How to Use the American Geriatrics Society 2015 Beers Criteria-A Guide for Patients, Clinicians, Health Systems, and Payors.

The Beers Criteria are a valuable tool for clinical care and quality improvement but may be misinterpreted and implemented in ways that cause unintended harms. This article describes the intended role of the 2015 American Geriatrics Society (AGS) Beers Criteria and provides guidance on how patients, clinicians, health systems, and payors should use them. A key theme underlying these recommendations is to use common sense and clinical judgment in applying the 2015 AGS Beers Criteria and to remain mindful of nuances in the criteria. The criteria serve as a "warning light" to identify medications that have an unfavorable balance of benefits and harms in many older adults, particularly when compared with pharmacological and nonpharmacological alternatives. However, there are situations in which use of medications included in the criteria can be appropriate. As such, the 2015 AGS Beers Criteria work best not only when they identify potentially inappropriate medications, but also when they educate clinicians and patients about the reasons those medications are included and the situations in which their use may be more or less problematic. The criteria are designed to support, rather than supplant, good clinical judgment

Use of Indwelling Urinary Catheters in Nursing Homes: Implications for Quality Improvement Efforts

OBJECTIVES: To describe the epidemiology of indwelling urinary catheter use in nursing homes (NHs). DESIGN: Observational cohort study. SETTING: A purposeful sampling strategy was used to identify a diverse sample of 28 Connecticut NHs, defined in terms of ownership, quality ratings, and bed size. PARTICIPANTS: Long-stay (\u3e100 days) residents of study NHs with an indwelling urinary catheter present at any time over a 1-year period. MEASUREMENTS: Duration of catheter use was determined, and indications for catheter placement were documented. Indications considered appropriate included urinary retention or outlet obstruction, pressure ulcer (Stage 3 or 4 with risk of contamination by urine), hospice care, and need for accurate measurement of input and output. During quarterly follow-up assessments, whether the catheter was still in place or had been removed for any reason other than routine maintenance was determined. RESULTS: The overall rate of any urinary catheter use per 100 resident-beds over a 1-year period was 4.8 (range 1.0-9.9, median 5.1). Of the 228 residents meeting eligibility criteria, a documented indication for the catheter was present in the NH record for 195 (86%). Of those with a documented indication, 99% (n = 193) had one or more indications deemed appropriate, including urinary retention (83%), pressure ulcer (21%), hospice care (10%), and need for accurate measurement of input and output (6%). The urinary catheter was removed at some point during the period of observation in 49% (n = 111) of participants; those with a shorter duration of catheter use before study enrollment were more likely to have the catheter removed during the follow-up period. Of the 111 residents who had the catheter removed, 58 (52.3%) had it reinserted at some point during follow-up. CONCLUSION: These findings suggest that indwelling urinary catheter use in long-stay NH residents is uncommon and generally appropriate and that efforts to improve catheter care and outcomes should extend beyond a singular focus on reducing use

Effect of fesoterodine in vulnerable elderly subjects with urgency incontinence: a double-blind, placebo controlled trial

PURPOSE: We evaluated the efficacy and safety of flexible dose fesoterodine in medically complex vulnerable elderly subjects with urgency urinary incontinence. MATERIALS AND METHODS: In this 12-week, randomized, double-blind, flexible dose, placebo controlled trial, subjects were community dwelling men and women 65 years old or older. Subjects had scores of 3 or more on the VES-13 (Vulnerable Elders Survey) and 20 or more on the MMSE (Mini-Mental State Examination), and 2 to 15 urgency urinary incontinence episodes and 8 or more micturitions per 24 hours on 3-day baseline diaries. Subjects randomized to fesoterodine received 4 mg once daily for 4 weeks and could then increase to 8 mg based on discussion with the investigator. Subjects receiving 8 mg could decrease the dose to 4 mg at any time (sham escalation and de-escalation for placebo). The primary outcome measure was change in daily urgency urinary incontinence episodes. Secondary outcomes included changes in other diary variables and patient reported quality of life measures. Safety evaluations included self-reported symptoms and post-void residual volume. RESULTS: A total of 562 patients were randomized (mean age 75 years, 50.4% age 75 years or greater). Subjects had high rates of comorbidities, polypharmacy and functional impairment. At week 12 the fesoterodine group had significantly greater improvements in urgency urinary incontinence episodes per 24 hours (-2.84 vs -2.20, p = 0.002) and most other diary variables and quality of life, as well as a higher diary dry rate (50.8% vs 36.0%, p = 0.002). Adverse effects were generally similar to those of younger populations including risk of urinary retention. CONCLUSIONS: To our knowledge this is the first antimuscarinic study in a community based, significantly older, medically complex elderly population with urgency urinary incontinence. Flexible dose fesoterodine significantly improved urgency urinary incontinence episodes and other outcomes vs placebo, and was generally well tolerated. Published by Elsevier Inc. All rights reserved

The evaluation and treatment of nocturia: a consensus statement

What's known on the subject? and What does the study add? Nocturia is currently defined by the International Continence Society (ICS) as the complaint that an individual has to wake at night one or more times to void. It is, however, an underreported, understudied, and infrequently recognized problem in adults. Many factors may contribute to nocturia which are treatable, yet patients do not seek care or the condition may not be identified by providers. This paper aims to help healthcare providers better serve patients who are experiencing nocturia by summarizing current research, clinical approaches, and treatment options. The results of the conference provide a balanced evaluation of the full treatment armamentarium capable of meeting the needs of patients with the manifold causes of nocturia such as nocturnal polyuria, overactive bladder, or benign prostatic hyperplasia

The curriculum for the hospitalized aging medical patient program: A collaborative faculty development program for hospitalists, general internists, and geriatricians

10.1002/jhm.348Journal of Hospital Medicine35384-39