Interventions to reduce the prescription of inappropriate medicines in older patients

Potentially inappropriate medication prescribing based on 2019 Beers criteria and the impact of pharmacist intervention in elderly patients with kidney diseases: A report from Iran

Background and Aims

A potentially inappropriate medication (PIM) is a pharmaceutical agent that poses a greater risk of harm than potential benefit to elderly patients. This study aimed to detect PIMs and their risk factors in hospitalized elderly patients with kidney disease.

Methods

This cross-sectional study assessed medication orders of elderly patients (≥65 years old) with kidney diseases admitted to the hospital. In the first 6 months, we retrospectively evaluated all medications to identify PIMs according to the 2019 Beers criteria. In the second phase, a clinical pharmacist prospectively evaluated all medications and suggested modifications as needed. Data were analyzed to determine risk factors for prescribing PIMs.

Results

Based on our evaluation of 258 patients, we observed that the utilization of PIMs was prevalent among the study population. Of the total patients evaluated, 273 instances of PIM use were identified, with only 23.3% of patients not having any PIMs. Notably, proton pump inhibitors and benzodiazepines were the most frequently prescribed PIMs. The risk of experiencing a PIM was significantly amplified by a higher degree of polypharmacy, with odds approximately 2.68 times higher (p < 0.01). Several factors were found to be associated with an increased likelihood of having a PIM, including being male, undergoing hemodialysis, having chronic kidney disease or other comorbidities, and having an extended hospital stay. The second phase of study, in terms of addressing these issues, physicians adhered to 67.5% of the 120 recommendations made by pharmacists regarding the discontinuation of PIM usage.

Conclusion

High prevalence of PIMs was detected in our study population. Preventing medication-associated harms in the elderly can reduce the financial burden imposed on healthcare systems. Therefore, routine evaluation of medications with clinical pharmacists and/or implementation of computerized medication decision support systems is recommended to prevent PIMs use.

STOPP-START Criteria Used to Identify the Elderly Population Prone to Potentially Inadequate Prescribing in a Colombian Cohort

BACKGROUND

Elderly people have multiple comorbidities that often require treatment with multiple medications. Having strategies to lessen the risks associated with pharmacological interactions and potentially inadequate prescribing (PIP) is of major importance. The STOPP- START criteria are useful in identifying PIP along with other tools, such as LASA (look alike/sound alike) drugs and high-risk medications (HRM).

OBJECTIVE

We aimed to clinically and sociodemographically characterize the population with PIP according to the STOPP-START criteria in hospitalized elderly patients over 6 months in a third-level hospital in Colombia, South America. We also aimed to calculate the prevalence of PIP, LASA drugs and HRM and to identify other problems related with medication. Finally, we proposed an algorithm for the identification of PIP in this population.

METHODS AND MATERIALS

This was a descriptive, cross-sectional study in hospitalized patients older than 60 years during the first semester of 2021 to identify PIP according to STOPP- START criteria. An analysis of clinical and sociodemographic variables was conducted, as well as the construction of an algorithm to identify PIP in the elderly in a semiautomated way. Data were collected and analyzed using the software SPSS 2021, using descriptive statistics and measures of central tendency.

RESULTS

The prevalence of PIP in the study population was 25%. Furthermore, 60% of patients had one problem related to medication, and 27% used at least one LASA drug or HRM.

CONCLUSION

This study allows one to characterize, for the first time, the Colombian population prone to PIP, as well as the construction of an algorithm that identifies PIP in a semiautomated way.

Deprescribing Interventions for Older Patients: A Systematic Review and Meta-Analysis

OBJECTIVES

Deprescribing reduces polypharmacy in older adults. A thorough study of the effect of deprescribing interventions on clinical outcomes in older adults is presently lacking. As a result, we evaluated the impact of deprescribing on clinical outcomes in older patients.

DESIGN

Meta-analysis and systematic review of randomized controlled trials (RCTs). PubMed, EMBASE, and Cochrane Library were searched from the time of creation to March 2023.

SETTING AND PARTICIPANTS

Randomized controlled trial with participants at least 60 years old.

MEASURES

Mortality, falls (number of fallers), hospitalization rates, emergency department visits, medication adherence, HRQoL (health-regulated quality of life), incidence of ADR (adverse drug reactions), PIM (potentially inappropriate medication), and PPO (potentially prescription omission) were evaluated in the meta-analysis.

RESULTS

A total of 32 RCTs (18,670 patients) were included. Deprescribing interventions significantly reduced proportions of older adults with PIM, PPO, and the incidence of ADRs. The interventions group also improved medication compliance.

CONCLUSIONS AND IMPLICATIONS

Compared to routine care, deprescribing interventions significantly improve clinical outcome indicators for older adults.

Cost-effectiveness of an educational intervention to reduce potentially inappropriate medication

Background

Educational interventions can reduce potentially inappropriate medication (PIM) use in older people. Their effectiveness has been measured mainly as changes in PIM use. In this economic evaluation, we analyse the impact of an educational intervention in terms of costs and quality-adjusted life years (QALYs).

Methods

The educational intervention consisted of activating and interactive training sessions for nursing staff and consulting physicians, and was compared with treatment as usual (TAU). Participants (n = 227) in a cluster randomised trial (cRCT) were residents living permanently in assisted living facilities (n = 20 wards). For economic evaluation, participants’ healthcare service use costs and costs for the intervention were estimated for a 12 month period.

Incremental cost-effectiveness ratios (ICERs) were estimated for QALYs per participant. Cost-effectiveness analysis was conducted from a healthcare perspective. A bootstrapped cost-effectiveness plane and one-way sensitivity analysis were undertaken to analyse the uncertainty surrounding the estimates.

Results

The educational intervention was estimated to be less costly and less effective in terms of QALYs than TAU at the 12 month follow-up [incremental costs –€1,629, confidence interval (CI) –€5,489 to €2,240; incremental effect −0.02, CI –0.06 to 0.02]. The base case ICER was >€80,000/QALY.

Conclusion

The educational intervention was estimated to be less costly and less effective in terms of QALYs compared with TAU, but the results are subject to some uncertainties. Reduction in PIM use or benefits in quality of life did not seem to translate into improvements in QALYs. Our findings emphasise the need for better understanding of the impact of decreasing PIM use on health outcomes.

Deprescribing Interventions among Community-Dwelling Older Adults: A Systematic Review of Economic Evaluations

BACKGROUND

Deprescribing can reduce the use of inappropriate or unnecessary medication; however, the economic value of such interventions is uncertain.

OBJECTIVE

This study seeks to identify and synthetise the economic evidence of deprescribing interventions among community-dwelling older adults.

METHODS

Full economic evaluation studies of deprescribing interventions, conducted in the community or primary care settings, in community-dwelling adults aged ≥ 65 years were systematically reviewed. MEDLINE, EconLit, Scopus, Web of Science, CEA-TUFTS, CRD York and Google Scholar databases were searched from inception to February 2021. Two researchers independently screened all retrieved articles according to inclusion and exclusion criteria. The main outcome was the economic impact of the intervention from any perspective, converted into 2019 US Dollars. The World Health Organization threshold of 1 gross domestic product per capita was used to define cost effectiveness. Studies were appraised for methodological quality using the extended Consensus on Health Economics Criteria checklist.

RESULTS

Of 6154 articles identified by the search strategy, 14 papers assessing 13 different interventions were included. Most deprescribing interventions included some type of medication review with or without a supportive educational component (n = 11, 85%), and in general were delivered within a pharmacist-physician care collaboration. Settings included community pharmacies, primary care/outpatient clinics and patients' homes. All economic evaluations were conducted within a time horizon varying from 2 to 12 months with outcomes in most of the studies derived from a single clinical trial. Main health outcomes were reported in terms of quality-adjusted life-years, prevented number of falls and the medication appropriateness index. Cost effectiveness ranged from dominant to an incremental cost-effectiveness ratio of $112,932 per quality-adjusted life-year, a value above the country's World Health Organization threshold. Overall, 85% of the interventions were cost saving, dominated usual care or were cost effective considering 1 gross domestic product per capita. Nine studies scored > 80% (good) and two scored ≤ 50% (low) on critical quality appraisal.

CONCLUSIONS

There is a growing interest in economic evaluations of deprescribing interventions focused on community-dwelling older adults. Although results varied across setting, time horizon and intervention, most were cost effective according to the World Health Organization threshold. Deprescribing interventions are promising from an economic viewpoint, but more studies are needed.

Effectiveness of Interventions to Reduce Potentially Inappropriate Medication in Older Patients: A Systematic Review

Background: Age-related multiple comorbidities cause older adults to be prone to the use of potentially inappropriate medicines (PIM) resulting in an increased risk of adverse events. Several strategies have emerged to support PIM prescription, and a huge number of interventions to reduce PIM have been proposed. This work aims to analyze the effectiveness of PIM interventions directed to older adults.

Methods: A systematic review was performed searching the literature in the MEDLINE PubMed, EMBASE, and Cochrane scientific databases for interventional studies that assessed the PIM interventions in older adults (≥65 years).

Results: Forty-seven articles were included, involving 52 to 124,802 patients. Various types of interventions were analyzed such as medication review, educational strategies, clinical decision support system, and organizational and multifaceted approaches. In the hospital, the most successful intervention was medication review (75.0%), while in primary care, the analysis of all included studies revealed that educational strategies were the most effective. However, the analysis of interventions that have greater evidence by its design was inconclusive.

Conclusion: The results obtained in this work suggested that PIM-setting-directed interventions should be developed to promote the wellbeing of the patients through PIM reduction. Although the data obtained suggested that medication review was the most assertive strategy to decrease the number of PIM in the hospital setting, more studies are necessary.

Systematic Review Registration: [https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021233484], identifier [PROSPERO 2021 CRD42021233484].

Prevalence and Predictors of Potentially Inappropriate Medications Among Patients Aged ≥65 Years on Hospital Admissions in Kuwait

BACKGROUND

Potentially inappropriate medications are major health concerns for patients aged ≥65 years. To investigate the prevalence of potentially inappropriate medications, Beer's criteria can be used. We estimated the prevalence of potentially inappropriate medications prescription among patients aged ≥65 years admitted to Kuwait's largest hospital and identified the predictors of prescribing a potentially inappropriate medication.

METHODS

A cross-sectional study was conducted retrospectively using inpatient records from the medical department at the Hospital in Kuwait from 1 January 2019 to 31 December 2019. The latest version of Beer's criteria was used to identify potentially inappropriate medications in patients' medical records. Data were analyzed descriptively to estimate the prevalence of potentially inappropriate medications and to describe participant characteristics. The predictors of potentially inappropriate medications prescribing were determined using binary logistic regression.

RESULTS

A total of 423 medical records of patients were collected. The mean age of the patients admitted was 76 ± 7 years, and 222 of them (52.5%) were women. Upon hospital admission, potentially inappropriate medication was prevalent in 58.4% of patients. The most prevalent potentially inappropriate medications identified were proton pump inhibitors (27.3%), diuretics (21.5%), antipsychotic agents (9%), selective serotonin reuptake inhibitors (5%), and methyldopa (4%). Polypharmacy, Alzheimer's disease, depression, irritable bowel syndrome, hypothyroidism, chronic kidney disease were predictors of potentially inappropriate medications prescription.

CONCLUSION

A high prevalence of potentially inappropriate medication prescription was observed among patients aged ≥65 years admitted to a hospital in Kuwait. The most likely predictor of potentially inappropriate medication prescription was polypharmacy.

Psychotropic Use among Older Adults Living at Home: Use of the Anatomical Therapeutic Chemical (ATC) Drug Classification System and Beers Criteria®

The study examined medication use among older adults living at home and connection between background characteristics, urban/rural residency, and medication use according to Anatomical Therapeutic Chemical (ATC) drug classification system and Beers Criteria^®. Population-based cross-sectional study, participants (N = 175) were randomly selected from the Icelandic national registry, randomized by age, gender, and residence. On average, participants took 2.9 medications: 20% used psychotropics and 15% used psychotropics in ATC groups N05/N06A, which are deemed inappropriate for this age group according to Beers Criteria. Beers Criteria are useful for recognizing possible inappropriate medications for older adults and can be utilized by mental health nurses to assess the appropriateness of geriatric pharmaceutical treatments.

Reduction of inappropriate prescriptions in older adults through the support of Asynchronous Geriatric Counseling Online (AGAlink): Implemented in primary care

Background/Aim

Medication prescription is a fundamental component in the care of the elderly. Several characteristics of aging and geriatric medicine affect prescriptions for these people and make the selection of drug therapy a difficult and complex process. The objective of this study is to develop a geriatric portal for asynchronous online counseling (AGAlink) for use by physicians specializing in family medicine to reduce medication problems among older adult patients in the first level of care.

Method

A qualitative study was carried out in the first level of care at the Mexican Institute of Social Security (IMSS), 31 family doctors were interviewed to identify attitudes, preferences about the use of the AGAlink geriatric portal, as well as their recommendations for the implementation of this tool in their daily practice. For the analysis of the data obtained, a qualitative thematic content analysis was used.

Results

90% of the physicians used the geriatric portal outside office hours without the need for the patient to be present. The perception of the physician towards the use of the AGAlink geriatric portal was favorable, provided relevant information and had several positive effects on the process of care for medical prescription. The barriers identified to accept the change in medication were not having the proposed therapeutic option, lack of any laboratory analysis, continuing to consider their experience for the prescription of the medication.

Conclusions

The AGAlink geriatric portal was a tool that was well received by physicians who expressed a positive attitude, considered an investment of a short time that allowed them to update and learn about strategies to reduce the prescription problems presented among the elderly population. However, the main barrier was the use of technology, especially in the doctors with more seniority in the service.

Reviewing Potentially Inappropriate Medication in Hospitalized Patients Over 65 Using Explicit Criteria: A Systematic Literature Review

Potentially inappropriate medication (PIM) is a primary health concern affecting the quality of life of patients over 65. PIM is associated with adverse drug reactions including falls, increased healthcare costs, health services utilization and hospital admissions. Various strategies, clinical guidelines and tools (explicit and implicit) have been developed to tackle this health concern. Despite these efforts, evidence still indicates a high prevalence of PIM in the older adult population. This systematic review explored the practice of using explicit tools to review PIM in hospitalized patients and examined the outcomes of PIM reduction. A literature search was conducted in several databases from their inception to 2019. Original studies that had an interventional element using explicit criteria detecting PIM in hospitalized patients over 65 were included. Descriptive narrative synthesis was used to analyze the included studies. The literature search yielded 6116 articles; 25 quantitative studies were included in this systematic literature review. Twenty were prospective studies and five were retrospective. Approximately, 15,500 patients were included in the review. Various healthcare professionals were involved in reviewing PIM including physicians and hospital pharmacists. Several tools were used to review PIM for hospitalized patients over 65, most frequently Beer’s criteria and the STOPP/START tool. The reduction of PIM ranged from 3.5% up to 87%. The most common PIM were benzodiazepines and antipsychotics. This systematic review showed promising outcomes in terms of improving patient outcomes. However, the reduction of PIM varied in the studies, raising the question of the variance between hospitals in the explicit tools used for review. Additional studies need to be conducted to further investigate the outcomes of reviewing PIM at different levels, as well as assessing the cost-effectiveness of using explicit tools in reducing PIM.

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

TRIAL REGISTRATION NUMBER

ChiCTR2100047788.

Economic Evaluations of Interventions to Optimize Medication Use in Older Adults with Polypharmacy and Multimorbidity: A Systematic Review

Purpose

To conduct a systematic review of the economic impact of interventions intended at optimizing medication use in older adults with multimorbidity and polypharmacy.

Methods

We searched Ovid-Medline, Embase, CINAHL, Ageline, Cochrane, and Web of Science, for articles published between 2004 and 2020 that studied older adults with multimorbidity and polypharmacy. The intervention studied had to be aimed at optimizing medication use and present results on costs.

Results

Out of 3,871 studies identified by the search strategy, eleven studies were included. The interventions involved different provider types, with a majority described as a multidisciplinary team involving a pharmacist and a general practitioner, in the decision-making process. Interventions were generally associated with a reduction in medication expenditure. The benefits of the intervention in terms of clinical outcomes remain limited. Five studies were cost-benefit analyses, which had a net benefit that was either null or positive. Cost-utility and cost-effectiveness analyses resulted in incremental cost-effectiveness ratios that were generally within the willingness-to-pay thresholds of the countries in which the studies were conducted. However, the quality of the studies was generally low. Omission of key cost elements of economic evaluations, including intervention cost and payer perspective, limited interpretability.

Conclusion

Interventions to optimize medication use may provide benefits that outweigh their implementation costs, but the evidence remains limited. There is a need to identify and address barriers to the scaling-up of such interventions, starting with the current incentive structures for pharmacists, physicians, and patients.

Process evaluation of implementation strategies to reduce potentially inappropriate medication prescribing in older population: A scoping review

OBJECTIVES

Several implementation strategies can reduce potentially inappropriate medication (PIM) prescribing. Although use of PIMs has declined in recent years, it remains prevalent. Various strategies exist to improve the appropriateness of medication use. However, little is known about the processes of these different implementation strategies. This scoping review aims to investigate how the process evaluation of implementation strategies for reducing PIM prescribing in the older population has been studied.

METHODS

We searched for process evaluations of implementation strategies for reducing PIM prescribing in PUBMED, SCOPUS and Web of Science published between January 2000 and November 2019 in English. We applied the following inclusion criteria: patients aged ≥65 years, validated PIM criteria, and implementation process evaluated. The review focuses on decision support for health care professionals. We described the findings of the process evaluations, and compared the authors' concepts of process evaluation of the included publications to those of Proctor et al.( 2010).

RESULT

Of 9131 publications screened, 29 met our inclusion criteria. Different process evaluation conceptualizations were identified. Most process evaluations took place in the initial stages of the process (acceptability, adoption, appropriateness, and feasibility) and sustainability and implementation costs were seldom evaluated. None of the included publications evaluated fidelity. Multifaceted interventions were the most studied implementation strategies. Medication review was more common in acceptability evaluations, multidisciplinary interventions in adoption evaluations, and computerized systems and educational interventions in feasibility evaluations. Process evaluations were studied from the health care professionals' viewpoint in most of the included publications, but the management viewpoint was missing.

DISCUSSION

The conceptualization of process evaluation in the field of PIM prescribing is indeterminate. There is also a current gap in the knowledge of sustainability and implementation costs. Clarifying the conceptualization of implementation process evaluation is essential in order to effectively translate research knowledge into practice.

Antibiotic prescribing in UK out-of-hours primary care services: a realist-informed scoping review of training and guidelines for healthcare professionals

Background

Antibiotic overuse has contributed to antimicrobial resistance, which is a global public health problem. In the UK, despite the fall in rates of antibiotic prescription since 2013, prescribing levels remain high in comparison with other European countries. Prescribing in out-of-hours (OOH) care provides unique challenges for prudent prescribing, for which professionals may not be prepared.

Aim

To explore the guidance available to professionals on prescribing antibiotics for common infections in OOH primary care within the UK, with a focus on training resources, guidelines, and clinical recommendations.

Design & setting

A realist-informed scoping review of peer-reviewed articles and grey literature.

Method

The review focused on antibiotic prescribing OOH (for example, clinical guidelines and training videos). General prescribing guidance was searched whenever OOH-focused resources were unavailable. Electronic databases and websites of national agencies and professional societies were searched following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards. Findings were organised according to realist review components, that is, mechanisms, contexts, and outcomes.

Results

In total, 46 clinical guidelines and eight training resources were identified. Clinical guidelines targeted adults and children, and included recommendations on prescription strategy, spectrum of the antibiotic prescribed, communication with patients, treatment duration, and decision-making processes. No clinical guidelines or training resources focusing specifically on OOH were found.

Conclusion

The results highlight a lack of knowledge about whether existing resources address the challenges faced by OOH antibiotic prescribers. Further research is needed to explore the training needs of OOH health professionals, and whether further OOH-focused resources need to be developed given the rates of antibiotic prescribing in this setting.

Patient factors associated with new prescribing of potentially inappropriate medications in multimorbid US older adults using multiple medications

BACKGROUND

The use of potentially inappropriate medications (PIMs) is common in older adults and is associated with potential negative consequences, such as falls and cognitive decline. Our objective was to investigate measurable patient factors associated with new outpatient prescribing of potentially inappropriate medications in older multimorbid adults already using multiple medications.

METHODS

In this retrospective US cohort study, we used linked Medicare pharmacy and medical claims and electronic health record data from a large healthcare system in Massachusetts between 2007 and 2014. We identified patients aged ≥65 years with an office visit who had not been prescribed or used a PIM in the prior 180 days. PIMs were defined using 2019 Beers criteria of the American Geriatrics Society. To specifically evaluate factors in patients with polypharmacy and multimorbidity, we selected those who filled medications for ≥90 days (i.e., chronic use) from ≥5 pharmaceutical classes in the prior 180 days and had ≥2 chronic conditions. Multivariable Cox regression analysis was used to estimate the association between baseline demographic and clinical characteristics on the probability of being prescribed a PIM in the 90-day follow-up period.

RESULTS

In total, we identified 17,912 patients aged ≥65 years with multimorbidity and polypharmacy who were naïve to a PIM in the prior 180 days. Of those, 10,497 (58.6%) were female, and mean age was 78 (SD = 7.5). On average, patients had 5.1 (SD = 2.3) chronic conditions and previously filled 6.1 (SD = 1.4) chronic medications. In total, 447 patients (2.5%) were prescribed a PIM during the 90-day follow-up. Male sex (adjusted hazard ratio (HR) = 1.29; 95%CI: 1.06-1.57), age (≥85 years: HR = 0.75, 95%CI: 0.56-0.99, 75-84 years: HR = 0.87, 95%CI: 0.71-1.07; reference: 65-74 years), ambulatory visits (18-29 visits: HR = 1.42, 95%CI: 1.06-1.92; ≥30 visits: HR = 2.12, 95%CI: 1.53-2.95; reference: ≤9 visits), number of prescribing orders (HR = 1.02, 95%CI: 1.01-1.02 per 1-unit increase), and heart failure (HR = 1.38, 95%CI: 1.07-1.78) were independently associated with being newly prescribed a PIM.

CONCLUSION

Several demographic and clinical characteristics, including factors suggesting lack of care coordination and increased clinical complexity, were found to be associated with the new prescribing of potentially inappropriate medications. This knowledge could inform the design of interventions and policies to optimize pharmacotherapy for these patients.

Prevalence of Drug-Related Problems and Complementary and Alternative Medicine Use in Malaysia: A Systematic Review and Meta-Analysis of 37,249 Older Adults

Drug-related problems (DRPs) in the elderly include polypharmacy, potentially inappropriate medications, nonadherence, and drug-related falls. In this systematic review and meta-analysis, the prevalence of DRPs and complementary and alternative medicine (CAM) use among the Malaysian elderly was estimated. PubMed, Scopus, Web of Science, and Google Scholar databases were searched to identify studies published since their inception up to 24 August 2020. A random-effects model was used to generate the pooled prevalence of DRPs along with its corresponding 95% confidence interval (CI). The heterogeneity of the results was estimated using the I² statistics, and Cochran’s Q test and sensitivity analyses were performed to confirm the robustness of the results. We identified 526 studies, 23 of which were included in the meta-analysis. (n = 29,342). The pooled prevalence of DRPs among Malaysian elderly was as follows: (1) polypharmacy: 49.5% [95% CI: 20.5–78.6], (2) potentially inappropriate medications: 28.9% [95% CI: 25.4–32.3], (3) nonadherence to medications: 60.6% [95% CI: 50.2–70.9], and (4) medication-related falls 39.3% [95% CI: 0.0–80.8]. Approximately one in two Malaysian elderly used CAM. The prevalence of polypharmacy and potentially inappropriate medications among the Malaysian elderly population was high, calling for measures and evidence-based guidelines to ensure the safe medication use.

Trends in polypharmacy and potentially inappropriate medication (PIM) in older and middle-aged people treated for diabetes

Aims

Polypharmacy is common in people with diabetes and is associated with the use of potentially inappropriate medication (PIM). This study aimed to assess trends in the prevalence of polypharmacy and PIM in older and middle‐aged people with diabetes.

Methods

A repeated cross‐sectional study using the University Groningen IADB.nl prescription database was conducted. All people aged 45 years and over who were treated for diabetes registered in the period 2012–2016 were included. Polypharmacy was assessed for three age groups. PIMs were assessed using Beers criteria for people ≥65 years old, and PRescribing Optimally in Middle‐aged People's Treatments (PROMPT) criteria for 45–64 years old. Chi‐square tests and regression analysis were applied.

Results

The prevalence of polypharmacy increased significantly in all age groups in the study period. In 2016, the prevalence of polypharmacy was 36.9% in patients aged 45–54 years, 50.3% in those aged 55–64 years, and 66.2% in those aged ≥65 years. The prevalence of older people with at least one PIM decreased by 3.1%, while in the middle‐aged group this prevalence increased by 0.9% from 2012 to 2016. The most common PIMs in both age groups were the use of long‐term high‐dose proton pump inhibitors, benzodiazepines and strong opioids without laxatives. Of those, only benzodiazepines showed a decreasing trend.

Conclusions

Polypharmacy increased in older and middle‐aged people with diabetes. While the prevalence of PIM decreased over time in older age, this trend was not observed in middle‐aged people with diabetes. Efforts are needed to decrease the use of PIMs in populations already burdened with many drugs, notably at middle age.

Effect of a Rational Drug Use Policy on the prescribing safety in outpatient settings in Thailand

OBJECTIVE

In Thailand, the 'Rational Drug Use (RDU) policy' has been implemented in the Ministry of Public Health (MOPH) hospitals since October 2016. This study aimed to explore the effects of the RDU policy on prescribing safety indicators for elderly patients and those with common chronic diseases.

METHOD

Electronic outpatient databases were obtained from 15 MOPH hospitals. The selected indicators were the (1) glibenclamide prescribing in patients with diabetes mellitus who were elderly or had renal impairment; (2) duplicate prescribing of renin angiotensin system (RAS) blockers in patients with hypertension; (3) non-steroidal anti-inflammatory drugs (NSAIDs) prescribing in patients with chronic kidney disease stages 3-5; and (4) long-acting benzodiazepines prescribing in patients ≥65 years. The policy effects in terms of changes in prescribing trends were estimated using interrupted time-series analysis based on quarterly (Q) data. The postpolicy trends (2016, Q4-2017, Q4) were compared with the prepolicy trend (2014, Q1-2016, Q3).

KEY FINDINGS

The unsafe prescribing of glibenclamide in patients with diabetes mellitus was 19.2% in Q1, 2014 and decreased significantly due to the RDU policy to 11.0% in Q4, 2017 (-4.23 percentage points quarterly, P < 0.001). The unsafe prescribing of RAS blockers and long-acting benzodiazepines was relatively low in Q1, 2014 (1.0% and 1.1%, respectively) and did not decrease further after the RDU policy. The unsafe prescribing of NSAIDs was 4.2% in Q1, 2014, increased abruptly one quarter after the policy and decreased afterwards.

CONCLUSION

The RDU policy seemed to be a contributing factor that decreased the unsafe prescribing of glibenclamide, while the policy effect was minimal for the other indicators.

Potentially inappropriate medications in elderly patients with heart failure: Beers Criteria-based study

OBJECTIVES

Primary objectives were to evaluate the use of potentially inappropriate medication (PIM) use in elderly heart failure (HF) patients and the factors associated with the number of PIMs. Secondary objectives were to test for the correlation between PIMs and quality of life (QOL) and depression.

METHODS

A cross-sectional study was conducted among 125 elderly Lebanese HF patients with left ventricular ejection fraction <50%. Data on socio-demographics, clinical data and medications were collected. Patients were interviewed with Minnesota living with Heart Failure Questionnaire (MLHFQ) and Patient Health Questionnaire-9 (PHQ-9). Medication profile per patient was evaluated for PIMs using Beers Criteria. The correlations between the number of PIMs and the MLHFQ, PHQ-9 and the number of medications were tested using Pearson's correlation. Linear regression was done to predict the factors associated with the number of PIMs.

KEY FINDINGS

Patients were taking a total of 1035 medications with a mean of 8.28 ± 3.14 medications. In total, 80.0% of patients were taking at least one PIM. Diuretics (55.2%) and proton pump inhibitors (41.6%) were most commonly prescribed PIMs. The number of PIMs was moderately correlated with the number of medications and the MLHFQ score. Linear regression showed that the number of medications, age ≥85 years, chronic kidney disease and HF with New York Heart Association III were associated with more PIMs.

CONCLUSIONS

A high percentage of PIMs was found among a sample of elderly Lebanese HF patients. HF multidisciplinary team is needed to control the prescription of PIMs in this vulnerable population.

[Prevalence and factors associated with polypharmacy among the elderly treated in Primary Healthcare in Belo Horizonte, State of Minas Gerais, Brazil]

The scope of this article is to analyze the prevalence of polymedication and excessive polypharmacy, as well as associated factors, among the elderly attended at two Basic Health Units in Belo Horizonte, State of Minas Gerais. A cross-sectional observational study was conducted using information obtained from a structured interview of the patient. The individual associations of each explanatory variable with polypharmacy and with excessive polypharmacy were analyzed. For the variables that showed a significant association with polypharmacy, multivariate analysis was performed using the logistic regression model. The elderly used, on average, 5.2 drugs. The prevalence of polymedication was 57.7% and excessive polypharmacy was 4.8%. In univariate analysis the conditions associated with polypharmacy were: age ≤ 70 years, schooling > 8 years, presence of more than three diseases and presenting symptoms of depression. For excessive polypharmacy, the presence of more than three diseases, self-perception of negative health, and partial dependence on instrumental activities of daily living were associated with the conditions. In the final multivariate model for polypharmacy, the age ≤ 70 years and presence of more than three disease variables remained.