Potentially inappropriate medication use by elderly Mexican Americans

Potentially inappropriate medications in older adults according to Beers criteria 2019: Prevalence and risk factors

AIM

Older patients are more prone to receive potentially inappropriate medications (PIMs) that are better to be avoided or dose adjusted to protect them from their unnecessary or harmful use. This study aims to detect the prevalence of PIMs among older patients discharged from Tawam hospital according to Beers criteria 2019. Moreover, the common risk factors of the older patients may subject them to PIMs use.

METHODS

A retrospective charts review study of older patients ≥65 years who were prescribed 5 or more medications and were discharged from Tawam hospital from 1 October 2018 to 31 December 2018. Each patient's medical record was scanned to detect PIMs. (PIMs) were classified according to Beers criteria 2019, and the predictors of PIMs were also assessed.

RESULTS

A total of 502 older patients (51.6% females and 48.4% males) medical charts were reviewed. The prevalence of PIMs among the study population was 34.7%. Antipsychotics (27.5%) and sulphonylurea's (16.8%) were among the most common avoided PIMs. Anticoagulants (40%) and ranitidine (35%) were the most PIMs based on the kidney function of the patient. Female gender [OR 1.8; 95% CI (1.22-2.66), P < .05] and increasing number of medications [OR 1.08; 95% CI (1.03-1.14), P < .05] were the independent predictors of PIMs.

CONCLUSION

Based on the prevalence of PIMs among older patients, it is recommended to revise each patient's medications prescription to avoid inappropriate prescribing and hence decrease the prevalence of PIMs.

Multi-Dimensional Impact of Chronic Low Back Pain among Underserved African American and Latino Older Adults

Chronic low back pain is one of the most common, poorly understood, and potentially disabling chronic pain conditions from which older adults suffer. The existing low back pain research has relied almost exclusively on White/Caucasian participant samples. This study examines the correlates of chronic low back pain among a sample of underserved urban African American and Latino older adults. Controlling for age, gender, race/ethnicity, education, living arrangement, and number of major chronic conditions, associations between low back pain and the following outcome variables are examined: (1) healthcare utilization, (2) health-related quality of life (HR-QoL) and self-rated quality of health; and (3) physical and mental health outcomes.

METHODS

We recruited nine hundred and five (905) African American and Latino older adults from the South Los Angeles community using convenience and snowball sampling. In addition to standard items that measure demographic variables, our survey included validated instruments to document HR-QoL health status, the Short-Form McGill Pain Questionnaire-2, Geriatric Depression Scale, sleep disorder, and healthcare access. Data analysis includes bivariate and 17 independent multivariate models.

RESULTS

Almost 55% and 48% of the Latino and African American older adults who participated in our study reported chronic low back pain. Our data revealed that having low back pain was associated with three categories of outcomes including: (1) a higher level of healthcare utilization measured by (i) physician visits, (ii) emergency department visits, (iii) number of Rx used, (iv) a higher level of medication complexity, (v) a lower level of adherence to medication regimens, and (vi) a lower level of satisfaction with medical care; (2) a lower level of HR-QoL and self-assessment of health measured by (i) physical health QoL, (ii) mental health QoL, and (iii) a lower level of self-rated health; and (3) worse physical and mental health outcomes measured by (i) a higher number of depressive symptoms, (ii) a higher level of pain, (iii) falls, (iv) sleep disorders, (v) and being overweight/obese.

DISCUSSION

Low back pain remains a public health concern and significantly impacts the quality of life, health care utilization, and health outcomes of underserved minority older adults. Multi-faceted and culturally sensitive interventional studies are needed to ensure the timely diagnosis and treatment of low back pain among underserved minority older adults. Many barriers and challenges that affect underserved African American and Latino older adults with low back pain simply cannot be addressed in over-crowded EDs. Our study contributes to and raises the awareness of healthcare providers and health policymakers on the necessity for prevention, early diagnosis, proper medical management, and rehabilitation policies to minimize the burdens associated with chronic low back pain among underserved older African American and Latino patients in an under-resourced community such as South Los Angeles.

Anticholinergic/sedative drug burden predicts worse memory acquisition in older racially/ethnically diverse patients with type 2 diabetes mellitus

OBJECTIVE

Anticholinergic/sedative drug use, measured by the Drug Burden Index (DBI), is linked to cognitive impairment in older adults. Yet, studies on the DBI's association with neuropsychological functioning are lacking, especially in underserved groups at increased risk of cognitive impairment. We examined cross-sectional relationships between total DBI (DBI_T ) and an age-adjusted analogue (Adj DBI_T ) with the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) in diverse adults with type 2 diabetes mellitus (T2DM). Based on results of a prior study, we anticipated higher DBIs would be associated with worse memory at older ages.

METHODS

One hundred five adults with T2DM (age = 57 ± 9 years, 65% female, 62% Black, 27% Hispanic/Latino, Hb_A1c = 7.8 ± 1.8) participated. Although memory outcomes were normally distributed, DBI_T values were positively skewed. Spearman correlations assessed their bivariate relationships with RBANS. Adjusting for comorbidities, polypharmacy, Hb_A1c , and education, we tested the moderating effect of age on DBI-RBANS associations at mean ±1 standard deviations of age.

RESULTS

One third of the participants endorsed current sedative/anticholinergic use. Mean DBI_T was 0.385, and mean Adj DBI_T was 0.393 (ranges = 0.00-4.22). Drug burden negatively correlated with RBANS Immediate Memory (DBI_T r_s = -0.237, P = .013; Adj DBI_T r_s = -0.239, P = .014) but no other indices. There was a significant DBI*Age interaction; the negative effect of drug burden on Immediate Memory was significant for ages greater than or equal to 55 years old.

CONCLUSIONS

Sedative/anticholinergic drug exposure was prevalent in these diverse T2DM patients. Adjusting for covariates, greater drug burden was associated with worse memory acquisition among older adults only. Prospective studies should examine these relationships over time and assess whether dementia biomarkers affect the interaction.

Conceptualizing and measuring potentially inappropriate drug therapy

WHAT IS KNOWN AND OBJECTIVE

Elderly people are the principal consumers of prescription drugs. The more the medication used by the patient, the greater the likelihood there is of the patient being subjected to potentially inappropriate drug therapy (PIDT). PIDT has been measured in the literature with both implicit and explicit tools. The purpose of this review was to assess the use of tools to detect PIDT in various studies and to determine which terms are used to refer to PIDT in practice.

METHODS

A systematic review was conducted according to the following steps: the first was identification. In this step, studies were selected from different combinations of the descriptors 'aged', 'elderly', 'inappropriate prescribing' and 'drug utilization' in three different languages, using the Embase, Medline, Scielo, Scopus and Web of Science databases. Second, the papers that satisfied the inclusion criteria for data extraction were carefully examined by three evaluators to determine the tools used and terms that referred to PIDT.

RESULTS AND DISCUSSION

From the combinations of keywords, 8610 articles were found. At the end of the selection process, 119 of the articles complied with the specified criteria. The degree of agreement among evaluators was moderate for the study titles (κ1  = 0·479) and substantial for abstracts (κ2  = 0·647). With respect to the PIDT evaluation criteria used by the studies, 27·7% used two criteria. Of the 27 evaluation criteria identified, the Beers criteria were used by 82·3% of the studies. More than 50 different terms to identify PIDT were found in the literature.

WHAT IS NEW AND CONCLUSION

This review is the first study to conceptualize and discuss terms that refer to PIDT. At present, there is no consensus regarding terms used to refer to PIDT, with over 50 different terms currently in use. This review shows an increase in the number of articles aimed at evaluating PIDT using implicit and explicit tools.

A systematic review of prescribing criteria to evaluate appropriateness of medications in frail older people

This study systematically reviews the published literature regarding inappropriate prescribing in frail individuals aged at least 65 years. Twenty-five of 466 identified studies met the inclusion criteria. All papers measured some surrogate indicators of frailty, such as performance-based tests, cognitive function and functional dependency. Beers criteria were used in 20 studies (74%) to evaluate inappropriate medication use and 36% (9/25) studies used more than one criterion. The prevalence of inappropriate medications ranged widely from 11 to 92%. Only a few studies reported the relationship between potentially inappropriate medication use and surrogate measures of frailty. These diverse findings indicate the need for a standardized measure for assessing appropriateness of medication in frail older individuals. Prescribing tools should address both medication and patient-related factors such as life expectancy and functional status to minimize inappropriate prescribing in frail individuals.

The impact of family caregivers on potentially inappropriate medication use in noninstitutionalized older adults with dementia

BACKGROUND

The risk of potentially inappropriate medication (PIM), both prescription and over-the-counter, use in dementia patients is high. Informal caregivers often facilitate patients' use of medications, but the effect of caregiver factors on PIM use has not been a focus of previous research.

OBJECTIVE

The aim of this study was to examine PIM use in dementia patients and caregivers and identify caregiver risk factors for PIM use in dementia patients.

METHODS

We conducted a secondary data analysis of the baseline wave of the Resources for Enhancing Alzheimer's Caregiver's Health study. The sample comprised 566 persons with dementia aged 65 and older and their coresiding family caregiver. PIM was defined using the 2003 Beers criteria and was examined in both dementia patients and their caregivers. Caregiver and patient risk factors included a range of sociodemographic and health variables.

RESULTS

In dementia patients, 33% were taking at least 1 PIM, and 39% of their caregivers were also taking a PIM. In fully adjusted models, the following caregiver factors were associated with an increased risk of dementia patient PIM use: caregiver's own PIM use, spouse caregivers, Hispanic caregivers, and greater number of years that the caregiver has lived in the United States. Increased caregiver age was associated with a decreased risk of PIM use in patients.

CONCLUSIONS

PIM use may be higher in dementia patients and their informal caregivers compared with the general older adult population. Further, patterns of medication use in 1 member of the dyad may influence PIM risk in the other dyad member. These results suggest that interventions to increase appropriate medication use in dementia patients and their caregivers should target both members of the dyad and target over-the-counter agents along with prescription medications.

Inappropriate medications using the Beers criteria in Brazilian hospitalized elderly patients

OBJECTIVE

To study the prevalence and to identify risk factors of using potentially inappropriate medication (PIM) in hospitalized elderly patients.

DESIGN

A cross-sectional study was conducted. For identification of PIM, modified 2003 Beers criteria were used.

SETTING

The private Hospital Israelita Albert Einstein admission wards.

PATIENTS, PARTICIPANTS

250 elderly patients (>or = 60 years of age) with a length of stay > or = 48 hours up to 30 days.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

The main outcome measure was to study the prevalence and to identify risk factors of using PIM in hospitalized elderly patients.

RESULTS

156 (62%) patients used at least one PIM independent of diagnosis or condition, and 28% currently used the PIMs at home. The most frequent PIM, independent of diagnosis or condition, was scopolamine (27.2%), followed by clonazepam (17.9%) and amiodarone (16.4%). The prescription of PIM was related to number of drugs (odds ratio [OR] 1.14, 95% confidence interval [CI] 1.05-1.23, P = 0.001), female gender (OR 2.36, 95% CI 1.34-4.14, P = 0.003), nongeriatrician prescribers (OR 5.54, 95% CI 1.62-18.89, P = 0.006), heart disease (OR 2.17, 95% CI 1.22-3.85, P = 0.008), and depression (OR 3.34, 95% CI 1.33-8.31, P = 0.010).

CONCLUSION

The present study has shown that the use of PIM is usual in hospitalized patients, and the Beers list must be used as a guide of good practices rather than being used prohibitively. This study will serve as a base for selection and intervention programs on medical prescription in order to warrant a safe and effective drug therapy for hospitalized elderly patients.

Prevalence of the prescribing of potentially inappropriate medications at ambulatory care visits by elderly patients covered by the Taiwanese National Health Insurance program

BACKGROUND

The use of potentially inappropriate medications can have profound medical consequences for elderly patients and place a substantial burden on the health care system.

OBJECTIVES

This study was conducted to determine the prevalence of potentially inappropriate medication prescribing at ambulatory care visits by patients aged > or =65 years covered by the Taiwanese National Health Insurance program, to examine the characteristics of and risk factors for such prescribing, and to investigate its influence on health care resource utilization.

METHODS

Ambulatory care visits by patients aged > or =65 years in 2001-2004 were identified from the National Health Insurance claims database. The 2003 Beers criteria for drugs to be avoided in the elderly were used to identify potentially inappropriate medications prescribed at these visits. Only drugs with the potential to lead to higher-severity adverse events were included. Multivariate logistic regression was used to determine predictors of the prescribing of potentially inappropriate medications at ambulatory care visits. Independent variables in the regression model included patient characteristics (eg, sex, age), physician characteristics (sex, age, and specialty), and visit characteristics (site and prescribed drug number). The dependent variable was visits that included a prescription for a potentially inappropriate medication.

RESULTS

Overall, 176,661,994 ambulatory care visits by patients aged > or =65 years were identified in 2001-2004. Of these, 19.1% involved a prescription for a potentially inappropriate medication. Although the frequency of potentially inappropriate medication prescribing declined over the study period, 62.5% of elderly patients were exposed to such medications in 2004. The only patient characteristic associated with an increased likelihood of the prescribing of potentially inappropriate medications was female sex (male sex: odds ratio [OR] = 0.982 [95% CI, 0.980-0.983], P < 0.001). Physician characteristics associated with a greater likelihood of the prescribing of potentially inappropriate medications was male sex (OR = 1.206 [95% CI, 1.202-1.210], P < 0.001); older age (43-50 years: OR = 1.021 [95% CI, 1.018-1.025], P < 0.001; >/=51 years: OR = 1.238 [95% CI, 1.235-1.242], P < 0.001); and family medicine/general practice (OR = 1.267 [95% CI, 1.265-1.269], P < 0.001). For visit characteristics, significant associations were found with visits to a primary care clinic (OR = 1.887 [95% CI, 1.881-1.892], P < 0.001) and the number of drugs prescribed (4-6 drugs: OR = 2.701 [95% CI, 2.696-2.706], P < 0.001; > or =7 drugs: OR = 4.528 [95% CI, 4.517-4.538], P < 0.001). The most commonly prescribed types of potentially inappropriate medications were antihistamines (4.8% of all prescriptions in 48.3% of elderly patients), muscle relaxants/antispasmodics (4.0% and 40.3%, respectively), and long-acting benzodiazepines (2.4% and 21.4%). In 2004, the mean number of ambulatory care visits per patient was significantly higher among those who received potentially inappropriate medications compared with those who did not (30.78 vs 16.57, respectively; P < 0.001). Patients who received potentially inappropriate medications also had significantly more emergency department visits (0.27 vs 0.15; P < 0.001) and hospital admissions (0.46 vs 0.27; P < 0.001).

CONCLUSION

There was a high prevalence of the prescribing of potentially inappropriate medications at ambulatory care visits by elderly patients in Taiwan in 2001-2004.

Applying the 2003 Beers update to Medicaid/Medicare enrollees

Purpose

The purpose of this paper is to examine rates of potentially inappropriate prescribing in a population dually eligible for Medicare and Medicaid using the new 2003 Fick update, which revises the previous 1997 Beers list.

Design/methodology/approach

Cross sectional retrospective review of 2003 Centers for Medicare and Medicaid Service (CMS) Medicaid Pharmacy claims data. Claims data submitted for outpatient and nursing home residents for elderly enrollees dually eligible for Medicare and Medicaid were analyzed. Potentially inappropriate drug use was assessed using the 2003 Fick update to the previous 1997 Beers list. Inappropriate use was identified based on these criteria for drugs independent of diagnosis.

Findings

Of enrollees with drug use, 34 percent received an inappropriate drug per the 1997 Beers list; 47 percent per the 2003 Fick update. Hispanics had the highest percentage of drug recipients receiving an inappropriate drug in the Northeast region per the 2003 Fick update. Within therapeutic category, the number of inappropriate genitourinary products dispensed to total genitourinary products ranked the highest at 20 percent per the 2003 Fick update.

Practical implications

This study examines variations in Beers drug use in the elderly dually eligible Medicare and Medicaid population in 2003 by applying the 2003 Fick et al. update of the 1997 Beers list to one of the nation's largest sources of person‐specific data on prescribed drugs. Inappropriate use was identified for drugs independent of diagnosis. Of enrollees with drug use, 34 percent received an inappropriate drug per the 1997 Beers list; 47 percent per the 2003 Fick update. Within therapeutic category, the number of inappropriate genitourinary products dispensed to total genitourinary products ranked the highest at 20 percent per the 2003 Fick update. The paper's findings provide evidence that the potential use of inappropriate drugs in Hispanics should be considered separately from other ethnicity groups.

Originality/value

A markedly higher rate of potentially inappropriate drug use in the elderly Medicaid population exists following the Fick update. These findings provide evidence that the potential use of inappropriate drugs in Hispanics should be considered separately from other ethnicity groups. By comparing drug use based on therapeutic category, genitourinary products were found to have the highest potential for inappropriate prescribing.

Sex differences in inappropriate prescribing among elderly veterans

BACKGROUND

Previous studies have suggested that older women may be more likely than older men to receive potentially inappropriate prescriptions. A better understanding of sex differences in inappropriate prescribing can help inform the development of effective interventions.

OBJECTIVE

This study was conducted to assess sex differences in rates of inappropriate prescribing before and after accounting for potentially appropriate indications and to examine sex differences in predictors of inappropriate drug use.

METHODS

This was a retrospective cohort study of administrative data from the national Veterans Health Administration (VA). Participants were veterans aged >or=65 years who had >or=1 patient visit at VA outpatient facilities in fiscal year 1999 (FY99) and 2000 (FY00). The main outcome measure was the diagnosis-adjusted prevalence of 33 potentially inappropriate medications as judged by the Beers criteria in FY00: overall, by individual drug, and in 3 categories grouped by potential indication ("always avoid," "rarely appropriate," and "some indications").

RESULTS

The study population included 965,756 patients (946,641 men and 19,115 women). Women were more likely than men to receive inappropriate medications overall and in all 3 categories, even after accounting for diagnoses that may have justified the prescription. Women were more likely to receive 16 of the 33 medications (analgesics, psychotropic drugs, and anticholinergic agents), and men were more likely to receive 3 of the 33. After controlling for sociodemographic characteristics, number of medications, and care characteristics, women remained more likely to receive inappropriate drugs. Receipt of geriatric care was equally protective for men and women, although only a small proportion received this care. Psychiatric comorbidity was associated with inappropriate prescribing for men but not for women.

CONCLUSIONS

Analgesic, psychotropic, and anticholinergic medications that should be avoided contributed to higher rates of inappropriate drug use among older women than among older men. Targeted efforts to avoid these medications in older women may help reduce overall rates of inappropriate prescribing. Sex-stratified reporting of quality indicators that assess inappropriate prescribing among community-dwelling elders would help monitor the effectiveness of improvement efforts.

Criteria for high-risk medication use in Thai older patients

Many older patients have multiple diseases that require high-risk drug use, which may cause serious adverse effects. Criteria for the use of these drugs in older people are vital to the prevention of adverse events. This study aimed to develop explicit criteria for determining high-risk medication use in Thai older patients. It was conducted using a Delphi technique with the three-round survey of 16 geriatric medicine (GM) experts. A structured questionnaire with 56, 93, and 95 statements were devised for Rounds 1, 2, and 3, respectively. In each statement, the panelists were requested to confirm a high-risk drug in Round 1, and to rate on a 5-point Likert scale and classify the high-risk medication use in Rounds 2 and 3. The results showed that 77 practice statements (81.1%) that embraced the use of high-risk medications with potential adverse reactions, drug-disease interactions, and drug-drug interactions were agreed by the expert panel. A total of 23 statements (29.9%) were categorized as Groups 1-3 and the rest remained unclassified. Most high-risk medications were utilized in the central nervous system, musculoskeletal system, and cardiovascular system. Further studies are warranted to evaluate the criteria in terms of prescribing and monitoring medication use in older patients.

Randomized Trial to Improve Prescribing Safety in Ambulatory Elderly Patients

OBJECTIVES

To determine whether a computerized tool that alerted pharmacists when patients aged 65 and older were newly prescribed potentially inappropriate medications was effective in decreasing the proportion of patients dispensed these medications.

DESIGN

Prospective, randomized trial.

SETTING

U.S. health maintenance organization.

PARTICIPANTS

All 59,680 health plan members aged 65 and older were randomized to intervention (n=29,840) or usual care (n=29,840). Pharmacists received alerts on all patients randomized to intervention who were newly prescribed a targeted medication.

INTERVENTION

Prescription and age information were linked to alert pharmacists when a patient aged 65 and older was newly prescribed one of 11 medications that are potentially inappropriate in older people.

MEASUREMENTS

Physicians and pharmacists collaborated to develop the targeted medication list, indications for medication use for which an intervention should occur, intervention guidelines and scripts, and to implement the intervention.

RESULTS

Over the 1-year study, 543 (1.8%) intervention group patients aged 65 and older were newly dispensed prescriptions for targeted medications, compared with 644 (2.2%) usual care group patients (P=.002). For medication use indications in which an intervention should occur, dispensings of amitriptyline (P<.001) and diazepam (P=.02) were reduced.

CONCLUSIONS

This study demonstrated the effectiveness of a computerized pharmacy alert system plus collaboration between healthcare professionals in decreasing potentially inappropriate medication dispensings in elderly patients. Coupling data available from information systems with the knowledge and skills of physicians and pharmacists can improve prescribing safety in patients aged 65 and older.

Inappropriate medication use in elderly lebanese outpatients: prevalence and risk factors

BACKGROUND

Inappropriate use of medications has become an international cause for concern in geriatric patients, who are at high risk of drug-related morbidity. This study is the first attempt to determine the prevalence of inappropriate drug use in elderly Lebanese outpatients, using community pharmacy data, and to identify factors that predict potentially inappropriate drug intake in this population.

METHODS

Records of elderly patients aged > or =65 years were selected from different community pharmacies. Each patient profile was reviewed and to confirm patient record information, in-person interviews were conducted with elderly patients between November 2004 and May 2005 by qualified pharmacists. Based on a literature review describing guidelines for the inappropriate use of medications in the elderly, courses of therapy were assessed and classified as either appropriate or inappropriate. Courses of therapy that were judged inappropriate were further classified according to the specific area of inappropriate use (i.e. Beers' criteria, duplicate therapy, indication, dose, dose frequency including missing doses, duration and discontinuation of therapy, adverse effects, drug-drug and/or drug-disease interactions, and poor memory). Statistical analyses were performed to estimate the prevalence of inappropriate medication use and to identify potentially predictive factors of such use arising from patients' sociodemographic characteristics, health factors and drug regimen intake.

RESULTS

A total of 350 elderly patient profiles were reviewed, from which 277 evaluable records were obtained. More than half (59.6%) of the patients taking drugs at the time of the study were taking at least one inappropriate medication. Inappropriate medication use was most frequently identified in terms of Beers' criteria (22.4%), missing doses (18.8%) or incorrect frequency of administration of drugs (13.0%). Factors predicting potentially inappropriate drug intake included female sex (65.7% vs 53.3% for males, p = 0.03) and alcohol intake (p = 0.007). There were also significant associations between the likelihood of use of an inappropriate drug and (i) increased number of medical illnesses (p < 0.00002); and (ii) consumption of an over-the-counter drug (OTC) and/or prescription drug (p = 0.048 and p = 0.0035, respectively). The likelihood of use of an inappropriate drug was higher again when patients concurrently used both OTC and prescription drugs (p < 0.0002).

CONCLUSION

The present study is the first to describe and assess inappropriate medication use by elderly outpatients in the Lebanese community setting. With increasing availability of newer and more appropriate medications, use of potentially inappropriate drugs may decrease. Pharmacists have a major role to play in counselling patients about the importance of appropriate drug use.

Suboptimal Medication Use and Mortality in an Older Adult Community-Based Cohort: Results From the Hispanic EPESE Study

BACKGROUND

Numerous methods have been used to evaluate medication management quality in older adults; however, their predictive validities are unknown. Major medication quality indicators include polypharmacy, drug-drug interactions, and inappropriate medication use. To date, no study has attempted to evaluate the three approaches systematically or the effect of each approach on mortality in a Hispanic population. Our objective was to evaluate the relationship between polypharmacy, drug-drug interactions, and inappropriate medication use on the mortality of a community-based population of Mexican American older adults.

METHODS

We used a life table survival analysis of a longitudinal survey of a representative sample of 3,050 older Mexican Americans of whom 1,823 were taking prescription and over-the-counter medications.

RESULTS

After adjustment for relevant covariates, use of more than four different medications (polypharmacy) was independently associated with mortality. The presence of major drug interactions and the use of inappropriate medications were not significantly associated with mortality in our study sample.

CONCLUSION

Polypharmacy (>4 medications) is significantly associated with mortality in Mexican American older adults. This community-based study is the first to demonstrate a direct association between polypharmacy and mortality in this population.

Perception of potentially inappropriate medication in elderly patients by Slovak physicians

PURPOSE

The aim of the present study was to determine the risk perception of potentially inappropriate drug treatment of elderly patients by Slovak physicians. In Slovakia, a list of such drugs is not available.

METHODS

The study sample consisted of 600 patients aged > or =65 years hospitalized at the Department of Internal Medicine in a Slovak general hospital between 1 December 2003 and 31 March 2005. The use of potentially inappropriate drugs at the time of hospital admission and discharge was compared. Potentially inappropriate drug use was defined by Beers 2003 criteria. In addition, 206 physicians were asked to mark the drugs that they considered potentially inappropriate for elderly patients out of a list provided in a questionnaire analysis.

RESULTS

Out of 600 patients 20.2% and 20% were treated with at least one potentially inappropriate drug at the time of hospital admission and discharge, respectively. Hospitalization had no significant influence on the number of potentially inappropriate medicines used. The most frequently prescribed potentially inappropriate drugs were digoxin >0.125 mg/day and ticlopidine. Out of 206 responding physicians only 4.9% considered ticlopidine as potentially inappropriate for elderly patient. On the other hand, more than 20% of respondents were aware of the potential inappropriateness of amitriptyline, diazepam and chlordiazepoxide. Mentioned drugs were observed in less than 2% of study population (n = 600).

CONCLUSIONS

The results of the questionnaire analysis in physicians as well as the prevalence of potentially inappropriate medication demonstrate that Slovak clinicians are aware of the risk of certain treatments in elderly patients.

Potentially inappropriate prescribing in elderly veterans: are we using the wrong drug, wrong dose, or wrong duration?

OBJECTIVES

To identify the extent of inappropriate prescribing using criteria for proper use developed by the Agency for Healthcare Research and Quality (AHRQ) and dose-limitation criteria defined by Beers, as well as to describe duration of use and patient characteristics associated with inappropriate prescribing for older people.

DESIGN

Retrospective national Veterans Health Administration (VA) administrative database analysis.

SETTING

VA outpatient facilities during fiscal year 2000 (FY00).

PARTICIPANTS

Veterans aged 65 and older having at least one VA outpatient visit in FY00 (N=1,265,434).

MEASUREMENTS

Operational definitions of appropriate use were developed based on recommendations of an expert panel convened by the AHRQ (Zhan criteria). Inappropriate use was identified based on these criteria and inappropriate use of drugs per Beers criteria for dose-limitations in older people. Furthermore, duration of use and patient characteristics associated with inappropriate use were described.

RESULTS

After adjusting for diagnoses, dose, and duration, inappropriate prescribing decreased from 33% to 23%. Exposure to inappropriate drugs was prolonged. Pain relievers, benzodiazepines, antidepressants, and musculoskeletal agents constituted 61% of inappropriate prescribing. Whites, patients with psychiatric comorbidities, and patients receiving more medications were most likely to receive inappropriate drugs. Women were more likely to receive Zhan criteria drugs; men were more likely to receive dose-limited drugs

CONCLUSION

For the most part, the Zhan criteria did not explain inappropriate prescribing, which includes problems related to dose and duration of prescriptions. Interventions targeted at prescriptions for pain relievers, benzodiazepines, antidepressants, and musculoskeletal agents may dramatically decrease inappropriate prescribing and improve patient outcomes.

Use of Prescription Drugs: Rising or Declining?

Prescribing practices are a reflection of health professionals' abilities to discriminate among the various choices of drugs and determine the ones that will most benefit their patients. As selective as practitioners must be, they cannot limit themselves to knowing only those drugs that fit within the dominant paradigm of acute care. They must broaden their exposure to incorporate knowledge of drugs that permeate clients' lives through media and self-administration. Health promotion drug use is just emerging as a prescriptive activity, but it will become more significant in the future. Primary and secondary prevention drug uses are in flux, and tertiary prevention drug use is likely to overwhelm our system, particularly with the baby boom generation, until our society can switch its focus to more health promotion and disease prevention. It is imperative that health professionals develop shared decision-making capabilities for client education and appropriate prescribing. Only when the health care system exhibits a true client-provider partnership will the "five rights"-right drug, right dose, right route, right time, right client-be accurately applied. With the increasing and overwhelming costs of prescription drugs, health practitioners cannot afford to sit idle; as professionals and stakeholders, they must engage health policy makers and persuade these entities to share their concerns and views, and help their clients, the profession, and themselves.