Ace acute care for elders: creating the business case
HIGH RISK MEDICATIONS IN ELDERLY PATIENTS (All doses listed are initial doses) Medications of Risk Considerations Examples of Alternatives
Adverse effects: confusion, falls, functional
Slow Onset (long-term use):
Sertraline 25mg daily-titrate prn
Long acting agents have a prolonged half-life
Venlafaxine (Effexor) XR 37.5-75mg daily**-titrate prn
(up to 4 days). If use is necessary, use low
Citalopram 10 mg daily -titrate prn Fast Onset:
Lorazepam (Ativan) 0.25- 0.5 mg bid-tid
Trazadone (Desyrel) 25-50mg qhs For Delirium: see delirum orderset
Oxazepam ( Serax) Temazepam ( Restoril) Tricyclic Antidepressants,
Most anticholinergic of tricyclics. Adverse
For neuropathy:
Gabapentin (Neurontin)-dose renally
Nortriptyline (Pamelor) 10 mg qhs
Lidocaine 5% Patch: 12 hrs on, 12 hrs off For depression: Sertraline 25mg daily-titrate prn Venlafaxine (Effexor) XR 37.5-75mg daily**-titrate prn Citalopram 10 mg daily –titrate prn
All have anticholinergic effects. Adverse
See delirium orderset for full recommendations
effects::confusion, oversedation,, orthostatic
Avoid haloperidol use in Parkinson’s pts
Haloperidol (Haldol) loading dose of 0.5-1mg po q2hrs prn until pt is calm or 0.5-1 mg IM q30 minutes until
Studies show increased risk of mortality in
pt is calm then 0.5 mg bid , then wean off (max dose=5 mg/day) *** Risperidone (Risperdal) 0.5 mg bid *** Quetiapine (Seroquel) 12.5 mg bid*** For antihistamine effect:
Loratadine (Claritin) 10 mg daily, every other day if CrCl <30 ml/min For urinary Incontinence:
Tolterodine LA (Detrol LA) 2 mg daily For other uses:
Avoid use if able, if not, use lowest effective dose for shortest period of time
Avoid when possible. Use lowest effective dose.
Promethazine (Phenergan) 6.25-12.5 mg IV q4-6 hrs prn or 12.5 mg po/pr q4-6 hrs prn
Ondansetron 4mg IV q8hrs prn
a high incidence of extrapyramidal effects.
Metoclopramide (Reglan) 5 mg qid Acute Care for Elders (ACE) Unit Adverse effects (Opioids): All below doses are in opioid naïve :
Confusion, over-sedation and constipation
Scheduled acetaminophen 1 gram q8hrs or 650 mg q6hr Pentazocine (Talwin) has more CNS effects
Add morphine 5 mg to 7.5 mg q4hrs prn or oxycodone 2.5 mg -5mg q4hrs prn ( oxycodone preferred in renal Fentanyl patches have a delay to maximal
effect and prolonged effects last after removal
If parental route is needed:
(18-36 hours or longer in patients with renal
Morphine 2 mg to 4 mg IV q3hrs prn or
dysfunction) Rapid titration may result in
Hydromorphone 0.5 mg IV q3hrs prn
overdose. Contraindicated in opioid naïve
When opioid is needed for chronic pain:
Morphine SR 15 mg q12hrs with Morphine Propoxyphene ( Darvon) has more CNS 5 mg to 7.5 mg q4hrs prn pain or if significant renal
effects than other equianalgesic opioids It is no
impairment Oxycodone SR 10 mg q12 hrs with
oxycodone 2.5 mg to 5mg q4hrs prn Meperidine ( Demerol) is biotransformed to a
NSAIDs and COX-2 inhibitors may be considered
dysfunction. It is no longer on formulary
rarely and with extreme caution in highly selected
individuals per American Geriatric Society pain
Adverse effects (NSAIDs):
GI bleed and nephrotoxicity, increased risk of
If NSAID is necessary use for short period or add
proton pump inhibitor for GI protection
*Greatest potential for adverse effects **Monitor for small increase in blood pressure ***see delirium or antipsychotic orderset 11/09
Acute Care for Elders (ACE) Unit
Allen, PP Slides ACE business plan.pdf
ACE Acute Care for Elders: Creating the Business Case
The ABCs of ACE Unit Implementation
“The Burning Platform” & The Rosetta Stone for ACE
Key Stat Comparison 5 N vs. Entire Hospital for ACE-like population
5 North Contribution to Overhead and Net Income compared to entire hospital for ACE-like population
If other units could perform at the same variable cost and utilization rates of 5 North for a Medicare population
The “Technology” of ACE is Transferrable
Senior Services ALOS and Contribution Margin: The Results are Outstanding…
Allen 1_Business Model for Mercy ACE Unit explain
Allen 2_Business Model of ACE Unit -2 (2)
Allen 3C_Altered bowel elimination
Allen 3D_Care Plan Guideline-pain
Allen 3E_Care Plan Guidelines - Urinary Elimination
Allen 3F_Care Plan Guidelines Falls
Allen 3G_Care Plan Guidelines- Impaired Skin
Allen 3H_Care plan Guidelines- Situational Depression
I’d like to begin by asking you, Nancy, where and when you were born? I was born in Waterloo, Iowa, February 21st, 1941. Could you talk a little bit about your family, like brothers and sisters, parents. Did you grow up with your parents? My father was diagnosed with schizophrenia when he was in World War II, a veteran, and I was separated from him at the age of two and then I saw him once wh
HEALTH HISTORY Date of last medical exam __________________What was this exam for? __________________________ Have you been hospitalized in the last 5 years? If yes, reason: ______________________________________________________________________________ Are you currently receiving care? No Yes If yes, nature of care: _____________________________ Please list all the names and phone numb
HIGH RISK MEDICATIONS IN ELDERLY PATIENTS 
Adverse effects (Opioids):