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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
  • Allen 4D_Job Description ACE Medical Director
  • Source: http://adgap.americangeriatrics.org/toolkits/allen/high_risk_meds_in_elderly_patients.pdf

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