Medication Appropriateness in Vulnerable Older Adults

Healthy Skepticism of Appropriate Polypharmacy

Terri R. Fried, MD; Marcia C. Mecca, MD


J Am Geriatr Soc. 2019;67(6):1123-1127. 

In This Article

Potential Limitations of Existing Tools to Identify Medication Appropriateness

Indirect lines of evidence suggest that although substantial progress has been made in developing tools for evaluating the appropriateness of medication regimens for older adults, we may nonetheless still be overestimating benefits and underestimating harms of medications. A recent systematic review of these tools concluded that many require clinical judgment.[6] The challenge is the limitations of randomized clinical trials (RCTs) in informing this clinical judgment. Commentators have argued persuasively that older persons with multiple conditions may not accrue the same benefits from medications as seen in RCTs because they are not as healthy as the trial participants, with competing mortality risks and risk for adverse effects from the medications themselves.[7] Although the limitations in generalizability of findings from RCTs to older adults are well recognized, these limitations have not been examined among tools used to measure PPOs. These tools include the Assessment of Underutilization (AOU), based on a review of the patient's chronic conditions and the use of clinical judgment and clinical guidelines to identify missing medications,[8] and the Screening Tool to Alert to Right Treatment (START) criteria, consensus recommendations based on a review of systematic reviews and RCTs.[9]