Frequency of inappropriate drugs in primary care: analysis of a sample of immobile patients who received periodic home visits

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.

Medication review and reconciliation in older adults

Older people are frequently exposed to polypharmacy, inappropriate prescribing, and adverse drug events. Two clinical processes can help geriatricians to optimize and increase the safety of drug prescriptions for older adults: medication reconciliation and medication review. Medication reconciliation provides the best possible medication history and identifies and resolves discrepancies in drug prescriptions. During the medication review, the best possible medication history is crosschecked against other data, including morbidities, patient's preferences, or geriatric syndromes, to produce a personalized medication strategy. Alignment of treatment recommendations with patient preferences and goals through shared decision-making is particularly important in medication review. Medication reconciliation and medication review have proven to be effective, but their broad implementation remains difficult. Indeed, these procedures are time-consuming and require specific skills, coordination between different healthcare professionals, organizations and dedicated means. The involvement of geriatricians therefore remains essential for the successful implementation of medication reconciliation and medication review in geriatric settings and among frail older people.

[Which factors are associated with the use of potentially inadequate medications (PIM) in the elderly? : Results from the German health interview and examination survey (DEGS1)]

BACKGROUND

Recent studies demonstrate a relationship between the prescription of potentially inappropriate medications (PIM) for patients 65 years or older and an increased risk for adverse events, in particular hospitalisations. The RKI conducted DEGS1-Survey ("German health interview and examination survey for adults") provides a representative sample of the target population to identify determinants for PIM use.

OBJECTIVE

The aim of this study was to determine characteristics of older persons in Germany, who currently use PIM, and if there are subpopulations among older persons with a particularly high PIM use.

METHODS

Within the DEGS1-Survey a total of 175 variables regarding health and social aspects were documented from 1392 community-dwelling persons between 65 and 79 years of age, and medication intake during the last seven days was recorded. PIM drugs were identified according to the PRISCUS list. Associations between PIM use and variables recorded were evaluated by means of multivariate statistical models.

RESULTS

Within seven days before the survey PIM drugs were used by 13.0% (95%-CI: 10.7-15.6) of the respondents. The following factors significantly increase the risk for receiving a PIM: number of drugs taken in the last seven days; number of visits to different physician specialists during the last 12 months; sleep disorders; psychiatric condition, and diseases affecting the musculoskeletal system. The majority of PIMs were antidepressants and anxiolytics/sedatives. Elderly women with depression, sleep disorders, and a need for analgesics are particularly affected by increased PIM use. They deserve special attention in this regard.

The associations of geriatric syndromes and other patient characteristics with the current and future use of potentially inappropriate medications in a large cohort study

PURPOSE

To assess the changes in use of potentially inappropriate medication (PIM) as defined by the 2015 Beers criteria, the EU(7)-PIM, and the PRISCUS list over a 6-year period and to identify determinants for current and future PIM use with a particular focus on geriatric syndromes.

METHODS

In a German cohort of 2878 community-dwelling adults aged ≥ 60 years, determinants of the use of ≥ 1 PIM were identified in multivariable logistic regression (cross-sectional analysis) and weighted generalized estimating equation models (longitudinal analysis).

RESULTS

Prevalences for Beers, EU(7), and PRISCUS PIM were 26.4, 37.4, and 13.7% at baseline and decreased to 23.1, 36.5, and 12.3%, respectively, 6 years later. Unadjusted prevalences in participants with any geriatric syndrome (frailty, co-morbidity, functional, or cognitive impairment) were approximately twice as high as in robust older adults. In multivariable analyses, cognitive impairment was statistically significantly associated with the use of PIM of all three criteria in the cross-sectional (odds ratio (OR) point estimates 1.90-2.21) but not in the longitudinal models. In contrast, frailty, co-morbidity, and functional impairment were statistically significantly associated with the use of PIM of at least one of the three criteria in both models. However, the associations varied for the PIM criteria, and in the longitudinal analysis, associations were only statistically significant for Beers PIM (ORs [95% confidence intervals]: frailty (2.23 [1.15, 4.31]), co-morbidity by five total co-morbidity score points (1.21 [1.05, 1.38]), and functional impairment (1.51 [1.00, 2.27]). Other statistically significant determinants of the incidence of PIM (any definition) were female sex, age, coronary heart disease, heart failure, biomarkers of the metabolic syndrome, and history of ulcer, depressive episodes, hip fracture, or any cancer.

CONCLUSIONS

Older adults with frailty, co-morbidity, cognitive, and functional impairment had higher odds of taking PIM or getting a PIM prescription in the future (exception: cognitive impairment). Physicians should be especially cautious when prescribing drugs for these patients who are particularly susceptible to adverse reactions.

Fall-Risk-Increasing Drugs: A Systematic Review and Meta-analysis: III. Others

BACKGROUND AND OBJECTIVE

The use of psychotropic medication and cardiovascular medication has been associated with an increased risk of falling. However, other frequently prescribed medication classes are still under debate as potential risk factors for falls in the older population. The aim of this systematic review and meta-analysis is to evaluate the associations between fall risk and nonpsychotropic and noncardiovascular medications.

METHODS AND DESIGN

A systematic review and meta-analysis. A search was conducted in Medline, PsycINFO, and Embase. Key search concepts were "falls," "aged," "medication," and "causality." Studies were included that investigated nonpsychotropic and noncardiovascular medications as risk factors for falls in participants ≥60 years or participants with a mean age ≥70 years. A meta-analysis was performed using the generic inverse variance method, pooling unadjusted and adjusted odds ratio (OR) estimates separately.

RESULTS

In a qualitative synthesis, 281 studies were included. The results of meta-analysis using adjusted data were as follows (a pooled OR [95% confidence interval]): analgesics, 1.42 (0.91-2.23); nonsteroidal anti-inflammatory drugs (NSAIDs), 1.09 (0.96-1.23); opioids, 1.60 (1.35-1.91); anti-Parkinson drugs, 1.54 (0.99-2.39); antiepileptics, 1.55 (1.25-1.92); and polypharmacy, 1.75 (1.27-2.41). Most of the meta-analyses resulted in substantial heterogeneity that did not disappear after stratification for population and setting in most cases. In a descriptive synthesis, consistent associations with falls were observed for long-term proton pump inhibitor use and opioid initiation. Laxatives showed inconsistent associations with falls (7/20 studies showing a positive association).

CONCLUSION

Opioid and antiepileptic use and polypharmacy were significantly associated with increased risk of falling in the meta-analyses. Long-term use of proton pump inhibitors and opioid initiation might increase the fall risk. Future research is necessary because the causal role of some medication classes as fall-risk-increasing drugs remains unclear, and the existing literature contains significant limitations.

A prevalence study of potentially inappropriate medications use in hospitalized Pakistani elderly

BACKGROUND

Inappropriate prescribing in elderly patients is a widespread health problem. It is associated with increased drug-related problems and health expenditure.

AIMS

To determine the prevalence and types of potentially inappropriate medications (PIM) prescribed to elderly patients with polypharmacy and the factors associated with their use in these patients.

METHODS

A cross-sectional study conducted among 228 elderly hospitalized patients with polypharmacy. Elderly patients were defined as patients ≥65 years of age, and polypharmacy was defined as taking ≥5 drugs. Based on previously published criteria (Beers and STOPP), a list of 32 PIM was developed using a Delphi technique, which was used as a tool to detect the prevalence of PIM. Age, gender, comorbidity, patients' functional status, and complete medication history were recorded to evaluate as variables related to PIM. The association between PIM used and independent variables was also assessed.

RESULTS

The prevalence of PIM used among the hospitalized elderly patients was 64%. PIM use according to STOPP criteria was identified in 44% of patients, whereas Beers-listed PIM were identified in 50% of patients. The most frequently observed PIM were the combination of nonsteroidal anti-inflammatory drugs (NSAIDs) with antihypertensives and long-term NSAIDs, which account for more than 90 and 75% of the total observed PIM, respectively. Patients with age ≥85 years were more likely to be prescribed PIM. High comorbidity was found to be an independent predictor of PIM use. Polypharmacy with ≥10 drugs prescribed to patients predicted the presence of PIM.

DISCUSSION

The study showed a high prevalence of PIM use among hospitalized elderly patients. The consensus-validated list of PIM was a useful tool for screening inappropriate prescribing in this particular patient population.

CONCLUSION

Our findings support the need for measures to improve the quality of drug treatment in the elderly Pakistani population, especially among dependent patients with polypharmacy.

A systematic review of the outcomes reported in trials of medication review in older patients: the need for a core outcome set

AIM

Medication review has been advocated as one of the measures to tackle the challenge of polypharmacy in older patients, yet there is no consensus on how best to evaluate its efficacy. This study aimed to assess outcome reporting in trials of medication review in older patients.

METHODS

Randomized controlled trials (RCTs), prospective studies and RCT protocols involving medication review performed in patients aged 65 years or older in any setting of care were identified from: (1) a recent systematic review; (2) RCT registries of ongoing studies; (3) the Cochrane library. The type, definition, and frequency of all outcomes reported were extracted independently by two researchers.

RESULTS

Forty-seven RCTs or prospective published studies and 32 RCT protocols were identified. A total of 327 distinct outcomes were identified in the 47 published studies. Only one fifth (21%) of the studies evaluated the impact of medication reviews on adverse events such as drug reactions or drug-related hospital admissions. Most of the outcomes were related to medication use (n = 114, 35%) and healthcare use (n = 74, 23%). Very few outcomes were patient-related (n = 24, 7%). A total of 248 distinct outcomes were identified in the 32 RCT protocols. Overall, the number of outcomes and the number and type of health domains covered by the outcomes varied largely.

CONCLUSION

Outcome reporting from RCTs concerning medication review in older patients is heterogeneous. This review highlights the need for a standardized core outcome set for medication review in older patients, to improve outcome reporting and evidence synthesis.

Drug Prescribing in the Elderly Receiving Home Care

BACKGROUND

To compare the prevalence of potentially inappropriate medications (PIMs) using the 2012 and 2003 Beers Criteria in frail older patients receiving home health care services (HHS), and to explore the correlates of PIMs based on the 2012 Beers criteria.

MATERIALS AND METHODS

A total of 145 older patients (mean age, 80.9 ± 7.6 years) with Barthel scale ≤ 60 receiving regular HHS from a university hospital between January 2013 and June 2013 were retrospectively enrolled. The 2003 and 2012 Beers criteria were used separately to detect PIMs. Logistic regressions, receiver-operating-characteristic curve analyses and number needed to harm were used, where appropriate.

RESULTS

The 2012 Beers Criteria identified more PIM cases than did the 2003 Beers Criteria (66.9% versus 55.9%, P < 0.05). Multivariate analysis revealed that PIM identified by the 2012 Beers Criteria was associated with an increased number of medications prescribed (P = 0.019) and the presence of psychiatric diseases (P = 0.001). Moreover, the area under the receiver-operating-characteristic curve for the number of drugs to predict the risk of PIM was 0.674 (P < 0.001) with the optimal cutoff value of 6 medications. After adjusting for age, sex, Charlson comorbidity index and psychiatric disorders, patients taking ≥6 drugs (adjusted odds ratio, 2.33; adjusted number needed to harm, 3.93; P < 0.05) had a significantly higher risk for PIM than those taking <6 drugs.

CONCLUSIONS

Our data showed that the 2012 Beers Criteria was more sensitive in detecting PIMs than the 2003 Beers Criteria. Furthermore, frail older patients receiving HHS with polymedication and with psychiatric illnesses had higher risk of PIM when using the 2012 criteria. The number of medications prescribed could be a useful index for risk stratification, and at the same time help physicians to be aware of the high risk for PIM when prescribing 6 or more drugs to frail older adults during in-home visits.

Potentially Inappropriate Medication Use in Multimorbid Elderly Inpatients: Differences Between the FORTA, PRISCUS and STOPP Ratings

Background

Several classifications to identify and avoid use of potentially inappropriate medications (PIMs) in the elderly have been published. To what extent these classifications match each other and whether there are differences in the prevalence of PIM use at admission, during the inpatient stay and at discharge are largely unreported.

Objectives

To determine the PIM prevalence in elderly patients at a university hospital, with a special focus on different classification systems and the chronological sequence, and to examine a possible association between PIM use and the reason for admission, as well as severe side effects and consequences of PIM use during hospitalization.

Methods

On the basis of the criteria provided by FORTA (Fit for the Aged), PRISCUS (Latin for ‘time-honoured’) and STOPP (Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions), medication in patients over the age of 65 years was screened retrospectively within four point prevalence analyses at admission, during the inpatient stay and at discharge. Evaluation of a possible association between PIM use and the primary diagnosis or severe side effects during hospitalization was performed according to an analysis using the World Health Organization Uppsala Monitoring Centre system for standardized case causality assessment.

Results

Of 200 patients, 176 (88 %) received at least one PIM at admission, during the inpatient stay and/or at discharge (116 patients according to FORTA, 113 according to PRISCUS and 138 according to STOPP). When the PIM prevalence was compared between the three different sets of criteria, STOPP identified significantly more patients receiving PIMs than FORTA (P = 0.022) and PRISCUS (P = 0.010). At the patient level and at the drug level, the use of PIMs increased during the inpatient stay; however, the PIM prevalence was similar at admission and at discharge, both at the patient level and at the drug level.

Conclusion

Medication is rated significantly differently by FORTA, PRISCUS and STOPP. In addition, a significant rise in prescribing of PIMs during the inpatient stay illustrates that a reduction in PIM use during the inpatient stay is essential, as it is known that avoiding PIM use in older adults is one strategy to decrease the risk of adverse events.

Electronic supplementary material

The online version of this article (doi:10.1007/s40801-016-0085-2) contains supplementary material, which is available to authorized users.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Amsterdam tool for clinical medication review: development and testing of a comprehensive tool for pharmacists and general practitioners

Background

Drug-related problems are prevalent among older patients, and substantially increase the risk of morbidity, (re-)hospitalisation and mortality. To detect drug-related problems and optimize treatment primary caregivers should periodically review the medication of older patients. The aim was to develop a structured, comprehensive but practicable tool to facilitate and support the reviewing of medication of older patients with a chronic disease by pharmacists and general practitioners.

Methods

A tool facilitating clinical medication review by community pharmacists was developed on the basis of treatment guidelines, literature data on drug-related problems. For the identification of drug-related problems from the patient’s perspective, a script for structured interviews was developed. The tool was optimized by means of a Delphi method with an expert panel and testing in a trial.

Results

The medication review tool consists of a comprehensive checklist of 124 drug-related problems divided by 20 sections according to physiological systems and diseases, and includes a structured interview script for a patient interviews.

Conclusion

A structured, comprehensive and practical tool to assist pharmacists and general practitioners to perform clinical medication review including a list of potential drug-related problems in older patients with chronic disease, as well as a script for structured patient interviews, was developed.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-015-1566-1) contains supplementary material, which is available to authorized users.

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

BACKGROUND

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Potentially Inappropriate Prescribing in Disabled Older Patients with Chronic Diseases: A Screening Tool of Older Persons' Potentially Inappropriate Prescriptions versus Beers 2012 Criteria

OBJECTIVE

To evaluate the prescription of potentially inappropriate medications (PIM), using the Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) and Beers criteria, to disabled older people.

SUBJECTS AND METHODS

One hundred and forty-one patients aged ≥65 years with Barthel scale scores ≤60 and a regular intake of medication for chronic diseases at Chung Shan Medical University Hospital from July to December 2012 were included, and their medical records were reviewed. Comprehensive patient information was extracted from the patients' medical notes. The STOPP and Beers 2012 criteria were used separately to identify PIM, and logistic regression analyses were performed to identify risk factors for PIM. The optimal cutoff for the number of medications prescribed for predicting PIM was estimated using the Youden index.

RESULTS

Of the 141 patients, 94 (66.7%) and 94 (66.7%) had at least one PIM identified by the STOPP and Beers criteria, respectively. In multivariate analysis, PIM identified by the Beers criteria were associated with the prescription of multiple medications (p = 0.013) and the presence of psychiatric diseases (p < 0.001), whereas PIM identified by the STOPP criteria were only associated with the prescription of multiple medications (p = 0.008). The optimal cutoff for the number of medications prescribed for predicting PIM by using the STOPP or Beers criteria was 6. After adjustment for covariates, patients prescribed ≥6 medications had a significantly higher risk of PIM, identified using the STOPP or Beers criteria, compared to patients prescribed <6 medications (both p < 0.05).

CONCLUSION

This study revealed a high frequency of PIM in disabled older patients with chronic diseases, particularly those prescribed ≥6 medications.

Impact of Medication Reconciliation and Review on Clinical Outcomes

Objective: To examine the evidence regarding the effectiveness of medication reconciliation and review and to improve clinical outcomes in hospitals, the community, and aged care facilities. Data Source: This systematic review was undertaken in concordance with the PRISMA statement. Electronic databases, including MEDLINE, PsycINFO, EMBASE, and CINAHL were searched for relevant articles published between January 2000 and March 2014. Study Selection and Data Extraction: Randomized and nonrandomized studies rating the severity of medication discrepancies and medication-related problems identified during medication reconciliation and/or review were considered for inclusion. Data were extracted independently by 2 authors using a data collection form. Data Synthesis: Of the 5292 articles identified, 83 articles met the inclusion criteria. Medication reconciliation identified unintentional medication discrepancies in 3.4% to 98.2% of patients. There is limited evidence of the potential of these discrepancies to cause harm. Medication reviews identified medication-related problems or possible adverse drug reactions in 17.2% to 94.0% of patients. The studies reported conflicting findings regarding the impact of medication review on length of stays, readmissions, and mortality. Conclusions: The evidence demonstrates that medication reconciliation has the potential to identify many medication discrepancies and reduce potential harm, but the impact on clinical outcomes is less clear. Similarly, medication review can detect medication-related problems in many patients, but evidence of clinical impact is scant. Overall, there is limited evidence that medication reconciliation and medication review processes, as currently performed, significantly improve clinical outcomes, such as reductions in hospital readmissions.

2012 American Geriatrics Society Beers criteria: enhanced applicability for detecting potentially inappropriate medications in European older adults? A comparison with the Screening Tool of Older Person's Potentially Inappropriate Prescriptions

OBJECTIVES

To determine the prevalence of potentially inappropriate medications (PIMs) and related factors through a comparative analysis of the Screening Tool of Older Person's Potentially Inappropriate Prescriptions (STOPP), the 2003 Beers criteria, and the 2012 AGS update of the Beers criteria.

DESIGN

Cross-sectional.

SETTING

Primary care.

PARTICIPANTS

Community-dwelling persons aged 65 and older who live on the island of Lanzarote, Spain (N = 407).

MEASUREMENTS

Sociodemographic characteristics; independence in activities of daily living; cognitive function; Geriatric Depression Scale; clinical diagnoses; and complete data on indication, dosage, and length of drug treatments. One thousand eight hundred seventh-two prescriptions were examined, and the rate of PIMs was assessed with the three criteria. The primary endpoint was the percentage of participants receiving at least one PIM. Multivariate logistic regression was used to examine the factors related to PIMs.

RESULTS

Potentially inappropriate medications were present in 24.3%, 35.4%, and 44% of participants, according to the 2003 Beers criteria, STOPP, and 2012 Beers criteria, respectively. The profile of PIMs was also different (the most frequent being benzodiazepines in both Beers criteria lists and aspirin in the STOPP). The number of drugs was associated with risk of prescribing PIMs in all three models, as was the presence of a psychological disorder in the 2003 Beers criteria (odds ratio (OR) = 2.07, 95% confidence interval (CI) = 1.26-3.40) and the 2012 Beers criteria (OR = 2.91, 95% CI = 1.83-4.66). The kappa for degree of agreement between STOPP and the 2012 Beers criteria was 0.35 (95% CI = 0.25-0.44).

CONCLUSION

The 2012 Beers criteria detected the highest number of PIMs, and given the scant overlapping with the STOPP criteria, the use of both tools may be seen as complementary.

Potentially inappropriate prescribing in elderly outpatients in Croatia

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Potentially inappropriate medications in community-dwelling older adults

Potentially inappropriate medication (PIM) use is a significant worldwide public health problem. Community-dwelling older adults are susceptible to the negative outcomes associated with the use of PIMs. A database search (January 1991-June 2013) produced 19 prospective correlational and 10 intervention studies. The current state of the science reveals that conceptual clarity is lacking regarding the use of PIMs. The prevalence of PIM use is well documented in an abundance of descriptive studies. However, researchers have not examined an intervention's effects on health outcomes in community-dwelling older adults. Although independent older adults can acquire PIMs outside of a provider, current interventions aim to change the behavior of the prescribing physician and pharmacist. Nurses need to collaborate with other disciplines in PIM use research. Priority needs are to design interventions that reduce the use of PIMs and negative health outcomes.

Identification of drug-related problems of elderly patients discharged from hospital

BACKGROUND

Drug-related problems (DRP) following hospital discharge are common among elderly patients using multiple drugs for the treatment of chronic diseases. The aim of this study was to investigate the occurrence of DRP in these patients using a specific tool for the identification of DRP by community pharmacists.

METHODS

An observational study involving 340 patients aged over 60 years using at least five prescription drugs and discharged from hospital. The occurrence of DRP was assessed by means of an identification tool specifically developed for use by community pharmacists, including a semistructured patient interview and a checklist of common DRP.

RESULTS

In total, 992 potential DRP were observed in the 340 patients (mean 2.9 ± 1.7). No drug prescribed but clear indication, an unnecessarily long duration of treatment, dose too low, and incorrect drug selection were the DRP most commonly observed. Ten percent of DRP occurring in 71 patients were drug-drug interactions. The number of DRP was related to the number of drugs prescribed. Frequently occurring DRP found using the patient interview were fear of side effects and no or insufficient knowledge of drug use. Medication of patients discharged from the pulmonary department and of those with type 2 diabetes was particularly associated with occurrence of DRP.

CONCLUSION

Following hospital discharge, DRP occur frequently among elderly patients using five or more drugs for the treatment of chronic disease. The number of DRP increased with the number of drugs used. An important task for community pharmacists is to identify, resolve, and prevent the occurrence of DRP among this patient group. Since DRP are associated with an increased risk of hospital readmissions, morbidity, and mortality, it is very important to develop intervention strategies to resolve and prevent DRP.

Global research priorities to better understand the burden of iatrogenic harm in primary care: an international Delphi exercise

Using a modified Delphi exercise, Aziz Sheikh and colleagues identify research priorities for patient safety research in primary care contexts. Please see later in the article for the Editors' Summary.

Prescribing potentially inappropriate medication (PIM) in Germany's elderly as indicated by the PRISCUS list. An analysis based on regional claims data

PURPOSE

The aim of this study was to estimate the prevalence of potentially inappropriate medication (PIM) in the elderly as indicated by Germany's recently published list (PRISCUS) and to assess factors independently associated with PIM prescribing, both overall and separately for therapeutic groups.

METHODS

Claims data analysis (Health Insurance Sample AOK Hesse/KV Hesse, 18.75% random sample of insurants from AOK Hesse, Germany) is used in the study. The study population is composed of 73,665 insurants >64 years of age continuously insured in the last quarter of 2009 and either continuously insured or deceased in 2010. Prevalence estimates are standardized to the population of Germany (31 December 2010). The variables age, sex, polypharmacy, hospital stay and nursing care are assessed for their independent association with general PIM prescription and among 11 therapeutic subgroups using multivariate logistic regression analysis.

RESULTS

In 2010, 22.0% of the elderly received at least one PIM prescription (men: 18.3%, women: 24.8%). The highest PIM prevalence was observed for antidepressants (6.5%), antihypertensives (3.8%) and antiarrhythmic drugs (3.5%). Amitriptyline, tetrazepam, doxepin, acetyldigoxin, doxazosin and etoricoxib were the most frequently prescribed PIMs. Multivariate analyses indicate that women (OR 1.39; 95% CI: 1.34-1.44) and persons with extreme polypharmacy (≥10 vs. <5 drugs: OR 5.16; 95% CI: 4.87-5.47) were at higher risk for receiving a PRISCUS-PIM. Risk analysis for therapeutic groups shows divergent associations.

CONCLUSION

PRISCUS-PIMs are widely used. Educational programs should focus on drugs with high treatment prevalence and call professionals' attention to those elderly patients who are at special risk for inappropriate medication.

Cognitive impairment in primary ambulatory health care: pharmacotherapy and the use of potentially inappropriate medicine

OBJECTIVE

Drug intake is associated with a risk of drug-related problems, for example, the intake of potentially inappropriate medication (PIM), especially for cognitively impaired individuals. The proportion of PIM taken by immobile individuals, especially patients with suspicion of dementia in the AGnES studies (German: Arzt-entlastende Gemeinde-nahe E-Health-gestützte Systemische Intervention), and possible determinants were analyzed.

METHODS

In a community-based, prospective cohort study in the ambulatory healthcare sector, a sample of 342 patients aged ≥65 years were screened for dementia and received a home medication review. The screening for dementia was positive in 111 cases (32.5%). Data assessment included sociodemographic variables and medical diagnoses. The German PRISCUS list was used to detect PIM and drug-condition interactions.

RESULTS

Potentially inappropriate medication in dementia was identified in 22 (19.8%) patients with suspicion of dementia. A multivariate binary logistic regression revealed that the number of drugs taken (one to four drugs: OR = 0.059; 95% CI 0.006-0.55, p = 0.0133; Ref.: >9 drugs) and female gender (OR = 10.362; 95% CI: 1.28-83.87) were risk factors for PIM intake in patient with suspicion of dementia.

CONCLUSIONS

Inappropriate medication use in a community-based sample positively screened for dementia appears to be determined by sex and the number of drugs taken. The intake of fewer than five drugs and receiving support with regard to drug intake protects from the intake of PIM. Patients could benefit from medication management in a collaborative network of healthcare professionals. The implementation of systematic medication review and drug documentation should be extended and standardized in both research studies and routine primary health care.

[Potentially inappropriate medication: the quality of pharmacotherapy in the elderly]

Potentially inappropriate medication (PIM) in the elderly is a common problem in primary care. Depending on the setting under investigation, recent studies reported a prevalence of PIM up to 24% in Germany. In 2010 the German national PRISCUS list containing explicit criteria to identify PIM was published. First data show a possible association between PIM as defined by the Priscus list and negative health outcomes. However, prospective controlled trials are needed to assess whether interventions based on explicit criteria are able to improve patient-related outcome. Against this backdrop, the present review comments on recent data, especially those with impact for the German health care system.

Prescribing of potentially inappropriate medications for the elderly: an analysis based on the PRISCUS list

BACKGROUND

The PRISCUS list of potentially inappropriate medications (PIM) for the elderly was published in 2010 and is the first systematically constructed list of this type in Germany. The aim of the present study is to estimate the baseline prevalence of the prescribing of PIM, as defined by the PRISCUS list.

METHODS

Pseudonymized claims data from three statutory health insurances in Germany, which together covered more than 8 million insurants, for the year 2007 were used to determine the age- and sex-standardized one-year period prevalence of PIM among the elderly, as well as the frequency of PIM prescribing per person. The study population included all insurants who were at least 65 years old and were continuously insured throughout the year 2007 or died during that year.

RESULTS

Of the 804 400 elderly persons in the study population, 201 472 (25.0%) received at least one PIM prescription in 2007. The PIM prevalence was higher in women than in men (32.0% vs. 23.3%) and increased with age. The most commonly prescribed PIM were amitriptyline (2.6%), acetyldigoxin (2.4%), tetrazepam (2.0%), and oxazepam (2.0%). 8.8% of all elderly persons received the same PIM drug four or more times in 2007.

CONCLUSION

These data show that PIM were frequently prescribed to elderly persons in Germany before the PRISCUS list was published. Medications on the PRISCUS list are not necessarily absolutely contraindicated, and this study contained no information about the individual risk/benefit analyses that may have been carried out before these drugs were prescribed; thus, no conclusion can be drawn about the prevalence of inappropriate prescribing. Further research is needed to validate the PRISCUS list, which was generated by expert consensus, as a basis for therapeutic guidelines in geriatric medicine.

The future of Alzheimer's disease: the next 10 years

Alzheimer's disease (AD) is a fast growing world-wide epidemic. AD is a genetically complex, slowly progressive, and irreversible neurodegenerative disease of the brain. During decades of asymptomatic progression multiple interactive systems, pathways and molecular mechanisms (e.g. protein processing, aberrant signaling, inflammation and immune system, lipid transport, endocytosis, apoptosis, oxidative damage and response to stress, tau pathology, neuron and synapse loss, energy metabolism), contribute to the development of the early clinical prodromal stage with episodic memory deficits and to further decline and loss of general cognitive functioning during the final syndromal dementia stage. The non-mendelian genetically complex "sporadic" AD type is the most common form of dementia affecting people usually over the age of 65. Despite considerable progress of AD research in recent years and evolving paradigm shifts in both pathophysiological concepts as well as in diagnostic criteria fundamental challenges have not yet been resolved. The strong age-related incidence, the recent failure and complete lack of disease-modifying or preventive therapy that may delay onset or substantially affect the pathophysiology of AD, result in an enormous burden posed both on individuals, their families and care givers, and the societies at large, and these call for urgent concerted worldwide measures. Based on the meeting of the German Task Force on Alzheimer's Disease (GTF-AD) in Paris on July 19th 2011, the present position paper provides an overview on the current state and future developments in epidemiology, pathophysiology, disease conceptualization, diagnostic criteria and their use in research and clinical practice, as well as preventive and symptomatic therapeutic approaches. Particular emphasis is placed on a discussion of the different approaches to diagnostics and therapy taken by preventive/public health medicine, methodologically advanced academic research propagating the use of sophisticated biomarkers, and everyday clinical practice focusing on patient-centered care. During the next 10 years, major advances both in early detection as well as in therapy and comprehensive AD care seem mandatory. These still unmet needs call for ever more concerted and focused efforts in research across the world to combat the erupting and as yet uncontrolled epidemic of AD.