Potentially inappropriate medications: predictor for mortality in a cohort of community-dwelling older adults

Effect of the use of potentially inappropriate medications on the mortality of Brazilian older adults: SABE cohort study

OBJECTIVE

Investigate the association between potentially inappropriate medication (PIM) use and the risk of death among community-dwelling older Brazilian adults.

METHODS

Participants from the Health, Well-Being, and Aging Cohort Study (SABE) in São Paulo, Brazil, between 2000 and 2016 were included. The dependent variable was all-cause mortality, measured as the time elapsed until death. The exposure of interest was the use of PIM according to the Beers Criteria 2019 version. All covariates, except for sex and education, were considered time-varying.

RESULTS

PIM use was not associated with mortality after adjusting for covariates (HR = 0.99; 95 % CI: 0.88-1.12). There was a significant interaction between PIM use and age (HR = 0.98; 95 % CI: 0.96-0.99).

CONCLUSION

The association between PIM use and the risk of death was moderated by age. Future studies should consider the impact of necessary medication omissions when assessing the mortality risk associated with PIM use.

Assessment of Potentially Inappropriate Prescribing for People With Type 2 Diabetes Mellitus Using IMPACT2DM, a New Explicit Tool

Background: People with type 2 diabetes mellitus (T2DM) are at greater risk of potentially inappropriate prescribing (PIP) due to multiple comorbidities and polypharmacy. IMPACT2DM (Inappropriate Medication Prescribing Assessment Criteria for Type 2 Diabetes Mellitus) is a tool designed to identify PIP for adults with T2DM. Objectives: To assess PIP for adults with T2DM in Ethiopia using the IMPACT2DM and to test the face validity and clinical validity of the tool. Methods: A cross-sectional study was undertaken using data extracted retrospectively from the medical records of adults being managed for T2DM at Debretabore Hospital. PIP was assessed using IMPACT2DM. Some items/item components of IMPACT2DM were modified to increase the tool's applicability for the outpatient setting, to clarify content or to use the terms most common in this particular setting. Multivariant logistic regression analyses were conducted to identify factors associated with PIP. Results: More than 90% of medical records had at least 1 PIP. Prescribing omission (80.9%) was the most commonly identified type of PIP. Adults with prescribing omissions are more likely to be ≥40 years old or to be prescribed with <5 medications. Adults with dosing problems were more likely ≥50 years old, or have had a fasting blood sugar (FBS) level out of the target range (80-130 mg/dL). Conclusions: IMPACT2DM is a clinically valid PIP identification tool for application in an Ethiopian outpatient setting. Health professionals should be alert to check for potential prescribing omissions for adults ≥40 years old and dosing problems for adults with an FBS level out of the target range or >50 years.

Potentially inappropriate medication use is associated with increased risk of incident disability in healthy older adults

BACKGROUND

Efforts to minimize medication risks among older adults include avoidance of potentially inappropriate medications (PIMs). However, most PIMs research has focused on older people in aged or inpatient care, creating an evidence gap for community-dwelling older adults. To address this gap, we investigated the impact of PIMs use in the ASPirin in Reducing Events in the Elderly (ASPREE) clinical trial cohort.

METHODS

Analysis included 19,114 community-dwelling ASPREE participants aged 70+ years (65+ if US minorities) without major cardiovascular disease, cognitive impairment, or significant physical disability. PIMs were defined according to a modified 2019 AGS Beers Criteria. Cox proportional-hazards regression models were used to estimate the association between baseline PIMs exposure and disability-free survival, death, incident dementia, disability, and hospitalization, with adjustment for sex, age, country, years of education, frailty, average gait speed, and comorbidities.

RESULTS

At baseline, 7396 (39% of the total) participants were prescribed at least one PIM. Compared with those unexposed, participants on a PIM at baseline were at an increased risk of persistent physical disability (adjusted hazard ratio [HR] 1.47, 95% confidence interval [CI] 1.21, 1.80) and hospitalization (adjusted HR 1.26, 95% CI 1.20, 1.32), but had similar rates of disability-free survival (adjusted HR 1.02; 95% CI 0.93, 1.13) and death (adjusted HR 0.92, 95% CI 0.81, 1.05). These effects did not vary by polypharmacy status in interaction analyses. PIMs exposure was associated with higher risk of disability followed by hospitalization (adjusted HR 1.92, 95% CI 1.25, 2.96) as well as vice versa (adjusted HR 1.54, 95% CI 1.15, 2.05). PPIs, anti-psychotics and benzodiazepines, were associated with increased risk of disability.

CONCLUSIONS

PIMs exposure is associated with subsequent increased risk of both incident disability and hospitalization. Increased risk of disability prior to hospitalization suggests that PIMs use may start the disability cascade in healthy older adults. Our findings emphasize the importance of caution when prescribing PIMs to older adults in otherwise good health.

Clinical pharmacist intervention to improve medication safety for hip fracture patients through secondary and primary care settings: a nonrandomised controlled trial

BACKGROUND

Hip fracture patients face a patient safety threat due to medication discrepancies and adverse drug reactions when they have a combination of high age, polypharmacy and several care transitions. Consequently, optimised pharmacotherapy through medication reviews and seamless communication of medication information between care settings is necessary. The primary aim of this study was to investigate the impact on medication management and pharmacotherapy. The secondary aim was to evaluate implementation of the novel Patient Pathway Pharmacist intervention for hip fracture patients.

METHODS

Hip fracture patients were included in this nonrandomised controlled trial, comparing a prospective intervention group (n = 58) with pre-intervention controls who received standard care (n = 50). The Patient Pathway Pharmacist intervention consisted of the steps: (A) medication reconciliation at admission to hospital, (B) medication review during hospitalisation, (C) recommendation for the medication information in the hospital discharge summary, (D) medication reconciliation at admission to rehabilitation, and (E) medication reconciliation and (F) review after hospital discharge. The primary outcome measure was quality score of the medication information in the discharge summary (range 0-14). Secondary outcomes were potentially inappropriate medications (PIMs) at discharge, proportion receiving pharmacotherapy according to guidelines (e.g. prophylactic laxatives and osteoporosis pharmacotherapy), and all-cause readmission and mortality.

RESULTS

The quality score of the discharge summaries was significantly higher for the intervention patients (12.3 vs. 7.2, p < 0.001). The intervention group had significantly less PIMs at discharge (- 0.44 (95% confidence interval - 0.72, - 0.15), p = 0.003), and a higher proportion received prophylactic laxative (72 vs. 35%, p < 0.001) and osteoporosis pharmacotherapy (96 vs. 16%, p < 0.001). There were no differences in readmission or mortality 30 and 90 days post-discharge. The intervention steps were delivered to all patients (step A, B, E, F = 100% of patients), except step (C) medication information at discharge (86% of patients) and step (D) medication reconciliation at admission to rehabilitation (98% of patients).

CONCLUSION

The intervention steps were successfully implemented for hip fracture patients and contributed to patient safety through a higher quality medication information in the discharge summary, fewer PIMs and optimised pharmacotherapy.

TRIAL REGISTRATION

NCT03695081.

Medication management for patients with hip fracture at a regional hospital and associated primary care units in Norway: a descriptive study based on a survey of clinicians' experience and a review of patient records

OBJECTIVE

Patients with hip fracture are at high risk of medication errors due to a combination of high age, comorbidities, polypharmacy and several care transitions after fracture. The aim was to study medication management tasks concerning patient safety: medication reconciliation, medication review and communication of key medication information in care transitions.

DESIGN

Descriptive study comprising a self-administered clinician survey (MedHipPro-Q) and a retrospective review of hospital medical records of patients with hip fracture.

SETTING

Regional hospital and the associated primary care units (South-Eastern Norway).

PARTICIPANTS

The survey received responses from 253 clinicians, 61 medical doctors and 192 nurses, involved in the medication management of patients with hip fracture, from acute admittance to the regional hospital, through an in-hospital fast track, primary care rehabilitation and back to permanent residence. Respondents' representativeness was unknown, introducing a risk of selection and non-response bias, and extrapolating findings should be done with caution. The patient records review included a random sample of records of patients with hip fracture (n=50).

OUTCOME MEASURES

Medication reconciliation, medication review and communication of medication information from two perspectives: the clinicians' (ie, experiences with medication management) and the practice (ie, documentation of completed medication management).

RESULTS

In the survey, most clinicians stated they performed medication reconciliation (79%) and experienced that patients often arrived without a medication list after care transition (37%). Doctors agreed that more patients would benefit from medication reviews (86%). In the hospital patient records, completed medication reconciliation was documented in most patients (76%). Medication review was documented in 2 of 50 patients (4%). Discharge summary guidelines were followed fully for 3 of 50 patients (6%).

CONCLUSION

Our study revealed a need for improved medication management for patients with hip fracture. Patients were at risk of medication information not being transferred correctly between care settings, and medication reviews seemed to be underused in clinical practice.

Risk factors for potentially inappropriate medication use in older adults: a cohort study

BACKGROUND

Much of the knowledge on the use of potentially inappropriate medications (PIM) in older adults is derived from cross-sectional studies, with little known about the risk factors over time.

AIM

Longitudinal analysis was applied to estimate the occurrence and risk factors of PIM use among older adults in a 10-year follow-up.

METHOD

Longitudinal study with 418 older adult residents of a capital city of Central-West Brazil. The PIM were classified according to the Beers criteria 2019. The usage rate was calculated at baseline (2008) and at the 10-year follow-up moment (2018). Analysis of predictors (sociodemographic, self-rated health, hospitalization, number of comorbidities, polypharmacy, diabetes, hypertension, hypercholesterolemia and nutritional status) was performed using Generalized Estimating Equation (GEE) models.

RESULTS

Mean age at baseline was 70.6 years (SD 7.1) and 76% were women; 221 older adults took part in the follow up. The rate of PIM use was 50.4% at baseline and 57.5% at the 10-year follow-up. Multiple analysis showed that PIM use in the cohort was statistically higher in the older adults with a history of hospitalization (RR_adj 1.20; 95% CI 1.01-1.40), with three or more diseases (RR_adj 1.41; 95% CI 1.14-1.74), with polypharmacy (RR_adj 1.81; 95% CI 1.47-2.24) and with diabetes mellitus (RR_adj 1.24; 95% CI 1.05-1.47).

CONCLUSION

A high level of potentially inappropriate medication use was observed, reaching 50% of the older adults, with a 7% increase in the prevalence over the 10-year follow-up period. Hospitalization, multimorbidities, polypharmacy and diabetes mellitus were associated with the use of these medications. Interventions for surveillance of the deprescribing process need to be encouraged to avoid potential harm caused by the use of medications.

Assessment of Potentially Inappropriate Medications Using the EU (7)-PIM List, in a Sample of Portuguese Older Adults' Residents in Nursing Homes

Abstract

Prescription of potentially inappropriate medication (PIM) in older adults is associated with poor clinical outcomes. The EU (7)-PIM list was created for the European market to improve pharmacotherapy in older adults.

Purpose

This work aims to characterize the medication profile and assess the presence of PIM, using the EU (7)-PIM list in older adults’ residents at nursing homes.

Methods

Retrospective data were collected from the anonymized nursing home records. After PIM identification, a descriptive analysis was performed, and a generalized linear model for dependent negative binomial-type variables was constructed to assess the risk of PIM.

Results

Of the 210 participants (mean age 85.10), 82.40% were polymedicated. PIM was observed in 86.4% participants (mean per patient = 2.30± 0.10). The most common PIM were proton pump inhibitors (n = 121, 57.62%), followed by anxiolytics (n = 96, 45.71%). 64.30% of all patients take 2–4 PIM and 5.80% take five or more PIM. The occurrence of PIM is influenced by the number of prescribed medicines (RR 1.14; 95% CI 1.1.-1.17) and the presence of digestive system diseases (RR 1.05; 95% CI 1.0–1.09).

Conclusion

The high prevalence of PIM observations highlights the necessity of the implementation of guidelines to prevent PIM.

Potentially inappropriate medications at admission among elderly patients transported to a tertiary emergency medical institution in Japan

Aim

Potentially inappropriate medications (PIMs) have been reported to be associated with lower adherence, higher rates of adverse events, and higher health‐care costs in elderly patients with high comorbidity. However, inappropriate prescribing has not been adequately reported in studies of patients transported to tertiary care hospitals. In this study, we investigated PIMs at the time of admission, on the basis of the prescription status of elderly patients admitted to a tertiary emergency room (ER).

Methods

We included 316 patients (168 men and 148 women, aged 75–97 years) who were admitted to our ER from September 2018 to August 2019, whose prescriptions were available on admission. Drugs that met the Screening Tool of Older Persons' Potentially Inappropriate Prescriptions (STOPP) criteria version 2 were defined as PIMs. The primary outcome was the proportion of older adults taking at least one PIM at admission.

Results

The proportion of patients taking PIMs at admission was 57% (n = 179). The most common PIMs were benzodiazepines, proton pump inhibitors, and nonsteroidal anti‐inflammatory drugs. The total number of medications prescribed at admission, prescriptions from multiple institutions, and prescriptions from clinics were the risk factors for PIMs at admission (P < 0.01, P < 0.001, and P < 0.001, respectively).

Conclusion

We must be careful to avoid inappropriate prescribing for patients transported to tertiary care hospitals who have numerous prescriptions at the time of admission, patients who receive prescriptions from multiple medical institutions, and patients who receive prescriptions from clinics.

Potentially inappropriate medications at discharge among elderly patients at a single tertiary emergency medical institution in Japan: a retrospective cross-sectional observational study

Aim

Potentially inappropriate medications (PIMs) are associated with a lower medication adherence and a higher incidence of adverse events and medical costs among elderly patients. The current study aimed to examine the prescription status of elderly patients transported to tertiary emergency medical institutions to compare the proportion of elderly patients using PIMs at admission and discharge and to investigate the characteristics of PIMs at discharge and their associated factors.

Methods

In total, 264 patients aged 75 years or older who were transferred to and discharged from the emergency room at Tokyo Medical University Hospital, a tertiary care hospital, from September 2018 to August 2019 were included in this study. We quantified the number of PIMs at admission and discharge based on the Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions (STOPP) criteria version 2. The primary outcomes were the proportion of elderly patients taking at least one PIM at admission and discharge.

Results

The proportions of patients taking PIMs at admission and discharge were 55% (n = 175) and 28% (n = 74), respectively. Old age, greater number of PIMs at admission, and greater number of medications at discharge were directly associated with PIMs at discharge.

Conclusions

Admission to tertiary care hospitals resulted in a lower number of prescribed PIMs. Elderly patients with a higher number of PIMs at admission and higher number of medications at discharge might have been prescribed with PIMs.

Based on the Beers Criteria 2019 Edition Over-the-Counter Drugs Risk Confirmation of Elderly Chinese

OBJECTIVE

To explore OTC (over-the-counter drugs) in Chinese community pharmacies often causes ADE (adverse drug event) in elderly patients.

METHODS

Use the drugs in the Beers Criteria 2019 potentially inappropriate medication use (PIM) list as search terms. Search for drugs registered on the National Medical Products Administration of China website before December 2019 to determine the drugs containing PIM active ingredients and, then, search the Chinese OTC selection and conversion catalog database to determine it as OTC. Two databases are considered to be the same drug if they have the same drug composition.

RESULTS

The incidence of PIM in elderly patients in our community is relatively high, and the management of OTC may be related to risk factors. Statistics found that 71 OTC contained the Beers Criteria ingredients, including 65 chemicals and six Chinese patent medicines. Varieties of compound preparations accounted for 78.9% and cold medicines accounted for 47.9%.

CONCLUSIONS

The high detection rate of the Beers Criteria in Chinese OTC suggests that medical practitioners in China, especially community pharmacists, should pay attention to the rational use of OTC in the elderly.

A multidimensional measure of polypharmacy for older adults using the Health and Retirement Study

Polypharmacy is commonly defined based on the number of medications taken concurrently using standard cut-offs, but several studies have highlighted the need for a multidimensional assessment. We developed a multidimensional measure of polypharmacy and compared with standard cut-offs. Data were extracted for 2141 respondents of the 2007 Prescription Drug Survey, a sub-study of the Health Retirement Study. Latent classes were identified based on multiple indicators of polypharmacy, including quantity, temporality and risk profile. A four-class model was selected based on fit statistics and clinical interpretability: 'High risk, long-term' (Class 1), 'Low risk, long-term' (Class 2), 'High risk, short-term' (Class 3), and 'High risk for drug interactions, medium-term, regular' (Class 4). Classes differed regarding sex, cohabitation, disability and multimorbidity. Participants in the 'low risk' class tended to be male, cohabitating, and reported fewer health conditions, compared to 'high risk' classes. Polypharmacy classes were compared to standard cut-offs (5+ or 9+ medications) in terms of overlap and mortality risk. The three 'high risk' classes overlapped with the groups concurrently taking 5+ and 9+ medications per month. However, the multidimensional measure further differentiated individuals in terms of risk profile and temporality of medication taking, thus offering a richer assessment of polypharmacy.

Disparities in all-cause mortality with potentially inappropriate medication use: Analysis of the Reasons for Geographic and Racial Differences in Stroke study

OBJECTIVES

Health disparities across different socioeconomic subgroups have been reported in previous studies. Mortality with potentially inappropriate medication (PIM) use may be subject to similar disparities. We aimed to assess the association between PIM use and all-cause mortality and the effect of disparity parameters (sex, race, income, education, and location of residence) on this relationship.

METHODS

This longitudinal cohort study included 26,399 U.S. adults aged 45 years and older from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, of which 13,475 participants were aged 65 years and older (recruited 2003-2007). PIM use and drug-drug interactions (DDIs) were identified through the 2015 Beers Criteria and a clinically significant DDIs list by the American Family Physicians, respectively. Cox regression was used to assess disparities in mortality with PIM use, iteratively adjusting for disparity parameters and other covariates. The full models included interaction terms between PIM use and other covariates. A similar method was used for the analyses of disparities in mortality with DDIs.

RESULTS

Approximately 87% of older adults used at least 1 drug listed in the Beers Criteria, and 3.8% of all participants used 2 or more drugs with DDIs. In the adjusted analysis, an increased risk of mortality was observed among whites with PIM use (hazard ratio [HR] = 1.27 [95% CI 1.10-1.47]). The higher mortality rate was observed among blacks without PIM use (1.34 [1.09-1.65]). Lower income and education were independent predictors for higher mortality.

CONCLUSION

Racial differences in all-cause mortality with PIM use were observed. Further research is needed to better understand the contributing factors of such disparities to develop appropriate interventions.

Potentially inappropriate medication use in older adults: prevalence and physician knowledge

OBJECTIVE: To analyze the frequency, profile, and additional variables associated with the prescription of potentially inappropriate medications (PIM) to older adults in primary care, and evaluate physicians’ knowledge about these medications. METHODS: A cross-sectional study was conducted based on data from patient records for the period of January 2014 to December 2017 in a city located in the state of Minas Gerais. The frequency of PIM use was evaluated based on the 2019 Beers-Fick criteria. Physician knowledge was evaluated using a validated questionnaire as a primary data source. RESULTS: In a sample of 423 older adults, 75.89% (n = 321) used at least one PIM, the most common of which were medications used to treat central nervous system disorders (48.00%; n = 203). Most participants were female (62.41%; n = 264) and 70 years or older (69.50%; n = 294). When presented with clinical cases illustrating common situations in the management of older patients, 53.33% of physicians (n = 8) answered four or five questions correctly out of a possible seven; 13.33% (n = 2) answered six questions correctly; and 33.33% (n = 5) obtained three correct answers or fewer. CONCLUSIONS: These findings showed a high frequency of PIM use among older adults treated in Primary Health Care settings, with medications used in the treatment of central nervous system disorders. Our results highlight the importance of continuing education for health professionals and improved assessments of the medication available in the Unified Health System (Sistema Único de Saúde; SUS) for use in older adults, especially those taking multiple medications

Physician and patient-related factors associated with inappropriate prescribing to older patients within primary care: a cross-sectional study in Brazil

BACKGROUND

Physician and patient-related characteristics can influence prescription of medications to older patients within primary healthcare. Use of Brazilian criteria may indicate the real prevalence of prescription of potentially inappropriate medications to this population.

OBJECTIVES

To evaluate prescription of potentially inappropriate medications to older patients within primary care and identify patient-related and prescribing physician-related factors.

DESIGN AND SETTING

This cross-sectional study was conducted in 22 public primary care facilities in Brazil, among older people (≥ 60 years) who were waiting for medical consultations.

METHODS

Interviews were conducted before and after the medical consultations. If the patient received a medical prescription at the consultation, all the drugs prescribed and the physician's medical council registration number were recorded. Prevalence ratios were estimated to ascertain the magnitude of prescription of potentially inappropriate medications, along with patient and physician-related factors associated with such prescription.

RESULTS

In total, 417 older patients were included; 45.3% had received ≥ 1 potentially inappropriate medication, and 86.8% out of 53 physicians involved had prescribed ≥ 1 potentially inappropriate medication. The strongest patient-related factor associated with higher prevalence of prescription of potentially inappropriate medications was polypharmacy. Among physician-related factors, the number of patients attended, number of prescriptions and length of medical practice < 10 years were positively associated with prescription of potentially inappropriate medications.

CONCLUSIONS

High prevalence of prescription of potentially inappropriate medications was observed. Physician-related characteristics can influence prescription of medications to older people within primary healthcare. This suggests that there is a need for interventions among all physicians, especially younger physicians.

Utilization and Spending on Potentially Inappropriate Medications by US Older Adults with Multiple Chronic Conditions using Multiple Medications

BACKGROUND

The utilization of potentially inappropriate medications (PIMs) in older adults can lead to adverse events and increased healthcare costs. Polypharmacy, the concurrent utilization of multiple medications, is common in older adults with multiple chronic conditions.

OBJECTIVE

To investigate the utilization and costs of PIMs in multimorbid older adults with polypharmacy over time.

METHODS

This retrospective cross-sectional study used linked Medicare claims and electronic health records from seven hospitals/medical centers in Massachusetts (2007-2014). Participants were ≥65 years old, had ≥2 chronic conditions (to define multimorbidity), and used drugs from ≥5 pharmaceutical classes for ≥90 days (to define polypharmacy). Chronic conditions were defined using the Chronic Conditions Indicator from the Agency for Health Research and Quality. PIMs were defined using the American Geriatrics Society 2019 version of the Beers criteria. We calculated the percentage of patients with ≥1 PIMs and the percentages of patients using different types of PIMs. We used logistic regression analyses to test the odds of taking ≥1 PIMs. We calculated mean costs spent on PIMs by dividing the costs spent on PIMs by the total medication cost.

RESULTS

≥69% of patients used ≥1 PIM. After adjusting for healthcare utilization, chronic conditions, medication intake, and demographic factors, female sex (2014: Odds ratio (OR)=1.27, 95%CI 1.25-1.30), age (2014: OR=0.92, 95%CI 0.90-0.93), and Hispanic ethnicity (2014: OR=1.41, 95%CI 1.27-1.56) were associated with PIM use. Gastrointestinal drugs and central nervous system drugs were the most commonly-used PIMs. In patients using ≥1 PIM, >10% of medication costs were spent on PIMs.

CONCLUSION

The utilization of PIMs in US older adults with multimorbidity and polypharmacy is high.

Evolution of publications on health of the older adults in the Journal Ciência & Saúde Coletiva

The present study analyzed the profile of publications related to the health of the older adults in the Journal Ciência & Saúde Coletiva, in terms of quantitative evolution, methodological approach, thematic and institutions involved. The selection of articles considered the title, abstract and descriptors and covered all the content published between 1996 and 2019. The articles included were classified according to the year of publication, type, theme, methodological approach and institutional link of the first author. Data analysis was based on absolute and relative frequencies, in addition to summary (mean) and variability (standard deviation) measures. The results showed a consistent increase in publications on the health of the older adults in the Journal Ciência & Saúde Coletiva, with a predominance of the quantitative approach, mainly focused on investigating the topic related to health conditions and the use of health services and supplies. In the majority, the main author was linked to a public teaching/research institution, located in the Southeast region. The results indicate that the journal contributed to give greater visibility to the health of the older adults, but that the publications on this theme reproduce the inequality observed in the national scientific production.

Application of the GheOP3S-tool in nursing home residents: acceptance and implementation of pharmacist recommendations

Background and objective: The prevalence of potentially inappropriate prescribing (PIP) among nursing home (NH) residents is high. This study aimed to investigate the acceptance and implementation of pharmacist recommendations based on a screening tool for PIP, the Ghent Older People's Prescriptions community Pharmacy Screening (GheOP³S)-tool. Setting and method: Prospective observational study in NH residents (≥ 70 years, using ≥ 5 medications) with a 3-month follow-up period. A pharmacist screened the medication lists using the GheOP³S-tool and formulated recommendations to reduce PIP. The acceptance of recommendations discussed during face-to-face pharmacist-general practitioner (GP) meetings was recorded. Implementation was examined by comparing baseline and follow-up medication lists. A pre-post comparison of the number of chronic medications and GheOP³S-criteria; the anticholinergic and sedative burden quantified by the Drug Burden Index (DBI); and medication costs was performed. Results: Screening with the GheOP³S-tool resulted in 168 pharmacist recommendations for 50 NH residents, mainly to stop (78.0%) and to substitute (14.3%) medications. Ninety-three % (156/168) of recommendations were considered relevant. GPs acceptance rate was 44.9%. Fifty-four % of all accepted recommendations were implemented. At follow-up, the number of chronic medications (p = 0.007), and DBI scores (p = 0.004) significantly differed from baseline. There was no significant decrease in the number of GheOP³S-criteria (p = 0.075) and medication costs (p > 0.05). Conclusion: The acceptance and implementation of pharmacist recommendations were relatively low. Future studies should increase the involvement of patients and all health-care providers. Interdisciplinary collaboration with sufficient education for all disciplines and patients is essential.

The impact of decreasing potentially inappropriate medications on activities of daily living in a convalescent rehabilitation setting

Background Polypharmacy or potentially inappropriate medications negatively affect the functional recovery of rehabilitation. However, limited research exists regarding the effect of decreasing in potentially inappropriate medications use on functional improvement of rehabilitation in geriatric Japanese patients. Objective To elucidate whether decreasing PIM during hospitalization could be a predictor of rehabilitation outcomes among geriatric patients in a convalescent rehabilitation setting. Setting This study was conducted at the convalescent rehabilitation ward in the Hitachinaka General Hospital in Japan. Methods This retrospective observational cohort study included consecutive geriatric patients admitted at the convalescent rehabilitation ward between 2010 and 2018. Participants were divided based on presence or absence of decreasing in potentially inappropriate medications use during hospitalization. A multiple linear regression analysis was performed to analyze whether decreasing potentially inappropriate medications use during hospitalization could be a predictor of Functional Independence Measure-Motor at discharge. Main outcome measures The primary outcome was the Functional Independence Measure-Motor at discharge. Results In total, 569 participants (interquartile range 73-85 years; 33.6% men) were included in the present study. A multiple linear regression analysis of Functional Independence Measure-Motor at discharge, adjusting for confounding factors, revealed that decreasing in potentially inappropriate medications use was independently correlated with Functional Independence Measure-Motor at discharge. In particular, the use of first-generation antihistamines, antipsychotics, benzodiazepines, and non-steroidal anti-inflammatory drugs among potentially inappropriate medications decreased significantly during hospitalization. Conclusion Decreased potentially inappropriate medications use during hospitalization may be a predictor of improvement of rehabilitation outcomes in geriatric patients.

Potentially inappropriate medications for the elderly: Incidence and impact on mortality in a cohort ten-year follow-up

INTRODUCTION

Pharmacological therapy plays an important role in disease control in the elderly; unfortunately, this comes with a high prevalence in the use of medications classified as potentially inappropriate.

OBJECTIVE

To analyze the incidence, risk factors, and survival of elderly people using potentially inappropriate medications (PIM).

METHOD

A ten-year follow-up assessment of elderly participants residing in a capital of Central Brazil was conducted. The initial assessment (baseline) included 418 elderly people. Data were collected through home interviews guided by a questionnaire covering socioeconomic, demographic, living conditions, and health variables. The medication information obtained comprised active ingredient, dosage, route, and regimen for the medications. The PIMs were classified according to 2019 Beers Criteria. The analyses were performed using STATA 15.0. For survival analysis, a Cox Regression was performed with the respective Kaplan Meier curve.

RESULTS

The incidence of PIM was 44.1 cases (95% CI: 35.2-54.7) per 1,000 people a year. The most used PIMs were nifedipine, glibenclamide, and sodium diclofenac. The risk factors were polypharmacy (aRR: 3.00; 95% CI: 1.31-6.88) and diabetes mellitus (aRR: 1.57; 95% CI: 1.03-2.39). We identified no statistically significant association between survival and the use of PIM.

CONCLUSION

The study highlights the high consumption of PIM among the elderly causing polypharmacy risks. Health professionals working in drug treatment need to be alert to polypharmacy risks to ensure the rational use of medications to prevent adverse reactions and other health problems.

Potentially inappropriate medications in older individuals with diabetes: A population-based study in Quebec, Canada

AIM

To study the population-based prevalence of potentially inappropriate medication (PIM) among older individuals with diabetes, and to identify factors associated with their use.

METHODS

We used the Quebec Integrated Chronic Disease Surveillance System (QICDSS) database to conduct a population-based cohort study of individuals with diabetes ≥66 years between April 1st, 2014 and March 31st, 2015. PIMs were defined according to the 2015 Beers Criteria. Factors associated with PIM use were identified using robust Poisson regression models. Risk ratios (RR) and 99% confidence intervals (99%CI) were calculated.

RESULTS

More than half (56%) of the 286,962 older individuals with diabetes used at least one PIM over a year. Benzodiazepines (41%), proton pump inhibitors (27%) and endocrine medication (mainly glibenclamide) (25%) were the most common PIMs used. Factors associated with PIM use included female sex (RR: 1.17; 99%CI: 1.16-1.18), and comorbidities such as schizophrenia (1.48; 1.45-1.51), anxiety disorders (1.34; 1.33-1.35) and Alzheimer's disease (1.14; 1.13-1.25). Risks of using PIMs increased both with increasing comorbidities and number of medications.

CONCLUSION

PIM use is highly prevalent among older individuals with diabetes. Interventions to promote optimal medication use should particularly target individuals with comorbidities and polypharmacy who are most vulnerable to adverse drug events.

Use of potentially inappropriate medications in institutionalized elderly: prevalence and associated factors

This study aimed to verify the prevalence of the use of Potentially Inappropriate Medications (PIM) for elderly living in Long-Term Care Institutions for the Elderly (LTCIE), as well as the types of medications and their associated factors. This is a cross-sectional study carried out in 10 LTCIEs in the city of Natal in the period October-December 2013. Potentially inappropriate medications were classified according to the 2015 American Geriatric Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults - 2015. Sociodemographic, LTCIE-related and health-related variables were considered. Univariate and multivariate analyses were performed between the primary variable (PIM use) and the independent variables using Poisson regression. The sample consisted of 321 older people, of whom 304 used medications. The prevalence of PIM use was 54.6% (95% CI: 48.9-60.2) and was associated with polypharmacy and dementia in the final model. The most common PIMs were antipsychotics and benzodiazepines. The study revealed a high prevalence of PIM use among the elderly of the LTCIEs, evidencing the need to adopt indicators on the use of these drugs and the implementation of strategies that make drug therapy safer and more adequate for older adults.

Hypertension and Drug Adherence in the Elderly

Hypertension is highly prevalent after the age of 65 years affecting more than 60% of individuals in developed countries. Today, there is sufficient evidence from clinical trials that treating elderly subjects with hypertension with antihypertensive medications has a positive benefit/risk ratio even in very elderly patients (>80 years). In recent years, partial or total non-adherence has been recognized as major issues in the long-term management of hypertension in all age categories. However, whether non-adherence is more frequent in hypertensive patients older than 65 years or not is still a matter of debate and the common belief is that adherence is lower in older than in younger patients. Are clinical data supporting this belief? In this brief review, we discuss the topic of drug adherence in elderly in the context of the medical treatment of hypertension. Studies show that drug adherence is actually better in patients aged 65 to 80 years when compared to younger hypertensive patients (<50 years). However, in very old patients (>80 years) the prevalence of non-adherence does increase. In this patients' group, there are specific risk factors for non-adherence such as cognitive ability, depression, and health believes, in addition to classical risk factors for non-adherence. One important aspect in the elderly is the prescription of potentially inappropriate medications that will interfere with the adherence to necessary treatments. In this context, an interesting new concept was developed few years ago, i.e., the process of deprescribing. Thus, today, in addition to conventional guidelines recommendations (use of single pill combinations, individualization of treatments), the evaluation of cognitive abilities, the regular assessment of potentially inappropriate medications, and the process of deprescribing appear to be three new additional steps to improve drug adherence in the elderly and thereby ameliorate the global management of hypertension.

Potentially inappropriate medications in older adults: a population-based cohort study

BACKGROUND

Non-optimal medication use among older adults is a public health concern. A concrete picture of potentially inappropriate medication (PIM) use is imperative to ensure optimal medication use.

OBJECTIVE

To assess the prevalence of PIMs in community-dwelling older adults and identify associated factors.

METHODS

A retrospective population-based cohort study was conducted using the Quebec Integrated Chronic Disease Surveillance System (QICDSS). The QICDSS includes data on drug claims for community-dwelling older adults with chronic diseases or at risk of developing chronic diseases aged ≥65 years who are insured by the public drug insurance plan. Individuals aged ≥66 years who were continuously insured with the public drug plan between 1 April 2014 and 31 March 2016 were included. PIMs were defined using the 2015 Beers criteria. We conducted multivariate robust Poisson regression analyses to explore factors associated with PIM use.

RESULTS

A total of 1 105 295 individuals were included. Of these, 48.3% were prescribed at least one PIM. The most prevalent PIMs were benzodiazepines (25.7%), proton-pump inhibitors (21.3%), antipsychotics (5.6%), antidepressants (5.0%) and long-duration sulfonylureas (3.3%). Factors associated with PIM exposure included being a woman [rate ratio (RR): 1.20; 95% confidence interval (CI): 1.20-1.21], increased number of medications and having a high number of chronic diseases, especially mental disorders (RR: 1.50; 95% CI: 1.49-1.51).

CONCLUSION

Almost one out of two community-dwelling older adults use a PIM. It is imperative to reduce the use of PIMs, by limiting their prescription and by promoting their deprescribing, which necessitates not only the active involvement of prescribers but also patients.

Pain and Inflammation Management in Older Adults: A Brazilian Consensus of Potentially Inappropriate Medication and Their Alternative Therapies

Purpose: The aim of the present study was to develop and validate a Potentially Inappropriate Medications (PIM) list and alternative therapies for treatment of pain and inflammation in older people adapted to the Brazilian context.

Methods: A preliminary PIM list suitable for the Brazilian market was developed on the basis of three published international PIM lists [Beers 2015, Screening Tool of Older People’s Potentially Inappropriate Prescriptions - 2015, European Union (7) PIM list]. We used the modified Delphi technique (two-round) to validate concerns of use and alternative therapies related to PIM for treatment of pain and inflammation in older adults ≥65 years in Brazil. The panel involved nine Brazilian experts in geriatric pharmacotherapy. All items with mean Likert scale score ≥4.0 (agree) and the lower limit of 95% confidence interval ≥4.0 were considered validated in this study.

Results: At the end of the consensus process, 94 (65.3%) items of 144 were validated. In total, consensus was reached for 33/35 (94.3%) concerns about drugs that should be avoided in older patients regardless of diagnosis, for 22/23 (95.7%) concerns about drugs that should be avoided in older patients with specific conditions or diseases, for 11/23 (47.8%) with special considerations of use, and for 28/63 (44.4%) of therapeutic alternatives.

Conclusion: Although these criteria are not designed to replace clinical judgement, PIM and alternative therapies lists can be useful to inform prescribers, pharmacists, and health care planners and may serve as a starting point for safe and effective use of medications in older people.

Potentially inappropriate medications among the elderly in primary care in Thailand from three different sets of criteria

Objective:

The primary objective was to examine potentially inappropriate medications (or PIMs) in the elderly using three different criteria: Beers 2015, STOPP version 2, and Winit-Watjana (for Thai elderly patients). The secondary objective was to examine PIM-related factors.

Methods:

This is a retrospective cross-sectional study. Eligible patients were aged ≥65 years in a primary care unit. Demographic data, medical prescriptions in the past year, clinical data and diagnoses were collected from electronic medical records. PIMs, including the use of ≥2 medications, were identified using the three criteria. Descriptive and analytical statistics were conducted. The type I error was 0.05. Multiple logistic regression analysis was used to examine associations between PIMs and other factors.

Results:

A total of 400 patients were recruited, and 1,640 prescriptions were reviewed. The median age was 70.5 years, and the median numbers of diseases, medications, and prescriptions were 3 (interquartile range or IQR=2), 11 (IQR=20), and 3 (IQR=4), respectively. Of all the patients, 213 (53.3%) showed a use of ≥5 medications, and 301 (75.3%) were prescribed PIMs. Of the 1,640 prescriptions, 60% had at least one PIM. The Winit-Watjana criteria, Beers 2015 criteria and STOPP version 2 identified 66.8%, 59.0% and 40.3% of the patients receiving PIMs, respectively. Approximately 16% of the patients showed at least one potential drug-drug interaction. The use of duplicate drug classes accounted for the highest proportion of potential drug-drug interactions (41.3%). Polypharmacy (odds ratio or OR 3.93, 95% confidence interval or 95%CI 2.17-71.2) and the presence of ≥4 diseases (OR 2.78, 95%CI 1.39-5.56) were associated with PIMs.

Conclusions:

PIMs are common among the elderly patients in primary care in Thailand. Prescriptions of the elderly with polypharmacy or multiple concurrent diagnoses should be reviewed for PIMs because they have a high chance of receiving PIMs.

Associations Between Potentially Inappropriate Medications and Adverse Health Outcomes in the Elderly: A Systematic Review and Meta-analysis

Background: Adverse drug outcomes in the elderly have led to the development of lists of potentially inappropriate medications (PIMs), such as the Beers criteria, and these PIMs have been studied widely; however, it is still unclear whether PIM use is predictive of adverse outcomes in older people. Objective: To qualitatively examine the associations between exposure to PIMs from the general Beers criteria and the Screening Tool of Older Persons' Prescriptions list and adverse outcomes, such as adverse drug reactions (ADRs)/adverse drug events (ADEs), hospitalization, and mortality. Methods: Specified databases were searched from inception to February 1, 2018. Two reviewers independently selected studies that met the inclusion criteria, assessed study quality, and extracted data. Data were pooled using Stata 12.0. The outcomes were ADRs/ADEs, hospitalization, and mortality. Results: A total of 33 studies met the inclusion criteria. The combined analysis revealed a statistically significant association between ADRs/hospitalizations and PIMs (odds ratio [OR] = 1.44, 95% CI = 1.33-1.56; OR = 1.27, 95% CI = 1.20-1.35), but no statistically significant association was found between mortality and PIMs (OR = 1.04; 95% CI = 0.75-1.45). It is interesting to note that the results changed when different continents/criteria were used for the analysis. Compared with the elderly individuals exposed to 1 PIM, the risk of adverse health outcomes was much higher for those who took ≥2 PIMs. Conclusion and Relevance: We recommend that clinicians avoid prescribing PIMs for older adults whenever feasible. In addition, the observed associations should be generalized to other countries with different PIM criteria with caution.

The association of potentially inappropriate medication use on health outcomes and hospital costs in community-dwelling older persons: a longitudinal 12-year study

AIMS

To determine (1) whether potentially inappropriate medication (PIM) use defined by the Meds75 + database is associated with fracture-specific hospitalisations and all-cause mortality, and (2) the association between PIM use and all-cause hospitalisation costs in a 12-year follow-up of a nationwide sample of people aged ≥ 65 years in Finland.

METHODS

This is a longitudinal study of 20,666 community-dwelling older persons with no prior purchases of PIMs within a 2-year period preceding the index date (1 Jan 2002), who were followed until the end of 2013. Data were obtained from the Finnish Prescription Register, and it was accompanied by information on inpatient care, causes of deaths and socioeconomic status from other national registers. Propensity score matching (PSM) analysis was used to account for potential selection effect in PIM use. Cox proportional hazards regression was used to identify the time to the first fracture or death by comparing PIM-users (n = 10,333) with non-users (n = 10,333). The association between PIM use and hospital costs was analysed with a fixed effects linear model.

RESULTS

PIM use was weakly associated with an increased risk of fractures and death. The association was stronger in the first PIM-use periods. Hospitalised PIM-users had 15% higher hospital costs compared to non-users during the 12-year follow-up.

CONCLUSION

PIM initiation was associated with an increased risk of fracture-specific hospitalisation and mortality and PIM-users had higher hospital costs than non-users. Health care providers should carefully consider these issues when prescribing PIM for older persons.

American Geriatrics Society-Beers Criteria and adverse drug reactions: a comparative cross-sectional study of Nigerian and South African older inpatients

Background

The Beers Criteria were developed with the aim of improving the safety of medicines among older persons. While the association between the Beers' list of potentially inappropriate medicines (PIMs) and adverse drug reactions (ADRs) among older Caucasians is contentious, the ability of the Criteria to predict ADRs among older persons in Africa remains unexplored.

Objectives

This study aimed to compare the prevalence of PIMs and ADRs among hospitalized older persons in Nigeria and South Africa, and to determine the association between the 2015 American Geriatrics Society-Beers (AGS-Beers) PIMs and ADRs.

Methods

The medical records of older persons aged ≥60 years who were hospitalized in teaching hospitals in Nigeria and South Africa were randomly selected, and retrospectively evaluated for ADRs by two clinical pharmacists using the Naranjo algorithm. The PIMs were assessed using the 2015 AGS-Beers Criteria. A multivariate logistic regression was used to determine the associated factors for ADRs among the hospitalized older persons, with P<0.05 being considered significant.

Results

The samples which comprised 268 and 339 hospitalized older persons (mean age 70.53±8.22; 95% CI -0.21 to 2.32 vs mean age 69.49±7.64; 95% CI -0.25 to 2.34, P=0.11) were evaluated in Nigeria and South Africa, respectively. The PIMs among the older persons in Nigeria were 32.1% (86/268) and 30.1% (102/339, OR=0.91, 95% CI 0.64-1.29, P=0.6) for South Africa; 13.8% (37/268) of the hospitalized older persons in Nigeria experienced 43 cases of ADRs compared to 9.1% (31/339) in South Africa (95% CI 0.38-1.04, P=0.07). The multivariate analysis showed no association between PIMs and ADRs among the hospitalized older persons in Nigeria (OR=1.48 95% CI 0.70-3.17, P=0.31) and South Africa (OR=1.09, 95% CI 0.48-2.49, P=0.83).

Conclusion

The 2015 AGS-Beers PIMs were not associated with ADRs among the hospitalized older persons in Nigeria and South Africa. However, physicians should be cautious when prescribing certain medications in the AGS-Beers list.

Polypharmacy leads to increased prevalence of potentially inappropriate medication in the Indonesian geriatric population visiting primary care facilities

Background

The geriatric population is particularly vulnerable to being prescribed potentially inappropriate medication (PIM); however, the prevalence of this occurrence remains poorly investigated in Indonesia. Thus in this research, we focused on investigating the prevalence and predictors of PIM among the Indonesian geriatric population in a primary health care setting.

Methods

A retrospective observational study was conducted in 25 primary health care facilities in Karawang District, Indonesia. The medical prescriptions of patients aged ≥60 years during January–December 2014 were documented, and the PIM was assessed based on Beers and McLeod criteria. The influence of age, sex, number of diseases, and polypharmacy toward PIM was assessed using a logistic regression model. A P-value of <0.05 defined statistical significance.

Results

A total of 3,819 subjects were included in the study. PIM was highly prevalent (52.2%) among the Indonesian elderly. Chlorpheniramine, mefenamic acid, ibuprofen, and nifedipine were the most commonly prescribed PIM. Polypharmacy (odds ratio: 1.2 [0.6, 2.1]) was the only factor associated with the use of PIM, while sex, age, and multiple diseases did not show significant association.

Conclusion

PIM is a concern in the Indonesian geriatric population. Health care professionals are encouraged to review the medications of their geriatric patients using updated safety guidelines to prevent risks associated with PIM.

Factors associated with potentially harmful drug-drug interactions in older Korean people: A population-based study

AIM

The present study investigated the status of potentially harmful drug-drug interactions (PHDI) in older adults, to obtain insight into factors that influence the risk of PHDI.

METHODS

The present study included Korean people aged ≥65 years who were prescribed one or more drugs included in the list of PHDI under the Beers Criteria 2015 from January to December, 2016 (n = 1 257 317). PHDI were defined based on the Beers Criteria 2015. Among 10 PHDI, a prevalence of >5% was taken to be clinically significant, and the relationships between multiple variables and PHDI were examined.

RESULTS

The most frequent PHDI was corticosteroids and non-steroidal anti-inflammatory drugs (n = 259 499, 20.64%), followed by a combination of two or more anticholinergic drugs (n = 139 622, 11.1%), and three or more drugs acting on the central nervous system (n = 86 023, 6.84%). These three types of PHDI were more frequent in women (OR 1.066-1.141) and medical aid beneficiaries (OR 1.095-1.510). The risk of PHDI increased in proportion to the number of healthcare institutions used by the participants and their outpatient visits during the year (OR 1.043-1.079, 1.008-1.010, respectively). The risk of PHDI was low when patients took no more than five medications in a single prescription (OR 0.017-0.791).

CONCLUSIONS

The findings of the present study highlight the three most frequent PHDI in Korea according to the Beers Criteria 2015. Healthcare providers should take PHDI into account when treating female patients, medical aid beneficiaries, patients using multiple healthcare institutions, frequent outpatient visitors and patients prescribed more than six medications in a single prescription. Geriatr Gerontol Int 2018; 18: 1378-1382.

Factors associated with the use of potentially inappropriate medications by older adults in primary health care: An analysis comparing AGS Beers, EU(7)-PIM List , and Brazilian Consensus PIM criteria

BACKGROUND

Potentially inappropriate medications (PIM) for the older adults are those with an unfavorable risk-benefit ratio when more effective and safe therapeutic alternatives are available and is an important public health problem.

PURPOSE

To analyze the factors associated with the use of PIM by the older adults and to investigate the agreement of PIM use frequency using the 2015 American Geriatric Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults - 2015 AGS Beers Criteria, the Brazilian consensus on potentially inappropriate medication for older adults (BCPIM) and the European union list of potentially inappropriate medications - EU (7)-PIM List.

METHODS

This is a cross-sectional study conducted in two primary health care centers in southeastern Brazil. The 2015 AGS Beers Criteria, BCPIM, and EU (7)-PIM List were used for the classification of PIM. The association between PIM use and independent variables was assessed by multiple logistic regression. The level of agreement of PIM use among the three criteria was measured with the Cohen's kappa coefficient.

RESULTS

A total of 227 patients ≥60 years of age were included in the study. The frequency of PIM use was 53.7% for 2015 AGS Beers, 55.9% for BCPIM and 63.4% for the EU (7)-PIM List. The agreement between 2015 AGS Beers and BCPIM and between this and the EU (7)-PIM List was high, and moderate between the 2015 AGS Beers and the EU (7)-PIM List. Logistic regression showed association of PIM use with polypharmacy, self-reported neuropsychiatric and musculoskeletal diseases, age ≤70 years, preserved cognition and positive self-perception of health.

CONCLUSION

The frequency of PIM use by the older adults of health centers investigated is high. Strategies for improving the pharmacotherapy of the older adults in primary health care should be implemented.

The role of geriatrician-hospitalists in the care of older adults: A retrospective cohort study

INTRODUCTION

Medicare patients account for over 50% of hospital days at a cost of over $1 trillion per year. Yet, hospitalization of older adults often results in poor outcomes. We evaluated the role of geriatrician-hospitalists in the care of older adults. Materials and methods A retrospective cohort study was conducted in a 764-bed tertiary care hospital with patients 65 and older admitted to medicine. Geriatrician-hospitalists care was compared to usual care by non-geriatrician hospitalists (staff and non-staff). Outcome measures included length of stay (LOS) and 30-day readmissions. Process measures included geriatric-focused care practices, such as early mobilization, safety precautions, delirium management, use of potentially inappropriate medications and documentation of advanced directives as well as discharge disposition.

RESULTS

Of the 10,529 patients, 2949 (28.0%) were cared for by staff hospitalists, 7181 (68.2%) by non-staff hospitalists and 399 (3.79%) by geriatrician-hospitalists. Patients cared for by geriatrician-hospitalists were significantly older with more comorbidities than those admitted to staff and non-staff hospitalists (average age: 86.3, 79.7, and 80.3, respectively, p < 0.0001; Charlson Comorbidity Index: 7.46, 7.01, and 7.17, respectively, p = 0.0005). Multivariate analysis showed no difference in LOS, 30-day readmissions, and discharge disposition. In terms of care practices, significant differences were found for the following: time to PT (p < 0.0001), duration of indwelling bladder catheters (p = 0.018), documentation of Do-Not-Resuscitate (p < 0.0001), benzodiazepine use (p < 0.0001) and anticholinergics (p = 0.0029), respectively.

CONCLUSIONS

As the population continues to age at unprecedented rates and hospitals struggle to meet the demands and expectations, geriatrician-hospitalists may improve care practices important for older adult care management.