Potentially inappropriate medications in the elderly: a French consensus panel list

The St Vincent's potentially inappropriate medicines study: development of a disease-specific consensus list and its evaluation in ambulatory heart failure care

AIMS

Heart failure (HF) patients may be at risk of prescription of potentially inappropriate medicines (PIMs) yet no disease-specific list is available to assess PIM use in this population. A Consensus Potentially Inappropriate Medicines in Heart Failure (PIMHF) list was developed, assessed, and compared with an established, general tool in an ambulatory HF population.

METHODS AND RESULTS

The Consensus PIMHF list was compiled using modified Delphi methodology with a multidisciplinary team. The list consisted of 11 items. The medication profile of 350 patients was assessed. The association of a Consensus PIMHF item use over a median follow-up period of 1.8 (interquartile range 1.3-2.1) years with the primary endpoint of death, acute hospitalization, or unscheduled outpatient visit was examined. Fifty-one patients (14.6%) were prescribed ≥1 Consensus PIMHF item. In univariable analysis, patients prescribed ≥1 Consensus PIMHF item were 58% more likely to experience the primary endpoint than those with none [95% confidence interval (CI) 1.02-2.45]. When adjusted for age, sex, and HF severity, this difference remained [hazard ratio (HR) 1.88, 95% CI 1.16-3.06] and these associations were in contrast to the use of a more general tool (HR 1.24, 95% CI 0.83-1.84). However, when further adjusted to include co-morbidity score and polypharmacy, there was no association with outcome using either tool (HR 1.40, 95% CI 0.83-2.38; HR 1.05, 95% CI 0.69-1.60, respectively).

CONCLUSION

The Consensus PIMHF list provides the first HF-specific medicines review tool. These results provide some support for more disease-specific tools with limited lists of PIMs to rationalize medicines management in HF. However, more prospective work on the application of these tools in practice is needed.

Indication for pharmacological treatment is often lacking: a cross-sectional study on the quality of drug therapy among the elderly

BACKGROUND

Although the elderly have a substantially higher drug use than younger patients, even after adjustment for multimorbidity, there is limited knowledge about the elderly's indication for treatment. It is essential for elderly patients to have a well-planned drug therapy. The first step towards a correct and safe drug therapy is to ensure that the patient's drugs have an indication, i.e. correct diagnoses are linked to all of the prescription drugs. The aim of this study was to examine to what extent elderly patients have indication for a number of their prescribed drugs and, furthermore, if there are any differences in indication for treatment depending on gender, age, level of multimorbidity and income.

METHOD

Data were collected on individuals aged 65 years or older in Östergötland County in Sweden. To estimate the individual level of multimorbidity the Johns Hopkins ACG Case-Mix System was used. A report from the Swedish National Board of Health and Welfare was used to identify prescription drugs, for which it is important to have a correct diagnosis. The proportions of patients having indication for these prescription drugs were calculated. Odds ratios of having indication for treatment depending on gender, age, multimorbidity level and income were calculated.

RESULTS

On average 45.1 % (range 12.9 % - 75.8 %) of the patients' prescribed drugs had indication. Proton pump inhibitors were associated with the lowest level of indication (12.9 %) and digoxin was associated with the highest level of indication for treatment (75.8 %). Patients aged 80 years or older had the lowest odds ratios of having indication for treatment.

CONCLUSION

On average, there was indication for treatment in less than half of the prescription drugs studied. The quality was highest in relation to multimorbidity and lowest in relation to age. The result may to some extent be explained by substandard registration of diagnoses. Since lack of quality of prescription drug use is highly associated with inconvenience among the elderly, as well as high costs to society, it is important that future research and allocation of resources focus on the quality of elderly patients' drug therapy.

Cause or Effect? Selective Serotonin Reuptake Inhibitors and Falls in Older Adults: A Systematic Review

A 2012 update of the Beers criteria categorizes selective serotonin reuptake inhibitors (SSRIs) as potentially inappropriate medications in all older adults based on fall risk. The application of these recommendations, not only to frail nursing home residents, but to all older adults, may lead to changes in health policy or clinical practice with harmful consequences. A systematic review of studies on the association between SSRIs and falls in older adults was conducted to examine the evidence for causation. Twenty-six studies met the inclusion criteria. The majority of studies were observational and suggest an association between SSRIs and falls. The direction of the relationship--causation or effect--cannot be discerned from this type of study. Standardized techniques for determining likely causation were then used to see if there was support for the hypothesis that SSRIs lead to falls. This analysis did not suggest causation was likely. There is no Level 1 evidence that SSRIs cause falls. Therefore, changes in the current treatment guidelines or policies on the use of SSRIs in older adults based on fall risk may not be justified at this time given the lack of an established evidence base. Given its significance to public health, well-designed experimental studies are required to address this question definitively.

Potentially inappropriate prescribing in community-dwelling older people across Europe: a systematic literature review

BACKGROUND

Potentially inappropriate prescribing (PIP) is one of the main risk factors for adverse drug events (ADEs) in older people.

PURPOSE

This systematic literature review aims to determine prevalence and type of PIP in community-dwelling older people across Europe, as well as identifying risk factors for PIP.

METHODS

The PubMed and Web of Science database were searched systematically for relevant manuscripts (January 1, 2000-December 31, 2014). Manuscripts were included if the study design was observational, the study participants were community-dwelling older patients in Europe, and if a published screening method for PIP was used. Studies that focused on specific pathologies or that focused on merely one inappropriate prescribing issue were excluded. Data analysis was performed using R statistics.

RESULTS

Fifty-two manuscripts were included, describing 82 different sample screenings with an estimated overall PIP prevalence of 22.6 % (CI 19.2-26.7 %; range 0.0-98.0 %). Ten of the sample screenings were based on the Beers 1997 criteria, 19 on the Beers 2003 criteria, 14 on STOPP criteria (2008 version), 8 on START-criteria (2008 version), and 7 on the PRISCUS list. The 24 remaining sample screenings were carried out using compilations of screening methods or used country-specific lists such as the Laroche criteria. It appears that only PIP prevalence calculated from insurance data significantly differs from the other data collection method categories. Furthermore, risk factors most often positively associated with PIP prevalence were polypharmacy, poor functional status, and depression. Drug groups most often involved in PIP were anxiolytics (ATC-code: N05B), antidepressants (N06A), and nonsteroidal anti-inflammatory and anti-rheumatic products (M01A).

CONCLUSION

PIP prevalence in European community-dwelling older adults is high and depends partially on the data collection method used. Polypharmacy, poor functional status, and depression were identified as the most common risk factors for PIP.

Algorithm of medication review in frail older people: Focus on minimizing the use of high-risk medications

AIM

Frail older people typically suffer several chronic diseases, receive multiple medications and are more likely to be institutionalized in residential aged care facilities. In such patients, optimizing prescribing and avoiding use of high-risk medications might prevent adverse events. The present study aimed to develop a pragmatic, easily applied algorithm for medication review to help clinicians identify and discontinue potentially inappropriate high-risk medications.

METHODS

The literature was searched for robust evidence of the association of adverse effects related to potentially inappropriate medications in older patients to identify high-risk medications. Prior research into the cessation of potentially inappropriate medications in older patients in different settings was synthesized into a four-step algorithm for incorporation into clinical assessment protocols for patients, particularly those in residential aged care facilities.

RESULTS

The algorithm comprises several steps leading to individualized prescribing recommendations: (i) identify a high-risk medication; (ii) ascertain the current indications for the medication and assess their validity; (iii) assess if the drug is providing ongoing symptomatic benefit; and (iv) consider withdrawing, altering or continuing medications. Decision support resources were developed to complement the algorithm in ensuring a systematic and patient-centered approach to medication discontinuation. These include a comprehensive list of high-risk medications and the reasons for inappropriateness, lists of alternative treatments, and suggested medication withdrawal protocols.

CONCLUSIONS

The algorithm captures a range of different clinical scenarios in relation to potentially inappropriate medications, and offers an evidence-based approach to identifying and, if appropriate, discontinuing such medications. Studies are required to evaluate algorithm effects on prescribing decisions and patient outcomes. Geriatr Gerontol Int 2016; 16: 1002-1013.

Correlation of Incident Potentially Inappropriate Medication Prescriptions and Hospitalization: An Analysis Based on the PRISCUS List

Background

Multimorbidity and polypharmacy represent a major problem for elderly patients. Potentially inappropriate medication (PIM) use is highly prevalent among the elderly. PIMs are considered high-risk drugs and are suspected to be responsible for adverse drug events (ADEs) leading to hospitalization.

Objective

The objective of this study was to determine hospitalization rates related to selected ADEs in elderly patients with an incident prescription of a PIM as defined by the PRISCUS list. A second objective was to identify other factors independently associated with hospitalization.

Methods

We retrospectively analysed a full census of pharmaceutical claims, from one of the largest public sickness funds in Germany, for 647,073 patients aged ≥65 years in 2010, the year of publication of the PRISCUS list. Patients who received an incident PIM in 2010 were assigned to the intervention group. Propensity score matching was used to build a control group of patients at a comparable risk level who received an incident equivalent non-PIM. The risk of hospitalization due to PIM prescription was estimated via the odds ratio (OR). Risk factors were analysed via logistic regression models.

Results

The results showed significantly more ADEs in the PIM group. The OR for hospitalization was 1.54 [95 % confidence interval (CI) 1.23–1.93] for patients receiving any PIM compared with those who received a non-PIM. This trend remained stable [OR 1.46 (95 % CI 1.16–1.84)] after adjustment for relevant covariates in the logistic regression models showing ORs for each risk factor. Besides PIMs, common risk factors such as greater age, comorbidity and specific drug classes were significantly responsible for hospitalization.

Conclusion

PIMs (as defined by the PRISCUS list) are associated with high rates of ADEs associated with hospitalization. Our study suggests that PIM reduction may result in a lower risk of hospitalization in the elderly.

Prescribing for Australians living with dementia: study protocol using the Delphi technique

INTRODUCTION

Prescribing is complicated for people living with dementia, and careful consideration should be given to continuing and initiating all medicines. This study aims to elicit opinion and gain consensus on appropriate medicine use for people living with dementia in Australia to create a consensus-based list of explicit prescribing criteria.

METHODS AND ANALYSIS

A Delphi technique will be used to develop explicit criteria of medication use in adults aged 65 years and above. An interdisciplinary panel of Australian experts in geriatric therapeutics will be convened that will consist of a minimum of 10 participants. To develop the consensus-based criteria, this study will use an iterative, anonymous, multistaged approach with controlled feedback. Round 1 questionnaire will be administered, and subsequently qualitatively analysed. The round 1 results will be fed back to the panel members, and a round 2 questionnaire developed using questions on a five-point Likert scale. This process will repeat until consensus is developed, or diminishing returns are noted.

ETHICS AND DISSEMINATION

All participants will be provided with a participant information sheet, and sign a written consent form. Ethical approval has been granted from the University of Western Australia's Human Research Ethics Committee (HREC) (reference: RA/4/1/7172). We expect that data from this study will result in a paper published in a peer-reviewed clinical journal and will also present the results at conferences.

Majority of drug-related problems identified during medication review are not associated with STOPP/START criteria

Purpose

STOPP and START criteria identify potential inappropriate prescribing and potential prescribing omissions. It is unknown whether STOPP/START criteria identify all drug-related problems. This study aims to determine to what extent STOPP/START correspond to drug-related problems (DRPs) identified during a full clinical medication review.

Methods

In 13 Dutch community pharmacies, 457 community-dwelling patients aged ≥65 years and using ≥5 drugs, received a full clinical medication review. Community pharmacists identified potential DRPs and recommendations by implicit criteria. After completion, all identified DRPs and recommendations were compared with STOPP and START criteria by investigators.

Results

The total number of potential DRPs identified by community pharmacists was 1656 in 457 patients (mean 3.6 per patient). Eighty-one percent of DRPs were not associated with STOPP/START criteria. The percentage of START criteria present in identified DRPs was higher than the percentage of STOPP criteria (13 vs. 5.7 %, p < 0.01).

The implementation rate for recommendations associated with STOPP criteria was higher compared to recommendations associated with START criteria (56 vs. 39 %, p < 0.01). Both implementation rates of STOPP and START recommendations were lower compared to recommendations not associated with STOPP/START criteria (66 %, p = 0.047 and p < 0.001, respectively).

Conclusions

This study shows that the majority of drug-related problems of community-dwelling older patients was not associated with STOPP/START criteria. These findings suggest that application of STOPP/START criteria in full clinical medication review should preferably be combined with implicit criteria.

Older patients' prescriptions screening in the community pharmacy: development of the Ghent Older People's Prescriptions community Pharmacy Screening (GheOP³S) tool

BACKGROUND

Ageing of the population often leads to polypharmacy. Consequently, potentially inappropriate prescribing (PIP) becomes more frequent. Systematic screening for PIP in older patients in primary care could yield a large improvement in health outcomes, possibly an important task for community pharmacists. In this article, we develop an explicit screening tool to detect relevant PIP that can be used in the typical community pharmacy practice, adapted to the European market.

METHODS

Eleven panellists participated in a two-round RAND/UCLA (Research and Development/University of California, Los Angeles) process, including a round zero meeting, a literature review, a first written evaluation round, a second face-to-face evaluation round and, finally, a selection of those items that are applicable in the contemporary community pharmacy.

RESULTS

Eighteen published lists of PIP for older patients were retrieved from the literature, mentioning 398 different items. After the two-round RAND/UCLA process, 99 clinically relevant items were considered suitable to screen for in a community pharmacy practice. A panel of seven community pharmacists selected 83 items, feasible in the contemporary community pharmacy practice, defining the final GheOP³S tool.

CONCLUSION

A novel explicit screening tool (GheOP³S) was developed to be used for PIP screening in the typical community pharmacy practice.

Drug-induced cerebral glucose metabolism resembling Alzheimer's Disease: a case study

BACKGROUND

With aging of society the absolute number and the proportion of patients with cognitive deficits increase. Multiple disorders and diseases can foster cognitive impairment, e.g., Alzheimer's disease (AD), depressive disorder, or polypharmacy.

CASE PRESENTATION

A 74 year old man presented to the Old Age Psychiatry Service with cognitive deficits while being treated for recurrent depressive episodes and essential tremor with Venlafaxine, Lithium, and Primidone. Neuropsychological testing revealed a medio-temporal pattern of deficits with pronounced impairment of episodic memory, particularly delayed recall. Likewise, cognitive flexibility, semantic fluency, and attention were impaired. Positron emission tomography (PET) with fluorodeoxyglucose was performed and revealed a pattern of glucose utilization deficit resembling AD. On cessation of treatment with Lithium and Primidone, cognitive performance improved, particularly episodic memory performance and cognitive flexibility. Likewise, glucose metabolism normalized. Despite normalization of both, clinical symptoms and glucose utilization, the patient remained worried about possible underlying Alzheimer's disease pathology. To rule this out, an amyloid-PET was performed. No cortical amyloid was observed.

CONCLUSION

Pharmacological treatment of older subjects may mimic glucose metabolism and clinical symptoms of Alzheimer's disease. In the present case both, imaging and clinical findings, reversed to normal on change of treatment. Amyloid PET is a helpful tool to additionally rule out underlying Alzheimer's disease in situations of clinical doubt even if clinical or other imaging findings are suggestive of Alzheimer's disease.

Association between drug-specific indicators of prescribing quality and quality of drug treatment: a validation study

Purpose

To evaluate the concurrent validity of three European sets of drug‐specific indicators of prescribing quality

Methods

In 200 hip fracture patients (≥65 years), consecutively recruited to a randomized controlled study in Sahlgrenska University Hospital in 2009, quality of drug treatment at study entry was assessed according to a gold standard as well as to three drug‐specific indicator sets (Swedish National Board of Health and Welfare, French consensus panel list, and German PRISCUS list). As gold standard, two specialist physicians independently assessed and then agreed on the quality for each patient, after initial screening with STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions) and START (Screening Tool to Alert to Right Treatment).

Results

According to the Swedish, French, and German indicator sets, 82 (41%), 54 (27%), and 43 (22%) patients had potentially inappropriate drug treatment. A total of 141 (71%) patients had suboptimal drug treatment according to the gold standard. The sensitivity for the indicator sets was 0.51 (95% confidence interval: 0.43; 0.59), 0.33 (0.26; 0.41), and 0.29 (0.22; 0.37), respectively. The specificity was 0.83 (0.72; 0.91), 0.88 (0.77; 0.94), and 0.97 (0.88; 0.99). Suboptimal drug treatment was 2.0 (0.8; 5.3), 1.9 (0.7; 5.1), and 6.1 (1.3; 28.6) times as common in patients with potentially inappropriate drug treatment according to the indicator sets, after adjustments for age, sex, cognition, residence, multi‐dose drug dispensing, and number of drugs.

Conclusions

In this setting, the indicator sets had high specificity and low sensitivity. This needs to be considered upon use and interpretation. Copyright © 2015 The Authors Pharmacoepidemiology and Drug Safety Published by John Wiley & Sons, Ltd.

Geriatrician interventions on medication prescribing for frail older people in residential aged care facilities

Objective

In Australian residential aged care facilities (RACFs), the use of certain classes of high-risk medication such as antipsychotics, potent analgesics, and sedatives is high. Here, we examined the prescribed medications and subsequent changes recommended by geriatricians during comprehensive geriatric consultations provided to residents of RACFs via videoconference.

Design

This is a prospective observational study.

Setting

Four RACFs in Queensland, Australia, are included.

Participants

A total of 153 residents referred by general practitioners for comprehensive assessment by geriatricians delivered by video-consultation.

Results

Residents’ mean (standard deviation, SD) age was 83.0 (8.1) years and 64.1% were female. They had multiple comorbidities (mean 6), high levels of dependency, and were prescribed a mean (SD) of 9.6 (4.2) regular medications. Ninety-one percent of patients were taking five or more medications daily. Of total medications prescribed (n=1,469), geriatricians recommended withdrawal of 9.8% (n=145) and dose alteration of 3.5% (n=51). New medications were initiated in 47.7% (n=73) patients. Of the 10.3% (n=151) medications considered as high risk, 17.2% were stopped and dose altered in 2.6%.

Conclusion

There was a moderate prevalence of potentially inappropriate high-risk medications. However, geriatricians made relatively few changes, suggesting either that, on balance, prescription of these medications was appropriate or, because of other factors, there was a reluctance to adjust medications. A structured medication review using an algorithm for withdrawing medications of high disutility might help optimize medications in frail patients. Further research, including a broader survey, is required to understand these dynamics.

Appropriate prescribing in the elderly: Current perspectives

Advances in medical therapeutics have undoubtedly contributed to health gains and increases in life expectancy over the last century. However, there is growing evidence to suggest that therapeutic decisions in older patients are frequently suboptimal or potentially inappropriate and often result in negative outcomes such as adverse drug events, hospitalisation and increased healthcare resource utilisation. Several factors influence the appropriateness of medication selection in older patients including age-related changes in pharmacokinetics and pharmacodynamics, high numbers of concurrent medications, functional status and burden of co-morbid illness. With ever-increasing therapeutic options, escalating proportions of older patients worldwide, and varying degrees of prescriber education in geriatric pharmacotherapy, strategies to assist physicians in choosing appropriate pharmacotherapy for older patients may be helpful. In this paper, we describe important age-related pharmacological changes as well as the principal domains of prescribing appropriateness in older people. We highlight common examples of drug-drug and drug-disease interactions in older people. We present a clinical case in which the appropriateness of prescription medications is reviewed and corrective strategies suggested. We also discuss various approaches to optimising prescribing appropriateness in this population including the use of explicit and implicit prescribing appropriateness criteria, comprehensive geriatric assessment, clinical pharmacist review, prescriber education and computerized decision support tools.

Potentially inappropriate drug use in older people: a nationwide comparison of different explicit criteria for population-based estimates

AIMS

The aim was to investigate the prevalence of potentially inappropriate medication use among older people in Sweden according to five different published sets of explicit criteria from Europe and the US.

METHODS

This was a nationwide cross-sectional, register-based study across the whole of Sweden in 2008. All individuals aged 65 years and older were included (n = 1 346 709, both community-dwelling and institutionalized persons). We applied all drug-specific criteria included in the 2012 Beers Criteria, the Laroche's list, the PRISCUS list, the NORGEP criteria and the Swedish National Board of Health and Welfare criteria. The main outcome was the potentially inappropriate drug use according to each set of criteria, separately and combined. Multivariate logistic regression models were used to identify individual factors associated with the use of potentially inappropriate drugs.

RESULTS

The prevalence of potentially inappropriate medication use varied between the explicit criteria from 16% (NORGEP criteria) to 24% (2012 Beers criteria). Overall, 38% of the older people were exposed to potentially inappropriate drug use by at least one of the five sets of criteria. While controlling for other possible covariates, female gender, institutionalization and polypharmacy were systematically associated with inappropriate drug use, regardless of the set of explicit criteria we considered.

CONCLUSION

Although explicit criteria for inappropriate drug use among older people have been reported to be quite different in their content, they provide similar measures of the prevalence of potentially inappropriate drug use at the population level.

Evaluating medication-related quality of care in residential aged care: a systematic review

Given the growing aged care population, the complexity of their medication-related needs and increased risk of adverse drug events, there is a necessity to systematically monitor and manage medication-related quality of care. The aim of this systematic review was to identify and synthesise medication-related quality of care indicators with respect to application to residential aged care. MEDLINE (Ovid), Psychinfo, CINAHL, Embase and Google® were searched from 2001 to 2013 for studies that were in English, focused on older people aged 65+ years and discussed the development, application or validation of original medication-related quality of care indicators. The quality of selected articles was appraised using the Critical Appraisal Skills Program and psychometric qualities extracted and synthesised using content analysis. Indicators were mapped to six medication-related quality of care attributes and a minimum indicator set derived. Thirty three articles describing 25 indicator sets met the inclusion criteria. Thirteen (52%) contained prescribing quality indicators only. Eight (32%) were developed specifically for aged care. Twenty three (92%) were validated and seven (28%) assessed for reliability. The most common attribute addressed was medication appropriateness (n = 24). There were no indicators for evaluating medication use in those with limited life expectancy, which resulted in only five of the six attributes being addressed. The developed minimum indicator set contains 28 indicators representing 22 of 25 identified indicator sets. Whilst a wide variety of validated indicator sets exist, none addressed all aspects of medication-related quality of care pertinent to residential aged care. The minimum indicator set is intended as a foundation for comprehensively evaluating medication-related quality of care in this setting. Future work should focus on bridging identified gaps.

The EU(7)-PIM list: a list of potentially inappropriate medications for older people consented by experts from seven European countries

Purpose

The aim of the study was to develop a European list of potentially inappropriate medications (PIM) for older people, which can be used for the analysis and comparison of prescribing patterns across European countries and for clinical practice.

Methods

A preliminary PIM list was developed, based on the German PRISCUS list of potentially inappropriate medications and other PIM lists from the USA, Canada and France. Thirty experts on geriatric prescribing from Estonia, Finland, France, the Netherlands, Spain and Sweden participated; eight experts performed a structured expansion of the list, suggesting further medications; twenty-seven experts participated in a two-round Delphi survey assessing the appropriateness of drugs and suggesting dose adjustments and therapeutic alternatives. Finally, twelve experts completed a brief final survey to decide upon issues requiring further consensus.

Results

Experts reached a consensus that 282 chemical substances or drug classes from 34 therapeutic groups are PIM for older people; some PIM are restricted to a certain dose or duration of use. The PIM list contains suggestions for dose adjustments and therapeutic alternatives.

Conclusions

The European Union (EU)(7)-PIM list is a screening tool, developed with participation of experts from seven European countries, that allows identification and comparison of PIM prescribing patterns for older people across European countries. It can also be used as a guide in clinical practice, although it does not substitute the decision-making process of individualised prescribing for older people. Further research is needed to investigate the feasibility and applicability and, finally, the clinical benefits of the newly developed list.

Electronic supplementary material

The online version of this article (doi:10.1007/s00228-015-1860-9) contains supplementary material, which is available to authorized users.

Prescription of potentially inappropriate medication in older persons in Switzerland: does the dispensing channel make a difference?

Background

Drugs can be supplied either directly from the prescribing physician (physician dispensing [PD]) or via a pharmacy. It is unclear whether the dispensing channel is associated with quality problems. Potentially inappropriate medication (PIM) is associated with adverse outcomes in older persons and can be considered a marker for quality deficits in prescribing. We investigated whether prevalence of PIM differs across dispensing channels.

Patients and methods

We analyzed basic health insurance claims of 50,747 person quarter years with PIM use of residents of the Swiss cantons Aargau and Lucerne of the years 2012 and 2013. PIM was identified using the Beers 2012 criteria and the PRISCUS list. We calculated PIM prevalence stratified by supply channel. Adjusted mixed effects logistic regression analysis was done to estimate the effect of obtaining medications through the dispensing physician as compared to the pharmacy channel on receipt of PIM. The most frequent PIMs were identified.

Results

There is a small but detectable difference in total PIM prevalence: 30.7% of the population supplied by a dispensing physician as opposed to 29.3% individuals who received medication in a pharmacy. According to adjusted logistic regression individuals who obtained the majority of their medications from their prescribing physician had a 15% higher chance to receive a PIM (odds ratio 1.15, 95% confidence interval 1.08–1.22; P<0.001).

Conclusion

Physician dispensing seems to affect quality and safety of drug prescriptions. Quality issues should not be neglected in the political discussion about the regulations on PD. Future studies should explore whether PD is related to other indicators of inefficiency or quality flaws. The present study also underlines the need for interventions to reduce the high rates of PIM prescribing in Switzerland.

A tool for prediction of risk of rehospitalisation and mortality in the hospitalised elderly: secondary analysis of clinical trial data

OBJECTIVES

To construct and internally validate a risk score, the '80+ score', for revisits to hospital and mortality for older patients, incorporating aspects of pharmacotherapy. Our secondary aim was to compare the discriminatory ability of the score with that of three validated tools for measuring inappropriate prescribing: Screening Tool of Older Person's Prescriptions (STOPP), Screening Tool to Alert doctors to Right Treatment (START) and Medication Appropriateness Index (MAI).

SETTING

Two acute internal medicine wards at Uppsala University hospital. Patient data were used from a randomised controlled trial investigating the effects of a comprehensive clinical pharmacist intervention.

PARTICIPANTS

Data from 368 patients, aged 80 years and older, admitted to one of the study wards.

PRIMARY OUTCOME MEASURE

Time to rehospitalisation or death during the year after discharge from hospital. Candidate variables were selected among a large number of clinical and drug-specific variables. After a selection process, a score for risk estimation was constructed. The 80+ score was internally validated, and the discriminatory ability of the score and of STOPP, START and MAI was assessed using C-statistics.

RESULTS

Seven variables were selected. Impaired renal function, pulmonary disease, malignant disease, living in a nursing home, being prescribed an opioid or being prescribed a drug for peptic ulcer or gastroesophageal reflux disease were associated with an increased risk, while being prescribed an antidepressant drug (tricyclic antidepressants not included) was linked to a lower risk of the outcome. These variables made up the components of the 80+ score. The C-statistics were 0.71 (80+), 0.57 (STOPP), 0.54 (START) and 0.63 (MAI).

CONCLUSIONS

We developed and internally validated a score for prediction of risk of rehospitalisation and mortality in hospitalised older people. The score discriminated risk better than available tools for inappropriate prescribing. Pending external validation, this score can aid in clinical identification of high-risk patients and targeting of interventions.

Exposure to atropinic drugs and frailty status

BACKGROUND

Atropinic drugs can increase the risk of falls, cognitive impairment, and mortality in older patients; however, whether exposure to atropinic drugs is associated with frailty status remains unknown. Our aim was to assess the association between frailty status and exposure to atropinic drugs in a geriatric day hospital population.

METHODS

We carried out a cross-sectional study that included all the patients consulting for the first time at the Geriatric Frailty Clinic for Assessment of Frailty and Prevention of Disability in Toulouse, France, from January 2013 to October 2013. Frailty was defined by 3 or more of Fried et al's criteria. Atropinic drugs were those with clinical antimuscarinic effect from the Anticholinergic Drug Scale (excluding drugs weighted 1 point and not listed by Durán et al) and from Laroche et al list (to include drugs marketed in France not present in the Anticholinergic Drug Scale). To explore a dose-effect relationship, we calculated the atropinic burden using the Anticholinergic Drug Scale weights. We performed logistic regression models adjusted for age, gender, comorbidities, being community dwelling or not, cognitive status, educational level, and polypharmacy (≥6 drugs).

RESULTS

We included 437 patients (227 frail and 210 robust or prefrail). Exposure to at least one atropinic drug was associated with frailty (odds ratio 1.97, 95% confidence interval 1.10-3.53, P = .02). Due to a statistically significant interaction between age and atropinic burden, a dose-effect relationship for atropinic burden was explored in patients younger than 85 years, showing a significant association between atropinic burden score and frailty (P = .01). The Odds ratio for an atropinic burden greater than or equal to 3 versus 0 was 3.84, 95% confidence interval 1.43-10.34 (P < .01).

CONCLUSIONS

In a geriatric day hospital, population frailty is associated with a high atropinic burden.

Side effects related to potentially inappropriate medications in elderly psychiatric patients under everyday pharmacotherapy

PURPOSE

Potentially inappropriate medication (PIM) is suggested to give rise to adverse drug events. To study this suggestion for elderly psychiatric patients, an observational analysis related prescription of PRISCUS PIMs and drug-induced side effects in old aged (≥65 years) psychiatric inpatients and outpatients under conditions of everyday pharmacotherapy.

METHODS

Request forms from a therapeutic drug monitoring (TDM) survey and medical files were screened for medication to identify PIMs of the PRISCUS list and assessed using the Udvalg for Kliniske Undersøgelser (UKU) side effect rating scale.

RESULTS

From 914 TDM request forms, data were available for 168 patients (64.3 % female). Patients (mean ± SD age 73.0 ± 5.5 years) received by mean 6.4 ± 3.9 drugs per day. More than half of them (53.0 %, n = 89) had at least one PIM, inpatients 0.9 ± 0.8 and outpatients 0.5 ± 0.7. Predominant PIMs were hypnotic drugs (69 %) in inpatients and antipsychotic drugs (35.6 %) in outpatients. The number of PIMs correlated with the total number of drugs administered per day (Spearman correlation coefficient 0.225, p < 0.01, CI 95 %). Side effects were documented for 106 patients (63 %). Severity of side effects did not correlate significantly (p > 0.05) with number of PIMs. However, only 6 of 77 patients who took no PRISCUS PIMs but 2 of 3 patients who took 3 PRISCUS PIMs exhibited severe side effects.

CONCLUSIONS

Though the prevalence for PIMs and side effects was high in old aged psychiatric inpatients and outpatients, PIMs could not be identified as major determinants of overall unwanted side effects. Nevertheless, prescription of PIMs should be minimized, especially of hypnotic drugs, to improve safety.

Potentially inappropriate medication use in institutionalized older adults according to the Beers Criteria

The need for specific care, coupled with new family arrangements, has contributed to the increasing institutionalization of elderly members. The purpose of this study was to evaluate drug use by institutionalized older adults according to Beers Criteria. This prospective, longitudinal study was conducted in the three non-profit long-stay geriatric care institutions of Campo Grande, in the Central-West region of Brazil. All subjects aged 60 years and above on November 2011 were included and followed until November 2012. Eighteen subjects were excluded and the final sample consisted of 133 individuals aged 60 to 113 years. Overall, 212 medications were used at geriatric care institution A, 532 at B, and 1329 at C. Thirty-four drugs were inappropriately prescribed 89 times at geriatric care institution A (41.98%), 49 prescribed 177 times at B (33.27%), and 91 prescribed 461 times at C (34.68%). Statistical differences in the inappropriate drug use were found between genders (p=0.007). The most commonly used potentially inappropriate medication were first-generation antihistamines (15.34%). There was a high frequency in the use of potentially inappropriate medications which can initiate marked side effects and may compromise the fragile health of institutionalized elderly. Thus, adopting the Beers Criteria in prescribing medication contributes to minimize adverse reactions and drug interactions.

Use of benzodiazepines and association with falls in older people admitted to hospital: a prospective cohort study

BACKGROUND

Hypnosedatives are commonly prescribed for anxiety and sleep problems. Changes in pharmacokinetics and pharmacodynamics of benzodiazepines (BZDs) during ageing may increase their potential to cause adverse outcomes.

OBJECTIVE

This study aimed to investigate the use of BZDs in acute care settings and explore their association with falls.

METHODS

A prospective cohort study was undertaken of patients aged over 70 years consecutively admitted to 11 acute care hospitals in Australia. Data were collected using the interRAI Acute Care assessment tool. Falls were recorded prospectively (in hospital) and retrospectively (in the 90 days prior to admission).

RESULTS

Of 1,412 patients, 146 (10.3 %) were taking BZDs at admission and 155 (11.3 %) at discharge. Incidence rates of in-hospital fallers for users and non-users of BZDs were not statistically different [incidence rate ratio 1.03, 95 % confidence interval (CI) 0.58-1.82]. There was also no significant association between benzodiazepine use at admission and history of falls in the previous 90 days compared with non-users. However, patients on diazepam were significantly more likely to have a history of falls than all other benzodiazepine users (70.8 vs. 36.1 %; p = 0.002), particularly when compared with oxazepam users (70.8 vs. 25.0 %; p < 0.001). Adjusting for confounders, use of diazepam at admission was positively associated with a history of falls compared with all other benzodiazepine users (odds ratio 3.0; 95 % CI 1.1-8.5; p = 0.036).

CONCLUSIONS

Different BZDs may vary in their propensity to predispose to falls, with diazepam having the strongest association. The selection of particular BZDs for older patients should be carefully evaluated.

A systematic review of prescribing criteria to evaluate appropriateness of medications in frail older people

This study systematically reviews the published literature regarding inappropriate prescribing in frail individuals aged at least 65 years. Twenty-five of 466 identified studies met the inclusion criteria. All papers measured some surrogate indicators of frailty, such as performance-based tests, cognitive function and functional dependency. Beers criteria were used in 20 studies (74%) to evaluate inappropriate medication use and 36% (9/25) studies used more than one criterion. The prevalence of inappropriate medications ranged widely from 11 to 92%. Only a few studies reported the relationship between potentially inappropriate medication use and surrogate measures of frailty. These diverse findings indicate the need for a standardized measure for assessing appropriateness of medication in frail older individuals. Prescribing tools should address both medication and patient-related factors such as life expectancy and functional status to minimize inappropriate prescribing in frail individuals.

The development of the PROMPT (PRescribing Optimally in Middle-aged People's Treatments) criteria

Background

Whilst multimorbidity is more prevalent with increasing age, approximately 30% of middle-aged adults (45–64 years) are also affected. Several prescribing criteria have been developed to optimise medication use in older people (≥65 years) with little focus on potentially inappropriate prescribing (PIP) in middle-aged adults. We have developed a set of explicit prescribing criteria called PROMPT (PRescribing Optimally in Middle-aged People’s Treatments) which may be applied to prescribing datasets to determine the prevalence of PIP in this age-group.

Methods

A literature search was conducted to identify published prescribing criteria for all age groups, with the Project Steering Group (convened for this study) adding further criteria for consideration, all of which were reviewed for relevance to middle-aged adults. These criteria underwent a two-round Delphi process, using an expert panel consisting of general practitioners, pharmacists and clinical pharmacologists from the United Kingdom and Republic of Ireland. Using web-based questionnaires, 17 panellists were asked to indicate their level of agreement with each criterion via a 5-point Likert scale (1 = Strongly Disagree, 5 = Strongly Agree) to assess the applicability to middle-aged adults in the absence of clinical information. Criteria were accepted/rejected/revised dependent on the panel’s level of agreement using the median response/interquartile range and additional comments.

Results

Thirty-four criteria were rated in the first round of this exercise and consensus was achieved on 17 criteria which were accepted into the PROMPT criteria. Consensus was not reached on the remaining 17, and six criteria were removed following a review of the additional comments. The second round of this exercise focused on the remaining 11 criteria, some of which were revised following the first exercise. Five criteria were accepted from the second round, providing a final list of 22 criteria [gastro-intestinal system (n = 3), cardiovascular system (n = 4), respiratory system (n = 4), central nervous system (n = 6), infections (n = 1), endocrine system (n = 1), musculoskeletal system (n = 2), duplicates (n = 1)].

Conclusions

PROMPT is the first set of prescribing criteria developed for use in middle-aged adults. The utility of these criteria will be tested in future studies using prescribing datasets.

Utilization of potentially inappropriate medications in elderly patients in a tertiary care teaching hospital in India

Aim:

To evaluate the use of potentially inappropriate medicines in elderly inpatients in a tertiary care teaching hospital.

Materials and Methods:

Retrospective analysis was performed for cases of elderly patients admitted between January 2010 and December 2010. Data on age, gender, diagnosis, duration of hospital stay, treatment, and outcome were collected. Prescriptions were assessed for the use of potentially inappropriate medications in geriatric patients by using American Geriatric Society Beer's criteria (2012) and PRISCUS list (2010).

Results:

A total of 676 geriatric patients (52.12% females) were admitted in the medicine ward. The average age of geriatric patients was 72.69 years. According to Beer's criteria, at least one inappropriate medicine was prescribed in 590 (87.3%) patients. Metoclopramide (54.3%), alprazolam (9%), diazepam (8%), digoxin > 0.125 mg/day (5%), and diclofenac (3.7%) were the commonly used inappropriate medications. Use of nonsteroidal anti-inflammatory drugs (NSAIDs) in heart and renal failure patients was the commonly identified drug–disease interaction. According to PRISCUS list, at least one inappropriate medication was prescribed in 210 (31.06%) patients.

Conclusion:

Use of inappropriate medicines is highly prevalent in elderly patients.

Medication in nursing homes in Alsace: a preferential list of drugs obtained by consensus

Abstract

In order to improve patient care, OMEDIT (Observatory of drugs, medical devices and therapeutic innovation) Alsace, conducted a study to develop a Preferential list of Drugs adapted to the Elderly (PDE list) in nursing homes. The study conducted from December 2011 to June 2012 was organized in 4 phases: 1) creation of a preliminary list of drugs from those currently used in nursing homes in Alsace, 2) application of a two-round Delphi process to evaluate the preliminary list involving mobilization of experts from different backgrounds (geriatricians, general practitioners, pharmacists …), 3) identification of molecules considered in literature as potentially inappropriate, 4) generation of a final PDE list, including information concerning proper use of drugs for prescription and administration. 53 experts participated in the study. In the first round, 338 drugs were on the preliminary list, 246 were considered as appropriate by experts and 28 as inappropriate. 64 drugs without consensus were submitted to a second round. 32 of them were considered as inappropriate and 32 others remained on the list with no consensus. These last 32 were evaluated by OMEDIT and 3 were considered as appropriate drugs for the elderly. Totally, 252 drugs constitute the final PDE list from our study. The PDE list constitutes a new guide for optimization of both prescription and administration of drugs in nursing homes and could help reduce misuses and poly-medication, which are constant preoccupations to avoid adverse drug reactions in elderly.

Key points

● The study was carried out with the aim to create a Preferential list of Drugs adapted to the Elderly (PDE list) in nursing homes using a modified Delphi method.

● The PDE list constitutes a new guideline to harmonize practices in nursing homes and to help physicians and nurses to achieve best possible care management.

[Medical treatment of the elderly in residential care: a multicenter cross-sectional study]

OBJECTIVE

To retrospectively assess the quality of prescriptions in elderly patients prior the distribution of guidelines for geriatric drug prescriptions.

METHODS

A cross-sectional study was conducted for one day in 2012 to investigate the quality of the prescriptions in 495 residents of 8 nursing homes. A 6 items-quality score was calculated, ranging from 0 (lowest quality) to 6 (highest quality).

RESULTS

The median number of prescribed drugs was 8,5 per resident. Over a total of 4311 prescribed drugs, the average quality score was 4,96 ± 0,45; 4,54 ± 0,70 in computerized orders and 3,4 ± 1,02 in handwritten orders. Among 939 drugs considered as at high risk of inducing serious adverse reactions, monitoring was prescribed 154 times only (16,4%).

CONCLUSIONS

A lack of drug monitoring was highlighted, especially for high risk drugs. The quality of prescription may be improved by the use of computerized orders.

Did the new French pay-for-performance system modify benzodiazepine prescribing practices?

Background

French general practitioners (GPs) were enrolled in a new payment system in January 2012. As part of a national agreement with the French National Ministry of Health, GPs were asked to decrease the proportion of patients who continued their benzodiazepine treatment 12 weeks after its initiation and to decrease the proportion of patients older than 65 who were prescribed long half-life benzodiazepines. In return, GPs could expect an extra payment of up to 490 euros per year. This study reports the evolution of the corresponding prescribing practices of French GPs during that period regarding patients who were prescribed a benzodiazepine for the first time.

Methods

The national healthcare system's administrative database was used to report the longitudinal follow-up of two historical cohorts of French patients from the Pays de la Loire area.

Study patients: The “2011” and “2012” cohorts included all patients who initiated benzodiazepine regimens from April 1 to June 30 in 2011 and 2012, respectively.

The primary outcomes were the proportion of those study patients who continued benzodiazepine treatment after 12 weeks and the proportion of study patients >65 years who were prescribed long half-life benzodiazepines.

Analyses were performed using a multi-level regression.

Results

In total, 41,436 and 42,042 patients initiated benzodiazepine treatment in 2011 and 2012, respectively. A total of 18.97% of patients continued treatment for more than 12 weeks in 2012, compared with 18.18% in 2011. In all, 27.43% and 28.06% of patients >65 years continued treatment beyond 12 weeks in 2011 and 2012, respectively. The proportion of patients >65 years who were prescribed long half-life benzodiazepines decreased from 53.5% to 48.8% (p < 0.005) due to an increase in short half-life benzodiazepine prescriptions. Patients >65 years who were prescribed short half-life benzodiazepines were more likely to continue treatment after 12 weeks (p < 0.005).

Conclusions

Despite the pay-for-performance strategy, the number of short half-life benzodiazepine prescriptions increased between 2011 and 2012, and the number of long half-life benzodiazepine initiations remained unchanged. Reducing the proportion of long half-life benzodiazepine prescriptions might be counterproductive because prescribing short half-life benzodiazepines was associated with higher rates of continuation beyond the recommended duration.

POPI (Pediatrics: Omission of Prescriptions and Inappropriate prescriptions): development of a tool to identify inappropriate prescribing

INTRODUCTION

Rational prescribing for children is an issue for all countries and has been inadequately studied. Inappropriate prescriptions, including drug omissions, are one of the main causes of medication errors in this population. Our aim is to develop a screening tool to identify omissions and inappropriate prescriptions in pediatrics based on French and international guidelines.

METHODS

A selection of diseases was included in the tool using data from social security and hospital statistics. A literature review was done to obtain criteria which could be included in the tool called POPI. A 2-round-Delphi consensus technique was used to establish the content validity of POPI; panelists were asked to rate their level of agreement with each proposition on a 9-point Likert scale and add suggestions if necessary.

RESULTS

108 explicit criteria (80 inappropriate prescriptions and 28 omissions) were obtained and submitted to a 16-member expert panel (8 pharmacists, 8 pediatricians hospital-based -50%- or working in community -50%-). Criteria were categorized according to the main physiological systems (gastroenterology, respiratory infections, pain, neurology, dermatology and miscellaneous). Each criterion was accompanied by a concise explanation as to why the practice is potentially inappropriate in pediatrics (including references). Two round of Delphi process were completed via an online questionnaire. 104 out of the 108 criteria submitted to experts were selected after 2 Delphi rounds (79 inappropriate prescriptions and 25 omissions).

DISCUSSION CONCLUSION

POPI is the first screening-tool develop to detect inappropriate prescriptions and omissions in pediatrics based on explicit criteria. Inter-user reliability study is necessary before using the tool, and prospective study to assess the effectiveness of POPI is also necessary.

Polypharmacy and potentially inappropriate medication in the adult, community-dwelling population in Switzerland

BACKGROUND

Polypharmacy and potentially inappropriate medication (PIM) are associated with adverse outcomes such as hospitalization, loss of productivity, and death.

OBJECTIVE

This study evaluates the prevalence of polypharmacy and PIM in the adult community-dwelling population in Switzerland.

METHODS

The analysis is done based on claims data from the largest health insurance in Switzerland. We calculated the number of medications submitted for reimbursement, the proportion of persons with polypharmacy, and the proportion of persons receiving PIM according to the 2003 Beers criteria and the PRISCUS list. Additionally, we estimated cost for medications and PIM, and identified the most prevalent groups of PIM according to the Anatomical Therapeutic Chemical Classification System (ATC).

RESULTS

17 % of the adult community-dwelling population in Switzerland received 5 or more medications which is one of the common definitions of polypharmacy, and over 21 % of adults aged more than 65 years had a PIM according to 2003 Beers criteria or the PRISCUS list. The most prevalent classes of PIM were psycholeptics, sex hormones, psychoanaleptics, and antiinflammatory drugs.

CONCLUSION

Although the present study has a number of limitations, we conclude that the prevalence of polypharmacy and PIM in Switzerland is high. A broad spectrum of interventions on the individual level as well as on the population level is urgently needed.

Potentially inappropriate medications and adverse drug reactions in the elderly: a study in a PharmacoVigilance database

BACKGROUND

Lists of potentially inappropriate medications (PIM) in the elderly were developed in order to identify patients and/or drugs at risk of adverse drug reactions (ADRs) or inefficacy. However, the relationship between PIMs and ADRs remains discussed. We hypothesized that PIM use is associated with more ADRs than other prescriptions.

METHODS

All ADRs registered by the Midi-Pyrénées PharmacoVigilance Center between the 1st January and the 30th June 2012 in patients ≥75 years were included. Data on patients (age, gender, Charlson comorbidity index), drugs (number, ATC classification, Laroche PIM classification) and ADRs (type, seriousness, mechanisms) were analyzed.

RESULTS

Among the 923 ADRs recorded, 272 (29.5%) were in patients ≥75 years. Mean age was 83.5 ± 5.5 years. Most of them (59%) were females. Mean Charlson index was 5.6 ± 2.0 by ADR report. These 272 prescriptions involved 1,775 drugs [mean value, 6.5 (±3.4) drugs by ADR report] with 129 (7.3%) PIM. Main PIM classes were nervous (n = 98, 76.0%) and cardiovascular (17.8%) drugs, including 32 atropinics (23.4%). ADR-associated drugs were mainly antithrombotics, antibacterials, and analgesics for non-PIM drugs whereas PIM-associated ADRs were mainly observed with digoxine, psycholeptics, and psychoanaleptics. ADRs were mainly found with non-PIM drugs (89.3%). Associated factors were the number of drugs for PIMs and the number of PIMs for PIM-induced ADRs.

CONCLUSION

Out of the ADR reports registered in the Midi-Pyrénées PharmacoVigilance Database for patients ≥75 years, 1 drug out of 12 is potentially inappropriate (mainly benzodiazepines, imipraminic antidepressants, and atropinic drugs). PIM use is not associated with more ADRs' reports than other prescriptions.

Content validation of a tool for assessing risks for drug-related problems to be used by practical nurses caring for home-dwelling clients aged ≥65 years: a Delphi survey

PURPOSE

Home care services are becoming a critically important part of health care delivery as populations are aging. Those using home care services are increasingly older, more frail than previously, and use multiple medications, making them vulnerable to drug-related problems (DRPs). Practical nurses (PN) visit home-dwelling aged clients frequently and, thus, are ideally situated to identify potential DRPs and, if needed, to communicate them to physicians for resolution. This study developed and validated the content of a tool to be used by PNs for assessing DRP risks for their home-dwelling clients aged ≥65 years.

METHODS

The first draft of the tool was based on two systematic literature reviews and clinical experience of our research group. Content validity of the tool was determined by a three-round Delphi survey with a panel of 18 experts in geriatric care and pharmacotherapy. An agreement by ≥80% of the panel on an item was required.

RESULTS

The final tool consists of 18 items that assess risks for DRPs in home-dwelling aged clients. It is divided into four sections: (1) Basic Client Data, (2) Potential Risks for DRPs in Medication Use, (3) Characteristics of the Client's Care and Adherence, and (4) Recommendations for Actions to Resolve DRPs.

CONCLUSIONS

The Delphi process resulted in a structured DRP Risk Assessment Tool that is focused on the highest priority DRPs that should be identified and resolved. The tool also assists the PNs to identify solutions to these problems, which is a unique feature compared to similarly purposed prior tools.

Use of cognitive enhancers and associated medical care costs among patients with dementia: a nationwide study in Taiwan

BACKGROUND

Pharmaceutical therapy for patients with dementia including cholinesterase inhibitors (ChEI) and memantine is covered by Taiwan's National Health Insurance (NHI) but with strict reimbursement criteria. This study compared utilization of selected cognitive enhancers among elderly patients with dementia and estimated associated differences in medical care costs.

METHODS

This study used medical claims and pharmacy claims from the NHI Research Database of Taiwan from 2009 to 2011, which included all patients 65 years or older diagnosed with dementia in their outpatient or inpatient claims. Both individual-level and market-level analysis were performed to calculate the average medical costs per person and the share of drug expenditures. Generalized linear models with propensity score adjustment estimated differences in medical care costs by use of selected cognitive enhancers.

RESULTS

Users of ChEI had the highest medication and outpatient costs but the lowest inpatient costs among all users of cognitive enhancers. However, annual adjusted total medical care costs per ChEI user were not significantly different from those who used cerebral vasodilators (CBV). In 2011, 52.4% of the elderly with dementia in Taiwan used cognitive enhancers, but among them 88.3% used CBV while 9.2% used ChEI. Among patients with dementia who used at least one cognitive enhancer, the aggregated expenditure as a share of their total drug expenditures was 9.7% in 2011.

CONCLUSION

Given that CBV had a much higher utilization rate than ChEI or memantine among elderly people with dementia, the strict reimbursement policy for ChEI and memantine may need to be revisited to increase access to those drugs by patients with dementia in Taiwan.

Safety assessment of essential medicines for elderly people: a bibliographic survey

Certain medicines are considered potentially inappropriate (PIM) for elderly people as they increase the risk of adverse drug events (ADE) and because safer alternative therapies are available on the market. In this context, in order to identify the instruments that assess the quality of medical prescriptions for elderly and to determine which drugs are considered PIM, a bibliographic survey was conducted in PUBMED, LILACS and PAHO databases, in February and March/2010. The search strategy included the use of health descriptors and a manual search in the references cited by selected papers. During the period of data collection, 15 instruments were identified. In 2012, with the publication of the update of Beers criteria, this instrument was included in the study. We identified 163 PIM of 25 therapeutic classes, of which 125 (76.7%) are marketed in Brazil. Of these, 31 (24.8%) are essential medicines (RENAME 2012), of which 13 have safer therapeutic equivalents and 19 (15.2%) are over-the-counter drugs. Data suggest the need for inclusion of safer alternatives for the elderly in the national list of essential medicines and the pharmaceutical care for early detection of ADE in this age group, in order to contribute to the safe use of medicines.

Fall risk-increasing drugs and falls: a cross-sectional study among elderly patients in primary care

BACKGROUND

Falls are the most common cause of injuries and hospital admissions in the elderly. The Swedish National Board of Health and Welfare has created a list of drugs considered to increase the fall risk (FRIDs) and drugs that might cause/worsen orthostatism (ODs). This cross-sectional study was aimed to assess FRIDs and their correlation with falls in a sample of 369 community-dwelling and nursing home patients aged ≥75 years and who were using a multi-dose drug dispensing system.

METHODS

Data were collected from the patients' electronic medication lists. Retrospective data on reported falls during the previous three months and severe falls during the previous 12 months were collected. Primary outcome measures were incidence of falls as well as numbers of FRIDs and ODs in fallers and non-fallers.

RESULTS

The studied sample had a high incidence of both reported falls (29%) and severe falls (17%). Patients were dispensed a mean of 2.2 (SD 1.5) FRIDs and 2.0 (SD 1.6) ODs. Fallers used on average more FRIDs. Severe falls were more common in nursing homes patients. More women than men experienced severe falls. There were positive associations between number of FRIDs and the total number of drugs (p < 0.01), severe falls (p < 0.01) and female sex (p = 0.03). There were also associations between number of ODs and both total number of drugs (p < 0.01) and being community dwelling (p = 0.02). No association was found between number of ODs and severe falls. Antidepressants and anxiolytics were the most frequently dispensed FRIDs.

CONCLUSIONS

Fallers had a higher number of FRIDs. Numbers of FRIDs and ODs were correlated with the total number of drugs dispensed. Interventions to reduce falls in the elderly by focusing on reducing the total number of drugs and withdrawal of psychotropic medications might improve the quality and safety of drug treatment in primary care.

[Role of clinical pharmacist in the therapeutical optimization in geriatric outpatient hospital]

SETTING

Cares in outpatient hospital for elderly patients is a period of interest for multidisciplinary reassessment and pharmaceutical care of the prescription. The objective is to present the implementation of the pharmaceutical care activity at the outpatient hospital.

METHODS

Between August and October 2011, elderly patients hospitalized in the outpatient hospital for a brief appraisal had a pharmaceutical care. The clinician introduced pharmaceutical reviews in the synthesis letter for general practitioner. An analysis of the activity was carried out over 3 months.

RESULTS

A pharmaceutical care had been realized for 67 patients, mean age of 81.7 years. Among medical related problems identified, 39.6% were for potentially unnecessary medication. A stop was proposed for 44% of pharmaceutical interventions. A total of 91 pharmaceutical interventions and 13 recommendations were made and 34% of patients had potentially inappropriate medication.

CONCLUSION

According to the objective to reduce the therapeutics contributing to the iatrogenesis, this approach allowed us to undertake a multidisciplinary collaboration oriented toward the relay between hospital and city cares.

Potentially inappropriate prescribing to the elderly: comparison of new protocol to Beers criteria with relation to hospitalizations for ADRs

PURPOSE

Screening tools for detecting potentially inappropriate medications (PIMs) represent an important way to assess drug prescribing in the elderly. Recently, we introduced a new comprehensive tool to detect both PIMs and clinically important drug-drug interactions (DDI). The aim of the study was to assess the applicability of the new tool.

METHODS

The new tool was used to detect PIMs and DDI and to assess their relation to morbidity and hospital admissions. It was also compared to the widely used Beers criteria. The study population included 454 consecutive patients aged ≥65 years who were acutely admitted to the Department of Internal Medicine of the University Hospital of Osijek. The Naranjo protocol was used to analyze the causal relationship between a drug and an adverse event.

RESULTS

According to the new protocol, 44 % patients were taking PIMs, while 33 % patients were taking drugs with potentially serious DDIs. In 11 % of the overall number of patients, the cause of admission was adverse drug reaction (ADR), and among contributing drugs, 44 % were potentially inappropriate according to our protocol. Gastrointestinal bleeding was the most common diagnosis causing ADR-associated admission, and in 72 % cases, either PIM or a potentially serious DDI was involved.

CONCLUSION

The new Croatian tool detected a high number of patients taking PIMs and/or having potentially important drug-drug interactions. The tool also detected almost half of the drugs contributing to ADR-associated admission. We expect the tool to be useful in prescription evaluation for the elderly inpatient and outpatient population.