AMDA – The Society for Post-Acute and Long-Term Care Medicine

Fifteen Things Physicians and Patients Should Question

Released September 4, 2013 (1–5); March 20, 2015 (6–10); #8 updated July 2, 2015; #3, 4, 5 & 8 updated July 1, 2019; November 22, 2020 (11–15); #4, 9, 10, & 13 updated July 6, 2021

  1. 1

    Don’t insert percutaneous feeding tubes in individuals with advanced dementia. Instead, offer oral assisted feedings.

    Strong evidence exists that artificial nutrition does not prolong life or improve quality of life in patients with advanced dementia. Substantial functional decline and recurrent or progressive medical illnesses may indicate that a patient who is not eating is unlikely to obtain any significant or long-term benefit from artificial nutrition. Feeding tubes are often placed after hospitalization, frequently with concerns for aspirations, and for those who are not eating. Contrary to what many people think, tube feeding does not ensure the patient’s comfort or reduce suffering; it may cause fluid overload, diarrhea, abdominal pain, local complications, less human interaction and may increase the risk of aspiration. Assistance with oral feeding is an evidence-based approach to provide nutrition for patients with advanced dementia and feeding problems.

  2. 2

    Don’t use sliding scale insulin (SSI) for long-term diabetes management for individuals residing in the nursing home.

    SSI is a reactive way of treating hyperglycemia after it has occurred rather than preventing it. Good evidence exists that SSI is neither effective in meeting the body’s physiologic insulin needs nor is it efficient in the long-term care (LTC) setting in medically stable individuals. Use of SSI is associated with more frequent glucose checks and insulin injections, leads to greater patient discomfort and increased nursing time and resources. With SSI regiments, patients may be at risk from wide glucose fluctuations or hypoglycemia when insulin is given when food intake is erratic.

  3. 3

    Don’t obtain urine tests until clinical criteria are met.

    Clinical uncertainty surrounding asymptomatic bacteriuria (ASB) and/or pyuria is the major driver for overtreatment of Urinary Tract Infections (UTI) in PALTC, (Nace). Colonization (a positive bacterial culture without signs or symptoms of a localized UTI) is a common problem in PALTC facilities that contributes to the over-use of antibiotic therapy in this setting, leading to an increased risk of diarrhea or other adverse drug events, resistant organisms, and infection due to Clostridioides difficile. An additional concern is that the finding of asymptomatic bacteriuria may lead to an erroneous assumption that a UTI is the cause of an acute change of status, hence failing to detect or delaying the timely detection of 5 signs and symptoms likely indicative of uncomplicated cystitis. These include dysuria, and one or more of the following: frequency, urgency, supra-pubic pain or gross hematuria. In the presence of dysuria and one or more sign/symptom, collection of a urine culture is indicated.

  4. 4

    Don’t prescribe antipsychotic medications for behavioral and psychological symptoms of dementia (BPSD) in individuals with dementia unless management of underlying causes fails to respond to best treatment practices. Only use for symptoms that severely impact quality of life or safety from self and/or others, in lowest dose possible and with frequent re-assessment for necessity and efficacy.

    Careful differentiation of cause of the symptoms (physical or neurological versus psychiatric, psychological) may help better define appropriate treatment options. The therapeutic goal of the use of antipsychotic medications is to treat patients who present an imminent threat of harm to self or others, or are in extreme distress – not to treat nonspecific agitation or other forms of lesser distress. Treatment of BPSD in association with the likelihood of imminent harm to self or others includes assessing for and identifying and treating underlying causes (including pain; constipation; and environmental factors such as noise, being too cold or warm, etc.), ensuring safety, reducing distress and supporting the patient’s functioning.

    If treatment of other potential causes of the BPSD is unsuccessful, antipsychotic medications can be considered, taking into account their significant risks compared to potential benefits. When an antipsychotic is used for BPSD, it is advisable to obtain informed consent.

    Refer to F-758: Free from Unnecessary Psychotropic Medications/PRN Use.

  5. 5

    Don’t routinely prescribe lipid-lowering medications in individuals with a limited life expectancy.

    Hypercholesterolemia, or low HDL-C, is an important risk factor for all-cause mortality, coronary heart disease mortality, hospitalization for myocardial infarction or unstable angina in persons older than 70 years. In fact, studies show that elderly patients with the lowest cholesterol have the highest mortality after adjusting other risk factors. In addition, a less favorable risk-benefit ratio may be seen for patients older than 85, where benefits may be more diminished and risks from statin drugs more increased (cognitive impairment, falls, neuropathy and muscle damage).

  6. 6

    Don’t place an indwelling urinary catheter to manage urinary incontinence.

    The most common source of bacteremia in the post-acute and long-term care (PA/LTC) setting is the bladder when an indwelling urinary catheter is in use. The federal Healthcare Infection Control Practices Advisory Committee (HICPAC) recommends minimizing urinary catheter use and duration of use in all patients. Specifically, HICPAC recommends not using a catheter to manage urinary incontinence in the PA/LTC setting. Appropriate indications for indwelling urinary catheter placement include acute retention or outlet obstruction, to assist in healing of deep sacral or perineal wounds in patients with urinary incontinence, and to provide comfort at the end of life if needed.

  7. 7

    Don’t recommend screening for breast, colorectal or prostate cancer if life expectancy is estimated to be less than 10 years.

    Many patients residing in the LTC setting are elderly and frail, with multimorbidity and limited life expectancy. Although research evaluating the impact of screening for breast, colorectal and prostate cancer in older adults in general and LTC residents in particular is scant, available studies suggest that multimorbidity and advancing age significantly alter the risk-benefit ratio. Preventive cancer screenings have both immediate and longer term risks (e.g., procedural and psychological risks, false positives, identification of cancer that may be clinically insignificant, treatment-related morbidity and mortality). Benefits of cancer screening occur only after a lag time of 10 years (colorectal or breast cancer) or more (prostate cancer). Patients with a life expectancy shorter than this lag time are less likely to benefit from screening. Discussing the lag time (“When will it help?”) with patients is at least as important as discussing the magnitude of any benefit (“How much will it help?”). Prostate cancer screening by prostate-specific antigen testing is not recommended for asymptomatic patients because of a lack of life-expectancy benefit. One-time screening for colorectal cancer in older adults who have never been screened may be cost-effective; however, it should not be considered after age 85 and for most LTC patients older than 75 the burdens of screening likely outweigh any benefits.

  8. 8

    Don’t obtain a C. difficile toxin test to confirm “cure” if symptoms have resolved.

    Patients residing in PA/LTC facilities are particularly at risk for CDI because of advanced age, frequent hospitalizations and frequent antibiotic exposure. However, only symptomatic patients should be tested. Furthermore, studies have shown that C. difficile tests may remain positive for as long as 30 days after symptoms have resolved. False positive “test-of-cure” specimens may complicate clinical care and result in additional courses of inappropriate anti-C. difficile therapy. To limit the spread of C. difficile, care providers in the PA/LTC setting should concentrate on early detection of symptomatic patients and the consistent use of proper infection control practices, including hand washing with soap and water, contact precautions, and environmental cleaning with 1:10 dilution of sodium hypochlorite (bleach) prepared fresh daily.

  9. 9

    Don’t recommend aggressive or hospital-level care for frail individuals without a clear understanding of the individual’s goals of care and the possible benefits and burdens.

    Hospital-level care has known risks, including delirium, infections, side effects of medications and treatments, disturbance of sleep, and loss of mobility and function. These risks are often more significant for patients in the PA/LTC setting, who are more likely to be frail and to have multimorbidity, functional limitations and dementia. Therefore, for some frail elders, the balance of benefits and harms of hospital-level care may be unfavorable. To avoid unnecessary hospitalizations, care providers should engage in advance care planning by defining goals of care for the patient and discussing the risks and benefits of various interventions, including hospitalization, in the context of prognosis, preferences, indications, and the balance of risks and benefits. Advance directives such as the Physician Orders for Life Sustaining Treatment (POLST) paradigm form and Do Not Hospitalize (DNH) orders communicate a patient’s preferences about end-of-life care. Patients with DNH orders are less likely to be hospitalized than those who do not have these directives. Patients who opt for less-aggressive treatment options are less likely to be subjected to unnecessary, unpleasant and invasive interventions and the risks of hospitalization.

  10. 10

    Don’t initiate aggressive antihypertensive treatment in frail individuals ≥60 years of age. For frail individuals with hypertension, multiple medical comorbidities, and limited life expectancy, use clinical judgment, patient/family preferences, and evaluation of risk/benefit in deciding on medication(s) and the intensity of control.

    There is strong evidence for the treatment of hypertension in older adults. Achieving a goal SBP of 150mm Hg reduces stroke incidence, all-cause mortality and heart failure. There is less consistent evidence that lower BP targets are beneficial for high-risk patients, especially frail patients in the post-acute and long-term care setting. Target SBP and DBP levels should be based on shared decision-making with the patient as there is data supporting benefit in treating more aggressively to a goal SBP of <140mm Hg in community-dwelling individuals ≥75 years of age with elevated cardiovascular risk. Using a reliable, representative method of taking blood pressures with special attention to orthostatic hypotension is important, as orthostatic hypotension has been associated with increased mortality and cardiovascular events. In addition, moderate or high-intensity treatment of hypertension has been associated with an increased risk of serious falls and injury in frail older adults.

  11. 11

    Don’t continue hospital-prescribed stress ulcer prophylaxis with Proton- Pump Inhibitor (PPI) therapy in the absence of an appropriate diagnosis in the post-acute and long-term care (PALTC) population.

    In the absence of an appropriate diagnosis for the use of PPI’s long-term in PALTC populations, stop hospital prescribed medications for stress prophylaxis, as literature does not support PPI use for stress ulcer prophylaxis outside the Intensive Care Unit setting. It is important to determine the indication for use and balance potential harm versus benefit recognizing known adverse events with long-term PPI use, including pneumonia, diminished vitamin absorption and bacterial infections such as Clostridium Difficile.

  12. 12

    Don’t order routine follow up chest imaging for post-acute and long-term care residents with community acquired pneumonia whose symptoms have resolved within 5–7 days.

    Radiographic findings tend to lag behind clinical response. Obtaining routine follow up chest radiograph in patients with CAP who have responded to prescribed therapy is therefore not indicated and does not improve care outcomes. This approach is similar to that outlined by the American Thoracic Society (ATS) and Infectious Diseases Society of America (IDSA), both of whom recommend not obtaining a follow-up chest radiograph in patients whose symptoms have resolved within five to seven days.

  13. 13

    Don’t routinely prescribe or continue sedative hypnotics such as Restoril or Ambien, diphenhydramine (Benadryl), benzodiazepines, or Serotonin Modulators (Trazadone) for long-term treatment of sleep disorders in geriatric populations. Consider the use of nonpharmacological interventions (e.g., physical activity, a regular schedule or cognitive behavioral therapy.)

    Use of diphenhydramine (or other first generation antihistamines), benzodiazepines or sedative hypnotics with anticholinergic side effects should be avoided as the data suggests these drugs may cause confusion and delirium in the short term, and some have been associated with an increased risk of dementia with long-term use. These drugs are associated with a five-fold increase in adverse cognitive events, an increase in adverse psychomotor events and are associated with an increased risk of falls. The 2019 updated Beers criteria for potentially inappropriate medications for use in older adults recognized these medications as problematic.

  14. 14

    Don’t routinely prescribe or continue acetyl cholinesterase inhibitors or N-Methyl-D-Aspartate antagonists in patients with advanced dementia.

    Use of acetyl cholinesterase inhibitors in mild to moderate dementia or NMDA antagonists in moderate to severe dementia may help with Behavioral and Psychological Symptoms of Dementia (BPSD) but have not been shown to prolong life. Once an individual is institutionalized, review of the risks and benefits of the medications should be reviewed periodically and de-prescribed when no longer demonstrating benefit to the patient. Acetyl cholinesterase inhibitors can worsen anorexia and NMDA receptor agonists are not indicated with severe renal insufficiency, both of which could be present in the older population.

  15. 15

    Don’t provide long-term opioid therapy for chronic non-cancer pain in the absence of clear and documented benefits to functional status and quality of life.

    Long-term use of opioids is common in the PALTC setting. The Society’s 2018 Position Statement on the use of opioids states that nursing home practitioners who prescribe opioids should do so based on thoughtful inter-professional assessment indicating a clear indication for opioid use.

    For admitted residents on long term opioid therapy for chronic pain (not for cancer, palliative care, or end-of-life), tapering plans should be individualized and should minimize symptoms of opioid withdrawal while maximizing pain treatment with non-pharmacologic therapies and non-opioid medications.

    Periodic review to evaluate risk factors for potential harms should be incorporated into the individualized plan of care. In addition, clinicians should offer alternative behavioral therapies, non-opioid analgesics and other non-pharmacologic treatments whenever available and appropriate.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

AMDA – The Society for Post-Acute and Long-Term Care Medicine is the only professional association representing medical directors, attending physicians and others practicing in the long term care continuum. AMDA is dedicated to excellence in patient care and provides education, advocacy, information and professional development to promote the delivery of quality long term care medicine. AMDA strives to provide cutting edge education, information and tools on clinical, management and technology topics that are specific to the evolving long term care setting. AMDA offers opportunities to learn about best practices and activities that can maximize the quality of care and quality of life for patients.

How This List Was Created

1–5: AMDA – The Society for Post -Acute and Long-Term Care Medicine convened a work group made up of members from the Clinical Practice Steering Committee (CPSC). Members of the CPSC include board certified geriatricians, certified medical directors, multi-facility medical directors, attending practitioners, physicians practicing in both office-based and nursing facility practice, physicians in rural, suburban and academic settings, those with university appointments, and more. It was important to AMDA that the workgroup chosen represent the core base of the AMDA membership. Ideas for the “five things” were solicited from the workgroup. Suggested elements were considered for appropriateness, relevance to the core of the specialty and opportunities to improve patient care. They were further refined to maximize impact and eliminate overlap, and then ranked in order of potential importance both for the specialty and for the public. A literature search was conducted to provide supporting evidence or refute the activities. The list was modified and a second round of selection of the refined list was sent to the workgroup for paring down to the final “top five” list. Finally, the work group chose its top five recommendations before submitting a final draft to the AMDA Executive Committee, which were then approved.

6–10: The AMDA Choosing Wisely® endeavor utilized a similar procedure as published in JAMA Intern Med. 2014;174(4):509-515 – A Top 5 List for Emergency Medicine for our five items.

The AMDA Clinical Practice Committee acted as the Technical Expert Panel (TEP).

Phase 1 – The Clinical Practice Steering Committee (CPSC) along with the Infection Advisory Committee clinicians brainstormed an initial list of low-value clinical decisions that are under control of PA/LTC physicians that were thought to have a potential for cost savings.

Phase 2 – Each member of the CPSC selected five low-value tests considering the perceived contribution to cost (how commonly the item is ordered and the individual expense of the test/treatment/action), benefit of the item (scientific evidence to support use of the item in the literature or in guidelines); and highly actionable (use decided by PA/LTC clinicians only).

Phase 3 – A survey was sent to all AMDA members. Statements were phrased as specific overuse statements by using the word “don’t,” thereby reflecting the action necessary to improve the value of care.

Phase 4 – CPSC members reviewed survey results and chose the five items.

The AMDA Choosing Wisely project utilized procedures similar to previous workgroups.
In Phase 1 – The Clinical Practice Steering Committee (CPSC) solicited recommendations from members of the Society’s five subcommittees.

In Phase 2 – Each member of the CPSC reviewed the submitted recommendations (with the goal to selecting the best five recommendations) considering the
perceived contribution to cost, benefit of the item and scientific evidence to support use of the item in the literature or in guidelines. Based on the feedback of the CPSC, the recommendations were narrowed to five, revised, and supporting evidence was added.

Phase 3 – The revised five recommendations and sources were reviewed by the CPSC for final approval, and then approved by the Board of Directors.

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  1. Teno JM, Gozalo PL, Mitchell SL, Kuo S, Rhodes RL, Bynum JP, Mor V. Does feeding tube insertion and its timing improve survival? J Am Geriatr Soc. 2012 Oct;60(10):1918-21.

    Hanson LC, Ersek M, Gilliam R, Carey TS. Oral feeding options for people with dementia: a systematic review. J Am Geriatr Soc. 2011;59(3):463-72

    Palecek EJ, Teno JM, Casarett DJ, Hanson LC, Rhodes RL, Mitchell SL. Comfort feeding only: a proposal to bring clarity to decision-making regarding difficulty with eating for persons with advanced dementia. J Am Geriatr Soc. 2010;58(3):580-4.

    Sorrell JM. Use of feeding tubes in patients with advanced dementia: are we doing harm? J Psychosoc Nurs Ment Health Serv. 2010 May;48(5):15-8.

    Sampson EL, Candy B, Jones L. Enteral tube feeding for older people with advanced dementia. Cochrane Database Syst Rev. 2009 Apr 15;(2):CD007209.

    Gillick MR, Volandes AE. The standard of caring: why do we still use feeding tubes in patients with advanced dementia? J Am Med Dir Assoc. 2008 Jun;9(5):364-7.

    Ganzini L. Artificial nutrition and hydration at the end of life: ethics and evidence. Palliat Support Care. 2006 Jun;4(2):135-43.

    Li I. Feeding tubes in patients with severe dementia. Am Fam Physician. 2002 Apr 15;65(8):1605-11.

    Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia: a review of the evidence. JAMA. 1999 Oct 13;282(14):1365-70.

    Mitchell SL, Kiely DK, Lipsitz LA. The risk factors and impact on survival of feeding tube placement in nursing home residents with severe cognitive impairment. Arch Intern Med. 1997 Feb 10;157(3):327-32.

  2. Sue Kirkman M, Briscoe VJ, Clark N, Florez H, Haas LB, Halter JB, Huang ES, Korytkowski MT, Munshi MN, Odegard PS, Pratley RE, Swift CS. Consensus Development Conference on Diabetes and Older Adults. Diabetes in older adults: a consensus report. J Am Geriatr Soc. 2012 Dec;60(12):2342-56.

    American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012 Apr;60(4):616-31.

    Haq J. Insulin sliding scare, does it exist in the nursing home. JAMDA. 2010 Mar;11(3):B14.

    Hirsch IB. Sliding scale insulin—time to stop sliding. JAMA. 2009;301(2):213-214.

    American Medical Directors Association. diabetes management in the long-term care setting clinical practice guideline. Columbia, MD:AMDA 2008, revised 2010.

    Pandya N, Thompson S, Sambamoorthi U. The prevalence and persistence of sliding scale insulin use among newly admitted elderly nursing home residents with diabetes mellitus. J Am Med Dir Assoc. 2008 Nov;9(9):663-9.

    Umpierrez GE, Palacio A, Smiley D. Sliding scale insulin use: myth or insanity? Am J Med. 2007;120(7):563-67.

    Golightly LK, Jones MA, Hamamura DH, Stolpman NM, McDermott MT. Management of diabetes mellitus in hospitalized patients: efficiency and effectiveness of sliding-scale insulin therapy. Pharmacotherapy. 2006;26(10):1421-32.

    Munshi et al. Management of Diabetes in Longterm Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association. Diabetes Care 2016;39:308-318/DOI: 10.2337/dc15-2512.

    Queale WS, Seidler AJ, Brancati FL. Glycemic control and sliding scale insulin use in medical inpatients with diabetes mellitus. Arch Intern Med. 1997;157(5):545-52.

  3. Stone ND, Ashraf MS, Calder J, Crnich CJ, Crossley K, Drinka PJ, Gould CV, Juthani-Mehta M, Lautenbach E, Loeb M, MacCannell T, Malani TN, Mody L, Mylotte JM, Nicolle LE, Roghmann MC, Schweon SJ, Simor AE, Smith PW, Stevenson KB, Bradley SF. Surveillance definitions of infections in long-term care facilities: revisiting the McGeer Criteria. Infec Control Hosp Epidemiol. 2012;33(10):965-77.

    Drinka P. Treatment of bacteriuria without urinary signs, symptoms, or systemic infectious illness (S/S/S). J Am Med Dir Assoc. 2009 Oct;10(8):516-9.

    Arinzon Z, Peisakh A, Shuval I, Shabat S, Berner YN. Detection of urinary tract infection (UTI) in long-term care setting: is the multireagent strip an adequate diagnostic tool? Arch Gerontol Geriatr. 2009 Mar-Apr;48(2):227-31.

    High KP, Bradley SF, Gravenstein S, Mehr DR, Quagliarello VJ Richards C, Yoshikawa TT. Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America. J Am Geriatr Soc. 2009 Mar;57(3):375-94.

    Zabarsky TF, Sethi AK, Donskey CJ. Sustained reduction in inappropriate treatment of asymptomatic bacteriuria in a long-term care facility through an educational intervention. Am J Infect Control. 2008 Sep;36(7):476-80.

    Richards CL Jr. Infection control in long-term care facilities. J Am Med Dir Assoc. 2007 Mar;8(3 Suppl):S18-25.

    Ducharme J, Neilson S, Ginn JL. Can urine cultures and reagent test strips be used to diagnose urinary tract infection in elderly emergency department patients without focal urinary symptoms? CJEM. 2007 Mar;9(2):87-92.

    Loeb M, Brazil K, Lohfeld L, McGeer A, Simor A, Stevenson K, Zoutman D, Smith S, Liu X, Walter SD. Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes: cluster randomized controlled trial. BMJ. 2005 Sep 24;331(7518):669.

    Loeb M, Brazil K, Lohfeld L, McGeer A, Simor A, Stevenson K, Walter S, Zoutman D. Optimizing antibiotics in residents of nursing homes: protocol of a randomized trial. BMC Health Serv Res. 2002 Sep 3;2(1):17.

    Nace D, Perera S, Hanlon J, Saracco S, Anderson G, Schweon S, Klein-Fedyshin M, Wessel C, Mulligan M, Drinka P, Crnich C. J Am Med Dir Association. 2018(19) 765-769.

    Nicolle LE. Urinary tract infection in geriatric and institutionalized patients. Curr Opin Urol. 2002 Jan;12(1):51-5.

    Boscia JA, Kobasa WD, Abrutyn E, Levison ME, Kaplan AM, Kaye D. Lack of association between bacteriuria and symptoms in the elderly. Am J Med. 1986 Dec;81(6):979-82.

    Nicolle LE, Bentley D, Garibaldi R, Neuhaus E, Smith P. SHEA Long-Term Care Committee. Antimicrobial use in long-term-care facilities. Infect Control Hosp Epidemiol. 1996;17:119-28.

    High KP, Bradley SF, Gravenstein S, Mehr DR, Quagliarello VJ, Richards C, Yoshikawa TT. Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America. Clin Infect Dis 2009;48: 149-71.

  4. American Medical Directors Association. Dementia in the long term care setting clinical practice guideline. Columbia, MD: AMDA 2012.

    Perkins, R. Evidence-based practice interventions for managing behavioral and psychological symptoms of dementia in NH residents. Ann LTC. 2012:20(12):20-4.

    Flaherty J, Gonzales J, Dong B. Antipsychotics in the treatment of delirium in older hospitalized adults: a systematic review. JAGS. 2011;59:S269-76.

    American Medical Directors Association. Delirium and acute problematic behavior clinical practice guideline. Columbia, MD: AMDA 2008.

    Ozbolt LB, Paniagua MA, Kaiser RM. Atypical antipsychotics for the treatment of delirious elders. J Am Med Dir Association. 2008;9:18–28.

    U.S. Food and Drug Administration. Information for healthcare professionals: antipsychotics. FDA Alert, [Internet]. 2008 Jun 16. [Cited 2008 Sep 23]. Available from:

    U.S. Food and Drug Administration, U.S. Department of Health and Human Services. 2007 information for healthcare professionals: haloperidol (marketed as Haldol, Haldol decanoate, and Haldol lactate). [Internet]. 2007 Sep 17. [Cited 2013 Jul 23]. Available from

    Schneeweiss S, Setoguchi S, Brookhart A, Dormuth C, Wang PS. Risk of death associated with the use of conventional versus atypical antipsychotic drugs among elderly patients.
    CMAJ 2007;176(5): 627–32.

    Gill SS, Bronskill SE, Normand SL, Anderson GM, Sykora K, Lam K, Bell CM, Lee PE, Fischer HD, Herrmann N, Gurwitz JH, Rochon PA. Antipsychotic drug use and mortality in older adults with
    dementia. Ann Intern Med. 2007;146(11):775–86.

    Schneider LS, Dagerman KS, Insel P. Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials. JAMA. 2005;294(15):1934–1943.

    Schneider LS, Tariot PN, Dagerman KS. Effectiveness of atypical antipsychotic drugs in patients with Alzheimer’s disease. N Engl J Med. 2006;355(15):1525–38.

    Sink KM, Holden KF, Yaffe K. Pharmacological treatment of neuropsychiatric symptoms of dementia: a review of the evidence. JAMA. 2005;293:596–608.

    U.S. Food and Drug Administration, U.S. Department of Health and Human Services. FDA public health advisory: deaths with antipsychotics in elderly patients with behavioral disturbances. [Internet]. 2005 Apr 11. [Cited 2013 Jul 23]. Available from

  5. Dalleur O, Spinewine A, Henrard S, Losseau C, Speybroeck N, Boland B. Inappropriate prescribing and related hospital admissions in frail older persons according to the STOPP and START criteria. Drugs Aging. 2012 Oct;29(10):829-37.

    Schiattarella GG, Perrino C, Magliulo F, Ilardi F, Serino F, Trimarco V, Izzo R, Amato B, Terranova C, Cardin F, Militello C, Leosco D, Trimarco B, Esposito G. Statins and the elderly: recent evidence and current indications. Aging Clin Exp Res. 2012 Jun;24(3 Suppl):47-55.

    Maraldi C, Lattanzio F, Onder G, Gallerani M, Bustacchini S, De Tommaso G, Volpato S. Variability in the prescription of cardiovascular medications in older patients: correlates and potential explanations. Drugs Aging. 2009 Dec;26 Suppl 1:41-51.

    Schatz IJ, Masaki K, Yano K, Chen R, Rodriguez BL, Curb JD. Cholesterol and all-cause mortality in elderly people from the Honolulu Heart Program: a cohort study. Lancet. 2001 Aug 4;358(9279):351-5.

    Weverling-Rijnsburger AW, Blauw GJ, Lagaay AM, Knook DL, Meinders AE, Westendorp RG. Total cholesterol and risk of mortality in the oldest old. Lancet. 1997 Oct 18;3 (9085):1119-23.

    Krumholz HM, Seeman TE, Merrill SS, Mendes de Leon CF, Vaccarino V, Silverman DI, Tsukahara R, Ostfeld AM, Berkman LF. Lack of association between cholesterol and coronary heart disease mortality and morbidity and all-cause mortality in persons older than 70 years. JAMA. 1994 Nov 2;272(17):1335-40.

  6. CMS Manual System Pub. 100-07 State Operations Provider Certification. Transmittal 8. Revision of Appendix PP–Section 483.25(d)–Urinary Incontinence, Tags F315 and F316.  Centers for Medicare and Medicaid Services, U.S. Department of Health and Human Services; 2005 Jun 28 [cited 2014 Dec 31].  Available from:

    Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA; Healthcare Infection Control Practices Advisory Committee. Guideline for prevention of catheter-associated urinary tract infections 2009. Infect Control Hosp Epidemiol. 2010 Apr;31(4):319-26.

    Hooton TM, Bradley SF, Cardenas DD, Colgan R, Geerlings SE, Rice JC, Saint S, Schaeffer AJ, Tambayh PA, Tenke P, Nicolle LE; Infectious Diseases Society of America. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis.  2010 Mar;50(5):625-63.

  7. Clarfield AM. Screening in frail older people: an ounce of prevention or a pound of trouble? J Am Geriatr Soc. 2010 Oct;58:2016-21.

    Gill TM. The central role of prognosis in clinical decision making. JAMA. 2012 Jan 11;307(2):199-200.

    Gross CP. Cancer screening in older persons: a new age of wonder. JAMA Intern Med. 2014 Oct;174(10):1565-7.

    Lee SJ, Leipzig RM, Walter LC. Incorporating lag time to benefit into prevention decision for older adults. JAMA. 2013 Dec (25);310(24):2609-10.

    Lonsdorp-Vogelaar I, Gulati R, Mariotto AB, Schechter CB, de Carvalho TM, Knudsen AB, van Ravesteyn NT, Heijnsdijk EA, Pabiniak C, van Ballegooijen M, Rutter CM, Kuntz KM, Feuer EJ, Etzioni R, de Koning HJ, Zauber AG, Mandelblatt JS. Personalizing age of cancer screening cessation based on comorbid conditions: model estimates of harms and benefits. Ann Intern Med. 2014 Jul 15;161(2):104-12.

    Moyer VA. Screening for prostate cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2012 Jul 17;157(2):120-34.

    Royce TJ, Hendrix LH, Stokes WA, Allen IM, Chen RC. Cancer screening rates in individuals with different life expectancies. JAMA Intern Med. 2014 Oct;174(10):1558-65.

    Spivack B, Cefalu C, Kamel H, et al. Health Maintenance in the Long Term Care Setting Clinical Practice Guideline. 2012. Columbia, MD: American Medical Directors Association.

    van Hees F, Habbema JD, Meester RG, Lansdorp-Vogelaar I, van Ballegooijen M, Zauber AG. Should colorectal cancer screening be considered in elderly persons without previous screening? A cost-effectiveness analysis. Ann Intern Med. 2014 Jun 3;160(11):750-9.

    Walter LC, Covinsky KE. Cancer screening in elderly patients: a framework for individualized decision making. JAMA. 2001 Jun 6;285(21):2750-6.

  8. Riggs MM, Sethi AK, Zabarsky TF, Eckstein EC, Jump RL, Donskey CJ. Asymptomatic carriers are a potential source for transmission of epidemic and nonepidemic Clostridium difficile strains among long-term care facility residents. Clin Infect Dis. 2007 Oct 15;45 (8):992.

    Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH, McFarland LV, Mellow M, Zuckerbraun BS. Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. Am J Gastroenterol. 2013 Apr;108(4):478–98.

  9. Creditor MC. Hazards of hospitalization of the elderly. Ann Intern Med. 1993 Feb 1;118(3):219.

    Deciding About Going to the Hospital. Interact v4.0 Tool. Florida Atlantic University; 2011 [cited 2015 Jan 2]. Available from:

    Inouye SK, Westendorp RG, Saczynski JS. Delirium in elderly people. Lancet. 2014 Mar 8;383(9920):911-22.

    Murray LM, Laditka SB. Care transitions in older adults from nursing homes to hospitals: implications for long-term care practice, geriatrics education, and research. J Am Med Dir Assoc. 2010 May;11(4):231-8.

    Tulsky JA. Beyond advance directives: importance of communication skills at the end of life. JAMA. 2005 Jul 20;294(3):359-65.

  10. Beckett NS, Peters R, Fletcher AE, Staessen JA, Liu L, Dumitrascu D, Stoyanovsky V, Antikainen RL, Nikitin Y, Anderson C, Belhani A, Forette F, Rajkumar C, Thijs L, Banya W, Bulpitt CJ; HYVET Study Group. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008 May 1; 358(18):1887-98.

    James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, Lackland DT, LeFevre ML, MacKenzie TD, Ogedegbe O, Smith SC Jr, Svetkey LP, Taler SJ, Townsend RR, Wright JT Jr, Narva AS, Ortiz E. 2014 evidence-based guideline for the management of high blood pressure in adults. JAMA. 2014 Feb 5;311(5):507-20.

    Muntner P, Bowling CB, Shimbo D. Systolic blood pressure goals to reduce cardiovascular disease among older adults. Am J Med Sci. 2014 Aug;348(2):129-34.

    Tinetti ME, Han L, Lee DSH, McAvay GJ, Peduzzi P, Gross CP, Zhou B, Lin H. Antihypertensive medications and serious fall injuries in a nationally representative sample of older adults.  JAMA Intern Med. 2014 Apr;174(4):588-95.

    Angelousi  A, Girerd N, Benetos A, Frimat L, Gautier S, Weryha G, Boivin J-M. Association between orthostatic hypotension and cardiovascular risk, cerebrovascular risk, cognitive decline and falls as well as overall mortality: a systematic review and meta-analysis. Journal of Hypertension 2014, 32:1562–1571.

    Williamson JD, Supiano MA, Applegate WB, Berlowitz DR, Campbell RC, Chertow GM, Fine LJ, Haley WE, Hawfield AT, Ix JH, Kitzman DW, Kostis JB, Krousel-Wood MA, Launer LJ, Oparil S, Rodriguez CJ, Roumie CL, Shorr RI, Sink KM, Wadley VG, Whelton PK, Whittle J, Woolard NF, Wright JT Jr, Pajewski NM, SPRINT Research Group. Intensive vs Standard Blood Pressure Control and Cardiovascular Disease Outcomes in Adults Aged≥75 Years: A Randomized Clinical Trial. JAMA. 2016;315(24):2673.

    The SPRINT Research Group. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med 2015;373:2103-16. DOI:10.1056/NEJMoa1511939

  11. Wilson, TD, Hendox I, Thymal, TRH, et al. Effectiveness of Intervention De-prescribe Inappropriate Proton Pump Inhibitors in Older Adults. Drugs Aging. 34. 265-287. (2017)

    Ito, T., Jensen, R.T. Association of Long-Term Proton Pump Inhibitor Therapy with Bone Fractures and Effects on Absorption of Calcium, Vitamin B12, Iron, and Magnesium. Curr Gastroenterol Rep 12, 448–457 (2010).

    Wilhelm, SM, Rjater, RG, Kale-Pradhan, PB. Perils and pitfalls of long-term effects of proton pump inhibitors. Expert Review of Clinical Pharmacology. Volume 6, 2013 – Issue 4.

    Johnson, DA, Oldfield, EC. Reported Side Effects and Complications of Long-term Protein Pump Inhibitor Use: Dissecting the Evidence: Clinical Gastroenterology and Hepatology; 2013;1:458-464.

  12. Diagnosis and Treatment of adults with Community-acquired Pneumonia. Official guideline of the American Thoracic Society and Infectious Disease Society of America. August 2019;

    Metlay JP, Waterer GW, Long AC, et al. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med 2019; 200:e45.

    Bruns AH, Oosterheert JJ, Prokop M, et al. Patterns of resolution of chest radiograph abnormalities in adults hospitalized with severe community-acquired pneumonia. Clin Infect Dis 2007; 45:983.

    Mittl RL Jr, Schwab RJ, Duchin JS, et al. Radiographic resolution of community-acquired pneumonia. Am J Respir Crit Care Med 1994; 149:630.

  13. Jacobs GD, Pace-Schott EF, Stickgold R, Otto MW. Cognitive behavior therapy and pharmacotherapy for insomnia: A randomized controlled trial and direct comparison. Arch Intern Med 2004;164:1888-1896.

    McMillan JM, Aitken E, Holroyd-Leduc JM. Management of insomnia and long-term use of sedative-hypnotic drugs in older patients. CMAJ. 2013;185(17):1499–1505. doi:10.1503/cmaj.130025

    Randall T. Espinoza, Clarifying the Relationship Between Benzodiazepines and Dementia, Journal of the American Medical Directors Association, 10.1016/j.jamda.2019.12.006, 21, 2, (143-145), (2020).

    Khusbu Patel, High-Risk Prescriptions for Aging Patients, Geriatric Practice, 10.1007/978-3-030-19625-7_14, (177-184), (2019).

    Claire K. Ankuda and Olusegun Apoeso, Diagnosis and Management of Delirium, Geriatric Practice, 10.1007/978-3-030-19625-7_19, (237-246), (2019).

    Kelly Cummings and Helen Fernandez, Driving, Geriatric Practice, 10.1007/978-3-030-19625-7_27, (335-344), (2019).

    “American Geriatrics Society Updated Beers Criteria®.”, American Geriatrics Society. January 31, 2019.

  14. Tjia, J et al. Daily Medication Use in Nursing Home Residents with Advanced Dementia (2010) JAGS 58 (5) 880-888.
    Pelosi, A, McNulty, S. Role of cholinesterase inhibitors in dementia care needs rethinking. BMJ 2006; 333 doi: (Published 31 August 2006)

    Deardorff, W.J., Feen, E. & Grossberg, G.T. The Use of Cholinesterase Inhibitors Across All Stages of Alzheimer’s Disease. Drugs Aging 32, 537–547 (2015).

    Palmer, J.B., Albrecht, J.S., Park, Y. et al. Use of Drugs with Anticholinergic Properties Among Nursing Home Residents with Dementia: A National Analysis of Medicare Beneficiaries from 2007 to 2008. Drugs Aging 32, 79–86 (2015).

    Colloca, G., Tosato, M., Vetrano, D. L., Topinkova, E., Fialova, D., Gindin, J., van der Roest, H. G., Landi, F., Liperoti, R., Bernabei, R., Onder, G., & SHELTER project (2012). Inappropriate drugs in elderly patients with severe cognitive impairment: results from the shelter study. PloS one, 7(10), e46669.

  15. Opioids in Nursing Homes. AMDA Resolution & Position Statement 12/2018. Chou R, Turner JA, Devine EB, Hansen RN, Sullivan SD, Blazina I, Dana T, Bougatsos C, Deyo RA. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med. 2015;1-62(4):276

    Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1-49. DOI: icon

    Pimentel, C. B., Gurwitz, J. H., Tjia, J., Hume, A. L., & Lapane, K. L. (2016). New Initiation of Long-Acting Opioids in Long-Stay Nursing Home Residents. Journal of the American Geriatrics
    Society, 64(9), 1772–1778.

    Hunnicutt, J. N., Chrysanthopoulou, S. A., Ulbricht, C. M., Hume, A. L., Tjia, J., & Lapane, K. L. (2018). Prevalence of Long-Term Opioid Use in Long-Stay Nursing Home Residents. Journal of the American Geriatrics Society, 66(1), 48–55.

    Fain, KM, Alexander, GC, Dore, DD, Segal, JB, Zullo, AR, Castillo-Salgado, C. Frequency and Predictors of Analgesic Prescribing in U.S. Nursing Home Residents with Persistent Pain. J Am Geriatr Soc. 2017 Feb;65(2):286-293. doi: 10.1111/jgs.14512. Epub 2016 Nov 7.

    PALTC Practitioners Step Up to Address Opioid Crisis: Joanne Kaldy Caring for the Ages, Volume 20, ISSUE 4, P19, May 01, 2019 DOI:

    Tapering Long Term Opioid Therapy in Chronic Noncancer pain: