Goodyear‐Smith F, et al. Validation of PHQ‐2 and PHQ‐9 to screen for major depression in the primary care population. Annals of Family Medicine. 2010; 8(4):348–353.
26 26. Alexopoulos GS, Abrams RC, Young RC, Shamoian CA. Cornel scale for depression in dementia. Biol Psychiatry. 1988; 23:271–84.
27 27. Mathias S, Nayak US, Isaacs B. Balance in elderly patients: the ‘get‐up and go’ test. Arch Phys Med Rehabil. 1986; 67:387–89.
28 28. Podsiadlo D, Richardson S. The timed ‘Up & Go’: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991; 39:142–8.
29 29. Molloy DW, Guyatt GH, Russo R, et al. Systematic implementation of an advance directive program in nursing homes: a randomized controlled trial. JAMA. 2000; 283:1437–44.
30 30. Dexter PR, Wolinsky FD, Gramelspacher GP, et al. Effectiveness of computer‐generated reminders for increasing discussions about advance directives and completion of advance directive forms. A randomized, controlled trial. Ann Intern Med. 1998; 128:102–10.
31 31. Saah AJ, Neufeld R, Rodstein M, et al. Influenza vaccine and pneumonia mortality in a nursing home population. Arch Intern Med. 1986; 146:2353–7.
32 32. Gross PA, Quinnan GV, Rodstein M, et al. Association of influenza, immunization with reduction in mortality in an elderly population. A prospective study. Arch Intern Med. 1988; 148:562–5.
33 33. Kim DK, Hunter P. Clinical Guideline, Recommended Adult Immunization Schedule, United States. Annals of Internal Medicine. 2019; 170(3):182–192.
34 34. Smith BD, Morgan RL. Recommendations for the identification of chronic Hepatitis C virus infection among persons born during 1945‐1965. MMWR. 2012; 61(RR04);1–18).
35 35. American Cancer Society. Cancer facts and figures 2019. American Cancer Society; 2019.
36 36. National Comprehensive Cancer Network. Breast Cancer Screening Version 1. 2019.
37 37. Kerlikowske K. Progress towards consensus on breast cancer screening guidelines and reducing screening harms. JAMA. 2015; 175(12):1970–1971.
38 38. Curry SJ, Krist AH, et al. Screening for cervical cancer: US Preventive Services task force recommendation statement. JAMA. 2018; 320(7): 674–686.
39 39. Bibbins D, Kirsten DC, et al. Screening for colorectal cancer: US Preventive Services Task Force recommendation statement. JAMA 2016; 315(23):2564–2575.
40 40. National Comprehensive Cancer Network. Colorectal cancer screening. Version 2. 2019.
41 41. National Comprehensive Cancer Network. Prostate cancer early detection. Version 2. 2019
42 42. National Comprehensive Cancer Network. Lung cancer screening. Version 1. 2020. www.NCCN.org.
43 43. Moyer VA. Screening for lung cancer: US Preventive Services Task Force recommendation statement. Annals of Internal Medicine. 2014; 160(5):330–338.
44 44. Kanis JA, McCloskey EV, Johansson H, et al. Case finding for the management of osteoporosis with FRAX assessment and intervention thresholds for the UK. Osteoporosis Int. 2008; 19:1395–408.
45 45. Liu H, Paige NM, Goldzweig CL, et al. Screening for osteoporosis in men: a systematic review for an American College of Physician guideline. Ann Intern Med. 2008; 148: 685–701.
46 46. Mortensen MB, Falk E. Primary prevention with statins in the elderly. Journal of the American College of Cardiology. 2018; 71(1):85‐93.
47 47. Page MR. New guidelines for thyroid disease screening: perspectives for pharmacists. 2015. www.Pharmacytimes.com>News>New‐Guidelines‐for‐Thyroid‐Disease‐Screening‐Perspectives‐for‐Pharmacists.
48 48. Gussekloo J, Van Exel E, De Craen AJ, et al. Thyroid status, disability and cognitive function and survival in old age. JAMA. 2004; 292:2591–9.
49 49. Mokshagundam S, Barzel US. Thyroid disease in the elderly. J Am Geriatr Soc. 1993; 41:1361–9.
50 50. Pippitt K, Marlana L, et al. Diabetes mellitus: screening and diagnosis. American Family Physician 2016; 93(2):103–109.
51 51. Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep. 1991; 14:540–55.
52 52. Sexton S. Screening for obstructive sleep apnea in adults: US Preventive Services Task Force recommendation statement. American Family Physician. 2017; 96(2):122A–C.
53 53. Zucker EJ, Prabhakar AM. Abdominal aortic aneurysm screening: concepts and controversies. Cardiovascular Diagnosis and Therapy. 2017; 8(Suppl 1):S108–S117.
CHAPTER 10 Polypharmacy and deprescribing in older adults
Fernanda Heitor1 and Milta Little2
1 Division of General Internal Medicine and Geriatrics, Department of Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
2 Division of Geriatric Medicine, Department of Internal Medicine, Duke University School of Medicine, Durham, North, Carolina, USA
Introduction
The physician must be able to tell the antecedents, know the present, and foretell the future — must mediate these things, and have two special objects in view with regard to disease, namely, to do good or to do no harm.
—Hippocrates
L.H. is an 88‐year‐old female with a diagnosis of hypertension, type 2 diabetes mellitus, chronic venous insufficiency, chronic depression, osteoporosis, osteoarthritis of the knees, recurrent dizziness, and mild Alzheimer’s dementia. Two weeks ago, she experienced one fall, without loss of consciousness, when she felt weak while standing in line at her local pharmacy. Subsequently, she was in hospital observation for two days and had a negative workup for acute vascular or infectious etiologies. While her sitting blood pressure was 168/90, her standing blood pressure was 132/72 and her pulse was 58. Her medications are (all taken orally) nadolol 40 mg daily, lisinopril 5 mg daily, furosemide 20 mg twice a day, spironolactone 25 mg daily, nifedipine 10 mg three times a day, metformin 1000 mg three times a day, glimepiride 4 mg twice a day, aspirin 325 mg daily, simvastatin 40 mg at bedtime, cilostazol 100 mg twice a day, omeprazole 40 mg once a day, famotidine 20 mg twice a day, sertraline 150 mg daily, trazodone 100 mg at bedtime, tramadol 50 mg three times a day, meclizine 12.5 mg every morning, oxybutynin 5 mg twice a day, donepezil 10 mg at bedtime, a multivitamin daily, ferrous sulfate 325 mg twice a day, and calcium carbonate 1000 mg three times a day. Her daughter, who is her healthcare durable power of attorney, is concerned that a medication side effect might have played a role in the fall.
Mythology introduced us to the memorable symbol of abundance known as the cornucopia, which is ubiquitously pictured as an overflowing horn‐shaped basin, typically filled with fruits and vegetables and with a positive connotation toward plenitude. On the other hand, the same idea of a cornucopia filled beyond capacity with capsules and tablets is rather ominous. Abundance, in this regard, is not necessarily a good thing. The Hippocratic maxim ‘Do no harm’ is sometimes a trying goal when it pertains to medication prescribing, and harm related to pharmacotherapy is common, pervasive, and costly. It is well known that one of the most common causes of avoidable hospital admissions in the elderly is adverse drug reactions, which, in turn, are directly correlated to the number of medications being taken.1,2
The concepts of polypharmacy and deprescribing are relatively new, gaining traction in the mid‐1990s and becoming a more prominent and complex problem over the past two decades, as indicated by an increasing body of literature. A study in Scotland demonstrated that from 1995 to 2010, the use of five or more medications in the elderly increased from about 11% to 20%, while for 10 or more medications, it rose from