A comparison of the Beers and STOPP criteria for identifying the use of potentially inappropriate medications among elderly patients in primary care

Comparing AGS Beers 2019, STOPP version 2, and EU(7)-PIM list in Portuguese older adults in primary health care

PURPOSE

This study aims to identify PIM prevalence in older adults according to the 2019 Beers criteria, Screening Tool of Older Person's Prescriptions version 2 (STOPP v2) criteria, and the Portuguese EU(7)-PIM list and also to analyze the concordance between these criteria.

METHODS

A retrospective study was conducted among 1200 Portuguese older adults (≥ 65 years old), users of primary health care. Demographic, clinical, and pharmacological data were collected concerning the period between April 2021 and August 2022. A comparative analysis was performed between the three PIM identification criteria, and the concordance was determined according to the Lin concordance correlation coefficient.

RESULTS

The mean age was 76.3 (SD 7.7) years old and 57.6% of the older adults were females. Our findings indicate varying prevalence rates among these criteria with 63.8% (95% CI 61.0-66.6%), 66.8% (95% CI 64.1-69.5%), and 50.1% (95% CI 47.2-53.0%) of the older adults take at least one PIM according to the EU(7)-PIM list, Beers 2019, and STOPP v2 criteria, respectively. The highest prevalence observed was for proton pump inhibitors according to EU(7)-PIM list (30.1%, 95% CI 27.6-32.9) and Beers criteria (30.1%, 95% CI 27.6-32.9) and alprazolam according to STOPP v2 criteria (10.1%, 95% CI 8.4-11.9%). A poor concordance between criteria was observed (< 0.834). The highest concordance coefficient was found between the EU(7)-PIM list and the Beers criteria (0.833), and the lowest between the EU(7)-PIM list and STOPP criteria (0.735).

CONCLUSION

This study reveals varying prevalence rates of PIM in older adults, as assessed by different criteria, and highlights the need for targeted interventions and improved prescribing practices. In the future, studies should focus on the occurrence of negative outcomes in older adults associated with PIM consumption.

Using a mobile application to reduce potentially inappropriate prescribing for older Brazilian adults in primary care: a triple-blind randomised clinical trial

BACKGOUND

Potentially inappropriate prescribing (PIP) has been evaluated in several countries, and several strategies have been devised for deprescribing drugs in older adults. The aim of this study was to evaluate the efficacy of a mobile application in reducing PIP for older adults in primary care facilities in Brazil.

METHODS

This randomised, triple-blind, parallel-group trial was conducted in 22 public primary care facilities in Brazil. During the intervention phase, the general practitioners (GPs) were randomly allocated to the intervention (MPI Brasil app provides information about PIP, therapeutic alternatives and deprescribing) or control (MedSUS app provides general information about medications) group. All GPs were trained on the Clinical Decision-Making Process and how to access an Evidence-Based Health website. The GPs received an Android tablet with an installed mobile application depending on their allocated group, which they used when caring for older patients over at least 3 months. At the end of this period, a sample of older patients aged ≥ 60 years who had been awaiting medical consultation by the participating GPs were interviewed and their prescriptions analysed. The primary outcome was the frequency of PIP in and between the groups.

RESULTS

Among 53 GPs who were administered the baseline survey, 14 were included in the clinical trial. At baseline, 146 prescriptions were analysed: the PIP overall was 37.7% (55/146), in the intervention group was 40.6% (28/69), and in the control group was 35.1% (27/77). After the intervention, 284 prescriptions were analysed: the PIP overall was 31.7% (90/284), in the intervention group was 32.2% (46/143), and in the control group was 31.2% (44/141) (RR: 1.16; 95% CI, 0.76-1.76). In the within-group analysis, the PIP reduced from before to after the intervention in both groups-more significantly in the intervention than in the control group (p < 0.001). In the stratified analysis of PIP frequency by GPs, there was a relative risk reduction in 86% (6/7) of GPs in the intervention group compared to 71% (5/7) in the control group.

CONCLUSION

We found that the MPI Brasil app effectively reduced PIP, suggesting that it may be useful to incorporate this tool into clinical practice.

TRIAL REGISTRATION

The study was registered at ClinicalTrials.gov (NCT02918643). First registration on 22/09/2016.

Potentially inappropriate medication uses and associated factors among elderly primary health care clinics attendees: A call to action

BACKGROUND

Polypharmacy is a significant risk factor for using potentially inappropriate medication (PIM), which is using drugs with more risks than benefits, especially for elders. This study aimed to estimate the prevalence of PIM using Beers Criteria, polypharmacy, and their related risk factors.

METHODS

A descriptive cross-sectional study was conducted in West Bank primary health care clinics (PHC)from December 2021 to March 2022. Data were collected from PHC clinic attendees aged 65 and above via an interviewer-administered questionnaire and a review of their medical records. We used the Beers Criteria 2019 update to identify PIM and performed a multivariable analysis to determine its associated factors.

RESULTS

The study included 421 older people (197 men and 224 women) with an average age of 73.6 years. The prevalence of polypharmacy was 75.1% (95%CI: 70.6%-79.1%), with an average of six medications dispensed per patient. On the other hand, PIM was identified among 36.8% of the study participants (CI:95%CI: 32.2%- 41.6%). Sulfonylureas were the most common (24.2%) reported PIM, followed by peripheral alpha-blockers (4.3%), non-steroidal anti-inflammatory drugs (3.1%), proton pump inhibitors (2.9%), and central nervous system medications (2.1%). Hyperpolypharmacy (> 10 drugs) [aOR = 4.1, 95%CI: 1.6-10.7], polypharmacy [aOR = 2.8, 95%CI: 1.4-5.4], and Diabetes [aOR = 3.5, 95%CI: 2.0-6.0] are the main associated factors of PIM.

CONCLUSION

This study found that over one-third of the older people attending PHC clinics have PIM, with polypharmacy and Diabetes being the main predicting variables. Improving physicians' awareness of clear and specific PIM lists can reduce the number of PIM prescribed and decrease their impact.

Medication Review in Turkish Older Adults at Community Pharmacy: A Pilot Study by Using Medication Appropriateness Index

Objective: The study aimed to evaluate medication review in older adults (≥65 years) at a community pharmacy by identifying the prevalence of potentiality inappropriate medication and calculating medication appropriateness index. Methods: This descriptive study was carried out in a community pharmacy for six months. The older adults (≥65 years) using one or more medications were included. During clinical pharmacist-led medication review; the medication appropriateness index was calculated for each medication of older adults. Potentially inappropriate medications were evaluated according to the 2019 American Geriatrics Society Beers Criteria®. Result: Among a hundred older adults, 46.0% were female. The median age of the patients was 75.5 (IQR, 68.0-78.8). The median number of medications was 9.0 (7.0-10.0). Polypharmacy has been detected in 97.0% of the patients. At least one potentially inappropriate medication was detected in 63.0% of them. The median score of medication appropriateness index score was 53.0 (IQR: 38.6-67.9). Conclusion: To best our knowledge, this is the first study of clinical pharmacist-led medication review by calculating the medication appropriateness index carried out at a community pharmacy in Turkey. There was a high rate of potentially inappropriate medication with a higher score of medication appropriateness in older adults. This study highlights the importance of medication review led by the clinical pharmacist at community pharmacy to optimize medication usage in 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.

Prevalence and Factors that Influence Potentially Inappropriate Medication Use among Thai Elderly in Primary Care Settings

Background

Older age increases the likelihood of chronic diseases and polypharmacy with the likelihood of potentially inappropriate medications (PIMs) in secondary and tertiary care levels, but in the primary care settings of Thailand there still is a need for more evidence. This study aimed to examine the prevalence of PIM in primary care settings, and to identify factors that influence the use of PIM.

Methods

A cross-sectional retrospective study was conducted in 2017. Eight primary care units from four regions of Thailand were randomly selected. People aged ≥ 60 years in the eight units were studied as participants. The List of Risk Drugs for Thai Elderly (LRDTE) was used as the reference. Multivariate logistic regression was carried out to identify factors that influence.

Results

A total of 4,848 patients aged ≥60 years with 20,671 prescriptions were studied. The mean age was 70.7±8.3 years for males, and 61.2% for females. A little more than 5% (5.1%) had ≥ 3 chronic diseases and 15.0% received polypharmacy (≥5 medications). The prevalence of prescriptions with PIMs was 65.9%. The most frequent PIMs were antidepressants: amitriptyline (28.1%), antihistamines: dimenhydrinate (22.4%) and chlorpheniramine maleate (CPM) (11.2%); and Benzodiazepines: lorazepam (6.5%). Three factors that significantly influenced prescribing of PIMs were polypharmacy (adjusted OR 3.51; 95% CI 2.81-4.32), having ≥3 chronic diseases (adjusted OR 1.44; 95% CI 1.04-2.01), and age ≥75 years (adjusted OR 1.18; 95% CI 1.01-1.38).

Conclusion

More than two-thirds of elderly Thai patients in the primary care settings were prescribed PIMs. Multidisciplinary prescription review and PIM screening in patients aged ≥75 years who have ≥3 chronic diseases or polypharmacy should be implemented in primary care and supportive computerized PIMs alert system is needed.

Comparison of the extent and prevalence of prescription of potentially inappropriate medications prescribed to geriatric age group residing in old-age homes versus those receiving care from tertiary care hospital using Beers criteria

Context:

Certain medications have higher chances of causing adverse effects in geriatric age group. Evidence is against prescribing these medications to the elderly. A list of such medications is called Beers criteria, which was revised by the American Geriatrics Society in 2015.

Aims:

Using the Beer's list as reference, the researchers intend to find the extent and prevalence of potentially inappropriate medication (PIM) in geriatric population residing in different settings.

Settings and Design:

The researchers analyzed prescription pattern of 200 individuals with age ≥65 years, 100 individuals from old-age homes (OAHs) and 100 individuals from a tertiary care hospital. After collecting data, the researchers tallied each prescription with list of drugs in Beers criteria to find all the possible PIMs in both the groups.

Results:

It was found that the average age of residents of OAHs was significantly higher (P < 0.002) than the corresponding group from a tertiary care hospital. The residents of OAHs were also a receiving significantly higher (P < 0.0001) number of PIM than their counterparts from the tertiary care hospital. The average number of PIMs prescribed to females in OAHs was also significantly higher than those in the other group. About 55% of residents of OAHs received at least one PIM, compared to just 26% in the other group. At least 27% of individuals of OAHs received two or more PIMs, compared to just 2% in a tertiary care hospital. Lorazepam was the most commonly prescribed PIM in OAHs, whereas ranitidine was the most common PIM in a tertiary care hospital. Ibuprofen was the second most common PIM, with 15% of OAHs residents receiving this drug, while none of the patients from a tertiary care hospital received ibuprofen.

Conclusion:

All the results point toward a poor prescription pattern in the residents of OAHs compared to those receiving care from a tertiary care hospital.

Disparities in the appropriateness of medication use: Analysis of the REasons for Geographic And Racial Differences in Stroke (REGARDS) population-based cohort study

BACKGROUND

Prior work has identified disparities in the quality and outcomes of healthcare across socioeconomic subgroups. Medication use may be subject to similar disparities.

OBJECTIVE

To assess the association between demographic and socioeconomic factors (gender, age, race, income, education, and rural or urban residence) and appropriateness of medication use.

METHODS

US adults aged ≥45 years (n = 26,798) from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study were included in the analyses, of which 13,623 participants aged ≥65 years (recruited 2003-2007). Potentially inappropriate medication (PIM) use in older adults and drug-drug interactions (DDIs) were identified through 2015 Beers Criteria and clinically significant drug interactions list by Ament et al., respectively as measures of medication appropriateness. Multivariable logistic regression was used to assess the association of disparity parameters with PIM use and DDIs. Interactions between race and other disparity variables were investigated.

RESULTS

Approximately 87% of the participants aged ≥65 years used at least one drug listed in the Beers Criteria, and 3.8% of all participants used two or more drugs with DDIs. Significant gender-race interaction across prescription-only drug users revealed that white females compared with white males (OR = 1.33, 95% CI 1.20-1.48) and black males compared with white males (OR = 1.60, 95% CI 1.41-1.82) were more likely to receive PIM. Individuals with lower income and education also were more likely to use PIM in this sub-group. Females were less likely than males (female vs. male: OR = 0.55, 95% CI 0.48-0.63) and individuals resided in small rural areas as opposed to urban areas (small rural vs. urban: OR = 1.37, 95% CI 1.07-1.76) were more likely to have DDIs.

CONCLUSION

Demographic and socioeconomic disparities in PIM use and DDIs exist. Future studies should seek to better understand factors contributing to the disparities in order to guide development of interventions.

Association of Deprescribing With Reduction in Mortality and Hospitalization: A Pragmatic Stepped-Wedge Cluster-Randomized Controlled Trial

OBJECTIVES

Deprescribing has gained awareness recently, but the clinical benefits observed from randomized trials are limited. The aim of this study was to examine the effectiveness of a pharmacist-led 5-step team-care deprescribing intervention in nursing homes to reduce falls (fall risks and fall rates). Secondary aims include reducing mortality, number of hospitalized residents, pill burden, medication cost, and assessing the deprescribing acceptance rate.

DESIGN

Pragmatic multicenter stepped-wedge cluster randomized controlled trial.

SETTING AND PARTICIPANTS

Residents across 4 nursing homes in Singapore were included if they were aged 65 years and above, and taking 5 or more medications.

METHODS

The intervention involved a 5-step deprescribing intervention, which involved a multidisciplinary team-care medication review with pharmacists, physicians, and nurses (in which pharmacists discussed with other team members the feasibility of deprescribing and implementation using the Beers and STOPP criteria) or to an active waitlist control for the first 3 months.

RESULTS

Two hundred ninety-five residents from 4 nursing homes participated in the study from February 2017 to March 2018. At 6 months, the deprescribing intervention did not reduce falls. Subgroup analysis showed that intervention reduced fall risk scores within the deprescribing-naïve group by 0.18 (P = .04). Intervention was associated with a reduction in mortality [hazard ratio (HR) 0.16, 95% confidence interval 0.07, 0.41; P < .001] and number of hospitalized residents (HR 0.16, 95% CI 0.10, 0.26; P < .001). Pre-post analysis witnessed a reduction in pill burden at the end of the study, and a conservative daily cost saving estimate of US$11.42 (SG$15.65) for the study population. Approximately three-quarters of deprescribing interventions initiated by the pharmacists were accepted by the physicians.

CONCLUSIONS AND IMPLICATIONS

Multidisciplinary medication review-directed deprescribing was associated with reductions in mortality and number of hospitalized residents in nursing homes and should be considered for all nursing home residents.

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.

Medicamentos potencialmente inapropriados prescritos a pacientes de um Centro de Referência em Atenção à Saúde da Pessoa Idosa

Resumo Objetivo Analisar o perfil farmacoterapêutico dos idosos atendidos em um Centro de Referência em Atenção à Saúde da Pessoa Idosa quanto ao uso de medicamentos potencialmente inapropriados (MPI) por meio de três critérios de rastreamento e determinar fatores associados à prescrição de MPI. Método Estudo transversal com dados obtidos por revisão retrospectiva dos prontuários de idosos, atendidos entre 2017 e 2018 por médico geriatra. Para identificar os MPI, utilizaram-se os Critérios de Beers, o Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions (STOPP) e o Consenso Brasileiro de Medicamentos Potencialmente Inapropriados para Idosos. Características relacionadas ao perfil sociodemográfico (idade e sexo), de hábitos de vida (tabagismo e consumo de álcool), clínico (doenças) e farmacoterapêutico (medicamentos e Índice de Complexidade da Farmacoterapia - ICFT) foram avaliadas. Resultados Foram analisados 406 prontuários e identificados 3.059 medicamentos prescritos, dos quais 32,1% são MPI segundo Critérios STOPP, 14,4% pelo Consenso Brasileiro e 11,7% pelos Critérios de Beers. No total, 81,1% dos idosos apresentaram ao menos um MPI. Regressão de Poisson demonstrou associação entre a prescrição de MPI com polifarmácia, maior número de sinais e sintomas e maior valor de ICFT em ao menos um dos critérios. A força de concordância entre os critérios de MPI foi moderada. Conclusões A maioria dos prontuários analisados possuíam ao menos um MPI prescrito, sendo que os Critérios STOPP identificaram uma maior quantidade de MPI. Estratégias devem ser implementadas para melhorar a farmacoterapia dos idosos com atenção para os que apresentam fatores associados a MPI em seu perfil.

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

Objective:

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

Methods:

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

Results:

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

Conclusions:

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

Potentially inappropriate prescribing to older adults in ambulatory care: prevalence and associated patient conditions

PURPOSE

To analyze potentially inappropriate prescribing (PIP), its prevalence and patient conditions associated with this phenomenon, in a cohort of older adults receiving outpatient care in Mexico.

METHODS

Data from 1252 adults ≥ 60 years of age, from primary care centers were analyzed. Information included sociodemographic data, medications, chronic diseases, polypharmacy (≥ 5 medications), functional dependence, cognitive impairment and frailty. Three logistic regression models were employed to identify associations between PIP (according to the Beers criteria) and different variable combinations.

RESULTS

A total of 41.8% of participants had at least one PIP. The most frequently identified PIPs involved nonsteroidal anti-inflammatory drugs (NSAIDs) and glibenclamide; clonazepam in patients with cognitive impairment; and interactions of warfarin with NSAIDs. In the multivariate analyses, Model 1 showed that frailty and polypharmacy were associated with PIP. In Model 2, only polypharmacy was associated with PIP. For Model 3, lower educational levels, taking hypoglycemics, nervous system disease drugs, antiasthmatics, gastrointestinal disease drugs and anti-inflammatories-antirheumatics and analgesics, were associated with PIP.

CONCLUSION

PIP is common in outpatient treatment of health care services in Mexico. Its association with medical and nonmedical factors highlights the need to improve drug treatment quality focused on implementation of effective strategies, such as educative interventions, electronic medication safety alerts, and inclusion of pharmacists in the health team.

Exploring instruments used to evaluate potentially inappropriate medication use in hospitalised elderly patients in Kosovo

OBJECTIVES

A number of instruments are used to identify potentially inappropriate medications (PIMs) in the elderly. In this study we identify PIMs in elderly patients and aim to compare three different instruments used to assess PIMs.

METHODS

In this prospective cohort study, we compared medications of elderly patients against three commonly used instruments: Beers' list, PRISCUS and STOPP/START, at the point of hospital admission and discharge in the nephrology clinic of Kosovo's largest hospital. Readmission risk was evaluated using the LACE Index and correlations with the number of PIMs and PIMs criteria were analysed.

RESULTS

Of 184 patients admitted to the nephrology clinic, 84 met study inclusion criteria. Patients had a median of three drugs at admission and four at discharge. Hospital readmission risk was high with median LACE Index being 11 (63% of patients). A higher number of PIMs was associated at the point of discharge compared with admission for all three tools (Beers' list: 29% vs 38 %, P=0.04; STOPP/STRART: 20% vs 23%, P<0.001; PRISCUS list: 12% vs 21%, P<0.001). The number of drugs at admission predicted the number of PIMs at discharge only when using Beers' criteria (P=0.006). At discharge, each increase in medication was associated with an increase in PIMs based on Beers' [0.134; (P=0.007)] and STOPP/START criteria [0.130; (P=0.005)]. Nitrofurantoin was the main PIM identified with Beers' and PRISCUS list in comparison to proton- pump-inhibitors being the most prevalent agents identified with STOPP/START criteria.

CONCLUSIONS

There are differences when using Beers' criteria, STOPP/START criteria and PRISCUS list during identification of PIMs in elderly patients with high readmission risk. These differences should be considered when identifying PIMs in hospital settings.

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

BACKGROUND

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Potentially Inappropriate Prescribing in Older Adults with Hypertension or Diabetes Mellitus and Hypertension in a Primary Care Setting in Bahrain

OBJECTIVES

The aims of this study were to evaluate: (1) the prevalence and types of potentially inappropriate prescribing in older adults with hypertension or diabetes mellitus and hypertension, and (2) whether or not differences in the training of primary care physicians were associated with potentially inappropriate prescribing.

MATERIALS AND METHODS

Primary care prescriptions issued by family physicians and general practitioners were audited using Screening Tool of Older Persons' Prescriptions criteria (version 1), with 18 out of 65 applicable criteria. Descriptive statistics were used to test the difference between proportions, and two-tailed t test was used for continuous variables.

RESULTS

A total of 2,090 outpatient prescriptions were written during the study period; of these, 712 (34.1%) were potentially inappropriate. The mean number of drugs per patient was 6.03 (±2.5). Of the 712 prescriptions, 543 (76.3%) were used for the treatment of acute medical illnesses. The most common examples of potentially inappropriate prescribing were: orphenadrine (n = 174; 8.33%), long-term nonsteroidal anti-inflammatory drugs for > 3 months (n = 150; 7.18%), proton pump inhibitors for > 8 weeks (n = 135; 6.46%), antihypertensive therapy duplication (n = 59; 2.82%), long-acting glyburide (n = 48; 2.29%), and chlordiazepoxide for > 1 month (n = 44; 2.11%). Family physicians showed a greater tendency toward potentially inappropriate prescribing compared to general practitioners, but the difference was nonsignificant (n = 514 [34.75%] vs. n = 162 [31.3%]; p = 0.16).

CONCLUSIONS

The prevalence of potentially inappropriate prescribing (i.e., 34.1%) was within the spectrum reported worldwide and unrelated to the training backgrounds of physicians. Most of the identified potentially inappropriate prescribing (76.3%) in older adults was associated with medications for acute medical illnesses and hence inappropriate polypharmacy should be discouraged.

Potentially inappropriate prescriptions for elderly people taking antidepressant: comparative tools

Background

The use of psychotropic drugs by elderly people is widely spread around the world, given that prevalence of inappropriate medication is frequent. Strictly speaking, in Brazil, the vulnerable population of elderly people is more likely to use Potentially Inappropriate Psychotropic (PIP) due to the impact of social-economic characteristics, to the Brazilian Public Health System, and to the lack of patient monitoring. However, neither the use pattern nor the prevalence rate of PIP have been studied in Brazil so far. The objectives of this study were to determine the prevalence of PIP in elderly outpatients taking antidepressants, and to compare the performance of two different tools (Beers, STOPP).

Methods

This cross-sectional study involved all the aged outpatients (≥ 60 years of age) taking antidepressants attended by the public health system in a city of the State of São Paulo, Brazil. Data were obtained from a pharmacy database and medical records. All psychotropic drugs evaluated included: antidepressants, antipsychotics, anti-epileptics and benzodiazepines. STOPP and Beers criteria were applied to detect PIP.

Results

One thousand one hundred forty prescriptions from 174 outpatients were subjected to two different screening tools. The average patient age was 67 (interquartile range 63–74) and the median number of drugs used was 3.0 (interquartile 2–4) per patient. The overall prevalence of PIP was 121 (69.5%). The levels of PIP observed according to tools were 39.6% (STOPP) and 29.9% (Beers).The long-term use of benzodiazepines was the most common PIP recognized, and the one which contributed more significantly to higher levels of PIP than other medications.

Conclusions

The prevalence of PIP was high among the elderly. STOPP criteria identified more PIP than Beers criteria. Knowledge of PIP prevalence should gear efforts to reduce the level of inappropriate prescriptions and may provide the need for developing national criteria.

Potentially inappropriate prescribing and associated factors in elderly patients at hospital discharge in Brazil: a cross-sectional study

Background The Screening Tool of Older Persons' Prescriptions/Screening Tool to Alert doctors to Right Treatment (STOPP/START) criteria is used to identify instances of potentially inappropriate prescribing in a patient's medication regimen. Objective To determine the prevalence and predictors of potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) among elderly patients at hospital discharge. Setting A university hospital medical clinic in Brazil. Method Discharge prescriptions were examined using the STOPP/START criteria. Subjects were inpatients aged ≥60 years receiving at least one medication prior to hospitalization and with a history of cardiovascular disease. The prevalence of PIMs and PPOs was determined and a multivariable binary regression analysis was performed to identify independent predictors associated with PIMs or PPOs. Main outcome measure Prevalence of PIMs and PPOs. Results Of the 230 subjects, 13.9% were prescribed at least one PIM. The most frequently prescribed PIMs were glibenclamide or chlorpropamide prescribed for type 2 diabetes mellitus (31.0%), and aspirin at doses >150 mg/day (14.3%). Ninety patients had at least one PPO (39.1%). The most prevalent PPOs were statins (29.8%) and antiplatelet therapy (13.7%) for diabetes mellitus when coexisting major cardiovascular risk factors were present. No predictors for PIMs were found. In contrast, diabetes was a risk factor while dyslipidaemia was a protective factor for PPOs. Conclusion PIMs and PPOs commonly occur with elderly people at hospital discharge. Diabetes and dyslipidaemia were significantly associated with PPOs. Our findings show the need for interventions to reduce potentially inappropriate prescribing, such as a pharmacist medication review process at hospital discharge.

Potentially Inappropriate Medications by Beers Criteria in Older Outpatients: Prevalence and Risk Factors

BACKGROUND

Prescription of inappropriate medicine to elderly patients is a major public health care concern. The Beers criteria have been commonly employed as a screening tool to identify the use of potentially inappropriate medications (PIMs). The present study investigated the prevalence of PIM use according to the Beers criteria as well as factors related to PIM use.

METHODS

Data obtained from a retrospective survey included 25,810 outpatients aged ≥65 years from a university medical center in Seoul, Korea. PIMs were defined using the Beers criteria. Factors associated with PIM use were evaluated using multiple regression analysis.

RESULTS

Of all participants, 7,132 (27.6%) were prescribed at least one PIM. The most commonly prescribed PIMs were alprazolam (11.2%), clonazepam (10.8%), zolpidem (8.7%), quetiapine (8.4%), and hydroxyzine (5.4%). In multivariate logistic regression analysis, having five or more prescription medicines (odds ratio [OR], 11.32; 95% confidence interval [CI], 9.38 to 13.66) and five or more prescribing doctors (OR, 4.40; 95% CI, 3.59 to 5.39) were strongly associated with PIM. In a likelihood ratio test for trend, an increasing number of medications and prescribing doctors were both significantly associated with PIM.

CONCLUSION

At a university medical center, the number of medications and the number of prescribing doctors was associated with PIM in older outpatients.

The pharmacotherapy of cirrhosis: concerns and proposed investigations and solutions

WHAT IS KNOWN AND OBJECTIVE

The presence of cirrhosis has a multifaceted impact on hepatic drug metabolism. An area of concern and uncertainty in the care of patients with cirrhosis is the safe use of both prescription and over-the-counter medications.

COMMENT

Retrospective studies indicate a high incidence of adverse drug reactions (ADRs) among patients with cirrhosis related to use of certain medication classes including angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and non-steroidal anti-inflammatory drugs. Conversely, use of appropriate medications, such as statins, may be decreased in this population due to fear of precipitating hepatotoxicity.

WHAT IS NEW AND CONCLUSION

Pharmacotherapy in cirrhosis is an area of uncertainty and heterogeneity in clinical practice. Prescribing and dosing guidelines are needed to decrease the risk of serious ADRs in this high-risk patient population.

Polytherapy and the risk of potentially inappropriate prescriptions (PIPs) among elderly and very elderly patients in three different settings (hospital, community, long-term care facilities) of the Friuli Venezia Giulia region, Italy: are the very elderly at higher risk of PIPs?

PURPOSE

The aim of this point-prevalence study was to assess the occurrence of polypharmacy and hyperpolypharmacy and the risk of potentially inappropriate prescriptions (PIPs) among elderly and very elderly patients in different health-care settings of the Friuli-Venezia Giulia region in the North-East of Italy.

METHODS

Prescription pattern of elderly (65-79 years) and very elderly (>79 years) patients in three different health-care settings [hospitals, general practitioners, and long-term care facilities (LTCFs)] was assessed in March 2014, and PIPs were assessed according to the Beers criteria. Other situations at potentially high risk were checked.

RESULTS

A total of 1582 patients (hospital, n = 528; outpatients, n = 527; nursing homes, n = 527) were included. Very elderly were more represented in hospitals (60.4%) and LTCFs (77.1%) than among general practitioners (37.6%). Polypharmacy and hyperpolypharmacy rates ranged 57.7-73.7% and 9.7-15.6%, respectively. The most frequently prescribed drugs were the proton pump inhibitors, whereas the most common PIPs resulted the benzodiazepines. Multinomial regression analysis showed that female sex, age > 79 years, hyperpolypharmacy, and chronic kidney disease were associated with the risk of having ≥2 PIPs. Two situations at high risk of PIPs not contemplated by the Beers criteria were recurrent in the study population and concerned the statins and metformin.

CONCLUSIONS

Polypharmacy and hyperpolypharmacy among elderly and very elderly are strictly associated with the risk of multiple PIPs. The findings offer the opportunity to remark that improvement of the knowledge of safe drug use is generally needed in aging societies and may become of utmost relevance among health-care workers operating in LTCFs. Copyright © 2016 John Wiley & Sons, Ltd.

What doctors need to know: Prescribing or not for the oldest old

Given the global increase in the number of people over the age of 85, there is a growing body of work concerning this group, termed the oldest old. Much of this work is confined to the literature specialising in geriatrics and the more generic health care papers refer to 'older people' with little definition of what is meant by 'older'. Iatrogenesis (ill health caused by doctors) is a major issue and general practitioners (GPs) need practical help in prescribing for the oldest old. This paper presents a narrative review of the literature on prescribing and the oldest old. The results showed that all papers sourced referred to prescribing for the 'old' as those aged over 65, with only scant mention of oldest old. Yet prescribing for the oldest old involves clinical judgement and knowledge of the patient. It includes weighing up what will do good, cause no harm and is acceptable to the individual. GPs have to make treatment choices mostly in isolation from colleagues, during time-limited consultations and with few relevant guidelines on managing multi-morbidities in the oldest old. A major issue in prescribing for people over the age of 85 is that guidelines for diseases are based on trials with younger adults, outline the best practice for one disease in isolation (i.e. not in the presence of other diseases) and take little account of the interactions between the drugs used in managing several diseases in frail older people. There is a growing body of work, however, calling for specialist services for the oldest old.

Polypharmacy and potentially inappropriate prescriptions identified by Beers and STOPP criteria in co-morbid older patients at hospital discharge

RATIONALE, AIMS AND OBJECTIVES

The objective of this study was to evaluate the prevalence of potentially inappropriate prescriptions (PIP) and the association with polypharmacy (more than six drugs prescribed) in co-morbid older patients in a critical moment of care transition such as hospital discharge by means of two explicit criteria (Beers 2012 and STOPP 2008).

METHOD

Cross-sectional study carried out in an older patients' population (≥65 years old) discharged from a university hospital in Spain. We recorded patients' information regarding demographics, diagnosis, drugs prescribed and associated pathological conditions and calculated the Charlson co-morbidity index. Data were obtained from the electronic medical records of hospital discharge. Beers (2012) and STOPP criteria (2008) were applied for PIP detection. The strength of association between polypharmacy and the presence of PIP was assessed by calculating the crude and adjusted odds ratio and its 95% confidence interval.

RESULTS

From 1004 patients of a 15% random sample, just 624 that fulfilled the inclusion criteria were included in the study. The number of prescribed drugs was a risk factor for PIP according to both criteria, even after adjusting for confounding variables. PIP frequency was higher in patients who received more than 12 medications (Beers: 34.8%, STOPP: 54.4%). Each additional medication increased the risk of PIP by 14 or 15% (Beers or STOPP).

CONCLUSIONS

Our results suggest that the strategies used for PIP reduction in co-morbid older patients should focus on the management of polypharmacy. Medication review at hospital discharge is highly recommended for patients taking more than six drugs.