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

Potentially Inappropriate Medication: A Pilot Study in Institutionalized Older Adults

Institutionalized older adults often face complex medication regimens, increasing their risk of adverse drug events due to polypharmacy, overprescribing, medication interactions, or the use of Potentially Inappropriate Medications (PIM). However, data on medication use and associated risks in this population remain scarce. This pilot study aimed to characterize the sociodemographic, clinical and pharmacotherapeutic profiles, and the use of PIM among institutionalized elders residing in Residential Structures for Elderly People (ERPI) in the Faro municipality, located in the Portuguese region of the Algarve. We conducted a cross-sectional study in a non-randomized sample of 96 participants (mean age: 86.6 ± 7.86 years) where trained researchers reviewed medication profiles and identified potentially inappropriate medications using the EU(7)-PIM list. Over 90% of participants exhibited polypharmacy (≥5 medications), with an average of 9.1 ± 4.15 medications per person. About 92% had potential drug interactions, including major and moderate interactions. More than 86% used at least one potentially inappropriate medication, most commonly central nervous system drugs. This pilot study demonstrates that institutionalized older adults may be at high risk of potential medication-related problems. Implementing comprehensive medication review programs and promoting adapted prescribing practices are crucial to optimize medication use and improve the well-being of this vulnerable population.

Older people, medication usage and long-term care pharmacists: a retrospective cohort study

OBJECTIVE

To investigate the impact of the presence of a pharmacist on medication usage in long-term care facilities.

METHODS

The study followed a retrospective cohort design, with a sample of patients aged ≥65 years admitted to three long-term care facilities over 30 months. Data on age, gender, type of stay, the presence or absence of a pharmacist and pharmacotherapeutic profile at admission and discharge were obtained for study patients. Variations in the number of medicines, anticholinergic burden and potentially inappropriate medications at admission and discharge were assessed as outcome variables. Anticholinergic burden and potentially inappropriate medications were assessed using the Anticholinergic Cognitive Burden scale and the EU(7)-PIM List, respectively. One-sample t-tests were used to compare the mean values of the outcome variables. A four-way ANOVA was used to test the association between background and outcome variables. Partial eta squared (η2) was used to measure the effect size.

RESULTS

A total of 1366 patients were studied. All outcome variables showed a statistically significant increase at discharge compared with admission. The presence of a pharmacist was statistically significant in improving the number of medicines (p<0.001) and the anticholinergic burden score (p<0.001), while no statistically significant value was reached on potentially inappropriate medications (p=0.642). Small effect size values were obtained for the impact of the pharmacist on the number of medicines and anticholinergic burden scores (η2=0.021 and η2=0.011, respectively).

CONCLUSION

These findings suggest that the presence of a long-term care pharmacist can positively impact the use of medication associated with poor health outcomes. An integrated interprofessional approach is needed to address potentially inappropriate medications, anticholinergic burden and polypharmacy in long-term care settings, particularly at the time of discharge.

The MGPIDP-L project: Potentially inappropriate drug prescribing and its associated factors

OBJECTIVE

The aim of this study was to identify the prevalence of potentially inappropriate drug prescribing¹ (PIDP) using a combination of explicit and implicit criteria in a sample of Lebanese older adults taking 5 or more chronic medications per day in ambulatory care settings and to identify which factors were associated with PIDP. The explicit criteria included five different lists: Beers, Laroche, European Union (EU(7)-PIM list), STOPP/ START, STOPP Frail, and Alert and Mastering of Iatrogenesis issued by the French High Authority of Health. We also performed a sensitivity analysis to compare the potentially inappropriate medications according to each criterion.

METHODS

Data were collected from each patient via a face-to-face interview. Logistic regressions were conducted to evaluate both objectives.

RESULTS

Many factors were positively associated with PIDP. The risk of PIDP was positively associated with age (OR =4.692, 95% CI [1.889-11.655]). Treatment for insomnia doubled the odds of PIDP (P<0.05). Participants who picked their medications from the pharmacy and had excess stock of drugs were at higher risk of having PIDP by 2.042 (95% CI [1.199-3.478]) and 2.965(95% CI [1.133-7.762]) respectively. However, patients with a perception of being heavily medicated and patients with a missed dose in the last two weeks had lower odds of PIDP.

CONCLUSION

Our study showed a high prevalence of PIDP in Lebanon, which is associated with various correlates. Selecting the appropriate tools to assess PIDP and providing patient education regarding the risks associated with potentially inappropriate medications are issues to be addressed among older adults.

Potentially inappropriate medication use and associated factors in residents of long-term care facilities: A nationwide cohort study

Background: Residents in long-term care (LTC) facilities (LTCFs) may have multimorbidity and be unable to self-administer medication. Thus, due to the risk of potentially inappropriate medications (PIMs), epidemiological studies on PIM use and its associated factors should be conducted to ensure safe medication use for residents in LTCFs. Objective: We evaluated PIM use among residents of LTCF and the associated factors in residents of LTCFs in Korea using a nationwide database. Methods: This cross-sectional study used the Korea National Health Insurance Service Senior Cohort (KNHIS-SC) database 2.0 of the National Health Insurance Service (NHIS), a single public insurer in Korea. We analyzed older adults aged ≥65 years who were residents of LTCFs in 2018, using the KNHIS-SC database. The 2019 American Geriatrics Society (AGS) Beers criteria was used for PIM identification. The prevalence of PIM use was defined as the proportion of LTCF residents who received PIM prescriptions at least once. We evaluated the frequency of prescriptions, including PIMs, and determined the most frequently used PIMs. We also conducted a multivariable logistic regression analysis to identify the factors associated with PIM use. Results: The prevalence of PIM among the LTCF residents was 81.6%. The prevalence of PIM was 74.9% for LTC grades 1 or 2 (high dependence) and 85.2% for LTC grades 3-5 (low dependence). Quetiapine was the most frequently prescribed PIM, followed by chlorpheniramine. The low dependence level was significantly associated with PIM use (odds ratio of LTC grades 3-5: 1.49, 95% confidence interval 1.32-1.68, reference: LTC grades 1 or 2); moreover, the number of medical institutions visited, and medications emerged as primary influencing factors. Conclusion: Most LTCF residents were vulnerable to PIM exposure. Furthermore, exposure to PIMs is associated with LTC grade. This result highlights the need for comprehensive medication management of LTCF residents.

Applicability of tools to identify potentially inappropriate prescribing in elderly during medication review: Comparison of STOPP/START version 2, Beers 2019, EU(7)-PIM list, PRISCUS list, and Amsterdam tool—A pilot study

Potentially inappropriate prescribing (PIP) is one of the major risk factors of adverse drug events in elderly patients. Pharmacotherapy assessment criteria may help reduce the instances of PIP among geriatric patients. This study aimed to verify the applicability of selected tools designed to assess prescribing appropriateness in elderly and to identify PIP in the study population. Based on pharmacist-led medication reviews that were performed among patients attending senior day-care centers based in Poland, aged 65 years and over, the following tools were applied for assessing the appropriateness of pharmacotherapy: PILA (patient-in-focus listing approach): STOPP/START v.2 and Amsterdam tool, DOLA (drug-oriented listing approach): PRISCUS list, and DOLA+: Beers criteria v.2019 and the EU(7)-PIM list–the criteria oriented on medications requiring indications. Fifty patients participated in the study. The prevalence of prescribing issues in the study population was very high and ranged from 28% to 100%, depending on the criteria applied. The highest number of PIP cases was identified based on the PILA criteria: STOPP/START v.2 (171, a mean of 3.4 PIP cases per patient), and the Amsterdam criteria (124, a mean of 2.5 PIP cases per patient). The lack of protective vaccinations against pneumococci identified using the START criterion was found to be the most common PIP (identified in 96% of the patients). Proton-pump inhibitors (PPIs) were identified as the most problematic group of medications. The STOPP, EU(7)-PIM and Beers criteria revealed cases of inappropriate prolonged PPI use, whereas the Amsterdam tool identified cases where PPIs should have been prescribed but were not. The highest number of PIP cases in the study population were identified with the PILA tools, and on this basis the most comprehensive assessment of pharmacotherapy appropriateness in geriatric patients was conducted. Further studies should be designed, covering a larger group of patients across different healthcare settings (inpatient and outpatient), with access to comprehensive patient data.

Physicians’ Knowledge, Altitudes, and Perceived Barriers of Inappropriate Prescribing for Older Patients in Shanghai, China

Background: Inappropriate medication use is common around the world, particularly among older patients, and, despite potentially being preventable, often leads to adverse clinical and economic outcomes. However, there is a dearth of information regarding this prominent issue in China.

Objectives: To evaluate the extent to which the physician can correctly identify potentially inappropriate medication (PIM) in older patients and to understand physicians’ attitudes towards improving PIM knowledge.

Methods: An online, cross-sectional survey was conducted anonymously among practicing physicians in China from November through December 2020. Knowledge of PIM was accessed using seven clinical vignettes covering a wide variety of therapeutic areas. Source of information and perceived barriers regarding PIM were also evaluated. We performed the ordinary least square regression analysis to understand the potential factors related to physicians’ knowledge of PIM.

Results: A total of 597 study participants were included in the analysis. More than half of them had never heard of any screening tool for PIMs (n = 328, 54.9%) and the most frequently acknowledged tool was the China PIM Criteria (n = 259, 43.4%). For the seven clinical vignettes testing physicians’ knowledge on the medications that should be generally avoided in older patients, the mean score was 2.91 points out of 7 (SD: 1.32), with the median score of three points (IQR: 2–4). Only one-third of the respondents were feeling confident when prescribing for older patients (n = 255, 35.08%). Package inserts have been used as the major source of PIM information (always, n = 177, 29.65%; frequently, n = 286, 47.91%). Perceived barriers to appropriate prescribing include polypharmacy (n = 460, 77.05%), lack of formal education on prescribing for the older patients (n = 428, 71.69%).

Conclusion: In this online survey evaluating physicians’ ability to detect PIM for older patients, approximately 40% of PIM were recognized, suggesting an insufficient level of knowledge about appropriate prescribing.

Calidad de vida asociada con polifarmacia en personas con lesiones cutáneas crónicas

Objetivo:

Analizar la asociación entre el uso de polifarmacia y la calidad de vida de personas con lesiones cutáneas crónicas.

Método:

Estudio transversal con una muestra conformada por 146 personas afectadas por lesiones cutáneas crónicas, vinculadas con la atención primaria de salud. La recolección de datos se realizó entre julio de 2017 y febrero de 2018. La información se recopiló mediante un cuestionario sociodemográfico y el cuestionario Cardiff Wound Impact Schedule (CWIS).

Resultados:

Hubo predominio de hipertensión arterial sistémica en 86 personas (58,9%) y de diabetes mellitus en 50 (34,2%). La etiología de la lesión cutánea predominante fue vasculogénica (38,4%), y se identificó polifarmacia en el 46,7% de los pacientes. En el cuestionario CWIS, el dominio con el puntaje promedio más bajo fue el bienestar (promedio de 46,2±17,9). Hubo asociación estadísticamente significativa (p<0.05) entre polifarmacia y las siguientes variables: dominio de “síntomas físicos/vida diaria", dominio de “vida social” y “autosatisfacción con la calidad de vida".

Conclusión:

La polifarmacia está asociada con un detrimento en la calidad de vida de personas con lesiones cutáneas crónicas. Por lo tanto, los profesionales de la salud que trabajan en la atención primaria deberían considerar la terapia farmacológica en sus planes de atención, coordinar con asistencia médica y farmacéutica la elaboración de estrategias de monitoreo de los riesgos que involucran la polifarmacia, y evaluar sus impactos en la calidad de vida.

Conflicto de interés:

Ninguno.

Calidad de vida asociada con polifarmacia en personas con lesiones cutáneas crónicas

Objetivo:

Analizar la asociación entre el uso de polifarmacia y la calidad de vida de personas con lesiones cutáneas crónicas.

Método:

Estudio transversal con una muestra conformada por 146 personas afectadas por lesiones cutáneas crónicas, vinculadas con la atención primaria de salud. La recolección de datos se realizó entre julio de 2017 y febrero de 2018. La información se recopiló mediante un cuestionario sociodemográfico y el cuestionario Cardiff Wound Impact Schedule (CWIS).

Resultados:

Hubo predominio de hipertensión arterial sistémica en 86 personas (58,9%) y de diabetes mellitus en 50 (34,2%). La etiología de la lesión cutánea predominante fue vasculogénica (38,4%), y se identificó polifarmacia en el 46,7% de los pacientes. En el cuestionario CWIS, el dominio con el puntaje promedio más bajo fue el bienestar (promedio de 46,2±17,9). Hubo asociación estadísticamente significativa (p<0.05) entre polifarmacia y las siguientes variables: dominio de “síntomas físicos/vida diaria", dominio de “vida social” y “autosatisfacción con la calidad de vida".

Conclusión:

La polifarmacia está asociada con un detrimento en la calidad de vida de personas con lesiones cutáneas crónicas. Por lo tanto, los profesionales de la salud que trabajan en la atención primaria deberían considerar la terapia farmacológica en sus planes de atención, coordinar con asistencia médica y farmacéutica la elaboración de estrategias de monitoreo de los riesgos que involucran la polifarmacia, y evaluar sus impactos en la calidad de vida.

Conflicto de interés:

Ninguno.

Introducing New Paths towards Public Primary Healthcare Services in Greece: Efforts for Scaling-Up Mental Healthcare Services Addressed to Older Adults

The exponential growth in the aging population challenges the Primary Care Providers (PCPs) who provide health care services to older adults who are considered highly vulnerable and are in need of specialized healthcare services. The development of new policies and the adoption of appropriate health strategies by PCPs may improve the early detection and prevention of mental disorders in older adults. This reduces both queuing and costs in outpatient clinics while preventing stigma for patients and families. To this end, specialized training for PCPs at the Local Primary Health Care Unit (LPHCU) was provided in order to conduct efficient assessments of older adults (65 and above years old, without previously diagnosed depression or dementia, and willing to participate). The assessment is based on the Mini Mental State Examination (MMSE) and Geriatric Depression Scale (GDS). Older adults identified with MMSE <20 and GDS >5 were referred to the psychiatric outpatient clinic. The aim of this study is to discuss evidence-informed policymaking in Greece with a focus on advancing mental health practices and scaling up quality primary healthcare services for older adults.

Ambulatory Medication Safety in Primary Care: A Systematic Review

PURPOSE

To review the literature on medication safety in primary care in the electronic health record era.

METHODS

Included studies measured rates and outcomes of medication safety in patients whose prescriptions were written in primary care clinics with electronic prescribing. Four investigators independently reviewed titles and analyzed abstracts with dual-reviewer review for eligibility, characteristics, and risk of bias.

RESULTS

Of 1464 articles identified, 56 met the inclusion criteria. Forty-three studies were noninterventional and 13 included an intervention. The majority of the studies (30) used their own definition of error. The most common outcomes were potentially inappropriate prescribing/medications (PIPs), adverse drug events (ADEs), and potential prescribing omissions (PPOs). Most of the studies only included high-risk subpopulations (39), usually older adults taking > 4 medications. The rate of PIPs varied widely (0.19% to 98.2%). The rate of ADEs was lower (0.47% to 14.7%). There was poor correlation of PIP and PPO with documented ADEs leading to physical harm.

CONCLUSIONS

This literature is limited by its inconsistent and highly variable outcomes. The majority of medication safety studies in primary care were in high-risk populations and measured potential harms rather than actual harms. Applying algorithms to primary care medication lists significantly overestimates rate of actual harms.

Evaluation of Factors Associated With Appropriate Drug Prescription and Effectiveness of Informative and Educational Interventions—The EDU.RE.DRUG Project

Background: EDU.RE.DRUG study is a prospective, multicentre, open-label, parallel-arm, controlled, pragmatic trial directed to general practitioners (GPs) and their patients.

Methods: The study data were retrieved from health-related administrative databases of four local health units (LHUs) of Lombardy and four LHUs in Campania. According to the LHUs, the GPs/patients were assigned to (A) intervention on both GPs (feedback reports about appropriate prescribing among their patients and online courses) and patients (flyers and posters on proper drug use), (B) intervention on GPs, (C) intervention on patients, and (D) no intervention (control arm). A set of appropriate prescribing indicators (potential drug–drug interactions [pDDIs], potential and unnecessary therapeutic duplicates [pTDs], and inappropriate prescriptions in the elderly [ERD-list]) were measured at baseline and after the intervention phase. The effectiveness of the intervention was evaluated estimating the absolute difference in percentages of selected indicators carrying out linear random-intercept mixed-effect models.

Results: A cohort of 3,586 GPs (2,567 in intervention groups and 1,019 in the control group) was evaluated. In Campania, the mean pre-intervention percentage of patients with at least one pDDI was always greater than 20% and always lower than 15% in Lombardy. The pre–post difference was quite heterogeneous among the LHUs, ranging from 1.9 to −1.4 percentage points. The mean pre-intervention percentage of patients with pTDs ranged from 0.59 to 2.1%, with slightly higher values characterizing Campania LHUs. The magnitude of the pre–post difference was very low, ranging from −0.11 to 0.20. In Campania, the mean pre-intervention percentage of patients with at least one ERD criterium was considerably higher than in Lombardy (approximately 30% in Lombardy and 50% in Campania). The pre–post difference was again quite heterogeneous. The results from the models accounting for GP geographical belonging suggested that none of the interventions resulted in a statistically significant effect, for all the three indicators considered.

Conclusion: The proposed strategy was shown to be not effective in influencing the voluntary changes in GP prescription performance. However, the use of a set of explicit indicators proved to be useful in quantifying the inappropriateness. Further efforts are needed to find more efficient strategies and design more tailored interventions.

Factors associated with the identification of drug therapy problems among older patients in Primary Health Care

Objective

To determine the frequency of drug therapy problems among older adults in Primary Health Care, and to analyze the factors associated with their identification in the initial patient assessment, carried out by pharmacists offering medication therapy management services.

Methods

A cross-sectional study conducted with data from 758 older adults followed up in medication therapy management services in Primary Health Care in the cities of Belo Horizonte, Betim, and Lagoa Santa (MG, Brazil). Univariate and multivariate analyses were performed to evaluate the factors associated with identification of four or more drug therapy problems in the initial clinical assessment.

Results

A total of 1,683 drug therapy problems were identified, 73.6% of older patients had at least one problem. The most frequent problems were nonadherence (23.0%) and the need for additional drug therapy (18.0%). Polypharmacy, chronic obstructive pulmonary disease, hypertension, diabetes mellitus, heart failure, and aged 75 years or older remained positively and statistically associated with identification of four or more drug therapy problems (p<0.05).

Conclusion

There is a high frequency of problems related to medication use among older users of Primary Health Care, and the medication therapy management services should be prioritized to the older patients, who present with polypharmacy, chronic obstructive pulmonary disease, hypertension, diabetes mellitus, heart failure, and age ≥ 75 years, since they are more likely to have more drug therapy problems.

A multifactorial intervention to lower potentially inappropriate medication use in older adults in Argentina

BACKGROUND

Adverse drug reactions are a common cause of potentially avoidable harm, particularly in older adults.

AIMS

To evaluate the feasibility and efficacy of a pilot multifactorial intervention to reduce potentially inappropriate medication (PIM) use in older adults.

METHODS

We conducted a phase 2, feasibility, open-label study in the ambulatory setting of an integrated healthcare network in Buenos Aires, Argentina. We recruited primary care physicians (PCPs) and measured PIM use in a sample of their patients (65 years or older). Educational workshops for PCPs were organized with the involvement of clinician champions. Practical deprescribing algorithms were designed based on Beers criteria. Automatic email alerts based on specific PIMs recorded in each patient's electronic health record were used as a reminder tool. PCPs were responsible for deprescribing decisions. We randomly sampled 879 patients taking PIMs from eight of the most commonly used drug classes at our institution and compared basal (6 months prior to the intervention) and final (12 months after) prevalence of PIM use using a test of proportions.

RESULTS

There was a significant reduction (p < 0.05) in all drug classes evaluated. Non-Steroidal Anti-Inflammatory Drugs (basal prevalence 5.92%; final 1.59%); benzodiazepines (10.13%; 6.94%); histamine antagonists (7.74%; 3.07%); opioids (2.16%; 1.25%); tricyclic antidepressants (8.08%; 4.10%); muscle relaxants (7.74%; 3.41%), anti-hypertensives (3.53%; 1.82%) and oxybutynin (2.96%; 1.82%). The absolute reduction in the overall prevalence was 8.5 percentage points (relative reduction of 51.4%).

CONCLUSION

This multifactorial intervention is feasible and effective in reducing the use of potentially inappropriate medication in all drug classes evaluated.

Potentially inappropriate medication use in elderly patients treated in intensive care units: A cross-sectional study using 2019 Beers, STOPP/v2 Criteria and EU(7)-PIM List

OBJECTIVE

To determine the prevalence of and the risk factors for Potentially Inappropriate Medication (PIM), the drug groups most commonly evaluated as PIMs in elderly patients in the ICUs by using 2019 Beers Criteria, STOPP version 2 (v2) Criteria and EU(7)-PIM List. The relation between mortality rate and length of ICU stay with PIMs was also examined.

METHODS

This was a cross sectional study conducted on patients aged ≥65 years, treated in ICUs (n = 139) between June 8, 2020, and January 11, 2021. Patients' demographic characteristics, clinical data and laboratory findings about the drugs used were collected prospectively. PIMs were evaluated according to each of the criteria applied. Relationship of dependent and independent variables was evaluated using chi-square analysis, t-test and logistic regression analysis. P < .05 was considered statistically significant.

RESULTS

The number of patients with at least 1 PIM according to three criteria was 118 (84.9%) (80.6%, 59.7%, 48.2%, Beers, STOPP/v2 and EU(7)-PIM List, respectively). In the univariate analysis, receiving renal replacement therapy and high number of drugs were the covariates that significantly affected the presence of PIM according to all three criteria (P < .05). Combined use of anxiolytics and opioids in Beers Criteria (58.3%), antipsychotics (26.6%) in STOPP/v2 Criteria, and antiarrhythmics (23.7%) in EU(7)-PIM List were the drugs that caused PIM at most. No relationship was found between the presence of PIM and mortality. The length of ICU stay was determined significantly longer in the presence of PIM according to Beers Criteria (P = .028).

CONCLUSIONS

In this study, the prevalence of PIM was determined higher in elderly patients in ICU. Our results supported that 2019 Beers Criteria for ICU patients seems to be more directive in detecting PIMs and determining the prognosis. Reducing the number of drugs administered may be the first step to decrease PIMs in elderly patients in ICU and to maintain the treatment safely.

[Adverse drug reaction affecting the urinary tract - the Witten urinary tract adverse reaction score]

The urinary tract is the site of many adverse drug reactions, including the formation of residual urine, urinary retention, pollakisuria, polyuria, nycturia, detrusor stimulation, detrusor inhibition, haematuria, dysuria and other symptoms. Nevertheless, there is no general overview or evaluation of the substances that can trigger these adverse drug reactions. The available lists of "potential inadequate medication" either focus on a pharmacological group of adverse reactions ("anticholinergic burden score"), a group of drugs for a specific indication (LUTS-Forta) or on a selected group of patients (PRISKUS List, Beers List).The following interdisciplinary project has been processed by the group for urogeriatrics in the University of Witten/Herdecke and is intended to fill this gap. We have identified substances which can in principle trigger adverse reactions in the urinary tract - according to a variety of databases. We also categorise the available literature (case reports, case series, RCT, meta-analysis) and present a structured analysis of the risk by 33 experts. This results in a list of 235 substances that can lead to various different adverse reactions of the urinary tract. This list includes a "theoretical" score from the reports in the databases or the corresponding literature, a "practical" score based on an expert evaluation of clinical reality and a cumulative score, classified in accordance with the Rote Liste".It is now possible to classify the extent to which newly prescribed drugs may pose a risk of adverse reactions in different patients. Conversely, this may also help to clarify whether a functional disorder of the urinary tract is fully or partially linked to treatment with a specific drug. We plan to develop an app to assess adverse drug reactions in the urinary tract.

Protocol of a tailored educational intervention for general practitioners on potentially inappropriate medications among older patients at community healthcare institutions in Beijing, China: a cluster-randomised controlled trial

INTRODUCTION

Prescribing of potentially inappropriate medications (PIMs) has become a prominent issue of public concern among elderly patients. However, no research has involved interventions on PIMs of Chinese elderly patients seeking care at primary healthcare. This study aims to evaluate the effectiveness of a tailored educational intervention programme for general practitioners (GPs), aiming at reducing the occurrence of PIMs in elderly patients.

METHODS AND ANALYSIS

This is a parallel group, controlled, cluster-randomised trial, with blinded evaluation of outcomes and data analysis, and un-blinded intervention. Twenty primary community healthcare stations (CHSs) in Dongcheng district in Beijing will be randomised to intervention and control arm with an allocation ratio of 1:1. GPs in CHSs randomised to the intervention arm will receive a two-component intervention: general training of PIMs and distribution of PIMs handbook. GPs in the control arm will assess and manage patients according to the institutions' routine practice. The primary outcome is the change in PIMs patient visit rate.

ETHICS AND DISSEMINATION

Ethics committee approval of this study was obtained from Peking University Institution Review Board (IRB00001052-19074). The findings will be published in scientific and conference presentations.

TRIAL REGISTRATION NUMBER

ChiCTR2100047788.

[Prescription of potentially inappropriate medications for the elderly: a study in Primary Health Care]

The elderly population is vulnerable to the risks of the use of medications, especially those considered potentially inappropriate medications (PIMs), in which the risks outweigh the benefits. The study sought to evaluate the PIMs prescribed in Primary Health Care (PHC) and associated factors. A cross-sectional, analytical study was carried out from March to December 2019 in PHC in Campina Grande, Paraíba, through interviews with 458 elderly individuals. The independent variables included socioeconomic characteristics, health status and the use of medications, and the outcome was classified as PIM by the Brazilian Consensus on Potentially Inappropriate Medications. There was a prescription of at least one PIM for 44.8% of the elderly and the majority affecting the Central Nervous System (54.4%). In the adjusted model, depression (PR=2.01; 95%CI 1.59-2.55), using other medications in addition to those prescribed (PR=1.36; 95%CI 1.08-1.72) and polypharmacy (PR=1.80; 95%CI 1.40-2.33) remained an associated factor, and self-reporting systemic arterial hypertension became a protective factor (PR=0.65; 95%CI 0.49-0.87). This reveals the need for actions to monitor closely the use of PIMs by the elderly to ensure access in conjunction with safety.

Preoperative medication use and development of postoperative delirium and cognitive dysfunction

Postoperative delirium (POD) and postoperative (neuro‐)cognitive disorder (POCD) are frequent and serious complications after operations. We aim to investigate the association between pre‐operative polypharmacy and potentially inappropriate medications and the development of POD/POCD in elderly patients. This investigation is part of the European BioCog project (www.biocog.eu), a prospective multicenter observational study with elderly surgical patients. Patients with a Mini‐Mental State Examination score less than or equal to 23 points were excluded. POD was assessed up to 7 days after surgery using the Nursing Delirium Screening Scale, Confusion Assessment Method (for the intensive care unit [ICU]), and a patient chart review. POCD was assessed 3 months after surgery with a neuropsychological test battery. Pre‐operative long‐term medication was evaluated in terms of polypharmacy (≥5 agents) and potentially inappropriate medication (defined by the PRISCUS and European list of potentially inappropriate medications [EU(7)‐PIM] lists), and associations with POD and POCD were analyzed using logistic regression analysis. Eight hundred thirty‐seven participants were included for analysis of POD and 562 participants for POCD. Of these, 165 patients (19.7%) fulfilled the criteria of POD and 60 (10.7%) for POCD. After adjusting for confounders, pre‐operative polypharmacy and intake of potentially inappropriate medications could not be shown to be associated with the development of POD nor POCD. We found no associations between pre‐operative polypharmacy and potentially inappropriate medications and development of POD and POCD. Future studies should focus on the evaluation of drug interactions to determine whether patients benefit from a pre‐operative adjustment.

Association between potentially inappropriate medication and adverse drug reactions in hospitalized elderly patients

WHAT IS KNOWN AND OBJECTIVE

The Beers, European Union (EU) and Screening Tool of Older Persons' potentially inappropriate Prescription (STOPP) criteria were developed to improve the safe use of medicines in the elderly. However, the predictive validity of existing criteria to detect adverse drug reactions (ADRs) remains unexplored. The objective of the current study was to determine whether the 2019 Beers, 2015 STOPP or 2015 EU potentially inappropriate medicine (PIM) criteria were associated with ADRs.

METHODS

A retrospective, cross-sectional investigation was conducted among older persons (≥60 years of age) admitted to a tertiary hospital in China between April 2019 and December 2019. PIMs were identified as per the Beers, EU and STOPP criteria definitions. ADRs were retrospectively evaluated by two clinical pharmacists using the Naranjo algorithm. Multivariate logistic regression was used to evaluate the factors associated with ADRs in the hospitalized patients.

RESULTS AND DISCUSSION

The study participants included 560 hospitalized patients (mean age 72.05 ± 8.15). The prevalence of patients receiving at least one PIM was 52.1%, 37.0% and 42.9% according to the Beers, EU and STOPP criteria, respectively. Univariate analysis showed that ADRs were associated with PIMs listed in the Beers criteria (OR: 2.093, 95% CI: 1.028-4.263, 0.042), but not with the STOPP-listed (OR: 0.536, 95% CI: 0.255-1.123, 0.098) and EU-listed PIMs (OR: 0.258, 95% CI: 0.118-0.563, 0.001).

WHAT IS NEW AND CONCLUSION

In contrast to the STOPP and EU criteria on PIMs, the Beers criteria were significantly associated with avoidable ADRs in hospitalized older persons.

Medical overuse of therapies and diagnostics in rheumatology

Medical overuse leads to a burden on healthcare costs and potentially is harmful to patients. We wanted to address medical overuse in musculoskeletal disease and rheumatology. We performed a systemic literature review from PubMed and Embase to study medical overuse. On the initial screen, 1499 studies were identified, 839 of them were related to medical overuse. Out of these, 52 were related to overuse in musculoskeletal diseases. Finally, 20 articles were chosen for this systemic review that reported overuse in rheumatology. The article identifies issues with overtesting, including the use of dual-energy X-ray absorptiometry to screen for osteoporosis in women younger than 65 years old and the use of magnetic resonance imaging to evaluate for osteoarthritis. Studies related to overtreatment reported over-prescription of vitamin D supplements resulting in vitamin D toxicity and increased risk of inappropriate prescriptions in patients with osteoarthritis and rheumatoid arthritis. Overtreating osteoporosis was reported after industry-sponsored education. Articles describing methods to reduce overuse included a study showing the reduction of unnecessary dual-energy X-ray absorptiometry scans after the introduction of the Choosing Wisely Campaign. Our findings suggest that there is some evidence that overtesting and overtreatment may be present in the field of rheumatology. This review aims to highlight this and help rheumatologists to be aware of overuse practices and provide appropriate evidence-based healthcare.

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

Potentially inappropriate medications among elderly patients in community healthcare institutions in Beijing, China

PURPOSE

To evaluate potentially inappropriate medications (PIMs) prevalence and predictors in community healthcare institutions (CHIs) for the elderly.

METHODS

We conducted a retrospective observational study, deriving data of patients aged ≥60 from 66 CHIs in Beijing, 2014-2018. The system of Criteria of PIM for Older Adults in China was applied to identify PIMs. The primary outcome was the prevalence of visits with at least one PIM; secondary outcomes were the frequency and rate per thousand visits of specific PIMs. We used descriptive analysis and generalized linear models to analyzed PIMs and the predictors, and marginal effects methods were applied to estimate the mean adjusted PIMs prevalence.

RESULTS

Overall, 4 528 884 elderly patient visits from 2014 to 2018 were eligible for inclusion. A total of 719 757 PIMs were detected, with 14.1% of the visits contained at least one PIM. PIM prevalence was significantly correlated with age, number of prescribed medications and number of diagnoses. Overall, 6.0 per thousand elderly patients in CHIs were exposed to at least one high-risk PIM, while 117.5 per thousand were exposed to at least one low-risk PIM. In 2018, 20% of GPs were responsible for more than half of overall PIM visits.

CONCLUSION

Prescribing of PIMs for older adults is common in CHIs in China, especially for patients who are aged, having multiple medications and diagnostic diseases. Strategies should be developed to enhance prescribing quality for geriatric patients, with special targeting of doctors responsible for a high number of PIMs.

Potentially inappropriate medications for older adults in a primary healthcare unit in southern Brazil

Background Potentially inappropriate medications for older adults are those that offer more risks than benefits for this population. Such medications found in older adults' prescriptions across the world are associated with higher rates of comorbidities and hospitalizations, along with high expenditure on healthcare resources. Objectives To estimate the frequency of older adults using potentially inappropriate medications according to four different criteria, to identify factors associated with the use of such medicines and differences between the tools. Setting A primary healthcare unit linked to a university hospital in Porto Alegre, Brazil. Method This was a cross-sectional study conducted via data collection from the electronic medical records of 390 older adults. The information collected comprised sex, age, chronic diseases diagnosed and medications used. The dependent variable of the study was the use of at least one potentially inappropriate medication, according to the following criteria: Beers, Screening Tool of Older Persons' Prescriptions (STOPP), Brazilian consensus and Anticholinergic Risk Scale (ARS). Main outcome measurement Prevalence of inappropriate medication, differences between the tools and associated factors. Results: The use of at least one potentially inappropriate medication was found in 55.1% of the sample according to the Beers criterion, 51.3% according to the Brazilian consensus, 42.6% according to STOPP and 23.6% according to ARS. It was also seen that 14.9% of the studied population was exposed to a very strong anticholinergic risk. Depending on which tools were used, the agreement observed between the criteria was considered high, moderate, or low. Regarding the four criteria, the use of potentially inappropriate medication is associated with polypharmacy, the diagnosis of three or more chronic diseases and the presence of neuropsychiatric and musculoskeletal diseases. Conclusion Among the older adult population studied, the prevalence of potentially anappropriate medication is high, according to the four different classification criteria used. As a more specific tool, the agreement between Anticholinergic Risk Scale and other criteria was lower, but it can be an important complement to other lists.

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.

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

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

One-year persistence of potentially inappropriate medication use in older adults: A population-based study

AIMS

To assess the 1-year persistence of potentially inappropriate medication (PIM) use and identify associated factors in community-dwelling older adults in Quebec, Canada.

METHODS

A population-based cohort study was conducted using the Quebec Integrated Chronic Disease Surveillance System. Individuals insured by the public drug plan and aged ≥66 years who initiated a PIM between 1 April 2014 and 31 March 2015 were followed-up for 1 year. PIMs were identified using the 2015 Beers criteria. One-year persistence of PIM use was defined as continuous treatment with any PIM, without interruption for more than 60 days between prescriptions refills. Poisson regression models were performed to identify factors associated with 1-year persistence of any PIM.

RESULTS

In total, 25.1% of PIM initiators were persistent at 1 year. In non-persistent individuals, the median time to PIM discontinuation was 31 days (interquartile range 21-92). Individuals were more persistent at 1 year with antipsychotics (43.9%), long-duration sulphonylureas (40.2%), antiarrhythmics/immediate-release nifedipine (36.5%) and proton pump inhibitors (36.0%). Factors significantly associated with persistence were an increased age, being a man and having a high number of medications and chronic diseases, especially dementia, diabetes and cardiovascular diseases.

CONCLUSIONS

One-quarter of community-dwelling older adults are continuously exposed to PIMs. To optimize medication prescribing in the older population, further interventions are needed to limit the use of PIMs most likely to be continued, especially in individuals most at risk of being persistent and also particularly vulnerable to adverse events.

The analysis of the use of potentially inappropriate medications in elderly in the Slovak Republic

Background The prevalence of potentially inappropriate medications (PIM) using explicit criteria has been well documented in European countries, however, there is a lack of evidence in the Slovak Republic. There are no specific guidelines and there is a lack of geriatricians in Slovakia. Higher use of PIM leads to greater healthcare services use as well as increases healthcare costs. Objective The aim of this study was to perform an evaluation of the availability and the actual use of PIM by geriatric patients in the nursing homes in Slovakia. Setting Together 459 residents ≥ 65 years living in nursing homes in the Slovak Republic were included for analysis of their drug therapy. Methods Retrospective analysis of medical records of patients' therapy for evaluation of PIM use. Identification of PIM was based on the Renom-Guiteras EU7 PIM list published in 2015. Main outcome measure Potentially inappropriate medications use. The presence of polypharmacy in patients. Results Inappropriate drug use according to EU7 PIM list was identified in 90.60% (416) patients. The mean number of PIM was 2.34 ± 0.07 PIM/patient/day. Polypharmacy (use of ≥ 5 drugs by patient daily) was found in 83% of all patients. The mean number of prescribed drugs was 8.32 ± 0.17 drugs/patient/day. Out of all 282 PIM listed in EU7 PIM list, there are 150 (53.19%) available on the Slovak market and 86 (30.50%) were used in patients. Patients using at least one PIM took two times more drugs compared to patients without PIM (8.77 ± 0.17 vs. 3.98 ± 0.39 drugs/patient/day, p < 0.001). The most common PIM were PPI (36% of patients), piracetam (17.2%) and alprazolam (16.80%). Conclusions The risk of PIM was almost 9.5 times higher if polypharmacy was present in geriatric patients (OR 9.51, 95% CI, 4.86 - 18.61, p < 0.001). There was a strong, positive correlation (ρ = 0.65) between the number of drugs and the number of PIM (p < 0.01). There was neither association between age/gender of patient and polypharmacy; nor age/gender of patient and presence of PIM. The lack of geriatricians and national guidelines for inappropriate prescribing results in alarmingly high use of PIM in the Slovak Republic.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Patients' clinical information requirements to apply the STOPP/START criteria

Background The STOPP/START criteria are an explicit tool to detect potentially inappropriate medications (PIMs). Patient clinical information may not be available in all settings. Objective To identify patient clinical information needed to apply the STOPP/START criteria. Setting: Four nursing homes in Portugal. Methods First, a theoretical analysis was performed to identify the patient information required to apply the STOPP/START criteria (v2), according to the following categories: patients' current medication, medication history (previous medication and duration), medical records (current and past medical conditions), and laboratory test results. A verification of the information requirements was conducted through a cross-sectional study on a nursing home population with patients over 65 years old. Patients' medical records were appraised to extract only demographic data and current medication profiles. Main outcome measure Information requirements of STOPP/START. Results For only 29 of the 81 STOPP criteria and 1 of the 34 START criteria, a judgement could be made with only the information in the patient's medication profile. 52 STOPP and 33 START criteria require additional information, (i.e. duration of therapy, previous medication, current and past medical conditions, and laboratory data). The 208 evaluated persons (87 years; 68.75% female) used 1770 medications, with 989 (55.9%) potentially involved in 1629 STOPP criteria. Sufficient information to judge STOPP criteria was available for only 529 (32.5%) potential STOPP criteria situations, with a positive identification of a STOPP PIM in 397 instances (75.0%). Conclusions Although STOPP/START criteria can be considered a high-level tool to identify PIMs, their use may be compromised in scenarios where access to patients' clinical information is limited.

Prevalence of Potentially Inappropriate Medication use in older drivers

Background

Potentially Inappropriate Medication (PIM) use has been studied in a variety of older adult populations across the world. We sought to examine the prevalence and correlates of PIM use in older drivers.

Methods

We applied the American Geriatrics Society 2015 Beers Criteria to baseline data collected from the “brown-bag” review of medications for participants of the Longitudinal Research on Aging Drivers (LongROAD) study to examine the prevalence and correlates of PIM use in a geographically diverse, community-dwelling sample of older drivers (n = 2949). Proportions of participants who used one or more PIMs according to the American Geriatrics Society 2015 Beers Criteria, and estimated odds ratios (ORs) and 95% confidence intervals (CIs) of PIM use associated with participant characteristics were calculated.

Results

Overall, 18.5% of the older drivers studied used one or more PIM. The most commonly used therapeutic category of PIM was benzodiazepines (accounting for 16.6% of the total PIMs identified), followed by nonbenzodiazepine hypnotics (15.2%), antidepressants (15.2%), and first-generation antihistamines (10.5%). Compared to older drivers on four or fewer medications, the adjusted ORs of PIM use were 2.43 (95% CI 1.68–3.51) for those on 5–7 medications, 4.19 (95% CI 2.95–5.93) for those on 8–11 medications, and 8.01 (95% CI 5.71–11.23) for those on ≥12 medications. Older drivers who were female, white, or living in urban areas were at significantly heightened risk of PIM use.

Conclusion

About one in five older drivers uses PIMs. Commonly used PIMs are medications known to impair driving ability and increase crash risk. Implementation of evidence-based interventions to reduce PIM use in older drivers may confer both health and safety benefits.

Trial registration

Not applicable.

Inappropriate prescribing defined by STOPP and START criteria and its association with adverse drug events among hospitalized older patients: A multicentre, prospective study

Objectives

To provide baseline information on inappropriate prescribing (IP), and to evaluate whether potentially inappropriate medications (PIMs), as defined by STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions) criteria, were associated with preventable adverse drug events (ADEs) and/or hospitalization.

Methods

We prospectively studied older patients (n = 301) admitted to three urban, public-funded hospitals. We scrutinized their medical records and used STOPP-START (Screening Tool to Alert Prescribers to Right Treatment) criteria to determine PIM and potential prescribing omissions (PPO) respectively- together these constitute IP. Prescriptions with PIM(s) were subjected to a pharmacist medication review, aimed at detecting cases of ADE(s). The vetted cases were further assessed by an expert consensus panel to ascertain: i) causality between the ADE and hospitalization, using, the World Health Organization Uppsala Monitoring Centre criteria, and, ii) whether the ADEs were avoidable (using Hallas criteria). Finally, percentages of PIM-associated ADEs that were both preventable and linked to hospitalization were calculated.

Results

IP prevalence was 58.5% (n = 176). A majority (49.5%, n = 150) had moderate to severe degree of comorbidities (Charlson Comorbidity Index score ≥ 3). Median age was 72 years. Median number of medications was 6 and 30.9% (n = 93) had ≥8 medications. PIM prevalence was 34.9% (117 PIMs, n = 105) and PPO 37.9% (191 PPOs, n = 114). Most PIMs and PPOs involved overuse of aspirin and underuse of both antiplatelets and statins respectively. With every increase in the number of medications prescribed, the likelihood of PIM occurrence increased by 20%, i.e.1.2 fold (OR 1.20, 95% CI: 1.1–1.3). Among the 105 patients with PIMs, 33 ADEs (n = 33); 31 ADEs (n = 31) considered “causal” or “contributory” to hospitalization; 27 ADEs (n = 27) deemed “avoidable” or “potentially avoidable”; and 25 PIM-associated ADEs, preventable, and that induced hospitalization (n = 25), were identified: these equated to prevalence of 31.4%, 29.5%, 25.7%, and 23.8% respectively. The most common ADEs were masked hypoglycemia and gastrointestinal bleed. With every additional PIM prescribed, the odds for ADE occurrence increased by 12 folds (OR 11.8, 95% CI 5.20–25.3).

Conclusion

The majority of the older patients who were admitted to secondary care for acute illnesses were potentially exposed to IP. Approximately a quarter of the patients were prescribed with PIMs, which were plausibly linked with preventable ADEs that directly caused or contributed to hospitalization.

Assessment of potentially inappropriate medications using the EU (7)-PIM list and the Swedish quality indicators

Background Several tools to evaluate the appropriateness of prescriptions have been developed over the years. Objective To compare the prevalence of potentially inappropriate medication (PIM) among elderly, using the European Union (EU) (7)-PIM list and the Swedish quality indicators. Secondary objectives were to investigate factors associated with the use of PIMs using the two tools. Setting Medical ward in a hospital in Northern Sweden. Methods Medical records for patients aged ≥ 65 years admitted to the medical ward were reviewed by clinical pharmacists from September to November 2015 and from February to April 2016. PIMs were identified through the abovementioned identification tools. Main outcome measure Prevalence of PIMs. Results Of 93 patients, 18.3% had one PIM according to the Swedish quality indicators. The most common PIM class was non-steroidal anti-inflammatory drugs and diclofenac was one of the most commonly prescribed PIMs. According to the EU (7)-PIM list, 45.2% of the study population was prescribed one or more PIMs. The most common PIM class was hypnotic and sedative drugs, and the most frequently prescribed PIM was apixaban. No significant associations between PIMs and different factors were found using either identification tool. Conclusion The prevalence of PIMs was relatively low in the study sample according to the Swedish guidelines but high according to the EU (7)-PIM list. Different evaluation tools might give inconclusive results, but it is still important to continuously evaluate the need for PIMs in older patients in order to improve drug treatment and to decrease the risk of adverse drug reactions.

Physician's Knowledge of Appropriate Prescribing for the Elderly-A Survey Among Family and Internal Medicine Physicians in Nigeria

Background: Prescription and use of inappropriate medications have been identified as a major cause of morbidity among the elderly. Several screening tools have been developed to identify inappropriate medications prescribed for elderly patients. There is dearth of information about the knowledge of Nigerian physicians regarding these screening tools and appropriate prescribing for the elderly in general. The primary objective of this study was to assess the knowledge of Nigerian physicians about these screening tools and appropriate prescribing of medications for the elderly.

Methods: The study was a cross-sectional questionnaire-based study conducted among physicians working in Family Medicine and Internal Medicine departments of four tertiary health care facilities in Nigeria. The questionnaire consisted of sections on general characteristics of respondents and their knowledge of four selected screening tools for inappropriate medications in the elderly. Ten clinical vignettes representing different therapeutic areas (using the best option type questions) about medicine use in the elderly were included with a score of 1 and 0 for correct and wrong answers, respectively. The knowledge of respondents was classified as (total score, over 10): poor (score, < 5), average (score, 5-6), and good (score, 7-10).

Results: One hundred and five physicians returned completed questionnaires. Twenty percent of respondents knew about Beers criteria, whereas 15.6% were familiar with the STOPP criteria. Majority (83; 84.7%) of the respondents were confident of their ability to prescribeappropriately for elderly patients. The mean knowledge score was 5.3 ± 2.0 with 32 (30.5%), 41 (39%), and 32 (30.5%) having low, average, and good scores, respectively. The association between the knowledge score, duration of practice, and seniority was statistically significant (OR, 3.6, p = .004 and OR, 3; p = .012), respectively.

Conclusion: There are significant gaps in the knowledge of Nigerian physicians about screening tools for inappropriate medications. There is a need for stakeholders involved in the care of elderly Nigerian patients to develop new strategies to improve services being offered. These may include introduction of modules on appropriate prescribing in the curriculum of undergraduate and postgraduate medical education and the routine use of some screening tools for inappropriate medications in daily clinical practice.

Consequences of ignoring patient diagnoses when using the 2015 Updated Beers Criteria

BACKGROUND

Beers Criteria are one of the best known explicit criteria to identify inappropriate medication in elderly that can be used in medication review. The access to patients' medical records may be different among healthcare professionals and settings and, subsequently, the identification of patients' diagnoses may be compromised.

OBJECTIVE

To assess the consequences of ignoring patient diagnoses when applying 2015 Beers Criteria to identify potentially inappropriate medication (PIM).

SETTING

Three nursing homes in Central Portugal.

METHOD

Medical records of nursing home residents over 65 years old were appraised to identify medication profile and medical conditions. 2015 Beers Criteria were used with and without considering patients' diagnoses. To compare the number of PIM and PIM-qualifying criteria complied in these two judgements, Wilcoxon signed-rank tests were performed.

MAIN OUTCOME MEASURE

Number of PIMs and number of PIM-qualifying criteria.

RESULTS

A total of 185 patients with a mean age of 86.7 years (SD = 7.8) with a majority of female (70.3%) were studied. When assessing the patients with full access to the diagnoses, median number of PIMs was 4 (IQR 0-10) and number of PIM-qualifying criteria was 5 (IQR 0-15). When evaluating only patient current medication, median number of PIMs was 4 (IQR 0-10) and PIM-qualifying criteria was 4 (IQR 0-12). Statistical difference was found in the number of PIM-qualifying criteria identified (p < 0.001), but not in the number of PIMs per patient (p = 0.090). In 171 patients (92.4%) PIMs identified were identical when using or ignoring their medical diagnoses. However, in 80 patients (43.2%) the PIM-qualifying criteria complied were different with and without access to patient diagnoses.

CONCLUSION

Although restricted access to patients' diagnoses may limit the judgement of Beers PIM-qualifying criteria, this limitation had no effect on the number of PIM identified.

Prevalence Of Potentially Inappropriate Medication In The Older Adult Population Within Primary Care In Portugal: A Nationwide Cross-Sectional Study

BACKGROUND

In potentially inappropriate medications harm potentially outweighs benefits. Even appropriately prescribed medications may become inappropriate. They can lead to a high risk of adverse drug reactions, morbidity and mortality. The aim of this study was to determine the prevalence of potentially inappropriate medication in the older adult population attending primary care in Portugal and to identify associated sociodemographic and clinical factors.

METHODS

We conducted a cross-sectional, analytical study in primary care centres from the five Portuguese healthcare administrative regions and the two autonomous regions. We used a random sample of 757 older patients provided by the information department of the ministry of health (SPMS) and family doctors from the autonomous regions. Data collection occurred March 2018 and we studied sociodemographic characteristics, clinical profile and medication. We used 2015 Beers Criteria to assess potentially inappropriate medications. Logistic regression analyses were performed to determine associations between potentially inappropriate medications' prescriptions and other variables.

RESULTS

Potentially inappropriate medication was present in 68.6% and 46.1% of the sample had two or more. The likelihood of having potentially inappropriate medication increased significantly with being female (OR=1.56 [1.05 to 2.31]), number of chronic health problems (OR=1.06 [1.01 to 1.13]), number of pharmacological subclasses (OR=1.40 [1.30 to 1.51]) and number of prescribers (OR=1.34 [1.09 to 1.65]). Proton-pump inhibitors, nonsteroidal anti-inflammatory drugs and benzodiazepines were the most commonly found ones.

CONCLUSION

Potentially inappropriate medication in older adults was found to be a common occurrence in Portugal. It is important that doctors are aware of this problem, namely in the primary care setting due to the longitudinal care.