Assessing potentially inappropriate prescribing (PIP) and predicting patient outcomes in Ontario's older population: a population-based cohort study applying subsets of the STOPP/START and Beers' criteria in large health administrative databases

Effect of Medication Management at Home via Pharmacist-Led Home Televisits: Protocol for a Cluster Randomized Controlled Trial

BACKGROUND

Older adults are more likely to have multiple chronic conditions, be prescribed multiple medications, and be more susceptible to adverse drug reactions (ADRs) to their medications. In addition, older adults often use over-the-counter medications and supplements, further complicating their medication regimens. Complex medication regimens are potentially harmful to older adults. Interventions aimed at reducing medication discrepancy in the ambulatory clinic setting, such as reviews of medication lists and the implementation of "brown bag" reconciliation, continue to be challenging, with limited success. Pharmacist-led interventions to improve appropriate medication use in older adults have demonstrated effectiveness in reducing ADRs. Video visits have the potential to provide direct visualization of medications in older adults' homes, thereby reducing medication discrepancy and increasing medication adherence. Pharmacist-led management of older adults' medication regimens may improve appropriate medication use in older adults.

OBJECTIVE

The objective of this study is to examine the effect of pharmacist-led medication through home televisits compared to usual care on appropriate medication use, medication discrepancies, medication adherence, and ADRs.

METHODS

We will conduct a 2-site cluster randomized controlled trial (RCT). The intervention will be a pharmacist-led home televisit including medication reconciliation and assessment of actual medication use. The cluster RCT was iteratively adapted after a pilot test. The primary outcome of medication appropriateness of the intervention will be measured using the STOPP (Screening Tool of Older Persons' Prescriptions) criteria for potentially inappropriate medications (PIMs) at 6 months. Medication lists obtained will be compared against electronic medical records (EMRs) by a clinician to establish discrepancies in medications. The clinician will review medications using the validated Medication Appropriateness Index (MAI).

RESULTS

This project has been peer-reviewed and selected for support by the Veterans Affairs (VA) Health Services Research Service. The pilot phase of the study was completed December 2021 with 20 veterans and was primarily informed by the Steinman model of the prescribing process adapted to include system- and provider-level factors. The last date of enrollment was August 6, 2021. We anticipate the completion of the ongoing trial in spring 2025. The first results are expected to be submitted for publication in 2025.

CONCLUSIONS

The cluster RCT will provide evidence on medication management through televisits. If found effective in improving the use of medications, the intervention has the potential to impact older adults with multiple chronic conditions and polypharmacy.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04340570; https://clinicaltrials.gov/study/NCT04340570.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/65141.

Potentially Inappropriate Use of Medication and Its Determinants Among Ambulatory Older Adults in Six Community Chain Pharmacies in Asmara, Eritrea: A Cross-Sectional Study Using the 2023 American Geriatric Society Beers Criteria®

Background

Potentially inappropriate medication (PIM) use is one of the main drug-related problems encountered in older adults. It is associated with adverse drug events, morbidity, mortality, increased economic costs, and negative effects on the quality of life that requires strict monitoring of prescriptions in older adults. Thus, the study aimed to assess potentially inappropriate medication use and its determinants among older adults.

Methods

A cross-sectional study was conducted among all outpatient prescriptions dispensed to older adults (aged 65 years and above) in six community chain pharmacies in Asmara, Eritrea. Data were collected retrospectively, between June 16 and July 16, 2023. PIMs were detected using the 2023 American Geriatric Society (AGS) Beers Criteria®. Descriptive statistics and logistic regression analysis were performed using IBM SPSS® (Version-26.0).

Results

A total of 2680 outpatient prescriptions dispensed to older adults were included in this study. The prevalence of PIM among prescriptions was 18.1% (95% CI: 16.7, 19.6). Moreover, a total of 470 medications were found to be avoided in older adults. The most commonly prescribed PIMs were sulfonylureas (27.2%) and substituted alkylamines (16.2%). The prevalence of prescriptions containing medications to be used with caution in older adults was 13.2% (95% CI: 12.0, 14.5). Age (Adjusted Odds Ratio (AOR))=0.98, 95% CI: 0.97, 0.99), polypharmacy (AOR=2.77, 95% CI: 1.49, 5.15), and general practitioner prescriber (AOR=1.38, 95% CI: 1.11, 1.70) were significantly associated with PIMs.

Conclusion

A considerable number of ambulatory older adults were exposed to PIMs which require a close attention by policymakers, program managers, and healthcare professionals.

Potentially Inappropriate Prescribing in Long-Term Care and its Relationship With Probable Delirium

OBJECTIVES

This study examined potentially inappropriate prescribing (PIP) of medication and its association with probable delirium among long-term care (LTC) residents in Ontario, Canada.

DESIGN

Population-based cross-sectional study using provincial health administrative data, including LTC assessment data via the Resident Assessment Instrument-Minimum Dataset version 2.0 (RAI-MDS 2.0).

SETTING AND PARTICIPANTS

LTC residents in Ontario between January 1, 2016, and December 31, 2019.

METHODS

We used residents' first RAI-MDS 2.0 assessment in the study period as the index assessment. Probable delirium was identified via the delirium Clinical Assessment Protocol. Medication use in the 2 weeks preceding assessment was captured using medication claims data. PIP was measured using the STOPP/START criteria and 2015 Beers criteria, with residents classified as having 0, 1, 2, or 3+ instances of PIP. Relationships between PIP and probable delirium was assessed via bivariate and multivariable logistic regression models.

RESULTS

The study population included 171,190 LTC residents (mean age 84.5 years, 66.8% female, 62.9% with dementia). More than half (51.8%) of residents had 1+ instances of PIP and 21% had 3+ instances of PIP according to the STOPP/START criteria; PIP prevalence was slightly lower when assessed using Beers criteria (36.5% with 1+, 11.1% with 3+). Overall, 3.7% of residents had probable delirium. The prevalence of probable delirium increased as the number of instances of PIP increased, with residents with 3+ instances of STOPP/START PIP being 1.66 times more likely (95% CI 1.56-1.77) to have probable delirium compared to those with no instances of PIP. Similar findings were observed when PIP was measured using the Beers criteria. Central nervous system (CNS)-related PIP criteria showed a stronger association with probable delirium than non-CNS-related PIP criteria.

CONCLUSIONS AND IMPLICATIONS

This population-based study highlighted that PIP was highly prevalent in long-term care residents and was associated with an increased prevalence of probable delirium.

Barriers and enablers to deprescribing in long-term care: A qualitative investigation into the opinions of healthcare professionals in Ireland

INTRODUCTION

The prevalence of polypharmacy increases with age, increasing the exposure of older adults to potentially inappropriate medications (PIMs). Deprescribing has been shown to reduce PIMs for older residents in long-term care; however, deprescribing is not universally implemented. This study aims to identify the barriers and enablers to deprescribing in Irish long-term care facilities from the healthcare professionals' (HCPs) perspective.

METHODS

A qualitative descriptive approach was conducted using semi-structured interviews with HCPs working in long-term care (general practitioners, pharmacists and nurses). Purposive sampling with maximum variation was applied to select long-term care sites to identify HCPs, supplemented with convenience sampling of post-graduate HCPs from University College Cork. Data was thematically analysed and mapped to a framework of deprescribing barriers and enablers informed by the Theoretical Domains Framework.

RESULTS

Twenty-six HCPs participated from 13 long-term care facilities. The main barriers and enablers identified mapped to five domains. Barriers included insufficient resources, lack of co-ordination between healthcare settings and negative social influences. Additional barriers exist in private settings including deprescribing awareness, commitment and the need for incentives. Deprescribing enablers included interprofessional support and patient social influence. To encourage deprescribing, potential enablers include HCP education, pharmacist role expansion and tailored deprescribing guidelines within a structured process.

CONCLUSION

Interventions to support deprescribing should build on existing systems, involve stakeholders and utilise guidelines within a structured process. Any intervention must account for the nuanced barriers and enablers which exist in both public and private settings.

Potentially inappropriate medication and attitudes of older adults towards deprescribing

INTRODUCTION

Multimorbidity and polypharmacy are current challenges when caring for the older population. Both have led to an increase of potentially inappropriate medication (PIM), illustrating the need to assess patients' attitudes towards deprescribing. We aimed to assess the prevalence of PIM use and whether this was associated with patient factors and willingness to deprescribe.

METHOD

We analysed data from the LESS Study, a cross-sectional study on self-reported medication and on barriers and enablers towards the willingness to deprescribe (rPATD questionnaire). The survey was conducted among multimorbid (≥3 chronic conditions) participants ≥70 years with polypharmacy (≥5 long-term medications). A subset of the Beers 2019 criteria was applied for the assessment of medication appropriateness.

RESULTS

Data from 300 patients were analysed. The mean age was 79.1 years (SD 5.7). 53% had at least one PIM (men: 47.8%%, women: 60.4%%; p = 0.007). A higher number of medications was associated with PIM use (p = 0.002). We found high willingness to deprescribe in both participants with and without PIM. Willingness to deprescribe was not associated with PIM use (p = 0.25), nor number of PIMs (p = 0.81).

CONCLUSION

The willingness of older adults with polypharmacy towards deprescribing was not associated with PIM use in this study. These results suggest that patients may not be aware if they are taking PIMs. This implies the need for raising patients' awareness about PIMs through education, especially in females, in order to implement deprescribing in daily practice.

Potentially Inappropriate Prescriptions in Ambulatory Elderly Patients Living in Rural Areas of Romania Using STOPP/START (Version 2) Criteria

Background

Rational use of medications and monitoring of prescriptions in elderly patients is important to decrease the number and duration of hospitalizations, emergency medical consultations, mortality, as well as medical costs.

Purpose

To identify potentially inappropriate medications (PIMs) and potential prescription omissions (PPOs), and determine their prevalence based on the Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) v2 criteria and Screening Tool to Alert doctors to Right Treatment (START) v2 criteria for patients aged >65 years.

Methods

This cross-sectional study was conducted in two rural counties in Romania based on electronic prescriptions for chronic conditions (EPCCs) issued from 30 days to 90 days by a specialist or general practitioner. Collected EPCCs were evaluated by an interdisciplinary team of specialists based on 26 STOPP v2 criteria and 10 START v2 criteria.

Results

PIM prevalence was 25.80% and PPO prevalence was 41.72% for 646 EPCCs. The mean age of patients was 75 years and the mean number of drugs per EPCC was four. The most frequently identified PIMs were treatment duration (6.65%), theophylline administration (5.72%), drug indication (4.64%), cyclo-oxygenase-2 non-steroidal anti-inflammatory drugs (1.39%), and zopiclone prescription (0.77%). Statins (24.76%), beta-blockers (8.04%), and beta-2 agonist/antimuscarinic bronchodilators (5.88%) were the most frequently identified PPOs.

Conclusion

PPOs were more prevalent than PIMs for elderly populations living in the two rural counties in Romania we studied. Health practitioners (family physicians, specialists, and pharmacists) should focus on prophylactic and curative considerations when prescribing agents to decrease the morbidity and mortality of elderly rural Romanian patients.

The Health System Costs of Potentially Inappropriate Prescribing: A Population-Based, Retrospective Cohort Study Using Linked Health Administrative Databases in Ontario, Canada

OBJECTIVE

The aim of this study was to determine the health system costs from hospitalizations, emergency department (ED) visits, and medications due to potentially inappropriate prescribing (PIP) in Ontario, Canada, at the population-level.

METHODS

A retrospective cohort of individuals ≥ 66 years of age and prescribed at least one medication from April 2002 to March 2015 was identified using linked population-level health administrative databases from Ontario, Canada. Patients were identified as having PIP or no PIP by applying a subset of the Screening Tool of Older Persons' Potentially Inappropriate Prescribing/Screening Tool to Alert Doctors to Right Treatment (STOPP/START) criteria. The number of days spent in hospital, new medications prescribed, and ED visits in the 90 days following PIP or patient index date were captured, as well as the total costs from each of these health services. Count regression models were used to generate incidence rate ratios (IRRs) for each outcome given the presence of PIP versus no PIP and combined with the prevalence of PIP to generate population attributable fractions (PAFs). The PAF was then multiplied by the cost for each health service to obtain the costs attributable to PIP in the whole cohort, and by age and sex.

RESULTS

PIP was associated with an increased rate of hospitalization (IRR 2.77, 95% confidence interval [CI] 2.72-2.82), ED visits (IRR 1.87, 95% CI 1.82-1.92), and newly prescribed medications (IRR 1.13, 95% CI 1.13-1.14), resulting in PAFs of 55.7, 37.9, and 5.0% for each outcome, respectively. PIP was associated with 38.8% of the total spent on these healthcare services ($1.22 billion) in the 90 days after PIP. Costs attributable to PIP decreased with age despite increasing prevalence.

CONCLUSIONS

PIP in older adults is a significant source of health system costs from healthcare service use beyond medication costs, with a significant portion of hospitalizations and ED visit costs attributable to PIP. Future work should focus on identifying strategies and priorities for intervention.

How do potentially inappropriate medications and polypharmacy affect mortality in frail and non-frail cognitively impaired older adults? A cohort study

OBJECTIVES

To test whether the use of potentially inappropriate central nervous system acting medications, proton pump inhibitors (PPIs) or polypharmacy are associated with mortality in cognitively impaired older adults and whether frailer people are at greater risk of harm.

SETTING

A cohort study nested within the Cognitive Function and Ageing Study II, a population representative cohort study of the older population in Cambridgeshire, Nottingham and Newcastle, UK.

PARTICIPANTS

A total of 1154 cognitively impaired participants, aged 65 years or older.

EXPOSURES

Any use of antipsychotics, antidepressants, other anticholinergic medication, benzodiazepines or PPIs, polypharmacy (5-9) and hyperpolypharmacy (≥10 reported medications) were ascertained at baseline. Frailty was assessed using the Fried criteria.

PRIMARY OUTCOME

Mortality up to 8 years follow-up. HRs associated with potentially inappropriate medication (PIM), frailty and their interaction were estimated adjusting for covariates.

RESULTS

Within the sample, 44% were taking one or more PIM. Apart from antipsychotics (adjusted HR=3.24, 95% CI 1.83 to 5.73), use of specific PIM was not associated with greater subsequent mortality. Polypharmacy (HR=1.17, 95% CI 0.95 to 1.45) and hyperpolypharmacy were associated with mortality (HR=1.60, 95% CI 1.16 to 2.22). Being frail (HR=1.90, 95% CI 1.32 to 2.72) or prefrail (HR=1.56, 95% CI 1.10 to 2.20) was associated with increased mortality. There was some evidence that the HR for polypharmacy on mortality was lower among frailer individuals, but the overall polypharmacy by frailty interaction was not statistically significant (p=0.102).

CONCLUSIONS

For those with cognitive impairment, greater concern should be afforded to the number of medications than the prescription of specific classes. Frailer individuals may have a lower relative risk of mortality associated with polypharmacy than less frail individuals.

Drug-drug interactions of a two-drug regimen of dolutegravir and lamivudine for HIV treatment

INTRODUCTION

The GEMINI trials have recently shown that a two-drug regimen of dolutegravir plus lamivudine was non-inferior to a three-drug regimen in HIV-infected naïve patients. Accordingly, it is important that physicians be aware and confident about the drug-drug interactions (DDIs) involving dolutegravir, lamivudine, and other medications. Areas covered: Here, we firstly update the available information on the pharmacokinetic features of dolutegravir and lamivudine; subsequently, the articles mainly deals with the predictable DDIs for both antiretroviral drugs, attempting to underline their clinical implications. This review focuses on the DDIs of dolutegravir/lamivudine combined regimen and, therefore, does not provide an exhaustive list of all the potential DDIs involving the two single agents. A MEDLINE Pubmed search for articles published from January 2000 to December 2018 was completed matching the terms dolutegravir or lamivudine with pharmacokinetics, DDIs, and pharmacology. Moreover, additional studies were identified from the reference list of retrieved articles. Expert opinion: The antiretroviral dual regimen of dolutegravir and lamivudine represents an attractive therapeutic option for HIV in terms of DDIs. This is particularly relevant considering that the population with HIV is aging and is increasingly experience age-related comorbidities, increasing pill burden, polypharmacy and the risk of DDIs.

Potentially inappropriate medication and hospitalization/emergency department visits among the elderly in Korea

Objective

To investigate the association between potentially inappropriate medicine (PIM) use, defined using the American Geriatric Society (AGS) 2012 Beers criteria, and the risk of hospitalization or emergency department (ED) visits in elderly patients, and to examine the most frequently used PIMs among patients with adverse outcomes.

Design/Setting

This was a retrospective study using National Health Insurance claims data from 2010 to 2012.

Intervention(s)

Elderly patients who took PIMs are compared to those who were not taking PIMs.

Study participants

Elderly patients (n = 79 552) who visited medical institutions in Jeju Island during 2011.

Main outcome measure

Hospitalization and ED visits were evaluated according to whether the patients took PIMs during the study period. The most frequent medications used by the PIM group were also investigated.

Results

The likelihood of hospitalization was higher in older patients who took at least one PIM than in those who were not taking PIMs during the study period (odds ratio 2.25, 95% confidence interval 2.09-2.44). Patients taking PIMs were more likely to visit EDs (odds ratio 1.59, 95% confidence interval 1.50-1.67). Among patients who were hospitalized or visited EDs, 45.5% had taken at least one PIM on that day. The most commonly used PIMs included chlorpheniramine maleate, diazepam, metoclopramide HCl and diclofenac sodium.

Conclusion

Our findings indicate that PIM use can lead to negative health consequences, providing further evidence of the inappropriateness of these medications. Thus, pharmaceutical policies regarding PIM use may need to be implemented for elderly adults in Korea.

Health system costs of potentially inappropriate prescribing in Ontario, Canada: a protocol for a population-based cohort study

INTRODUCTION

Adverse drug events (ADEs) are common in older persons and contribute significantly to emergency department visits, hospitalisations and mortality. ADEs are often due to potentially inappropriate prescriptions (PIP) or potentially inappropriate omissions (PIO), and are avoidable if inappropriate prescriptions or omissions are identified and prevented. Identifying PIP/PIO at the population level through the application of PIP/PIO assessment tools to health administrative data can provide a unique opportunity to assess the economic burden of PIP/PIO on the healthcare system beyond medication costs which is yet to be done. The objective of this study is to assess the economic burden associated with PIP/PIO and to estimate the incremental costs associated with distinct PIP/PIO in the province of Ontario.

METHODS AND ANALYSIS

We will conduct a retrospective cohort study using Ontario's health administrative databases. Eligible patients aged 66 years and older who were prescribed at least one medication between 1 April 2003 and 31 March 2014 (approximately 2.4 million patients) will be included. Population attributable fraction methodology will be used to assess the overall burden of PIP in Ontario, while regression analyses will be used to estimate the incremental costs of having specific PIP criteria and aid in prioritising targets for intervention.

ETHICS AND DISSEMINATION

This study was approved by the Institutional Review Board at Sunnybrook Health Sciences Centre, Toronto, Canada. Dissemination will occur via publication, presentation at national and international conferences, and knowledge exchange with various stakeholders.

Demographic and Socioeconomic Characteristics of Outpatients Could Modify Their Attitude Towards Misusing Medications in Northern Jordan

Background

Potentially inappropriate drug use, including prescribed and over-the-counter medications, is associated with increased morbidity and mortality. It also contributes to unnecessary expenditure on health services. This survey was undertaken to investigate the incidence of drug misuse and associated socioeconomic/demographic characteristics in Irbid, Jordan.

Design and Methods

The present cross section study was conducted using a validated 5-point Likert scale questionnaire to be self-reported by 480 outpatients visiting clinics in three major medical centres in Irbid, Jordan between 20th October 2015 and 27th November 2015. Descriptive analysis, chi-square tests and ordinal logistic regression models were performed.

Results

Patients demonstrated distinctive attitudes towards medication misuse (P<0.001). Whereas around 40% of patients sometimes stopped taking medications earlier than prescribed or doubled the dose in case of missing a dose, three quarters and two fifth of participants neither used expired drugs nor continued to take a drug when adverse drug reactions occurred, respectively. Also, there were significant associations (P<0.05) between patients’ attitudes towards misusing medications and characteristics like age, gender, income and marital status. For instance, senior patients (>45 years) tended to double a medication’s dose in case of no improvement, and to use others’ leftover drugs without medical supervision. Further, male and female patients exhibited different attitude towards misusing medications. Unemployment and little earnings increased the risk for not using drugs properly. Furthermore, married patients were less likely to misuse medications. In particular, the educational level of patients was found to play a major role in modifying patients’ attitudes towards potentially inappropriate drug use. Patients holding one or more university degrees were at lower risk for using medications inappropriately.

Conclusions

This survey indicated that northern Jordanians inappropriately used medications to a great extent, suggesting that the current policies should be revised, and emphasising the importance of running public antidrug misuse awareness campaigns and establishing advanced educational/training events targeting healthcare professionals.

Too many, too few, or too unsafe? Impact of inappropriate prescribing on mortality, and hospitalization in a cohort of community-dwelling oldest old

AIMS

Little is known about the impact of inappropriate prescribing (IP) in community-dwelling adults, aged 80 years and older. The prevalence at baseline (November 2008September 2009) and impact of IP (misuse and underuse) after 18 months on mortality and hospitalization in a cohort of community-dwelling adults, aged 80 years and older (n = 503) was studied.

METHODS

Screening Tool of Older People's Prescriptions (STOPP-2, misuse) and Screening Tool to Alert to Right Treatment (START-2, underuse) criteria were cross-referenced and linked to the medication use (in Anatomical Therapeutic Chemical coding) and clinical problems. Survival analysis until death or first hospitalization was performed at 18 months after inclusion using Kaplan-Meier, with Cox regression to control for covariates.

RESULTS

Mean age was 84.4 (range 80-102) years. Mean number of medications prescribed was 5 (range 0-16). Polypharmacy (≥5 medications, 58%), underuse (67%) and misuse (56%) were high. Underuse and misuse coexisted in 40% and were absent in 17% of the population. A higher number of prescribed medications was correlated with more misused medications (r_s  = .51, P < 0.001) and underused medications (r_s  = .26, P < 0.001). Mortality and hospitalization rate were 8.9%, and 31.0%, respectively. After adjustment for number of medications and misused medications, there was an increased risk of mortality (HR 1.39, 95% CI 1.10, 1.76) and hospitalization (HR 1.26, 95% CI 1.10, 1.45) for every additional underused medication. Associations with misuse were less clear.

CONCLUSION

IP (polypharmacy, underuse and misuse) was highly prevalent in adults, aged 80 years and older. Surprisingly, underuse and not misuse had strong associations with mortality and hospitalization.

Potentially Inappropriate Medications in Older Adults: Why the Revised Criteria Matter

The 2 most widely used explicit criteria regarding inappropriate medication use in older adults are the American Geriatrics Society's Beers Criteria and the Screening Tool of Older People's Prescriptions/Screening Tool to Alert to Right Treatment (STOPP/START). Both documents were updated recently. They are important educational tools that highlight medications for which risks of use may often exceed benefits in older adults and situations in which potentially appropriate medications should be considered for use. The application of these tools has the potential to significantly affect patient care. Thus, it is important for clinicians to be familiar with both documents.

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.