health level in the era of electronic health record use is significant.
The Fit fOR The Aged (FORTA) tool was introduced in 2008 as a classification system to help prescribers screen for PIMS and PPOs in older adults.37,38 It is the first to combine both positive and negative labelling into one tool and has been validated in various settings and countries. The FORTA system classifies each medication into one of the following four categories:
Class A (A‐bsolutely) = indispensable drug; clear‐cut benefit in terms of efficacy/safety ratio proven in elderly patients for a given indication
Class B (B‐eneficial) = drugs with proven or obvious efficacy in the elderly but limited extent of effect or safety concerns
Class C (C‐areful) = drugs with questionable efficacy/safety profiles in the elderly, to be avoided or omitted in the presence of too many drugs, lack of benefits, or emerging side effects; review/find alternatives
Class D (D‐on’t) = avoid in the elderly; omit first; review/find alternatives
Initial studies have shown improvement in medication management and fall reduction with the use of FORTA.39
Principles of appropriate prescribing
The prescribing and management of medications is a clinical procedure that takes time, expertise, and accuracy to improve patient outcomes. Appropriate prescribing for patients of any age balances a particular medication’s potential benefits against the known risks for that individual. Appropriate prescribing avoids clinical inertia but limits the medication list to what is absolutely necessary to prevent disease or decline, manage chronic diseases, and improve quality of life. While extreme polypharmacy (taking 10 or more medications) has been associated with increased adverse events, including death,40‐44 there is no known ‘appropriate polypharmacy threshold’ for people with multimorbidity. Appropriate prescribing will always consider the patient’s age, goals of care, functional status, and life expectancy.
With patients’ increasing age, prescribers need to heed the principle of the happy medium for chronic disease management. That is, as we age, the benefit of tight disease control decreases and the risk of overtreatment increases. For many chronic diseases, the clinical targets shift to become more liberalized depending on the individual person’s age and functional status. As an example, people over the age of 70 with hypertension have a U‐shaped mortality curve with increased risk with very high blood pressure and low blood pressure. This curve becomes sharper with each decade of life.45 However, recent clinical trials suggest that the individual’s functional status is just as important, if not more so, than age alone. Robust patients over age 80 may benefit from stricter blood pressure control, while frail or disabled patients will have worse outcomes with stricter blood pressure control.46‐48
Medications used for primary prevention of diseases, such as cardiovascular disease, become less effective as patients near the end of life. If certain drugs take years to show benefit, then the risk of side effects may outweigh benefits in those with less than 5‐ to 10‐year life expectancy. Life expectancy tables based on age and gender exist to help guide decision‐making.49,50 Caution should be taken not to underestimate life expectancy, especially in healthy older people. Prognostication is more accurate if you combine clinical judgment with life tables, functional status assessment, and severity of comorbid conditions. Appropriate prescribing, therefore, needs to include a good geriatric assessment that evaluates for frailty, physical function, physical fitness, and life expectancy. For evaluation of these, please see Chapters 7 (‘Physical Fitness and Exercise’), 95 (‘Maintaining Functional Status’), 97 (‘Frailty’), and 120 (‘End‐of‐Life and Palliative Care’).
When prescribing medications for older adults, remember the following basic principles:
Consider the Eight Cs of Appropriate Prescribing (Figure 10.1):Care goals should always be at the centre of every medication prescribing decision, and patient‐related factors will help determine appropriate drug use.Compliance: Assess for cognitive impairment, conditions (multimorbidity, depression, decreased hearing, poor vision, unwanted or unintended side effects), complicated regimens, and excessive medication cost, which can all lead to treatment burden and decrease medication compliance. The treatment burden is the perception of the effort required to self‐manage the patient’s medical conditions and adhere to a prescribed regime, and the impact that this has on general well‐being.51‐54 Treatment burden can be minimized by including the patient and caregiver in decision‐making and helping them understand the risks versus the benefits of the various treatment options. Engaging the clinical team, such as pharmacists, nurses, and social workers, can help identify and minimize treatment burden issues.Avoid the prescribing Cascade: Consider every new symptom to potentially be a medication side effect, and don’t prescribe a medication to treat a symptom without first considering stopping the potentially offending medication. In addition, can the list be simplified by using one medication to treat multiple symptoms?
Never be the first to start a new medication that hasn’t been well tested in this population, and never the be last to stop using an old, unsafe, or ineffective medication.
Start on the lowest dose of the most cost‐effective medication, and slowly titrate up to the goal (‘start low and go slow’).
Prescribe evidence‐based non‐pharmacologic alternatives to treat diseases and symptoms.
Ask yourself the following questions:Medication efficacy: Do I really expect this will make a significant difference to the patient? What is the expected outcome? What is the evidence for using this medication for this age/clinical condition?Cost: Is there a cheaper alternative that is just as effective?Drug timing: Can a once–a‐day regimen be as effective?Drug dosing: What is the lowest effective dose for this patient?Potential side‐effects: How well will this person tolerate this drug? What concerns do I have in starting it?Drug–drug/drug–disease interactions: Do any contraindications exist?
Figure 10.1 The Eight C considerations of appropriate prescribing.
Consider the following example. Mr. Xavier Smith is a 79‐year‐old man brought to your office by his wife with complaints of memory loss. He has a diagnosis of systolic heart failure, urinary incontinence, chronic bronchitis, hyperlipidemia, and a lacunar infarct at age 70. You find that he scores low on a cognitive evaluation, indicating probable early dementia. He has also lost about 25 pounds in the last six months due to a decreased sense of taste and appetite with some nausea related to constipation. He had two witnessed falls when his legs suddenly ‘gave out’. His heart rate is 56, and his blood pressure is 98/50. His wife requests a medication to help his memory, as his goals are to ‘take care of myself and keep driving. I don’t want to be an invalid in a home’. Before you start an acetylcholinesterase inhibitor, you review his current medication list, which includes perindopril (an ACE inhibitor), metoprolol (a beta blocker), oxybutynin (an anticholinergic medication), furosemide (a loop diuretic), a combination beta‐agonist/inhaled corticosteroid inhaler, aspirin, and simvastatin (an HMG‐CoA reductase inhibitor). After discussion with Mr Smith and his wife, you decide to forego starting an acetylcholinesterase inhibitor due to the drug’s risk of worsening bradycardia (falls or heart block), nausea, and anorexia (weight loss). In addition, you stop the anticholinergic agent, which could be worsening his memory, adjust the doses of some of the other medications, and institute aggressive non‐pharmacologic interventions for his memory, falls, and urinary incontinence.
Appropriate prescribing also includes periodic deprescribing. Deprescribing is defined as ‘a patient‐centered, systematic optimization