Associations Between Potentially Inappropriate Medications and Adverse Health Outcomes in the Elderly: A Systematic Review and Meta-analysis

The rate, causes and predictors of ambulance call outs to residential aged care in the Australian Capital Territory: A retrospective observational cohort study

Older people in residential aged care are susceptible to acute illness or injury which may necessitate an ambulance call out, assessment/treatment by a paramedic and transfer to a hospital emergency department. Understanding the case mix of residential aged care ambulance attendances is important for prevention strategies and for planning services. A retrospective observational closed cohort study was designed to investigate the characteristics of emergency ambulance call outs to 15 residential aged care sites in the Australian Capital Territory over a 12-month period. Data were collected from the local ambulance service and the aged care sites. Case load data were analysed to determine rates, clinical characteristics, ambulance attendance outcomes and the temporal distribution of call outs. A Poisson regression model was developed to investigate demographic, morbidity and medication-related risk factors associated with the number of ambulance call outs per resident. Annual ambulance call out costs were estimated. There were 1,275 residents, with 396 (31.1%) requiring at least one ambulance call out over 12 months. Of 669 ambulance attendances, the majority (87.0%) were transported to emergency departments. Trauma (23.9%), pain (16.9%) and infections (9.4%) were the most common primary assessments by the ambulance attendees. Cases/day were similar throughout the year and on weekdays compared to weekends/public holidays. The main predictors of ambulance call out were multi-morbidity, taking regular anticholinergic medicines, being male and younger age. Estimated costs of ambulance call outs/year were $475/resident and $40,375/residential aged care site. The most frequent primary assessments (trauma, pain, infections) may constitute priorities for developing prevention strategies and for treatment initiatives within residential aged care. Strategies to reduce anticholinergic medication prescribing may also be a potential intervention to decrease ambulance call outs and hospital emergency department demand. The ambulance usage data from this study may be useful to compare with future datasets to measure the impact of the introduction of new services.

Prevalence of potentially inappropriate medications and prescription dynamics in elderly hospitalized patients in Spain

PURPOSE

In recent years, the need for a more appropriate prescription of medications in the older population has emerged as a significant public health concern. In this study, we aimed to evaluate the prevalence of potentially inappropriate medications (PIM) in hospitalized adults aged ≥ 75.

PATIENTS AND METHODS

This was a retrospective descriptive observational study of patients at 16 hospitals in Spain. The study population included inpatients aged ≥ 75 admitted during a 7-day period (May 10 to 16, 2021). Data were obtained from the pharmacy databases of the participating hospitals. The list of PIMs was based on the Beers, STOPP-START, EU-PIM and PRISCUS criteria.

RESULTS

A total of 4,183 patients were included. PIMs were detected in 23.5% (N = 1,126) of the cohort. The prevalence rates at the participating hospitals ranged from 10% to 42.5%. The PIM/patient ratio was 1.2. The most common PIMs were midazolam, dexketoprofen, diazepam, and doxazosin, all of which (except for doxazosin) were more common in women. Benzodiazepines accounted for 70% of all PIMs. In 35% of cases, the PIMs were initiated before hospital admission. Of the 818 PIMs initiated during hospitalization, the two most common were benzodiazepines (49%) and anti-inflammatory drugs (25%). At discharge, only 4.9% of the PIMs initiated during the hospital stay were still prescribed.

CONCLUSION

In this population of older hospitalized patients, the overall prevalence of PIMs was moderate. However, the prevalence rate at the participating hospitals was highly variable. In most cases, PIMs prescribed prior to hospitalization for chronic conditions were not withdrawn during the hospital stay. No significant increase in PIMs was observed from pre-admission to post-discharge. These findings underscore the need for multidisciplinary interventions to optimize the pharmaceutical treatment in older adults in the hospital setting to reduce the consequences of PIMs in patients.

Geriatric Emergency Medication Safety Recommendations (GEMS-Rx): Modified Delphi Development of a High-Risk Prescription List for Older Emergency Department Patients

STUDY OBJECTIVE

Half of emergency department (ED) patients aged 65 years and older are discharged with new prescriptions. Potentially inappropriate prescriptions contribute to adverse drug events. Our objective was to develop an evidence- and consensus-based list of high-risk prescriptions to avoid among older ED patients.

METHODS

We performed a modified, 3-round Delphi process that included 10 ED physician experts in geriatrics or quality measurement and 1 pharmacist. Consensus members reviewed all 35 medication categories from the 2019 American Geriatrics Society Beers Criteria and ranked each on a 5-point Likert scale (5=highest) for overall priority for avoidance (Round 1), risk of short-term adverse events and avoidability (Round 2), and reasonable medical indications for high-risk medication use (Round 3).

RESULTS

For each round, questionnaire response rates were 91%, 82%, and 64%, respectively. After Round 1, benzodiazepines (mean, 4.60 [SD, 0.70]), skeletal muscle relaxants (4.60 [0.70]), barbiturates (4.30 [1.06]), first-generation antipsychotics (4.20 [0.63]) and first-generation antihistamines (3.70 [1.49]) were prioritized for avoidance. In Rounds 2 and 3, hypnotic "Z" drugs (4.29 [1.11]), metoclopramide (3.89 [0.93]), and sulfonylureas (4.14 [1.07]) were prioritized for avoidability, despite lower concern for short-term adverse events. All 8 medication classes were included in the final list. Reasonable indications for prescribing high-risk medications included seizure disorders, benzodiazepine/ethanol withdrawal, end of life, severe generalized anxiety, allergic reactions, gastroparesis, and prescription refill.

CONCLUSION

We present the first expert consensus-based list of high-risk prescriptions for older ED patients (GEMS-Rx) to improve safety among older ED patients.

Potentially Inappropriate Medication Use in Older Adults With Multimorbidity in Taiwan

BACKGROUND

Medication-related problem is a concerning issue in older adults with multimorbidity due to complexity of disease conditions and polypharmacy, and may lead to increase in risk for adverse health outcomes. This study aims to investigate the prevalence and associated factors of potentially inappropriate medication use among the growing population of older adults with multimorbidity in Taiwan.

METHOD

The study population was composed of patients who were aged 65 years or older with multimorbidity (two or more chronic diseases) and had at least one outpatient clinic visit with drug prescription in 2018 identified from the Taiwan National Health Insurance Research Database. Potentially inappropriate medication use was defined using the 2019 Beers criteria for drugs to be avoided for older adults. Multiple logistic regression model was conducted to examine patient-related and prescriber-related factors associated with PIM use.

RESULTS

A total of 2 432 416 patients (69.7% of the entire older adult population) had multimorbidity and received at least one drug prescription at the outpatient clinic in Taiwan in 2018. The prevalence of having at least one PIM in this population was found to be 85.6%. Patient-related factors (age, sex, specific chronic diseases, frequency of outpatient visits) and prescriber-related factors (physician characteristics, healthcare setting, total number of medications, prior PIM use) were found to be associated with use of PIM.

CONCLUSION

High prevalence of PIM use was found in older patients with multimorbidity in Taiwan. Both patient-related and prescriber-related factors had been found to be predictors of PIM use, and should be addressed when trying to improve the medication quality in this population.

Effect of the use of potentially inappropriate medications on the mortality of Brazilian older adults: SABE cohort study

OBJECTIVE

Investigate the association between potentially inappropriate medication (PIM) use and the risk of death among community-dwelling older Brazilian adults.

METHODS

Participants from the Health, Well-Being, and Aging Cohort Study (SABE) in São Paulo, Brazil, between 2000 and 2016 were included. The dependent variable was all-cause mortality, measured as the time elapsed until death. The exposure of interest was the use of PIM according to the Beers Criteria 2019 version. All covariates, except for sex and education, were considered time-varying.

RESULTS

PIM use was not associated with mortality after adjusting for covariates (HR = 0.99; 95 % CI: 0.88-1.12). There was a significant interaction between PIM use and age (HR = 0.98; 95 % CI: 0.96-0.99).

CONCLUSION

The association between PIM use and the risk of death was moderated by age. Future studies should consider the impact of necessary medication omissions when assessing the mortality risk associated with PIM use.

Potentially Inappropriate Medications Involved in Drug-Drug Interactions in a Polish Population over 80 Years Old: An Observational, Cross-Sectional Study

The clinical context of drug interactions detected by automated analysis systems is particularly important in older patients with multimorbidities. We aimed to provide unique, up-to-date data on the prevalence of potentially inappropriate medications (PIMs) and drug-drug interactions (DDIs) in the Polish geriatric population over 80 years old and determine the frequency and the most common PIMs involved in DDIs. We analyzed all non-prescription and prescription drugs in a representative national group of 178 home-dwelling adults over 80 years old with excessive polypharmacy (≥10 drugs). The FORTA List was used to assess PIMs, and the Lexicomp® Drug Interactions database was used for DDIs. DDIs were detected in 66.9% of the study group, whereas PIMs were detected in 94.4%. Verification of clinical indications for the use of substances involved in DDIs resulted in a reduction in the total number of DDIs by more than 1.5 times, as well as in a nearly 3-fold decrease in the number of interactions requiring therapy modification and drug combinations that should be strictly avoided. The most common PIMs involved in DDIs were painkillers, and drugs used in psychiatry and neurology. Special attention should be paid to DDIs with PIMs since they could increase their inappropriate character. The use of automated interaction analysis systems, while maintaining appropriate clinical criticism, can increase both chances for a good therapeutic effect and the safety of the elderly during treatment processes.

Development of a Predictive Model for Potentially Inappropriate Medications in Older Patients with Cardiovascular Disease

BACKGROUND

Older patients with cardiovascular disease (CVD) are highly susceptible to adverse drug reactions due to age-related physiological changes and the presence of multiple comorbidities, polypharmacy, and potentially inappropriate medications (PIMs).

OBJECTIVE

This study aimed to develop a predictive model to identify the use of PIMs in older patients with CVD.

METHODS

Data from 2012 to 2021 from the Changhua Christian Hospital Clinical Research Database (CCHRD) and the Kaohsiung Medical University Hospital Research Database (KMUHRD) were analyzed. Participants over the age of 65 years with CVD diagnoses were included. The CCHRD data were randomly divided into a training set (80% of the database) and an internal validation set (20% of the database), while the KMUHRD data served as an external validation set. The training set was used to construct the prediction models, and both validation sets were used to validate the proposed models.

RESULTS

A total of 48,569 patients were included. Comprehensive data analysis revealed significant associations between the use of PIMs and clinical factors such as total cholesterol, glycated hemoglobin (HbA1c), creatinine, and uric acid levels, as well as the presence of diabetes, hypertension, and cerebrovascular accidents. The predictive models demonstrated moderate power, indicating the importance of these factors in assessing the risk of PIMs.

CONCLUSIONS

This study developed predictive models that improve understanding of the use of PIMs in older patients with CVD. These models may assist clinicians in making informed decisions regarding medication safety.

Potentially Inappropriate Medication: A Pilot Study in Institutionalized Older Adults

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

Enhancing healthcare access for an older population: The age-friendly emergency department

Healthcare systems face significant challenges in meeting the unique needs of older adults, particularly in the acute setting. Age-friendly healthcare is a comprehensive approach using the 4Ms framework-what matters, medications, mentation, and mobility-to ensure that healthcare settings are responsive to the needs of older patients. The Age-Friendly Emergency Department (AFED) is a crucial component of a holistic age-friendly health system. Our objective is to provide an overview of the AFED model, its core principles, and the benefits to older adults and healthcare clinicians. The AFED optimizes the delivery of emergency care by integrating age-specific considerations into various aspects of (1) ED physical infrastructure, (2) clinical care policies, and (3) care transitions. Physical infrastructure incorporates environmental modifications to enhance patient safety, including adequate lighting, nonslip flooring, and devices for sensory and ambulatory impairment. Clinical care policies address the physiological, cognitive, and psychosocial needs of older adults while preserving focus on emergency issues. Care transitions include communication and involving community partners and case management services. The AFED prioritizes collaboration between interdisciplinary team members (ED clinicians, geriatric specialists, nurses, physical/occupational therapists, and social workers). By adopting an age-friendly approach, EDs have the potential to improve patient-centered outcomes, reduce adverse events and hospitalizations, and enhance functional recovery. Moreover, healthcare clinicians benefit from the AFED model through increased satisfaction, multidisciplinary support, and enhanced training in geriatric care. Policymakers, healthcare administrators, and clinicians must collaborate to standardize guidelines, address barriers to AFEDs, and promote the adoption of age-friendly practices in the ED.

A Nationwide Emergency Department Data Analysis to Predict Beers List Medications Use Among Older Adults

BACKGROUND

The use of potentially inappropriate medications (PIMs) is considered an important quality indicator for older adults seen in the ambulatory care setting.

STUDY OBJECTIVES

To evaluate the pattern of potentially inappropriate medication (PIMs) use as specified in the Beers Criteria, for older adults during emergency department (ED) visits in the United States.

METHODS

Using data from the National Hospital Ambulatory Care Survey (NHAMCS) we identified older adults (age 65 or older) discharged home from an ED visit in 2019. We defined PIMs as those with an 'avoid' recommendation under the American Geriatrics Society (AGS) 2019 Beers Criteria in older adults. Logistic regression models were used to assess demographic, clinical, and hospital factors associated with the use of any PIMs upon ED discharge.

RESULTS

Overall, 5.9% of visits by older adults discharged from the ED included administration or prescriptions for PIMs. Among those who received any PIMs, 25.5% received benzodiazepines, 42.5 % received anticholinergics, 1.4% received nonbenzodiazepine hypnotics, and 0.5% received barbiturates. A multivariable model showed statistically significant associations for age 65 to 74 (OR 1.91, 95% CI 1.39-2.62 vs. age >=75), dementia (OR 0.45, 95% CI 0.21-0.95), lower immediacy (OR 2.45, 95% CI 1.56-3.84 vs. higher immediacy), and Northeastern rural region (OR 0.34, 95% CI 0.21-0.55 vs. Midwestern rural).

CONCLUSION

We found that younger age and lower immediacy were associated with increased prescriptions of PIMs for older adults seen, while dementia and Northeastern rural region was associated with reduced use of PIMs seen and discharged from EDs in United States.

Lists of potentially inappropriate medications for older people in primary care: a systematic review of health outcomes

This study is a systematic literature review of the association between lists of potentially inappropriate medications (PIM) in clinical practice and health outcomes of older adults followed up in primary health care. For this purpose, the PRISMA protocol was used to systematize the search for articles in the PubMed, Web of Science, Scopus, Cochrane Central, LIVIVO and LILACS databases, in addition to the gray literature. Studies with randomized clinical trials were selected, using explicit criteria (lists) for the identification and management of PIM in prescriptions of older patients in primary care. Of the 2,400 articles found, six were used for data extraction. The interventions resulted in significant reductions in the number of PIM and adverse drug events and, consequently, in potentially inappropriate prescriptions (PIP) in polymedicated older adults. However, there were no significant effects of the interventions on negative clinical outcomes, such as emergency room visits, hospitalizations and death, or on improving the health status of the older adults. The use of PIM lists promotes adequate medication prescriptions for older adults in primary health care, but further studies are needed to determine the impact of reducing PIM on primary clinical outcomes.

Potentially inappropriate prescribing for people with dementia in ambulatory care: a cross-sectional observational study

BACKGROUND

Studies have shown that potentially inappropriate prescribing (PIP) is highly prevalent among people with dementia (PwD) and linked to negative outcomes, such as hospitalisation and mortality. However, there are limited data on prescribing appropriateness for PwD in Saudi Arabia. Therefore, we aimed to estimate the prevalence of PIP and investigate associations between PIP and other patient characteristics among PwD in an ambulatory care setting.

METHODS

A cross-sectional, retrospective analysis was conducted at a tertiary hospital in Saudi Arabia. Patients who were ≥ 65 years old, had dementia, and visited ambulatory care clinics between 01/01/2019 and 31/12/2021 were included. Prescribing appropriateness was evaluated by applying the Screening Tool of Older Persons Potentially Inappropriate Prescriptions (STOPP) criteria. Descriptive analyses were used to describe the study population. Prevalence of PIP and the prevalence per each STOPP criterion were calculated as a percentage of all eligible patients. Logistic regression analysis was used to investigate associations between PIP, polypharmacy, age and sex; odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. Analyses were conducted using SPSS v27.

RESULTS

A total of 287 PwD were identified; 56.0% (n = 161) were female. The mean number of medications prescribed was 9.0 [standard deviation (SD) ± 4.2]. The prevalence of PIP was 61.0% (n = 175). Common instances of PIP were drugs prescribed beyond the recommended duration (n = 90, 31.4%), drugs prescribed without an evidence-based clinical indication (n = 78, 27.2%), proton pump inhibitors (PPIs) for > 8 weeks (n = 75, 26.0%), and acetylcholinesterase inhibitors with concurrent drugs that reduce heart rate (n = 60, 21.0%). Polypharmacy was observed in 82.6% (n = 237) of patients and was strongly associated with PIP (adjusted OR 24.1, 95% CI 9.0-64.5).

CONCLUSIONS

Findings have revealed a high prevalence of PIP among PwD in Saudi Arabia that is strongly associated with polypharmacy. Future research should aim to explore key stakeholders' experiences and perspectives of medicines management to optimise medication use for this vulnerable patient population.

Preventable or potentially inappropriate psychotropics and adverse health outcomes in older adults: systematic review and meta-analysis

OBJECTIVE

To systematically review and quantitatively synthetize evidence on the use of PIPs linked to adverse health outcomes in older adults.

METHODS

A Medline, Embase® and Opengrey libraries search was conducted from 2004 to February 2021, using the PICO model: older people, psychotropic drugs, inappropriate prescribing, and adverse drug events. Fixed-effects and random-effects meta-analysis were performed from 3 eligible studies using an inverse-variance method.

RESULTS

Of the 1943 originally identified abstracts, 106 met the inclusion criteria and 7 studies were included in this review. All were of good quality. The number of participants ranged from 318 to 383,150 older adults (54.5-74.4% women). Associations were found between PIPs use and decreased personal care activities of daily living (ADL), unplanned hospitalizations, falls and mortality. In the pooled analysis, association with falls was confirmed (1.23 [95%CI: 1.15;1.32]).

CONCLUSIONS

Participants of 65 years and older treated with PIPs were more at risk of adverse health outcomes than those using no PIPs, including greater risks of falls, functional disabilities, unplanned hospitalizations, and mortality. Results of the present systematic review and meta-analysis provide additional evidence for an appropriate and safe use of psychotropics in older adults.

A mixed methods analysis of the medication review intervention centered around the use of the 'Systematic Tool to Reduce Inappropriate Prescribing' Assistant (STRIPA) in Swiss primary care practices

BACKGROUND

Electronic clinical decision support systems (eCDSS), such as the 'Systematic Tool to Reduce Inappropriate Prescribing' Assistant (STRIPA), have become promising tools for assisting general practitioners (GPs) with conducting medication reviews in older adults. Little is known about how GPs perceive eCDSS-assisted recommendations for pharmacotherapy optimization. The aim of this study was to explore the implementation of a medication review intervention centered around STRIPA in the 'Optimising PharmacoTherapy In the multimorbid elderly in primary CAre' (OPTICA) trial.

METHODS

We used an explanatory mixed methods design combining quantitative and qualitative data. First, quantitative data about the acceptance and implementation of eCDSS-generated recommendations from GPs (n = 21) and their patients (n = 160) in the OPTICA intervention group were collected. Then, semi-structured qualitative interviews were conducted with GPs from the OPTICA intervention group (n = 8), and interview data were analyzed through thematic analysis.

RESULTS

In quantitative findings, GPs reported averages of 13 min spent per patient preparing the eCDSS, 10 min performing medication reviews, and 5 min discussing prescribing recommendations with patients. On average, out of the mean generated 3.7 recommendations (SD=1.8). One recommendation to stop or start a medication was reported to be implemented per patient in the intervention group (SD=1.2). Overall, GPs found the STRIPA useful and acceptable. They particularly appreciated its ability to generate recommendations based on large amounts of patient information. During qualitative interviews, GPs reported the main reasons for limited implementation of STRIPA were related to problems with data sourcing (e.g., incomplete data imports), preparation of the eCDSS (e.g., time expenditure for updating and adapting information), its functionality (e.g., technical problems downloading PDF recommendation reports), and appropriateness of recommendations.

CONCLUSIONS

Qualitative findings help explain the relatively low implementation of recommendations demonstrated by quantitative findings, but also show GPs' overall acceptance of STRIPA. Our results provide crucial insights for adapting STRIPA to make it more suitable for regular use in future primary care settings (e.g., necessity to improve data imports).

TRIAL REGISTRATION

Clinicaltrials.gov NCT03724539, date of first registration: 29/10/2018.

Are Lists of Potentially Inappropriate Medications Associated with Hospital Readmissions? A Systematic Review

BACKGROUND

Suboptimal prescribing, including the prescription of potentially inappropriate medications (PIM), is frequent in patients aged 65 years and older. PIMs are associated with adverse drug events, which may lead to hospital admissions and readmissions for the most serious cases. Several tools, known as lists of PIMs, can detect suboptimal prescription.

OBJECTIVE

This systematic review aimed to identify which lists of PIMs are associated with hospital readmission of older patients.

PATIENTS AND METHODS

MEDLINE, the Cochrane Library, EMBASE, and clinicaltrials.gov were searched for the period from 1 January 1991 up to 12 May 2022 to identify original studies assessing the association between PIMs and hospital readmissions or emergency department (ED) revisits within 30 days of discharge in older patients. This study is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 Checklist, and the risk of bias was assessed with the Newcastle-Ottawa Quality Assessment Scale for Cohort Studies (NOS) and the revised Cochrane risk-of-bias tool for randomized trials (RoB 2).

RESULTS

A total of six studies presenting four different lists of PIMs were included. Readmission rates varied from 4.3 to 25.5% and the odds ratio (OR) between PIMs and hospital readmission varied from 0.92 [95% confidence interval (CI) 0.59; 1.42] to 6.48 [95% CI 3.00; 14.00]. Only two studies found a statistically significant association between a list of PIMs and hospital readmission. These two studies used different tools: the Screening Tool of Older Person's Prescriptions (STOPP) and the Screening Tool to Alert Doctors to Right Treatment (START) and a combination of Beers Criteria® and STOPP and START.

CONCLUSION

This systematic review shows that the association between list of PIMs and 30-day unplanned readmissions remains unclear and seems dependent on the PIM detection tool. Further studies are needed to clarify this association. PROSPERO registration number CRD42021252107.

Efficacy of deprescribing on health outcomes: An umbrella review of systematic reviews with meta-analysis of randomized controlled trials

BACKGROUND

Deprescribing is an important intervention across different settings in medicine, but the literature supporting such a practice is still conflicting. Therefore, we aimed to capture the breadth of outcomes reported and assess the strength of evidence of the use of deprescribing for health outcomes.

METHODS

Umbrella review of systematic reviews of the use of deprescribing searching in Medline, Scopus, and Web of Science until 01 November 2023. The grading of evidence was carried out using the GRADE for intervention studies, whilst data regarding systematic reviews were reported as narrative findings.

RESULTS

Among 456 papers, 12 systematic reviews (six with meta-analysis) for a total of 231 RCTs and 44,193 patients were included. In any setting, deprescribing was able to significantly reduce the number of total and of potentially inappropriate medications (PIMs) in older patients (low certainty of evidence) and to reduce the proportion of participants potentially having several or PIMs (moderate certainty of evidence). In community, supported by a high certainty of evidence, deprescribing was not more effective than standard care in decreasing injurious falls, any falls or number of fallers. In nursing home, deprescribing was associated with a significantly lower PIMs than standard care (very low certainty of evidence). In end-of-life situations, deprescribing significantly reduced mortality rate of approximately 41% (high certainty of evidence).

CONCLUSIONS

Deprescribing is a promising intervention across different settings and situations, but a notable gap in the literature concerning its effects on substantial outcomes still exists.

Tools and guidelines to assess the appropriateness of medication and aid deprescribing: An umbrella review

AIMS

The aim of this umbrella review was to identify tools and guidelines to aid the deprescribing process of potentially inappropriate medications (PIMs), evaluate development and validation methods, and describe evidence levels for medication inclusion.

METHODS

Searches were conducted on MEDLINE (Ovid), Embase.com, Cochrane CDSR, CINAHL (EBSCO), Web of Science Core Collection and guideline databases from the date of inception to 7 July 2022. Following the initial search, an additional search was conducted to identify an updated versions of tools on 17 July 2023. We analysed the contents of tools and guidelines.

RESULTS

From 23 systematic reviews and guidelines, we identified 95 tools (72 explicit, 12 mixed and 11 implicit) and nine guidelines. Most tools (83.2%) were developed to use for older persons, including 14 for those with limited life expectancy. Seven tools were for children <18 years (7.37%). Most explicit/mixed tools (78.57%) and all guidelines were validated. We found 484 PIMs and 202 medications with different appropriateness independent of disease for older persons with normal and limited life expectancy, respectively. Only two tools and eight guidelines reported the evidence level, and a quarter of medications had high-quality evidence.

CONCLUSIONS

Tools are available for a diversity of populations. There were discrepancies, with the same medication being classified as inappropriate in some tools and appropriate in others, possibly due to low-quality evidence. In particular, tools for patients with limited life expectancy were developed based on very limited evidence, and research to generate this evidence is urgently needed. Our medication lists, along with the level of evidence, could facilitate efforts to strengthen the evidence.

Association between changes in potentially inappropriate medication use and adverse outcomes during hospitalization in older adults: A retrospective study

PURPOSE

To evaluate the association between the change in the number of PIMs in older adults during hospitalization and adverse outcomes.

METHODS

This retrospective cohort study was conducted in the internal medicine wards of a tertiary teaching hospital between May and December 2017. 3,460 patients (77.5±8.4 years, 60.4% male) were enrolled, and 206 patients died during hospitalization. PIMs were defined using the Beers Criteria as suggested by the American Geriatrics Society. Adverse outcomes studied were functional decline (a loss in 1 or more activities of daily living from admission to discharge), prolonged length of stay (LOS) (≥14 days), and mortality.

RESULTS

2258 patients (65.3%) had increasing PIMs during hospitalization. They tended to be younger (77.0±8.3 versus 78.5±8.5 years, p<0.001) and had lower numbers of PIMs at admission (0.4±0.8 versus 0.8±1.1, p<0.001). Increasing PIM use was strongly associated with greater functional decline (aOR 1.36, 95%CI 1.01-1.67, p=0.005), prolonged LOS (aOR 3.47, 95%CI 2.71-4.44, p<0.001) and higher mortality rate (aOR 2.68, 95%CI 1.75-4.12, p<0.001), even after adjusting for all covariates. We observed a strong association between adverse outcomes and increasing PIMs in older adults during hospitalization (p for trend <0.001).

CONCLUSIONS

Older adults with increasing PIMs during hospitalization were at greater risk for functional decline, prolonged LOS, and mortality, especially in those with three or more PIMs. Further studies are needed to better understand the complex interactions and to evaluate the effectiveness of intervention programs to lower PIM number and improve discharge outcomes for patients who had increasing PIM use during hospitalization.

The role of qualification and quality management in the prescription of antipsychotics and potentially inappropriate medication (PIM) in nursing home residents in Germany: results of the HIOPP-3-iTBX study

BACKGROUND

Nursing home residents (NHR) show high rates of polypharmacy. The HIOPP-3-iTBX study is the first cRCT on medication optimization in nursing homes (NH) in Germany. The intervention did not result in a reduction of PIM and/or antipsychotics. This analysis looks at structure quality in the HIOPP-3-iTBX study participants.

AIMS

Evaluation of structure quality as part of a cluster-randomized controlled intervention study.

METHODS

Structure quality in multiprofessional teams from n = 44 NH (n = 44 NH directors, n = 91 family doctors (FD), and n = 52 pharmacies with n = 62 pharmacists) was assessed using self-designed questionnaires at baseline. Main aspects of the questionnaires related to the qualification of participants, quality management, the medication process and size of the facilities. All completed questionnaires were included. number of PIM/antipsychotics was drawn from the baseline medication analysis in 692 NHR. Data were analyzed by descriptive statistics and mixed model logistic regression.

RESULTS

The presence of a nurse with one of the additional qualifications pain nurse or Zertifiziertes Curriculum (Zercur) Geriatrie in the participating NH was associated with a lower risk for the prescription of PIM/antipsychotics. No association between any characteristic in the other participants at baseline was observed.

CONCLUSIONS AND DISCUSSION

The results support the known role of nursing qualification in the quality and safety of care. Further studies need to look more closely at how use is made of the additional qualifications within the multiprofessional teams. Perspectively, the results can contribute to the development of quality standards in NH in Germany.

Impact of on-site pharmacists in residential aged care facilities on the quality of medicines use: a cluster randomised controlled trial (PiRACF study)

Residents of residential aged care facilities (RACFs) have a high prevalence of use of potentially inappropriate medications (PIMs) and resultant medicines-related harm. This study investigated the effect of an on-site pharmacist model on PIMs use and other medication outcomes for residents in RACFs. A multi-facility, non-blind, cluster randomised controlled trial, with randomisation at the facility level, was conducted. Fifteen facilities enrolled and participated in the study, 7 facilities (560 residents) were allocated to the intervention arm and 8 facilities (737 residents) were allocated to the control arm. Each facility in the intervention arm employed an on-site pharmacist for 12 months to perform medication management activities as part of an interdisciplinary care team. The primary outcome was the proportion of residents taking at least one PIM according to the 2019 Beers® Criteria. Using generalised linear mixed-effects models, accounting for confounders and clustering, there was a significant reduction in the proportion of residents prescribed at least one PIM (odds ratio 0.50, 95% confidence interval, 0.335-0.750; p = 0.001) in the intervention arm. There were also significant decreases in the Anticholinergic Cognitive Burden scale and chlorpromazine equivalent daily dose of antipsychotics. The on-site pharmacist intervention significantly improved the appropriateness of medicines use in RACFs.

Development of a patient-centred medication management model for polymedicated home-dwelling older adults after hospital discharge: results of a mixed methods study

OBJECTIVE

This study aimed to investigate medication management among polymedicated, home-dwelling older adults after discharge from a hospital centre in French-speaking Switzerland and then develop a model to optimise medication management and prevent adverse health outcomes associated with medication-related problems (MRPs).

DESIGN

Explanatory, sequential, mixed methods study based on detailed quantitative and qualitative findings reported previously.

SETTING

Hospital and community healthcare in the French-speaking part of Switzerland.

PARTICIPANTS

The quantitative strand retrospectively examined 3 years of hospital electronic patient records (n=53 690 hospitalisations of inpatients aged 65 years or older) to identify the different profiles of those at risk of 30-day hospital readmission and unplanned nursing home admission. The qualitative strand explored the perspectives of older adults (n=28), their informal caregivers (n=17) and healthcare professionals (n=13) on medication management after hospital discharge.

RESULTS

Quantitative results from older adults' profiles, affected by similar patient-related, medication-related and environment-related factors, were enhanced and supported by qualitative findings. The combined findings enabled us to design an interprofessional, collaborative medication management model to prevent MRPs among home-dwelling older adults after hospital discharge. The model comprised four interactive fields of action: listening to polymedicated home-dwelling older adults and their informal caregivers; involving older adults and their informal caregivers in shared, medication-related decision-making; empowering older adults and their informal caregivers for safe medication self-management; optimising collaborative medication management practices.

CONCLUSION

By linking the retrospective and prospective findings from our explanatory sequential study involving multiple stakeholders' perspectives, we created a deeper comprehension of the complexities and challenges of safe medication management among polymedicated, home-dwelling older adults after their discharge from hospital. We subsequently designed an innovative, collaborative, patient-centred model for optimising medication management and preventing MRPs in this population.

[Spanish version of the STOPP/START 3 criteria: Advances in the detection of inappropriate prescribing medication in the older people]

The STOPP/START criteria are explicit physiologic systems-based criteria that summarize evidence on clinically relevant prescribing problems related to the use of potentially inappropriate medications (STOPP criteria) and potential prescribing omissions (START criteria). The two previous versions of the STOPP/START criteria were published in 2008 and 2015, and their Spanish versions in 2009 and 2015. Version3 of these criteria has just been published in 2023. The aim of this article is to present the Spanish translated version, and to review the use and impact that version2 of 2015 has had in our language. A translation from English to Spanish was performed by expert professionals with a high level of English of version3 of the STOPP/START criteria, which incorporates the evidence published from April 2014 to March 2022. In addition, a systematic review of publications that have used the Spanish translation of the previous version (version2 of 2015) of the STOPP/START criteria was performed. The new version, presented in this article, has 190 STOPP/START criteria (133 STOPP criteria and 57 START criteria), which is a 40% increase in the number of criteria compared to the previous version. The review found 37 studies (21 observational, 11 interventional and 5 other) that used the Spanish version instead of the international version. The Spanish version 3 of the STOPP/START criteria is an updated explicit list of potentially inappropriate medications and possible omissions in prescribing that aims to optimize medication and minimize adverse drug reactions during medication review in the elderly, particularly those with multimorbidity and polypharmacy. With this new version, the original criteria are intended to be more widely disseminated within the Spanish-speaking healthcare community. The Spanish version2 of the STOPP/START has been widely used, so we consider that the translation into Spanish has helped to improve pharmacotherapy in older patients with polypharmacy and multimorbidity in our linguistic environment.

Potentially inappropriate medication use is associated with increased risk of incident disability in healthy older adults

BACKGROUND

Efforts to minimize medication risks among older adults include avoidance of potentially inappropriate medications (PIMs). However, most PIMs research has focused on older people in aged or inpatient care, creating an evidence gap for community-dwelling older adults. To address this gap, we investigated the impact of PIMs use in the ASPirin in Reducing Events in the Elderly (ASPREE) clinical trial cohort.

METHODS

Analysis included 19,114 community-dwelling ASPREE participants aged 70+ years (65+ if US minorities) without major cardiovascular disease, cognitive impairment, or significant physical disability. PIMs were defined according to a modified 2019 AGS Beers Criteria. Cox proportional-hazards regression models were used to estimate the association between baseline PIMs exposure and disability-free survival, death, incident dementia, disability, and hospitalization, with adjustment for sex, age, country, years of education, frailty, average gait speed, and comorbidities.

RESULTS

At baseline, 7396 (39% of the total) participants were prescribed at least one PIM. Compared with those unexposed, participants on a PIM at baseline were at an increased risk of persistent physical disability (adjusted hazard ratio [HR] 1.47, 95% confidence interval [CI] 1.21, 1.80) and hospitalization (adjusted HR 1.26, 95% CI 1.20, 1.32), but had similar rates of disability-free survival (adjusted HR 1.02; 95% CI 0.93, 1.13) and death (adjusted HR 0.92, 95% CI 0.81, 1.05). These effects did not vary by polypharmacy status in interaction analyses. PIMs exposure was associated with higher risk of disability followed by hospitalization (adjusted HR 1.92, 95% CI 1.25, 2.96) as well as vice versa (adjusted HR 1.54, 95% CI 1.15, 2.05). PPIs, anti-psychotics and benzodiazepines, were associated with increased risk of disability.

CONCLUSIONS

PIMs exposure is associated with subsequent increased risk of both incident disability and hospitalization. Increased risk of disability prior to hospitalization suggests that PIMs use may start the disability cascade in healthy older adults. Our findings emphasize the importance of caution when prescribing PIMs to older adults in otherwise good health.

Association of Potentially Inappropriate Medication Classes with Mortality Risk Among Older Adults Initiating Hemodialysis

BACKGROUND AND OBJECTIVE

Older adults initiating dialysis have a high risk of mortality and that risk may be related to potentially inappropriate medications (PIMs). Our objective was to identify and validate mortality risk associated with American Geriatrics Society Beers Criteria PIM classes and concomitant PIM use.

METHODS

We used US Renal Data System data to establish a cohort of adults aged ≥ 65 years initiating dialysis (2013-2014) and had no PIM prescriptions in the 6 months prior to dialysis initiation. In a development cohort (40% sample), adjusted Cox proportional hazards models were performed to determine which of 30 PIM classes were associated with mortality (or "high-risk" PIMs). Adjusted Cox models were performed to assess the association of the number of "high-risk" PIM fills/month with mortality. All models were repeated in the validation cohort (60% sample).

RESULTS

In the development cohort (n = 15,570), only 13 of 30 PIM classes were associated with a higher mortality risk. Compared with those with no "high-risk" PIM fills/month, patients having one "high-risk" PIM fill/month had a 1.29-fold (95% confidence interval 1.21-1.38) increased risk of death; those with two or more "high-risk" PIM fills/month had a 1.40-fold (95% confidence interval 1.24-1.58) increased risk. These findings were similar in the validation cohort (n = 23,569).

CONCLUSIONS

Only a minority of Beers Criteria PIM classes may be associated with mortality in the older dialysis population; however, mortality risk increases with concomitant use of "high-risk" PIMs. Additional studies are needed to confirm these associations and their underlying mechanisms.

The role of on-site pharmacist in residential aged care facilities: findings from the PiRACF study

BACKGROUND

Residents in residential aged care facilities (RACFs) have a high number of medication-related problems. Integrating on-site pharmacists (OSPs) into this setting is a possible solution and is currently gaining traction in Australia and internationally. The Pharmacists in Residential Aged Care Facilities (PiRACF) cluster-randomised controlled trial integrated pharmacists into the RACF care team to improve medication management. The aim of this descriptive observational study is to explore the activities of OSPs when they are integrated into multidisciplinary care team in RACFs.

METHOD

An online survey tool was developed to record the activities of OSPs in RACFs using the Qualtrics© software. OSPs were asked questions about their activities in RACFs under categories that included description, time spent, outcomes where applicable and who the pharmacists communicated with to undertake the activity.

RESULTS

Six pharmacists were integrated into 7 RACFs. Overall, they recorded 4252 activities over 12 months. OSPs conducted 1022 (24.0%) clinical medication reviews; 48.8% of medication reviews identified and discussed potentially inappropriate medications with prescribers and 1025 other recommendations were made to prescribers. Overall, the prescriber accepted 51.5% of all recommendations made by OSPs. The most frequently accepted outcome was deprescribing of medications (47.5% for potentially inappropriate medications and 55.5% for other recommendations). OSPs performed facility-level activities including staff education (13.4%), clinical audits (5.8%), and quality improvement activities (9.4%). OSPs spent a large proportion of their time communicating (23.4%) extensively with prescribers, RACF's healthcare team, and residents.

CONCLUSION

OSPs successfully performed a wide range of clinical activities aimed both at improving residents' medication regimens, and organisational-level quality improvement. The OSP model presents an opportunity for pharmacists to enhance medication management in the residential aged care setting. Trial registration The trial was registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) (ACTRN: ACTRN12620000430932) on April 1, 2020.

Hospitalization and emergency department visits associated with potentially inappropriate medication in older adults: self-controlled case series analysis

Introduction

Potentially inappropriate medications (PIM) and resulting adverse health outcomes in older adults are a common occurrence. However, PIM prescriptions are still frequent for vulnerable older adults. Here, we sought to estimate the risk of hospitalization and emergency department (ED) visits associated with PIM prescriptions over different exposure periods and PIM drug categories.

Methods

We used the National Health Insurance Service-Elderly Cohort Database (NHIS-ECDB) to construct the cohort and implemented a Self-Controlled Case Series (SCCS) method. Hospitalization or ED visits during the exposure and post-exposure periods were compared to those during the non-exposure period, and six PIM drug categories were evaluated. A conditional Poisson regression model was applied, and the risk of outcomes was presented as the incidence rate ratio (IRR). All potential time-varying covariates were adjusted by year. A total of 43,942 older adults aged ≥65 y who had at least one PIM prescription and the events of either hospitalization or ED visits between Jan 2016 and Dec 2019 were selected..

Results

Mean days of each exposure period was 46 d (±123); risk was highest in exposure1 (1-7 d, 37.8%), whereas it was similar during exposure2 (15-28 d), and exposure3 (29-56 d) (16.6%). The mean number of total PIM drugs administered during the study period was 7.34 (±4.60). Both hospitalization and ED visits were significantly higher in both exposure (adjusted IRR 2.14, 95% Confidence Interval (CI):2.11-2.17) and post-exposure periods (adjusted IRR 1.41, 95% CI:1.38-1.44) in comparison to non-exposure period. The risk of adverse health outcomes was highest during the first exposure period (1-14 d), but decreased gradually over time. Among the PIM categories, pain medication was used the most, followed by anticholinergics. All PIM categories significantly increased the risk of hospitalization and ED visits, ranging from 1.18 (other PIM) to 2.85 (pain medication). Sensitivity analyses using the first incidence of PIM exposure demonstrated similar results. All PIM categories significantly increased the risk of hospitalization and ED visits, with the initial period of PIM prescriptions showing the highest risk. In subgroup analysis stratified by the number of medications, PIM effects on the risk of hospitalization and ED visits remained significant but gradually attenuated by the increased number of medications.

Discussion

Therefore, the development of deprescribing strategies to control PIM and polypharmacy collectively is urgent and essential.

Potentially Inappropriate Medications Use among Older Adults with Dyslipidaemia

BACKGROUND

Since older patients with dyslipidemia frequently receive many prescriptions, medication errors are typical and expected in this population. This risk has increased by using potentially inappropriate medications. The 2019 Beers criteria were used in this study to investigate potentially inappropriate medication use among older individuals with dyslipidemia.

METHODS

A cross-sectional retrospective analysis used data from electronic medical records from an ambulatory-care environment. Patients with dyslipidemia who were older adults (>65 years old) were included. To describe and find potential determinants of potentially inappropriate medication usage, descriptive statistics and logistic regression were employed.

RESULTS

This study included 2209 older adults (age ≥ 65) with dyslipidemia. The mean age was 72.1 ± 6.0 years, and the majority of the study sample had hypertension (83.7%) and diabetes (61.7%), and around 80.0% were using polypharmacy. The prevalence of potentially inappropriate medications to be avoided among older adults with dyslipidemia was 48.6%. A high risk of potentially inappropriate medication usage was found in older patients with dyslipidemia who had polypharmacy and comorbid diabetes, ischemic heart disease, and anxiety.

CONCLUSIONS

This study showed that the number of medications prescribed and the presence of concurrent chronic health conditions are important indicators of the risk of potentially inappropriate medications in ambulatory older patients with dyslipidemia.

Optimising prescribing in older adults with multimorbidity and polypharmacy in primary care (OPTICA): cluster randomised clinical trial

OBJECTIVE

To study the effects of a primary care medication review intervention centred around an electronic clinical decision support system (eCDSS) on appropriateness of medication and the number of prescribing omissions in older adults with multimorbidity and polypharmacy compared with a discussion about medication in line with usual care.

DESIGN

Cluster randomised clinical trial.

SETTING

Swiss primary care, between December 2018 and February 2021.

PARTICIPANTS

Eligible patients were ≥65 years of age with three or more chronic conditions and five or more long term medications.

INTERVENTION

The intervention to optimise pharmacotherapy centred around an eCDSS was conducted by general practitioners, followed by shared decision making between general practitioners and patients, and was compared with a discussion about medication in line with usual care between patients and general practitioners.

MAIN OUTCOME MEASURES

Primary outcomes were improvement in the Medication Appropriateness Index (MAI) and the Assessment of Underutilisation (AOU) at 12 months. Secondary outcomes included number of medications, falls, fractures, and quality of life.

RESULTS

In 43 general practitioner clusters, 323 patients were recruited (median age 77 (interquartile range 73-83) years; 45% (n=146) women). Twenty one general practitioners with 160 patients were assigned to the intervention group and 22 general practitioners with 163 patients to the control group. On average, one recommendation to stop or start a medication was reported to be implemented per patient. At 12 months, the results of the intention-to-treat analysis of the improvement in appropriateness of medication (odds ratio 1.05, 95% confidence interval 0.59 to 1.87) and the number of prescribing omissions (0.90, 0.41 to 1.96) were inconclusive. The same was the case for the per protocol analysis. No clear evidence was found for a difference in safety outcomes at the 12 month follow-up, but fewer safety events were reported in the intervention group than in the control group at six and 12 months.

CONCLUSIONS

In this randomised trial of general practitioners and older adults, the results were inconclusive as to whether the medication review intervention centred around the use of an eCDSS led to an improvement in appropriateness of medication or a reduction in prescribing omissions at 12 months compared with a discussion about medication in line with usual care. Nevertheless, the intervention could be safely delivered without causing any harm to patients.

TRIAL REGISTRATION

NCT03724539Clinicaltrials.gov NCT03724539.

Classifying Polypharmacy According to Pharmacotherapeutic and Clinical Risks in Older Adults: A Latent Class Analysis in Quebec, Canada

INTRODUCTION

The simplistic definition of polypharmacy, often designated as the concomitant use of five medications or more, does not distinguish appropriate from inappropriate polypharmacy. Classifying polypharmacy according to varying levels of health risk would help optimise medication use.

OBJECTIVE

We aimed to characterise different types of polypharmacy among older adults and evaluate their association with mortality and institutionalisation.

METHODS

Using healthcare databases from the Quebec Integrated Chronic Disease Surveillance System, we selected a community-based random sample of the population ≥ 66 years old covered by the public drug plan. Categorical indicators used to describe polypharmacy included number of medications, potentially inappropriate medications (PIMs), drug-drug interactions, enhanced surveillance medications, complex route of administration medications, anticholinergic cognitive burden (ACB) score and use of blister cards. We used a latent class analysis to subdivide participants into distinct groups of polypharmacy. Their association with 3-year mortality and institutionalisation was assessed with adjusted Cox models.

RESULTS

In total, 93,516 individuals were included. A four-class model was selected with groups described as (1) no polypharmacy (46% of our sample), (2) high-medium number of medications, low risk (33%), (3) medium number of medications, PIM use with or without high ACB score (8%) and (4) hyperpolypharmacy, complex use, high risk (13%). Using the class without polypharmacy as the reference, all polypharmacy classes were associated with 3-year mortality and institutionalisation, with the most complex/inappropriate classes denoting the highest risk (hazard ratio [HR] [95% confidence interval]: class 3, 70-year-old point estimate for mortality 1.52 [1.30-1.78] and institutionalisation 1.86 [1.52-2.29]; class 4, 70-year-old point estimate for mortality 2.74 [2.44-3.08] and institutionalisation 3.11 [2.60-3.70]).

CONCLUSIONS

We distinguished three types of polypharmacy with varying pharmacotherapeutic and clinical appropriateness. Our results highlight the value of looking beyond the number of medications to assess polypharmacy.

Pharmacist-Driven Geriatric Medication Assessment at an Acute Care Teaching Hospital

Older patients are often prescribed many medications and are at higher risk for medication-related problems. Pharmacists can help to identify potentially inappropriate medication use that may precipitate adverse drug events resulting in mental status changes, falls, and hospitalization. A Pharmacist-Driven Geriatric Medication Assessment program was established by clinical pharmacists to evaluate medication use in older patients admitted to a pilot unit of an acute care hospital as part of an Age-Friendly Care initiative. This article describes the implementation of this program and the types of medication interventions pursued by the pharmacists. Pharmacist recommendation acceptance rate by the health care team was greater than 90% overall for medication reconciliation, potentially inappropriate medications, and other medication interventions.

The Impact of Potentially Inappropriate Medications and Polypharmacy on 3-Month Hospital Readmission among Older Patients: A Retrospective Cohort Study from Malaysia

INTRODUCTION

Potentially inappropriate medications (PIMs) use and polypharmacy are two issues that are commonly encountered among older people. They are associated with several negative outcomes including adverse drug reactions and medication-related hospitalization. There are insufficient studies regarding the impact of both PIMs and polypharmacy on hospital readmission, especially in Malaysia.

AIM

To investigate the possible association between polypharmacy and prescribing PIMs at discharge and 3-month hospital readmission among older patients.

MATERIALS AND METHOD

A retrospective cohort study involved 600 patients ≥60 years discharged from the general medical wards in a Malaysian teaching hospital. The patients were divided into two equal groups: patients with or without PIMs. The main outcome was any readmission during the 3-month follow-up. The discharged medications were assessed for polypharmacy (≥five medications) and PIMs (using 2019 Beers' criteria). Chi-square test, Mann-Whitney test, and a multiple logistic regression were conducted to study the impact of PIMs/polypharmacy on 3-month hospital readmission.

RESULTS

The median number for discharge medications were six and five for PIMs and non-PIMs patients, respectively. The most frequently prescribed PIMs was aspirin as primary prevention of cardiovascular diseases (33.43%) followed by tramadol (13.25%). The number of medications at discharge and polypharmacy status were significantly associated with PIMs use. Overall, 152 (25.3%) patients were re-admitted. Polypharmacy and PIMs at discharge did not significantly impact the hospital readmission. After applying the logistic regression, only male gender was a predictor for 3-month hospital readmission (OR: 2.07, 95% CI: 1.022-4.225).

CONCLUSION

About one-quarter of the patients were admitted again within three months of discharge. PIMs and polypharmacy were not significantly associated with 3-month hospital readmissions while male gender was found to be an independent risk factor for readmission.

Polypharmacy, Potentially Inappropriate Medications, and Drug-to-Drug Interactions in Patients with Chronic Myeloproliferative Neoplasms

Polypharmacy, potentially inappropriate medications (PIMs), and drug-to-drug interactions (DDIs) are highly prevalent in the elderly and may have adverse effects on health-related outcomes. Their occurrence and clinical and prognostic associations in patients with chronic myeloproliferative neoplasms (MPN) are unknown. We retrospectively evaluated polypharmacy, PIMs, and DDIs in a cohort of 124 MPN patients (essential thrombocythemia, ET = 63, polycythemia vera, PV = 44, myelofibrosis = 9, MPN unclassifiable = 8) from a single community hematology practice. There were 761 drug prescriptions with a median of five prescribed medications per patient. Polypharmacy, at least one PIM (calculated for persons >60 years of age, n = 101), and at least one DDI were recorded in 76 (61.3%), 46 (45.5%), and 77 (62.1%) of patients, respectively. Seventy-four (59.6%) and twenty-one (16.9%) patients had at least one C or at least one D interaction, respectively. Among other associations, polypharmacy and DDIs were associated with older age, management of disease-related symptoms, osteoarthritis/osteoporosis, and different CV disorders. In multivariate analyses adjusted for clinically meaningful parameters, both polypharmacy and DDIs were significantly associated with inferior overall survival (OS) and time to thrombosis (TTT), whereas PIMs had no significant associations with neither OS nor TTT. There were no associations with bleeding or transformation risks. Polypharmacy, DDIs, and PIMs are very frequent among MPN patients and may have important clinical associations.

Optimising Medications in Older Vascular Surgery Patients Through Geriatric Co-management

BACKGROUND

Prescribing of potentially inappropriate medications and under-prescribing of guideline-recommended medications for cardiovascular risk modification have both been associated with negative outcomes in older adults. Hospitalisation represents an important opportunity to optimise medication use and may be achieved through geriatrician-led interventions.

OBJECTIVE

We aimed to evaluate whether implementation of a novel model of care called Geriatric Comanagement of older Vascular (GeriCO-V) surgery patients is associated with improvements in medication prescribing.

METHODS

We used a prospective pre-post study design. The intervention was a geriatric co-management model, where a geriatrician delivered comprehensive geriatric assessment-based interventions including a routine medication review. We included consecutively admitted patients to the vascular surgery unit at a tertiary academic centre aged ≥ 65 years with an expected length of stay of ≥ 2 days and who were discharged from hospital. Outcomes of interest were the prevalence of at least one potentially inappropriate medication as defined by the Beers Criteria at admission and discharge, and rates of cessation of at least one potentially inappropriate medication present on admission. In the subgroup of patients with peripheral arterial disease, the prevalence of guideline-recommended medications on discharge was determined.

RESULTS

There were 137 patients in the pre-intervention group (median [interquartile range] age: 80.0 [74.0-85.0] years, 83 [60.6%] with peripheral arterial disease) and 132 patients in the post-intervention group (median [interquartile range] age: 79.0 (73.0-84.0) years, 75 [56.8%] with peripheral arterial disease). There was no change in the prevalence of potentially inappropriate medication use from admission to discharge in either group (pre-intervention: 74.5% on admission vs 75.2% on discharge; post-intervention: 72.0% vs 72.7%, p = 0.65). Forty-five percent of pre-intervention group patients had at least one potentially inappropriate medication present on admission ceased, compared with 36% of post-intervention group patients (p = 0.11). A higher number of patients with peripheral arterial disease in the post-intervention group were discharged on antiplatelet agent therapy (63 [84.0%] vs 53 [63.9%], p = 0.004) and lipid-lowering therapy (58 [77.3%] vs 55 [66.3%], p = 0.12).

CONCLUSIONS

Geriatric co-management was associated with an improvement in guideline-recommended antiplatelet agent prescribing aimed at cardiovascular risk modification for older vascular surgery patients. The prevalence of potentially inappropriate medications was high in this population, and was not reduced with geriatric co-management.

Potentially inappropriate medication including drug-drug interaction and the risk of frequent falling, hospital admission, and death in older adults - results of a large cohort study (getABI)

Introduction: With growing age, multiple chronic diseases may result in polypharmacy. Drugs that should be avoided in older adults are called potentially inappropriate medications (PIM). Beyond PIM, drug-drug interactions (DDI) are known to be related to adverse drug events. This analysis examines the risk of frequent falling, hospital admission, and death in older adults associated with PIM and/or DDI (PIM/DDI) prescription. Materials and methods: This post hoc analysis used data of a subgroup of the getABI study participants, a large cohort of community-dwelling older adults. The subgroup comprised 2120 participants who provided a detailed medication report by telephone interview at the 5-year getABI follow-up. The risks of frequent falling, hospital admission, and death in the course of the following 2 years were analysed by logistic regression in uni- and multivariable models with adjustment for established risk factors. Results: Data of all 2,120 participants was available for the analysis of the endpoint death, of 1,799 participants for hospital admission, and of 1,349 participants for frequent falling. The multivariable models showed an association of PIM/DDI prescription with frequent falling (odds ratio (OR) 1.66, 95% confidence interval (CI) 1.06-2.60, p = 0.027) as well as with hospital admission (OR 1.29, 95% CI 1.04-1.58, p = 0.018), but not with death (OR 1.00, 95% CI 0.58-1.72, p = 0.999). Conclusion: PIM/DDI prescription was associated with the risk of hospital admission and frequent falling. No association was found with death by 2 years. This result should alert physicians to provide a closer look at PIM/DDI prescriptions.

Regional variations in excessive polypharmacy and potentially inappropriate drug use among older adults in Sweden: Trends from 2006 to 2020

Introduction: Potentially inappropriate drug use (PID) is common among older adults. Cross-sectional data suggest that there are marked regional variations in PID in Sweden. There is, however, a lack of knowledge about how the regional variations have changed over time. Objectives: This study aimed to investigate the regional differences in the prevalence of PID in Sweden, 2006-2020. Methods: In this repeated cross-sectional study, we included all older adults (≥75 years) registered in Sweden, yearly from 2006 to 2020. We used nationwide data from the Swedish Prescribed Drug Register linked at the individual level to the Swedish Total Population Register. We selected three indicators of PID according to the Swedish national "Quality indicators for good drug therapy in the elderly": 1) Excessive polypharmacy (use of ≥10 drugs); 2) Concurrent use of three or more psychotropic drugs; 3) Use of "drugs that should be avoided in older adults unless specific reasons exist." The prevalence of these indicators was calculated for each of Sweden's 21 regions, yearly from 2006 to 2020. The annual coefficient of variation (CV) was calculated for each indicator by dividing the standard deviation of the regions by the national average, to measure relative variability. Results: In the population of about 800,000 older adults per year, the national prevalence of "drugs that should be avoided in older adults," was reduced by 59% from 2006 to 2020. There was a slight decline in the use of three or more psychotropics, while the prevalence of excessive polypharmacy increased. The CV for excessive polypharmacy was 14% in 2006 and 9% in 2020 compared to 18% and 14% for "use of three or more psychotropics", and stable at around 10% for 'drugs that should be avoided in older adults.' Conclusions: The regional variation in potentially inappropriate drug use decreased or were stable from 2006 to 2020. The regional differences were largest for the use of three or more psychotropics. We found a general tendency that regions with a good performance at the start of the period performed well across the entire period. Future studies should investigate the reasons for regional variation and explore strategies to reduce unwarranted differences.

Risk factors predictive of adverse drug events and drug-related falls in aged care residents: secondary analysis from the ReMInDAR trial

BACKGROUND

Residents of aged-care facilities have high rates of adverse drug events. This study aimed to identify risk factors for adverse drug events in aged-care residents.

METHOD

This was a secondary study using data from a multicentre randomised controlled trial. Data from 224 residents for whom there was 6 months of baseline information were analysed. We assessed the risk of adverse drug events and falls (post hoc) in the subsequent 6 months. Adverse events were identified via a key word search of the resident care record and adjudicated by a multidisciplinary panel using a modified version of the Naranjo criteria. Covariates identified through univariable logistic regression, including age, sex, medicines, physical activity, cognition (Montreal Cognitive Assessment), previous adverse events and health service use were included in multivariable models.

RESULTS

Overall, 224 residents were included, with a mean age of 86 years; 70% were female. 107 (48%) residents had an adverse drug event during the 6-month follow-up. Falls and bleeding were experienced by 73 (33%) and 28 (13%) residents, respectively. Age (odds ratio [OR] 1.05, 95% confidence interval [CI] 1.01-1.10), weight (OR 1.02, 95% CI 1.002-1.04), previous fall (OR 2.58, 95% CI 1.34-4.98) and sedative or hypnotic medicine use (OR 1.98, 95% CI 1.52-2.60) were associated with increased risk of adverse drug events. Increased cognition (OR 0.89, 95% CI 0.83-0.95) was protective. Risk factors for falls were previous fall (OR 3.27, 95% CI 1.68-6.35) and sedative or hypnotic medicines (OR 3.05, 95% CI 1.14-8.16). Increased cognition (OR 0.88, 95% CI 0.83-0.95) was protective.

CONCLUSION

Our results suggest residents with a previous fall, reduced cognition, and prescription of sedative or hypnotic medicines were at higher risk of adverse drug events and should be considered for proactive prevention.

Challenges and opportunities in creating a deprescribing program in the emergency department: A qualitative study

BACKGROUND

As the population of older adults increases, appropriate deprescribing becomes increasingly important for emergency geriatric care. Older adults represent the sickest patients with chronic medical conditions, and they are often exposed to high-risk medications. We need to provide an evidence-based, standardized deprescribing program in the acute care setting, yet the evidence base is lacking and standardized medication programs are needed.

METHODS

We conducted a qualitative study with the goal to understand the perspective of healthcare workers, patients, and caregivers on deprescribing high-risk medications in the context of emergency care practices, provider preferences, and practice variability, along with the facilitators and barriers to an effective deprescribing program in the emergency department (ED). To ensure rich, contextual data, the study utilized two qualitative methods: (1) a focus group with physicians, advanced practice providers, nurses, pharmacists, and geriatricians involved in care of older adults and their prescriptions in the acute care setting; (2) semi-structured interviews with patients and caregivers involved in treatment and emergency care. Transcriptions were coded using thematic content analysis, and the principal investigator (S.L.) and trained research staff categorized each code into themes.

RESULTS

Data collection from a focus group with healthcare workers (n = 8) and semi-structured interviews with patients and caregivers (n = 20) provided evidence of a potentially promising ED medication program, aligned with the vision of comprehensive care of older adults, that can be used to evaluate practices and develop interventions. We identified four themes: (1) Challenges in medication history taking, (2) missed opportunities in identifying high-risk medications, (3) facilitators and barriers to deprescribing recommendations, and (4) how to coordinate deprescribing recommendations.

CONCLUSIONS

Our focus group and semi-structured interviews resulted in a framework for an ED medication program to screen, identify, and deprescribe high-risk medications for older adults and coordinate their care with primary care providers.

Polypharmacy in Older Adults with Alzheimer’s Disease

The number of patients with Alzheimer’s disease is increasing annually. Most of these patients are older adults with comorbid physical illnesses, which means that they are often treated with a combination of medications for the disease they have and those for Alzheimer’s disease. Thus, older adults with Alzheimer’s disease are potentially at risk for polypharmacy. In addition, the drug interactions between Alzheimer’s disease medications and those for the treatment of physical illnesses may reduce their efficacy and increase side effects. This article reviews polypharmacy and drug interactions in elderly patients with Alzheimer’s disease, with a focus on psychotropic drugs.

Prevalence and factors associated with potentially inappropriate medication and medication complexity for older adults in the emergency department of a secondary teaching hospital in Indonesia

Background

Older adults experience progressive decline in various organs and changes in pharmacokinetics and pharmacodynamics of the drugs in the body which lead to an increased risk of medication-related problems. Potentially inappropriate medications (PIMs) and medication complexity are key factors contributing to adverse drug events in the emergency department (ED).

Objective

To estimate the prevalence and investigate the risk factors of PIMs and medication complexity among older adults admitted to the ED.

Methods

A retrospective observational study was conducted among patients aged > 60 years admitted to the ED of Universitas Airlangga Teaching Hospital in January - June 2020. PIMs and medication complexity were measured using the 2019 American Geriatrics Society Beers Criteria® and Medication Regimen Complexity Index (MRCI), respectively.

Results

A total of 1005 patients were included and 55.0% (95% confidence interval [CI]: 52 - 58%) of them received at least one PIM. Whereas, the pharmacological therapy prescribed to older adults had a high complexity index (mean MRCI 17.23 + 11.15). Multivariate analysis showed that those with polypharmacy (OR= 6.954; 95% CI: 4.617 - 10.476), diseases of the circulatory system (OR= 2.126; 95% CI: 1.166 - 3.876), endocrine, nutritional, and metabolic diseases (OR= 1.924; 95% CI: 1.087 - 3.405), and diseases of the digestive system (OR= 1.858; 95% CI: 1.214 - 2.842) had an increased risk of receiving PIM prescriptions. Meanwhile, disease of the respiratory system (OR = 7.621; 95% CI: 2.833 - 15.150), endocrine, nutritional and metabolic diseases (OR = 6.601; 95% CI: 2.935 - 14.847), and polypharmacy (OR = 4.373; 95% CI: 3.540 - 5.401) were associated with higher medication complexity.

Conclusion

In our study, over one in every two older adults admitted to the ED had PIMs, and a high medication complexity was observed. Endocrine, nutritional and metabolic disease was the leading risk factors for receiving PIMs and high medication complexity.

Reduction of care-relevant risks to older patients during and after acute hospital care (ReduRisk) - study protocol of a cluster randomized efficacy trial in a stepped wedge design

BACKGROUND

Older patients are at an increased risk of hospitalization, negatively affecting their health and quality of life. Such patients also experience a lack of physical activity during their inpatient stay, as well as being at increased risk of delirium and inappropriate prescribing. These risk factors can accumulate, promoting a degree of morbidity and the development of cognitive impairment.

METHODS

Through the ReduRisk-program, patients at risk of functional impairment, immobility, falls, delirium or re-hospitalization shortly after hospital discharge, will be identified via risk-screening. These patients will receive an individually tailored, multicomponent and risk-adjusted prevention program. The trial will compare the effectiveness of the ReduRisk-program against usual care in a stepped-wedge-design, with quarterly cluster randomization of six university hospital departments into intervention and control groups. 612 older adults aged 70 years or more are being recruited. Patients in the intervention cluster (n = 357) will receive the ReduRisk-program, comprising risk-adjusted delirium management, structured mobility training and digitally supported planning of post-inpatient care, including polypharmacy management. This study will evaluate the impact of the ReduRisk-program on the primary outcomes of activities of daily living and mobility, and the secondary outcomes of delirium, cognition, falls, grip strength, health-related quality of life, potentially inappropriate prescribing, health care costs and re-hospitalizations. Assessments will be conducted at inpatient admission (t0), at discharge (t1) and at six months post-discharge (t2). In the six-month period following discharge, a health-economic evaluation will be carried out based on routine health insurance data (t3).

DISCUSSION

Despite the importance of multicomponent, risk-specific approaches to managing older patients, guidelines on their effectiveness are lacking. This trial will seek to provide evidence for the effectiveness of a multicomponent, risk-adjusted prevention program for older patients at risk of functional impairment, immobility, falls, delirium and re-hospitalization. Positive study results would support efforts to improve multicomponent prevention and the management of older patients.

TRIAL REGISTRATION

German Clinical Trials Register, DRKS00025594, date of registration: 09/08/2021.

Potentially Inappropriate Medication Use in Patients with Dementia

The objective of this study was to characterize the epidemiology of using potentially inappropriate medications associated with dementia exacerbation (DPIMs) in elderly outpatients with dementia. Electronic medical records were retrospectively reviewed for geriatric patients with dementia who were prescribed at least one medication in 2016 at a tertiary, university-affiliated hospital. The 2015 Beers criteria were used to define DPIMs. Logistic regression was performed to identify factors associated with prescribing DPIMs in patients with dementia. Among 2100 patients included in our study, 987 (47.0%) patients were prescribed at least one DPIM. Benzodiazepines were the most frequently prescribed DPIM followed by anticholinergics, histamine H2-receptor blockers, and zolpidem. The risk of prescribing DPIMs was significantly increased in female patients (odds ratio (OR) 1.355) with polypharmacy (OR 5.146) and multiple comorbidities (OR 1.129) (p < 0.05 for all). Coexistence of Parkinson's disease (OR 1.799), mood disorder (OR 1.373), or schizophrenia (OR 4.116) in patients with dementia further increased the likelihood of receiving DPIMs. In conclusion, DPIMs were commonly used in elderly patients with dementia in Korea with benzodiazepines most frequently prescribed followed by anticholinergics. Female patients using polypharmacy with multiple comorbidities should be closely monitored to minimize unnecessary DPIM use and, ultimately, DPIM-related harms.

Quality Use of Medicines Indicators and Associated Factors in Residential Aged Care Facilities: Baseline Findings from the Pharmacists in RACF Study in Australia

Prescribing potentially inappropriate medications (PIMs), including antipsychotics and benzodiazepines, has been used as an indicator of the quality use of medicines in residential aged care facilities (RACFs). PIMs are associated with an increased risk of falls and hospitalisations in the elderly. The purpose of this study is to assess the extent of prescribing of PIMs in RACFs at baseline in the Pharmacists in residential aged care facilities (PiRACF) study and examine the association of resident and system factors with the number of PIMs. A cross-sectional analysis of 1368 participants from 15 Australian RACFs was performed to detect PIMs using the American Geriatrics Society 2019 Beers® criteria. Most residents (68.1%) were taking at least one regular PIM; 16.9% were taking regular antipsychotics and 11.1% were taking regular benzodiazepines. Long-term proton pump inhibitors were the most frequent class of PIMs. History of falls and higher Charlson Comorbidity Index were associated with an increased number of prescribed PIMs, while dementia diagnosis and older age (85 years or more) were associated with decreased number of PIMs (p-value <0.05). Residents in facilities with lower nurse-to-resident ratios were more likely to have an increased number of PIMs (p value = 0.001). This study indicates that potentially inappropriate prescribing is common in RACFs and interventions to target residents at highest risk are needed.

Provision of a comprehensive medicines review is associated with lower mortality risk for residents of aged care facilities: a retrospective cohort study

Background

no studies have examined the impact of residential medication management review (RMMR, a 24-year government subsidised comprehensive medicines review program) in Australian residential aged care facilities (RACFs) on hospitalisation or mortality.

Objective

to examine associations between RMMR provision in the 6–12 months after RACF entry and the 12-month risk of hospitalisation and mortality among older Australians in RACFs.

Design

retrospective cohort study.

Subjects

individuals aged 65–105 years taking at least one medicine, who entered an RACF in three Australian states between 1 January 2012 and 31 December 2015 and spent at least 6 months in the RACF (n = 57,719).

Methods

Cox regression models estimated adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs) for associations between RMMR provision and mortality. Adjusted subdistribution hazard ratios were estimated for associations between RMMR provision and next (i) emergency department (ED) presentation or unplanned hospitalisation or (ii) fall-related ED presentation or hospitalisation.

Results

there were 12,603 (21.8%) individuals who received an RMMR within 6–12 months of RACF entry, of whom 22.2% (95%CI 21.4–22.9) died during follow-up, compared with 23.3% (95%CI 22.9–23.7) of unexposed individuals. RMMR provision was associated with a lower risk of death due to any cause over 12-months (aHR 0.96, 95%CI 0.91–0.99), but was not associated with ED presentations or hospitalisations for unplanned events or falls.

Conclusions

provision of an RMMR in the 6–12 months after RACF entry is associated with a 4.4% lower mortality risk over 12-months but was not associated with changes in hospitalisations for unplanned events or falls.

Prevalence of Polypharmacy and Potentially Inappropriate Medications Use in Elderly Chinese Patients: A Systematic Review and Meta-Analysis

Objectives: Polypharmacy and potentially inappropriate medication (PIM) use among elderly Chinese patients have not yet been investigated by systematic review and meta-analysis. The purposes of this study were to investigate the prevalence of polypharmacy and PIM use and the risk factors associated with PIM use in elderly Chinese patients.

Methods: Databases including PubMed, EMBase, and Web of Science were searched to collect studies which used Chinese criteria, Beers criteria, or STOPP criteria to evaluate the PIM status of elderly Chinese patients from inception to August 2021 (PROSPERO Code No: CRD42021262821). Observational studies reporting the prevalence of polypharmacy and PIM use in elderly Chinese patients were meta-analyzed. The pooled prevalence and risk ratio (RR) were calculated with a 95% confidence interval (CI).

Results: A total of 8 articles involving 4,558,786 patients were included. The overall prevalence of polypharmacy (concomitant use of more than 5 medicines) and PIM use pooled by meta-analysis in Chinese older patients was 48% (95% CI: 0.17, 0.79, p = 0.003) (inpatients 73%, outpatients 23%) and 39% (95% CI: 0.25, 0.54, p < 0.001) (inpatients 50%, outpatients 29%), respectively. Polypharmacy (RR: 2.03, 95% CI: 1.13, 3.64) was significantly associated with PIM use.

Conclusion: This meta-analysis demonstrated a high prevalence of polypharmacy and PIM use among elderly patients in China. Affected by the quantity and quality of the included studies, the aforementioned conclusions need to be confirmed by large samples and high-quality studies.

The Effectiveness of Interventions to Evaluate and Reduce Healthcare Costs of Potentially Inappropriate Prescriptions among the Older Adults: A Systematic Review

Potentially inappropriate prescribing (PIP) is associated with an increased risk of adverse drug reactions, recognized as a determinant of adherence and increased healthcare costs. The study's aim was to explore and compare the results of interventions to reduce PIP and its impact on avoidable healthcare costs. A systematic literature review was conducted according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement guidelines. PubMed and Embase were queried until February 2021. Inclusion criteria followed the PICO model: older patients receiving PIP; Interventions aimed at health professionals, structures, and patients; no/any intervention as a comparator; postintervention costs variations as outcomes. The search strategy produced 274 potentially relevant publications, of which 18 articles met inclusion criteria. Two subgroups were analyzed according to the study design: observational studies assessing PIP frequency and related-avoidable costs (n = 10) and trials, including specific intervention and related outcomes in terms of postintervention effectiveness and avoided costs (n = 8). PIP prevalence ranged from 21 to 79%. Few educational interventions carried out to reduce PIP prevalence and avoidable costs resulted in a slowly improving prescribing practice but not cost effective. Implementing cost-effective strategies for reducing PIP and clinical and economic implications is fundamental to reducing health systems' PIP burden.

Improvement in prescriptions while maintaining overall health outcomes: a prospective observational study conducted in Japanese facilities for older people

Background

Improvements in the use of polypharmacy or potentially inappropriate medication (PIM) may reduce medication costs in Japan. We aimed to evaluate the impact of improvement in prescription on both overall health outcomes and medication costs in Japanese facilities for older people.

Methods

Residents in Japanese facilities for older people between March 2019 and March 2020 were included in this study. The following five indices were used to evaluate overall health outcomes: EuroQoL-5D-5L, Barthel Index, Mini Mental State Examination, Dementia Behaviour Disturbance Scale, and Vitality Index. The team, which consisted of one physician and several pharmacists, suggested improved prescriptions for the attending physicians of the participants. The impact of improvement in prescriptions on the health outcomes score, medication costs, and the number of medications were evaluated through two comparison groups: those whose number of medications decreased (decrement group, DG) and those whose medications did not (not decrement group, NDG); those prescribed PIMs in March 2019 and those not prescribed PIMs in March 2020 (improvement group, IG) and those prescribed PIMs both in March 2019 and March 2020 (not improvement group, NIG). In both comparison groups, propensity score matching was performed to balance demographics, and all health outcome scores, medication costs, and the number of medications in March 2020 were assessed using a t-test. Statistical significance was set at a p-value of < 0.05.

Results

Eight-hundred-and-ninety-one participants (75.5% women, 86.2 ± 7.9 years old) were enrolled. After matching, in the comparison between the DG (N = 232, 77.2%, 85.7 ± 8.5) and NDG (N = 232, 78.5%, 86.0 ± 3.1), changes in the health outcomes score were nonsignificant. However, the medication costs and the number of medications significantly decreased. After matching, in the comparison between IG (N = 141, 75.2%, 86.7 ± 8.1) and NIG (N = 273, 74.2%, 86.2 ± 8.3), changes in health outcome scores and medication costs were not significant. However, the number of medications significantly decreased.

Conclusions

Improvements in prescriptions did not adversely affect the overall health outcomes. However, it impacted medication costs and the number of medications. Improvement in prescriptions could decrease medication costs while maintaining overall health outcomes.