Geriatricians Lead the Way in Safe Prescribing for Older Adults

By Jonathan Vandergraft, MS, and Bruce Leff, MD

Despite considerable advocacy over the past two decades, prescribing safety for older adults remains an important quality issue, with about one in five older adults in the United States being prescribed a medication that is potentially inappropriate given their age.1-3

The risks of these potentially inappropriate medications (PIMs) are outlined in guidelines including the American Geriatric Society’s (AGS) Beers criteria.4 Potential hazards are diverse and include short-term problems, such as impaired functioning leading to falls and fractures,5 as well as long-term health concerns, such as an increased risk of Alzheimer’s disease and dementia.6

Illustrating the quality gap in PIM prescribing, a recent quantitative study found that outpatient geriatricians certified by the American Board of Internal Medicine prescribed fewer PIMs to their patients than did similar physicians who were only certified in internal medicine (IM).3

In particular, about 3,000 geriatricians certified since 1994 were each matched to one general internist to ensure the two sets of physicians trained at similar quality residency programs and performed equally well on their IM certification exam, except one group subsequently received 12 months of geriatric medicine specialty training and certification. Their PIM prescribing rates were measured using a Healthcare Effectiveness Data and Information Set quality indicator and considered care for fee-for-service Medicare beneficiaries with part D drug coverage.

All told, geriatricians were 17% less likely to prescribe a PIM medication during the 2013 to 2019 period. Fewer patients were prescribed potentially inappropriate central nervous system, anticholinergic, pain, or endocrine medications.

This gap in prescribing persisted across the study period and was even found among the most recently trained physicians. Highlighting the potential real-world benefit of closing this gap, if all clinically active general internists were to prescribe like geriatricians, then more than 90,000 fewer older adults would be prescribed a PIM every year. This figure is even more impressive given it does not consider any benefits for older adults with Medicare advantage or who lack part D coverage.

A Geriatrician for Every Older Adult?
These data illustrate the value geriatricians have for an older adult seeking a provider and, in an ideal world, each older adult in the United States would have the opportunity to choose a physician trained and certified in geriatric medicine.

There are more 50 million adults older than 65 in the United States7 and only roughly 6,000 clinically active geriatricians.8 While this shortage of geriatricians has been long recognized,9 attempts to address this problem by recruiting more physicians into geriatric medicine have had limited success. This is exemplified by the fact that half of geriatric medicine fellowships go unfilled each year.10 As is, it’s unlikely there will ever be enough geriatricians to provide one-on-one care to all older adults in the United States.

If Not the Specialist, Then Maybe Their Principles?
An alternative approach to building a large, specialized workforce was proposed in 2016 by Mary Tinetti,11 a professor of geriatric medicine at Yale University and former MacArthur Fellow, who suggested the goal for geriatrics should not focus on creating more certified geriatricians but on leading the development and dissemination of geriatric principles of care that can be embedded into the health care system more broadly.

Efforts along this path have progressed, including the “age-friendly health system” collaboration,12 which seeks to create a framework that hospitals and health systems can leverage to align their care delivery with select geriatric principles. This primarily employs its “4M” framework; ensuring care delivery considers what matters to their older age patients, includes age-appropriate medications where necessary, and is attentive to supporting their patient’s mentation and mobility.

Focusing specifically on medication safety for older adults, the US Deprescribing Research Network13 has created educational materials and guidelines for practicing clinicians to help them make better prescribing recommendations as well as transition their patients off of potentially dangerous medications.

In addition to building geriatric principles into the health care delivery system, it’s also important they are infused into physician training programs. Residencies and fellowships lay the skill and knowledge foundation from which practicing physicians grow throughout their careers, and it is imperative this foundation includes geriatric principles of care.

Progress in this area includes the “Geriatrics Education for Specialty Residents Program” which grew out the AGS’s Geriatrics for Specialists Initiative.14 This program creates and promotes educational materials focused on ensuring trainees in select emergency and procedural specialties are well versed in geriatric principles when caring for older adults. With regards to appropriate prescribing, efforts to ensure residents are equipped to prescribe safely to older adults are more idiosyncratic and it is unclear how well geriatric principles related to safe prescribing are being taught in many residencies.

One intriguing study employed the EQUiPPED intervention,15 developed by the VA to educate IM residents on using the AGS Beers criteria during their emergency medicine rotations.16 Prior to the educational program, about one-half of the residents reported either never having heard of or never having used the AGS Beers criteria despite 90% of them reporting they were confident in their ability to prescribe appropriately to older adults. After receiving tailored education about safe prescribing, these residents reduced their PIM prescribing by 30%. While these data reflect the experience of only one residency program, they suggest more research is warranted, especially considering the quality gap between general internists and geriatricians discussed previously was present even among the most newly trained physicians. At a minimum, we must understand the readiness of newly trained residents to prescribe appropriately for older adults.

The Path Forward for Safer Prescribing for Older Adults
More needs to be done to ensure the US health care system is prepared to care for an aging US population, and geriatricians have a key role in the vanguard of this evolution. The importance of baking geriatric principles into the health care system is further reinforced by the array of physicians who collaborate in caring for older adults.

In the study comparing geriatrician and general internist PIM prescribing rates discussed previously, each physician was only one of five different clinicians prescribing medications to each patient each year. Collectively, these five clinicians prescribed PIMs to more than 20% of patients in the study, demonstrating that it’s beyond the ability of any one physician to continually ensure medications are prescribed responsibly to older adults.

While many efforts are underway, these programs need to be supported and expanded as the notion of treating older adults according to geriatric principles of care ultimately means providing them with quality care.

— Jonathan Vandergrift, MS, is a health services researcher at the American Board of Internal Medicine.

— Bruce Leff, MD, is a professor of medicine at the Johns Hopkins University School of Medicine.

References
1. Li G, Andrews HF, Chihuri S, et al. Prevalence of potentially inappropriate medication use in older drivers. BMC Geriatr. 2019;19(1):260.

2. Medication management in the elderly (DAE/DDE). National Committee for Quality Assurance website. https://www.ncqa.org/hedis/measures/medication-management-in-the-elderly/. Accessed May 15, 2023.

3. Vandergrift JL, Weng W, Leff B, Gray BM. Geriatricians, general internists, and potentially inappropriate medications for a national sample of older adults [published online June 23, 2023]. J Am Geriatr Soc. doi: 10.1111/jgs.18489.

4. 2023 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023;71(7):2052-2081.

5. Seppala LJ, Wermelink A, de Vries M, et al. Fall-risk-increasing drugs: a systematic review and meta-analysis: II. Psychotropics. J Am Med Dir Assoc. 2018;19(4):371.e11-371.e17.

6. 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(3):401-407.

7. Older Americans Month: May 2023. US Census Bureau website. https://www.census.gov/newsroom/stories/older-americans-month.html. Published May 2023. Accessed July 23, 2023.

8. Active physicians in the largest specialties by major professional activity, 2021. American Association of Medical Colleges website. https://www.aamc.org/data-reports/workforce/data/active-physicians-largest-specialties-major-professional-activity-2021. Published 2022. Accessed July 24, 2023.

9. Kovner CT, Mezey M, Harrington C. Who cares for older adults? Workforce implications of an aging society. Health Aff (Millwood). 2002;21(5):78-89.

10. National Resident Matching Program. Results and data: Specialties Matching Service. https://www.nrmp.org/wp-content/uploads/2022/03/2022-SMS-Results-Data-FINAL.pdf. Published March 2022. Accessed September 6, 2022.

11. Tinetti M. Mainstream or extinction: can defining who we are save geriatrics? J Am Geriatr Soc. 2016;64(7):1400-1404.

12. What is an age-friendly health system? Institute for Healthcare Improvement website. https://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/default.aspx. Published 2023. Accessed July 24, 2023.

13. Explore the US Deprescribing Research Network (USDeN). US Deprescribing Research Network website. https://deprescribingresearch.org/. Published 2023. Accessed July 24, 2023.

14. Miller M, Rosenthal RA. Meeting the need for training in geriatrics: the geriatrics education for specialty residents program. J Am Geriatr Soc. 2017;65(10):e142-e145.

15. Vandenberg AE, Echt KV, Kemp L, McGwin G, Perkins MM, Mirk AK. Academic setailing with provider audit and feedback improve prescribing quality for older veterans. J Am Geriatr Soc. 2018;66(3):621-627.

16. Moss JM, Bryan III WE, Wilkerson LM, et al. An interdisciplinary academic detailing approach to decrease inappropriate medication prescribing by physician residents for older veterans treated in the emergency department. J Pharm Pract. 2019;32(2):167-174.