Part 18 - Aging
Part 18 - Aging
■ AGING
The dramatic increase in the population of older people is one of the
most significant changes in human history. In the past few years, the
number of people over the age of 65 exceeded that of children under
the age of 5 for the first time, and by 2050, older people will likely
outnumber children under the age of 14 (Fig. 476-1).
FIGURE 476-1 Globally, the people over the age of 65 years now exceed
children under the age of 5 years.
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FIGURE 476-3 Some species undergo negligible senescence while others,
such as the semelparous animals, undergo programmed aging and death. In
some long-lived species, including humans, there is a prolonged post-reproductive
period of life which may be secondary to the beneficial effects of grandmothers on
the survival of infants.
FIGURE 476-5 Nutrient sensing pathways. The main molecular switches that
respond to changes in dietary intake (red boxes: Insulin/IGF1, MTOR, AMPK,
SIRT1, FGF21) influence a range of downstream effectors (some of these are
shown in the grey boxes). These regulate key cellular processes (green boxes),
such as metabolism of fat and carbohydrates (CHO), autophagy, mitochondria,
and protein synthesis. CHO, carbohydrate.
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factors, with genetic variation in some FOXO genes being
associated with human longevity.
2. mTOR pathway. This pathway is activated by amino acids and
the insulin/IGF-1 signaling pathway and, therefore, can be
manipulated by dietary protein intake. Inactivation of mTOR by
dietary restriction or rapamycin is associated with reduced protein
synthesis and increased autophagy, leading to increased life span.
3. Sirtuins. The sirtuin family of NAD+-dependent deacetylases
encompasses seven members in mammals that are activated in
response to low energy supply. Sirtuins regulate gene expression
via histone deacetylation and mitochondrial biogenesis. Increased
sirtuin activity induced by genetic manipulation, CR mimetics, or
NAD supplementation has been associated with increased life
span.
4. Adenosine monophosphate (AMP)–activated protein kinase
(AMPK). Dietary energy restriction is associated with high levels of
AMP in cells, which triggers the activation of AMPK. Observational
studies in humans have suggested that metformin impacts age-
related conditions. Human clinical trials of metformin are planned
to determine its effects on aging.
5. Fibroblast growth factor 21 (FGF21). Dietary protein restriction
increases the production and release of FGF21 into the blood,
with a subsequent increase in AMPK signaling and insulin
sensitivity. Overexpression of FGF21 increases life span in mice.
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death. For millennia, it has been a dream of mankind to prolong both
life span and health span. Developed countries have profited from
advances in medical care and technology, improvements in their
public health care systems, and better living conditions derived from
their socioeconomic power to achieve remarkable increases in life
expectancy during the last century. In the United States, the
percentage of the population aged ≥65 years is projected to increase
from 13% in 2010 to 19.3% in 2030. However, old age remains the
leading risk factor for major life-threatening disorders. The number of
people suffering from age-related diseases is anticipated to almost
double over the next two decades. The prevalence of age-related
pathologies represents a major threat and an economic burden that
urgently needs effective interventions.
Molecules, drugs, and other interventions that might decelerate
aging processes continue to be a major focus among the general
public and scientists of all biological and medical fields. Over the
past two decades, this interest has taken root because many of the
molecular mechanisms underlying aging are interconnected and
linked with pathways that cause diseases, including cancer,
cardiovascular disease, and neurodegenerative disorders.
Unfortunately, results often lack reproducibility because of the
unavoidable problem of the time needed to assess the effectiveness
of antiaging interventions in mammals. Experiments lasting the
lifetime of animal models are prone to develop artifacts, increasing
the possibilities and time windows for experimental discrepancies.
Some inconsistencies in the field arise from overinterpreting the
results of animal models with shortened life span and scenarios of
accelerated aging.
Molecules, drugs, and other interventions have been proposed to
have antiaging properties throughout history and into the present. In
the following sections, interventions will be restricted to those that
meet the following highly selective criteria: (1) promotion of life span
and/or health span, (2) validation in at least three model organisms,
and (3) confirmation by at least three different laboratories. These
include (1) caloric restriction (CR) and intermittent fasting regimens,
(2) some pharmacotherapies (resveratrol, rapamycin, spermidine,
and metformin), and (3) exercise.
Caloric Restriction One of the most important and robust
interventions that delays aging is CR. This outcome has been
recorded in rodents, dogs, worms, flies, yeasts, monkeys, and
prokaryotes. CR is defined as a reduction in the total caloric intake,
usually of ∼30%, and without malnutrition. CR reduces the nutrient-
mediated release of growth factors, such as growth hormone, insulin,
and IGF-1, which have been shown to accelerate aging and enhance
the probability for mortality in many organisms. Yet, the effects of CR
on aging were first discovered by McCay in 1935, long before the
discovery and signaling properties of these hormones and growth
factors. Some of the pathways that mediate this remarkable
response of CR have been elucidated in experimental models.
These include the nutrient-sensing pathways (mTOR, AMPK,
insulin/IGF-1, and sirtuins) and the family of FOXO transcription
factors (orthologs are found in D. melanogaster and C. elegans). The
transcription factor Nrf2 appears to confer most of the anticancer
properties of CR in mice, even though it is dispensable for life span
extension.
The effects of CR in monkeys have been assessed in two studies
with different outcomes: one study observed prolonged life, while the
other did not. In these monkey studies, key differences were noted in
the onset of the intervention, diet composition, feeding protocols, and
genetic background that may explain this discordance. However,
both studies confirmed that CR increases health span by reducing
the risk for diabetes, cardiovascular disease, and cancer. In humans,
CR is associated with extended life span and increased health span.
This is most convincingly demonstrated in Okinawa, Japan, where
one of the most long-lived human populations resides. In comparison
to the rest of the Japanese population, Okinawan people usually
combine an above-average amount of daily exercise with a below-
average food intake. However, when Okinawan families moved to
Brazil, they adopted a Western lifestyle that affected both exercise
and nutrition, causing a rise in weight and a reduction in life
expectancy by nearly two decades. In the Biosphere II project,
volunteers lived together for 24 months undergoing an unforeseen
severe CR that led to improvements in insulin, blood sugar, glycated
hemoglobin, cholesterol levels, and blood pressure—all outcomes
that would be expected to benefit life span. CR changes many
aspects of human aging that might influence life span such as the
transcriptome, hormonal status (especially IGF-1 and thyroid
hormones), oxidative stress, inflammation, mitochondrial function,
glucose homeostasis, and cardiometabolic risk factors. Epigenetic
modifications are also an emerging target for CR.
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RESVERATROL Resveratrol, an agonist of SIRT1, is a polyphenol that
is found in grapes and red wine. The potential of resveratrol to
promote life span was first identified in yeast, and it has gathered
fame since, at least in part, because it has been suggested to be
responsible for the so-called French paradox whereby wine reduces
some of the cardiometabolic risks of a high-fat diet. Resveratrol has
been reported to increase life span in many lower order species such
as yeast, fruit flies, worms, and fish, as well as mice on high-fat
diets. In monkeys fed a diet high in sugar and fat, resveratrol had
beneficial outcomes related to inflammation and cardiometabolic
parameters. Some studies in humans have also shown
improvements in cardiometabolic function, while others have not.
Gene expression studies in animals and humans reveal that
resveratrol mimics some of the metabolic and gene expression
changes of CR. In most experimental models, resveratrol induces
beneficial health effects by suppressing inflammation, oxidative
damage, tumorigenesis, and immunomodulatory activities.
Resveratrol also leads to improvements in mitochondrial function
and protection against obesity, cancer, and cardiovascular
dysfunction.
■ CONCLUSIONS
Clinicians need to understand aging biology in order to better
manage and care for the older people. Moreover, there is an urgent
need to develop strategies based on aging biology that delay aging,
reduce the onset of age-related disorders, and increase health span
for future generations. Dietary interventions and drugs that act on
nutrient-sensing pathways are being developed and, in some cases,
are already being tested in humans. Recently, well-controlled human
clinical trials have started to recapitulate the preclinical evidence of
intermittent fasting on obesity, diabetes mellitus, cardiovascular
disease, cancers, and neurologic disorders. While most animal
studies show that intermittent fasting improves health throughout the
life span, most recent human studies are focused on relatively short-
term interventions over a few days or months. While intriguing, it
remains to be seen whether people will be willing to maintain strict
intermittent fasting regimens over long periods of time or if there are
short-term clinical benefits in combination with other therapeutic
approaches.
■ FURTHER READING
DE CABO R, MATTSON MP: Effects of intermittent fasting on health,
aging, and disease. N Engl J Med 381:2541, 2019.
FERRUCCI L et al: Measuring biological aging in humans: A quest.
Aging Cell 19:e13080, 2020.
LÓPEZ-OTÍN C et al: The hallmarks of aging. Cell 153:1194, 2013.
477 Caring for the Geriatric Patient
Joseph G. Ouslander, Bernardo Reyes
Evaluation of the Older Driver For many older adults in the United
States, driving is essential for maintaining independence and driving
cessation is associated with negative outcomes including social
isolation and depression. On the other hand, older adults are at
higher risk of being involved in fatal crashes than younger
counterparts, with up to a ninefold higher risk for those ≥85 years
old. Older people should be routinely assessed for their driving
status and whether they have been in any car crashes, in addition to
assessment for sensory, functional, and cognitive impairments that
can make driving unsafe (Table 477-3). In addition to common
geriatric conditions, several different types of drugs can impair
various aspects of driving performance and should be carefully
considered in older people who continue to drive, including
antianxiety agents, narcotic analgesics, antipsychotics,
anticonvulsants, and drugs with strong anticholinergic properties.
Suspected driving impairment can be a source of conflict
between the patient (who wants to maintain independence), the
family (who may want their relative to continue driving due to lack of
other transportation, or may be concerned about their safety, or
both), and the physician (who is concerned about the patient’s,
passengers’, and other drivers’ safety). These decisions involve
liability, since local governments might not require driving retesting
for all older drivers, but in some states, physicians are required to
report older people who they believe are unsafe drivers. Evaluation
of driving should be interprofessional and aimed to first try to correct
any reversible causes of losing driving skills, such as vision and
hearing impairment. Although tests of executive function such as the
Trails B have been associated with poor driving performance, no
single screening test predicts unsafe driving. A combination of
neuropsychological testing by a psychologist and on-road testing by
a trained occupational therapist can provide the physician with
essential input in making the difficult decision on driving cessation.
The AGS and the U.S. Department of Transportation’s National
Highway Traffic Safety Administration have updated the “Physician’s
Guide to Assessing and Counseling Older Drivers,” which can be
helpful to practicing clinicians and is available on the AGS website.
■ DIABETES
The prevalence of diabetes in the older adult population is now
>25% and expected to increase due to adverse lifestyle changes
and an increased incidence of obesity. Those between the ages of
65 and 74 have the highest rates of complications associated with
diabetes. Nonetheless, due to a lack of data on patients with
multimorbidity and those age 80 and older, as well as the high
incidence of hypoglycemia in this population when treated with
multiple hypoglycemic agents, the approach to managing diabetes
requires a person-centered approach like that described for
hypertension. Older diabetic patients are at significant risk of
hypoglycemia because of potential medication errors, progressive
renal insufficiency, and inconsistent oral intake, among other
reasons. Diabetic patients age 75 or older are in fact at twice the risk
of visiting the emergency department due to hypoglycemia.
Hypoglycemic episodes are associated with progressive cognitive
decline in older adults, especially those with existing cognitive
impairment. On the other hand, uncontrolled diabetes is associated
with an increased risk of all-cause dementia.
Data from randomized clinical trials suggest that intensive
glycemic control does not reduce major macrovascular events in
older adults for at least 10 years or result in improved microvascular
outcomes for at least 8 years and, at the same time, increases the
risk of severe hypoglycemia by 1.5 to 3 folds. Thus, the AGS
guideline on diabetes in older adults (see “Further Readings”) and
the Choosing Wisely recommendations (Table 477-2) suggest that,
in most older adults, the harms associated with a hemoglobin A1C
(HbA1C) target <7.5% are likely to outweigh the benefits. These
recommendations are consistent with the American Diabetes
Association guidelines from 2020 that recommends an HbA1C target
of <7.5% among older adults with intact cognitive function and
functional capacity and few comorbidities. The goals of treating
diabetes in the geriatric population should be tailored to the patient’s
functional status, coexisting geriatric syndromes, social support,
personal goals, perception of risk, and life expectancy. For specifics
of treatment options, see Table 477-5. Regardless of the therapeutic
goals for HbA1C, older diabetic patients should be regularly
examined for neuropathy, which can lead to the development of
lesions on the feet that could become infected, as well as for
retinopathy and vision loss that may require ophthalmologic
intervention. In addition, lifestyle management is an important
component of the plan of care. If possible, diabetic older adults
should exercise regularly and should have an adequate protein
intake to try maintaining muscle mass. For patients living in LTC
facilities, diabetes education of staff and periodic revision of
individual glucose targets could reduce unnecessary complications
associated with diabetes treatment.
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■ HYPERLIPIDEMIA
While good evidence exists regarding the benefits of statins on
primary cardiovascular risk prevention in patients ≤75 years old, for
those older than 75, the data are very limited. The use of statins in
those older than 75 or 80 for prevention of cardiovascular events and
mortality is the subject of ongoing debate in the geriatric literature.
The Prospective Study of Pravastatin in the Elderly at Risk
(PROSPER) demonstrated a significant reduction in cardiovascular
events over a 3.2-year follow-up among older adults taking statins
when compared with those not taking them. Nonetheless, the study
failed to demonstrate a mortality benefit. For secondary prevention, a
large observational study in Europe demonstrated that after
excluding patients who die within the first year of a myocardial
infarction, those taking statins may have a 37% reduction in
cardiovascular mortality. In contrast, a review published in 2014
concluded that no evidence from randomized controlled trials exists
to guide statin initiation after age 80 years and that treatment of
hypercholesterolemia for patients at risk of atherosclerotic
cardiovascular disease should start before they turn 80 years old.
Two other factors make the use of statins in older adults
controversial. First, the major benefits have been demonstrated over
long-term use; thus, life expectancy is a limiting factor to observe
any meaningful change in outcomes. A substantial proportion of
patients are maintained on statins at the end of life, even though
such agents can be safely discontinued. Thus, continuing statins in
older patients with end-stage illnesses does not make any clinical
sense. On the other hand, statins are safe to use in older adults,
especially at moderate to low doses. Although many older adults on
statins complain of muscle pain, the risk of myositis and
rhabdomyolysis is increased mostly with the coexistence of other risk
factors such as sarcopenia, polypharmacy, and use of high doses of
statins. Adverse effects of statins on cognitive function appear to be
uncommon. Thus, some relatively healthy adults older than 75 with
life expectancy of >10 years may benefit from statin use, and the
approach to hyperlipidemia should be person-centered in this
population, as discussed for both hypertension and diabetes.
■ OSTEOARTHRITIS
The approach to the management of symptomatic osteoarthritis (OA)
in the geriatric population differs from the approach in younger
patients (Chaps. 370 and 371) because of the substantial toxicity of
nonsteroidal anti-inflammatory drugs (NSAIDs) in older patients.
Nonpharmacologic interventions, briefly discussed below, should be
the first line of treatment. While some patients older than 65 can
tolerate NSAID use with concomitant protection from gastrointestinal
(GI) bleeding with a proton pump inhibitor (PPI), this regimen
exposes patients to two drugs with numerous potential adverse drug
effects. NSAIDs are well known to be associated not only with GI
bleeding but also with worsening renal function based on multiple
potential mechanisms and with sodium and fluid retention and
exacerbation of hypertension and congestive heart failure. In
addition, a substantial number of older patients are on
anticoagulants or platelet aggregation inhibitors, which could further
increase the risk of bleeding from NSAIDs. PPIs are associated with
a higher incidence of pneumonia, osteoporosis, and Clostridioides
difficile–associated diarrhea, and they may be associated with a
higher risk of dementia.
Thus, in older patients with multimorbidity who have painful OA,
the risks of NSAIDs most often outweigh the benefits, and older
patients should be discouraged from taking nonprescription NSAIDs
without consulting their primary care clinician. Topical NSAIDs are
better tolerated, and lidocaine patches and other nonprescription
analgesic creams may also be effective. The AGS guideline on the
management of chronic pain recommends that routine
acetaminophen in doses up to 1 g four times daily should be the
basis of pharmacologic treatment. Failure to respond could be
followed up with careful trials of tramadol or a narcotic agent (started
in a short-acting preparation) with appropriate attention to avoiding
narcotic-induced constipation. Although prescription of narcotics is
getting increasingly cumbersome because of high rates of abuse,
this should not deter prescription of these agents to relieve pain and
disability in older patients. Despite recent guidelines from
governmental agencies, professional societies endorse the use of
opioids for chronic pain, especially among older adults in LTC
facilities.
Many older patients respond well to a variety of
nonpharmacologic interventions, including stretching, strengthening,
timely and appropriate use of heat and ice, massage, swimming and
whirlpool therapy, bracing, acupuncture, and therapeutic electrical
stimulation. These interventions are best carried out under the
supervision of physical therapists or other professionals with
appropriate expertise to avoid injury. Surgical interventions, including
replacement of major joints, has improved over the past several
years, and even older patients with multimorbidity may benefit in
terms of function and quality of life. Total knee replacement, for
example, has been shown to be effective in generally healthy older
patients and should be considered in selected higher risk patients.
“Pre-habilitation,” with targeted strengthening and endurance
exercises, and willingness to go through several weeks of
postoperative physical therapy should be prerequisites for referring
older patients for joint replacement.
■ CANCER
More than half of new cases of cancer and mortality associated with
it occur after the age of 65. Data regarding older adults with multiple
comorbid conditions and their response to cancer treatment are
limited. While only ∼10% of clinical trials have had age-stratification
analyses, the available evidence suggests that age alone is not a
predictor of harm. Nonetheless, making treatment decisions is
challenging due to both shorter life expectancy in older adults and
the cumulative effect of multiple comorbidities. Thus, a person-
centered approach is essential.
Older adults generally experience decreases in functional status
after receiving chemotherapy. Most of this negative effect appears to
be related to comorbidity and baseline functional status, rather than
due to age alone. For this reason, specialists in geriatric oncology
have proposed using comprehensive geriatric assessment, including
many of the issues addressed in Table 477-3, as a strategy to better
predict which older adults will tolerate and benefit most from cancer
treatment. Other considerations before making decisions about
treatment plans should include socioeconomic factors. Lack of social
support has been associated with poor outcomes after radiation and
chemotherapy, especially in older women. Other important issues in
cancer treatment planning include availability of transportation for
treatments, economic and insurance status, the patient’s ability to
follow treatment plans, and family and social support available during
therapy, when adverse effects and functional decline may occur.
■ ANEMIA
A low hemoglobin or hematocrit is not a normal age-related change
in older adults. All anemic older adults should have a basic
evaluation to determine the etiology including a complete blood
count, examination of a peripheral red blood cell smear, reticulocyte
count, and measurement of iron, iron binding capacity, and
transferrin saturation. A serum ferritin level can help distinguish iron
deficiency from anemia of chronic disease; the two types of anemia
occur commonly in older adults. The prevalence of anemia in older
adults varies between 7% and 47%, with the highest prevalence
among nursing home residents. Even mild anemia is associated with
worse overall outcomes in older adults, including functional and
cognitive decline, falls, hospitalization, frailty, and mortality.
Microcytic indices suggest occult blood loss. Iron deficiency is the
most common cause, with other nutritional anemias (e.g., B12
deficiency) and myelodysplasia each accounting for a small
percentage. Anemia of chronic disease is common in older people
who have several chronic illnesses. The etiology of the anemia in
older adults cannot be specifically explained in more than a third of
the cases, and this unexplained anemia is generally normocytic, mild
in degree, with a low reticulocyte count, and associated with normal
or low erythropoietin levels in the face of inadequate production of
new red cells. Red cell life span is not decreased, but the production
of erythropoietin is compromised even in the absence of overt renal
disease. Anemia is frequently asymptomatic, but severe cases could
present with symptoms such as generalized weakness and
functional decline, shortness of breath, chest pain, or syncope. The
unexplained anemia of aging appears to be responsive to
erythropoietin, but it is unclear whether correction of the anemia
improves outcomes. Thresholds for transfusion of packed red cells
among older adults should be based on symptoms and associated
conditions. For example, for geriatric patients suffering acute blood
loss anemia after an orthopedic procedure, the trigger for transfusion
should be a hemoglobin <8 mg/dL instead of 7 mg/dL for patients
with anemia associated with chronic disease or a myelodysplastic
syndrome. Similarly, older patients with active cardiovascular
disease, such as angina or heart failure, may need to be transfused
a levels <8 or 9 mg/dL. For details of the general evaluation and
management of anemia, please refer to the Chap. 63 on anemia.
■ FALLS
Epidemiology and Impact Among all geriatric syndromes, falls are
probably the most common that internists will encounter. Falls are
responsible for potentially devastating consequences for function
and quality of life, as well as mortality. About one in three older
community-dwelling and one in two older LTC facility residents fall
annually, with many more at risk for falls. The consequences of falls
include fear of falling with adverse effects on quality of life, painful
injures including hip and wrist fractures, subdural hematomas, and
death. Falls are associated with loss of function and death within the
year after a fall. For these reasons, internists should regularly screen
older people for falling using questions such as, “Have you fallen in
the past year?” “Are you afraid of falling?” “Do you have trouble
climbing stairs or rising from chairs?” (Table 477-3).
■ POLYPHARMACY
Epidemiology and Impact Polypharmacy is defined as the
prescription of multiple medications using various thresholds
(generally ranging from five up to nine simultaneous drugs) and has
been identified as a major challenge in the geriatric population for
decades. About 40% of the U.S. population age 65 and older take
five to nine medications, and close to 20% take 10 or more.
Polypharmacy is an increasingly complex challenge because of the
rising prevalence of multimorbidity, a plethora of clinical practice
guidelines, proliferation of medications that can effectively treat
common geriatric conditions, and rising patient and family demand
for medications due in part to television advertising and information
available on the Internet. For example, based on several condition-
specific clinical practice guidelines (which do not account for
multimorbidity), an 80-year-old person with multimorbidity including
diabetes, chronic obstructive lung disease, hypertension,
osteoporosis, and degenerative joint disease might be prescribed an
extremely complicated nonpharmacologic regimen and over a dozen
medications with the potential for multiple drug-drug and drug-
disease interactions.
Polypharmacy increases the risks associated with age-related
changes in the pharmacology of many drugs and the risk of adverse
drug events. Such events cause >100,000 hospitalizations per year;
the main culprits are warfarin and other antiplatelet agents and
insulin and other hypoglycemic agents. Other categories of drugs are
also involved, including cardiovascular drugs that can cause
electrolyte and volume disturbances and hypotension, falls, and
syncope; central nervous system drugs associated with altered
mental status and falls; and antimicrobials, which cause allergic
reactions, diarrhea, and other adverse drug effects.
■ FURTHER READING
AMDA—THE SOCIETY FOR POST-ACUTE AND LONG-TERM CARE MEDICINE:
Ten things clinicians and patients should question.
http://www.choosingwisely.org/societies/amda-the-society-for-
post-acute-and-long-term-care-medicine/. Accessed September
20, 2020.
AMERICAN DIABETES ASSOCIATION: Older adults: Standards of medical
care in diabetes—2020. Diabetes Care 43(Suppl 1):S152, 2020.
AMERICAN GERIATRICS SOCIETY: Choosing Wisely: Ten things clinicians
and patients should question.
http://www.choosingwisely.org/societies/american-geriatrics-
society/. Accessed September 20, 2020.
AMERICAN GERIATRICS SOCIETY PANEL ON PHARMACOLOGIC MANAGEMENT
OF PERSISTENT PAIN IN OLDER PERSONS: Pharmacologic
management of persistent pain in older persons. J Am Geriatr
Soc 46:1331, 2009.
CENTERS FOR DISEASE CONTROL AND PREVENTION: CDC Immunization
Schedules–Feb, 2020.
https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html?
CDC_AA_refVal=https%3A%2F%2F1.800.gay%3A443%2Fhttps%2Fwww.cdc.gov%2Fvaccines%
2Fschedules%2Fhcp%2Fadult.html#table-age. Accessed
September 21, 2020.
CLINICIAN’s GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS.
http://www.michigan.gov/documents/sos/Clinicians_Guide_To_Ol
derDrivers_3rd_edition_523147_7.pdf. Accessed September 20,
2020.
HALTER JB et al (eds): Hazzard’s Geriatric Medicine and Gerontology,
7th ed. New York, McGraw-Hill, 2018.
INSTITUTE FOR HEALTHCARE IMPROVEMENT: Age-friendly health systems.
http://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-
Systems/Pages/default.aspx. Accessed September 20, 2020.
KANE RL et al (eds): Essentials of Clinical Geriatrics, 8th ed. New
York, McGraw-Hill, 2017.
THE 2019 AMERICAN GERIATRICS SOCIETY BEERS CRITERIA® UPDATE
EXPERT PANEL: American Geriatrics Society 2019 Updated AGS
Beers Criteria® for potentially inappropriate medication use in
older adults. J Am Geriatr Soc 67:674, 2019.
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