The continuing challenge of inappropriate prescribing in the elderly: an update of the evidence

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.

Global Mapping of Potentially Inappropriate Prescribing for Older Adults in Community Settings: An Umbrella Review

Potentially inappropriate prescribing (PIP) is a major public health concern with several undesirable health consequences for older adults. In this overview, we aimed to map and gather information from existing literature to provide a better insight into the prevalence of PIP among community dwellers. Electronic databases were searched from their inception to April 2022. The quality of the included systematic reviews (SRs) was assessed using the assessment of multiple systematic reviews checklist. The degree of overlap within the SRs was also evaluated (2% overlap). All SRs on the prevalence of PIP in older individuals in community settings were included, and a narrative approach was used to synthesize data. Nineteen SRs comprising 548 primary studies met the inclusion criteria, and the average quality of the included SRs was moderate. More than half (50.5%) of the primary studies were conducted in Europe, followed by the United States (22.8%), and Asia (18.9%). Thirty different criteria were used in the primary studies to estimate the prevalence of PIP. The most widely used criteria were those presented in Beers (41.8%) and STOPP (Screening Tool of Older Persons' Prescriptions)/START (Screening Tool to Alert to Right Treatment) (21.8%) criteria. Benzodiazepines, nonsteroidal anti-inflammatory drugs, and antidepressants were the most frequently reported PIPs. A considerable variation in the prevalence of PIP ranging from 0% to 98% was reported by SRs. However, there is a high degree of uncertainty regarding the extent of PIP in community settings. To identify knowledge-to-action gaps, SR authors should consider the differences in prevalence of PIP according to settings, applied tools, data sources, geographical areas, and specific pathologies. There is also a need for primary and SR studies from low- and middle-income countries regarding the prevalence of PIP.

Potentially Inappropriate Prescribing among Elderly Outpatients: Evaluation of Temporal Trends 2012-2018 in Piedmont, Italy

Pharmacological intervention is one of the cornerstones in the treatment and prevention of disease in modern healthcare. However, a large number of drugs are often prescribed and used inappropriately, especially in elderly patients. We aimed at investigating the annual prevalence of potentially inappropriate prescriptions (PIPs) among older outpatients using administrative healthcare databases of the Piedmont Region (Italy) over a seven-year period (2012–2018). We included all Piedmont outpatients aged 65 years or older with at least one drug prescription per year. Polypharmacy and the prevalence of PIPs according to the ERD list explicit tool were measured on an annual basis. A range between 976,398 (in 2012) and 1,066,389 (in 2018) elderly were evaluated. Among them, the number of subjects with at least one PIP decreased from 418,537 in 2012 to 339,764 in 2018; the prevalence significantly reduced by ~25% over the study period. The stratified analyses by age groups and sex also confirmed the downward trend and identified several differences in the most prevalent inappropriately prescribed drugs. Overall, despite a reduction in PIP prevalence, one out of three older outpatients was still exposed to inappropriateness, highlighting the extensive need for intervention to improve prescribing.

Characterization of potentially inappropriate medications use in Indian elderly population and their impact on quality of life using Beers criteria

Background

Methods

Results

Conclusion

Factors associated with potentially inappropriate prescriptions and barriers to medicines optimisation among older adults in primary care settings: a systematic review

Objective

To identify factors that likely contribute to potentially inappropriate prescriptions (PIPs) among older adults in primary care settings, as well as barriers to medicines optimisation and recommended potential solutions.

Design

Systematic review.

Eligibility criteria

Quantitative studies that analysed the factors associated with PIPs among older adults (≥65 years) in primary care settings, and qualitative studies that explored perceived barriers and potential solutions to medicines optimisation for this population.

Information sources

PubMed, EMBASE, Scopus, CINAHL, PsycINFO, Web of Science, CNKI and Wanfang.

Results

Of the 13 167 studies identified, 50 were included (14 qualitative, 34 cross-sectional and 2 cohort). Nearly all quantitative studies examined patient-related non-clinical factors (eg, age) and clinical factors (eg, number of medications) and nine studies examined prescriber-related factors (eg, physician age). A greater number of medications were identified as positively associated with PIPs in 25 quantitative studies, and a higher number of comorbidities, physical comorbidities and psychiatric comorbidities were identified as patient-related clinical risk factors for PIPs. However, other factors showed inconsistent associations with the PIPs. Barriers to medicines optimisation emerged within four analytical themes: prescriber related (eg, inadequate knowledge, concerns of adverse consequences, clinical inertia, lack of communication), patient related (eg, limited understanding, patient non-adherence, drug dependency), environment related (eg, lack of integrated care, insufficient investment, time constraints) and technology related (eg, complexity of implementation and inapplicable guidance). Recommended potential solutions were based on each theme of the barriers identified accordingly (eg, prescriber-related factors: incorporating training courses into continuing medical education).

Conclusions

Older adults with more drugs prescribed and comorbidities may have a greater risk of receiving PIPs in the primary care setting, but it remains unclear whether other factors are related. Barriers to medicines optimisation among primary care older adults comprise multiple factors, and evidence-based and targeted interventions are needed to address these difficulties.

PROSPERO registration number

CRD42020216258.

A pragmatic controlled trial to improve the appropriate prescription of drugs in adult outpatients: design and rationale of the EDU.RE.DRUG study

Introduction:

Pharmacological intervention is an important component of patient care. However, drugs are often inappropriately used. It is necessary for countries to implement strategies to improve the rational use of drugs, including independent information for healthcare professionals and the public, which must be supported by well-trained staff. The primary objectives of the EDU.RE.DRUG (Effectiveness of informative and/or educational interventions aimed at improving the appropriate use of drugs designed for general practitioners and their patients) study are the retrospective evaluation of rates of appropriate prescribing indicators (APIs) and the assessment of the effectiveness of informative and/or educational interventions addressed to general practitioners (GPs) and their patients, aimed at improving prescribing quality and promoting proper drug use.

Methods and analysis:

This is a prospective, multicentre, open-label, parallel-arm, controlled, pragmatic trial directed to GPs and their patients in two Italian regions (Campania and Lombardy). The study data are retrieved from administrative databases (Demographic, Pharmacy-refill, and Hospitalization databases) containing healthcare information of all beneficiaries of the National Health Service in the Local Health Units (LHUs) involved. According to LHU, the GPs/patients will be assigned to one of the following four intervention arms: (1) intervention on GPs and patients; (2) intervention on GPs; (3) intervention on patients; and (4) no intervention (control). The intervention designed for GPs consists of reports regarding the status of their patients according to the APIs determined at baseline and in two on-line Continuous Medical Education (CME) courses. The intervention designed for patients consists in flyers and posters distributed in GPs ambulatories and community pharmacies, focusing on correct drug use.

A set of indicators (such as potential drug–drug interactions, unnecessary duplicate prescriptions, and inappropriate prescriptions in the elderly), adapted to the Italian setting, has been defined to determine inappropriate prescription at baseline and after the intervention phase. The primary outcome was a composite API.

Ethics and dissemination:

The study was approved by the Ethics Committee of the University of Milan on 7th June 2017 (code 15/17). The investigators will communicate trial results to stakeholders, collaborators, and participants via appropriate presentations and publications.

Registration details: NCT04030468. EudraCT number 2017-002622-21

Risks of Benzodiazepines in Chronic Obstructive Pulmonary Disease with Comorbid Posttraumatic Stress Disorder

RATIONALE

Benzodiazepines are associated with mortality and poor outcomes among patients with chronic obstructive pulmonary disease (COPD), but use of benzodiazepines for dyspnea among patients with end-stage disease may confound this relationship.

OBJECTIVES

Assess the mortality risks of long-term benzodiazepine exposure among patients with COPD and comorbid post-traumatic stress disorder (PTSD), patients with chronic nonrespiratory indications for benzodiazepines.

METHODS

We identified all patients with COPD and PTSD within the Veteran's Health Administration between 2010 and 2012. We calculated propensity scores for benzodiazepine use and compared overall and cause-specific mortality of patients with long-term (≥90 d) benzodiazepine use relative to matched patients without use. Secondary analyses assessed propensity-adjusted survival by characteristics of benzodiazepine exposure.

RESULTS

Among 44,555 eligible patients with COPD and PTSD, 23.6% received benzodiazepines long term. In the matched sample of 19,552 patients, we observed no mortality difference (hazard ratio [HR] for long-term use, 1.06; 95% confidence interval [CI], 0.95-1.18) but greater risk of death by suicide among those with long-term use (HR, 2.33; 95% CI, 1.14-4.79). Among matched and unmatched patients, short-term benzodiazepine use, but not long-term use, was associated with increased mortality (short-term: HR, 1.16; 95% CI, 1.05-1.28; long-term: HR, 1.03; 95% CI, 0.94-1.13).

CONCLUSIONS

Risks for respiratory compromise related to long-term benzodiazepine use in COPD may be less than previously estimated, but short-term use of benzodiazepines could still pose a mortality risk. Suicide associated with benzodiazepine use in this population warrants further investigation.

The observed effect of adverse drug reactions on the length of hospital stay among medical inpatients in a Nigerian University Teaching Hospital

Background:

The potential impact of an adverse drug reaction (ADR) is multidimensional, and includes prolonged length of hospitalization which significantly increased morbidity, mortality, and economic burden with additional intense medical care.

Aim:

This study was designed to characterize and evaluate the potential effect of ADRs on the length of hospital stay among adult medical inpatients in an academic teaching hospital in a large West African nation. The overarching goal of the study is to highlight approaches toward mitigating the sequelae of ADRs in this setting, and improving their recognition and timely optimal management.

Methods:

The patients admitted into the adult medical wards of a Nigerian University Teaching Hospital over a 9-month period from December 2013 to August 2014 were prospectively recruited for the study and followed up till discharge.

Results:

A total of 507 patients were evaluated during the study, out of which 269 (53.1%) of them were males and 238 (46.9%) were females. The mean age of the study population was 48.9 ± 17.8 years (median of 46 years). In this study, the mean duration of hospital stay for all patients was 11.9 ± 11.3 days (median of 9 days). Females had a mean duration stay of 12.9 ± 12.3 days (median of 10 days) and stayed significantly longer than males who stayed a mean duration of 10.9 ± 10.2 days with a median of 7 days ( t = −1.985, df = 505, p = 0.048). Furthermore, patients admitted solely because of ADRs (ADR-out) had a significantly shorter duration of stay with a mean duration stay of 6.1 ± 3.7 days (median duration stay of 7 days) when compared to those without ADRs whose mean duration of stay was 11.6 ± 11.0 days (median duration stay of 8 days), and this was found to be statistically significant ( t = 2.110, df = 472, p = 0.035). Those patients who developed ADRs during admission (ADR-in) had a mean duration of stay of 18.3 ± 14.8 (median of 15 days). This was significantly longer than the duration of stay for patients without ADRs ( t = −3.398, df = 487, p = 0.001) and also significantly longer than the duration for those who were admitted solely because of ADRs ( t =3.432, df = 49, p = 0.001).

Conclusion:

In this study, ADRs were associated with a significantly prolonged length of hospital stay for adult medical inpatients in this Nigerian University Teaching Hospital.

Evaluation of Rationality of Geriatric Patients' Prescription Based On Beers Criteria in a Tertiary Care Hospital in India

AIM

Irrational prescribing for geriatric patients has become an important public health problem worldwide. Because India is one of the most populated countries having a great proportion of old people in the world, studies on the prevalence of inappropriate prescriptions can be very beneficial to increase the knowledge of health care providers and to reduce the occurrence of adverse drug events among this population.

METHODS

A group of 482 inpatients above 64 years old were enrolled in a prospective study. Chart review method was used. The data were collected from patients' prescription and medicine charts. Each prescription was checked individually for the inappropriate drug by using the AGS 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Suggestions were given to the physicians for inappropriate medications.

RESULTS

The prevalence of potentially inappropriate medication is found to be 11.66% (n = 56). Out of 56 inappropriate medications, the most frequently inappropriate medication is Digoxin (25%) followed by Sprinolactone 19.64%. This study founds age, some medication, length of stay and number of diagnosis as predictors for getting a PIM. Feedback of the physicians varies based on the suggestions.

CONCLUSION

This study concludes that the prevalence of PIMs among geriatrics patients of ≥ 65 years old is 11.66%. Some predictors have been identified for getting a PIM. This study shows that physicians' feedback is dependent on the suggestions being given.

Potentially Inappropriate Prescribing of Oral Solid Medications in Elderly Dysphagic Patients

Pharmaceutical formulations suitable for dysphagic patients are not always commercially available, motivating caregivers to crush tablets or open capsules to facilitate swallowing. Since this action may modify the characteristics of the medicine, it should be considered potentially inappropriate. This paper is the first to focus on how hospitalization affected the rate of potentially inappropriate prescriptions (PIPs) and the incidence of dosage form-related PIPs in elderly patients with dysphagia. Data was collected by reviewing patient medical records in the Italian National Research Center on Aging of Ancona. The therapy at admission and discharge was analysed in terms of: inappropriate drug associations, inappropriate drugs for dysphagic patients, inappropriate dosage forms and inappropriate dosage form modifications. Forty-one dysphagic patients with an average age of 88.3 years were included in the study and 451 prescriptions were analysed. PIPs were widespread at admission, and hospitalization did not improve the situation in a statistically significant manner. The most common PIPs identified (>80%) were related to dosage form selection and modification. This study highlights a clear need for continuing medical education about prescription appropriateness and modification of solid dosage forms in patients with dysphagia.

Potentially inappropriate medication use among older patients attending a geriatric centre in south-west Nigeria

Objectives

To determine the prevalence and describe factors associated with the use of potentially inappropriate medication (PIM) among older patients.

Methods

Cross sectional study of 400 older patients selected systematically at the geriatric centre, University College Hospital, Ibadan between July and September 2016. With the aid of semi-structured questionnaires, information on the socio-demographic characteristics, lifestyle habits, healthcare utilisation and morbidities was obtained. The Beer's criteria 2015 update was used to identify the PIMs. Predictors of PIMs were determined using multivariate analyses at alpha 0.05.

Results

Age was 70.2 (SD=5.9) years and 240 (60%) were females. General prescription pattern showed antihypertensives (34.7%) as the commonest medications used. The point prevalence of PIMs use was 31%. In all, 10 PIMs were used by the respondents. The majority (81.5%) were using one PIM, while (17.7%) used two PIMs and (0.8%) 3 PIMs. NSAIDs (72.6%) were the commonest PIMs identified, followed by the benzodiazepines (24.2%). Respondents had an average of 1.9 morbidities, and mulitmorbidity found in 60.5%. Logistic regression analysis showed self-rated health assessed as better compared with age-mates [OR =1.718 (1.080-2.725)] and being physically active [OR =1.879 (1.026-3.436)] as the most significantly associated with PIMs use.

Conclusions

The use of PIMs among older patients in our setting was high with NSAIDs being the most frequently used medications. An interdisciplinary approach, of medication review by pharmacists', working with physicians may improve prescribing practices among older persons. Therefore, it is necessary to create public health awareness on the use of PIMs among older persons.

Cannabis as a substitute for prescription drugs - a cross-sectional study

Background

The use of medical cannabis is increasing, most commonly for pain, anxiety and depression. Emerging data suggest that use and abuse of prescription drugs may be decreasing in states where medical cannabis is legal. The aim of this study was to survey cannabis users to determine whether they had intentionally substituted cannabis for prescription drugs.

Methods

A total of 2,774 individuals were a self-selected convenience sample who reported having used cannabis at least once in the previous 90 days. Subjects were surveyed via an online anonymous questionnaire on cannabis substitution effects. Participants were recruited through social media and cannabis dispensaries in Washington State.

Results

A total of 1,248 (46%) respondents reported using cannabis as a substitute for prescription drugs. The most common classes of drugs substituted were narcotics/opioids (35.8%), anxiolytics/benzodiazepines (13.6%) and antidepressants (12.7%). A total of 2,473 substitutions were reported or approximately two drug substitutions per affirmative respondent. The odds of reporting substituting were 4.59 (95% confidence interval [CI], 3.87–5.43) greater among medical cannabis users compared with non-medical users and 1.66 (95% CI, 1.27–2.16) greater among those reporting use for managing the comorbidities of pain, anxiety and depression. A slightly higher percentage of those who reported substituting resided in states where medical cannabis was legal at the time of the survey (47% vs. 45%, p=0.58), but this difference was not statistically significant.

Discussion

These patient-reported outcomes support prior research that individuals are using cannabis as a substitute for prescription drugs, particularly, narcotics/opioids, and independent of whether they identify themselves as medical or non-medical users. This is especially true if they suffer from pain, anxiety and depression. Additionally, this study suggests that state laws allowing access to, and use of, medical cannabis may not be influencing individual decision-making in this area.

Sex differences in the risk of receiving potentially inappropriate prescriptions among older adults

Objectives: to measure sex differences in the risk of receiving potentially inappropriate prescription drugs and to examine what are the factors that contribute to these differences.

Design: a retrospective cohort study.

Setting: community setting of British Columbia, Canada.

Participants: residents of British Columbia aged 65 and older (n = 660,679).

Measurements: we measured 2013 period prevalence of prescription dispensations satisfying the American Geriatrics Society's 2012 version of the Beers Criteria for potentially inappropriate medication use in older adults. We used logistic regressions to test for associations between this outcome and a number of clinical and socioeconomic factors.

Results: a larger share of women (31%) than of men (26%) filled one or more potentially inappropriate prescription in the community. The odds of receiving potentially inappropriate prescriptions are associated with several clinical and socioeconomic factors. After controlling for those factors, community-dwelling women were at 16% higher odds of receiving a potentially inappropriate prescription than men (adjusted odds ratio = 1.16, 95% confidence interval = 1.12–1.21). Much of this sex difference stemmed from women's increased odds of receiving potentially inappropriate prescriptions for benzodiazepines and other hypnotics, for tertiary tricyclic antidepressants and for non-selective NSAIDs.

Conclusion: there are significant sex differences in older adults' risk of receiving a potentially inappropriate prescription as a result of complex intersections between gender and other social constructs. Appropriate responses will therefore require changes in the information, norms and expectations of both prescribers and patients.

Effect of Potentially Inappropriate Use of Antimuscarinic Medications on Healthcare Use and Cost in Individuals with Overactive Bladder

OBJECTIVES

To examine potentially inappropriate medication (PIM) use in older adults initiating an antimuscarinic medication for the treatment of overactive bladder (OAB).

DESIGN

Retrospective database analysis.

SETTING

Medical and pharmacy claims data.

PARTICIPANTS

Medicare Advantage Prescription Drug Plan members aged 65 and older newly initiated on an antimuscarinic OAB treatment were identified and assigned to PIM and non-PIM comparison groups based on 2012 American Geriatrics Society Beers Criteria and/or the presence of an anticholinergic medication interaction at the time of initiation of treatment (N = 66,275).

MEASUREMENTS

Healthcare costs and OAB medication use.

RESULTS

Of members initiated on an antimuscarinic OAB medication, 31.1% had a drug-drug or drug-disease or syndrome interaction. Dementia was the most common disease or syndrome interaction (11.3%), followed by constipation (8.6%) and delirium (2.9%). Paroxetine (2.6%), amitriptyline (2.2%), cyclobenzaprine (1.7%), and meclizine (1.6%) were the most common interacting medications. Subjects in the PIM group had greater healthcare costs over 12 months of follow-up ($12,001) than those in the non-PIM group ($9,373) after controlling for baseline characteristics (P < .001). There was no difference between the PIM and the non-PIM groups in odds of discontinuing OAB treatment at 12 months after controlling for baseline characteristics (odds ratio = 0.98, 95% confidence interval = 0.89-1.07, P = .63).

CONCLUSION

Potentially inappropriate medication use was highly prevalent and was associated with greater total healthcare costs. Providers should carefully consider medical history and concurrent medication use when initiating antimuscarinic medication for the treatment of OAB. Development of interventions to reduce potentially inappropriate use of antimuscarinics in individuals with OAB is warranted.

Potentially inappropriate anticholinergic medication use in community-dwelling older adults: a national cross-sectional study

BACKGROUND

Inappropriate medications are often used in older adults despite their unfavourable risk-to-benefit profile. Although many of the medications in the American Geriatrics Society (AGS) Beers list are potentially inappropriate because of their anticholinergic properties, little is known regarding the nature and extent of potentially inappropriate anticholinergic medication use in older adults.

OBJECTIVES

To determine the prevalence of, and factors associated with, potentially inappropriate anticholinergic medication use in the older population.

METHODS

A retrospective, cross-sectional study was conducted, involving older adults (aged 65 years and older), using 2009-2010 Medical Expenditure Panel Survey (MEPS) data. The 2012 AGS Beers Criteria were used to define potentially inappropriate anticholinergic medications on the basis of the list of medications to avoid using in older adults irrespective of the diagnosis. Descriptive analyses were used to examine the nature and extent of potentially inappropriate anticholinergic medication use. Multivariable logistic regression within the conceptual framework of the Andersen Behavioral Model was used to identify the factors associated with potentially inappropriate anticholinergic use in older adults.

RESULTS

According to the MEPS, there were 78.60 million older adults in the USA; an estimated 7.51 million (9.56 %) of these older adults used potentially inappropriate anticholinergic medications in 2009-2010. The most frequently used potentially inappropriate anticholinergics were cyclobenzaprine, promethazine, amitriptyline, hydroxyzine and dicyclomine. Multivariable regression analyses revealed that female sex, residing in the South and the presence of anxiety disorder increased the likelihood of receiving potentially inappropriate anticholinergic medications, whereas older adults aged 75-84 or ≥ 85 years, and those with over 15 years of education, had a decreased likelihood of receiving potentially inappropriate anticholinergic medications.

CONCLUSION

The study found that approximately one in ten older adults used potentially inappropriate anticholinergic medications. Several predisposing, enabling and need factors were associated with the use of potentially inappropriate anticholinergic medications. Concerted efforts are needed to optimize potentially inappropriate anticholinergic medication use in older adults.

Antibiotic Use in Cold and Flu Season and Prescribing Quality: A Retrospective Cohort Study

BACKGROUND

Excessive antibiotic use in cold and flu season is costly and contributes to antibiotic resistance. The study objective was to develop an index of excessive antibiotic use in cold and flu season and determine its correlation with other indicators of prescribing quality.

METHODS AND FINDINGS

We included Medicare beneficiaries in the 40% random sample denominator file continuously enrolled in fee-for-service benefits for 2010 or 2011 (7,961,201 person-years) and extracted data on prescription fills for oral antibiotics that treat respiratory pathogens. We collapsed the data to the state level so they could be merged with monthly flu activity data from the Centers for Disease Control and Prevention. Linear regression, adjusted for state-specific mean antibiotic use and demographic characteristics, was used to estimate how antibiotic prescribing responded to state-specific flu activity. Flu-activity associated antibiotic use varied substantially across states-lowest in Vermont and Connecticut, highest in Mississippi and Florida. There was a robust positive correlation between flu-activity associated prescribing and use of medications that often cause adverse events in the elderly (0.755; P<0.001), whereas there was a strong negative correlation with beta-blocker use after a myocardial infarction (-0.413; P=0.003).

CONCLUSIONS

Adjusted flu-activity associated antibiotic use was positively correlated with prescribing high-risk medications to the elderly and negatively correlated with beta-blocker use after myocardial infarction. These findings suggest that excessive antibiotic use reflects low-quality prescribing. They imply that practice and policy solutions should go beyond narrow, antibiotic specific, approaches to encourage evidence-based prescribing for the elderly Medicare population.

Prevalence and predictors of potentially inappropriate medications among home care elderly patients in Qatar

BACKGROUND

Older patients receiving home health care are particularly at risk of receiving potentially inappropriate medications compared to community-dwelling population. Data on appropriateness of prescribing in these patients is limited.

OBJECTIVE

To investigate the prevalence, patterns and determinants of potentially inappropriate medications among elderly patients receiving Home Health Care Services in Qatar.

SETTING

Home Health Care Services department in Hamad Medical Corporation-Qatar.

METHODS

A cross-sectional study, conducted over a 3 months period. Patients 65 years and older, taking at least one medication and receiving home care services were included. Potentially inappropriate medications were identified and classified in accordance with the American Geriatrics Society 2012 Beers Criteria.

MAIN OUTCOME MEASURE

Prevalence of potentially inappropriate medications using updated Beers criteria.

RESULTS

A total of 191 patients (38.2%) had at least one potentially inappropriate medication. As per Beers criteria, 35% of medications were classified as medications to be avoided in older adults regardless of conditions and 9% as potentially inappropriate medications when used with certain diseases or syndromes. The majority of potentially inappropriate medications (56%) were classified as medications to be used with caution. The two leading classes of potentially inappropriate medications were antipsychotics (27.4%) and selective serotonin reuptake inhibitors (16%). Significant predictors of inappropriate prescribing were hypertension [adjusted OR 1.7; 95% CI (1.0, 2.8)], dementia [adjusted OR 2.0; 95% CI (1.2, 3.1)], depression [adjusted OR 21.6; 95% CI (2.8, 168.4)], and taking more than ten prescribed medications [adjusted OR 1.9; 95% CI (1.3, 2.8)].

CONCLUSION

Prescribing potentially inappropriate medications is common among older adults receiving home health care services in Qatar, a finding that warrants further attention. Polypharmacy, hypertension, depression and dementia were significantly associated with potentially inappropriate prescribing.

Prescription of addictive and non-addictive drugs to home-dwelling elderly

BACKGROUND

Complex medical conditions are frequent among seniors, and their medical treatment represents a challenge. Older patients have a high rate of consumption of prescription drugs, greater risks of medication interactions, and a higher likelihood of side effects. Many common drugs used by the elderly also have addictive potential. Prescription patterns involving general practitioners (GPs) are not sufficiently known.

OBJECTIVE

Our objective was to examine the regular GP role in the prescription of addictive and non-addictive drugs to home-dwelling older people in Norway.

DESIGN

The study was designed as a panel data study.

SETTING

Data on all prescription drugs dispensed at pharmacies to patients 70 years and older from the Norwegian Prescription Database were merged with data on GPs and GPs' patient lists from the Regular General Practitioner Database. The dataset included 624,308 patients and 4,520 GPs in the period from 2004 to 2007.

OUTCOME MEASURES

Outcome measures included quantities of addictive and non-addictive drugs prescribed and dispensed per patient by the regular GP, other GPs, non-GP specialists, and hospital doctors; the number of prescribers per patient; and time trend over the observation period.

RESULTS

On average, 319 defined daily doses of medication were prescribed per quarter to an older patient, 6 % of which were classified as possibly addictive medications. Of all drugs, 72 % were prescribed by the patients' regular GP, 77 % of addictives and 71 % of non-addictives. Drug quantities prescribed increased with multiple prescribers and did so to a greater extent for addictives than for non-addictives. Time trends show an increasing number of prescribers and increasing drug quantities over the observation period.

CONCLUSION

The regular GP prescribes the major portion of non-addictive and, especially, addictive medications to older patients and thus holds a key role in the coordination of prescriptions to this group. Focusing on the role of the GP is important in view of the increasing time trends.

Use of the Screening Tool of Older Persons' Prescriptions (STOPP) and the Screening Tool to Alert doctors to the Right Treatment (START) in hospitalised older people

AIMS

To determine the prevalence and nature of potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) in patients aged 65 years and over.

METHOD

A retrospective clinical audit was undertaken (N = 200) in an Australian metropolitan teaching hospital.

RESULTS

The prevalence of at least one PIM was 51% (n = 101) whereas the prevalence of at least one PPO was 74% (n = 147). The most common PIM was prescribing aspirin to patients with no history of coronary, cerebral or peripheral arterial disease or occlusive arterial events. The most commonly detected PPO was the failure to prescribe statins to patients with a documented history of coronary, cerebral or peripheral vascular disease. Overall, 80 (24%) of the 335 PIMs identified were possibly associated with an adverse clinical outcome experienced by patients.

CONCLUSIONS

Inappropriate prescribing continues to be a problem as shown by complexities associated with the risk-benefit trade-offs of managing medications in older patients.

Multimorbidity and polypharmacy in the elderly: lessons from REPOSI

The dramatic demographic changes that are occurring in the third millennium are modifying the mission of generalist professionals such as primary care physicians and internists. Multiple chronic diseases and the related prescription of multiple medications are becoming typical problems and present many challenges. Unfortunately, the available evidence regarding the efficacy of medications has been generated by clinical trials involving patients completely different from those currently admitted to internal medicine: much younger, affected by a single disease and managed in a highly controlled research environment. Because only registries can provide information on drug effectiveness in real-life conditions, REPOSI started in 2008 with the goal of acquiring data on elderly people acutely admitted to medical or geriatric hospital wards in Italy. The main goals of the registry were to evaluate drug prescription appropriateness, the relationship between multimorbidity/polypharmacy and such cogent outcomes as hospital mortality and re-hospitalization, and the identification of disease clusters that most often concomitantly occur in the elderly. The findings of 3-yearly REPOSI runs (2008, 2010, 2012) suggest the following pertinent tasks for the internist in order to optimally handle their elderly patients: the management of multiple medications, the need to become acquainted with geriatric multidimensional tools, the promotion and implementation of a multidisciplinary team approach to patient health and care and the corresponding involvement of patients and their relatives and caregivers. There is also a need for more research, tailored to the peculiar features of the multimorbid elderly patient.

Potentially inappropriate medication use in older patients in Swiss managed care plans: prevalence, determinants and association with hospitalization

Objectives

To describe the prevalence and determinants of potentially inappropriate medication (PIM) use and association with hospitalizations in an elderly managed care population in Switzerland.

Methods

Using health care claims data of four health insurers for a sample of managed care patients 65 years of age and older to compare persons on PIM with persons not on PIM. Beers' 2012 and PRISCUS criteria were used to determine the potential inappropriateness of prescribed medications. The sample included 16′490 elderly patients on PIM and 33′178 patients not on PIM in the time period of January 1, 2008 through December 31, 2012. Prevalence estimates are standardized to the population of Switzerland. Associations between PIM and hospitalizations were examined by multivariate Cox regression analyses controlling for possible confounding variables.

Results

The estimated prevalence of PIM use in our managed care sample was 22.5%. Logistic regression analysis showed that number of different medications used in the previous year, total costs in the previous year and hospitalization in the previous year all significantly increased the likelihood of receiving PIM. Multiple Cox regression analysis revealed that those on cumulative levels of PIM use acted significantly as a factor related to greater hospitalization rates: the adjusted HR was 1.13 (95% CI 1.07–1.19) for 1 PIM, 1.27 (95% CI 1.19–1.35) for 2 PIM, 1.35 (95% CI 1.22–1.50) for 3 PIM, and 1.63 (95% CI 1.40–1.90) for more than 3 PIM compared to no PIM use.

Conclusions

The prevalence of PIM in managed care health plans are widely found but seem to be much lower than rates of non-managed care plans. Furthermore, our study revealed a significant association with adverse outcomes in terms of hospitalizations. These findings stress the need for further development of interventions to decrease drug-related problems and manage patients with multiple chronic conditions.

Did the new French pay-for-performance system modify benzodiazepine prescribing practices?

Background

French general practitioners (GPs) were enrolled in a new payment system in January 2012. As part of a national agreement with the French National Ministry of Health, GPs were asked to decrease the proportion of patients who continued their benzodiazepine treatment 12 weeks after its initiation and to decrease the proportion of patients older than 65 who were prescribed long half-life benzodiazepines. In return, GPs could expect an extra payment of up to 490 euros per year. This study reports the evolution of the corresponding prescribing practices of French GPs during that period regarding patients who were prescribed a benzodiazepine for the first time.

Methods

The national healthcare system's administrative database was used to report the longitudinal follow-up of two historical cohorts of French patients from the Pays de la Loire area.

Study patients: The “2011” and “2012” cohorts included all patients who initiated benzodiazepine regimens from April 1 to June 30 in 2011 and 2012, respectively.

The primary outcomes were the proportion of those study patients who continued benzodiazepine treatment after 12 weeks and the proportion of study patients >65 years who were prescribed long half-life benzodiazepines.

Analyses were performed using a multi-level regression.

Results

In total, 41,436 and 42,042 patients initiated benzodiazepine treatment in 2011 and 2012, respectively. A total of 18.97% of patients continued treatment for more than 12 weeks in 2012, compared with 18.18% in 2011. In all, 27.43% and 28.06% of patients >65 years continued treatment beyond 12 weeks in 2011 and 2012, respectively. The proportion of patients >65 years who were prescribed long half-life benzodiazepines decreased from 53.5% to 48.8% (p < 0.005) due to an increase in short half-life benzodiazepine prescriptions. Patients >65 years who were prescribed short half-life benzodiazepines were more likely to continue treatment after 12 weeks (p < 0.005).

Conclusions

Despite the pay-for-performance strategy, the number of short half-life benzodiazepine prescriptions increased between 2011 and 2012, and the number of long half-life benzodiazepine initiations remained unchanged. Reducing the proportion of long half-life benzodiazepine prescriptions might be counterproductive because prescribing short half-life benzodiazepines was associated with higher rates of continuation beyond the recommended duration.

Evaluating sustained quality improvements: long-term effectiveness of a physician-focused intervention to reduce potentially inappropriate medication prescribing in an older population

WHAT IS KNOWN AND OBJECTIVES

Although quality improvement initiatives targeting physician practice patterns have been effective, evidence is lacking on their long-term sustainability. We previously demonstrated the success of a population-wide, physician-focused quality improvement intervention targeting potentially inappropriate prescribing (PIP) in an aged population of the Local Health Authority (LHA) of Parma, Italy. We sought to assess whether the decrease in PIP incidence rates achieved during the intervention was sustained after discontinuation of the intervention, and which factors modified the effectiveness of the intervention.

METHODS

Using a regional administrative claims database, we assessed changes in quarterly PIP exposure incidence rates for each phase [pre-intervention (2005 Q1-2007 Q3), intervention (2007 Q4-2009 Q4) and post-intervention (2010 Q1-Q4)] of the study for both all and newly PIP-exposed patients. Piecewise-linear longitudinal logistic regression was used to model the odds of PIP exposure.

RESULTS

299 GPs (98·7%) serving 111,282 older patients were included. PIP incidence rates declined from 7·1% (pre-intervention) to 4·9% (intervention), and to 4·3% (post-intervention). There was no significant change in odds of PIP exposure following the intervention period (P = 0·52), and the rates of change in PIP exposure odds during pre-intervention and post-intervention periods were not significantly different (P = 0·39). The intervention was attributed to an 18% long-term reduction in the odds of PIP exposure. No assessed patient or GP characteristics modified this effect. Results among patients newly exposed to PIP were similar to results among all patients exposed to PIP.

WHAT IS NEW AND CONCLUSION

The significant reduction in the odds of PIP exposure achieved during the intervention was sustained after its discontinuation. Because the intervention showed success across the spectrum of patients and providers, it shows promise for generalizability to other healthcare settings.

The use of potentially inappropriate medications and changes in quality of life among older nursing home residents

Background

Nursing home residents are mainly older people with multiple diseases and taking multiple medications. The quality use of medication and its association with health related quality of life (HRQoL) have not been reported in Malaysia. This study aims to investigate the association between the use of potentially inappropriate medications (PIMs) and the changes observed in the HRQoL among older nursing home residents.

Methods

A prospective follow up study was conducted at four nongovernmental organization nursing homes in Penang, Malaysia. Older residents (≥65 years old) taking at least one prescribed medication were included. Residents with PIMs were identified by using Screening Tool of Older Person’s potentially inappropriate Prescriptions (STOPP) criteria. HRQoL was assessed using EuroQol-5 dimension (EQ-5D) and EuroQol-visual analog scale (EQ-VAS) at baseline and after a 3-month follow up. The association of PIMs with HRQoL was analyzed using Mann-Whitney U test.

Results

The median age of the 211 participants was 77 years (interquartile range 72–82 years) and the median number of prescription medicines was four (interquartile range three to six). The prevalence of PIMs was 23.7% and 18.6% at baseline and 3 months later, respectively. The most commonly prescribed PIMs in decreasing order were first generation antihistamine, prescriptions of duplicate drug class, glibenclamide with type 2 diabetes mellitus, and anticholinergic to treat extrapyramidal side effects of neuroleptic medications. At baseline, there was no significant difference among residents with or without PIMs in each bracket of EQ-5D, EQ-5D index, or EQ-VAS scores. Comparison of the differences in the mean score index of EQ-5D between baseline and after 3 months also showed no statistically significant differences.

Conclusion

PIMs were found to be relatively common among older nursing home residents. However, no significant changes were observed in HRQoL among these residents. Further studies with a bigger sample size and longer follow up period are required to establish this association.

Necrotizing soft tissue infections developing from pressure ulcers

AIM OF THE STUDY

Necrotizing soft tissue infections (STIs) are serious complications that may arise from pressure ulcers. However, there are few studies on this important issue. In addition, diagnostic criteria for necrotizing STIs developing from pressure ulcers and infected pressure ulcers are not well established.

METHODS

We defined necrotizing STIs developing from pressure ulcers based on clinical findings. Based on the definition, we retrospectively analyzed the medical records of 24 elderly patients with this condition to determine patient age, gender, comorbid disease, laboratory findings, wound location, bacteriology, and treatment outcomes.

RESULTS

In the examined population, necrotizing STIs developed primarily from pressure ulcers over the sacrum. Dementia and diabetes mellitus were also frequently observed in patients with necrotizing STIs. The average Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score was relatively low. Bacterial cultures from the debrided deep tissues exhibited mixed infections of gram-positive cocci and gram-negative bacilli, except 1 case. Anaerobic pathogens were isolated from 18 patients (72%), and 7 patients (29%) developed bacteremia. None of the cases were preceded by wounds dominated by granulation tissue. Surgical intervention, combined with antibacterial therapy involving intravenous carbapenem or cephem, was successfully used in most cases.

CONCLUSION

Necrotizing STIs arising from pressure ulcers are generally caused by mixed pathogens and exhibit symptoms that are milder than those of necrotizing fasciitis caused by group A Streptococcus.

People's attitudes, beliefs, and experiences regarding polypharmacy and willingness to Deprescribe

OBJECTIVES

To capture people's attitudes, beliefs, and experiences regarding the number of medications they are taking and their feelings about stopping medications.

DESIGN

Administration of a validated questionnaire.

SETTING

Multidisciplinary ambulatory consulting service at the Royal Adelaide Hospital.

PARTICIPANTS

Participants were individuals aged 18 and older (median 71.5) taking at least one regular prescription medication; 100 participants completed all items of the questionnaire, 65 of whom were aged 65 and older.

MEASUREMENTS

Participants were administered the 15-item Patients' Attitudes Towards Deprescribing (PATD) questionnaire.

RESULTS

Participants were taking an average of 10 different prescription and nonprescription (including complementary), regular and as-needed medications. More than 60% felt that they were taking a "large number" of medications, and 92% stated that they would be willing to stop one or more of their current medications if possible. Number of regular medications, age, and number of medical conditions were not found to be correlated with willingness to stop a medication. The findings were similar in older and younger participants.

CONCLUSION

This study has shown that a cohort of mostly older adults were largely accepting of a trial of cessation of medication(s) that their prescriber deemed to be no longer required. Because few factors were associated with willingness to cease medications, all patients should be individually evaluated for deprescribing.

Pharmacodynamics of vancomycin in elderly patients aged 75 years or older with methicillin-resistant Staphylococcus aureus hospital-acquired pneumonia

BACKGROUND

Methicillin-resistant Staphylococcus aureus (MRSA) infections are associated with significant mortality and health care costs. To improve treatment outcomes for MRSA, a better understanding of the pharmacokinetic/pharmacodynamic parameters of vancomycin is required to develop optimal dosing strategies, particularly in elderly patients (≥75 years of age) with limited renal function. The purpose of this study was to determine whether pharmacokinetic indices for vancomycin are associated with mortality from MRSA hospital-acquired pneumonia in elderly patients.

METHODS

We conducted a retrospective observational study with 28-day mortality as the primary outcome for 94 patients with MRSA hospital-acquired pneumonia who had been treated with vancomycin from January 2006 through December 2012. Our most recent sampling of MRSA isolates had a minimum inhibitory concentration (MIC) for vancomycin of 1 μg/mL (86%), indicating that the area under the curve (AUC) was equal to the AUC/MIC in these isolates. The primary data from 28-day survivors and nonsurvivors were compared.

RESULTS

Among 94 elderly patients, the mean age was 82 (75-99) years. Multivariate analyses revealed that, among the factors examined, only the nonoptimal AUC (<250, >450 μg*h/mL) was an independent predictor of 28-day mortality in elderly patients (odds ratio 23.156, 95% confidence interval 6.814-78.687, P < 0.001). We detected a significant difference for increasing nephrotoxicity in nonsurvivors (nine of 32 patients [28%]) compared with survivors (three of 62 patients [4.8%], P = 0.003).

CONCLUSION

This finding indicates that patients with potentially poor renal function are likely to have increased AUC values and a poor prognosis. Consideration of the pharmacokinetics/pharmacodynamics of vancomycin and targeting an AUC/MIC value of 250-450 μg*h/mL may result in improved treatment outcomes for elderly patients with MRSA hospital-acquired pneumonia.

An educational intervention to reduce the use of potentially inappropriate medications among older adults (EMPOWER study): protocol for a cluster randomized trial

Background

Currently, far too many older adults consume inappropriate prescriptions, which increase the risk of adverse drug reactions and unnecessary hospitalizations. A health education program directly informing patients of prescription risks may promote inappropriate prescription discontinuation in chronic benzodiazepine users.

Methods/Design

This is a cluster randomized controlled trial using a two-arm parallel-design. A total of 250 older chronic benzodiazepine users recruited from community pharmacies in the greater Montreal area will be studied with informed consent. A participating pharmacy with recruited participants represents a cluster, the unit of randomization. For every four pharmacies recruited, a simple 2:2 randomization is used to allocate clusters into intervention and control arms. Participants will be followed for 1 year. Within the intervention clusters, participants will receive a novel educational intervention detailing risks and safe alternatives to their current potentially inappropriate medication, while the control group will be wait-listed for the intervention for 6 months and receive usual care during that time period. The primary outcome is the rate of change in benzodiazepine use at 6 months. Secondary outcomes are changes in risk perception, self-efficacy for discontinuing benzodiazepines, and activation of patients initiating discussions with their physician or pharmacist about safer prescribing practices. An intention-to-treat analysis will be followed.

The rate of change of benzodiazepine use will be compared between intervention and control groups at the individual level at the 6-month follow-up. Risk differences between the control and experimental groups will be calculated, and the robust variance estimator will be used to estimate the associated 95% confidence interval (CI). As a sensitivity analysis (and/or if any confounders are unbalanced between the groups), we will estimate the risk difference for the intervention via a marginal model estimated via generalized estimating equations with an exchangeable correlation structure.

Discussion

Targeting consumers directly as catalysts for engaging physicians and pharmacists in collaborative discontinuation of benzodiazepine drugs is a novel approach to reduce inappropriate prescriptions. By directly empowering chronic users with knowledge about risks, we hope to imitate the success of individually targeted anti-smoking campaigns.

Trial registration

ClinicalTrials.gov identifier: NCT01148186

Prescription pattern and prevalence of potentially inappropriate medications among elderly patients in a Nigerian rural tertiary hospital

Introduction

Polypharmacy and inappropriate prescriptions are prominent prescribing issues with elderly patients. Beers criteria and other guidelines have been developed to assist in the reduction of potentially inappropriate medications prescribed to elderly patients. The objectives of this study were to assess the prescribing pattern for elderly Nigerian outpatients and estimate the prevalence of potentially inappropriate medications among them using the Beers criteria.

Methodology

This was a prospective cross-sectional study of elderly patients (65 years and above) who were attending the general outpatients clinic of a rural Nigerian hospital. For the drug utilization aspect of the study, drug-use indicators were assessed using established World Health Organization guidelines, while the Beers criteria was used to screen for potentially inappropriate medications.

Result

The medical records of 220 patients aged 65 years and above were utilized for the study. A total of 837 drugs were prescribed for the patients, giving an average of 3.8 ± 1.3 drugs per person. Antihypertensive drugs accounted for 30.6% of the prescriptions, followed by multivitamins/food supplements (11.5%) and analgesics (10.8%). A review of the prescribed medications using the 2012 Updated Beers Criteria by the American Geriatric Society identified 56 patients with at least one potentially inappropriate medication prescribed giving a rate of 25.5%. The drug groups identified were nonsteroidal anti-inflammatory drugs, antihistamines, and amitriptyline.

Conclusion

Polypharmacy and prescription of potentially inappropriate medications are major therapeutic issues in Nigeria. There is a need for prescriber training and retraining with emphasis on the geriatric population.

Potentially inappropriate prescribing in institutionalised older patients in Spain: the STOPP-START criteria compared with the Beers criteria

Objective

The aims of this study were to identify potentially inappropriate prescribing using the Beers and STOPP criteria. The START criteria were applied to detect prescription omission in the geriatric population. We compared the utility of these criteria in institutionalised older people.

Methods

Descriptive study reviewing the medication and clinical records of 81 residents (aged 65 years and more) by pharmacists in a nursing home in the Lleida region (Spain).

Results

The mean patients’'age was 84 (SD=8) years, with an average of 5 drugs per resident (total prescriptions: 416 medicines). The Beers criteria identified potentially inappropriate medication use in 25% of patients and 48% of patients used at least 1 inappropriate medication according to STOPP criteria. The most frequent potentially inappropriate medications for both criteria were long-acting benzodiazepines and NSAIDs. START detected 58 potential prescribing omissions in 44% of patients. Calcium-vitamin D supplementation in osteoporosis was the most frequent rule (15%), but omissions corresponding to the cardiovascular system implied 23% of patients.

Conclusions

The STOPP-START criteria reveal that potentially inappropriate prescribing (PIP) is a highly prevalent problem among Spanish nursing home residents, and a statistically significant positive correlation was found between the number of medicines prescribed and the number of PIP detected in this study. The STOPP criteria detect a larger number of PI medications in this geriatric population than the Beers criteria. The prescribing omissions detected by the START criteria are relevant and require intervention. Pharmacists’ review of medications may help identify potentially inappropriate prescribing and, through an interdisciplinary approach, working with physicians may improve prescribing practices among geriatric residents of nursing homes.

Potentially inappropriate prescribing and cost outcomes for older people: a cross-sectional study using the Northern Ireland Enhanced Prescribing Database

PURPOSE

We sought to estimate the prevalence of potentially inappropriate prescribing (PIP) in the Northern Ireland (NI) population aged ≥70 years, to investigate factors associated with PIP and to calculate total gross cost of PIP.

METHODS

A retrospective cross-sectional population study was carried out in those aged ≥70 years in 2009/2010 who were in primary care in NI. Data were extracted from the Enhanced Prescribing Database, which provides details of prescribed and dispensed medications for each individual registered with a general practitioner. Twenty-eight PIP indicators from the Screening Tool of Older Persons potentially inappropriate Prescriptions (STOPP) criteria were applied to these data. PIP prevalence according to individual STOPP criteria and the overall prevalence of PIP were estimated. The relationship between PIP and polypharmacy, age and gender was examined using logistic regression. Gross cost of PIP was ascertained.

RESULTS

The overall prevalence of PIP in the study population (n = 166,108) was 34 %. The most common examples of PIP identified were proton pump inhibitors at maximum therapeutic dose for >8 weeks (17,931 patients, 11 %), non-steroidal anti-inflammatory drugs >3 months (14,545 patients, 9 %) and long-term long-acting benzodiazepines (10,147 patients, 6 %). PIP was strongly associated with polypharmacy, with those receiving seven different medications being fivefold more likely to be exposed to PIP than those on zero to three medications (odds ratio 5.04, 95 % confidence interval 4.84-5.25) The gross cost of PIP was estimated to be <euro>6,098,419

CONCLUSIONS

Consistent with other research, the prevalence of PIP was high among the study cohort, increased with polypharmacy and was associated with significant cost.

Drug treatment in the elderly: an intervention in primary care to enhance prescription quality and quality of life

OBJECTIVE

The aim of the study was to assess the effect on prescription quality and quality of life after intervention with prescription reviews and promotion of patient participation in primary care.

DESIGN

A randomized controlled study with three groups: (A) controls, (B) prescription review sent to physician, and (C) as in B and with a current comprehensive medication record sent to the patient.

SETTING

The municipality of Örebro, Sweden (130 000 inhabitants).

INTERVENTION

The study focused on the easiest possible intervention to increase prescription quality and thereby increase quality of life. The intervention should be cost-efficient, focus on colleague-to-colleague advice, and be possible to perform in the primary health care centre without additional resources such as a pharmacist.

SUBJECTS

150 patients recently discharged from hospital. Inclusion criteria were: ≥ 75 years, ≥ five drugs and living in ordinary homes.

MAIN OUTCOME MEASURES

Quality of life (EQ-5D index, EQ VAS) and quality of prescriptions.

RESULTS

Extreme polypharmacy was common and persistent in all three groups and this was accompanied by an unchanged frequency of drug-risk indicators. There was a low EQ-5D index and EQ VAS in all three groups throughout the study. No statistically significant differences were found anywhere between the groups.

CONCLUSION

The intervention seems to have had no effect on quality of prescriptions or quality of life. This underlines the major challenge of finding new strategies for improving prescription quality to improve patient outcome measures such as quality of life and reduce the known risks of polypharmacy for the elderly.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Potentially inappropriate prescribing in elderly: assessing doctor knowledge, confidence and barriers

INTRODUCTION

Inappropriate medication prescribing by doctors is an important preventable cause of morbidity and mortality in the elderly. This study investigates doctor knowledge about potentially inappropriate prescribing (PIP) in elderly, their confidence in prescribing for the elderly and explores perceived barriers.

METHODS

Family and Internal Medicine resident and attending doctors at three teaching hospitals were asked to complete a survey. Six clinical vignettes based on the 2003 Beers criteria were used to evaluate doctor knowledge about medications to avoid in the elderly. Confidence in prescribing for the elderly and perceived barriers to appropriate prescribing in elderly was assessed using a 5-point Likert scale.

RESULTS

Eighty-nine doctors completed the survey, for a response rate of 45%. Forty-four per cent of surveyed doctors estimated that over 25% of their practice consisted of patients 65 years or older. When knowledge of PIP was assessed via vignettes, the mean correct response was 3.9 (SD: 1.1, min = 1, max = 6). Only 14% of those doctors scoring ≤4 vignettes correctly had used the Beers criteria for prescribing; 31% of the doctors answering ≥5 vignettes correctly had used the Beers criteria (P = 0.08). Overall, 75% of doctors felt confident about their prescribing irrespective of their knowledge scores. Seventy per cent of surveyed doctors cited at least seven different barriers to appropriate prescribing in elderly.

CONCLUSIONS

Many primary care doctors possess a poor knowledge of PIP and are unaware of prescribing guidelines such as the Beers criteria. Our survey indicates that doctor usage of the Beers criteria might correlate with improved judgement in prescribing for the elderly. Most doctors report multiple barriers to appropriate prescribing in the elderly. Lack of formal education about prescribing guidelines was the only barrier that correlated with the doctors' level of training.

Inappropriate medication use among the elderly: a systematic review of administrative databases

Background

Inappropriate medication use (IMU) by elderly people is a public health problem associated with adverse effects on health. There are a number of methods for identifying IMU, some involving clinical judgment and others, consensually generated lists of drugs to be avoided. This review aims to describe studies that used information from insurance company and social security administrative databases to assess IMU among community-dwelling elderly and to present the risk factors most often associated with IMU.

Methods

The paper search was conducted in Medline and Embase, using descriptors combined with free terms in the title or abstract. The limits applied were: publication date from January 1990 to June 2010, species (human) and publication type (excluding editorials, letters and reviews). Excluded were: case studies; studies in hospitals, nursing homes, or hospital emergency departments; studies of specific drugs or groups of drugs; studies exclusively of subgroups of ill, frail elderly or rural populations. Additional studies were identified from reference lists. Data were selected and extracted after independent reading by two of the authors, with disagreements resolved by a third author. The primary outcome assessed was prevalence of IMU, defined as the proportion of elderly who received at least one inappropriate medication.

Results

Of the 628 studies, 19 met the inclusion criteria, 78.9% of them conducted in the USA. All papers included used explicit criteria of inappropriateness, most commonly Beers criteria (73.7%) in their three versions (1991, 1997 and 2002). Other methods used included Zhan, which is derived from on Beers criteria and was applied in 21% of the papers selected. The study found that prevalence of IMU ranged from 11.5% to 62.5%. Only 68.4% of the studies included examined inappropriate use-related factors, the most important being female sex, advanced age and larger number of drugs.

Conclusions

The results show that the prevalence of IMU among community-dwelling elderly is high and depends partly on the method used to evaluate improper use. Besides the diversity of methods, other factors, such as patient sex, age and number of drugs used concurrently, appear to have influenced the estimates of IMU.

[Inadequate prescription of medications in hospitalised elderly patients according to Beers criteria]

OBJECTIVES

To estimate the prevalence of using potentially inadequate drugs in the elderly population admitted to the Nuestra Señora de Sonsoles Hospital in Ávila according to Beers criteria, and to describe the impacts on these prescriptions following an educational seminar for prescribers.

METHOD

Before and after observational study, with two periods of 28 days each (P1 in 2008, P2 in 2009), with educational seminars on Beers criteria provided between them. All patients >65 years that were admitted during both time periods in health centres with a single dose drug system were included, taking data on those with inadequate prescriptions.

RESULTS

The total number of hospitalised patients was 1276. Of these, 18.5% had at least one inadequate medication at P1 and 20.5% at P2, with no significant differences (χ2=0.56, P=.45). We identified a total of 295 inadequate medications (163 in P1 and 132 in P2) in 249 patients. Iron sulfate, digoxin, meperidine, and doxazosine were present in 70% of inadequate prescriptions. The prevalence of inadequate medication prescriptions did not vary between the two periods.

CONCLUSION

The prevalence of using potentially inadequate medications observed in this study was 23%, with no changes produced by the intervention provided.

National study of prescription poisoning with psychoactive and nonpsychoactive medications in Medicare/Medicaid dual enrollees age 65 or over

The purpose of this study is to assess prescription medication poisoning among psychoactive and nonpsychoactive medications used by elderly (65 years or older) Medicare & Medicaid dual enrollees as well as examine contextual components associated with poisoning. Our primary research goal was to compare medication poisonings among psychoactive medications to nonpsychoactive medications. Our second research goal was to identify components influencing medication poisonings and how they interrelate. The approach used a cross-sectional retrospective review of calendar year 2003 Centers for Medicare & Medicaid Service's Medicaid Pharmacy claims data for elderly dual enrollees. Poisonings were identified based on ICD-9-CM categorizations. Poisonings associated with the psychoactive medications were proportionally over twice as high as compared to nonpsychoactive medications (14.3 per 100,000 enrollees and 6.6 per 100,000 enrollees, respectively). Additionally, the two contextual components of (a) use of many drugs and (b) familiarity with the medication have a direct, but competing impact on poisoning. The reasons behind unintentional poisoning in the elderly have been somewhat a mystery. This study is among the first to attempt to distinguish between poisoning events associated with psychoactive medications versus nonpsychoactive medications as well as assess the impact of differing contextual components on medication poisoning.

Medication quality and quality of life in the elderly, a cohort study

BACKGROUND

Modern drugs have made large contributions to better health and quality of life. Increasing proportions of negative side effects due to extensive pharmacological treatment are however observed especially among elderly patients who have multiple health problems. The aim of our study was to see if there is an association between medication quality and quality of life.

METHODS

150 patients discharged from hospital. Inclusion criteria were: living in ordinary homes, ≥ 75 years and ≥ 5 drugs. Home visits were performed to all, including prescription reviews and calculation of medication appropriateness index. The patients were divided into three groups depending on index score and followed for 12 months. The validated and recognized EQ-5D and EQ VAS instruments were used to assess quality of life.

RESULTS

A lower medication quality was associated with a lower quality of life. EQ-5D index was statistically significantly different (declining for each group) among the groups (p = 0.001 at study start, p = 0.001 at 6 months and p = 0.013 at 12 months) as was EQ VAS (p = 0.026 at study start, p = 0.003 at 6 months and p = 0.007 at 12 months).

CONCLUSIONS

This study has shown the validity of the basic principle in prescribing: the more appropriate medication the better quality of life. Since drug quality is related to the patients' quality of life, there is immense reason to continuously evaluate every prescription and treatment. The evaluation and if possible deprescribing should be done as a process where both the patient and physician are involved.

Physician perspective on propoxyphene as a potentially inappropriate medication in Tennessee

Medicare Part D data from the Quality Improvement Organization's 9th Statement of Work drug safety indicator project under the direction of the Centers for Medicare & Medicaid Services define the potentially inappropriate medications (PIMs) list for Tennessee. These data reveal propoxyphene as the main contributor to the state's PIM rate. In Tennessee, PIM and drug-drug interaction (DDI) rates indicate propoxyphene as the most prescribed medication among elderly patients despite decades of attention for potentially adverse effects. During this project, physicians agreed that PIM rates are too high, but disagreed in approach preference, i.e., administrative limits and bans versus a proactive educational approach. Physicians were interested in participating in quality improvement by using individual pharmacy data to influence prescribing patterns. Exploring alternatives in research and survey, a potential and reachable point of intervention was found, a prescribing paradigm proposed by researchers to improve outcomes by reducing adverse effects in minimizing PIMs and DDIs.