People with dementia may exhibit aggression, resistance to care and other challenging or disruptive behaviours. In such instances, the modest effectiveness of atypical antipsychotics may be offset by the higher risks for adverse events and mortality. Non-pharmacological interventions can be an effective substitute for antipsychotic medications. Use of these drugs should therefore be limited to cases where non-pharmacologic measures have failed and patients pose an imminent threat to themselves or others

Ballard C, Waite J. The effectiveness of atypical antipsychotics for the treatment of aggression and psychosis in Alzheimer’s disease. Cochrane Database Syst Rev 2006; (1): CD003476

Declerq T. Withdrawal versus continuation of chronic antipsychotic drugs for behavioural and psychological symptoms in older people with dementia. Cochrane Database Syst Rev 2013; 3: CD007726

Ma H. The efficacy and safety of atypical antipsychotics for the treatment of dementia: a metaanalysis of randomized placebo controlled trials. J Alzheimers Dis 2014; 42(3): 915-37

Richter T. Psychosocial interventions for reducing antipsychotic medication in care home residents. Cochrane Database Syst Rev 2012; 12: CD008634

Schneider LS. Effectiveness of atypical antipsychotic drugs in patients with Alzheimer’s disease. New England Journal Med 2006; 355(15): 1525-38

There is strong evidence that use of benzodiazepines is associated with various adverse effects in elderly people such as falls and fractures. Older patients, their caregivers and their providers should recognize these potential harms when considering treatment strategies for insomnia, agitation or delirium. Thus these drugs should be prescribed with caution, and their use monitored closely.

Allain H. Postural instability and consequent falls and hip fractures associated with use of hypnotics in the elderly: a comparative review. Drugs Aging 2005; 22(9): 749–765

Finkle WD. Risk of fractures requiring hospitalization after an initial prescription for zolpidem, alprazolam, lorazepam, or diazepam in older adults. Journal of the American Geriatric Soc 2011; 59(10): 1883-90

Sithamparanathan K. Adverse effects of benzodiazepine use in elderly people: A meta-analysis. Asian J Gerontol Geriatr 2012; 7: 107–11

Stockl KM. Clinical and economic outcomes associated with potentially inappropriate prescribing in the elderly. American Journal Manag Care 2010; 16(1): e1-10

Studies have found that asymptomatic bacteriuria frequently resolves without any treatment. Antimicrobial treatment studies for asymptomatic bacteriuria in older adults demonstrate no benefits and, in fact, often show increased adverse antimicrobial effects.

Masumoto T. Urinary tract infections in the elderly. Curr Urol Rep 2001; 2(4): 330-3

Mody L, Juthani-Mehta M. Urinary tract infections in older women: a clinical review. JAMA 2014; 311(8): 844-54

Nicolle LE. Prospective randomized comparison of therapy and no therapy for asymptomatic bacteriuria in institutionalized elderly women. American Journal of Medicine 1987; 83(1): 27–33

Nicolle LE. Infectious Diseases Society of America Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults 2005.

Older patients disproportionately use more prescription and non-prescription drugs than other populations, increasing the risk for side effects and inappropriate prescribing. Thus evidence shows that polypharmacy is associated with adverse drug reactions and an increased risk of hospital admissions. Medication review with follow up is recommended for optimizing prescribed medication and improving quality of life in older adults with polypharmacy.

Fried TR. Health outcomes associated with polypharmacy in community-dwelling older adults: a systematic review. Journal of American Geriatric Society 2014; 62(12): 2261-72

Hajjar ER. Polypharmacy in elderly patients. American Journal Geriatr Pharmacotherapy 2007; 5(4): 345-51

Jodar-Sanchez F. Cost-Utility Analysis of a Medication Review with Follow-Up Service for Older Adults with Polypharmacy in Community Pharmacies in Spain: The conSIGUE Program. Pharmacoeconomics 2015; Mar 15

Lu WH. Effect of polypharmacy, potentially inappropriate medications and anticholinergic burden on clinical outcomes: a retrospective cohort study. CMAJ 2015; 187(4): e130-7

There is little evidence to support the effectiveness of physical restraints to manage people with delirium who exhibit behaviours that risk injury.

Physical restraints can lead to serious injury or death and may worsen agitation and delirium. Restraints should therefore be used as a last resort and should be discontinued at the earliest possible time, particularly given that effective non-pharmacological alternatives are available.

Flaherty J. Matching the environment to patients with delirium: lessons learned from the delirium room, a restraint-free environment for older hospitalized adults with delirium. Journal of the American Geriatric Soc 2011; 59 Suppl 2: S295-300

Maccolli GA. Clinical practice guidelines for the maintenance of patient physical safety in the intensive care unit: use of restraining therapies, American College of Critical Care Medicine Task Force 2001-2002. Critical Care Medicine 2003; 31(11): 2665-76

Mott S. Physical and chemical restraints in acute care: their potential impact on the rehabilitation of older people. Int J Nurs Pract 2005; 11(3): 95-101

Park M. Changing the practice of physical restraint use in acute care. J Gerontol Nursing 2007; 33(2): 9-16