“Referring a patient to a geriatrician or a geriatric pharmacist for a medication list review can be extremely helpful for common issues like falls.” – Stephanie Nothelle
A new study from Johns Hopkins researchers offers caution about the limitations of the Medicare Annual Wellness Visit, finding that up to 25% of older adults at risk for falls still were prescribed a medication that is considered high risk for that condition.
The visit, designed to provide an opportunity for primary care professionals to assess patients for aging concerns such as falls, cognitive impairment or incontinence, “is supposed to be a 30,000-foot view of a patient’s health, with a focus on prevention,” says geriatrician Stephanie Nothelle.
However, the study that Nothelle directed, published in the Journal of the American Geriatrics Society, found mixed results regarding these visits. On the plus side, patients at risk for falls or other issues appeared more likely to be referred to other specialists such as physical or occupational therapists, or geriatricians, for additional assessment. However, within a few months of that visit, some patients were twice as likely to be prescribed medications that could be more dangerous in seniors.
“It suggests that geriatricians have an opportunity to educate or partner with primary care doctors to try to reduce some of these medications,” she says. “Referring a patient to a geriatrician or a geriatric pharmacist for a medication list review can be extremely helpful for common issues like falls.”
Investigators reviewed electronic medical records from patients age 65 and up who had a wellness visit at a large mid-Atlantic group practice from 2014–2017, studying prevalence of positive screens for falls, cognitive impairment and/or impairments in activities of daily living (ADL). The practice has 34 primary clinics in Maryland, Virginia and Washington, D.C., which serve a diverse population.
Some 16,176 patients underwent at least one wellness visit during that time. Of those, 38% had a positive screen for falls, 23% had cognitive issues and 32% had some ADL impairment. A positive screen for one of these issues was significantly associated with having an order for testing or a referral.
However, a records review from 13,537 older adults with at least three months of follow-up data after the visit found that 25% of those with a positive screen for falls, and 19% with a positive screen for cognitive issues, still received a medication considered high risk for that condition, according to the Beers Criteria of potentially harmful drugs in the elderly, published by the American Geriatrics Society.
The most commonly prescribed medications considered high risk for falls were opioids, benzodiazepines and selective serotonin reuptake inhibitors, while those most often prescribed considered high risk in cognitive impairment were benzodiazepines, antihistamines, antiemetic/antivertigo agents and skeletal muscle relaxants.
The Centers for Disease Control and Prevention has an algorithm primary care professionals can use to investigate patients’ concerns, Nothelle says: “It includes items such as referrals to physical therapy or to ophthalmology to ensure a patient’s vision is good and not contributing to falls. There also is guidance to review patient medication lists to make sure there are no unnecessary medications or to find lower-risk substitutions for medications on the Beers List.”
Nothelle and colleagues continue to pursue research that can help advance health care for older adults.