Prevalence of potentially inappropriate medication use in older adults using the 2012 Beers criteria

Frequency of and risk factors for potentially inappropriate medication use in Parkinson's disease

BACKGROUND

impairments in neurotransmitter pathways put Parkinson's disease (PD) patients at risk for drug-disease interactions and adverse medication events.

OBJECTIVE

to determine the prevalence and risk factors for potentially inappropriate medication (PIM) prescriptions, as defined by the 2015 Beers List, in PD.

METHODS

cross-sectional analysis was conducted on 2014 Medicare beneficiaries with PD who had parts A, B and D coverage. The prevalence of PIM prescriptions for older adults was determined overall, and specifically for medications that can exacerbate motor symptoms or cognitive impairment in PD. Logistic regression models were constructed to determine the association between age, sex, race, geography and poverty with PIM prescriptions.

RESULTS

the final sample included 458,086 beneficiaries. In 2014, 35.8% of beneficiaries with PD filled a prescription for at least one PIM for older adults. In total, 8.7% of beneficiaries received a PIM that could exacerbate motor symptoms and 29.0% received a PIM that could worsen cognitive impairment. After adjustment, in all models, beneficiaries who were younger, female, white, urban-dwelling and eligible for Medicaid benefits were more likely to receive a PIM.

CONCLUSION

PIM prescriptions are not uncommon in PD, particularly for medications that can exacerbate cognitive impairment. Future research will examine underlying drivers of sex and other disparities in PIM prescribing. Additional studies are needed to understand the impact of PIMs on disease symptoms, healthcare utilisation and patient outcomes.

Opportunities and Recommendations for Improving Medication Safety: Understanding the Medication Management System in Primary Care Through an Abstraction Hierarchy

Background

Despite making great strides in improving the treatment of diseases, the minimization of unintended harm by medication therapy continues to be a major hurdle facing the health care system. Medication error and prescription of potentially inappropriate medications (PIMs) represent a prevalent source of harm to patients and are associated with increased rates of adverse events, hospitalizations, and increased health care costs. Attempts to improve medication management systems in primary care have had mixed results. Implementation of new interventions is difficult because of complex contextual factors within the health care system. Abstraction hierarchy (AH), the first step in cognitive work analysis (CWA), is used by human factors practitioners to describe complex sociotechnical systems. Although initially intended for the nuclear power domain and interface design, AH has been used successfully to aid the redesign of numerous health care systems such as the design of decision support tools, mobile patient monitoring apps, and a telephone triage system.

Objective

This paper aims to refine our understanding of the primary care office in relation to a patient’s medication through the development of an AH. Emphasis was placed on the elements related to medication safety to provide guidance for the design of a safer medication management system in primary care.

Methods

The AH development was guided by the methodology used by seminal CWA literature. It was initially developed by 2 authors and later fine-tuned by an expert panel of clinicians, social scientists, and a human factors engineer. It was subsequently refined until an agreement was reached. A means-ends analysis was performed and described for the nodes of interest. The model represents the primary care office space through functional purposes, values and priorities, function-related purposes, object-related processes, and physical objects.

Results

This model depicts the medication management system at various levels of abstraction. The resulting components must be balanced and coordinated to provide medical treatment with limited health care resources. Understanding the physical and informational constraints on activities that occur in a primary care office depicted in the AH defines areas in which medication safety can be improved.

Conclusions

Numerous means-ends relationships were identified and analyzed. These can be further evaluated depending on the specific needs of the user. Recommendations for optimizing a medication management system in a primary care facility were made. Individual practices can use AH for clinical redesign to improve prescribing and deprescribing practices.

Potentially Inappropriate Medications Are Associated with Increased Healthcare Utilization and Costs

BACKGROUND/OBJECTIVES

To examine the prevalence of potentially inappropriate medication (PIM) prescribing and its association with healthcare utilization and related expenditures utilizing nationally representative data from the United States.

DESIGN

Retrospective cohort study.

SETTING

The 2011-2015 Medical Expenditure Panel Survey (MEPS).

PARTICIPANTS

Community-dwelling sample of U.S. adults aged 65 and older during the first round of each MEPS cycle.

MEASUREMENTS

A qualified definition operationalized from the 2019 American Geriatrics Society Beers Criteria® was used to estimate the prevalence of PIM prescribing over the study period. Negative binomial models were assembled to examine associations between PIM exposure and healthcare utilization including hospitalizations, emergency department (ED) visits, and outpatient provider visits. Generalized linear models with the log link function and gamma distribution were used to analyze associations between PIM exposure and healthcare expenditures. Sensitivity analyses were conducted utilizing inverse probability treatment weighting using propensity scores for being prescribed a PIM.

RESULTS

The period prevalence of PIM prescribing over the 5-year sample was 34.4%. PIM prescribing was positively associated with hospitalizations (adjusted incidence rate ratio [aIRR] = 1.17; 95 confidence interval [CI] = 1.08-1.26; P < .001), ED visits (aIRR = 1.26; 95% CI = 1.17-1.35; P < .001), and outpatient provider visits (aIRR = 1.18; 95% CI = 1.14-1.21; P < .001). PIM exposure was associated with higher marginal costs within outpatient visits ($116; 95% CI = $105-$243; P < .001), prescription medications ($128; 95% CI = $72-$199; P < .001), and total healthcare expenditures ($458; 95% CI = $295-$664; P < .001). Similar results were found in our propensity score analyses.

CONCLUSION

PIMs continue to be prescribed at a high rate among older adults in the United States. Our results suggest that receipt of PIMs is associated with higher rates of healthcare utilization and increased costs across the healthcare continuum. Further work is needed to implement evidence-based deprescribing interventions that may in turn reduce unnecessary healthcare utilization.

Prescriber responsibility, predictors for initiation, and 20-year trends in use of non-aspirin non-steroidal anti-inflammatory drugs in patients with cardiovascular contraindications: a nationwide cohort study

AIMS

To examine whether prescription patterns complied with recommendations not to use nonsteroidal anti-inflammatory drugs (NSAIDs) in patients with cardiovascular contraindications. Moreover, we examined predictors for initiation and prescriber responsibility.

METHODS AND RESULTS

We identified first-time cardiovascular diseases from medical databases (1996-2017). We assessed standardized prevalence proportions, predictors from logistic regression, and prescriber identifiers. 1-year prevalence of NSAID initiation increased 3.4% from 1996 (19.4%) to 2001 (22.7%) and declined by 2.7% thereafter until 2017 (13.5%). Trends were independent of age, sex, and disease subtype, although larger annual declines occurred for heart failure (3.9%) and ischemic heart disease (3.5%) since 2002. One-year prevalence remained highest among patients with venous thromboembolism (16.6%) and angina (13.8%), and lowest for ST-segment elevation myocardial infarction (7.0%) and heart failure (8.8%). Initiators were predominantly prescribed ibuprofen (59%), diclofenac (23%) and etodolac (6%). Diclofenac and coxib use declined, while ibuprofen and naproxen use increased. Median prescribed pill dose of ibuprofen declined after 2008 from moderate/high (600 mg) to low (400 mg). Treatment duration declined for all NSAIDs, except celecoxib. Rheumatic, obesity, and pain-related conditions predicted NSAID initiation. General practitioners issued 86-91% of all NSAID prescriptions, followed by hospital prescribers (7.3-12%).

CONCLUSIONS

Initiation of NSAIDs in patients with cardiovascular disease declined since 2002. Shorter treatment duration, declining COX-2 inhibition, and increasing use of naproxen and low-dose ibuprofen suggest adherence to guidelines when NSAIDs cannot be avoided. Still, NSAID use remained prevalent despite cardiovascular contraindications, warranting awareness of appropriateness of use among general practitioners in particular.

The Prevalence of Beers Criteria Medication Use and Associations with Falls in Geriatric Patients at a Level 1 Trauma Center

The Beers Criteria for Potentially Inappropriate Medication (PIM) use is a list of medications with multiple risks in older patients. Approximately 24 per cent use rate is reported in prior studies. Our objective was to determine the local PIM use and subsequent fall risk in geriatric trauma patients. We conducted a retrospective analysis of PIM use in all geriatric patients evaluated at our Level 1 trauma center between 2014 and 2017. Patients were identified from our trauma database. Pre-admission medication use was determined through medication reconciliation from our electronic medical record (EMR). Patients not undergoing medication reconciliation were excluded. After initial analysis, patients were stratified by age into three groups: 65 to 74, 75 to 84, and ≥85 years. Multivariate logistic regression analyses were used to calculate odds ratios of falls for specific PIMs. In all, 2181 patients met the inclusion criteria. Overall, 71.2 per cent of geriatric trauma patients were prescribed at least one PIM—73.1 per cent of falls compared with 68.6 per cent for other mechanisms. Specific PIM use varied by age group. PIMs associated with fall risk in all patients included antipsychotics, benzodiazepines, and diclofenac. For those aged 65 to 74 years, antihistamines, diclofenac, proton pump inhibitors, and promethazine were associated. In those aged 75 to 84 years, alprazolam, antipsychotics, benzodiazepines, cyclobenzaprine, diclofenac, and muscle relaxants were implicated. No significant associations were found for patients aged ≥85 years. PIM use at our trauma center seems to be rampant and well above the national average. Geriatric falls were associated with using ≥1 PIM and multiple specific PIMs implicated. We are designing a targeted educational program for local primary care physicians (PCPs) that will attempt to decrease geriatric PIM use.

Interventions to deprescribe potentially inappropriate medications in the elderly: Lost in translation?

WHAT IS KNOWN AND OBJECTIVE

Use of potentially inappropriate medications (PIMs) remains common in older adults, despite the easy availability of screening tools such as the Beers and Screening Tool of Older Person's Prescriptions (STOPP) criteria. Multiple published studies have implemented these screening tools to encourage deprescribing of PIMs, with mixed results. Little is known about the reasons behind the success or failure of these interventions, or what could be done to improve their impact. Implementation science (IS) provides a set of theories, models and frameworks to address these questions. The goal of this study was to conduct a focused narrative review of the deprescribing literature through an IS lens-to determine the extent to which implementation factors were identified and the intermediate steps in the intervention were measured. A better understanding of the existing literature, including its gaps, may provide a roadmap for future research.

METHODS

PubMed search from 2000-2019 using appropriate MeSH headings.

INCLUSION CRITERIA

controlled trials or prospective cohort studies intended to reduce PIMs in the elderly that used hospitalizations and/or emergency department visits as outcome measures. Studies were reviewed to identify potential implementation factors (known as determinants), using the Consolidated Framework for Implementation Research (CFIR) as a guide. In addition, intermediate outcomes were extracted.

RESULTS AND DISCUSSION

Of the 548 reviewed abstracts, 14 studies met the inclusion criteria and underwent detailed analysis. Of the 14 studies, 10 acknowledged potential implementation determinants that could be mapped onto CFIR. The most commonly identified determinant was the degree of pharmacist integration into the medical team (seven of 14 studies), which mapped onto the CFIR construct of 'networks and communication'. Several important CFIR constructs were absent in the reviewed literature. Intermediate measures were captured by 12 of the 14 reviewed papers, but the choice of measures was inconsistent across studies.

WHAT IS NEW AND CONCLUSION

In recent high-quality studies of deprescribing interventions, we found limited acknowledgement of factors known to be important to successful implementation and inconsistent reporting of intermediate outcomes. These findings indicate missed opportunities to understand the factors underlying study outcomes. As a result, we run the risk of rejecting worthwhile interventions due to negative results, when the correct interpretation might be that they failed in implementation. In other words, they were 'lost in translation'. Studies that rigorously examine and report on the implementation process are needed to tease apart this important distinction.

Patient-Reported Barriers and Facilitators to Deprescribing Cardiovascular Medications

BACKGROUND

Medications endorsed by clinical practice guidelines, such as cardiovascular medications, could still have risks that outweigh potential benefits, and could thus warrant deprescribing.

OBJECTIVES

The objective of this study was to develop a framework of facilitators and barriers specific to deprescribing cardiovascular medications in the setting of uncertain benefit. Given the frequent use of β-blockers in heart failure with preserved ejection fraction, and its uncertain benefits with potential for harm, we used this scenario as an example case for a cardiovascular medication that may be reasonable to deprescribe.

METHODS

We conducted one-on-one, semi-structured interviews of older adults until we reached thematic saturation. Two coders independently reviewed each interview, and developed codes using deductive thematic analysis based on a prior conceptual framework for deprescribing. Subthemes and themes were finalized with a third coder.

RESULTS

Ten participants were interviewed. We identified three key previously described patient-reported facilitators to deprescribing: (1) appropriateness of cessation; (2) process of cessation; and (3) dislike of medications; and identified three key previously described patient-reported barriers: (1) appropriateness of cessation; (2) process of cessation; and (3) fear. We found that these facilitators and barriers often co-occurred within the same individual. This observation, coupled with subthemes from our patient interviews, yielded two barriers to deprescribing specific to cardiovascular medications-uncertainty and conflicting attitudes.

CONCLUSION

We adapted a new framework of patient-reported barriers and facilitators specific to deprescribing cardiovascular medications. In addition to addressing barriers previously described, future deprescribing interventions targeting cardiovascular medications must also address uncertainty and conflicting attitudes.

Prescribing for geriatrics in Tehran; is it appropriate and rational?

Background: The world’s population is growing older. Inappropriate and irrational use of drugs in the elderly is a considerable health concern due to consequences such as increased morbidity and adverse drug events. This study aimed to evaluate the rationality of prescribing and determining the extent of inappropriate prescribing in a sample of geriatric patients in Tehran.

Methods: This cross sectional study was performed on 1512 prescriptions of patients aged ≥ 65 years from 5 pharmacies affiliated to Tehran University of Medical Sciences in 2014. Prescription of potentially inappropriate medications (PIMs) was investigated using the Beers Criteria along with WHO prescribing indices. Date were analyzed using SPSS software, and significance level was set at less than 0.05.

Results: Mean (SD) age of patients was 73.9(6.7) years. A total of 472 (31.2%) patients received at least 1 PIM. Benzodiazepines were the most frequent drug class and general practitioners (GPs) were the most frequent prescriber of PIMs. The highest and the lowest percentage of prescriptions containing brand-names were prescribed by subspecialists (62.5%) and GPs (42.2%), respectively. Antibiotics and injectable medications were prescribed for 26.8% and 28.5% of patients by GPs. Mean (SD) number of drugs per prescription was 3.57 (1.92). Prescriptions containing systemic antibiotics and PIMs had significantly higher mean number of drugs compared to those without these items (both P < 0.001).

Conclusion: There is a need for interventions to improve the quality of prescribing for elderly patients, especially by GPs. Also, there are still some problems in rational use of drugs based on prescribing indices, especially, prescribing brand-names and injectable medications.

Adverse Outcomes Associated With Inpatient Administration of Beers List Medications Following Total Knee Replacement

PURPOSE

Beers List drugs are potentially harmful in older adults and are grouped by level of risk. Over 9000 total knee arthroplasties (TKAs) are performed each year Veterans Affairs (VA) hospitals, primarily on older adults. Minimal data on the administration of Beers List drugs following arthroplasty currently exists in the literature. Our goal was to quantify the risks of these drugs following TKA. We hypothesized that increasing doses of Beers List drugs would be associated with increased risks for readmission, reoperation, emergency department (ED) visits, and mortality.

METHODS

In this retrospective cohort study, data from TKAs performed in VA hospitals from 2010 to 2014 were examined, with complicated or bilateral procedures excluded. The data were obtained from the VA Corporate Data Warehouse. The outcomes examined were readmission, postoperative ED visits, reoperation on ipsilateral knee, and mortality. Beers List drugs were divided into 3 categories: medications to use with caution (Beers 0); medications to avoid in older adults (Beers 1); and medications to avoid in certain disease states (Beers 2). Beers 2 was not included in the final analysis due to an inability to verify appropriate diagnostic criteria without manual chart review. Logistic regression was performed looking at the total number of doses in the first 48 h after surgery compared to the above-mentioned outcomes.

FINDINGS

Data from 12,639 TKAs were analyzed; the mean age of the patients was 65.06 years, and 77.8% of patients received Beers List drugs while admitted. The most frequently administered Beers List drugs were proton pump inhibitors, NSAIDs, insulin, α-blockers, benzodiazepines, antihistamines, muscle relaxants, and antipsychotics. There was a dose-dependent increase in readmission and ED visits in the Beers 1 group. The odds ratios were 1.03 for 30-day readmission and 1.02 at 90 days. The odds ratios for ED visits were 1.05 for 72-h ED visits and 1.04 for ED visits within 7 and 30 days. The odds ratios were set at 1-unit dose intervals. All results were found after control for VA facility, sex, age, American Society of Anesthesiologists class, Charlson score, case length, and body mass index.

IMPLICATIONS

The group of medications to avoid (Beers 1) from the 2015 Beers List showed associations with increased frequency of readmission and postoperative ED visits. Reinforcement of the need to avoid those drugs during surgical care will hopefully reduce such complications. Limitations included not controlling for overall discharge drug count and reliance on the outpatient problem list for outpatient diagnoses. Additional subgroup analysis will be performed to see whether specific drugs pose a higher than risk others.

Integrating the 2019 AGS Beers Criteria into NP practice: A stepwise approach

The American Geriatrics Society Beers Criteria, designed to prevent the prescription of potentially inappropriate medications to older adult patients, were updated in 2019. This article provides a stepwise protocol on how to incorporate the Beers Criteria guidelines into NP practice using a case study model.

INtervention for Cognitive Reserve Enhancement in delaying the onset of Alzheimer's Symptomatic Expression (INCREASE), a randomized controlled trial: rationale, study design, and protocol

BACKGROUND

The course of Alzheimer's disease (AD) includes a 10-20-year preclinical period with progressive accumulation of amyloid β (Aβ) plaques and neurofibrillary tangles in the absence of symptomatic cognitive or functional decline. The duration of this preclinical stage in part depends on the rate of pathologic progression, which is offset by compensatory mechanisms, referred to as cognitive reserve (CR). Comorbid medical conditions, psychosocial stressors, and inappropriate medication use may lower CR, hastening the onset of symptomatic AD. Here, we describe a randomized controlled trial (RCT) designed to test the efficacy of a medication therapy management (MTM) intervention to reduce inappropriate medication use, bolster cognitive reserve, and ultimately delay symptomatic AD.

METHODS/DESIGN

Our study aims to enroll 90 non-demented community-dwelling adults ≥ 65 years of age. Participants will undergo positron emission tomography (PET) scans, measuring Aβ levels using standardized uptake value ratios (SUVr). Participants will be randomly assigned to MTM intervention or control, stratified by Aβ levels, and followed for 12 months via in-person and telephone visits. Outcomes of interest include: (1) medication appropriateness (measured with the Medication Appropriateness Index (MAI)); (2) scores from Trail Making Test B (TMTB), Montreal Cognitive Assessment (MoCA), and California Verbal Learning Test (CVLT); (3) perceived health status (measured with the SF-36). We will also evaluate pre- to post-intervention change in: (1) use of inappropriate medications as measured by MAI; 2) CR Change Score (CRCS), defined as the difference in scopolamine-challenged vs unchallenged cognitive scores at baseline and follow-up. Baseline Aβ SUVr will be used to examine the relative impact of preclinical AD (pAD) pathology on CRCS, as well as the interplay of amyloid burden with inappropriate medication use.

DISCUSSION

This manuscript describes the protocol of INCREASE ("INtervention for Cognitive Reserve Enhancement in delaying the onset of Alzheimer's Symptomatic Expression"): a randomized controlled trial that investigates the impact of deprescribing inappropriate medications and optimizing medication regimens on potentially delaying the onset of symptomatic AD and AD-related dementias.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02849639. Registered on 29 July 2016.

Prevalence and factors associated with potentially inappropriate medication use in older medicare beneficiaries with cancer

OBJECTIVE

To assess the factors related to potentially inappropriate medication (PIM) use in elderly patients with cancer, as well as to compare the PIM prevalence in older adults with and without cancer.

METHODS

Data from the Surveillance, Epidemiology, and End Results-Medicare-linked base (2009-2011) were accessed to conduct a retrospective study comparing patients with cancers of the breast, colon/rectum, and prostate against a matched population of subjects without cancer. PIM use was defined based on the 2015 Beers Criteria and was quantified using prescription claims. Multivariable logistic regression models were used to assess the associations between the patients' characteristics, clinical factors, and PIM use in patients with cancer based on Beers criteria. Propensity score matching was applied to compare use of PIM in patients with versus without cancer.

RESULTS

PIM usage rates in patients with colorectal and breast cancers were significantly higher than non-cancer-bearing adults; the difference in PIM usage rate was not significantly different in the prostate cancer-matched cohort. The prevalence of inappropriate medication use in the three types of cancers evaluated was directly correlated with number of medications prescribed, treatment with chemotherapy, and co-morbid medical problems.

CONCLUSION

Patients diagnosed with cancer were more likely to use PIM compared with their non-cancer counterparts. The updated Beers criteria has the potential to serve as an important tool in geriatric oncology practice but it may still need to take into consideration different cancer types and their respective treatments.

Effectiveness of Best Practice Alerts for Potentially Inappropriate Medication Orders in Older Adults in the Ambulatory Setting

INTRODUCTION

Information is limited about the effectiveness of best practice alerts (BPAs) for potentially inappropriate medications (PIMs) in improving clinical outcomes in older adults.

OBJECTIVE

To assess clinical outcomes of 11 BPAs for PIMs in older adults in the ambulatory setting.

METHODS

A retrospective cohort study was conducted at an integrated health care delivery system with computerized provider order entry. Patients aged 65 years and older were included if they had a BPA triggered when a prescriber attempted to order a sedating PIM in the ambulatory setting. Patients were categorized into dispensed and nondispensed groups if they did and did not, respectively, have the study PIM for which the BPA was triggered dispensed within 30 days of the alert. Rates of fall, fracture, or other injury and cognitive impairment were measured during 180-day follow-up.

RESULTS

A total of 2704 patients were included: 1373 (50.8%) and 1331 (49.2%) in the dispensed and nondispensed groups, respectively. The dispensed group had a lower unadjusted rate of fall/fracture/injury (3.4% vs 5.3%, p = 0.019), but this difference was attenuated with multivariable adjustment (adjusted odds ratio = 0.77, 95% confidence interval = 0.51-1.13). There was no difference in the rate of cognitive impairment between groups (4.6% vs 4.4%, adjusted odds ratio = 1.40, 95% confidence interval = 0.95-2.05).

CONCLUSION

No association was identified between PIM dispensing after a prescriber was alerted with a BPA and reduced rates of falls/fractures/injuries and cognitive impairment.

Suitability of patient education materials on proton-pump inhibitors deprescribing: a focused review

PURPOSE

Engaging patients in the process of deprescribing is a necessity. Several patient education materials have been developed for this purpose. The aim of this study was to assess the suitability of the existing patient education materials for proton-pump inhibitors deprescribing.

METHODS

We conducted a targeted inventory of the available materials on scientific literature and known repositories. We evaluated their suitability with the Suitability Assessment of Materials (SAM) instrument. Materials were rated independently by two researchers and then discussed until consensus was reached.

RESULTS

Seven patient education materials were identified. Three materials (42.9%) were deemed "superior" and 4 (57.1%) were deemed "adequate". Ratings were generally good in the categories of content, learning stimulation, motivation, typography and layout. The major weaknesses included the use of inappropriate graphics and the too demanding required reading grade level. These may decrease patient attention and comprehension and therefore the effectiveness of education materials.

CONCLUSIONS

Suitability of the patient education materials on proton-pump inhibitors deprescribing is overall satisfactory. Greater attention on readability, graphics and inclusion of summaries will be needed for development of future materials.

Relationship Between Potentially Inappropriate Medications And The Risk Of Hospital Readmission And Death In Hospitalized Older Patients

Objective

This study aimed to compare the prevalence of potentially inappropriate medications (PIMs) among hospitalized elderly patients using Beers and Chinese criteria and identify the correlation between PIMs and the risk of hospital readmission and death.

Methods

This study was conducted on geriatric patients aged ≥65 years at Beijing Fuxing Hospital between June 2015 and December 2017. The Beers criteria of 2015 and the Chinese criteria of 2017 were used to detect PIMs. Follow-ups were conducted for 12–36 months (or until patients’ death, if it came sooner). Cox proportional-hazards models were used to explore the correlations between PIM use and the risk of hospital readmission and death.

Results

Of 508 patients, 352 (69.3%) and 339 (66.7%) had at least one PIM identified using the Beers criteria and the Chinese criteria, respectively. Proton-pump inhibitors in the Beers criteria and clopidogrel in the Chinese criteria were the most leading PIMs. PIMs identified using the Beers criteria were a risk factor for the all-cause hospital readmission. After adjusting for age, gender, comorbidity, and so forth, PIM use was still an indicator of rehospitalization. PIM grouping defined using the Chinese criteria was not associated with hospital readmission. PIM grouping defined using either criteria was not associated with all-cause death.

Conclusion

The study showed a high prevalence of PIM use in China. PIMs defined using the Beers criteria increased the risk of hospital readmission. Clinicians should pay more attention to PIMs, carry out routine PIM assessment, and reduce adverse health outcomes in elderly patients.

Academic Detailing to Reduce Sedative-Hypnotic Prescribing in Older Veterans

BACKGROUND

Sedative-hypnotics, including benzodiazepines (BZDs) and benzodiazepine receptor agonists (BZD-RA), are considered potentially inappropriate medications (PIMs) in older adults. Academic detailing, an educational outreach delivered by trained clinicians to other clinicians to encourage evidence-based care, can promote deprescribing of PIMs.

OBJECTIVE

To evaluate the impact of academic detailing on sedative-hypnotic prescribing to older veterans.

METHODS

A retrospective analysis was performed to evaluate the impact of academic detailing on BZD and BZD-RA prescribing to veterans aged 75 years and older. Prescribing trends for primary care and mental health prescribers in the Veterans Health Administration (VA) Southeast Network were calculated for the 18 months before and after an initial academic detailing session for each prescriber. Pre-post interrupted time series analyses (ITSAs) were conducted, and period prevalence was calculated as the number of prescriptions per 1000 older veterans.

RESULTS

A total of 155 prescribers were followed for 36 months. BZD prevalence declined by 23% (69.08-53.33 per 1000 population; P < .001) and by 15% for BZD-RA (18.07-15.38 per 1000 population; P < .001). New starts on BZD declined by 54% (2.36-1.09 per 1000 population; P < .001) and new starts on BZD-RA declined by 53% (1.02-0.48 per 1000 population; P < .001). Alternative medications for insomnia increased by 23% (39.98-49.27 per 1000 population; P < .001). Findings from the ITSA confirmed those of the pre-post analysis with sustained effects in the postintervention period.

CONCLUSIONS

Academic detailing was associated with reduced sedative-hypnotic prescribing in the primary care and mental health setting.

Safer Prescribing and Care for the Elderly (SPACE): feasibility of audit and feedback plus practice mail-out to patients with high-risk prescribing

INTRODUCTION High-risk prescribing in general practice is common and places patients at increased risk of adverse events. AIM The Safer Prescribing and Care for the Elderly (SPACE) intervention, comprising audit and feedback plus practice mail-out to patients with high-risk prescribing, was designed to promote medicines review and support safer prescribing. This study aims to test the SPACE intervention feasibility in general practice. METHODS This feasibility study involved an Auckland Primary Health Organisation (PHO), a clinical advisory pharmacist, two purposively sampled urban general practices, and seven GPs. The acceptability and utility of the SPACE intervention were assessed by semi- structured interviews involving study participants, including 11 patients with high-risk prescribing. Interviews were audio-recorded, transcribed verbatim and analysed using a general inductive approach to identify emergent themes. RESULTS The pharmacist said the SPACE intervention facilitated communication with GPs, and provided a platform for their clinical advisory role at no extra cost to the PHO. GPs said the feedback session with the pharmacist was educational but added to time pressures. GPs selected 29 patients for the mail-out. Some GPs were concerned the mail-out might upset patients, but patients said they felt cared for. Some patients intended to take the letter to their next appointment and discuss their medicines with their GP; others said there were already many things to discuss and not enough time. Some patients were confused by the medicines information brochure. DISCUSSION The SPACE intervention is feasible in general practice. The medicines information brochure needs simplification. Further research is needed to test the effect of SPACE on high-risk prescribing.

Association between use of benzodiazepines and occurrence of acute angle-closure glaucoma in the elderly: A population-based study

OBJECTIVE

Because benzodiazepines (BZDs) can affect pupillae muscles, their use could be a risk factor for acute angle-closure glaucoma (AACG), which is an ophthalmic emergency. However, there is no research evidence for the association between BZDs and AACG, except two case reports. We aimed to investigate whether BZDs increase the risk of AACG in a geriatric population.

METHODS

We performed a case-control study using a geriatric cohort from the National Health Insurance database (2002-2013) in Korea. Case subjects (n = 1117) were patients diagnosed with AACG. Controls, people who have not been diagnosed with AACG, were randomly matched with the case according to age, sex, and index year (n = 4468). To examine the risk of BZD use for AACG, we performed conditional logistic regression analyses with potential confounders including comorbidities and concomitant medication.

RESULTS

The use of BZD within 30 days was not significantly associated with AACG risk (adjusted odds ratio [aOR] = 1.14, 95% confidence interval [CI] = 0.94-1.37). Further analyses showed that, compared with non-use of BZD, new BZD use had a significantly increased risk for the development of AACG (aOR = 1.62, 95% CI = 1.09-2.37). The risk was higher in the new BZD users exposed within 7 days (aOR = 3.09, 95% CI = 1.58-5.88).

CONCLUSION

We found that BZDs increase the risk of AACG at the beginning of its use among the Korean elderly. Clinicians should monitor visual disturbance in the elderly during the early period after prescription of BZD.

Association of pre-operative medication use with unplanned 30-day hospital readmission after surgery in oncology patients receiving comprehensive geriatric assessment

BACKGROUND

This study aimed to determine whether pre-operative medication use is associated with unplanned 30-day readmission in elderly people undergoing cancer surgery.

METHODS

Patients aged 65 years or older who were scheduled for cancer surgery and presented for comprehensive geriatric assessment were included. Comparisons of variables between patients with readmission and those without readmission were performed by univariate and multivariate analyses.

RESULTS

A total of 473 patients were included. Multivariate analysis showed that pre-operative discontinuation-requiring medications (PDRMs) and gastrointestinal/hepato-pancreato-biliary (GI/HPB) cancer were significant factors for 30-day readmission. PDRM increased the risk of readmission by about 2.2-fold. Attributable risk of PDRM to readmission was around 55%. The adjusted odds ratio and attributable risk for GI/HPB surgery was 3.4 (95% CI 1.0-11.5) and 70.8%, respectively.

CONCLUSIONS

Medication use has an impact on unplanned 30-day readmission in geriatric oncology patients, further highlighting the importance of medication optimization for elderly patients with cancer surgery.

Potentially inappropriate medications prescribing according to Beers criteria among elderly outpatients in Jordan: a cross sectional study

Background

Due to aging, along with its associated physiological changes, older adults are extremely vulnerable to be afflicted with multiple chronic conditions (multimorbidity). Accordingly, prescribing a large number of drugs to older adults would be inevitable. Resulted complex drug regimens can lead to prescribing of Potentially Inappropriate Medications (PIMs) with subsequent negative health and economic outcomes.

Objectives

The main objective of this study is to investigate the prevalence and predictors of PIMs prescribing among Jordanian elderly outpatients, using the last updated version of the American Geriatrics Society (AGS) Beers Criteria (2015 version).

Methods

A Unicenter, cross-sectional study were data was assessed using medical records of included study subjects conducted over three months period from beginning of October to the end of December 2016 at King Abdullah University Hospital, Al Ramtha, Jordan. Our study included patients aged 65 years or above who visited the outpatient clinics at King Abdullah University hospital (KAUH) and were prescribed at least one oral medication during the study period. PIMs were identified for these patients and further classified according to the 2015 AGS Beers Criteria. We measured the prevalence of PIMs prescribed among elderly outpatients in Jordan.

Results

A total of 4622 eligible older adults were evaluated in this study, of whom 62.5% (n=2891) were found to have at least one PIM prescribed during the three months study period. 69% of identified PIMs were medications to be used with caution in elderly, 22% were medications to avoid in many or most older adults, 6.3% were medications to be avoided or have their dosage adjusted based on kidney function in older adults, 2.04% medications were to avoid in older adults with specific diseases/syndromes, and 1.6% were potentially clinically important non-anti-infective drug-drug interactions to be avoided in older adults. Female gender and polypharmacy were found to be significant predictors of PIMs use among elderly.

Conclusions

Potentially Inappropriate Medication prescribing is common among Jordanian elderly outpatients. Female gender and polypharmacy are associated with more PIMs prescribing and so need further attention.

Applying Beers Criteria for Elderly Patients to Assess Rational Drug Use at a University Hospital in Northern Cyprus

Background:

Several regulations for potentially inappropriate medications (PIMs) have been published specifically for elderly patients to rationalize drug use in such vulnerable communities.

Objectives:

To determine the proportion and characteristics of PIMs in patients receiving one or more drugs according to Beers Criteria 2015.

Materials and Methods:

A cross-sectional prospective analysis of 451 inpatients admitted between September 25 and October 25, 2016, was conducted in Near East University Hospital, Northern Cyprus. Data were extracted from the patient medical records using special forms.

Results:

A total of 119 elderly patients were identified (26.4%) and evaluated, of which 107 were eligible and 12 were excluded. Of the 1039 prescribed medicines, 16.9% were PIMs during hospitalization, whereas 12% were at discharge. The most prevalent PIM group during hospitalization was identified as the “medications to be avoided in older adults” (48.8%), whereas it also formed 52% of medications prescribed at discharge. PIMs of the class “drugs used with caution” formed 19.4% of prescribed medicine during hospitalization and 18.4% on discharge. The prevalence of polypharmacy was 79.4%, mainly identified as unpreventable polypharmacy of elders.

Conclusion:

A significantly higher prevalence of PIMs was observed in hospitalized patients than those discharged, with high prevalence of polypharmacy. These results necessitate a nationwide assessment, and responsible bodies who adopt strategies should act to reduce or overcome the aforementioned high prevalence in Northern Cyprus.

Utilization of computerized clinical decision support for potentially inappropriate medications

Background: Electronic medical record (EMR) alerts may inform point of care decisions, including the decision to prescribe potentially inappropriate medications (PIM) identified in the Beers criteria. EMR alerts may not be considered relevant or informative in the clinician context, leading to a phenomenon colloquially known as “alert fatigue.”

Objective: To assess the frequency of clinical interaction with EMR alerts and associated deprescribing behaviors in ambulatory settings.

Methods: This is a retrospective observational study in two ambulatory clinics (the Kaye Edmonton Clinic Senior’s Clinic and the Lynnwood Family Practice Clinic) in Edmonton over an observational period of 30 months. Statistical analysis was done using descriptive statistics, chi-square and regression analysis.

Results: The reminder performance for interactions with the alert was 17.2% across the two clinics. The Number Needed to Remind (NNR) or mean number of alerts shown on clinician screens prior to a single interaction of any kind with the alert was 5.8. When actions were defined as a deprescribing (ie discontinuation) event that was related to the alert and that particular interaction in the EMR, the reminder performance was 1.2%, for an NNR of 82.8.

Conclusion: The configuration of alerts in the EMR was not associated with a clinically detectable increase in the uptake of the Beers criteria for high hazard medications.

Evaluation of Rationality of Geriatric Patients' Prescription Based On Beers Criteria in a Tertiary Care Hospital in India

AIM

Irrational prescribing for geriatric patients has become an important public health problem worldwide. Because India is one of the most populated countries having a great proportion of old people in the world, studies on the prevalence of inappropriate prescriptions can be very beneficial to increase the knowledge of health care providers and to reduce the occurrence of adverse drug events among this population.

METHODS

A group of 482 inpatients above 64 years old were enrolled in a prospective study. Chart review method was used. The data were collected from patients' prescription and medicine charts. Each prescription was checked individually for the inappropriate drug by using the AGS 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Suggestions were given to the physicians for inappropriate medications.

RESULTS

The prevalence of potentially inappropriate medication is found to be 11.66% (n = 56). Out of 56 inappropriate medications, the most frequently inappropriate medication is Digoxin (25%) followed by Sprinolactone 19.64%. This study founds age, some medication, length of stay and number of diagnosis as predictors for getting a PIM. Feedback of the physicians varies based on the suggestions.

CONCLUSION

This study concludes that the prevalence of PIMs among geriatrics patients of ≥ 65 years old is 11.66%. Some predictors have been identified for getting a PIM. This study shows that physicians' feedback is dependent on the suggestions being given.

A retrospective analysis of prescription medications as it correlates to falls for older adults

OBJECTIVES

To determine the correlation between falls and two medication factors: the class of medications and potentially inappropriate medications (PIMs) prescribed to community-dwelling older adults aged 55 and older.

METHODS

Retrospective, cross-sectional study. Home health patients residing in a Texas/Mexico border community and reporting at least one fall within the past month. Medication use, medication classification, and potentially inappropriate medications (PIM) recorded by level of falls; non-fallers and recurrent fallers.

RESULTS

Of 99 participants, 13.1% reported falling once and 86.9% reported two or more falls. Participant's average number of medications used was 10.51 (SD 5.75) with 93.9% having four or more prescribed medications. Average number of PIMs prescribed per participant was 1.42 (SD 1.51) with at least one PIM prescribed to 65.6% of participants. Twenty three out of 83 identified classes of prescribed medications met criteria for the study's analyses but resulted in no significant association to falls when comparing NF to RF. Agents acting on the renin-angiotensin system and lipid modifying agents were the most frequently prescribed medication classes (N=55, 55.6%). Ibuprofen was the PIM most frequently prescribed (n=13, 13.1%). The correlation between use of a prescribed PIM and number of falls was not statistically significant (p=0.128).

CONCLUSIONS

There was no correlation between classes of medication and level of falls. Recurrent fallers were more likely to have been prescribed a PIM than non-fallers (not significant). Although the analyses conducted for this study did not result in statistical significance, the high prevalence of polypharmacy and prescribed PIMs observed in these participants warrants a thorough review of medications to reduce fall risks among older adults.

Benzodiazepine receptor agonist dispensations in Alberta: a population-based descriptive study

BACKGROUND

There is increasing concern over the use of benzodiazepine receptor agonists (BZRAs). The objective of this study was to describe BZRA dispensations in the province of Alberta in 2015 according to age, sex and appropriateness.

METHODS

A population-based descriptive study of people 10 years of age or older with at least 1 BZRA dispensation in Alberta, Canada, between Jan. 1 and Dec. 31, 2015, was conducted. Prevalence of BZRA use, characteristics of BZRAs dispensations, use at the individual level and appropriateness were determined.

RESULTS

A total of 372 870 people received 2 463 585 BZRA dispensations in Alberta in 2015. Prevalence of use at the population level was 10% overall, increased with age (p value for trend < 0.001) and was consistently highest among females. Twenty percent of patients used both Z-drugs and benzodiazepines. BZRA users had an average of 7 dispensations (standard deviation [SD] 20), 137 days of use overall (SD 123) and a maximum period of consecutive use of 90 days (SD 95). Days of consecutive use were highest among those aged 65 years or older (126 d). A total of 62 795 (17%) people used more than 1 distinct BZRA ingredient concurrently and 10% had 3 or more distinct prescribers.

INTERPRETATION

The prevalence of BZRA use was high and a substantial proportion of use appeared to be potentially inappropriate. This study supports the need for continued monitoring for the prescribing and use of these medications at the population level.

The need for better access to pain treatment: learning from drug consumption trends in the USA

The Authors of this letter look at consumption of opioids and a2- ligands, also known as "gabapentinoids", in Italy, and specifically in the Provincial Health District of Cosenza, as compared with USA trends of recent decades. Access to analgesic drugs since the introduction of Italian law 38/2010 is also evaluated and possible future measures for better management of chronic pain are proposed.

Characteristics of New-Onset and Chronic Sleep Medication Users Among Older Adults: A Retrospective Study of a US Medigap Plan Population using Propensity Score Matching

Background

Prescription sleep medications are often utilized to manage sleep problems among older adults even though these drugs are associated with multiple risks.

Objective

The aim was to determine the prevalence and characteristics of new-onset compared to chronic sleep medication users and to examine factors associated with the conversion from new to chronic use. A secondary objective was to investigate the impact of sleep medications on health outcomes of injurious falls and patterns of healthcare utilization and expenditures.

Methods

A 25% random sample of adults ≥ 65 years with 3-year continuous AARP^® Medicare Supplement medical and AARP^® MedicareRx drug plan enrollment was utilized to identify new-onset and chronic sleep medication users. Prescription sleep medication drugs were defined using National Drug Codes (NDCs); falls or hip fractures were identified from diagnosis codes. New users had no sleep medication use in 2014, but initiated medication use in 2015; chronic users had at least one sleep medication prescription in 2014 and in 2015; both groups had follow-up through 2016. Characteristics associated with new users, new users who converted to chronic use, and chronic users were determined using multivariate logistic regression. Prevalence of falls, healthcare utilization and expenditures were regression adjusted.

Results

Among eligible insureds, 3 and 9% were identified as new-onset and chronic sleep medication users, respectively. New-onset sleep medication prescriptions were often associated with an inpatient hospitalization. The strongest characteristics associated with new users, those who converted to chronic use, and chronic users were sleep disorders, depression and opioid use. About 50% of new users had > 30 days’ supply; 25% converted to chronic use with ≥ 90 days’ supply. The prevalence of falls for new-onset users increased by 70% compared to a 22% increase among chronic users.

Conclusion

New-onset and chronic sleep medication users were characterized by sleep disorders, depression and pain. Addressing the underlying problems associated with sleep problems among older adults may decrease the need for sleep medications and thus reduce the risk of sleep medication-related adverse events.

Prevalence of the potentially inappropriate Kampo medications to be used with caution among elderly patients taking any prescribed Kampo medications at a single centre in Japan: a retrospective cross-sectional study

Background

Few studies have investigated the prevalence and characteristics of potentially inappropriate Kampo medication use among elderly ambulatory patients taking any prescribed Kampo medications.

Methods

A retrospective cross-sectional study was conducted using electronic medical records. All patients aged 65 years or older who continued visiting internal medicine physicians and were prescribed any Kampo medications from January 2015 to March 2015 were included. The primary outcome was the proportion of patients taking any potentially inappropriate Kampo medications that should be used with caution (hereafter referred to as UWC Kampo medications). The medication appropriateness was evaluated based on the 2015 Japan Geriatrics Society guidelines.

Results

Eighty eligible patients were identified. The mean age was 76.7 years, 45 patients (56.2%) were female, the mean Charlson Comorbidity Index was 1.7, the median number of non-Kampo medications used was 5.0, and the median number of Kampo medications used was 1.0. The proportion of patients taking any UWC Kampo medications was 28.8% (95% confidence interval, 18.6 to 38.9%). Medications containing Glycyrrhizae radix for chronic kidney disease or loop diuretics were the most common UWC Kampo medications. Compared with patients who did not take any UWC Kampo medications, patients who did take such medications used aconite compositions more frequently (p = 0.04) and were more likely to have uncontrolled hypertension (p = 0.02) and chronic kidney disease (p <  0.001). In a multivariable analysis, no predictive factors for the use of UWC Kampo medications were identified.

Conclusions

Approximately one-fourth of the elderly patients taking any prescribed Kampo medications took at least one UWC Kampo medication, although the association between UWC Kampo medications and adverse events remains unclear. When physicians prescribe medications containing Glycyrrhizae radix to elderly patients, chronic kidney disease and the use of loop diuretics should be evaluated.

Potentially Inappropriate Medications and the Time to Full Functional Recovery After Hip Fracture

BACKGROUND

Older adults after hip fracture are at increased risk of being prescribed potentially inappropriate medications, and may be particularly vulnerable to their adverse effects.

OBJECTIVE

The objective of this study was to examine the association of potentially inappropriate medication use with the time to full functional recovery within 1 year of hip fracture repair.

METHODS

We conducted a secondary analysis of a prospective longitudinal study of eight hospitals in St. Louis, MO, USA. The participants were older adults (n = 477) aged 60 years or older who had undergone surgical repair of a hip fracture free of delirium, dementia or depression at baseline. Drugs at baseline were categorised using the American Geriatrics Society 2012 Beers criteria. The outcome was the Functional Recovery Scale total score measured at four time points during a 12-month period of observation. Cox proportional hazards models examined the time to 95% recovery of function ('full recovery'), adjusting for demographics, cognition, depression, medical co-morbidity, pre-fracture functioning and pain as covariates.

RESULTS

Potentially inappropriate medication use was common following hip fracture, with 51% of participants prescribed at least one potentially inappropriate medication and 17.4% prescribed two or more potentially inappropriate medications. Potentially inappropriate medication use was significantly associated with a longer time to achieve full recovery with a hazard ratio of 0.69 (95% confidence interval 0.52-0.92; p = 0.012) and this association was stronger for two or more potentially inappropriate medications compared with one potentially inappropriate medication (hazard ratio = 0.60; 95% confidence interval 0.40-0.90; p = 0.014).

CONCLUSION

Potentially inappropriate medication use was associated with a longer time to full functional recovery in older adults who underwent surgery for a hip fracture, particularly in those using two or more potentially inappropriate medications at baseline.

Patient, Physician, and Health-System Factors Influencing the Quality of Antidepressant and Sedative Prescribing for Older, Community-Dwelling Adults

OBJECTIVE

To identify determinants of potentially inappropriate (PI) antidepressant and anxiolytic/sedative prescribing for older, community-dwelling adults.

DATA SOURCES/STUDY SETTING

Office visits from the 2010 National Ambulatory Medical Care Survey.

STUDY DESIGN

A cross-sectional study measuring associations between various patient and physician factors and prescribing of PI antidepressants, and PI sedatives among elderly, using Beers 2012/2015 criteria, a clinical decision model, and multivariate logistic regressions.

DATA COLLECTION

Visits by older adults (≥65 years) involving medications were extracted to identify visits with antidepressants and sedatives.

PRINCIPAL FINDINGS

Black race, asthma, depression, osteoporosis, payment type, consultation time, and computer systems with prescribing support were associated with reduced odds of PI antidepressant prescribing among users. Income, chronic renal failure, diabetes, and obesity were associated with reduced odds of PI sedative prescribing. Female sex, white race, depression, increasing number of medications, and physician specialty were associated with increased odds of PI sedative prescribing.

CONCLUSIONS

Various patient and health-system factors influence the quality of antidepressant and sedative prescribing for older community-dwelling adults. Longer consultations and the use of computer systems with prescribing support may minimize potentially inappropriate antidepressant prescribing. As medication numbers increase, exposure to PI sedatives is more likely, requiring medication review and monitoring.

Potential Medication-Related Problems in Older Breast, Colon, and Lung Cancer Patients in the United States

Background: Older adults are often exposed to multiple medications, some of which could be inappropriate or have the potential to interact with each other. Older cancer patients may be at increased risk for medication-related problems due to exposure to cancer-directed treatment.Methods: We described patterns of potentially inappropriate medication (PIM) use and potential drug-chemotherapy interactions among adults age 66+ years diagnosed with stage I-III breast, stage II-III colon, and stage I to II lung cancer. Within the Surveillance, Epidemiology, and End Results-Medicare database, patients had to have Medicare Part D coverage with 1+ prescription in the diagnosis month and Medicare Parts A/B coverage in the prior 12 months. We estimated monthly prevalence of any and cancer-related PIM from 6 months pre- to 23 months postcancer diagnosis and 12-month period prevalence of potential drug-chemotherapy interactions.Results: Overall, 19,318 breast, 7,283 colon, and 7,237 lung cancer patients were evaluated. Monthly PIM prevalence was stable prediagnosis (37%-40%), but increased in the year following a colon or lung cancer diagnosis, and decreased following a breast cancer diagnosis. Changes in PIM prevalence were driven primarily by cancer-related PIM in patients on chemotherapy. Potential drug-chemotherapy interactions were observed in all cohorts, with prevalent interactions involving hydrochlorothiazide, warfarin, and proton-pump inhibitors.Conclusions: There was a high burden of potential medication-related problems among older cancer patients; future research to evaluate outcomes of these exposures is warranted.Impact: Older adults diagnosed with cancer have unique medication management needs. Thus, pharmacy specialists should be integrated into multidisciplinary teams caring for these patients. Cancer Epidemiol Biomarkers Prev; 27(1); 41-49. ©2017 AACR.

Prescription of potentially inappropriate medications to older adults. A nationwide survey at dispensing pharmacies in Japan

OBJECTIVES

Prescriptions to older adults were surveyed to elucidate factors associated with potentially inappropriate medications (PIMs) in Japan.

METHODS

Adults aged ≥65 years, who were prescribed medications at 585 dispensing pharmacies across Japan, participated (N = 180,673). Data were collected between October 1 and October 31, 2014.

RESULTS

Proportion of polypharmacy and that of PIMs increased with age (p < 0.001). Analgesic drugs were most commonly prescribed for the older adults aged 65-74 years, whereas benzodiazepines were prescribed most commonly for those aged over 75 years. A logistic regression analysis revealed that the increase of PIMs was explained by polypharmacy and mainly the use of central nervous systems (CNS) and psychotropic drugs.

CONCLUSIONS

The increased prevalence of polypharmacy with age and the common use of CNS and psychotropic medications account for the PIMs in old age in the current nationwide survey.

Chikungunya Virus Infection: Why Should U.S. Geriatricians Be Aware of It?

Chikungunya virus (CHIKV) was until recently perceived only as a tropical disease. Since the first report of a case in Saint Martin Island in 2013, it has spread to South, Central, and North America. The first local transmission in the continental United States was reported in Florida in July 2014. CHIV infection is known to cause debilitating rheumatologic disease. Older adults are particularly susceptible to severe and chronic infection. Without an effective vaccine and antiviral therapy to prevent and control CHIKV, U.S. geriatricians could soon be confronted with major clinical, functional, and therapeutic challenges. After a general overview of CHIKV infection, this review will examine reasons why it has become such a threat to the United States and consider factors that contribute to the greater burden and effect of this disease in elderly adults. Consideration will be given to how aging and immunosenescence may contribute to CHIKV's atypical and more-severe clinical features in older adults. This review concludes with possible therapeutic approaches that best fit the unique needs of older adults, especially with regard to multimorbidity and polypharmacy.

Potentially inappropriate medication use in nursing homes: an observational study using the NORGEP-NH criteria

BACKGROUND

Frail residents in the nursing home sector call for extra care in prescribing. The Norwegian General Practice Nursing Home (NORGEP-NH) list of 34 explicit criteria for potentially inappropriate medication use in nursing homes was developed explicitly for this population. The aim of this study was to employ the NORGEP-NH Criteria to study the extent of potentially inappropriate medication use among nursing home residents and explore possible associated factors.

METHODS

Cross-sectional observational pharmacoepidemiological study from residents in nursing homes in the county of Vestfold, Norway. Data collected 2009-11 included residents' demographic and clinical status and all medications, regular and on demand.

RESULTS

881 patients from 30 institutions (mean 85.9 years, 68.6% female), were included. According to NORGEP-NH, 43.8% were prescribed at least one potentially inappropriate regular medication, and 9.9% regularly received three or more potentially inappropriate medications. When also including a) the NORGEP-NH Deprescribing Criteria and b) including drugs prescribed for use as needed, 92.7% of all residents received medication that needs particular surveillance according to the NORGEP-NH. 69.7% of the nursing home residents used at least one psychotropic drug regularly. Female residents received more often than males at least one potentially inappropriate regular medication (OR 1.60, p=0.007). Regarding the prescription of three or more concomitant psychotropic medications, odds ratio for females was 1.79 (p=0.03) compared to males. Residents with the best performance in activities of daily living, and residents residing in long-term wards, had higher risk of using three or more psychotropic drugs. Use of multiple psychoactive drugs increased the risk of falls in the course of an acute episode of infection or dehydration (odds ratio 1.70, p=0.009).

CONCLUSIONS

Prevalence of potentially inappropriate medications in nursing homes according to the NORGEP-NH was extensive, and especially the use of multiple psychotropic drugs. The high prevalence found in this study shows that there is a need for higher awareness of medication use and side effects in the elderly population.

TRIAL REGISTRATION

Retrospectively registered. Data obtained from clinical trial NCT01023763 registered with ClinicalTrials.gov 12/01/2009.

Hospitalization rates during potentially inappropriate medication use in a large population-based cohort of older adults

BACKGROUND AND AIMS

The temporal relationship between potentially inappropriate medication (PIM) use and hospitalization remains uncertain. We examined whether current PIM use increases the rate of hospitalization and estimated the rate of hospitalization during exposure to individual PIMs.

METHODS

A retrospective population-based cohort study of 1 480 137 older adults was conducted using the 2003-2013 Italian Emilia-Romagna Regional administrative healthcare database (~4.5 million residents), which includes demographic, hospital and outpatient prescription information. Each day of follow-up was defined as exposed/unexposed to PIMs that 'should always be avoided', according to the Maio criteria, an Italian modified version of the Beers criteria. The study outcome was all-cause hospitalizations. Crude PIM-related hospitalization rates were calculated for individual PIMs. Repeated-events Cox proportional hazards models with time-dependent covariates estimated adjusted hazard ratios for hospitalization during PIM exposure, as defined by three versions of the Maio criteria (v2007, v2011, v2014).

RESULTS

During >10 million person-years of follow-up, 54.2% of individuals used ≥1 PIM and 10.9% of all person-time was exposed to v2014 PIMs. Among 1 604 901 hospitalizations, 15.6% occurred during v2014 PIM exposure. Crude hospitalization rates during v2014 PIM-exposed and unexposed person-time were 228.1 and 152.1 per 1000 person-years, respectively. The PIM with the highest rate of hospitalization was ketorolac, while nonsteroidal anti-inflammatory drugs had the most exposure time. The hazard of hospitalization was 16% greater (hazard ratio = 1.16; 95% confidence interval 1.14, 1.18) among patients exposed to v2014 PIMs. The v2007 and v2011 estimates were similar.

CONCLUSIONS

In this large population-based cohort of older adults, we found a 16% increased hospitalization risk associated with PIM exposure.

Determinants of Potentially Inappropriate Medication Use among Community-Dwelling Older Adults

OBJECTIVE

To examine the determinants of potentially inappropriate medication (PIM) use.

DATA SOURCES/STUDY SETTING

U.S. nationally representative data on (n = 16,588) noninstitutionalized older adults (age ≥65) with drug use from the 2006-2010 Medical Expenditure Panel Survey.

STUDY DESIGN

We operationalized the 2012 Beers Criteria to identify PIM use during the year, and we examined associations with individual-level characteristics hypothesized to be quality enabling or related to need complexity.

PRINCIPAL FINDINGS

Almost one-third (30.9 percent) of older adults used a PIM. Multivariate results suggest that poor health status and high-PIM-risk conditions were associated with increased PIM use, while increasing age and educational attainment were associated with lower PIM use. Contrary to expectations, lack of a usual care source of care or supplemental insurance was associated with lower PIM use. Medication intensity appears to be in the pathway between both quality-enabling and need-complexity characteristics and PIM use.

CONCLUSION

Our results suggest that physicians attempt to avoid PIM use in the oldest old but have inadequate focus on the high-PIM-risk conditions. Educational programs targeted to physician practice regarding high-PIM-risk conditions and patient literacy regarding medication use are potential responses.

Non-adherence to medication regimens among older African-American adults

Background

Despite concerns about racial differences on adherence to prescribed medication rigimens among older adults, current information about nonadherence among underserved elderly African Americans with co-morbidities is limited. This study examines the association between adherence to drug regimens and an array of medication-related factors, including polypharmacy, medication regimen complexity, use of Potentially Inappropriate Medications (PIM), and knowledge about the therapeutic purpose and instructions of medication use.

Methods

Four-hundred African Americans, aged 65 years and older, were recruited from South Los Angeles. Structured, face-to-face interviews and visual inspection of participants’ medications were conducted. From the medication container labels, information including strength of the drug, expiration date, instructions, and special warnings were recorded. The Medication Regimen Complexity Index (MRCI) was measured to quantify multiple features of drug regimen complexity. The Beers Criteria was used to measure the PIM use.

Results

Participants reported taking an average of 5.7 prescription drugs. Over 56% could not identify the purpose of at least one of their medications. Only two-thirds knew dosage regimen of their medications. Thirty-five percent of participants indicated that they purposely had skipped taking at least one of their medications within last three days. Only 8% of participants admitted that they forgot to take their medications. The results of multivariate analysis showed that co-payment for drugs, memory deficits, MRCI, and medication-related knowledge were all associated with adherence to dosage regimen of medications. Participants with a higher level of knowledge about therapeutic purpose and knowledge about dosage regimen of their medications were seven times (CI: 4.2–10.8) more likely to adhere to frequency and dose of medications. Participants with a low complexity index were two times (CI: 1.1–3.9) more likely to adhere to the dosage regimen of their medications, compared with participants with high drug regimen complexity index.

Conclusions

While other studies have documented that non-adherence remains an important issue among older adults, our study shows that for underserved elderly African Americans, these issues are particularly striking. A periodic comprehensive assessment of all medications that they use remains a critical initial step to identify medication related issues. Assessment of their disease and medication related knowledge (e.g., therapeutic purposes, side-effects, special instructions, etc.) and their ability to follow complicated medication regimens and modification of their drug regimens requires inter-professional collaboration.

Swimming Against the Tide: Primary Care Physicians' Views on Deprescribing in Everyday Practice

PURPOSE

Avoidable hospitalizations due to adverse drug events and high-risk prescribing are common in older people. Primary care physicians prescribe most on-going medicines. Deprescribing has long been essential to best prescribing practice. We sought to explore the views of primary care physicians on the barriers and facilitators to deprescribing in everyday practice to inform the development of an intervention to support safer prescribing.

METHODS

We used a snowball sampling technique to identify potential participants. Physicians were selected on the basis of years in practice, employment status, and practice setting, with an additional focus on information-rich participants. Twenty-four semistructured interviews were audio-recorded, transcribed verbatim, and analyzed to identify emergent themes.

RESULTS

Physicians described deprescribing as "swimming against the tide" of patient expectations, the medical culture of prescribing, and organizational constraints. They said deprescribing came with inherent risks for both themselves and patients and conveyed a sense of vulnerability in practice. The only incentive to deprescribing they identified was the duty to do what was right for the patient. Physicians recommended organizational changes to support safer prescribing, including targeted funding for annual medicines review, computer prompts, improved information flows between prescribers, improved access to expert advice and user-friendly decision support, increased availability of non-pharmaceutical therapies, and enhanced patient engagement in medicines management.

CONCLUSIONS

Interventions to support safer prescribing in everyday practice should consider the sociocultural, personal, relational, and organizational constraints on deprescribing. Regulations and policies should be designed to support physicians in practicing according to their professional ethical values.

Rates of Nonsteroidal Anti-Inflammatory Drug Use in Patients with Established Cardiovascular Disease: A Retrospective, Cross-Sectional Study from NHANES 2009-2010

PURPOSE

Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to treat pain, inflammation, and fever in the USA. Unfortunately, NSAIDs have been associated with an increased risk of adverse cardiovascular events, especially among NSAID users with established cardiovascular disease (CVD). In 2005, the Food and Drug Administration (FDA) released an initial warning regarding NSAID use and CVD risk, and recently, in July 2015, released an updated statement strengthening this initial warning. The purpose of this study is to evaluate the rates of NSAID use among patients with CVD following the 2005 FDA warning regarding NSAID use and increased CVD risk.

METHODS

This was a retrospective, cross-sectional study of participants from the National Health and Nutrition Examination Survey, 2009-2010. Participants' CVD status was determined by self-reported diagnosis. Current use of over the counter (OTC) NSAIDs was defined by self-reported use of ibuprofen or naproxen, and we identified the current use of prescription NSAIDs in the database of prescription medication.

RESULTS

Respondents with CVD were 2.1 times more likely to use OTC NSAIDs or prescription NSAIDs than respondents without CVD. Among CVD patients, respondents with angina and myocardial infarction were 60% more likely to use any form of NSAID, and respondents with congestive heart failure were less likely to use any form of NSAID than those with other forms of CVD.

CONCLUSIONS

Our results indicate that there is still a large proportion of CVD patients using NSAIDs. It is now crucial to determine the reasons why prescribers are still prescribing NSAIDs despite the FDA warning.

Polypharmacy among Underserved Older African American Adults

The purpose of the present study was to examine correlates of polypharmacy among underserved community-dwelling older African American adults. Methods. This study recruited 400 underserved older African Americans adults living in South Los Angeles. The structured face-to-face interviews collected data on participants' characteristics and elicited data pertaining to the type, frequency, dosage, and indications of all medications used by participants. Results. Seventy-five and thirty percent of participants take at least five and ten medications per day, respectively. Thirty-eight percent of participants received prescription medications from at least three providers. Inappropriate drug use occurred among seventy percent of the participants. Multivariate analysis showed that number of providers was the strongest correlate of polypharmacy. Moreover, data show that gender, comorbidity, and potentially inappropriate medication use are other major correlates of polypharmacy. Conclusions. This study shows a high rate of polypharmacy and potentially inappropriate medication use among underserved older African American adults. We documented strong associations between polypharmacy and use of potentially inappropriate medications, comorbidities, and having multiple providers. Polypharmacy and potentially inappropriate medications may be attributed to poor coordination and management of medications among providers and pharmacists. There is an urgent need to develop innovative and effective strategies to reduce inappropriate polypharmacy and potentially inappropriate medication in underserved elderly minority populations.

A Systematic Review of the Impact of Potentially Inappropriate Medication on Health Care Utilization and Costs Among Older Adults

BACKGROUND

Potentially inappropriate medications (PIMs) are defined as those medicines having a greater potential risk than benefit for older adults. In this systematic literature review, we evaluate the current evidence on health care service use and health care costs associated with PIMs among older adults.

METHODS

A literature search was conducted in August 2015 without publication date restrictions using the databases PubMed and Scopus. Selected articles included in the review of articles were: (1) observational cohort or case-control, or intervention studies; (2) investigating PIM use among older adults aged 65 years or older with outcomes on health care utilization (eg, hospitalization) or health care costs; and (3) use of some published criteria for assessing PIMs.

RESULTS

Of 825 abstracts screened, in total 51 articles proceeded to full-text review. Of those full-text articles, 39 articles were included in this review. Most of the articles found that PIMs had a statistically significant effect on health care service use, especially on hospitalization, among older adults. The findings of impact on length of stay or readmissions were inconclusive. Five studies found statistically significant higher medical or total health care costs for PIM users compared those who did not use any PIMs.

CONCLUSIONS

PIMs can, in addition to health and quality of life problems, also lead to greater health care service use and, thus, higher health care costs. However, the heterogeneity of the study settings makes the interpretation of the results difficult. Further studies, especially on economic issues with country-specific criteria, are needed.

Utilization Pattern of Potentially Inappropriate Medications in Geriatric Patients in a Tertiary Care Hospital: A Retrospective Observational Study

INTRODUCTION

Geriatric population is on the rise throughout the world, hence the quality and the safety of prescribing in the elderly is a global healthcare concern. It is important for the healthcare providers to be aware of the limitations in prescribing certain drugs to the elderly. This study was an attempt to shed light on the utilization pattern of Potentially Inappropriate Medications (PIMs) in elderly patients admitted in the medicine wards in a tertiary care hospital in Goa.

AIM

To measure the percentage prevalence of PIMs prescribed in the admitted geriatric patients.

MATERIALS AND METHODS

In this retrospective observational study, 150 case records of patients aged 60 years or more were analysed. All the prescribed medications, for each case record, were then analysed by referring to the American Geriatrics Society (AGS) Beers Criteria 2015. Data was analysed using Statistical Package for Social Sciences (SPSS) software.

RESULTS

Of the 150 patients, 99 (66%) received at least one PIM according to the Beers Criteria 2015 (including drugs to be used with caution). However, after excluding the drugs to be used with caution, the prevalence of PIMs decreased to 44%. The most commonly prescribed PIMs were ranitidine (17.33%) and prazosin (8.66%) and the most commonly prescribed drug to be used with caution was furosemide (35.33%).

CONCLUSION

As the medication needs of the geriatric population are unique, it is essential that the healthcare professionals are aware of these needs and also follow the available guidelines and tools. Formulation of hospital policies and protocols in this regard would help to improve the scenario. Increased education, awareness and reporting of drug-related problems along with more doctor-patient interaction in these situations are some of the factors that could play an important role in promoting better and safer prescribing practices and a better quality of life to the older generations of our communities.

Empirical Assessment of the Impact of Low-Cost Generic Programs on Adherence-Based Quality Measures

In the United States, federally-funded health plans are mandated to measure the quality of care. Adherence-based medication quality metrics depend on completeness of administrative claims data for accurate measurement. Low-cost generic programs (LCGPs) cause medications fills to be missing from claims data as medications are not adjudicated through a patient’s insurance. This study sought to assess the magnitude of the impact of LCGPs on these quality measures. Data from the 2012–2013 Medical Expenditure Panel Survey (MEPS) were used. Medication fills for select medication classes were classified as LCGP fills and individuals were classified as never, sometimes, and always users of LCGPs. Individuals were classified based on insurance type (private, Medicare, Medicaid, dual-eligible). The proportion of days covered (PDC) was calculated for each medication class and the proportion of users with PDC ≥ 0.80 was reported as an observed metric for what would be calculated based on claims data and a true metric which included missing medication fills due to LCGPs. True measures of adherence were higher than the observed measures. The effect’s magnitude was highest for private insurance and for medication classes utilized more often through LCGPs. Thus, medication-based quality measures may be underestimated due to LCGPs.

Drug prescription appropriateness in the elderly: an Italian study

Purpose

Correct drug prescription in the elderly is a difficult task that requires careful survey of the current pharmacological therapies. In this article, we reviewed the drug prescriptions provided to 860 persons aged 65 years or over, residing in a small city of Lombardy, Italy.

Methods

Subjects were recruited from a local nursing home, the Pavia and Vigevano Neuropsychological Center for Alzheimer’s Disease, general practitioners’ offices, and the local University of the Third Age. For each patient, the amount of potentially inappropriate prescriptions (PIPs), sedative and anticholinergic load (SL and AL, respectively), and drug–drug interactions were evaluated.

Results

Widespread polypharmacy, giving rise to 10.06% of PIPs in the whole collection of prescriptions, was observed. In particular, PIPs mainly concern drugs acting at the central nervous system level, mostly benzodiazepines and antipsychotics. Moreover, approximately one-fourth of the subjects had an elevated SL and approximately one-tenth a high AL. Drug–drug interactions were frequent (266 requiring medical attention), up to five for each single patient. Of concern was the underuse of antidementia drugs: only 20 patients received a cholinesterase inhibitor or memantine, although 183 patients were potentially suitable for this treatment.

Conclusion

These results demonstrate the need to develop novel strategies aimed at improving the quality of drug prescription.

Comparative evaluation of methods approximating drug prescription durations in claims data: modeling, simulation, and application to real data

PURPOSE

The purpose of this study was to compare the predictive accuracy of different methods suggested for approximation of drug prescription durations in claims data.

METHODS

We expanded a well-established modeling and simulation framework to compare approximated drug prescription durations with 'true' (i.e., simulated) durations. Real claims data of persons aged ≥65 years insured by the German nationwide 'Statutory Health Insurance Fund' AOK between 2010 and 2012 provided empiric input parameters that were completed with missing information on actual dosing patterns from an observational cohort. The distinct approximation methods were based on crude measures (one tablet a day), population-averaged measures (defined daily doses), or individually-derived measures (longitudinal coverage approximation of the applied dose, COV). As a proof-of-principle, we assessed the methods' performance to predict the well-characterized bleeding risks of anticoagulant, antiplatelet, and/or non-steroidal anti-inflammatory drugs.

RESULTS

When applied to modeling and simulation data sets, the closest, least biased, and thus most accurate approximation was observed using the COV approximation. In a real-data example, rather similar results to an external reference were obtained for all methods. However, some of the differences between methods were meaningful, and the most reasonable and consistent results were obtained with the COV approach.

CONCLUSION

Based on theoretically most accurate approximations and practically reasonable estimates, the individual COV approach was preferable over the population-averaged defined daily dose technique, although the latter might be justified in certain situations. Advantages of the COV approach are expected to be even bigger for drug therapies with particularly large dosing heterogeneity. Copyright © 2016 John Wiley & Sons, Ltd.