CASE STUDY
A cardiologist saw an otherwise healthy 72-year-old woman in her outpatient clinic. The patient had recent onset atrial fibrillation, and following extensive evaluation, the cardiologist determined that long-term anticoagulation was indicated. The cardiologist started the patient on rivaroxaban and saw her in follow-up visits in the clinic over several years. The patient had been doing very well over this time period until she developed sudden onset aphasia and rapidly progressing neurological symptoms. Ultimately, she was diagnosed with a large hemorrhagic stroke and suffered persistent neurologic deficits and significant functional impairment.
The patient and her spouse sought a plaintiff attorney approximately three months after her hospitalization when they received a large bill for her prolonged hospitalization and rehabilitation stay. During discovery, the plaintiff hired a geriatrics specialist who pointed out that rivaroxaban was on the Beers Criteria list of increased risk of hemorrhage compared to other anticoagulants when used for chronic atrial fibrillation. The plaintiff’s expert physician opined that it was below the standard of care for the cardiologist to have used the medication without at least letting the patient know about the increased risk for bleeding compared to alternatives.
Allegations of medication prescribing errors remain a leading cause of medical liability lawsuits in all patients and are particularly common in the elderly population. Interestingly, although the legibility of prescriptions has improved with the introduction of electronic health records and electronic prescribing, the frequency of allegations of negligence around medication prescribing errors has not changed since the era when handwritten prescriptions were predominant. In all cases, present moment and situational attentiveness when prescribing is important and may help reduce risks of lawsuits. This includes awareness of the higher risk medications.
When using these higher risk medications, providers should consider documentation that supports the clinical decision-making, including why the medication was the best or the appropriate choice in the specific situation, why it was selected over alternatives, how the risk-benefit analysis was discussed with the patient in shared decision-making, and what additional steps and monitoring were undertaken to help prevent or catch early any adverse events. For very high-risk scenarios, providers should also consider an informed consent form in addition to the standard documentation of the discussions and thought process.
One useful resource that providers may consider searching when prescribing medications for adults aged 65 and older is the American Geriatrics Society (AGS) Beers Criteria which takes into account that as patients age some medications are associated with higher risks of unintended effects. The AGS has published this guide to medications that meet the criteria, known as Beers Criteria, for potentially higher risks in older patients since 2011 and has periodically updated this guide, most recently in 2023. The AGS makes it clear that the guide is designed as a tool to support shared clinical decision-making and does not set standards so providers should certainly use clinical judgment in all prescribing decisions. However, due to the aging of the U.S. population and the widespread use of many of the medications on the Beers Criteria list, it is reasonable for providers to be familiar with the list and with updates to the list.
In 2023, there have been multiple updates, and some of the notable ones for more widely prescribed medications include:
- Avoidance of aspirin for primary prevention of cardiovascular disease.
- Avoidance of initiating oral or transdermal estrogen. Importantly, topical vaginal estrogen remains appropriate for its major indications of symptomatic vaginal atrophy or urinary tract infection prophylaxis.
- Avoidance of warfarin as initial therapy for nonvalvular atrial fibrillation or venous thromboembolism unless alternatives are contraindicated or there are substantial barriers to their use.
- Avoidance of rivaroxaban for long-term treatment for nonvalvular atrial fibrillation or venous thromboembolism unless alternatives are contraindicated or there are substantial barriers to their use. This is due to higher risk of bleeding in older adults relative to other direct-acting oral anticoagulants.
- Avoidance of sulfonylureas as first- or second-line monotherapy or add on therapy. This is due to higher risk of cardiovascular events, all-cause mortality, and hypoglycemia than alternative choices.
- Avoidance of antipsychotics for behavioral problems of dementia and delirium due to increased risk of patient harm.
It may be very appropriate to prescribe medications in the elderly that are on the Beers Criteria list, but, if doing so, providers should consider the enhanced documentation guidance noted previously as a way to engage patients in the decision-making process and to reduce the risk of allegations of negligence in the event of adverse outcomes.
The updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults can be accessed on the American Geriatrics website.
Information in this article is for general educational purposes and is not intended to establish practice guidelines or provide legal advice.
Article originally published in 1Q24 Copiscope.
