Systematic Review: Medication

Emergency Department Programs to Support Medication Safety in Older Adults

A systematic review and meta-analysis

Rachel M. Skains, MD, MSPH; Jane M. Hayes, MD, MPH; Katherine Selman, MD; et al

JAMA Netw Open | Volume 8, Issue 3 | March 2025 |Pages 1-20
doi:10.1001/jamanetworkopen.2025.0814

Abstract

Importance  Given that older adults are at high risk for adverse drug events (ADEs), many geriatric medication programs have aimed to optimize safe ordering, prescribing, and deprescribing practices.

Objective  To identify emergency department (ED)–based geriatric medication programs that are associated with reductions in potentially inappropriate medications (PIMs) and ADEs.

Data Sources  A systematic search of Scopus, Embase, PubMed, PsycInfo, ProQuest Central, CINAHL, AgeLine, and Cochrane Library was conducted on February 14, 2024, with no date limits applied.

Study Selection  Randomized clinical trials or observational studies focused on ED-based geriatric (aged ≥65 years) medication programs that provide ED clinician support to avoid PIMs and reduce ADEs.

Data Extraction and Synthesis  Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for abstracting data and the Cochrane risk-of-bias tool were used to assess data quality and validity. Abstract screening and full-text review were independently conducted by 2 reviewers, with a third reviewer acting as an adjudicator.

Main Outcomes and Measures  Process (ordering, prescribing, and deprescribing PIM rates) and clinical (ADE, health care utilization, and falls) outcomes.

Results  The search strategy identified 3665 unique studies, 98 were assessed for eligibility in full-text review, and 25 studies, with 44 640 participants, were included: 9 clinical pharmacist reviews (with 28 360 participants), 1 geriatrician teleconsultation (with 50 participants), 8 clinician educational interventions (with 5888 participants), 4 computerized clinical decision support systems (CDSS; with 9462 participants), and 3 fall risk–increasing drug (FRID) reviews (with 880 participants). Clinical pharmacist review was not associated with decreased hospital admission or length of stay, but 2 studies showed a 32% reduction in PIMs from deprescribing (odds ratio [OR], 0.68 [95% CI, 0.50-0.92]; P = .01). One study also found that ED geriatrician teleconsultation was associated with enhanced deprescribing of PIMs. Three clinician educational intervention studies showed a 19% reduction in PIM prescribing (OR, 0.81 [95% CI, 0.68-0.96]; P = .02). Two computerized CDSS studies showed a 40% reduction in PIM ordering (OR, 0.60 [95% CI, 0.48-0.74]; P < .001). FRID reviews were not associated with reduced time to first fall or fall recurrence at 12 months.

Conclusions and Relevance  In this systematic review and meta-analysis of ED-based geriatric medication safety programs, a multidisciplinary team, including clinical pharmacists and/or geriatricians, was associated with improved PIM deprescribing. Furthermore, computerized CDSS, alone or in combination with ED clinician education, was associated with enhanced geriatric ordering and prescribing practices. These findings will inform the Geriatric ED Guidelines version 2.0 update.

Comparative Safety of Medications for Severe Agitation

A Geriatric Emergency Department Guidelines 2.0 Systematic Review

Martin F. Casey, MD, MPH; Natalie M. Elder, MD; Alexander Fenn, MD; et al

J Am Geriatr Soc | Epub | April 2025
doi: 10.1111/jgs.19485

Abstract

Background  Managing undifferentiated, severe agitation in older adults may require antipsychotic or sedative medications to prevent harm to self or others. Unfortunately, these medications are associated with serious adverse events in older adults, and little is known about their comparative safety.

Methods  We conducted a systematic review to identify comparative effectiveness studies on the safety of medications used in the treatment of severe agitation among older adults in the prehospital or emergency department (ED) setting. We searched eight databases including PubMed, EMBASE, SCOPUS, Cochrane library, CINAHL, Proquest Central, Ageline, and PsycInfo published in or before February 2024. Studies were included if they examined 1st generation antipsychotics, 2nd generation antipsychotics, benzodiazepines, or ketamine. Data were extracted on adverse respiratory events (apnea, hypoxemia, intubation) and other adverse events (arrhythmia, hypotension, worsening delirium, cardiac arrest, and mortality). We report the aggregate occurrence of any adverse events pooled by drug and report odds ratios (ORs) using haloperidol as the reference group.

Results  Among 8600 studies identified, eight observational studies and one randomized clinical trial met eligibility for further qualitative and quantitative analysis. The observational studies included 838 older adults receiving haloperidol (n = 117), droperidol (n = 129), lorazepam (n = 350), midazolam (n = 68), olanzapine (n = 101), quetiapine (n = 56), and ziprasidone (n = 17). Any adverse events were observed in 16.8% of the patients (141/838). Adverse events were most common among patients receiving midazolam (53%; 36/68). Relative to haloperidol, midazolam significantly increased the risk for any adverse events (OR 5.25 [95% CI: 2.64-10.45]). Quetiapine was the only drug observed to have a lower frequency of adverse events (OR 0.27 [95% CI: 0.08, 0.97]).

Conclusions  Adverse drug events are common among older adults receiving antipsychotic or anxiolytic medications for severe agitation. Benzodiazepines, particularly midazolam, pose an excessive risk to older adults requiring pharmacologic treatment for severe agitation.