Drug-prescribing patterns in old age. A study of the impact of hospitalization on drug prescriptions and follow-up survey in patients 75 years and older

"There Is Method to This Madness" A Qualitative Investigation of Home Medication Management by Older Adults

OBJECTIVES

This paper explores (1) the systems and processes older adults use to manage medications at home, and (2) the well-being goals of personal interest that motivate them.

METHODS

Qualitative interviews were conducted in the homes of 12 older adults in a small city in the Midwest United States. Interviews were analyzed using inductive template analysis.

RESULTS

The average age of older adults in this study was 74.2 years (SD = 10.5), 66.7% were women. The most prominent home medication management tools used were pill boxes, containers and vials, and medication lists. Routines were often aligned with activities of daily living such as teeth brushing and eating. Their medication management work occurred in contexts of other household members and budget constraints. Routines and practices were sometimes idiosyncratic adaptations and supported goals of maintaining control and decreasing vulnerability.

CONCLUSION

In developing routines for home medication management, older adults developed systems and deliberate processes to make sense of their medication experiences in the context of their home environment and based on available resources.

Factors associated with the use of potentially inappropriate medication by elderly patients prescribed at hospital discharge

Objective

To analyze the frequency of use of potentially inappropriate medication prescribed to elderly at hospital discharge from a public hospital, considering the Brazilian Consensus on Potentially Inappropriate Medication for Elderly, and to identify the associated factors.

Methods

Patients aged ≥60 years, admitted in clinical and geriatric units of a public hospital were invited to participate in the study. The information about the use of medicines was collected from the patient’s electronic record and through telephone contact. The Brazilian Consensus on Potentially Inappropriate Medication for Elderly was used to classify the medication, regardless of the clinical condition.

Results

A total of 255 elders were included in this study. The frequency of use of potentially inappropriate medication by elderly was 58.4%. The potentially inappropriate medication use in elderly was positively associated with the presence of depression (odds ratio of 2.208) and polypharmacy (odds ratio of 2.495). The hospitalization in a geriatric unit showed an inverse association with the potentially inappropriate medication use in elderly (odds ratio of 0.513).

Conclusion

The frequency of potentially inappropriate medication prescription to elderly upon hospital discharge was high. The presence of depression and polypharmacy were directly associated with use of potentially inappropriate medication in the elderly. Admission to the geriatric clinic has become a protection factor for the use of potentially inappropriate medication in elderly. Strategies to improve the elderly pharmacotherapy should implemented aiming at healthcare quality and safety in the transition of care.

Can screening tools for potentially inappropriate prescriptions in older adults prevent serious adverse drug events?

PURPOSE

The purpose of the study is to identify and explore risk factors of serious adverse drug events (SADE) and SADE-related admissions in acutely hospitalized multimorbid older adults and assess whether these could have been prevented by adherence to the prescription tools Screening Tool of Older Persons' Prescriptions (STOPP) and The Norwegian General Practice (NORGEP) criteria.

METHODS

Cross-sectional study of acutely admitted patients to a medical department in a Norwegian regional hospital. Eligible patients were community-dwelling, receiving home care services, and aged 75+, with ≥ 3 chronic diseases. Medications and information regarding the admission were retrieved from the referral letter and medical records, while an expert panel identified SADE using the Common Terminology Criteria for Adverse Events and SADE-related admissions.

RESULTS

We included 232 patients. Mean (SD) age was 86 (5.7) years, 137 (59%) were female, 121 (52%) used 5-9 drugs whereas 65 (28%) used ≥ 10. We identified SADEs in 72 (31%) of the patients, and in 49 (68%) of these cases, the SADE was considered to cause the hospital admission. A low body mass index (BMI) and a high Cumulative Illness Rating Scale-Geriatrics (CIRS-G) score were independent risk factors for SADEs. Among the SADEs identified, 32 (44%) and 11 (15%) were preventable by adherence to STOPP and NORGEP, respectively.

CONCLUSIONS

We found a high prevalence of SADE leading to hospitalization. Risk factors for SADE were high CIRS-G and low BMI. STOPP identified more SADEs than NORGEP, but adherence to the prescription tools could only to a limited degree prevent SADEs in this patient group.

Hospitalization Drug Regimen Changes in Geriatric Patients and Adherence to Modifications by General Practitioners in Primary Care

OBJECTIVES

To evaluate the overall rate of adherence by general practitioners (GPs) to treatment modifications suggested at discharge from hospital and to assess the way communication between secondary and primary care could be improved.

DESIGN

Observational prospective cohort study.

SETTING

Patients hospitalized from the emergency department to the acute geriatric care unit of a university hospital.

PARTICIPANTS

206 subjects with a mean age of 85 years.

MEASUREMENTS

Changes in drug regimen undertaken during hospitalization were collected with the associated justifications. Adherence at one month by GPs to treatment modifications was assessed as well as modifications implemented in primary care with their rationale in case of non-adherence. Community pharmacists' and GPs' opinions about quality of communication and information transfer at hospital-general practice interface were investigated.

RESULTS

5.5 ± 2.8 drug regimen changes were done per patient during hospitalization. The rate of adherence by GPs to treatment modifications suggested at discharge from hospital was 83%. In most cases, non-adherence by GPs to treatment modifications done during hospitalization was due to dosage adjustments, symptoms resolution but also worsening of symptoms. The last of which was particularly true for psychotropic drugs. All GPs received their patients' discharge letters but the timely dissemination still needs to be improved. Only 6.6% of community pharmacists were informed of treatment modifications done during their patients' hospitalization.

CONCLUSION

Our findings showed a successful rate of adherence by GPs to treatment modifications suggested at discharge from hospital, due to the fact that optimization was done in a collaborative way between geriatricians and hospital pharmacists and that justifications for drug regimen changes were systematically provided in discharge letters. Communication processes at the interface between secondary and primary care, particularly with community pharmacists, must be strengthened to improve seamless care.

Implementation of Ward-Based Clinical Pharmacy Services in Belgium—Description of the Impact on a Geriatric Unit

Background:

Patient-centered clinical pharmacy services are still poorly developed in Europe, despite their demonstrated advantages in North America and the UK. Reporting European pilot experiences is, therefore, important to assess the usefulness of clinical pharmacy services in this specific context.

Objective:

To report the results of the first implementation of Belgian clinical pharmacy services targeting patients at high risk of drug-related problems.

Methods:

An intervention study was conducted by a trained clinical pharmacist providing pharmaceutical care to 101 patients (mean age 82.2 y; mean ± SD number of prescribed drugs 7.8 ± 3.5) admitted to an acute geriatric unit, over a 7 month period. All interventions to optimize prescribing, and their acceptance, were recorded. An external panel (2 geriatricians, 1 clinical pharmacist) assessed the interventions' clinical significance. Persistence of interventions after discharge was assessed through telephone calls.

Results:

A total of 1066 interventions were made over the 7 month period. The most frequent drug-related problems underlying interventions were: underuse (15.9%), wrong dose (11.9%), inappropriate duration of therapy (9.7%), and inappropriate choice of medicine (9.6%). The most prevalent consequences were to discontinue a drug (24.5%), add a drug (18.6%), and change dosage (13.7%). Acceptance rate by physicians was 87.8%. Among interventions with clinical impact, 68.3% and 28.6% had moderate and major clinical significance, respectively. Persistence of chronic treatment changes 3 months after discharge was 84%.

Conclusions:

Involving a trained clinical pharmacist in a geriatric team led to clinically relevant and well-accepted optimization of medicine use. This initiative may be a springboard for further development of clinical pharmacy services.

[Assessment of polypharmacy: A question of definition and underlying data]

BACKGROUND

Older persons are often subjected to polypharmacy. There is a large degree of variability in the definitions used, the underlying data sources and the medications included. Our aim was to analyse the influence of different definitions on the prevalence of polypharmacy.

METHODS

We used data of the study "Inappropriate Medication in patients with REnal insufficiency in Nursing homes" (IMREN) conducted in nursing homes in Bremen and the surrounding area. Anonymised data were collected by nursing staff. Prescription drugs and over-the-counter drugs as well as scheduled and as-needed medications were assessed.

RESULTS

852 residents from 21 nursing homes were recruited (mean age: 83.5 years; 76.5% female). Each resident received an average of 8.8 scheduled and as-needed medications, the prevalence of polypharmacy (≥5 medications) was 83.5%. When including scheduled medications only, residents received an average of 6.3 medications (polypharmacy 69.7%). When restricting the analysis to prescription-only medicines, the results were comparable (6.3 medications per resident; polypharmacy 69.1%). However, the two analyses included different drugs. A total of 74.3% received at least one over-the-counter drug as scheduled medication (59.7% on an as-needed basis).

CONCLUSIONS

In studies investigating polypharmacy, the methods used should be reported in a transparent manner. This is particularly important when addressing the question of which drugs were included in the study.

The influence of comprehensive geriatric assessment on drug therapy in elderly patients

BACKGROUND

Comprehensive geriatric assessment of hospitalised patients implies optimising patients' medical treatment, and good coordination between hospital and general practice is essential for the quality of the drug treatment. Only a few studies have investigated the continuation of patients' medication from primary care to hospital and back again to primary care.

OBJECTIVES

To describe changes of drug therapy during hospital stay in a geriatric ward and the following acceptance of these changes in primary cares after discharge.

METHODS

An observational register study following 1,550 geriatric patients' pharmacological treatment longitudinally across hospital stay, by linkage of a primary care prescription database and hospital medical records. The medication regimens for the individual patients were compared at three cross sections: primary care before hospitalisation, during hospital stay and primary care after hospitalisation, analysed according to drug therapy, co-morbidity, functionality and outpatient follow-up.

RESULTS

Patients were using an average of 8.2 drugs before hospital admission, of which an average of 0.9 drugs per patient was discontinued or switched during hospitalisation. An average of 1.7 new drugs per patient was initiated by the hospital physicians. After discharge, 63.9 % of the changes initiated by hospital physicians were continued in primary care. Of new drugs initiated in hospital 42.7 % were accepted in primary care.

CONCLUSIONS

A relatively small proportion of drugs was switched or discontinued and the average number of drugs increased during hospital stay. Of these changes, two thirds were accepted in primary care after discharge and less than half of newly initiated drugs were continued in primary.

Adherence to medications after hospital discharge in the elderly

Objectives. To evaluate the adherence rate to prescribed medications in elderly patients 24-48 hours after being discharged from the hospital. Methods. Family medicine residents visited patients over the age of 65 years at their homes one to two days after being discharged from the hospital and documented all the medications that they were taking since coming home from the hospital. The list of medications was later compared to the medications recorded in hospital discharge instructions. Results. Complete data was available for 46 participants. The average patient age was 76 years; 54.4% were women. Only three patients (6.5%) adhered completely to the discharge medication list found in the medical record. Thirty-six patients (78.2%) reported taking at least one additional prescription medication, twenty patients (43.4%) missed at least one prescription medication, twenty patients (43.4%) reported taking the wrong dose of at least one medication, and nineteen patients (41.3%) reported taking medications at an incorrect frequency. Conclusion. The vast majority of elderly patients in our study did not adhere to the medication regimen in the first two days after hospital discharge. Cost-effective improvements to hospital discharge processes are needed to improve adherence and reduce preventable posthospitalization complications.

[Influence of hospitalisation on drug prescription in arterial hypertension and chronic conditions]

OBJECTIVES

To evaluate the influence of hospitalization on drug prescription in chronic conditions.

METHODS

Admission and discharge prescriptions from 92 patients consecutively admitted in a specialized department of the Assistance Publique-Hôpitaux de Paris hospital were recorded in a prospective two-month study. A Qualitative Therapeutical Score (QTS) was calculated as an estimation of qualitative modifications in the prescription.

RESULTS

Patients admitted for an hospital stay of over 24h have more lines of prescription than patients admitted for an hospitalization shorter than 24h (5.7±4.2/d vs 2.9±2.5/d, P<0.01). For all the patients enrolled, the hospital stay is not associated with any change in the global number of treatments. However, in patients treated with antihyperstensive drug, the number of drug intakes decreases (2.6±1.5/d vs 1.9±1.4/d, P<0.05) as a consequence of an increase in the prescription of fixed-dose combinations. In patients with cardiovascular diseases, the QTS is higher and qualitative modifications are more often found in patients admitted for an hospital stay of over 24h than for those admitted for a an hospitalization shorter than 24h (0.57 vs 0.11; P<0.01 and 31% vs 11%; P<0.05 respectively). Antihypertensive drugs are the most represented drugs within these qualitative modifications.

CONCLUSION

In patients with drug treatments for arterial hypertension or chronic conditions, hospitalization is not associated with quantitative but with qualitative modifications, especially for an over 24h hospital stay.

How are drug regimen changes during hospitalisation handled after discharge: a cohort study

OBJECTIVES

To investigate drug regimen changes during hospitalisation and explore how these changes are handled after patients are transferred back into the care of their general practitioners (GPs).

DESIGN

Cohort study.

SETTING

Patients in this multicentre study had undergone at least one change in their drug regimens at discharge from the general medicine departments at six hospitals in Norway. These changes were altered doses, discontinuation of drugs or start of new drugs. Clinical pharmacists visited the patients' GPs 4-5 months after patient discharge and recorded any additional drug regimen changes.

RESULTS

In total, 105 patients (mean age 76.1 years, 54.3% women) completed the study. On average, they used 5.6 drugs at admission (range 0-16) and 7.6 drugs at discharge (range 1-17). On average, 4.4 drug changes per patient (SD 2.7, range 1-16) were made at the hospital, and 3.4 drug changes per patient (SD 2.9, range 0-14) within 4-5 months of discharge. Of the 465 drug changes made in hospital, 153 were changed again after discharge (mean 1.5 per patient, SD 1.8, range 0-13). The drug regimens of 90 of these 105 patients were changed after discharge. The OR for extensive drug changes after discharge (≥ 4 changes) increased significantly with the number of drugs used at discharge from hospital (OR=1.29, 95% CI 1.04 to 1.59). Only 68 of 105 discharge notes contained complete drug lists, and only 24 of the discharge notes were received by the GPs within 7 days.

CONCLUSIONS

In addition to the extensive changes in drug regimens during hospitalisation, almost equally extensive changes were made in the initial months after discharge. Surveillance of drug regimens is particularly necessary in the period immediately after hospital discharge.

Relationship of in-hospital medication modifications of elderly patients to postdischarge medications, adherence, and mortality

BACKGROUND

Medication regimens are constantly modified and updated during a patient's hospitalization. These modifications and those made after discharge might increase the risk for nonadherence, polypharmacy, and poor outcomes among elderly patients.

OBJECTIVES

To investigate the extent of in-hospital modification of medication regimens of elderly patients and its relationship to medication adherence as well as one-month postdischarge drug regimen modifications and to examine the relationship of the modifications, adherence, and polypharmacy to mortality and readmissions 3 months postdischarge.

METHODS

Clinical and demographic data, postdischarge medication modifications, and adherence were prospectively obtained in 212 elderly patients. Inhospital drug regimen modifications were retrospectively recorded.

RESULTS

The average +/- SD in-hospital medication regimen modification rate was 49.8% +/- 28.4. No modifications were found in 9.7% of the patients. Using demographic and clinical parameters, we performed regression analysis and found that patients who were admitted with polypharmacy, discharged home, and cognitively normal experienced fewer medication modifications (p < 0.05). At one month postdischarge, the average medication regimen modification rate was 37.5% +/- 25.4. In- and posthospital modifications were directly correlated (p = 0.047). Three months postdischarge, 17 patients had died and 50 had been readmitted. The independent risk factors for mortality were in-hospital modification rate of 50% or greater (OR 6.4; 95% CI 1.3 to 29.7), impaired cognition (OR 4.2; 95% CI 1.4 to 12.3), and each chronic disease (OR 1.2; 95% CI 1 to 1.5). No relationships were found between in-hospital medication regimen modifications and readmissions or with postdischarge modifications, adherence, and polypharmacy to mortality and readmissions.

CONCLUSIONS

Hospitalization of elderly patients is characterized by extensive medication regimen modifications, which are directly correlated with postdischarge modifications and may indicate an increased risk of mortality.

Evaluation of pharmacotherapy in geriatric patients after performing complete geriatric assessment at a diagnostic day clinic

BACKGROUND

Elderly patients often take multiple drugs. It is known that polypharmacy, i.e. use of five or more drugs, may lead to drug interactions and adverse events. However, undertreatment of conditions or illnesses is also a concern in geriatric patients. A centralised review of both diagnoses and medication may play a key role in optimising pharmacotherapy in geriatric patients. The aims of this study were to evaluate the quality and appropriateness of medication after performing a complete geriatric assessment (CGA) and medication review at a diagnostic geriatric day clinic, to investigate reasons for drug changes, and to determine whether medication review leads to a reduction in the number of drugs used.

METHODS

A chart review was performed in 702 patients (mean age 82.0 years, range 57.1-104.1 years) who underwent a CGA at a diagnostic geriatric day clinic. Medication at admission, changes in medication and reasons for changes were noted.

RESULTS

Vitamins, for example folic acid and vitamin B(12) (cyanocobalamin), and trimethoprim for urinary tract infections were the most frequently started medications after CGA and medication review. The number of drugs used was reduced in only a minority of patients (11.7%); reasons for discontinuation were a diagnosis that was no longer relevant (38.8%), adverse events (33.2%) and identification of better pharmacotherapeutic options (22.0%). In 69.2% of the cases a new diagnosis was the reason for starting a new medication, followed by osteoporosis prophylaxis (15.0%) and improvement in pharmacotherapy (10.6%). At admission, patients were taking a mean number of 4.6 drugs (range 0-17). A mean of 0.8 drugs (range from reduction of 5 to addition of 7) had been added per patient, resulting in a mean number of 5.4 (range 0-18) prescribed drugs at discharge.

CONCLUSION

Evaluation of medication in patients after performing CGA at the geriatric day clinic investigated resulted in relevant medication changes. The main reason for prescribing new drugs was a new diagnosis. Absence of a relevant medical indication was the main reason for stopping drugs. CGA and medication review resulted in a mean net addition of 0.8 drugs per patient.

Impact of hospitalisation in an acute medical geriatric unit on potentially inappropriate medication use

BACKGROUND AND OBJECTIVE

Potentially inappropriate medication use is a major safety issue in the elderly and may cause a substantial proportion of drug-related hospital admissions. Hospitalisation could result in a change in the quantity and type of drugs, but its effect on potentially inappropriate drug use is still unknown. The aim of this study was to estimate the potentially inappropriate medication prevalence in patients > or =70 years of age at admission to and at discharge from an acute medical geriatric unit, and to identify the factors associated with no longer being a potentially inappropriate drug user at hospital discharge.

METHODS

A prospective drug surveillance study was undertaken in 2018 elderly patients (> or =70 years of age) admitted to an acute medical geriatric unit in Limoges University Hospital, France. Prescribing patterns were established at admission and at discharge. Potentially inappropriate medication use was evaluated according to a list derived from the Beers criteria and adapted to French practice. "To be no longer a potentially inappropriate drug user at discharge" was defined as using at least one potentially inappropriate medication at admission and not using it at discharge.

RESULTS

The numbers of drugs used at admission/discharge were 6.2 +/- 3.1/5.4 +/- 2.5. The prevalence of potentially inappropriate medication use decreased from 66% (95% CI 63.8, 68.0) at admission to 43.6% (95% CI 41.3, 45.9) at discharge. At discharge, 535 subjects were no longer potentially inappropriate medication users. Multivariate analysis showed that no longer being a potentially inappropriate medication user was associated with the number of drugs used (4-6 drugs vs < or =3 odds ratio [OR] 1.20; 95% CI 0.86, 1.68; 7-9 drugs vs < or =3 OR 1.37; 95% CI 0.97, 1.93; > or =10 drugs vs < or =3 OR 1.64; 95% CI 1.10, 2.44), age (80-89 years vs 70-79 years OR 1.38; 95% CI 1.03, 1.85; > or =90 years vs 70-79 years OR 1.69; 95% CI 1.22, 2.83), cerebral vasodilator use (OR 2.87; 95% CI 2.31, 3.57), analgesic use (OR 1.54; 95% CI 1.06, 2.25) and concomitant use of psychotropic drugs of the same therapeutic class (OR 1.94; 95% CI 1.29, 2.92).

CONCLUSION

Hospitalisation in geriatric services results in a reduction in potentially inappropriate medication use. Improved pharmacological education of practitioners, especially with regard to drug adverse effects, is desirable to improve management of geriatric patients.

Pattern of utilization of benzodiazepines in patients with hypertension: A pilot study

Background/Aim. The analysis of drug prescribing in general practice in Serbia showed that the use of benzodiazepines is most frequently associated with hypertension. The aim of this study was to establish the correlation of the characteristics of patients with hypertension to antihypertensive drug therapy, and the intake of benzodiazepines. Methods. A special questionnaire was used for interviewing the patients (n = 171) chronically treated for hypertenson. Statistical tests used were ?2-test and Student's t-test. Results. No differences were noted in terms of age, gender, education, body weight, smoking habits and blood pressure (155?4.9/100?2.7 mmHg vs. 160?2.2/105?3.7 mmHg), between the group I (antihypertensive drugs+benzodiazepines: n = 79), and the group II (antihypertensives only: n = 92). The patients taking benzodiazepines received a lower number of different antihypertensive drugs (2.3?0.09 vs. 2.7?0.10; p < 0.01), but the total antihypertensive drug load was significantly greater than in the group II (2.6?0.10 vs. 1.9?0.15 defined daily doses (DDD)/patient/day; p < 0.01). Benzodiazepines were taken for anxiety (62%) and hypertension (21%), rarely for insomnia, mostly once a day, at bedtime. About half the patients took benzodiazepines regularly for months or years aware of the risk for addiction. Diazepam was used by 82% of the patients. The average daily exposure to benzodiazepines was 0.45?0.05 DDD/patient/day. The drug was bought without prescription in 25% of the patients, and without consulting a physician in 12% of them. Conclusion. The study confirmed a close association of hypertension with the use of benzodiazepines. The frequent use of benzodiazepines in the patients with hypertension might be caused by an inadequate response to antihypertensive drug therapy, besides anxiety and insomnia. The therapeutic efficacy of a long-term use of low doses of benzodiazepines in hypertension requires further investigation.

Patterns of drug prescription in a geriatric evaluation and management unit as compared with the general medical wards: a randomised study

OBJECTIVE

This study's objective was to determine whether patients treated in a geriatric evaluation and management unit (GEMU) had a more appropriate drug profile than patients treated in the general medical wards (MW).

METHODS

Frail elderly patients admitted as emergencies to the medical department were randomised to treatment in the GEMU (n=127) or MW (n=127). Drugs used at inclusion and discharge were registered retrospectively and analysed with regard to polypharmacy, number of drugs withdrawn or started, potential drug-drug interactions (DDIs), number of anticholinergic drugs prescribed, and the number of inappropriate drug prescriptions according to Beers' criteria. Utilisation of psychotropic and cardiovascular drugs was compared in detail according to prespecified hypotheses.

RESULTS

The number of patients with polypharmacy did not differ significantly between the GEMU and MW. The median number of scheduled drugs withdrawn per patient was higher in the GEMU than in the MW (p=0.005). Drugs with anticholinergic effects (p=0.003); cardiovascular drugs (p<0.001), particularly digitalis glycosides (p<0.001); and antipsychotic drugs (p=0.009) were withdrawn more often in the GEMU. The median number of scheduled drugs started was higher in the GEMU than in the MW (p=0.03). In particular, antidepressants (p<0.001) and estriol (p=0.001) were started more often in the GEMU than in the MW. Fewer GEMU than MW patients had potential DDIs at discharge (p=0.009).

CONCLUSION

Drug treatment in the GEMU as compared with the MW was more appropriate in terms of prescription of fewer drugs with anticholinergic effects and fewer potential DDIs. There were distinct differences in treatment patterns of cardiovascular and psychotropic drugs.

Prescribing behavior for the elderly in the United Arab Emirates: psychotropic medication use remains low despite rising overall appropriate and inappropriate medication use

Inappropriate prescribing, especially for psychotropic agents, is a common and significant cause of morbidity in older people. This cross sectional survey was conducted in the United Arab Emirates (UAE), a country with a rapidly developing economy. Prescribing behavior for people aged 65+ years acutely admitted via a university teaching hospital was examined for 1994 and 1999. All 474 patients (which resulted in 627 acute admissions; 194 in 1994 and 433 in 1999) were included. The patients had a mean age of 74.1 +/- 7.6, mean annual admission rate of 1.3 +/- 0.8 and a female:male ratio of 0.46 in 1994 rising to 0.73 in 1999 (P=0.04). Pre-admission use of five or more medications as recorded in the admission notes increased from 12% in 1994 to 23% in 1999 (P=0.001), while on discharge rose from 26 to 45% (P<0.001). There was a rise in low dose aspirin use, an indicator of appropriate prescribing, both pre-hospital (13-21%, P=0.03) and on discharge (19-29%, P=0.007). There was also a significant rise in pre-hospital inappropriate prescribing from 5 to 13% of patients demonstrating at least 1 of 144 inappropriate medications or combinations looked for (P=0.002) and at discharge from 9 to 19% (P=0.001). The rate of psychotropic medication usage (pre-hospital 0.1 per person: at discharge 0.25) was low compared to western countries and showed no significant change over time. These findings show rises in both appropriate and inappropriate prescribing with the exception of psychotropic medications during a 5-year period, which corresponded to rapid development in the health care system.

[Evolution of drug treatments in the aged living at home]

PURPOSE

Although overprescription and overconsumption of drugs are common in the elderly, their features are still not well known since retrospective data on drug intake in this population is very limited. This study was therefore aimed at assessing the evolution of drug intake in the elderly.

METHODS

In a study undertaken in the context of the PAQUID project, drug intake was assessed in a group of elderly subjects living at home in either Gironde or Dordogne in south-western France. Each subject was visited by an investigator in successively 1988-89, 1991-92, 1993-94, and 1996-97. Three thousand seven hundred and seventy-seven subjects were included in the study since 1988. Their mean age was 75.4 years (CI 95%: 75.2-75.6 years) and the sex ratio was 0.72.

RESULTS

Eighty-nine percent of the subjects took at least one drug per day; 49% took one to four drugs per day; and 40% took more then five drugs per day. The total drug consumption showed an increase in drug intake during the 8-year follow-up, whether the subjects were or not dependent according to their IADL score.

CONCLUSION

Analysis of drug intake evolution according to age, sex and daily drug intake at inclusion in the study showed that during follow-up drug intake increased in younger people who had no treatment at study inclusion, while it decreased in older subjects receiving multiple medications. This decrease might be due to either adverse side-effects, drug interactions, or repeated episodes of hospitalization.

Drug consumption in workers in France: a comparative study at a 10-year interval (1996 versus 1986)

This study compared drug consumption and associated social factors in workers in France between 1986 and 1996. The same transversal survey was performed in 1986 and 1996 using the same methodology by means of an anonymous questionnaire given to the subject and answered in the presence of an occupational physician. The 1996 population (2674 subjects) was found to be older (37.0 +/- 9.8 versus 35.7 +/-10.2 years) and to take more drugs (+5.1%) than the population of 1986 (2221 subjects). There were fewer manual workers in the 1996 population. In both periods, women used significantly more drugs in general and more psychoactive (mainly anxiolytic), cardiovascular, endocrine metabolic, and homeopathic drugs than men. The mean value of estimated difficulty of work was higher in subjects taking drugs in general, and especially those taking hypnotic, anxiolytic, psychoactive, antiinflammatory, and digestive drugs in 1986 as well in 1996. In 1986 as well as in 1996, manual workers took no more drugs than did nonmanual workers in general, except for analgesic and antiinflammatory drugs. Nonmanual workers used homeopathic drugs more than manual workers. The presence of extraprofessional problems was associated with an increase in consumption of drugs in general and psychoactive, hypnotic, anxiolytic, antiinflammatory, cardiovascular, digestive, and endocrine metabolic drugs in particular, in 1986 as well as in 1996. After adjustment for variables linked to drug use, there was no significant change in total drug consumption in general but a significant decrease in psychoactive (-49%) (mainly hypnotic [-71%]), and digestive (-39%) drug consumption in this population between 1986 and 1996. In contrast, analgesic use significantly increased (+36%). This study underscores the high level of drug consumption in workers (more than 40% of the subjects were taking drugs). Although there were no quantitative changes, marked qualitative modifications were found with a decrease in consumption of psychoactive (and mainly hypnotic) and digestive drugs and an increase in analgesic drug use between 1986 and 1996. Thus, specific drug information programs designed to reduce psychoactive drug consumption and to favor analgesic drugs for better pain management seem to have been (at least partly) followed. The study also underscores the importance of some social factors associated to general and specific drug use (mainly difficulty of work and presence of extraprofessional problems, and to a lesser extent, kind of work). Their weight remained similar in 1986 and 1996.

Drug utilization and health behaviours among indigent elderly patients in Crete, Greece

AIM

To examine pharmaceutical needs, prescribed drugs, knowledge about pharmacotherapy and health behaviours among Social Care indigent elderly patients.

PATIENTS

There were a total of 551 Social Care indigent patients registers in Chania, Crete, Greece at the time of the study (1995-97), of whom 89 (40 men and 49 women) were elderly patients (> or =65 years old). The control group comprised 171 (81 men and 90 women) Social Security insured elderly patients (> or =65 years old).

RESULTS

The socio-demographic profile of the indigent elderly patients reveals an unemployment rate of 99% (versus 5% in the control group, P<0.05) and an illiteracy rate of 38% (versus 5%, P<0.05). The most commonly prescribed defined daily doses (DDD) of medications were cardiovascular drugs (45.0% indigent versus 48.3%) and nervous system drugs (14.4% versus 8.8%). The most frequently prescribed drug, as a percentage of DDD, was nitroglycerin (14.5% versus 26.0%) and the most expensive drug, expressed as a percentage of the total cost of drugs, was omeprazole (6.5% versus 4.6%). The most common disease was hypertension (42.1% versus 23.2%, P<0.05). There were also significant differences between the two groups of patients (P<0.05) in the understanding of drug usage instructions (35.4% versus 68.6%), in asking the pharmacist for advice (44.6% versus 71.5%) and in understanding special diet instructions (18.7% versus 34.7%). Regarding the health behavior patterns, significant differences (P<0.05) were found in the consumption of sausages (38.6% versus 15.6%), salt (29.8% versus 12.0%), more than one glass per day of alcoholic drinks (13.8% versus 4.3%) and in daily smoking cigarettes (48.8% indigent versus 12.8% control).

CONCLUSION

The present study emphasizes the need for more information on drug use and the necessity for a continuing health educational intervention among Social Care indigent elderly patients.

An intervention on discharge polypharmacy

OBJECTIVE

To determine if providing a way to cancel pre-admission prescriptions would reduce the number of active drug prescriptions (RXs) at discharge.

DESIGN

A randomized non-blinded clinical trial.

SETTING

Inpatient acute medical service of a university affiliated Veterans Administration medical center.

PARTICIPANTS

Twelve medicine ward teams were randomized to control and intervention groups. Patients controlled had been discharged from these teams during 12 weeks and were receiving outpatient medications from this facility at hospital admission; control = 180, intervention = 168.

INTERVENTION

At discharge, intervention teams used a computer-generated drug list to cancel or renew previous outpatient RXs or to prescribe new medications. Control teams could not cancel outpatient drugs and wrote all medications on individual prescriptions.

MEASUREMENTS

The difference between admission and discharge RXs.

RESULTS

There were no significant differences in patients' age, sex, race, Charlson Index (CI), or LOS between patient groups at discharge. The intervention group had fewer RXs on admission (5.4 vs 6.2, P < .05) and at discharge was not significantly different (2.9 vs 2.9, P = .87) from the control group.

CONCLUSIONS

Providing a method for canceling pre-admission medications did not reduce the number of RXs at discharge. Further research is needed to evaluate the appropriateness of the large increase in RXs from admission to discharge for patients in acute hospital settings.

Elderly patients' problems with medication. An in-hospital and follow-up study

OBJECTIVES

To examine medication problems during a stay in hospital and after discharge and to identify risk factors that contribute to poor compliance with medication a prospective observational study was carried out in an university-affiliated geriatric hospital and a patients' home.

PATIENTS

One hundred and nineteen patients admitted from home to the geriatric hospital underwent a comprehensive geriatric assessment. They were also tested in opening and removing tablets from various common medicine containers. Drug prescriptions before, during and after the hospital stay were recorded. Medication use at home was observed by a member of a hospital-based home intervention team. The patients' reports of their drug therapy was compared with those by their family doctors.

RESULTS

Of all tested patients 10.1% failed to open at least one container. This inability was associated with poor vision, impaired cognitive function and low manual dexterity. Compliance with prescribed medication was associated with cognitive function, ability to handle medication containers, number of prescribed drugs and recent changes in drug prescriptions. Of the patients only 39.5% had stable drug prescriptions during the 3-month study period. Doctor/patient agreement concerning drug therapy was low in all age groups. The agreement rate and patients' knowledge of their treatment was correlated with cognitive function and the number of prescribed drugs.

CONCLUSION

Patients' ability to open and remove tablets from common commercial packages/containers should be tested routinely during a stay in hospital. Management of medication should be taught and supervised within the first few days after discharge from hospital.

Measurement of drug compliance by continuous electronic monitoring: a pilot study in elderly patients discharged from hospital

OBJECTIVE

A pilot study to assess patient compliance with medication by using a new measurement technique, continuous electronic monitoring.

DESIGN

Survey. Compliance monitors were provided to eligible patients at discharge from the hospital to measure drug intake behavior prospectively for a period of 3 weeks.

SETTING

Ambulant patient care after discharge from a geriatric hospital, Krankenhaus Bethanien, which is affiliated with the University Clinic, Heidelberg.

PATIENTS

A consecutive convenience sample of 18 independently living elderly patients (median age 76 years) completed the study. The patients were on maintenance therapy with cardiac glycosides and/or potassium-sparing diuretics prescribed to be taken once daily.

INTERVENTION

The monitoring method provides information about patients' real timing of drug use by continuously recording date and time of openings and closings of the medication containers (monitors). In addition to a standard measure, the percentage of prescribed doses taken, information about regularity of drug use is obtained.

RESULTS

Compliance, percentage of prescribed doses taken, was remarkably variable; it ranged from 24% to 100%, 95% CI: 62%-84%. Mean compliance declined from the first to the third week after discharge, 85% vs 69%, 95% CI: 74%-95% and 56%-81%, respectively (P < 0.05). Omissions of doses, the predominant pattern of non-compliance, were observed in 17 of 18 patients. Regularity of dose timing, as defined by the number of interdose intervals within 24 h +/- 15%, varied from 10% to 100%, 95% CI: 46%-76%.

CONCLUSIONS

Continuous electronic monitoring revealed highly variable compliance in patients prescribed maintenance therapy. Even with a once-daily regimen, persistent and high compliance cannot be assumed. The monitoring technique may be of great value to research and, possibly, to practical therapeutic management.