Potentially inappropriate medication use among geriatric patients in primary care setting: A cross-sectional study using the Beers, STOPP, FORTA and MAI criteria

Adopting STOPP/START Criteria Version 3 in Clinical Practice: A Q&A Guide for Healthcare Professionals

The growing complexity of geriatric pharmacotherapy necessitates effective tools for mitigating the risks associated with polypharmacy. The Screening Tool of Older Persons' Potentially Inappropriate Prescriptions (STOPP)/Screening Tool to Alert doctors to Right Treatment (START) criteria have been instrumental in optimizing medication management among older adults. Despite their large adoption for improving the reduction of potentially inappropriate medications (PIM) and patient outcomes, the implementation of STOPP/START criteria faces notable challenges. The extensive number of criteria in the latest version and time constraints in primary care pose practical difficulties, particularly in settings with a high number of older patients. This paper critically evaluates the challenges and evolving implications of applying the third version of the STOPP/START criteria across various clinical settings, focusing on the European healthcare context. Utilizing a "Questions & Answers" format, it examines the criteria's implementation and discusses relevant suitability and potential adaptations to address the diverse needs of different clinical environments. By emphasizing these aspects, this paper aims to contribute to the ongoing discourse on enhancing medication safety and efficacy in the geriatric population, and to promote more person-centred care in an aging society.

Physicians' perceptions and awareness of adverse effects of proton pump inhibitors and impact on prescribing patterns

Background: Heightened scrutiny surrounds the inappropriate use of proton pump inhibitors (PPIs) due to concerns regarding potential serious adverse effects (AEs). Understanding the impact of these AEs on real-world practice is crucial. This study aimed to assess physicians' perceptions, experiences, awareness, and beliefs regarding published data on potential AEs associated with PPIs. Additionally, it sought to determine alterations in PPI prescribing patterns resulting from these AEs, explore attitudes towards PPI use, and ascertain recommendations for PPI use in clinical scenarios with varying levels of risk for upper gastrointestinal bleeding (UGIB). Method: A quantitative, cross-sectional study utilized a self-administered questionnaire, inviting 282 physicians from 55 primary healthcare centers and 334 internal medicine physicians from seven governmental hospitals to participate. Results: With a response rate of 87.8% (541/616), 74% (95% CI: 70.2-77.7) of respondents were somewhat or very familiar with published data on PPI AEs. Among the familiar, 69.5% (CI: 65.2-73.5) had somewhat or very much changed their PPI prescribing patterns. General concerns about AEs when prescribing PPIs were reported by 62% (CI: 56.7-65.1). Respondents displayed awareness of a median (IQR) of 15 (9) different AEs associated with long-term PPI use, including osteoporosis or osteopenia (90.2%), hypomagnesemia (81.5%), vitamin B12 deficiency (80.6%), and bone fracture (80.0%). Respondents believed that PPIs elevate the risk for a median (IQR) of 7 (6) different AEs, with osteoporosis or osteopenia (81.8%) being the most common, followed by hypomagnesemia (67.1%), and vitamin B12 deficiency (62.3%). The most common strategies for PPI de-escalation were PPI discontinuation (61%) and using PPI on-demand/as-needed (57.9%). The majority (87.4%) agreed or strongly agreed that PPI overuse is prevalent in Kuwait and 78.2% emphasized the necessity for large-scale education on rational PPI use for medical staff and the public. In the UGIB prevention scenarios, 43.6% recommended appropriately the PPI discontinuation in the minimal-risk scenario, while 56% recommended appropriately the PPI continuation in the high-risk scenario. Associations and comparative analyses revealed predictors influencing physicians' practices and attitudes toward PPI usage. Conclusion: These findings lay the foundation for future research and targeted interventions aimed at optimizing PPI prescribing practices and ensuring patient safety.

Potentially Inappropriate Medications in Hospitalized Older Patients in Tabuk, Saudi Arabia Using 2023 Beers Criteria: A Retrospective Multi-Centric Study

Purpose

Older persons are frequently prescribed several medications; therefore, inappropriate medication prescriptions are common. Prescribing potentially inappropriate medications (PIMs) poses a serious risk and hence, we aimed to assess the PIMs in older patients in Tabuk, using the 2023 Beers criteria.

Patients and Methods

A retrospective cross-sectional study was carried out, including older persons ≥65 years of age admitted in two government hospitals from June 2022 to May 2023, and prescribed with five or more medications. PIMs were assessed using the 2023 Beers criteria. Descriptive analysis was performed for the categorical and continuous variables. Logistic regression was used to assess the influence of age, gender, number of medications and comorbidities on PIMs using SPSS version 27.

Results

The study included 420 patients. The mean age of the participants was 75.52 ± 8.70 years (range, 65-105 years). There was a slightly higher proportion of females (52%). The prevalence of PIMs was 81.43%, where 35.41% were prescribed one PIM, 26.48% were prescribed two PIMs, and 17.32% were prescribed three PIMs. The proportion of medications considered potentially inappropriate among older patients was 70.11%, and proton pump inhibitors were the most commonly prescribed medication (52.99%). The proportion of medications to be used with caution was 19.55%, with diuretics being the most frequently administered medication (91.43%). Gender and comorbidity did not influence PIMs, but age and number of medications significantly influenced the likelihood of PIMs.

Conclusion

PIMs are prevalent among older people and are significantly associated with age and multiple medications. Caution should be exercised while prescribing medications to older persons. Frequent audits should be performed to assess PIMs, and clinicians should be informed of the same to avoid serious outcomes associated with PIMs. Interventions designed to reduce PIM need to be initiated.

Potentially Inappropriate Psychotropic Drugs in Nursing Homes: An Italian Observational Study

BACKGROUND AND OBJECTIVES

Physicians often face difficulties in selecting appropriate medications for older adults with multiple comorbidities. As people age, they are more likely to be living with a number of chronic conditions (multimorbidity) and be prescribed a high number of medications (polypharmacy). Multimorbidity is frequent in nursing home (NH) residents and the use of potentially inappropriate medications, especially psychotropic drugs, is widespread. This retrospective cross-sectional cohort study examined the frequency of potentially inappropriate psychotropic drugs using the Beers, Screening Tool of Older Persons' Prescriptions/Screening Tool to Alert doctors to Right Treatment (STOPP/START) and Fit fOR The Aged (FORTA) criteria, and their association with mortality.

METHODS

This retrospective cross-sectional cohort study was conducted on a sample of long-term care NHs across Italy. Of the 34 NHs with an electronic medical records system, 27 met the inclusion criteria, with complete web-based case report forms (CRFs). Residents under the age of 65 years were excluded. We calculated the prevalence of potentially inappropriate psychotropics drugs (antipsychotics, antidepressants and anxiolytics/hypnotics) according to three criteria for prescriptive appropriateness. Univariate and multivariate correlations were examined, taking into account age, sex, comorbidities, and the number of psychotropic drugs, to analyse the relationship between inappropriate psychotropic use and mortality rates. The rate of inappropriate psychotropic prescriptions was calculated with the prevalence of residents receiving potentially inappropriate psychotropic drugs according to the three criteria. We used a logistic model to check for a possible predictive relationship between inappropriate use of psychotropics and mortality. The study evaluated differences in prescriptive appropriateness among NHs by analysing the proportions of potentially inappropriately treated residents at the last visit. Differences were compared with the overall sample mean using confidence intervals (CIs) calculated using Wald's method.

RESULTS

This study involved 2555 residents, of whom 1908 (74.7% of the total) were treated with psychotropic drugs; 186 (7.3% of the total) were exposed to at least one psychotropic drug considered potentially inappropriate according to the FORTA criteria. Analysis using the Beers criteria showed that 1616 residents (63.2% of the total) received at least one psychotropic drug considered potentially inappropriate. In line with the Beers recommendation, patients receiving at least three psychotropic drugs were also included and 440 were identified (17.2% of the total sample). According to the STOPP criteria, 1451 residents (56.8% of the total sample) were prescribed potentially inappropriate psychotropic drugs. No correlation was found between potentially inappropriate use of psychotropic drugs and mortality, in either univariate analysis or in a multivariate model adjusted for age, sex and comorbidity index.

CONCLUSIONS

Different criteria for appropriate drug prescription identify very different percentages of patients in NHs exposed to psychotropics considered potentially inappropriate. The Beers and STOPP/START criteria identified a larger percentage of patients exposed in NHs than FORTA.

Performance of potentially inappropriate medications assessment tools in older Indian patients with cancer

BACKGROUND

Polypharmacy and potentially inappropriate medication (PIM) use are common problems in older adults. Safe prescription practices are a necessity. The tools employed for the identification of PIM sometimes do not concur with each other.

METHODS

A retrospective analysis of patients ≥60 years who visited the Geriatric Oncology Clinic of the Tata Memorial Hospital, Mumbai, India from 2018 to 2021 was performed. Beer's-2015, STOPP/START criteria v2, PRISCUS-2010, Fit fOR The Aged (FORTA)-2018, and the EU(7)-PIM list-2015 were the tools used to assess PIM. Every patient was assigned a standardized PIM value (SPV) for each scale, which represented the ratio of the number of PIMs identified by a given scale to the total number of medications taken. The median SPV of all five tools was considered the reference standard for each patient. Bland-Altman plots were utilized to determine agreement between each scale and the reference. Association between baseline variables and PIM use was determined using multiple logistic regression analysis.

RESULTS

Of the 467 patients included in this analysis, there were 372 (79.66%) males and 95 (20.34%) females with an average age of 70 ± 5.91 years. The EU(7)-PIM list was found to have the highest level of agreement given by a bias estimate of 0.010, the lowest compared to any other scale. The 95% CI of the bias was in the narrow range of -0.001 to 0.022, demonstrating the precision of the estimate. In comparison, the bias (95%) CI of Beer's criteria, STOPP/START criteria, PRISCUS list, and FORTA list were -0.039 (-0.053 to -0.025), 0.076 (0.060 to 0.092), 0.035 (0.021 to 0.049), and -0.148 (-0.165 to -0.130), respectively. Patients on polypharmacy had significantly higher PIM use compared to those without (OR = 1.47 (1.33-1.63), p = <0.001).

CONCLUSIONS

The EU(7)-PIM list was found to have the least bias and hence can be considered the most reliable among all other tools studied.

Potentially Inappropriate Medications Use and Associated Factors Among Older Patients on Follow-Up at the Chronic Care Clinic of Hiwot Fana Comprehensive Specialized Hospital in Eastern Ethiopia

Background

Potentially inappropriate medications (PIMs) use often cause to poor health outcomes in older patients. There is a dearth of information on PIMS use in this population of patients seeking treatment at Hiwot Fana Comprehensive Specialized Hospital.

Objective

To assess PIMs use and associated factors among older patients receiving follow-up treatment at the chronic care clinic of Hiwot Fana Comprehensive Specialized Hospital in eastern Ethiopia.

Methods

A retrospective cross-sectional study using medical records of 419 older patients was conducted. older patients, aged 65 years or older, treated in the ambulatory care clinic were included. Simple random sampling technique was used. PIMs use was identified by using the 2023 American Geriatrics Society Beers Criteria (AGS Beers Criteria) and Screening Tool of Older People's Potentially Inappropriate Prescriptions Criteria and Screening Tool to Alert Doctors to Right Treatment (STOPP/START) version 2 criteria. The multivariable logistic regression analysis was employed to identify factors associated with PIMs use. The strength of statistical association was measured by adjusted odds ratio (aOR) and 95% CI. P values < 0.05 were considered statistically significant.

Results

A total of 419 patients' medical records were reviewed. Of these, 411 patients' medical records fulfilled the inclusion criteria and were considered for final analysis. About 56.9% (n= 234) of the study population was women. The prevalence of PIMs use was 28.5% and 18.5%, according to 2023 AGS Beers Criteria and STOPP/START version 2 criteria, respectively. In accordance with 2023 AGS Beers Criteria, male sex (aOR = 1.78; 95% CI, 1.10-2.87), diabetes mellitus (aOR = 0.35; 95% CI, 0.19-0.62), and chronic kidney disease (aOR = 6.68; 95% CI, 2.55-9.32) were found to be the determining factors for PIMs use. According to STOPP/START version 2 criteria, deep vein thrombosis, diabetes mellitus, hypertension, and advanced age were the primary factors influencing PIMs use.

Conclusions

Compared with other study findings from across the world, the prevalence of PIMs use was low. Based on 2023 AGS Beers Criteria, male sex, diabetes mellitus, and chronic kidney disease were found to be the determinant factors for PIMs use. Deep vein thrombosis, diabetes mellitus, hypertension, and advanced age were significant factor of PIMs use according STOPP/START version 2 criteria.

Medication use problems and factors affecting older adults in primary healthcare

BACKGROUND

As the largest demographic group utilizing primary healthcare facilities, older adults often face the challenge of managing multiple chronic illnesses, leading to numerous medications.

OBJECTIVE

The present study aims to assess medication use problems among older adults and explore the factors affecting them in primary healthcare settings.

METHODS

A mixed-method study was conducted to establish a baseline understanding of the perspectives and challenges faced by older adults, with regards to medication use. Translated Medication Use Questionnaire (MedUseQ), a patient-centered tool, was distributed to older adults above 60 in primary healthcare settings to assess their frequency of problems related to medication use. Fifteen semi-structured interviews were conducted to explore this topic in depth. Descriptive and inferential analyses were conducted with quantitative data. Interviews were transcribed verbatim, and thematic analysis was conducted. Quantitative and qualitative findings data were triangulated.

RESULTS

The study involved 393 participants. The most common problems with regards to medication use were polypharmacy (55.4%), administration difficulties (48.4%), limited awareness about adverse drug events (47.3%), issues with adherence (46.5%), and accessibility to primary healthcare (42.7%). Approximately 55% were satisfied with the older adult-centered medication use services by pharmacist and doctors. The qualitative findings showed that major factors affecting medication use were forgetfulness, language barriers, lack of awareness, transportation problems, long waiting times, and multiple visits to healthcare facilities.

CONCLUSION

The findings of this study reveal that a significant proportion, around 50%, of the older adult population face challenges with medication use in Penang. These difficulties mainly stem from medication administration, adherence, accessibility, polypharmacy, and inadequate medication knowledge. The qualitative analysis further highlighted several factors that contribute to such medication-related problems. Given the rapidly aging Association of Southeast Asian Nations (ASEAN) population, it is essential to devise effective solutions and strategies to tackle medication use-related issues among older adults.

Potentially inappropriate medicine use and predicting risk factors in hospitalized older adult patients: findings of a prospective observational study from Ethiopia

BACKGROUND

Older patients are fragile and more susceptible to medication-related problems requiring a strict assessment of their medicine list. The present study was conducted with the intention to assess the quality use of medicines in older adult patients by detecting potentially inappropriate medicine use and its predictive risk factors.

METHODS

This prospective cross-sectional study involved 162 older medical patients admitted to Jimma Medical Center. A data abstraction format is employed to capture relevant information. Each patient was assessed for the presence of potentially inappropriate medicine using the 2019 American Geriatrics Associations Beers Criteria. Descriptive statistics and logistic regression analysis were conducted using STATA 15.0. A p value < 5% was considered a cutoff point for declaring statistical significance.

RESULTS

Over the hospital stay, 103 (63.6%) participants were on polypharmacy (5-9 concurrent medicines per patient), while 16 (9.9%) were on hyper polypharmacy (≥ 10 concurrent medicines per patient). On medicine use assessment using the Beers criteria, at least one potentially inappropriate medicine was detected in 118 (73%) participants. Overall, 191 potentially inappropriate medicines (range, 0 to 4) were identified, and 27 (14.1%) of these were associated with avoiding recommendations. Furosemide [83 (43%)], tramadol [26 (14.5%)], and spironolactone [22 (11.4%)] were the top three most frequent potentially inappropriate medicines identified. In terms of mode of prescription, 187 (96.9%) potentially inappropriate medicines were prescribed on a scheduled basis. Older adult patients with thrombocytopenia had a lower probability of taking potentially inappropriate medicine, while the odds of potentially inappropriate medicine use were 7.35 times higher in patients diagnosed with heart failure.

CONCLUSIONS

Nearly three-fourths of the participants had potentially inappropriate medicine in their medicine list. Therefore, generating local evidence on the clinical, economic, and humanistic consequences may help in determining whether the Beers criteria should be taken into account when prescribing medicine to older adults. Interventions targeting older adult patients with heart failure might reduce inappropriate medicine use.

Potentially Inappropriate Medication Dispensing in Outpatients: Comparison of Different Measurement Approaches

Purpose of the Research

This paper aims at comparing different approaches to measure potentially inappropriate medication (PIM) with routinely collected data on prescriptions, patient age institutionalization status (ie in nursing home or in the community). A secondary objective is to measure the rate and prevalence of PIM dispensing and to identify problematic practices in Switzerland.

Material and Methods

The studied population includes about 90,000 insured over 17 years old from a Swiss health maintenance organization in 2019 and 2020. We computed and compared the number of PIM per patient for Beers criteria, Priscus list, Laroche, NORGEP and Prescrire approaches. We also created a composite indicator that accounts for the specificities of the Swiss context (adaptation to the Swiss drugs' market, recommendations in force related to sleeping pills, anxiolytics and NSAIDs). We also stratified the analysis per physician, including initiation and cessation of PIM prescription.

Results

Our comparison revealed similarities between the approaches, but also that each of them had specific gaps that provides further motivation for the development of a composite approach. PIM rate was particularly high for sleeping pills, anxiolytics, NSAIDs, even when analyses were limited to chronic use. Drugs with anticholinergic effect were also frequently prescribed. Based on our composite indicator, 27% of insured over 64 years old received at least one PIM in 2020, and 8% received more than one. Our analyses also reveal that for sleeping pills and anxiolytics, half of the volume (or prevalence?) occurs in the <65 population. We observed strong variations between physicians and a significant proportion of new users among patients with PIM.

Conclusion

Our results show that PIMs prescribing is very frequent in Switzerland and is driven mostly by a few drug categories. There is important physician variation in PIM prescribing that warrants the development of intervention targeted at high PIM-prescribers.

Potentially Inappropriate Medications in Older Adults-Prevalence, Trends and Associated Factors: A Cross-Sectional Study in Saudi Arabia

(1) Background: Potentially inappropriate medications (PIMs) in older adults are associated with drug-related problems, adverse health consequences, repeated hospital admissions and a higher risk of mortality. In Saudi Arabia and some Arab countries, studies of PIMs among large cohorts of older adults are limited. This study aimed to determine the prevalence of PIMs, trends and associated factors among outpatient older adults in Saudi Arabia. (2) Methods: A cross-sectional study was carried out. Over three years (2017-2019), data on 23,417 people (≥65 years) were retrieved from outpatient clinics in a tertiary hospital in Riyadh, Saudi Arabia. PIMs were assessed using the 2019 Beers Criteria. Covariates included sex, age, nationality, number of dispensed medications, and number of diagnoses. A generalized estimating equation model was used to assess trends and factors associated with PIMs. (3) Results: The prevalence of PIMs was high and varied between 57.2% and 63.6% over the study years. Compared with 2017, the prevalence of PIMs increased significantly, with adjusted odds ratios (OR) (95% confidence interval (95% CI)) of 1.23 (1.18-1.29) and 1.15 (1.10-1.21) for 2018 and 2019, respectively. Factors associated with being prescribed PIMs included ≥5 dispensed medications (OR_adjusted = 23.91, 95% CI = 21.47-26.64) and ≥5 diagnoses (OR_adjusted = 3.20, 95% CI = 2.88-3.56). Compared with females, males had a lower risk of being prescribed PIMs (OR_adjusted = 0.90, 95% CI = 0.85-0.94); (4) Conclusions: PIMs were common with an increasing trend among older adults in Saudi Arabia. A higher number of dispensed medications, increased number of diagnoses and female sex were associated with being prescribed PIMs. Recommendations on how to optimize prescriptions and implement de-prescribing strategies are urgently needed.

Prevalence of Potentially Inappropriate Prescriptions According to the New STOPP/START Criteria in Nursing Homes: A Systematic Review

The demand for long-term care is expected to increase due to the rising life expectancy and the increased prevalence of long-term illnesses. Nursing home residents are at an increased risk of suffering adverse drug events due to inadequate prescriptions. The main objective of this systematic review is to collect and analyze the prevalence of potentially inadequate prescriptions based on the new version of STOPP/START criteria in this specific population. Databases (PubMed, Web of Science and Cochrane) were searched for inappropriate prescription use in nursing homes according to the second version of STOPP/START criteria. The risk of bias was assessed with the STROBE checklist. A total of 35 articles were assessed for eligibility. One hundred and forty nursing homes and more than 6900 residents were evaluated through the analysis of 13 studies of the last eight years. The reviewed literature returned prevalence ranges between 67.8% and 87.7% according to the STOPP criteria, according to START criteria prevalence ranged from 39.5% to 99.7%. The main factors associated with the presence of inappropriate prescriptions were age, comorbidities, and polypharmacy. These data highlight that, although the STOPP/START criteria were initially developed for community-dwelling older adults, its use in nursing homes may be a starting point to help detect more efficiently inappropriate prescriptions in institutionalized patients. We hope that this review will help to draw attention to the need for medication monitoring systems in this vulnerable population.

Detecting Medication Risks among People in Need of Care: Performance of Six Instruments

INTRODUCTION

Numerous tools exist to detect potentially inappropriate medication (PIM) and potential prescribing omissions (PPO) in older people, but it remains unclear which tools may be most relevant in which setting.

OBJECTIVES

This cross sectional study compares six validated tools in terms of PIM and PPO detection.

METHODS

We examined the PIM/PPO prevalence for all tools combined and the sensitivity of each tool. The pairwise agreement between tools was determined using Cohen's Kappa.

RESULTS

We included 226 patients in need of care (median (IQR age 84 (80-89)). The overall PIM prevalence was 91.6 (95% CI, 87.2-94.9)% and the overall PPO prevalence was 63.7 (57.1-69.9%)%. The detected PIM prevalence ranged from 76.5%, for FORTA-C/D, to 6.6% for anticholinergic drugs (German-ACB). The PPO prevalences for START (63.7%) and FORTA-A (62.8%) were similar. The pairwise agreement between tools was poor to moderate. The sensitivity of PIM detection was highest for FORTA-C/D (55.1%), and increased to 79.2% when distinct items from STOPP were added.

CONCLUSION

Using a single screening tool may not have sufficient sensitivity to detect PIMs and PPOs. Further research is required to optimize the composition of PIM and PPO tools in different settings.

Prescribing Practices in Geriatric Patients with Cardiovascular Diseases

Inappropriate prescribing (IP) increases the risk of adverse medication reactions and hospitalizations in elderly patients. Therefore, it is crucial to evaluate prescribing patterns among this population. This study was designed to assess the prevalence of potentially inappropriate medication (PIMs) use and potential prescribing omissions (PPOs) among geriatrics with cardiovascular diseases (CVDs). In addition, it determined the predictors for IP in this population. A multi-center study was performed retrospectively on 605 patients' medical records collected randomly from seven governmental hospitals in Kuwait. Three of these hospitals have specialized cardiac centers (tertiary care). Inclusion criteria were age ≥ 65 years, diagnosed with at least one CVD, and attended the outpatient clinic during the last 6 months before data collection. A total of 383 patients (63.3%; 95% CI: 59.3-67.1%) were found using at least one PIM or having PPO or both, based on STOPP/START criteria. Three hundred and ninety-one patients (64.6%; 95% CI: 60.7-68.4%) were prescribed PIMs categorized as C and/or D medicines according to the Euro-FORTA list. Over one-quarter (28.8%; 95% CI: 25.2-32.6%) of the patients had drug-drug interactions class D that require therapy modification and/or X that should be avoided. Patients taking ≥ five medications had significantly higher PIMs based on STOPP and FORTA criteria, drug-drug interactions (p < 0.001), and significantly higher PPOs based on START criteria (p = 0.041). Patients with three or more chronic diseases had significantly higher PIMs based on STOPP and FORTA criteria and PPOs based on START criteria (p-values: 0.028, 0.035, and 0.005, respectively). Significantly higher PIMs based on STOPP criteria and PPOs based on START criteria were found in general hospitals compared to specialized cardiac centers (p= 0.002, p= 0.01, respectively). These findings highlight the need to develop and implement multifaceted interventions to prevent or minimize inappropriate prescribing among the geriatric population with CVDs in Kuwait.

Potentially Inappropriate Medication Use in Patients with Dementia

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

Evaluating Inappropriate Medication Prescribing Among Elderly Patients in Palestine Using the STOPP/ START Criteria

Background

Elderly patients suffer from chronic diseases and are prone to polypharmacy and potentially inappropriate prescribing (PIP). This study aimed to identify potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) among elderly patients in a tertiary care hospital setting and to estimate the prevalence of polypharmacy.

Methods

This multicenter retrospective observational study reviewed patient data from two major Palestinian hospitals. The collected data included patient demographics, comorbidities, and medications administered during hospitalization and discharge. The study included 247 patients aged ≥ 65 years hospitalized between January 2019 and December 2019. The STOPP/START criteria version 2 was used to identify the prevalence of PIMs and PPOs. Clinical pharmacists verified the data, and SPSS was used for data analysis. Descriptive statistics, one-tailed bivariate correlations, and Pearson’s test were applied to the variables of interest to examine their association with the STOPP/START criteria.

Results

A total of 247 patients were included in the study, and 50.2% were females. As a result, 165 (66.8%) participants were identified with PIPs, including 30 patients with PPOs, 91 with PIMs, and 44 with both. Furthermore, the prevalence of PIP during hospitalization and discharge was 56.29% and 64.39%, respectively. Polypharmacy (5–9 medications) was 44.5% and 52.1% during hospitalization and discharge, respectively, and excessive polypharmacy (ten medications or more) was 33.6% and 16.4% during hospitalization and discharge, respectively. Moreover, 47.3% of the patients had a comorbidity index of ≥ 5.

Conclusion

This study identified a high prevalence of PIPs among elderly patients during hospital admission and discharge. In addition, more than half of the geriatric patients in this study had PIP and a high prevalence of polypharmacy. Therefore, this study emphasizes the importance of adapting evidence-based tools, such as the STOPP/START criteria, to optimize patient medication therapy and guide prescribers in identifying and resolving PIMs and PPOs.

Risk factors for potentially inappropriate medication use in older adults: a cohort study

BACKGROUND

Much of the knowledge on the use of potentially inappropriate medications (PIM) in older adults is derived from cross-sectional studies, with little known about the risk factors over time.

AIM

Longitudinal analysis was applied to estimate the occurrence and risk factors of PIM use among older adults in a 10-year follow-up.

METHOD

Longitudinal study with 418 older adult residents of a capital city of Central-West Brazil. The PIM were classified according to the Beers criteria 2019. The usage rate was calculated at baseline (2008) and at the 10-year follow-up moment (2018). Analysis of predictors (sociodemographic, self-rated health, hospitalization, number of comorbidities, polypharmacy, diabetes, hypertension, hypercholesterolemia and nutritional status) was performed using Generalized Estimating Equation (GEE) models.

RESULTS

Mean age at baseline was 70.6 years (SD 7.1) and 76% were women; 221 older adults took part in the follow up. The rate of PIM use was 50.4% at baseline and 57.5% at the 10-year follow-up. Multiple analysis showed that PIM use in the cohort was statistically higher in the older adults with a history of hospitalization (RR_adj 1.20; 95% CI 1.01-1.40), with three or more diseases (RR_adj 1.41; 95% CI 1.14-1.74), with polypharmacy (RR_adj 1.81; 95% CI 1.47-2.24) and with diabetes mellitus (RR_adj 1.24; 95% CI 1.05-1.47).

CONCLUSION

A high level of potentially inappropriate medication use was observed, reaching 50% of the older adults, with a 7% increase in the prevalence over the 10-year follow-up period. Hospitalization, multimorbidities, polypharmacy and diabetes mellitus were associated with the use of these medications. Interventions for surveillance of the deprescribing process need to be encouraged to avoid potential harm caused by the use of medications.

The patterns and implications of potentially suboptimal medicine regimens among older adults: a narrative review

In the context of an ageing population, the burden of disease and medicine use is also expected to increase. As such, medicine safety and preventing avoidable medicine-related harm are major public health concerns, requiring further research. Potentially suboptimal medicine regimens is an umbrella term that captures a range of indicators that may increase the risk of medicine-related harm, including polypharmacy, underprescribing and high-risk prescribing, such as prescribing potentially inappropriate medicines. This narrative review aims to provide a background and broad overview of the patterns and implications of potentially suboptimal medicine regimens among older adults. Original research published between 1990 and 2021 was searched for in MEDLINE, using key search terms including polypharmacy, inappropriate prescribing, potentially inappropriate medication lists, medication errors, drug interactions and drug prescriptions, along with manual checking of reference lists. The review summarizes the prevalence, risk factors and clinical outcomes of polypharmacy, underprescribing and potentially inappropriate medicines. A synthesis of the evidence regarding the longitudinal patterns of polypharmacy is also provided. With an overview of the existing literature, we highlight a number of key gaps in the literature. Directions for future research may include a longitudinal investigation into the risk factors and outcomes of extended polypharmacy, research focusing on the patterns and implications of underprescribing and studies that evaluate the applicability of tools measuring potentially inappropriate medicines to study settings.

Potentially Inappropriate Medication and Polypharmacy in Nursing Home Residents: A Cross-Sectional Study

Inappropriate prescribing in the elderly is a risk factor for higher adverse drugs reactions, hospitalisation, and mortality rates. Therefore, it is necessary to identify irrational prescriptions and implement interventions to improve geriatric clinical practices in nursing homes. This study aimed to examine and compare the prevalence of potentially inappropriate medications in nursing home residents using three different updated criteria: 2019 Beers criteria, PRISCUS list, and v2 STOPP criteria, and to determine the prevalence of potential prescribing omissions according to v2 START criteria. A descriptive, observational, and cross-sectional study design was used. A total of 218 residents were involved in this study. Data on drug use were collected from medical charts. Information was screened with the software CheckTheMeds. Potentially inappropriate medications were present in 96.3%, 90.8%, and 35.3% of residents, according to the STOPP, Beers, and PRISCUS criteria or list, respectively. Inappropriate medication was found to be significantly associated with polypharmacy and severe or moderate drug–drug interactions with the three tools and with pathologies and unnecessary drugs only for STOPP criteria. The most frequent inappropriate medications were benzodiazepines and proton pump inhibitors. A regular use of software to review medications in nursing home residents would help to reduce the risk of these drug-related problems.

Medication Review in Turkish Older Adults at Community Pharmacy: A Pilot Study by Using Medication Appropriateness Index

Objective: The study aimed to evaluate medication review in older adults (≥65 years) at a community pharmacy by identifying the prevalence of potentiality inappropriate medication and calculating medication appropriateness index. Methods: This descriptive study was carried out in a community pharmacy for six months. The older adults (≥65 years) using one or more medications were included. During clinical pharmacist-led medication review; the medication appropriateness index was calculated for each medication of older adults. Potentially inappropriate medications were evaluated according to the 2019 American Geriatrics Society Beers Criteria®. Result: Among a hundred older adults, 46.0% were female. The median age of the patients was 75.5 (IQR, 68.0-78.8). The median number of medications was 9.0 (7.0-10.0). Polypharmacy has been detected in 97.0% of the patients. At least one potentially inappropriate medication was detected in 63.0% of them. The median score of medication appropriateness index score was 53.0 (IQR: 38.6-67.9). Conclusion: To best our knowledge, this is the first study of clinical pharmacist-led medication review by calculating the medication appropriateness index carried out at a community pharmacy in Turkey. There was a high rate of potentially inappropriate medication with a higher score of medication appropriateness in older adults. This study highlights the importance of medication review led by the clinical pharmacist at community pharmacy to optimize medication usage in older adults.

Ambulatory Medication Safety in Primary Care: A Systematic Review

PURPOSE

To review the literature on medication safety in primary care in the electronic health record era.

METHODS

Included studies measured rates and outcomes of medication safety in patients whose prescriptions were written in primary care clinics with electronic prescribing. Four investigators independently reviewed titles and analyzed abstracts with dual-reviewer review for eligibility, characteristics, and risk of bias.

RESULTS

Of 1464 articles identified, 56 met the inclusion criteria. Forty-three studies were noninterventional and 13 included an intervention. The majority of the studies (30) used their own definition of error. The most common outcomes were potentially inappropriate prescribing/medications (PIPs), adverse drug events (ADEs), and potential prescribing omissions (PPOs). Most of the studies only included high-risk subpopulations (39), usually older adults taking > 4 medications. The rate of PIPs varied widely (0.19% to 98.2%). The rate of ADEs was lower (0.47% to 14.7%). There was poor correlation of PIP and PPO with documented ADEs leading to physical harm.

CONCLUSIONS

This literature is limited by its inconsistent and highly variable outcomes. The majority of medication safety studies in primary care were in high-risk populations and measured potential harms rather than actual harms. Applying algorithms to primary care medication lists significantly overestimates rate of actual harms.

Lower Blood Vitamin D Levels Are Associated with Depressive Symptoms in a Population of Older Adults in Kuwait: A Cross-Sectional Study

Low serum vitamin D has been associated with an increased risk of neuropsychiatry disorders. This study aimed to examine the association between vitamin D deficiency and depression in adults aged 65 years and older. This cross-sectional study was conducted in seven primary healthcare centers across Kuwait (November 2020 to June 2021). The participants (n = 237) had their serum vitamin D 25-(OH)-D concentrations (analyzed by LC-MS) classified as sufficient, ≥75 nmol/L (30 ng/mL); insufficient, 50−75 nmol/L (20−30 ng/mL); or deficient, <50 nmol/L (20 ng/mL). Depressive symptoms were evaluated using the 15-Item Geriatric Depression Scale (15-item GDS). The mean serum 25-OH-D levels (nmol/L) in volunteers with normal, mild, moderate, and severe depression were 100.0 ± 31.7, 71.2 ± 38.6, 58.6 ± 30.1 and 49.0 ± 6.93, respectively (p < 0.001). The participants in the vitamin D sufficiency group were significantly less likely to exhibit depressive symptoms (88.2%) than patients with mild (36%) and moderate (21%) depression (p < 0.001). Ordinal logistic regression showed that vitamin D deficiency (OR = 19.7, 95% CI 5.60, 74.86, p < 0.001) and insufficiency (OR = 6.40, 95% CI 2.20, 19.91, p < 0.001) were associated with higher odds of having depressive symptoms. A low serum vitamin D level is a significant predictor of symptoms of depression among older individuals.

Medication Appropriateness, Polypharmacy, and Drug-Drug Interactions in Ambulatory Elderly Patients with Cardiovascular Diseases at Tikur Anbessa Specialized Hospital, Ethiopia

Background

Objective

Methods

Results

Conclusion

A comprehensive look at explicit screening tools for potentially inappropriate medication: A systematic scoping review

OBJECTIVE

To map explicit screening tools to identify potentially inappropriate medication (PIMs), and the characteristics and limitations of these tools. Including PIMs-interactions, therapeutic alternatives and the clinical management of PIMs.

METHODS

A systematic scoping review was conducted in PubMed and Scopus (until May 2021). The number of PIMs listed as essential drugs was identified in Model List of Essential Medicines by the World Health Organization (WHO) and National List of Essential Medicines (Brazil). In addition to reporting the therapeutic alternatives and clinical management proposed by explicit screening tools to identify PIMs, we suggested our own alternatives for the PIMs most frequently reported.

RESULTS

Fifty-eight tools reported 614 PIMs and 747 PIMs-interactions. Limited overlap between the tools was observed: 123 (69.1%) of 178 therapeutic alternatives proposed by the tools were considered inappropriate by other tools, and 222 (36.1%) of the 614 PIMs identified were named as being inappropriate only once. Only 21 tools were developed by a Delphi panel technique associated with systematic review. The PIMs listed as essential medication in Brazil and by the WHO were 30.6% and 23.3% of the total reported, respectively. For the most-cited PIMs, such as non-steroidal anti-inflammatory drugs, tricyclic antidepressants and benzodiazepines, we suggested the use of non-opioid and opioid analgesics; agomelatine, bupropion or moclobemide; and melatonin, respectively.

CONCLUSIONS

The next stages in the development of explicit screening tools to identify PIMs include achieving more consensus between them and improving their applicability across countries. Further, it is recommended that tools include PIMs risks and advice on therapeutic alternatives.

Comparison of the prevalence and nature of potentially inappropriate medication use in geriatric outpatients between tertiary and community healthcare settings: a multicenter cross-sectional study

Background Geriatric outpatients with polypharmacy have a high risk of potentially inappropriate medication (PIM) use. Aim To identify differences in both prevalence and patterns of PIMs and drug-related problems (DRPs) in older outpatients who visited the tertiary hospitals (THs) and community health centers (CHCs) and analyze associated factors. Method A prospective cross-sectional study was conducted in five THs and five CHCs from September 2018 to November 2019 in Beijing, China. Data were collected from outpatients aged ≥ 65 years with chronic diseases and polypharmacy. PIMs were evaluated using the 2015 and 2019 Beers Criteria and the Screening Tool of Older Persons' Prescriptions (STOPP) criteria. DRPs were classified using the Helper-Strand DRP Classification. The prevalence and types of PIMs and DRPs were compared, and relevant factors were analyzed. Results The prevalence of PIMs based on the 2015 Beers Criteria was higher in patients from the THs, while PIMs based on the 2019 Beers Criteria did not show a significant difference. PIM prevalence based on STOPP Criteria and DRPs was higher in patients from CHCs. Visiting CHCs was an independent factor of PIMs based on the 2015 Beers Criteria (OR 0.774, 95% CI 0.604-0.992) and the STOPP Criteria (OR 2.427, 95% CI 1.883-3.128), and DRPs (OR 3.612, 95% CI 2.682-4.865). Conclusion Differences in PIM and DRP might be due to the patients and settings. Specific measures to improve the appropriateness of medications in both settings should be used.

Commentary on the EMA reflection paper on the pharmaceutical development of medicines for use in the older population

Older people are often affected by impaired organ and bodily functions resulting in multimorbidity and polypharmacy, turning them into the main user group of many medicines. Very often, medicines have not specifically been developed for older people, causing practical medication problems for them like limited availability of easy to swallow formulations, easy to open packaging and dosing instructions for enteral administration. In 2020, the European Medicines Agency (EMA) published a reflection paper 'Pharmaceutical development of medicines for use in the older population', which discusses how the emerging needs of an ageing European population can be addressed by medicines regulation. The paper intends to help industry to better consider the needs of older people during pharmaceutical/clinical medicines development by summarising data on the most relevant topics, providing early suggestions on how to move forward and prompting expert discussions and studies into knowledge gaps. Topics include patient acceptability, (dis)advantages of an administration route, formulation, dosage form, packaging, dosing device and user instruction. While the paper is directed at older people and the pharmaceutical industry, the reflections are also relevant to younger patients with similar disease-related needs and of value to other stakeholders parties, e.g., healthcare professionals, academics, patients and caregivers, as the paper makes clear what can be expected from industry and where collaborative work is needed. This commentary provides an overview of the different steps in the development of the reflection paper, discusses points considered most controversial and/or subject to (multidisciplinary) expert discussions and indicates their value for real world clinical practice.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Deprescribing Medications that Increase the Risk of Falls in Older People: Exploring Doctors' Perspectives Using the Theoretical Domains Framework (TDF)

BACKGROUND

Falls can lead to hospitalisation and death in older people. Polypharmacy is a major risk factor, and deprescribing fall-risk increasing drugs (FRIDs) is one of several possible important preventive measures. The objective of this study was to explore the factors that influence doctors when deprescribing FRIDs in a hospital setting.

METHOD

Semi-structured interviews were conducted with consultant geriatricians and hospital doctors experienced in dealing with patients aged 65 years or older, at a large academic teaching hospital (~ 1000 beds), Dublin, Ireland. The interviews were directed by an interview guide and audio recorded and transcribed verbatim, with subsequent thematic analysis in NVivo 12 software.

RESULTS

A total of 18 participants were interviewed. Barriers to deprescribing included: insufficient time, incomplete patient records, changing medications initiated by other specialists and difficulties following up patients after discharge. Facilitators included: enhanced documentation through electronic patient records, the support of other healthcare professionals such as clinical pharmacists, and patients' engagement, which is considered essential for the success of the deprescribing process's outcome.

CONCLUSION

Deprescribing FRIDs in older adults in the hospital setting is challenging. Implementation of the process in practice requires combined effort from stakeholders to tackle everyday work environment challenges. Future studies are required examining the clinical effect of the suggested interventions and exploring patients' involvement in deprescribing decisions.

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.

Characterization of potentially inappropriate medication prescriptions for the elderly in primary care and hospital settings

Background

Polypharmacy cannot be defined numerically due to its varied definitions, and inclusion of comorbidities aggravates the dilemma, creating challenges for the healthcare system and the patients' course of treatment. The introduction of the potentially inappropriate medication (PIM) list developed by the American Geriatrics Society (AGS) (AGS Beers Criteria®; updated in 2019) was deemed a solution. However, several risk factors are associated with PIMs, including increased emergency room visits, hospitalization and mortality, and a decline in daily activity. Differences in PIM prescription rates have been reported; however, with the recent Beers criteria update, the number of patients exposed to PIMs is expected to increase significantly due to the addition of new medications to the list.

Objectives

This study aimed to describe the characteristics of PIM prescriptions for the elderly in primary care and hospital settings.

Methods

Medications for elderly patients prescribed in our hospital between 2016 and 2019 were reviewed and sorted based on Beers criteria to identify patients with the most PIMs. Correlations were made between gender and facility.

Results

This study included 40,168 patients (51% males). The total and average numbers of PIM per elderly patient were 260,753 and 6.5, respectively. Proton pump inhibitors were prescribed the most, followed by nonsteroidal anti-inflammatory drugs.

Conclusions

We found that increasing numbers of PIMs are prescribed to the elderly in our healthcare facilities. Therefore, further recommendations from local geriatric communities and the implementation of reminders for physicians through electronic prescription systems are needed to decrease the rate of prescribed PIMs.

Potentially inappropriate medication use among older adult patients on follow-up at the chronic care clinic of a specialized teaching hospital in Ethiopia. A cross-sectional study

Background

Older adult patients are prone to potentially inappropriate medication use (PIMU); its use has been associated with multiple adverse consequences. As a result, it is crucial to determine the magnitude and factors associated with PIMU. The present study was mainly aimed to determine and assess the magnitude and predictors of potentially inappropriate medication use in older adult patients on follow-up at the chronic care clinic of Jimma medical center.

Methods

A retrospective cross-sectional study was conducted involving 219 patients aged 65 years and above on treatment follow-up. Data was collected using a checklist. The 2019 updated American Geriatric Society (AGS) Beers Criteria® and Screening Tool of Older People’s Potentially Inappropriate Prescriptions criteria and Screening Tool to Alert Doctors to Right Treatment (STOPP/START) criteria (version 2) were employed to assess PIMU. SPSS IBM (v22) was used for data entry and analysis. Categorical variables were described using frequency and percentage, whereas continuous variables were described using mean with standard deviation (SD) or median with interquartile range (IQR). Logistic regression was conducted to identify predictors of PIMU.

Results

The average number of medications prescribed per patient was 4.0 (IQR = 2.0). At least one PIMU was identified in 182 (83.1%) and 99 (45.2%) patients, based on Beers and STOPP criteria, respectively. Additionally, potential prescription omission (PPO) was observed in 24 (10.9%) patients. The risk of Beers PIMU was increased with age [AOR = 1.21, p <  0.001], hypertension [AOR = 4.17, p <  0.001], and polypharmacy [AOR = 14.10, p <  0.001], while a decrease in the risk was noted in patients with a diagnosis of ischemic stroke [AOR = 0.133, p = 0.01] and asthma [AOR = 0.03, p <  0.001]. Using STOPP criteria, hypertension [AOR = 2.10, p = 0.04], diabetes mellitus [AOR = 2.26, p = 0.04], ischemic heart disease [AOR = 2.84, p = 0.04], peripheral neuropathy [AOR = 10.61, p <  0.001], and polypharmacy [AOR = 6.10, p <  0.001] significantly increased the risk of PIMU.

Conclusions

Regardless of the screening tool used to assess, the present study revealed PIMU in the large proportion of the participants. Multiple medication use and certain disease condition had increased the probability of PIMU. Hence, it is imperative to use screening tools for reviewing medications prescribed in older adult patients to ensure safety of medication therapy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02463-9.

Potentially inappropriate medications in Chinese older outpatients in tertiary hospitals according to Beers criteria: A cross-sectional study

OBJECTIVES

Multimorbidity and polypharmacy in older adults always increase the prevalence of potentially inappropriate medications (PIMs) and affect the quality of life of older adults. Currently, the data of PIMs on Chinese geriatric outpatients based on Beers criteria 2015 and 2019 have not been studied. The purposes of this study were aimed to investigate the prevalence of PIMs prescription and the most frequent PIMs amongst outpatients according to the two criteria and to explore related risk factors for PIMs.

METHODS

The cross-sectional retrospective study was conducted amongst geriatric outpatients in Chengdu in tertiary hospitals from January 2018 to December 2018. The Beers criteria 2015 and 2019 were used to assess PIMs in geriatric outpatients. Univariate analysis and multivariate logistic regression analysis were adopted to determine the factors that may affect the prevalence of PIMs.

RESULTS

A total of 12 005 patient prescriptions were enrolled. The prevalence of PIMs in the Beers criteria 2015 and 2019 was 30.98% and 34.39%, respectively. Benzodiazepines, diuretics and selective serotonin reuptake inhibitors (SSRIs) were the most frequent PIMs used according to both criteria. Logistic regression analysis showed that patients with female, advanced age, polypharmacy and sleep disorder were the most important factors associated with PIMs use.

CONCLUSION

The results showed a high prevalence of PIMs amongst geriatric outpatients in China. The Beers criteria 2019 had a higher detection rate of PIMs, and it was more sensitive to assess the Chinese geriatric population.

Potentially inappropriate medication prescribing by nurse practitioners and physicians

BACKGROUND

Potentially inappropriate medication (PIM) use is a risk factor for hospitalization and mortality. However, there were few studies focusing on the impact of provider type on PIM use.

OBJECTIVE

We aimed to estimate the initial and refill PIM prescribing rate for physician visits and nurse practitioner (NP) visits and the impact of provider type on PIM prescribing.

RESEARCH DESIGN

We used 100% Texas Medicare data to define physician visits and NP visits in 2016. The rate of visits with a PIM prescription from the same provider was measured, distinguishing between initial and refill prescription to estimate the PIM rate and adjusted odds ratio (OR) by provider type.

RESULTS

There were 24.1 per 1000 visits with a prescription for a PIM: 9.0 per 1000 visits for an initial PIM and 15.1 per 1000 visits for a refill PIM. A visit to an NP was less likely to result in an initial (OR = 0.74, 95% confidence interval [CI] = 0.70-0.79) or refill (OR = 0.54, 95% CI = 0.51-0.57) PIM. The association of lower odds of receiving a prescription for an initial PIM from an NP was substantially stronger among black enrollees than white enrollees (OR = 0.44, 95%CI = 0.30-0.65 for blacks and OR = 0.73, 95%CI = 0.68-0.78 for white enrollees). The association of an NP provider with lower odds of receiving a PIM refill was more pronounced in older patients and in those with more comorbidities.

CONCLUSIONS

NPs prescribed fewer initial PIMs and were less likely to refill a PIM after an outpatient visit than physicians. The lower odds of receiving PIMs during an NP visit varied by age, race/ethnicity, rurality, and number of comorbidities.

Anti-Cholinergic Drug Burden Among Ambulatory Elderly Patients in a Nigerian Tertiary Healthcare Facility

Background: The use of drugs with anticholinergic effects among elderly patients is associated with adverse clinical outcomes. There is paucity of information about anticholinergic drug burden among Nigerian elderly population. Objectives: To determine the anticholinergic drug burden among elderly Nigerian patients. Methods: This was a retrospective cross-sectional study conducted among elderly patients (aged 65 and above) who visited the Family Medicine outpatients' clinics of the Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria between July 1 and October 31, 2018. Information extracted from the case files included patient's age, sex, diagnoses, and list of prescribed medications. Medicines with anticholinergic effects were identified and scored using the anticholinergic drug burden calculator (http://www.acbcalc.com). Results: The medical records of 400 patients were analyzed with females accounting for 60.5% of the study population. The mean age of participants was 73 ± 7.4 years with only 28 (7%) of patients having more than two co-morbid conditions. Polypharmacy was identified in 152 (38%) of the patients while 147 (36.7%) had drugs with anticholinergic effects prescribed. The anticholinergic burden was high in 60 (15%) patients. Polypharmacy was significantly associated with having more than two diagnosed conditions and high anticholinergic burden (p value of < 0 .001 and 0.013 respectively). There was significant correlation between total number of prescribed drugs and count of diagnoses (r = 0.598; p < 0 .000) and between total number of prescribed drugs and number of drugs with anticholinergic effects (r = 0 .196; p < 0 .000). Conclusion: The anticholinergic burden in this group of elderly Nigerian patients was low; majority (67%) had no exposure to drugs with anticholinergic effects with only 15% having high anticholinergic burden. Polypharmacy and multiple diagnosed conditions were positively associated with high anticholinergic burden. Based on the positive and significant correlations found in this study, a reduction in the number of prescribed medicines especially those with significant anticholinergic effects used for secondary indications may lessen the anticholinergic burden among the elderly.

Potentially inappropriate medications for the elderly: Incidence and impact on mortality in a cohort ten-year follow-up

INTRODUCTION

Pharmacological therapy plays an important role in disease control in the elderly; unfortunately, this comes with a high prevalence in the use of medications classified as potentially inappropriate.

OBJECTIVE

To analyze the incidence, risk factors, and survival of elderly people using potentially inappropriate medications (PIM).

METHOD

A ten-year follow-up assessment of elderly participants residing in a capital of Central Brazil was conducted. The initial assessment (baseline) included 418 elderly people. Data were collected through home interviews guided by a questionnaire covering socioeconomic, demographic, living conditions, and health variables. The medication information obtained comprised active ingredient, dosage, route, and regimen for the medications. The PIMs were classified according to 2019 Beers Criteria. The analyses were performed using STATA 15.0. For survival analysis, a Cox Regression was performed with the respective Kaplan Meier curve.

RESULTS

The incidence of PIM was 44.1 cases (95% CI: 35.2-54.7) per 1,000 people a year. The most used PIMs were nifedipine, glibenclamide, and sodium diclofenac. The risk factors were polypharmacy (aRR: 3.00; 95% CI: 1.31-6.88) and diabetes mellitus (aRR: 1.57; 95% CI: 1.03-2.39). We identified no statistically significant association between survival and the use of PIM.

CONCLUSION

The study highlights the high consumption of PIM among the elderly causing polypharmacy risks. Health professionals working in drug treatment need to be alert to polypharmacy risks to ensure the rational use of medications to prevent adverse reactions and other health problems.

Potentially inappropriate medication and attitudes of older adults towards deprescribing

INTRODUCTION

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

METHOD

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

RESULTS

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

CONCLUSION

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

Impact of Geriatric Pharmacy Specialist Interventions to Reduce Potentially Inappropriate Medication Among Hospitalized Elderly Patients at Medical Wards: A Prospective Quasi-Experimental Study

Background

Elderly patients are at greater risk of receiving potentially inappropriate medications (PIMs) and developing adverse drug events. Identification and correction of PIMs is essential to maximize medication safety.

Objective

To determine the prevalence of PIMs on admission in Thai elderly patients admitted to a medical ward and to compare changes of PIMs on discharge, following comprehensive care by a ward pharmacist with or without a geriatric pharmacy specialist.

Patients and method

A prospective, quasi-experimental study was performed at a tertiary university hospital in Bangkok, Thailand. Patients aged ≥ 60 years who were admitted to the medical ward were recruited and allocated to one of two groups: intervention (IG) and control (CG). The CG received pharmaceutical care from the ward pharmacist. The IG received pharmaceutical care from the geriatric pharmacy specialist along with the ward pharmacist. The 2012 Beers criteria were used to identify PIMs on admission, during hospitalization, and on discharge.

Results

Prevalence of PIMs on admission was 43.3% (N = 187). On discharge, prevalence of PIMs in the IG decreased significantly compared to that on admission (21.3% and 43.3%, p < 0.05) and was significantly lower than in the CG (21.3% and 40.9%, p = 0.036). Moreover, the percentage of patients without PIMs on discharge in the IG was significantly higher than in the CG (78.7% and 59.1%, p < 0.0001).

Conclusion

Use of PIMs was common among hospitalized elderly patients on admission. Pharmaceutical care provided by a geriatric pharmacy specialist in conjunction with a ward pharmacist significantly reduced the prevalence of PIMs on discharge compared with on admission.

Medication-Related Burden and Medication Adherence Among Geriatric Patients in Kuwait: A Cross-Sectional Study

The evaluation of medicines burden from the patients’ perspectives is a crucial endeavor to identify any barriers that may hinder achieving optimal health outcomes. Therefore, this study was designed, firstly to identify the prevalence of medication-related burden among geriatrics and factors influencing this burden. Secondly, to determine the prevalence of medication adherence and the correlation between the burden and adherence. A cross-sectional study was performed using Living with Medicines Questionnaire version-3 (LMQ-3) and Adherence to Refills and Medications Scale (ARMS) questionnaire. Four hundred and fifty patients attending primary healthcare centers were invited to participate, and 424 (94.2%) agreed. Data were collected via face-to-face structured interviews. The vast majority of respondents (97.4%; 95% CI: 95.3–98.6) perceived to suffer from minimum (35.4%) to moderate (62.0%) degrees of medicine burden. The median (IQR) LMQ overall score was 112 (21) indicating a moderate burden. LMQ-3 overall scores revealed a significant trend toward higher perceived burden among respondents aged ≥ 75 years, males, non-Kuwaitis, residents in Al-Farwaniyah and Al-Jahra governorates, using oral and nonoral formulations, paying prescription charges, and needing support with using medicines (p <0.05). Almost 55% (95% CI: 49.8–59.5) of respondents were nonadherent to their medications. The median (IQR) ARMS overall score was 20 (7.0) indicating low adherence to medications. There was a significant positive correlation between LMQ-3 and ARMS scores (p<0.001) showing that the higher the medications burden the lower the level of medication adherence. The key findings of this study underscore the need for multifaceted interventions that could be targeted at the identified problems to reduce medication burden and improve medication adherence.

Potentially inappropriate prescriptions according to explicit and implicit criteria in patients with multimorbidity and polypharmacy. MULTIPAP: A cross-sectional study

Background

Multimorbidity is a global health challenge that is associated with polypharmacy, increasing the risk of potentially inappropriate prescribing (PIP). There are tools to improve prescription, such as implicit and explicit criteria.

Objective

To estimate the prevalence of PIP in a population aged 65 to 74 years with multimorbidity and polypharmacy, according to American Geriatrics Society Beers Criteria^® (2015, 2019), the Screening Tool of Older Person’s Prescription -STOPP- criteria (2008, 2014), and the Medication Appropriateness Index -MAI- criteria in primary care.

Methods

This was an observational, descriptive, cross-sectional study. The sample included 593 community-dwelling elderly aged 65 to 74 years, with multimorbidity and polypharmacy, who participated in the MULTIPAP trial. Socio-demographic, clinical, professional, and pharmacological-treatment variables were recorded. Potentially inappropriate prescribing was detected by computerized prescription assistance system, and family doctors evaluated the MAI. The MAI-associated factors were analysed using a logistic regression model.

Results

A total of 4,386 prescriptions were evaluated. The mean number of drugs was 7.4 (2.4 SD). A total of 94.1% of the patients in the study had at least one criterion for drug inappropriateness according to the MAI. Potentially inappropriate prescribing was detected in 57.7%, 43.6%, 68.8% and 71% of 50 patients according to the explicit criteria STOPP 2014, STOPP 2008, Beers 2019 and Beers 2015 respectively. For every new drug taken by a patient, the MAI score increased by 2.41 (95% CI 1.46; 3.35) points. Diabetes, ischaemic heart disease and asthma were independently associated with lower summated MAI scores.

Conclusions

The prevalence of potentially inappropriate prescribing detected in the sample was high and in agreement with previous literature for populations with multimorbidity and polypharmacy. The MAI criteria detected greater inappropriateness than did the explicit criteria, but their application was more complex and difficult to automate.

Chemotherapy toxicities and geriatric syndromes in older patients with malignant gliomas

OBJECTIVE

To describe treatment toxicities and polypharmacy in older patients with malignant gliomas (MG).

BACKGROUND

Advanced age in cancer patients is associated with increased treatment-related toxicities, acute care utilization and functional decline. Most patients with MG are over age 65, yet treatment patterns and toxicities are poorly defined.

METHODS

A retrospective chart review of 125 patients with MG age 65 or older at the University of Rochester from January 2012 to December 2018.

RESULTS

115 patients with glioblastoma and 10 with anaplastic astrocytoma had a median age of 71 (range 65-89) at diagnosis and median overall survival (OS) of 10.3 months. Radiotherapy (RT) was offered and completed in 79% (fractionated, n = 69, hypofractionated, n = 30). 24% of the 98 patients treated with concurrent temozolomide (TMZ) experienced treatment delays (n = 24). Median of 4 cycles of adjuvant TMZ were taken by 61% (n = 76). Delays and dose reductions occurred in 55% during treatment with adjuvant TMZ, most commonly due to thrombocytopenia (n = 29) and fatigue (n = 15). 16/98 patients required transfusions during treatment with concurrent or adjuvant TMZ. At baseline, patients were prescribed a median of 11 medications. OS was longer in patients prescribed less than 8 medications vs. 8 or more (14 vs. 8.6 months, p = .0738). 96% experienced a non-elective hospital admission and 64% reported at least one fall.

CONCLUSION

Older patients with MG experience significant polypharmacy, treatment toxicities and falls. Studies incorporating geriatric assessment tools may better determine associations between geriatric syndromes and survival. Clinical trials in older patients should also include non-survival outcomes.