophagus, a pathologic hypersecretory condition, or a demonstrated need for maintenance treatment for reflux disease.48

Although proton pump inhibitors are highly effective and have low toxicity, there are reports of an association with Clostridium difficile infection,49 community-acquired pneumonia,50 hip fracture,51 vitamin B12 deficiency,52 atrophic gastritis,53 kidney disease,54 and dementia.55

Nondrug therapies such as weight loss and elevation of the head of the bed may improve esophageal pH levels and reflux symptoms.56

Deprescribing.org has practical advice for healthcare providers, patients, and caregivers on how to discontinue proton pump inhibitors, including videos, algorithms, and guidelines.

TOOLS TO EVALUATE APPROPRIATE DRUG THERAPY

Beers criteria

The 2015 Beers criteria: Selected drugs to avoid in older adults

The Beers criteria (Table 2), developed in 1991 by a geriatrician as an approach to safer, more effective drug therapy in frail elderly nursing home patients,57 were updated by the American Geriatrics Society in 2015 for use in any clinical setting.58 (The criteria are also available as a smartphone application through the American Geriatrics Society at www.americangeriatrics.org.)

The Beers criteria offer evidence-based recommendations on drugs to avoid in the elderly, along with the rationale for use, the quality of evidence behind the recommendation, and the graded strength of the recommendation. The Beers criteria should be viewed through the lens of clinical judgment to offer safer nonpharmacologic and pharmacologic treatments.

The Joint Commission recommends medication reconciliation at every transition of care.59 The Beers criteria are a good starting point for a comprehensive medication review.

STOPP/START criteria

STOPP: Selected warnings and recommendations

Another tool to aid safe prescribing in older adults is the Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions (STOPP), used in conjuction with the Screening Tool to Alert Doctors to Right Treatment (START). The STOPP/START criteria60,61 are based on an up-to-date literature review and consensus (Table 3).

THE BOTTOM LINE

Physicians caring for older adults need to diligently weigh the benefits of drug therapy and consider the patient’s care goals, current level of functioning, life expectancy, values, and preferences. Statin therapy for primary prevention, anticholinergics, benzodiazepines, antipsychotics, and proton pump inhibitors are widely used without proper indications, pointing to the need for a periodic comprehensive review of medications to reevaluate the risks vs the benefits of the patient’s medications. The Beers criteria and the STOPP/ START criteria can be useful tools for this purpose.

Medications started for appropriate indications in middle age may need to be monitored more closely as the patient ages. Some drugs may become unnecessary or even dangerous as the patient ages, functional status and renal function decline, and goals of care change.

See related editorial

Older adults tend to have multiple illnesses and therefore take more drugs, and polypharmacy increases the risk of poor outcomes. The number of medications a person uses is a risk factor for adverse drug reactions, nonadherence, financial burden, drug-drug interactions, and worse outcomes.1

The prevalence of polypharmacy increased from an estimated 8.2% to 15% from 1999 to 2011 based on the National Health and Nutrition Examination Survey.2 Guideline-based therapy for specific diseases may lead to the addition of more medications to reach disease targets.3 Most older adults in the United States compound the risk of prescribed medications by also taking over-the-counter medications and dietary supplements.4

In addition, medications are often used in older adults based on studies of younger persons without significant comorbidities. Applying clinical guidelines based on these studies to older adults with comorbidity and functional impairment is challenging.5 Age-related pharmacokinetic and pharmacodynamic changes increase the risk of adverse drug reactions.6

In this article, we review commonly used medications that are potentially inappropriate based on clinical practice. We also review tools to evaluate appropriate drug therapy in older adults.

DRUGS THAT ARE COMMONLY USED, BUT POTENTIALLY INAPPROPRIATE

Statins

Statins are effective when used as secondary prevention in older adults,7 but their efficacy when used as primary prevention of atherosclerotic cardiovascular disease in people age 75 and older is questionable.8 Nevertheless, they are widely used for this purpose. For example, before the 2013 joint guidelines of the American College of Cardiology and the American Heart Association (ACC/AHA) were released, 22% of patients age 80 and older in the Geisinger health system were taking a statin for primary prevention.9

The 2013 ACC/AHA guidelines included a limited recommendation for statins for primary prevention of atherosclerotic cardiovascular disease in adults age 75 and older.10 The guideline noted, however, that few data were available to support this recommendation.10

In a systematic review of 18 randomized clinical trials of statins for primary prevention of atherosclerotic cardiovascular disease, the mean age was 57, yet conclusions were extrapolated to an older patient population.11 The estimated 10-year risk of atherosclerotic cardiovascular disease based on pooled cohort risk equations of adults age 75 and older always exceeds the 7.5% treatment threshold recommended by the guidelines.8

Myopathy is a common adverse effect of statins. In addition, statins interact with other drugs that inhibit the cytochrome P450 3A4 isoenzyme, such as amlodipine, amiodarone, and diltiazem.8,12 If statin therapy caused no functional limitation due to muscle pain or weakness, statins for primary prevention would be cost-effective, but even a small increase in adverse effects in an elderly patient can offset the cardiovascular benefit.13 A recent post hoc secondary analysis found no benefit of pravastatin for primary prevention in adults age 75 and older.14

Thus, statin treatment for primary prevention in older patients should be individualized, based on life expectancy, function, and cardiovascular risk. Statin therapy does not replace modification of other risk factors.

Anticholinergics

Drugs with strong anticholinergic properties

Drugs with anticholinergic properties are commonly prescribed in the elderly for conditions such as muscle spasm, overactive bladder, psychiatric disorders, insomnia, extrapyramidal symptoms, vertigo, pruritus, peptic ulcer disease, seasonal allergies, and even the common cold,15 and many of the drugs often prescribed have strong anticholinergic properties (Table 1). Taking multiple medications with anticholinergic properties results in a high “anticholinergic burden,” which is associated with falls, impulsive behavior, poor physical performance, loss of independence, dementia, delirium, and brain atrophy.15–18

The 2014 American College of Physicians guideline on nonsurgical management of urinary incontinence in women recommends pharmacologic treatment for urgency and stress urinary incontinence after failure of nonpharmacologic therapy,19 and many drugs for these urinary symptoms have anticholinergic properties. If an anticholinergic is necessary, an agent that results in a lower anticholinergic burden should be considered in older patients.

A pharmacist-initiated medication review and intervention may be another way to adjust medications to reduce the patient’s anticholinergic burden.20,21 The common use of anticholinergic drugs in older adults reminds us to monitor their use closely.22

 

 

Benzodiazepines and nonbenzodiazepines

Benzodiazepines are among the most commonly prescribed psychotropics in developed countries and are prescribed mainly by primary care physicians rather than psychiatrists.23

In 2008, 5.2% of US adults ages 18 to 80 used a benzodiazepine, and long-term use was more prevalent in older patients (ages 65–80).23

Benzodiazepines are prescribed for anxiety,24 insomnia,25 and agitation. They can cause withdrawal26 and have potential for abuse.27 Benzodiazepines are associated with cognitive decline,28 impaired driving,29 falls,30 and hip fractures31 in older adults.

In addition, use of nonbenzodiazepine hypnotics (eg, zolpidem) is on the rise,32 and these drugs are known to increase the risk of hip fracture in nursing home residents.33

The American Geriatrics Society, through the American Board of Internal Medicine’s Choosing Wisely campaign, recommends avoiding benzodiazepines as a first-line treatment for insomnia, agitation, or delirium in older adults.34 Yet prescribing practices with these drugs in primary care settings conflict with guidelines, partly due to lack of training in constructive strategies regarding appropriate use of benzodiazepines.35 Educating patients on the risks and benefits of benzodiazepine treatment, especially long-term use, has been shown to reduce the rate of benzodiazepine-associated secondary events.36

Antipsychotics

Off-label use of antipsychotics is common and is increasing in the United States. In 2008, off-label use of antipsychotic drugs accounted for an estimated $6 billion.37 A common off-label use is to manage behavioral symptoms of dementia, despite a black-box warning about an increased risk of death in patients with dementia who are treated with antipsychotics.38,39 The Choosing Wisely campaign recommends against prescribing antipsychotics as a first-line treatment of behavioral and psychological symptoms of dementia.34

Antipsychotic drugs are associated with risk of acute kidney injury,40 as well as increased risk of falls and fractures (eg, a 52% higher risk of a serious fall, and a 50% higher risk of a nonvertebral osteoporotic fracture).41

Patients with dementia often exhibit aggression, resistance to care, and other challenging or disruptive behaviors. In such instances, antipsychotic drugs are often prescribed, but they provide limited and inconsistent benefits, while causing oversedation and worsening of cognitive function and increasing the likelihood of falling, stroke, and death.38,39,41

Because pharmacologic treatments for dementia are only modestly effective, have notable risks, and do not treat some of the behaviors that family members and caregivers find most distressing, nonpharmacologic measures are recommended as first-line treatment.42 These include caregiver education and support, training in problem-solving, and targeted therapy directed at the underlying causes of specific behaviors (eg, implementing nighttime routines to address sleep disturbances).42 Nonpharmacologic management of behavioral symptoms in dementia can significantly improve quality of life for patients and caregivers.42 Use of antipsychotic drugs in patients with dementia should be limited to cases in which nonpharmacologic measures have failed and patients pose an imminent threat to themselves or others.43

Proton pump inhibitors

Proton pump inhibitors are among the most commonly prescribed medications in the United States, and their use has increased significantly over the decade. It has been estimated that between 25% and 70% of these prescriptions have no appropriate indication.44

There is considerable excess use of acid suppressants in both inpatient and outpatient settings.45,46 In one study, at discharge from an internal medicine service, almost half of patients were taking a proton pump inhibitor.47

Evidence-based guidelines recommend these drugs to treat gastroesophageal reflux disease, nonerosive reflux disease, erosive esophagitis, dyspepsia, and peptic ulcer disease. However, long-term use (ie, beyond 8 weeks) is recommended only for patients with erosive esophagitis, Barrett esophagus, a pathologic hypersecretory condition, or a demonstrated need for maintenance treatment for reflux disease.48

Although proton pump inhibitors are highly effective and have low toxicity, there are reports of an association with Clostridium difficile infection,49 community-acquired pneumonia,50 hip fracture,51 vitamin B12 deficiency,52 atrophic gastritis,53 kidney disease,54 and dementia.55

Nondrug therapies such as weight loss and elevation of the head of the bed may improve esophageal pH levels and reflux symptoms.56

Deprescribing.org has practical advice for healthcare providers, patients, and caregivers on how to discontinue proton pump inhibitors, including videos, algorithms, and guidelines.

TOOLS TO EVALUATE APPROPRIATE DRUG THERAPY

Beers criteria

The 2015 Beers criteria: Selected drugs to avoid in older adults

The Beers criteria (Table 2), developed in 1991 by a geriatrician as an approach to safer, more effective drug therapy in frail elderly nursing home patients,57 were updated by the American Geriatrics Society in 2015 for use in any clinical setting.58 (The criteria are also available as a smartphone application through the American Geriatrics Society at www.americangeriatrics.org.)

The Beers criteria offer evidence-based recommendations on drugs to avoid in the elderly, along with the rationale for use, the quality of evidence behind the recommendation, and the graded strength of the recommendation. The Beers criteria should be viewed through the lens of clinical judgment to offer safer nonpharmacologic and pharmacologic treatments.

The Joint Commission recommends medication reconciliation at every transition of care.59 The Beers criteria are a good starting point for a comprehensive medication review.

STOPP/START criteria

STOPP: Selected warnings and recommendations

Another tool to aid safe prescribing in older adults is the Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions (STOPP), used in conjuction with the Screening Tool to Alert Doctors to Right Treatment (START). The STOPP/START criteria60,61 are based on an up-to-date literature review and consensus (Table 3).

THE BOTTOM LINE

Physicians caring for older adults need to diligently weigh the benefits of drug therapy and consider the patient’s care goals, current level of functioning, life expectancy, values, and preferences. Statin therapy for primary prevention, anticholinergics, benzodiazepines, antipsychotics, and proton pump inhibitors are widely used without proper indications, pointing to the need for a periodic comprehensive review of medications to reevaluate the risks vs the benefits of the patient’s medications. The Beers criteria and the STOPP/ START criteria can be useful tools for this purpose.

References
  1. Steinman MA. Polypharmacy—time to get beyond numbers. JAMA Intern Med 2016; 176:482–483.
  2. Kantor ED, Rehm CD, Haas JS, Chan AT, Giovannucci EL. Trends in prescription drug use among adults in the United States from 1999–2012. JAMA 2015; 314:1818–1831.
  3. Tinetti ME, Bogardus ST Jr, Agostini JV. Potential pitfalls of disease-specific guidelines for patients with multiple conditions. N Engl J Med 2004; 351:2870–2874.
  4. Qato DM, Wilder J, Schumm LP, Gillet V, Alexander GC. Changes in prescription and over-the-counter medication and dietary supplement use among older adults in the United States, 2005 vs 2011. JAMA Intern Med 2016; 176:473–482.
  5. Boyd CM, Darer J, Boult C, et al. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA 2005; 294:716–724.
  6. Atkin PA, Veitch PC, Veitch EM, Ogle SJ. The epidemiology of serious adverse drug reactions among the elderly. Drugs Aging 1999; 14:141–152.
  7. Collins R, Reith C, Emberson J, et al. Interpretation of the evidence for the efficacy and safety of statin therapy. Lancet 2016; 338:2532–2561.
  8. Gurwitz JH, Go AS, Fortman SP. Statins for primary prevention in older adults: uncertainty and the need for more evidence. JAMA 2016; 316:1971–1972.
  9. Chokshi NP, Messerli FH, Sutin D, Supariwala AA, Shah NR. Appropriateness of statins in patients aged ≥ 80 years and comparison to other age groups. Am J Cardiol 2012; 110:1477–1481.
  10. Stone NJ, Robinson J, Lichtenstein AH, et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 129(suppl 2):S1–S45.
  11. Taylor F, Huffman MD, Macedo AF, et al. Statins for the primary prevention of cardiovascular disease. Cochrane Database Syst Rev 2013; 1:CD004816.
  12. Chatzizisis YS, Koskinas KC, Misirli G, Vaklavas C, Hatzitolios A, Giannoglou GD. Risk factors and drug interactions predisposing to statin-induced myopathy: implications for risk assessment, prevention and treatment. Drug Saf 2010; 33:171–187.
  13. Odden MC, Pletcher MJ, Coxson PG, et al. Cost-effectiveness and population impact of statins for primary prevention in adults aged 75 years or older in the United States. Ann Intern Med 2015; 162:533–541.
  14. Han BH, Sutin D, Williamson JD, et al. Effect of statin treatment vs usual care on primary cardiovascular prevention among older adults. The ALLHAT-LLT randomized clinical trial. JAMA Intern Med 2017; 177:955–965.
  15. Gray SL, Anderson ML, Dublin S, et al. Cumulative use of strong anticholinergics and incident dementia: a prospective cohort study. JAMA Intern Med 2015; 175:401–407.
  16. Rudolph JL, Salow MJ, Angelini MC, McGlinchey RE. The anticholinergic risk scale and anticholinergic adverse effects in older persons. Arch Intern Med 2008; 168:508–513.
  17. Hilmer SN, Mager DE, Simonsick EM, et al. A drug burden index to define the functional burden of medications in older people. Arch Intern Med 2007; 167:781–787.
  18. Risacher SL, McDonald BC, Tallman EF, et al; Alzheimer’s Disease Neuroimaging Initiative. Association between anticholinergic medication use and cognition, brain metabolism, and brain atrophy in cognitively normal older adults. JAMA Neurol 2016; 73:721–732.
  19. Qaseem A, Dallas P, Forciea MA, Starkey M, Denberg TD, Shekelle P; Clinical Guidelines Committee of the American College of Physicians. Nonsurgical management of urinary incontinence in women: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2014; 161:429–440.
  20. Efjestad AS, Molden E, Oksengard AR. Pharmacist-initiated management of antagonistic interactions between anticholinergic drugs and acetyl cholinesterase inhibitors in individuals with dementia. J Am Geriatr Soc 2013; 61:1624–1625.
  21. Kersten H, Molden E, Tolo IK, Skovlund E, Engedal K, Wyller TB. Cognitive effects of reducing anticholinergic drug burden in a frail elderly population: a randomized controlled trial. J Gerontol A Biol Sci Med Sci 2013; 68:271–278.
  22. Curtis LH, Østbye T, Sendersky V, et al. Inappropriate prescribing for elderly Americans in a large outpatient population. Arch Intern Med 2004; 164:1621–1625.
  23. Olfson M, King M, Schoenbaum M. Benzodiazepine use in the United States. JAMA Psychiatry 2015; 72:136–142.
  24. Martin JL, Sainz-Pardo M, Furukawa TA, Martín-Sánchez E, Seoane T, Galán C. Benzodiazepines in generalized anxiety disorder: heterogeneity of outcomes based on a systematic review and meta-analysis of clinical trials. J Psychopharmacol 2007; 21:774–782.
  25. Buscemi N, Vandermeer B, Friesen C, et al. The efficacy and safety of drug treatments for chronic insomnia in adults: a meta-analysis of RCTs. J Gen Intern Med 2007; 22:1335–1350.
  26. Rickels K, Schweizer E, Case WG, Greenblatt DJ. Long-term therapeutic use of benzodiazepines, I. Effects of abrupt discontinuation. Arch Gen Psychiatry 1990; 47:899–907.
  27. Fenton MC, Keyes KM, Martins SS, Hasin DS. The role of a prescription in anxiety medication use, abuse, and dependence. Am J Psychiatry 2010; 167:1247–1253.
  28. Billoti de Gage S, Moride Y, Ducruet T, et al. Benzodiazepine use and risk of Alzheimer’s disease: case-control study. BMJ 2014; 349:g5205.
  29. Smink BE, Egberts AC, Lusthof KJ, Uges DR, de Gier JJ. The relationship between benzodiazepine use and traffic accidents: a systemic literature review. CNS Drugs 2010; 24:639–653.
  30. Tinett, ME, Speechley M, Ginter S. Risk factors for falls among elderly persons living in the community. N Engl J Med 1988; 319:1701–1707.
  31. Zint K, Haefeli WE, Glynn RJ, Mogun H, Avorn J, Stürmer T. Impact of drug interactions, dosage, and duration of therapy on the risk of hip fracture associated with benzodiazepine use in older adults. Pharmacoepidemiol Drug Saf 2010; 19:1248–1255.
  32. Briesacher BA, Soumerai SB, Field TS, Fouayzi H, Gurwitz JH. Medicare Part D’s exclusion of benzodiazepines and fracture risk in nursing homes. Arch Intern Med 2010; 170:693–698.
  33. Berry SD, Lee Y, Cai S, Dore DD. Nonbenzodiazepine sleep medication use and hip fractures in nursing home residents. JAMA Intern Med 2013; 173:754–761.
  34. American Geriatrics Society. Choosing Wisely. Ten things clinicians and patients should question. www.choosingwisely.org/societies/american-geriatrics-society/. Accessed December 3, 2017.
  35. Cook JM, Marshall R, Masci C, Coyne JC. Physicians’ perspectives on prescribing benzodiazepines for older adults: a qualitative study. J Gen Intern Med 2007; 22:303–307.
  36. Tannenbaum C, Martin P, Tamblyn R, Benedetti A, Ahmed S. Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial. JAMA Intern Med 2014; 174:890–898.
  37. Alexander GC, Gallagher SA, Mascola A, Moloney RM, Stafford RS. Increasing off-label use of antipsychotic medications in the United States, 1995–2008. Phamacoepidemiol Drug Saf 2011; 20:177–184.
  38. Gill SS, Bronskill SE, Normand SL, et al. Antipsychotic drug use and mortality in older adults with dementia. Ann Intern Med 2007; 146:775–786.
  39. US Food and Drug Administration (FDA). Public health advisory: deaths with antipsychotics in elderly patients with behavioral disturbances. www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm053171.htm. Accessed December 4, 2017.
  40. Hwang YJ, Dixon SN, Reiss JP, et al. Atypical antipsychotic drugs and the risk for acute kidney injury and other adverse outcomes in older adults. Ann Intern Med 2014; 161:242–248.
  41. Fraser L, Liu K, Naylor KL, et al. Falls and fractures with atypical antipsychotic medication use: a population-based cohort study. JAMA Intern Med 2015; 175:450–452.
  42. Gitlin LN, Kales HC, Lyketsos CG. Nonpharmacologic management of behavioral symptoms in dementia. JAMA 2012; 308:2020–2029.
  43. Schneider LS, Tariot PN, Dagerman KS, et al; CATIE-AD Study Group. Effectiveness of atypical antipsychotic drugs in patients with Alzheimer’s disease. N Engl J Med 2006; 355:1525–1538.
  44. Forgacs I, Loganayagam A. Overprescribing proton pump inhibitors. BMJ 2008; 336:2–3.
  45. Mazer-Amirshahi M, Mullins PM, van den Anker J, Meltzer A, Pines JM. Rising rates of proton pump inhibitor prescribing in US emergency departments. Am J Emerg Med 2014; 32:618–622.
  46. Heidelbaugh JJ, Goldberg KL, Inadomi JM. Magnitude and economic effect of overuse of antisecretory therapy in the ambulatory care setting. Am J Manag Care 2010; 16:e228–e324.
  47. Pham CQ, Regal RE, Bostwich TR, Knauf KS. Acid suppressive therapy used on an inpatient internal medicine service. Ann Pharmacother 2006; 40:1261–1266.
  48. Kahrilas PJ, Shaheen NJ, Vaezi MF, et al; American Gastroenterological Association. American Gastroenterological Association medical position statement on the management of gastroesophageal reflux disease. Gastroenterology 2008; 135:1383–1391.e1–e5.
  49. Howell MD, Novack V, Grgurich P, et al. Iatrogenic gastric acid suppression and the risk of nosocomial Clostridium difficile infection. Arch Intern Med 2010; 170:784–790.
  50. Gulmez SE, Holm A, Frederiksen H, Jensen TG, Pedersen C, Hallas J. Use of proton pump inhibitors and the risk of community-acquired pneumonia: a population-based case-control study. Arch Intern Med 2007; 167:950–955.
  51. Yang YX, Lewis JD, Epstein S, Metz DC. Long-term proton pump inhibitor therapy and risk of hip fracture. JAMA 2006; 296:2947–2953.
  52. Lam JR, Schneider JL, Zhao W, Corley DA. Proton pump inhibitor and histamine 2 receptor antagonist use and vitamin B12 deficiency. JAMA 2013; 310:2435–2442.
  53. Kuipers EJ, Lundell L, Klinkenberg-Knol EC, et al. Atrophic gastritis and Helicobacter pylori infection in patients with reflux esophagitis treated with omeprazole or fundoplication. N Engl J Med 1996; 334:1018–1022.
  54. Lazarus B, Chen Y, Wilson FP, et al. Proton pump inhibitor use and the risk of chronic kidney disease. JAMA Intern Med 2016; 176:238–246.
  55. Gomm W, von Holt K, Thomé F, et al. Association of proton pump inhibitors with risk of dementia: a pharmacoepidemiological claims data analysis. JAMA Neurol 2016; 73:410–416.
  56. Kaltenbach T, Crockett S, Gerson LB. Are lifestyle measures effective in patients with gastroesophageal reflux disease? An evidence-based approach. Arch Intern Med 2006; 166:965–971.
  57. Beers MH, Ouslander JG, Rollingher I, Reuben DB, Brooks J, Beck JC. Explicit criteria for determining inappropriate medication use in nursing home residents. Arch Intern Med 1991; 151:1825–1832.
  58. American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2015; 63:2227–2246.
  59. Joint Commission. Sentinel event alert, Issue 35: using medication reconciliation to prevent errors. www.jointcommission.org/sentinel_event_alert_issue_35_using_medication_reconciliation_to_prevent_errors/. Accessed August 18, 2017.
  60. Gallagher P, Ryan C, Byrne S, Kennedy J, O’Mahony D. STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation. Int J Clin Pharmacol Ther 2008; 46:72–83.
  61. O’Mahony D, O’Sullivan D, Byrne S, O’Connor MN, Ryan C, Gallagher P. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing 2015; 44:213–218.
References
  1. Steinman MA. Polypharmacy—time to get beyond numbers. JAMA Intern Med 2016; 176:482–483.
  2. Kantor ED, Rehm CD, Haas JS, Chan AT, Giovannucci EL. Trends in prescription drug use among adults in the United States from 1999–2012. JAMA 2015; 314:1818–1831.
  3. Tinetti ME, Bogardus ST Jr, Agostini JV. Potential pitfalls of disease-specific guidelines for patients with multiple conditions. N Engl J Med 2004; 351:2870–2874.
  4. Qato DM, Wilder J, Schumm LP, Gillet V, Alexander GC. Changes in prescription and over-the-counter medication and dietary supplement use among older adults in the United States, 2005 vs 2011. JAMA Intern Med 2016; 176:473–482.
  5. Boyd CM, Darer J, Boult C, et al. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA 2005; 294:716–724.
  6. Atkin PA, Veitch PC, Veitch EM, Ogle SJ. The epidemiology of serious adverse drug reactions among the elderly. Drugs Aging 1999; 14:141–152.
  7. Collins R, Reith C, Emberson J, et al. Interpretation of the evidence for the efficacy and safety of statin therapy. Lancet 2016; 338:2532–2561.
  8. Gurwitz JH, Go AS, Fortman SP. Statins for primary prevention in older adults: uncertainty and the need for more evidence. JAMA 2016; 316:1971–1972.
  9. Chokshi NP, Messerli FH, Sutin D, Supariwala AA, Shah NR. Appropriateness of statins in patients aged ≥ 80 years and comparison to other age groups. Am J Cardiol 2012; 110:1477–1481.
  10. Stone NJ, Robinson J, Lichtenstein AH, et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 129(suppl 2):S1–S45.
  11. Taylor F, Huffman MD, Macedo AF, et al. Statins for the primary prevention of cardiovascular disease. Cochrane Database Syst Rev 2013; 1:CD004816.
  12. Chatzizisis YS, Koskinas KC, Misirli G, Vaklavas C, Hatzitolios A, Giannoglou GD. Risk factors and drug interactions predisposing to statin-induced myopathy: implications for risk assessment, prevention and treatment. Drug Saf 2010; 33:171–187.
  13. Odden MC, Pletcher MJ, Coxson PG, et al. Cost-effectiveness and population impact of statins for primary prevention in adults aged 75 years or older in the United States. Ann Intern Med 2015; 162:533–541.
  14. Han BH, Sutin D, Williamson JD, et al. Effect of statin treatment vs usual care on primary cardiovascular prevention among older adults. The ALLHAT-LLT randomized clinical trial. JAMA Intern Med 2017; 177:955–965.
  15. Gray SL, Anderson ML, Dublin S, et al. Cumulative use of strong anticholinergics and incident dementia: a prospective cohort study. JAMA Intern Med 2015; 175:401–407.
  16. Rudolph JL, Salow MJ, Angelini MC, McGlinchey RE. The anticholinergic risk scale and anticholinergic adverse effects in older persons. Arch Intern Med 2008; 168:508–513.
  17. Hilmer SN, Mager DE, Simonsick EM, et al. A drug burden index to define the functional burden of medications in older people. Arch Intern Med 2007; 167:781–787.
  18. Risacher SL, McDonald BC, Tallman EF, et al; Alzheimer’s Disease Neuroimaging Initiative. Association between anticholinergic medication use and cognition, brain metabolism, and brain atrophy in cognitively normal older adults. JAMA Neurol 2016; 73:721–732.
  19. Qaseem A, Dallas P, Forciea MA, Starkey M, Denberg TD, Shekelle P; Clinical Guidelines Committee of the American College of Physicians. Nonsurgical management of urinary incontinence in women: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2014; 161:429–440.
  20. Efjestad AS, Molden E, Oksengard AR. Pharmacist-initiated management of antagonistic interactions between anticholinergic drugs and acetyl cholinesterase inhibitors in individuals with dementia. J Am Geriatr Soc 2013; 61:1624–1625.
  21. Kersten H, Molden E, Tolo IK, Skovlund E, Engedal K, Wyller TB. Cognitive effects of reducing anticholinergic drug burden in a frail elderly population: a randomized controlled trial. J Gerontol A Biol Sci Med Sci 2013; 68:271–278.
  22. Curtis LH, Østbye T, Sendersky V, et al. Inappropriate prescribing for elderly Americans in a large outpatient population. Arch Intern Med 2004; 164:1621–1625.
  23. Olfson M, King M, Schoenbaum M. Benzodiazepine use in the United States. JAMA Psychiatry 2015; 72:136–142.
  24. Martin JL, Sainz-Pardo M, Furukawa TA, Martín-Sánchez E, Seoane T, Galán C. Benzodiazepines in generalized anxiety disorder: heterogeneity of outcomes based on a systematic review and meta-analysis of clinical trials. J Psychopharmacol 2007; 21:774–782.
  25. Buscemi N, Vandermeer B, Friesen C, et al. The efficacy and safety of drug treatments for chronic insomnia in adults: a meta-analysis of RCTs. J Gen Intern Med 2007; 22:1335–1350.
  26. Rickels K, Schweizer E, Case WG, Greenblatt DJ. Long-term therapeutic use of benzodiazepines, I. Effects of abrupt discontinuation. Arch Gen Psychiatry 1990; 47:899–907.
  27. Fenton MC, Keyes KM, Martins SS, Hasin DS. The role of a prescription in anxiety medication use, abuse, and dependence. Am J Psychiatry 2010; 167:1247–1253.
  28. Billoti de Gage S, Moride Y, Ducruet T, et al. Benzodiazepine use and risk of Alzheimer’s disease: case-control study. BMJ 2014; 349:g5205.
  29. Smink BE, Egberts AC, Lusthof KJ, Uges DR, de Gier JJ. The relationship between benzodiazepine use and traffic accidents: a systemic literature review. CNS Drugs 2010; 24:639–653.
  30. Tinett, ME, Speechley M, Ginter S. Risk factors for falls among elderly persons living in the community. N Engl J Med 1988; 319:1701–1707.
  31. Zint K, Haefeli WE, Glynn RJ, Mogun H, Avorn J, Stürmer T. Impact of drug interactions, dosage, and duration of therapy on the risk of hip fracture associated with benzodiazepine use in older adults. Pharmacoepidemiol Drug Saf 2010; 19:1248–1255.
  32. Briesacher BA, Soumerai SB, Field TS, Fouayzi H, Gurwitz JH. Medicare Part D’s exclusion of benzodiazepines and fracture risk in nursing homes. Arch Intern Med 2010; 170:693–698.
  33. Berry SD, Lee Y, Cai S, Dore DD. Nonbenzodiazepine sleep medication use and hip fractures in nursing home residents. JAMA Intern Med 2013; 173:754–761.
  34. American Geriatrics Society. Choosing Wisely. Ten things clinicians and patients should question. www.choosingwisely.org/societies/american-geriatrics-society/. Accessed December 3, 2017.
  35. Cook JM, Marshall R, Masci C, Coyne JC. Physicians’ perspectives on prescribing benzodiazepines for older adults: a qualitative study. J Gen Intern Med 2007; 22:303–307.
  36. Tannenbaum C, Martin P, Tamblyn R, Benedetti A, Ahmed S. Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial. JAMA Intern Med 2014; 174:890–898.
  37. Alexander GC, Gallagher SA, Mascola A, Moloney RM, Stafford RS. Increasing off-label use of antipsychotic medications in the United States, 1995–2008. Phamacoepidemiol Drug Saf 2011; 20:177–184.
  38. Gill SS, Bronskill SE, Normand SL, et al. Antipsychotic drug use and mortality in older adults with dementia. Ann Intern Med 2007; 146:775–786.
  39. US Food and Drug Administration (FDA). Public health advisory: deaths with antipsychotics in elderly patients with behavioral disturbances. www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm053171.htm. Accessed December 4, 2017.
  40. Hwang YJ, Dixon SN, Reiss JP, et al. Atypical antipsychotic drugs and the risk for acute kidney injury and other adverse outcomes in older adults. Ann Intern Med 2014; 161:242–248.
  41. Fraser L, Liu K, Naylor KL, et al. Falls and fractures with atypical antipsychotic medication use: a population-based cohort study. JAMA Intern Med 2015; 175:450–452.
  42. Gitlin LN, Kales HC, Lyketsos CG. Nonpharmacologic management of behavioral symptoms in dementia. JAMA 2012; 308:2020–2029.
  43. Schneider LS, Tariot PN, Dagerman KS, et al; CATIE-AD Study Group. Effectiveness of atypical antipsychotic drugs in patients with Alzheimer’s disease. N Engl J Med 2006; 355:1525–1538.
  44. Forgacs I, Loganayagam A. Overprescribing proton pump inhibitors. BMJ 2008; 336:2–3.
  45. Mazer-Amirshahi M, Mullins PM, van den Anker J, Meltzer A, Pines JM. Rising rates of proton pump inhibitor prescribing in US emergency departments. Am J Emerg Med 2014; 32:618–622.
  46. Heidelbaugh JJ, Goldberg KL, Inadomi JM. Magnitude and economic effect of overuse of antisecretory therapy in the ambulatory care setting. Am J Manag Care 2010; 16:e228–e324.
  47. Pham CQ, Regal RE, Bostwich TR, Knauf KS. Acid suppressive therapy used on an inpatient internal medicine service. Ann Pharmacother 2006; 40:1261–1266.
  48. Kahrilas PJ, Shaheen NJ, Vaezi MF, et al; American Gastroenterological Association. American Gastroenterological Association medical position statement on the management of gastroesophageal reflux disease. Gastroenterology 2008; 135:1383–1391.e1–e5.
  49. Howell MD, Novack V, Grgurich P, et al. Iatrogenic gastric acid suppression and the risk of nosocomial Clostridium difficile infection. Arch Intern Med 2010; 170:784–790.
  50. Gulmez SE, Holm A, Frederiksen H, Jensen TG, Pedersen C, Hallas J. Use of proton pump inhibitors and the risk of community-acquired pneumonia: a population-based case-control study. Arch Intern Med 2007; 167:950–955.
  51. Yang YX, Lewis JD, Epstein S, Metz DC. Long-term proton pump inhibitor therapy and risk of hip fracture. JAMA 2006; 296:2947–2953.
  52. Lam JR, Schneider JL, Zhao W, Corley DA. Proton pump inhibitor and histamine 2 receptor antagonist use and vitamin B12 deficiency. JAMA 2013; 310:2435–2442.
  53. Kuipers EJ, Lundell L, Klinkenberg-Knol EC, et al. Atrophic gastritis and Helicobacter pylori infection in patients with reflux esophagitis treated with omeprazole or fundoplication. N Engl J Med 1996; 334:1018–1022.
  54. Lazarus B, Chen Y, Wilson FP, et al. Proton pump inhibitor use and the risk of chronic kidney disease. JAMA Intern Med 2016; 176:238–246.
  55. Gomm W, von Holt K, Thomé F, et al. Association of proton pump inhibitors with risk of dementia: a pharmacoepidemiological claims data analysis. JAMA Neurol 2016; 73:410–416.
  56. Kaltenbach T, Crockett S, Gerson LB. Are lifestyle measures effective in patients with gastroesophageal reflux disease? An evidence-based approach. Arch Intern Med 2006; 166:965–971.
  57. Beers MH, Ouslander JG, Rollingher I, Reuben DB, Brooks J, Beck JC. Explicit criteria for determining inappropriate medication use in nursing home residents. Arch Intern Med 1991; 151:1825–1832.
  58. American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2015; 63:2227–2246.
  59. Joint Commission. Sentinel event alert, Issue 35: using medication reconciliation to prevent errors. www.jointcommission.org/sentinel_event_alert_issue_35_using_medication_reconciliation_to_prevent_errors/. Accessed August 18, 2017.
  60. Gallagher P, Ryan C, Byrne S, Kennedy J, O’Mahony D. STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation. Int J Clin Pharmacol Ther 2008; 46:72–83.
  61. O’Mahony D, O’Sullivan D, Byrne S, O’Connor MN, Ryan C, Gallagher P. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing 2015; 44:213–218.
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  • Statins, anticholinergics, benzodiazepines, antipsychotics, and proton pump inhibitors are widely prescribed.
  • In older patients, a periodic comprehensive medication review is needed to reevaluate the risks and the benefits of current medications in light of goals of care, life expectancy, and the patient’s preferences.
  • The Beers criteria and the Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions provide valuable guidance for safe prescribing in older adults.
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When should I discuss driving with my older patients?

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When should I discuss driving with my older patients?

Most older drivers are safe drivers and are less likely than younger people to drive recklessly, at high speeds, or under the influence of alcohol.1 However, motor vehicle injuries are the second leading cause of injury-related deaths among older adults. Very old adults (80 years and over) have higher rates of fatality and injury in motor vehicle crashes per million miles driven than any other age group except for teenagers.1 Therefore, consider safety screening of all very old drivers plus any older adult with certain high-risk medical conditions, including the following.

NEUROCOGNITIVE DISORDERS

Drivers with Alzheimer disease—the most common type of major neurocognitive disorder (dementia) in older adults in the United States—are at high risk for adverse driving events due to impaired memory, attentiveness, problem-solving skills, multitasking, orientation, judgment, and reaction speed. Even in amnesic mild cognitive impairment—a mild neurocognitive disorder without functional decline—driving skills such as lane control may be impaired.2

Frontotemporal dementia, a less common cause of dementia in older adults, is associated with profound impairments in reasoning, task flexibility, planning, and execution. Persons with frontotemporal dementia are more likely to speed, run stop signs, and suffer more off-road crashes and collisions.3

Discuss driving safety with any patient age 80 or older or one with specific conditions

The diagnosis of dementia, however, is less predictive of driving risk than the stage of dementia. The American Academy of Neurology recommends that health care providers clinically “stage” all demented individuals using a validated tool at diagnosis and periodically afterwards. The Clinical Dementia Rating (CDR) scale is appropriate for staging dementia in the office. The CDR has also been shown to identify people with dementia who are at an increased risk of unsafe driving, with strong  evidence (level of evidence A) relating dementia stage to driving risk.4 The CDR assigns a score of 1 for mild dementia (function impaired in at least one complex activity); 2 for moderate dementia (function impaired in at least one basic activity); and 3 for severe dementia. Individuals with a CDR score of 2 or higher are considered to be at very high risk if still driving. These persons should be encouraged to surrender their driving privileges.4 Even with mild dementia (CDR score of 1), as few as 41% of drivers may drive safely.4 Most persons with mild cognitive impairment (CDR score of 0.5) are safe drivers.

Patients often have poor insight into their driving safety. However, a caregiver’s rating of driving skills as marginal or unsafe is useful in identifying unsafe drivers (level of evidence B) and can be considered a red flag.4 Predictors with less support in the literature (level of evidence C) include recent traffic citations, motor vehicle accidents, and self-reported situational avoidance, such as limiting driving to familiar roadways. Additional predictors include Mini-Mental State Examination scores of 24 or less, and/or the emergence of an aggressive or impulsive personality (Table 1). A driver evaluation is helpful when there is mild cognitive impairment or mild dementia with at least one red flag.

Clinicians who are not comfortable with staging dementia as mild, moderate, or severe may consider referring to a neurologist or geriatrician.

There is no evidence to support or refute the benefit of interventional strategies such as driver rehabilitation for drivers with dementia.

PARKINSON DISEASE

Individuals with mild motor disability from Parkinson disease may be fit drivers. As the disease progresses, drivers with Parkinson disease may make more errors than healthy elders in visual scanning, signaling, vehicle positioning, and velocity regulation (eg, traveling so slowly that it may be unsafe).5 Clinicians can consider referring a patient with Parkinson disease for a baseline driving evaluation upon diagnosis, and then every 1 to 2 years for reassessment. Alternate transportation should be arranged as the disease progresses.

 

 

EPISODIC INCAPACITATION

Approximately 1% to 3% of all motor vehicle accidents are due to sudden incapacitation of an otherwise safe driver.

Syncope. Neurally mediated (vasovagal) syncope accounts for 30% to 35% of syncopal episodes while driving.6 Cardiac arrhythmias are the next most common cause and include bradyarrhythmias (7%), supraventricular tachyarrhythmias (2%–15%), and ventricular tachyarrhythmias (5%–17%). Because neurocardiogenic syncope often recurs, consider restricting driving for those with recurrent or severe neurocardiogenic syncopal episodes until symptoms are controlled.

Arrhythmias. Driving recommendations for various arrhythmias7,8 are listed in Table 2.

Many patients who have an implantable cardioverter-defibrillator (ICD) device experience an unexpected shock. For individuals with a history of ventricular tachycardia or fibrillation, the 5-year actuarial incidence of appropriate ICD shocks ranges between 55% and 70%. However, data indicate that 90% to 100% of drivers who received ICD discharges while driving continued to drive without causing motor vehicle accidents.9,10

Seizures. States differ in their rules for reporting drivers who have epilepsy or breakthrough seizures. Physicians should refer to their state regulations when counseling these patients.

POLYPHARMACY

Polypharmacy is common in older adults. Many take psychoactive drugs that can impair tracking, alertness, coordination, and reaction time. With the “Roadwise Rx” tool  (www.roadwiserx.com), health care providers and patients can enter the names of medicines to check if they affect driving ability. Nonproprietary on-line tools such as “START” (Screening Tool to Alert doctors to Right Treatment) and “STOPP” (Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions) can be used to prune medication lists.

DRIVING EVALUATION

America is a nation of highways overflowing with cars. Cars provide transportation but also reflect wealth and personality, particularly for men. Practically, the ability to drive a car allows older men and women to socialize in the community, shop for essentials, and take care of themselves without being a burden. Driving cessation can cause social isolation and depressive symptoms and can strain caregiver resources.

Patients’ self-rating of driving correlates poorly with caregivers’ ratings

It is therefore understandable for health care providers to feel reluctant or uncomfortable counseling older adults to give up their driving privileges. A health care provider who identifies driving safety concerns can refer a patient to a geriatrician for further risk  assessment or to a certified driver rehabilitation specialist (CDRS) for a driving evaluation. A CDRS will also offer the patient and caregiver information on local resources for transportation alternatives. A list of local CDRSs can be found on the Association for Driver Rehabilitation Specialists website (www.aded.net). Many hospitals have occupational therapists who are CDRSs.

The evaluation typically involves an assessment of the driver’s knowledge of traffic signs and laws, a cognitive assessment, possibly a simulation, and finally an on-road driving evaluation if deemed appropriate. Medicare coverage depends on diagnosis and the state carrier.

References
  1. Williams AF. Teenage drivers: patterns of risk. J Safety Res 2003; 34:5–15.
  2. Griffith HR, Okonkwo OC, Stewart CC, et al. Lower hippocampal volume predicts decrements in lane control among drivers with amnestic mild cognitive impairment. J Geriatr Psychiatry Neurol 2013; 26:259–266.
  3. de Simone V, Kaplan L, Patronas N, Wassermann EM, Grafman J. Driving abilities in frontotemporal dementia patients. Dement Geriatr Cogn Disord 2007; 23:1–7.
  4. Iverson DJ, Gronseth GS, Reger MA, Classen S, Dubinsky RM, Rizzo M; Quality Standards Subcomittee of the American Academy of Neurology. Practice parameter update: evaluation and management of driving risk in dementia: report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2010; 74:1316–1324.
  5. Classen S, Brumback B, Monahan M, et al. Driving errors in Parkinson’s disease: moving closer to predicting on-road outcomes. Am J Occup Ther 2014; 68:77–85.
  6. Blitzer ML, Saliba BC, Ghantous AE, Marieb MA, Schoenfeld MH. Causes of impaired consciousness while driving a motorized vehicle. Am J Cardiol 2003; 91:1373–1374.
  7. Sorajja D, Shen WK. Driving guidelines and restrictions in patients with a history of cardiac arrhythmias, syncope,or implantable devices. Curr Treat Options Cardiovasc Med 2010; 12:443–456.
  8. Task force members; Vijgen J, Botto G, Camm J, et al. Consensus statement of the European Heart Rhythm Association: updated recommendations for driving by patients with implantable cardioverter defibrillators. Europace 2009; 11:1097–1107.
  9. Conti JB, Woodard DA, Tucker KJ, Bryant B, King LC, Curtis AB. Modification of patient driving behavior after implantation of a cardioverter defibrillator. Pacing Clin Electrophysiol 1997; 20:2200–2204.
  10. Lerecouvreux M, Aït Saïd M, Paziaud O, et al. Automobile driving and implantable defibrillators. Arch Mal Coeur Vaiss 2005; 98:288–293. Article in French.
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Barbara J. Messinger-Rapport, MD, PhD
Associate Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University; Director of Center for Geriatric Medicine, Cleveland Clinic. Review Committee, AMA Physician’s Guide to Assessing and Counseling Older Drivers

Quratulain Syed, MD
Assistant Professor of Medicine, Division of General Medicine and Geriatrics, Emory University School of Medicine, Atlanta, GA

Address: Quratulain Syed, MD, Emory School of Medicine, 1648 Pierce Dr. NE, Atlanta, GA 30322; e-mail: quratulain.syed@emory.edu

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Barbara J. Messinger-Rapport, MD, PhD
Associate Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University; Director of Center for Geriatric Medicine, Cleveland Clinic. Review Committee, AMA Physician’s Guide to Assessing and Counseling Older Drivers

Quratulain Syed, MD
Assistant Professor of Medicine, Division of General Medicine and Geriatrics, Emory University School of Medicine, Atlanta, GA

Address: Quratulain Syed, MD, Emory School of Medicine, 1648 Pierce Dr. NE, Atlanta, GA 30322; e-mail: quratulain.syed@emory.edu

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Department of Internal Medicine, Cleveland Clinic

Barbara J. Messinger-Rapport, MD, PhD
Associate Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University; Director of Center for Geriatric Medicine, Cleveland Clinic. Review Committee, AMA Physician’s Guide to Assessing and Counseling Older Drivers

Quratulain Syed, MD
Assistant Professor of Medicine, Division of General Medicine and Geriatrics, Emory University School of Medicine, Atlanta, GA

Address: Quratulain Syed, MD, Emory School of Medicine, 1648 Pierce Dr. NE, Atlanta, GA 30322; e-mail: quratulain.syed@emory.edu

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Related Articles

Most older drivers are safe drivers and are less likely than younger people to drive recklessly, at high speeds, or under the influence of alcohol.1 However, motor vehicle injuries are the second leading cause of injury-related deaths among older adults. Very old adults (80 years and over) have higher rates of fatality and injury in motor vehicle crashes per million miles driven than any other age group except for teenagers.1 Therefore, consider safety screening of all very old drivers plus any older adult with certain high-risk medical conditions, including the following.

NEUROCOGNITIVE DISORDERS

Drivers with Alzheimer disease—the most common type of major neurocognitive disorder (dementia) in older adults in the United States—are at high risk for adverse driving events due to impaired memory, attentiveness, problem-solving skills, multitasking, orientation, judgment, and reaction speed. Even in amnesic mild cognitive impairment—a mild neurocognitive disorder without functional decline—driving skills such as lane control may be impaired.2

Frontotemporal dementia, a less common cause of dementia in older adults, is associated with profound impairments in reasoning, task flexibility, planning, and execution. Persons with frontotemporal dementia are more likely to speed, run stop signs, and suffer more off-road crashes and collisions.3

Discuss driving safety with any patient age 80 or older or one with specific conditions

The diagnosis of dementia, however, is less predictive of driving risk than the stage of dementia. The American Academy of Neurology recommends that health care providers clinically “stage” all demented individuals using a validated tool at diagnosis and periodically afterwards. The Clinical Dementia Rating (CDR) scale is appropriate for staging dementia in the office. The CDR has also been shown to identify people with dementia who are at an increased risk of unsafe driving, with strong  evidence (level of evidence A) relating dementia stage to driving risk.4 The CDR assigns a score of 1 for mild dementia (function impaired in at least one complex activity); 2 for moderate dementia (function impaired in at least one basic activity); and 3 for severe dementia. Individuals with a CDR score of 2 or higher are considered to be at very high risk if still driving. These persons should be encouraged to surrender their driving privileges.4 Even with mild dementia (CDR score of 1), as few as 41% of drivers may drive safely.4 Most persons with mild cognitive impairment (CDR score of 0.5) are safe drivers.

Patients often have poor insight into their driving safety. However, a caregiver’s rating of driving skills as marginal or unsafe is useful in identifying unsafe drivers (level of evidence B) and can be considered a red flag.4 Predictors with less support in the literature (level of evidence C) include recent traffic citations, motor vehicle accidents, and self-reported situational avoidance, such as limiting driving to familiar roadways. Additional predictors include Mini-Mental State Examination scores of 24 or less, and/or the emergence of an aggressive or impulsive personality (Table 1). A driver evaluation is helpful when there is mild cognitive impairment or mild dementia with at least one red flag.

Clinicians who are not comfortable with staging dementia as mild, moderate, or severe may consider referring to a neurologist or geriatrician.

There is no evidence to support or refute the benefit of interventional strategies such as driver rehabilitation for drivers with dementia.

PARKINSON DISEASE

Individuals with mild motor disability from Parkinson disease may be fit drivers. As the disease progresses, drivers with Parkinson disease may make more errors than healthy elders in visual scanning, signaling, vehicle positioning, and velocity regulation (eg, traveling so slowly that it may be unsafe).5 Clinicians can consider referring a patient with Parkinson disease for a baseline driving evaluation upon diagnosis, and then every 1 to 2 years for reassessment. Alternate transportation should be arranged as the disease progresses.

 

 

EPISODIC INCAPACITATION

Approximately 1% to 3% of all motor vehicle accidents are due to sudden incapacitation of an otherwise safe driver.

Syncope. Neurally mediated (vasovagal) syncope accounts for 30% to 35% of syncopal episodes while driving.6 Cardiac arrhythmias are the next most common cause and include bradyarrhythmias (7%), supraventricular tachyarrhythmias (2%–15%), and ventricular tachyarrhythmias (5%–17%). Because neurocardiogenic syncope often recurs, consider restricting driving for those with recurrent or severe neurocardiogenic syncopal episodes until symptoms are controlled.

Arrhythmias. Driving recommendations for various arrhythmias7,8 are listed in Table 2.

Many patients who have an implantable cardioverter-defibrillator (ICD) device experience an unexpected shock. For individuals with a history of ventricular tachycardia or fibrillation, the 5-year actuarial incidence of appropriate ICD shocks ranges between 55% and 70%. However, data indicate that 90% to 100% of drivers who received ICD discharges while driving continued to drive without causing motor vehicle accidents.9,10

Seizures. States differ in their rules for reporting drivers who have epilepsy or breakthrough seizures. Physicians should refer to their state regulations when counseling these patients.

POLYPHARMACY

Polypharmacy is common in older adults. Many take psychoactive drugs that can impair tracking, alertness, coordination, and reaction time. With the “Roadwise Rx” tool  (www.roadwiserx.com), health care providers and patients can enter the names of medicines to check if they affect driving ability. Nonproprietary on-line tools such as “START” (Screening Tool to Alert doctors to Right Treatment) and “STOPP” (Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions) can be used to prune medication lists.

DRIVING EVALUATION

America is a nation of highways overflowing with cars. Cars provide transportation but also reflect wealth and personality, particularly for men. Practically, the ability to drive a car allows older men and women to socialize in the community, shop for essentials, and take care of themselves without being a burden. Driving cessation can cause social isolation and depressive symptoms and can strain caregiver resources.

Patients’ self-rating of driving correlates poorly with caregivers’ ratings

It is therefore understandable for health care providers to feel reluctant or uncomfortable counseling older adults to give up their driving privileges. A health care provider who identifies driving safety concerns can refer a patient to a geriatrician for further risk  assessment or to a certified driver rehabilitation specialist (CDRS) for a driving evaluation. A CDRS will also offer the patient and caregiver information on local resources for transportation alternatives. A list of local CDRSs can be found on the Association for Driver Rehabilitation Specialists website (www.aded.net). Many hospitals have occupational therapists who are CDRSs.

The evaluation typically involves an assessment of the driver’s knowledge of traffic signs and laws, a cognitive assessment, possibly a simulation, and finally an on-road driving evaluation if deemed appropriate. Medicare coverage depends on diagnosis and the state carrier.

Most older drivers are safe drivers and are less likely than younger people to drive recklessly, at high speeds, or under the influence of alcohol.1 However, motor vehicle injuries are the second leading cause of injury-related deaths among older adults. Very old adults (80 years and over) have higher rates of fatality and injury in motor vehicle crashes per million miles driven than any other age group except for teenagers.1 Therefore, consider safety screening of all very old drivers plus any older adult with certain high-risk medical conditions, including the following.

NEUROCOGNITIVE DISORDERS

Drivers with Alzheimer disease—the most common type of major neurocognitive disorder (dementia) in older adults in the United States—are at high risk for adverse driving events due to impaired memory, attentiveness, problem-solving skills, multitasking, orientation, judgment, and reaction speed. Even in amnesic mild cognitive impairment—a mild neurocognitive disorder without functional decline—driving skills such as lane control may be impaired.2

Frontotemporal dementia, a less common cause of dementia in older adults, is associated with profound impairments in reasoning, task flexibility, planning, and execution. Persons with frontotemporal dementia are more likely to speed, run stop signs, and suffer more off-road crashes and collisions.3

Discuss driving safety with any patient age 80 or older or one with specific conditions

The diagnosis of dementia, however, is less predictive of driving risk than the stage of dementia. The American Academy of Neurology recommends that health care providers clinically “stage” all demented individuals using a validated tool at diagnosis and periodically afterwards. The Clinical Dementia Rating (CDR) scale is appropriate for staging dementia in the office. The CDR has also been shown to identify people with dementia who are at an increased risk of unsafe driving, with strong  evidence (level of evidence A) relating dementia stage to driving risk.4 The CDR assigns a score of 1 for mild dementia (function impaired in at least one complex activity); 2 for moderate dementia (function impaired in at least one basic activity); and 3 for severe dementia. Individuals with a CDR score of 2 or higher are considered to be at very high risk if still driving. These persons should be encouraged to surrender their driving privileges.4 Even with mild dementia (CDR score of 1), as few as 41% of drivers may drive safely.4 Most persons with mild cognitive impairment (CDR score of 0.5) are safe drivers.

Patients often have poor insight into their driving safety. However, a caregiver’s rating of driving skills as marginal or unsafe is useful in identifying unsafe drivers (level of evidence B) and can be considered a red flag.4 Predictors with less support in the literature (level of evidence C) include recent traffic citations, motor vehicle accidents, and self-reported situational avoidance, such as limiting driving to familiar roadways. Additional predictors include Mini-Mental State Examination scores of 24 or less, and/or the emergence of an aggressive or impulsive personality (Table 1). A driver evaluation is helpful when there is mild cognitive impairment or mild dementia with at least one red flag.

Clinicians who are not comfortable with staging dementia as mild, moderate, or severe may consider referring to a neurologist or geriatrician.

There is no evidence to support or refute the benefit of interventional strategies such as driver rehabilitation for drivers with dementia.

PARKINSON DISEASE

Individuals with mild motor disability from Parkinson disease may be fit drivers. As the disease progresses, drivers with Parkinson disease may make more errors than healthy elders in visual scanning, signaling, vehicle positioning, and velocity regulation (eg, traveling so slowly that it may be unsafe).5 Clinicians can consider referring a patient with Parkinson disease for a baseline driving evaluation upon diagnosis, and then every 1 to 2 years for reassessment. Alternate transportation should be arranged as the disease progresses.

 

 

EPISODIC INCAPACITATION

Approximately 1% to 3% of all motor vehicle accidents are due to sudden incapacitation of an otherwise safe driver.

Syncope. Neurally mediated (vasovagal) syncope accounts for 30% to 35% of syncopal episodes while driving.6 Cardiac arrhythmias are the next most common cause and include bradyarrhythmias (7%), supraventricular tachyarrhythmias (2%–15%), and ventricular tachyarrhythmias (5%–17%). Because neurocardiogenic syncope often recurs, consider restricting driving for those with recurrent or severe neurocardiogenic syncopal episodes until symptoms are controlled.

Arrhythmias. Driving recommendations for various arrhythmias7,8 are listed in Table 2.

Many patients who have an implantable cardioverter-defibrillator (ICD) device experience an unexpected shock. For individuals with a history of ventricular tachycardia or fibrillation, the 5-year actuarial incidence of appropriate ICD shocks ranges between 55% and 70%. However, data indicate that 90% to 100% of drivers who received ICD discharges while driving continued to drive without causing motor vehicle accidents.9,10

Seizures. States differ in their rules for reporting drivers who have epilepsy or breakthrough seizures. Physicians should refer to their state regulations when counseling these patients.

POLYPHARMACY

Polypharmacy is common in older adults. Many take psychoactive drugs that can impair tracking, alertness, coordination, and reaction time. With the “Roadwise Rx” tool  (www.roadwiserx.com), health care providers and patients can enter the names of medicines to check if they affect driving ability. Nonproprietary on-line tools such as “START” (Screening Tool to Alert doctors to Right Treatment) and “STOPP” (Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions) can be used to prune medication lists.

DRIVING EVALUATION

America is a nation of highways overflowing with cars. Cars provide transportation but also reflect wealth and personality, particularly for men. Practically, the ability to drive a car allows older men and women to socialize in the community, shop for essentials, and take care of themselves without being a burden. Driving cessation can cause social isolation and depressive symptoms and can strain caregiver resources.

Patients’ self-rating of driving correlates poorly with caregivers’ ratings

It is therefore understandable for health care providers to feel reluctant or uncomfortable counseling older adults to give up their driving privileges. A health care provider who identifies driving safety concerns can refer a patient to a geriatrician for further risk  assessment or to a certified driver rehabilitation specialist (CDRS) for a driving evaluation. A CDRS will also offer the patient and caregiver information on local resources for transportation alternatives. A list of local CDRSs can be found on the Association for Driver Rehabilitation Specialists website (www.aded.net). Many hospitals have occupational therapists who are CDRSs.

The evaluation typically involves an assessment of the driver’s knowledge of traffic signs and laws, a cognitive assessment, possibly a simulation, and finally an on-road driving evaluation if deemed appropriate. Medicare coverage depends on diagnosis and the state carrier.

References
  1. Williams AF. Teenage drivers: patterns of risk. J Safety Res 2003; 34:5–15.
  2. Griffith HR, Okonkwo OC, Stewart CC, et al. Lower hippocampal volume predicts decrements in lane control among drivers with amnestic mild cognitive impairment. J Geriatr Psychiatry Neurol 2013; 26:259–266.
  3. de Simone V, Kaplan L, Patronas N, Wassermann EM, Grafman J. Driving abilities in frontotemporal dementia patients. Dement Geriatr Cogn Disord 2007; 23:1–7.
  4. Iverson DJ, Gronseth GS, Reger MA, Classen S, Dubinsky RM, Rizzo M; Quality Standards Subcomittee of the American Academy of Neurology. Practice parameter update: evaluation and management of driving risk in dementia: report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2010; 74:1316–1324.
  5. Classen S, Brumback B, Monahan M, et al. Driving errors in Parkinson’s disease: moving closer to predicting on-road outcomes. Am J Occup Ther 2014; 68:77–85.
  6. Blitzer ML, Saliba BC, Ghantous AE, Marieb MA, Schoenfeld MH. Causes of impaired consciousness while driving a motorized vehicle. Am J Cardiol 2003; 91:1373–1374.
  7. Sorajja D, Shen WK. Driving guidelines and restrictions in patients with a history of cardiac arrhythmias, syncope,or implantable devices. Curr Treat Options Cardiovasc Med 2010; 12:443–456.
  8. Task force members; Vijgen J, Botto G, Camm J, et al. Consensus statement of the European Heart Rhythm Association: updated recommendations for driving by patients with implantable cardioverter defibrillators. Europace 2009; 11:1097–1107.
  9. Conti JB, Woodard DA, Tucker KJ, Bryant B, King LC, Curtis AB. Modification of patient driving behavior after implantation of a cardioverter defibrillator. Pacing Clin Electrophysiol 1997; 20:2200–2204.
  10. Lerecouvreux M, Aït Saïd M, Paziaud O, et al. Automobile driving and implantable defibrillators. Arch Mal Coeur Vaiss 2005; 98:288–293. Article in French.
References
  1. Williams AF. Teenage drivers: patterns of risk. J Safety Res 2003; 34:5–15.
  2. Griffith HR, Okonkwo OC, Stewart CC, et al. Lower hippocampal volume predicts decrements in lane control among drivers with amnestic mild cognitive impairment. J Geriatr Psychiatry Neurol 2013; 26:259–266.
  3. de Simone V, Kaplan L, Patronas N, Wassermann EM, Grafman J. Driving abilities in frontotemporal dementia patients. Dement Geriatr Cogn Disord 2007; 23:1–7.
  4. Iverson DJ, Gronseth GS, Reger MA, Classen S, Dubinsky RM, Rizzo M; Quality Standards Subcomittee of the American Academy of Neurology. Practice parameter update: evaluation and management of driving risk in dementia: report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2010; 74:1316–1324.
  5. Classen S, Brumback B, Monahan M, et al. Driving errors in Parkinson’s disease: moving closer to predicting on-road outcomes. Am J Occup Ther 2014; 68:77–85.
  6. Blitzer ML, Saliba BC, Ghantous AE, Marieb MA, Schoenfeld MH. Causes of impaired consciousness while driving a motorized vehicle. Am J Cardiol 2003; 91:1373–1374.
  7. Sorajja D, Shen WK. Driving guidelines and restrictions in patients with a history of cardiac arrhythmias, syncope,or implantable devices. Curr Treat Options Cardiovasc Med 2010; 12:443–456.
  8. Task force members; Vijgen J, Botto G, Camm J, et al. Consensus statement of the European Heart Rhythm Association: updated recommendations for driving by patients with implantable cardioverter defibrillators. Europace 2009; 11:1097–1107.
  9. Conti JB, Woodard DA, Tucker KJ, Bryant B, King LC, Curtis AB. Modification of patient driving behavior after implantation of a cardioverter defibrillator. Pacing Clin Electrophysiol 1997; 20:2200–2204.
  10. Lerecouvreux M, Aït Saïd M, Paziaud O, et al. Automobile driving and implantable defibrillators. Arch Mal Coeur Vaiss 2005; 98:288–293. Article in French.
Issue
Cleveland Clinic Journal of Medicine - 82(1)
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Cleveland Clinic Journal of Medicine - 82(1)
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22-25
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When should I discuss driving with my older patients?
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