Australian & New Zealand Society for Geriatric Medicine
The Australian and New Zealand Society for Geriatric Medicine is the professional society for geriatricians and other medical practitioners with an interest in the medical care of older people.
The Society acts to represent the needs of its members and the wider community in a bid to constantly review and improve the care of the older people in Australia and Aotearoa New Zealand. Its major functions are around education, policy development and review, and political advocacy.
Download the Australian & New Zealand Society for Geriatric Medicine's Top-5 recommendations (PDF)
Top-5 recommendations on low-value practices
1. Do not use antipsychotics as the first choice to treat behavioural and psychological symptoms of dementia.
Rationale and evidence
Rationale
People with dementia may exhibit aggression, resistance to care and other challenging or disruptive behaviours. In such instances, the modest effectiveness of atypical antipsychotics may be offset by the higher risks for adverse events and mortality. Non-pharmacological interventions can be an effective substitute for antipsychotic medications. Use of these drugs should therefore be limited to cases where non-pharmacologic measures have failed and patients pose an imminent threat to themselves or others.
Evidence
Ballard C, Waite J. The effectiveness of atypical antipsychotics for the treatment of aggression and psychosis in Alzheimer’s disease. Cochrane Database Syst Rev. 2006; (1): CD003476.
Declerq T, Petrovic M, Azermai M, et al. Withdrawal versus continuation of chronic antipsychotic drugs for behavioural and psychological symptoms in older people with dementia. Cochrane Database Syst Rev. 2013; 3: CD007726.
Ma H, Huang Y, Cong Z, et al. The efficacy and safety of atypical antipsychotics for the treatment of dementia: a metaanalysis of randomized placebo controlled trials. J Alzheimers Dis. 2014; 42(3): 915-37.
Richter T, Myer G, Mohler R, et al. Psychosocial interventions for reducing antipsychotic medication in care home residents. Cochrane Database Syst Rev. 2012; 12: CD008634.
Schneider LS, Tariot PN, Dagerman K, et al. Effectiveness of atypical antipsychotic drugs in patients with Alzheimer’s disease. New England Journal Med. 2006; 355(15): 1525-38.
2. Do not prescribe benzodiazepines or other sedative-hypnotics to older adults as first choice for insomnia, agitation or delirium.
Rationale and evidence
Rationale
There is strong evidence that use of benzodiazepines is associated with various adverse effects in elderly people such as falls and fractures. Older patients, their caregivers and their providers should recognise these potential harms when considering treatment strategies for insomnia, agitation or delirium. Thus these drugs should be prescribed with caution, and their use monitored closely.
Evidence
Allain H, Bentue-Ferrer D, Polard E, et al. Postural instability and consequent falls and hip fractures associated with use of hypnotics in the elderly: a comparative review. Drugs Aging. 2005; 22(9): 749–765.
Finkle WD, Der JS, Greenland S, et al. Risk of fractures requiring hospitalization after an initial prescription for zolpidem, alprazolam, lorazepam, or diazepam in older adults. Journal of the American Geriatric Soc. 2011; 59(10): 1883-90.
Sithamparanathan K. Adverse effects of benzodiazepine use in elderly people: A meta-analysis. Asian J Gerontol Geriatr. 2012; 7: 107–11.
Stockl KM, Le L, Zhang S, et al. Clinical and economic outcomes associated with potentially inappropriate prescribing in the elderly. American Journal Managed Care. 2010; 16(1): e1-10.
3. Do not use antimicrobials to treat bacteriuria in older adults where specific urinary tract symptoms are not present.
4. Do not prescribe medication without conducting a drug regimen review.
Rationale and evidence
Rationale
Older patients disproportionately use more prescription and non-prescription drugs than other populations, increasing the risk for side effects and inappropriate prescribing. Thus evidence shows that polypharmacy is associated with adverse drug reactions and an increased risk of hospital admissions. Medication review with follow up is recommended for optimising prescribed medication and improving quality of life in older adults with polypharmacy.
Evidence
Fried TR, O’leary J, Towle V, et al. Health outcomes associated with polypharmacy in community-dwelling older adults: a systematic review. Journal of American Geriatric Society. 2014; 62(12): 2261-72.
Hajjar ER, Caffiero AC, Hanlon JT, et al. Polypharmacy in elderly patients. American Journal Geriatr Pharmacotherapy. 2007; 5(4): 345-51.
Jodar-Sanchez F, Malet-Larrea A, Martin JJ, et al. Cost-Utility Analysis of a Medication Review with Follow-Up Service for Older Adults with Polypharmacy in Community Pharmacies in Spain: The conSIGUE Program. Pharmacoeconomics. 2015; Mar 15.
Lu WH, Wen YW, Chen LK, et al. Effect of polypharmacy, potentially inappropriate medications and anticholinergic burden on clinical outcomes: a retrospective cohort study. CMAJ. 2015; 187(4): e130-7.
5. Do not use physical restraints to manage behavioural symptoms of hospitalised older adults with delirium except as a last resort.