Instruments for evaluating medication use and prescribing in older adults

Objective: To describe primarily implicit instruments for assessing medication use in older adults. Data sources: Literature was identified via PubMed (1966-2014) and Google Scholar using the following search terms: geriatric/medication use, implicit criteria, inappropriate medication use, inappropriate prescribing, older adults/medication use, and polypharmacy. Reference citations from identified publications were also reviewed. Study selection: All articles in English identified from data sources were evaluated. Instruments applicable to pharmacy and multiple medication classes were included. We excluded instruments developed for a single medication or medication class, for a single condition or disease state, as primarily an academic instrument, using primarily explicit criteria, for use primarily by health care practitioners other than pharmacists, or for regulatory purposes. Data synthesis: Seven instruments were reviewed by evaluating characteristics, components of prescribing and medication use addressed, and settings in which they have been evaluated and validated. Screening Medications in the Older Drug User (SMOG) is a six-question instrument developed specifically for community pharmacists. The Medication Appropriateness Index (MAI); Assess, Review, Minimize, Optimize, Reassess (ARMOR) tool; and Tool to Improve Medications in the Elderly via Review (TIMER) are more comprehensive instruments, but they require clinical judgment and are time intensive. Assessing Care of Vulnerable Elders-3 (ACOVE-3) and the Good Palliative-Geriatric Practice Algorithm (GPGPA) are useful in determining need for medication continuation in older adults who are closer to the end of life. The Assessment of Underutilization (AOU) is an implicit tool to guide medication initiation. Conclusion: Each instrument is unique in design, which may be beneficial in some pharmacy practice settings and present barriers in others. The use of multiple instruments may be necessary to optimize therapy in this vulnerable patient population.