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

Deprescribing psychotropic medications is associated with improvements in activities of daily living in post-stroke patients

AIMS

To examine the effect of deprescribing psychotropic medications on activities of daily living (ADLs) and swallowing function in patients undergoing convalescent rehabilitation following a stroke.

METHODS

In this retrospective cohort study, patients who underwent convalescent rehabilitation after a stroke were divided into two groups: deprescribing (number of psychotropic medications decreased during hospitalization) and non-deprescribing (number of psychotropic medications increased or remained unchanged). The primary outcome measure was ADLs assessed using the Functional Independence-Measured Motor Activity (FIM-motor) score at discharge. A multiple linear regression analysis was conducted to determine the independent association between deprescribing psychotropic medications and rehabilitation outcomes.

RESULTS

Of the 586 patients enrolled, 128 with a mean age of 74.1 ± 12.7 years were included in the final analysis after being prescribed psychotropic medications, with 36 of them (28.1%) in the deprescribing group. Multiple linear regression analysis revealed that deprescribing psychotropic medications was independently associated with FIM-motor function at discharge.

CONCLUSIONS

Deprescribing psychotropic medications is positively associated with improvements in ADLs among patients undergoing convalescent rehabilitation after a stroke. Geriatr Gerontol Int 2024; 24: 275-282.

Disentangling concepts of inappropriate polypharmacy in old age: a scoping review

INTRODUCTION

Polypharmacy is a common concern, especially in the older population. In some countries more that 50% of all individuals over 60 receive five or more drugs, most often due to multimorbidity and increased longevity. However, polypharmacy is associated with multiple adverse events, and more medication may not always be the answer. The terms "appropriate" and "inappropriate" are often used to distinguish between "much" and "too much" medications in relation to polypharmacy in research and practice, but no explicit definition exists to describe what these terms encompass. The aim of this review is to unfold the different understandings of and perspectives on (in)appropriate polypharmacy and suggest a framework for further research and practice.

METHOD

A scoping review was conducted using the framework of Arksey and O'Malley and Levac et al. Pubmed, Embase, PsycINFO, CINAHL, Cochrane database, Scopus and Web of Science were searched for references in English, Danish, Norwegian and Swedish using the search string "Polypharmacy" AND "Appropriate" OR "Inappropriate". Data was extracted on author information, aims and objectives, methodology, study population and setting, country of origin, main findings and implications, and all text including the words "appropriate," "inappropriate," and "polypharmacy." Qualitative meaning condensation analysis was used and data charted using descriptive and thematic analysis.

RESULTS

Of 3982 references, a total of 92 references were included in the review. Most references were from 2016-2021, from fields related to medicine or pharmacy, and occurred within primary and secondary healthcare settings. Based on the qualitative analysis, a framework were assembled consisting of Context, three domains (Standardization, Practices and Values & Concerns) and Patient Perspective.

CONCLUSION

Inappropriate polypharmacy is a concept loaded by its heterogeneity and the usefulness of a single definition is doubtful. Instead, the framework suggested in this article representing different dimensions of inappropriate polypharmacy may serve as an initial strategy for focusing research and practice on polypharmacy in old age.

Prevalence of potentially inappropriate prescribing in older adults in Central and Eastern Europe: a systematic review and synthesis without meta-analysis

We aimed to systematically review the prevalence of potentially inappropriate prescribing (PIP) in older adults in Central and Eastern Europe (CEE) in all care settings. We searched Embase and MEDLINE (up to June 2019) and checked the reference lists of the included studies and relevant reviews. Eligible studies used validated explicit or implicit tools to assess the PIP prevalence in older adults in CEE. All study designs were considered, except case‒control studies and case series. We assessed the risk of bias using the Joanna Briggs Institute Prevalence Critical Appraisal Tool and the certainty of evidence using the GRADE approach. Meta-analysis was inappropriate due to heterogeneity in the outcome measurements. Therefore, we used the synthesis without meta-analysis approach-summarizing effect estimates method. This review included twenty-seven studies with 139,693 participants. Most studies were cross-sectional and conducted in high-income countries. The data synthesis across 26 studies revealed the PIP prevalence: the median was 34.6%, the interquartile range was 25.9-63.2%, and the range was 6.5-95.8%. The certainty of this evidence was very low due to the risk of bias, imprecision, and inconsistency. These findings show that PIP is a prevalent issue in the CEE region. Further well-designed studies conducted across countries are needed to strengthen the existing evidence and increase the generalizability of findings.

A machine learning-based risk warning platform for potentially inappropriate prescriptions for elderly patients with cardiovascular disease

Potentially inappropriate prescribing (PIP), including potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs), is a major risk factor for adverse drug reactions (ADRs). Establishing a risk warning model for PIP to screen high-risk patients and implementing targeted interventions would significantly reduce the occurrence of PIP and adverse drug events. Elderly patients with cardiovascular disease hospitalized at the Sichuan Provincial People’s Hospital were included in the study. Information about PIP, PIM, and PPO was obtained by reviewing patient prescriptions according to the STOPP/START criteria (2nd edition). Data were divided into a training set and test set at a ratio of 8:2. Five sampling methods, three feature screening methods, and eighteen machine learning algorithms were used to handle data and establish risk warning models. A 10-fold cross-validation method was employed for internal validation in the training set, and the bootstrap method was used for external validation in the test set. The performances were assessed by area under the receiver operating characteristic curve (AUC), and the risk warning platform was developed based on the best models. The contributions of features were interpreted using SHapley Additive ExPlanation (SHAP). A total of 404 patients were included in the study (318 [78.7%] with PIP; 112 [27.7%] with PIM; and 273 [67.6%] with PPO). After data sampling and feature selection, 15 datasets were obtained and 270 risk warning models were built based on them to predict PIP, PPO, and PIM, respectively. External validation showed that the AUCs of the best model for PIP, PPO, and PIM were 0.8341, 0.7007, and 0.7061, respectively. The results suggested that angina, number of medications, number of diseases, and age were the key factors in the PIP risk warning model. The risk warning platform was established to predict PIP, PIM, and PPO, which has acceptable accuracy, prediction performance, and potential clinical application perspective.

Potentially inappropriate medication use in hospitalized elderly patients

OBJECTIVE:

This study aimed to assess the prevalence of potentially inappropriate medication prescription in hospitalized elderly patients according to the 2019 American Geriatrics Society Beers Criteria.

METHODS:

This study is a prospective analysis of electronic medical records of elderly patients admitted to the Department of Medicine, Hospital Central da Irmandade da Santa Casa de Misericórdia de São Paulo, between 1 September 2020 and 30 April 2021.

RESULTS:

A total of 142 patients (85 women and 57 men) with a mean age of 74.5±7.3 years (65–99 years) were assessed. Of these, 108 (76.1%) were elderly (age ≥65 years and <80 years) and 34 (23.9%) long-lived (age ≥80 years). The average length of stay found in the sample was 25.3±28.7 days (between 2 and 235 days), and 102 out of the 140 patients assessed remained in the hospital for up to 29 days. Sixteen drugs considered potentially inappropriate medication were found in the patients’ prescriptions, with at least one potentially inappropriate medication having been prescribed to 141 (99.3%) patients. Elderly patients had a mean of 2.57±0.94 potentially inappropriate medication prescribed versus 2.56±0.89 among long-lived patients. The most prescribed potentially inappropriate medication were as follows: regular human insulin as required (85.2%), and omeprazole (73.9%) and metoclopramide as required (61.3%).

CONCLUSION:

The study sample showed significant percentages of potentially inappropriate medication prescriptions for the elderly admitted to the hospital.

A machine learning-based risk warning platform for potentially inappropriate prescriptions for elderly patients with cardiovascular disease

Potentially inappropriate prescribing (PIP), including potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs), is a major risk factor for adverse drug reactions (ADRs). Establishing a risk warning model for PIP to screen high-risk patients and implementing targeted interventions would significantly reduce the occurrence of PIP and adverse drug events. Elderly patients with cardiovascular disease hospitalized at the Sichuan Provincial People's Hospital were included in the study. Information about PIP, PIM, and PPO was obtained by reviewing patient prescriptions according to the STOPP/START criteria (2nd edition). Data were divided into a training set and test set at a ratio of 8:2. Five sampling methods, three feature screening methods, and eighteen machine learning algorithms were used to handle data and establish risk warning models. A 10-fold cross-validation method was employed for internal validation in the training set, and the bootstrap method was used for external validation in the test set. The performances were assessed by area under the receiver operating characteristic curve (AUC), and the risk warning platform was developed based on the best models. The contributions of features were interpreted using SHapley Additive ExPlanation (SHAP). A total of 404 patients were included in the study (318 [78.7%] with PIP; 112 [27.7%] with PIM; and 273 [67.6%] with PPO). After data sampling and feature selection, 15 datasets were obtained and 270 risk warning models were built based on them to predict PIP, PPO, and PIM, respectively. External validation showed that the AUCs of the best model for PIP, PPO, and PIM were 0.8341, 0.7007, and 0.7061, respectively. The results suggested that angina, number of medications, number of diseases, and age were the key factors in the PIP risk warning model. The risk warning platform was established to predict PIP, PIM, and PPO, which has acceptable accuracy, prediction performance, and potential clinical application perspective.

Drug-Drug Interactions in Elderly Patients with Potentially Inappropriate Medications in Primary Care, Nursing Home and Hospital Settings: A Systematic Review and a Preliminary Study

Drug–drug interactions (DDI) occurring with potentially inappropriate medications (PIM) are additional risk factors that may increase the inappropriate character of PIM. The aim of this study was (1) to describe the prevalence and severity of DDI in patients with PIM and (2) to evaluate the DDI specifically regarding PIM. This systematic review is based on a search carried out on PubMed and Web-of-Science from inception to June 30, 2020. We extracted data of original studies that assessed the prevalence of both DDI and PIM in elderly patients in primary care, nursing home and hospital settings. Four hundred and forty unique studies were identified: 91 were included in the qualitative analysis and 66 were included in the quantitative analysis. The prevalence of PIM in primary care, nursing home and hospital were 19.1% (95% confidence intervals (CI): 15.1–23.0%), 29.7% (95% CI: 27.8–31.6%) and 44.6% (95% CI: 28.3–60.9%), respectively. Clinically significant severe risk-rated DDI averaged 28.9% (95% CI: 17.2–40.6), in a hospital setting; and were approximately 7-to-9 lower in primary care and nursing home, respectively. Surprisingly, only four of these studies investigated DDI involving specifically PIM. Hence, given the high prevalence of severe DDI in patients with PIM, further investigations should be carried out on DDI involving specifically PIM which may increase their inappropriate character, and the risk of adverse drug reactions.

Prescribing potentially inappropriate medications for the elderly according to Beers Criteria: systematic review

The study aimed to perform a systematic review to identify and evaluate the prevalence of potentially inappropriate medicines (PIM) prescriptions for the elderly, according to Beers Criteria, in hospitalized elderly individuals aged 65 years or older. Five databases consulted: VHL; Cochrane Library; CINAHL; MEDLINE and Web of Science. Nineteen articles identified, selected based on eligibility criteria. The mean age was 78.2 years and the most used criterion for the identification of PIM for the elderly was Beers 2015 (57.9%). A total of 221,879 elderly received a prescription for PIM, the mean prevalence was 65.0%, for the gastrointestinal system (15.3%) and proton-pump inhibitors (27.7%) highlighted as the main class of medicine prescribed. It concluded that the Beers Criteria have made it possible to identify the high prevalence in the prescription of PIM. The results of this review may help in the decision making of health professionals, to avoid the administration of PIM and to propose best practices to ensure the safety of the elderly hospitalized.

Adverse Drug Events in Older Adults: Review of Adjudication Methods in Deprescribing Studies

OBJECTIVES

Polypharmacy is common in older adults and associated with adverse drug events (ADEs). Several methods have been described in studies to help correlate ADE causation. We performed a narrative review to identify methods for ADE adjudication. We compared their strengths and limitations to assess their applicability to deprescribing studies (of which clinical trials are a subset) and to encourage the use of a standardized method in future studies.

DESIGN

We performed a review of original articles (1946-2019) using the Medline (Ovid) and Cochrane databases. We also conducted a manual reference search of review articles. Abstracts were screened for relevance.

MEASUREMENTS

Adjudication methods were compared for advantages and limitations including validity, ease of use, and applicability to clinical trials with deprescribing as the primary intervention.

RESULTS

The search yielded 1881 articles of which 175 articles were included for full-text review. Following in-depth review, 135 were excluded: 79 had no ADE outcome data, 35 were not specific to older adults, 9 were not relevant, 6 were review articles, 5 contained duplicate data, and 1 was not written in French or English. Forty articles remained for analysis, from which we identified 10 unique ADE adjudication methods. No method was developed originally for use in a deprescribing setting.

CONCLUSION

A standard method to identify ADEs is important to capture the outcome reliably in deprescribing studies. All methods we identified had limitations in terms of capturing adverse events from the withdrawal of medications. Future work should focus on refining adjudication methods for capturing ADEs related not only to medication continuation and new drug starts but also to deprescribing and drug discontinuation. J Am Geriatr Soc 68:1594-1602, 2020.

Prevalence of drug interactions in hospitalised elderly patients: a systematic review

BACKGROUND

The prevalence of drug-drug interactions (DDIs) in hospital settings is variable, and elderly patients are considered a high risk population for DDIs. There are no systematic reviews describing the prevalence of DDIs in hospitalised elderly patients.

OBJECTIVES

To assess and summarise the available data on the prevalence of DDIs in hospitalised elderly patients and to describe which drugs, drug classes and drug combinations are most commonly involved in DDIs.

DATA SOURCE

A systematic electronic literature search was conducted on Medline/PubMed, Embase, Lilacs, SciElo, Web of Science, Cinahl, Scopus, Cochrane, OpenGrey, Capes Thesis Bank, OasisBR, OpenAire and abstracts from scientific events, without limitation on language or period of publication. Study selection was completed on 21 September 2018.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS

Original observational studies that reported the prevalence of actual or potential DDIs during hospitalisation in patients aged 60 years or older were included. The main outcome measure was prevalence of DDIs and number of DDIs per patient. Subgroup analysis was performed in studies that reported the prevalence of DDIs in geriatric units.

STUDY APPRAISAL AND SYNTHESIS METHODS

Study quality was assessed using the Agency for Healthcare Research and Quality methodological checklist for cross sectional and prevalence studies.

RESULTS

34 studies were included, involving 9577 patients. The prevalence of DDIs ranged from 8.34% to 100%. In studies conducted in geriatric units, the prevalence ranged from 80.5% to 90.5%. The number of DDIs per patient ranged from 1.2 to 30.6. Single drugs most commonly involved in DDIs were furosemide, captopril, warfarin and dipyrone. Drug classes mostly involved were potassium sparing diuretics and angiotensin converting enzyme inhibitors.

LIMITATIONS

The main limitation is the heterogeneity between the included studies that precluded a meta-analysis. Several different methods were used to identify DDIs, majorly, and potential DDIs. Few studies have reported measures to control the quality of the collected data.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

The prevalence of DDIs ranged widely, and the variation may reflect differences in the conditions of the elderly patients and level of attention (or complexity of care), as well as methodological differences, especially the methods and/or software used to identify DDIs.

SYSTEMATIC REVIEW REGISTRATION NUMBER

CRD42018096720.

Assessment of prescribing potentially inappropriate medications listed in Beers criteria and its association with the unplanned hospitalization: a cross-sectional study in Lahore, Pakistan

BACKGROUND AND OBJECTIVES

Due to physiological and pharmacological variations, geriatrics are at high risk of experiencing life-threatening outcomes related to the use of potentially inappropriate medications (PIMs). Thus, the present study aims to evaluate prescribing practices of PIMs among elderly patients who may lead to unplanned hospitalization and associated risk factors.

METHODS

A cross-sectional study was conducted in different hospitals of Lahore, Pakistan. The study population consisted of geriatric patients aged ≥65 years. Data were collected from the medical records of geriatric patients, who attended these selected hospitals between December 1, 2017, and February 28, 2018. Data were analyzed using SPSS (IBM SPSS Statistics for Windows, Version 21.0) and Microsoft Excel (MS Office 2010).

RESULTS

The records of 385 geriatric patients were investigated. More than half (60.8%) of the patients were subjected to polypharmacy, which can be defined as the utilization of 5-9 drugs by the patient at the same time, whereas 36.4% were prescribed with one PIM and 56.4% were hospitalized due to PIMs. Majority of them were prescribed with PIMs including N02BA01 (aspirin, 32.4%), A02BC01 (omeprazole, 23.6%), A10AB02 (insulin, 17.4%), A02BC05 (esomeprazole, 8.5%), C08CA01 (amlodipine, 8.3%), and R06AA02 (diphenhydramine, 5.9%). Results of regression analysis revealed that patients exposed to polypharmacy (OR=2.556, 95% CI=1.579-4.135, P-value≤0.001) and excessive polypharmacy (OR=37.828, 95% CI=4.754-300.9, P-value≤0.001) were significantly associated with unplanned hospitalization, whereas factors such as age 75-84 years (OR=0.343, 95% CI=0.156-0.756, P-value=0.008) and polypharmacy (OR=2.480, 95% CI=1.219-5.048, P-value=0.012) were significantly correlated with PIMs.

CONCLUSION

The utilization of PIMs listed in Beers criteria among geriatric population can cause unplanned hospitalization. As the patients receiving polypharmacy are at high risk of unplanned hospitalization, so caution must be exercised in prescribing PIMs for elderly people.

Influence of Education Level of Older Patients on Polypharmacy, Potentially Inappropriate Medications Listed in Beer's Criteria, and Unplanned Hospitalization: A Cross-Sectional Study in Lahore, Pakistan

Objective: To evaluate influence of education level of older patients on polypharmacy, potentially inappropriate medications (PIMs) listed in Beer’s Criteria, and unplanned hospitalization. Methods: A cross-sectional study was conducted among older people aged ≥65 years between 1 December 2017 and 28 February 2018. For data analysis, descriptive statistics and logistic regression analysis were employed. Results: Among 385 older patients, 88.8% were prescribed PIMs and 56.4% underwent PIMs associated unplanned hospitalization. Older people were less exposed to polypharmacy or excessive polypharmacy as their education levels increased (no formal education vs. primary vs. secondary vs. tertiary, 74% vs. 69.8% vs. 60.5% vs. 58.1%). Patients having higher education were also accompanied by significantly lower prescription of PIMs (no formal education vs. primary vs. secondary vs. tertiary, 96% vs. 87.3% vs. 84.5% vs. 79.1%) as well as unplanned hospitalization (no formal education vs. primary vs. secondary vs. tertiary, 64.7% vs. 76.2% vs. 40.3% vs. 46.5%). Results of regression analysis revealed that no formal education (OR = 1.202, 95% CI = 1.032–2.146, p-value = 0.003) and primary education level (OR = 1.175, 95% CI = 1.014–1.538, p-value = 0.039) were significantly associated with the use of polypharmacy among older people. On the other hand, no formal education was significantly associated with the prescription of PIMs (OR = 1.898, 95% CI = 1.151–2.786, p-value = 0.007). Furthermore, older people with no formal education (OR = 1.402, 95% CI = 1.123–1.994, p-value = 0.010) and primary education level (OR = 1.775, 95% CI = 1.281–3.018, p-value = <0.001) were significantly more likely to undergo unplanned hospitalization. Conclusions: Patients having low literacy level are more likely to receive PIMs, polypharmacy, and undergo unplanned hospitalization in comparison to highly educated patients. Hence, promotion of health literacy for patients is crucial to overcome these problems.

Adverse-Drug-Reaction-Related Hospitalisations in Developed and Developing Countries: A Review of Prevalence and Contributing Factors

Adverse drug reactions (ADRs) are one of the leading causes of hospital admissions and morbidity in developed countries and represent a substantial burden on healthcare delivery systems. However, there is little data available from low- and middle-income countries. This review compares the prevalence and characteristics of ADR-related hospitalisations in adults in developed and developing countries, including the mortality, severity and preventability associated with these events, commonly implicated drugs and contributing factors. A literature search was conducted via PubMed, Scopus, Web of Science, Embase, ProQuest and Google Scholar to find articles published in English from 2000 to 2015. Relevant observational studies were included. The median (with interquartile range [IQR]) prevalence of ADR-related hospitalisation in developed and developing countries was 6.3 % (3.3-11.0) and 5.5 % (1.1-16.9), respectively. The median proportions of preventable ADRs in developed and developing countries were 71.7 % (62.3-80.0) and 59.6 % (51.5-79.6), respectively. Similarly, the median proportions of ADRs resulting in mortality in developed and developing countries were 1.7 % (0.7-4.8) and 1.8 % (0.8-8.0), respectively. Commonly implicated drugs in both settings were antithrombotic, non-steroidal anti-inflammatory and cardiovascular drugs. Older age, female gender, number of medications, renal impairment and heart failure were reported to be associated with an increased risk for ADR-related hospitalisation in both settings while HIV/AIDS was implicated in developing countries only. The majority of ADRs were preventable in both settings, highlighting the importance of improving medication use, particularly in vulnerable patient groups such as the elderly, patients with multiple comorbidities and, in developing countries, patients with HIV/AIDS.

Prevalence of potentially serious drug-drug interactions among South African elderly private health sector patients using the Mimica Matanović/Vlahović-Palčevski protocol

OBJECTIVES

To determine the prevalence of potentially serious drug-drug interactions (DDIs) and their relationship with gender and age, among elderly in South Africa.

METHODS

A cross-sectional study was conducted using pharmaceutical claims data for 2013, for a total of 103 420 medical scheme beneficiaries' ≥65 years. All medications dispensed within one calendar month where the days' supply of medication dispensed overlapped, were grouped as one prescription. DDIs per prescription were then identified using the Mimica Matanović/Vlahović-Palčevski DDI protocol. Results were interpreted using effect sizes, that is Cramér's V, Cohen's d and Cohen's ƒ² .

KEY FINDINGS

A total of 331 659 DDIs were identified on 235 870 (25.8%, N = 912 713) prescriptions (mean 0.36 (SD 0.7) (95% CI, 0.36 to 0.37)). Women encountered 63.5% of all DDIs. Effect sizes for the association between DDIs and age group (Cramér's V = 0.06), and gender (Cramér's V = 0.05) was negligible. There was no difference between men and women regarding the mean number of DDIs identified per prescription (Cohen's d = 0.10). The number of medicine per prescription (ƒ² = 0.51) was the biggest predictor of the DDIs. The most frequent interacting drug combinations were between central nervous system medicines (30.6%).

CONCLUSION

Our study is the first to report the prevalence of potentially serious DDIs among an elderly population in the South African private health sector utilising the Mimica Matanović/Vlahović-Palčevski DDI protocol. Overall, we identified DDIs in approximately 26% of the prescriptions in our study. Age and gender were not found to be predictors of potentially serious DDIs.

Potentially inappropriate medicines in elderly hospitalised patients according to the EU(7)-PIM list, STOPP version 2 criteria and comprehensive protocol

PURPOSE

The aim of this study was to measure the prevalence of potentially inappropriate medications (PIMs) by using the EU(7)-PIM list, STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions) version 2 criteria and the new comprehensive protocol.

METHODS

This prospective study involved a sample of 276 consecutive elderly patients discharged from the university teaching hospital. Age, gender, diagnoses, medication history and medicines at discharge were recorded. The main outcome measure was the prevalence of PIMs according to each set of criteria: EU(7)-PIM list, STOPP version 2 criteria and comprehensive protocol.

RESULTS

The median patient age (range) was 74 (65-92) years. The median number of prescribed medications was 7 (1-17). STOPP identified 393 PIMs affecting 190 patients (69%), EU(7)-PIM list identified 330 PIMs in 184 patients (66.7%) whilst the comprehensive protocol identified 134 PIMs in 102 patients (37%). STOPP version 2 criteria identified significantly more PIMs per patient than the other two protocols (p < 0.001). Gender (p = 0.002), glomerular filtration rate (p = 0.039) and number of comorbidities (p = 0.001) were associated with the proportion of PIMs for the STOPP version 2 criteria only.

CONCLUSION

A very high PIM prevalence at discharge was reported suggesting the urgent need for actions to reduce them. STOPP version 2 criteria identified significantly more PIMs than the EU(7)-PIM list and the comprehensive protocol and was found as a more sensitive tool for PIM detection.

Potentially inappropriate prescribing andthe risk of adverse drug reactions in critically ill older adults

Background:

Potentially inappropriate medication (PIM) use in the elderly is associated with increased risk of adverse drug reactions (ADRs), but there is limited information regarding PIM use in the intensive care unit (ICU) setting.

Objective:

The aim of the study is to describe the prevalence and factors associated with the use of PIM and the occurrence of PIM-related adverse reactions in the critically ill elderly.

Methods:

This study enrolled all critically ill older adults (60 years or more) admitted to medical or cardiovascular ICUs between January and December 2013, in a large tertiary teaching hospital. For all patients, clinical pharmacists listed the medications given during the ICU stay and data on drugs were analyzed using 2012 Beers Criteria, to identify the prevalence of PIM. For each identified PIM the medical records were analyzed to evaluate factors associated with its use. The frequency of ADRs and, the causal relationship between PIM and the ADRs identified were also evaluated through review of medical records.

Results:

According to 2012 Beers Criteria, 98.2% of elderly patients used at least one PIM (n=599), of which 24.8% were newly started in the ICUs. In 29.6% of PIMs, there was a clinical circumstance that justified their prescription. The number of PIMs was associated with ICU length of stay and total number of medications. There was at least one ADR identified in 17.8% of patients; more than 40% were attributed to PIM, but there was no statistical association.

Conclusions:

There is a high prevalence of PIM used in acutely ill older people, but they do not seem to be the major cause of adverse drug reactions in this population. Although many PIMs had a clinical circumstance that led to their prescription during the course of ICU hospitalization, many were still present upon hospital discharge. Therefore, prescription of PIMs should be minimized to improve the safety of elderly patients.

Utilização de medicamentos potencialmente inapropriados por idosos em domicílio

Resumo O objetivo foi avaliar a frequência de utilização em domicílio de medicamentos potencialmente inapropriados por idosos e analisar a significância clínica. Trata-se de estudo transversal retrospectivo, recorte de um estudo de utilização de medicamentos desenvolvido em um hospital público. Os medicamentos inapropriados foram classificados empregando os três grupos de critérios explícitos incluídos na Lista de Beers de 2012. Houve inclusão de 190 idosos na pesquisa e a prevalência encontrada para utilização de medicamentos inapropriados foi 44,2%. As classes terapêuticas de medicamentos inapropriados mais utilizados foram antiinflamatórios não esteroidais, agentes cardiovasculares, benzodiazepínicos e antidepressivos. Identificou-se associação positiva entre utilização de medicamentos inapropriados e polifarmácia, polipatologia e hipertensão. Na Rename 2013 identificou-se 35(34,3%) fármacos inapropriados. O estudo demonstrou alta prevalência de utilização de medicamentos inapropriados pelos idosos. As consequências clínicas da utilização de medicamentos inapropriados são importantes para a saúde pública devido ao risco de eventos adversos e impacto negativo na funcionalidade do idoso. Na atenção ao idoso é importante desenvolver ações para promover o uso racional de medicamentos.

[Potentially inappropriate medications in geriatrics: Which tools to detect them?]

BACKGROUND

Potentially inappropriate prescriptions include over-prescription, which refers to prescription of more drugs than clinically needed, mis-prescription which refers to incorrect prescription of a drug that is needed (as per drug, dose, drug interactions, duration of therapy, duplication, follow-up, etc.) and under-prescription which stands for failure to prescribe drugs that are needed. They are associated with adverse drug events, increased use of health-care services, morbimortality and health-care costs, and poorer quality of life. Due to polymorbidity and polypharmacy, potentially inappropriate prescription is common among the elderly. In the last 2 decades, explicit indicators to detect inappropriate prescriptions were developed in geriatrics.

OBJECTIVE

The aim of this review is to summarize, compare and critically review existing explicit criteria.

DOCUMENTARY SOURCES AND STUDY SELECTION

We conducted a systematic literature search in PubMed, Embase, Cochrane Library and Google Scholar, from January 1991 to November 2015. The following keywords were used: "("inappropriate prescribing" [MeSH Terms] OR "medication errors" [MeSH Terms] AND "potentially inappropriate medications" [MeSH Terms] AND "elderly" [MeSH All field] AND "explicit criteria" [MeSH Terms])". Articles describing the development of new list of explicit indicators dedicated to geriatrics, in English and in French, were included in this review. Their characteristics, organization, content, and assessments of their validity and of the optimal tool for geriatrics are presented.

RESULTS

Fourteen lists of explicit indicators were included in the review. An organization based on physiological systems and pathologies, as observed in ACOVE, 5th version of Beers criteria and STOPP/START enables quick application in general practice. A low overlap among criteria was observed between tools. This may be due to a lack of completeness for some tools. Mimica, ACOVE, PIEA, and STOPP/START are the most exhaustive ones, only the last three addressing the under-prescription issue. Finally, the ability to detect and reduce inappropriate prescriptions has only been evaluated for few tools; STOPP/START is the only one, which has demonstrated its ability to reduce them in a prospective study.

Potentially inappropriate medications in elderly ambulatory and institutionalized patients: an observational study

Background

The elderly are frequently exposed to drug related problems causing hospitalizations and increased costs of care. Information about Romanian prescribing practices among the elderly and potential medication associated- risks is lacking. The objective of this study was to identify and compare the most frequent potentially inappropriate medications (PIM) recommended to ambulatory and institutionalized Romanian elderly, through an observational retrospective design.

Methods

All reimbursed medications prescribed to a sample of ambulatory elderly accessing two community pharmacies and all medications recommended to a group of institutionalized elderly (urban facilities, Romania, same month) were analyzed. The STOPP/START criteria and the PRISCUS list were used for PIM identification and for classification as misprescribed, underprescribed or overprescribed -subtypes.

Results

The analysis involved 345 prescriptions recommended to ambulatory elderly and 91 medical files available for the institutionalized patients. The ambulatory elderly had a mean age of 74.8 years old and were daily exposed to a median number of 3 prescribed medications. The institutionalized elderly were older (mean age 80.77) received 8 medications daily and 69 % of them were functionally dependent. Cardiovascular and neuropsychiatric indications were the most frequent: 64.34 % and 18.55 % of the ambulatory prescriptions, 93.40 % and 41.75 % of the institutionalized patients’ medical files. 159 PIM were identified on 34.49 % of the ambulatory prescriptions. 82.41 % of the institutionalized patients’ medical files contained 140 PIM. The potential underprescribing of cardiovascular therapies was the most frequent PIM category on the ambulatory prescriptions (55.34 % of all PIM), while for the institutionalized patients’ medical files, the misprescribed and overprescribed PIM were those predominantly represented (62.14 % and 27.14 % of all PIM). In both subgroups of data, NSAIDs (56.66 % of ambulatory prescriptions and 35.63 % of institutionalized patients’ data) and benzodiazepines (26.66 % of ambulatory prescriptions and 24.13 % of institutionalized patient’s data) were predominantly misprescribed. Anticholinergics were rarely used (0.62 % of total PIM from ambulatory prescriptions, 2.14 % of total PIM from institutionalized patients’ data).

Conclusions

The PIM identified in both elderly groups suggested potential risks for the occurrence of adverse events specific to the elderly population. Larger studies, both observational and interventional, are needed to ensure a safer therapeutic approach.

Polypharmacy among the elderly in the Republic of Srpska: extent and implications for the future

The prescribing of medicines is a fundamental component of care for the elderly; however, there is increasing concern with polypharmacy and its impact on morbidity, mortality and costs. As a result, long-term prescription-medicine use and the prevalence of polypharmacy in the elderly in the Republic of Srpska were analyzed. The findings were subsequently used to suggest potential future measures. A retrospective study of all elderly patients during 2005-2010 stratified by age group (three groups), sex and long-term medicine use was performed. Polypharmacy (five or more medicines) increased from 1.4% of the elderly taking medicines long-term to 3.6% by 2010, with 53.6% of elderly taking two or more medicines long-term. The most prevalent diseases were cardiovascular diseases and diabetes. Most prescriptions were in accordance with recent guidelines; however, there was a concern with appreciable prescribing of digoxin and aminophylline. Whilst polypharmacy rates are low in the Republic, the increasing rate is a concern. Further studies are planned.

Potentially inappropriate prescribing in elderly outpatients in Croatia

PURPOSE

The purpose of this study was to determine the prevalence of inappropriate prescribing to the elderly and to identify possible gender-related differences in prescribing certain potentially inappropriate medications (PIMs) to outpatients by using large administrative prescription database.

METHODS

Medications prescribed for elderly outpatients (≥ 65 years) in Primorsko-Goranska County, Croatia, who received five or more different drugs simultaneously in 2010, were analyzed. The prevalence of potentially inappropriate drugs prescribed to the elderly was assessed using the new comprehensive protocol developed by authors Mimica Matanović and Vlahović-Palčevski.

RESULTS

A total of 62.4 % of patients received at least one medication with unfavorable benefit/risk ratio in the elderly. Female patients were given inappropriate medications in a significantly higher percentage than men (69.3 % vs. 50.5 %; p < 0.001). The average number of prescriptions for PIMs that should have been avoided with certain diseases or conditions was 0.88 per patient in the survey. The most common drug combination potentially leading to serious drug-drug interactions (DDIs) included an angiotensin-converting enzyme (ACE) inhibitor and a potassium supplement.

CONCLUSIONS

Our study has shown that every tenth medication prescribed to a patient > 65 years and receiving five or more drugs was potentially inappropriate. Elderly women were prescribed PIMs more often than men. Drugs of concern in female patients were benzodiazepines, antidepressants, and nonsteroidal anti-inflammatory drugs (NSAIDs). In male patients, there was a significantly higher proportion of possible interactions with warfarin, theophylline, and medications affecting the cardiovascular system, such as ACE inhibitors and amiodarone.