Inappropriate drug prescriptions for elderly residents of board and care facilities

Prevalence of Potentially Inappropriate Medication Use in Older Adults Living in Nursing Homes: A Systematic Review

IMPORTANCE

As older adults living in nursing homes are at a high risk of adverse drug-related events, medications with a poor benefit/risk ratio or with a safer alternative should be avoided.

OBJECTIVES

To systematically evaluate the prevalence of potentially inappropriate medication use in nursing home residents.

EVIDENCE REVIEW

We searched in PubMed and EMBASE databases (1990-2015) for studies reporting the prevalence of potentially inappropriate medication use in people ≥60 years of age living in nursing homes. The risk of bias was assessed with an adapted version of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist.

FINDINGS

A total of 91 articles were assessed for eligibility, and 48 met our inclusion criteria. These articles reported the findings from 43 distinct studies, of which 26 presented point prevalence estimates of potentially inappropriate medication use (227,534 nursing home residents). The overall weighted point prevalence of potentially inappropriate medication use in nursing homes was 43.2% [95% confidence interval (CI) 37.3%-49.1%], increasing from 30.3% in studies conducted during 1990-1999 to 49.8% in studies conducted after 2005 (P < .001). Point prevalence estimates reported in European countries were found to be higher (49.0%, 95% CI 42.5-55.5) than those reported in North America (26.8%, 95% CI 16.5-37.1) or in other countries (29.8%, 95% CI 19.3-40.3). In addition, 18 studies accounting for 326,562 nursing home residents presented 20 distinct period prevalence estimates ranging from 2.3% to 50.3%. The total number of prescribed medications was consistently reported as the main driving factor for potentially inappropriate medications use.

CONCLUSIONS AND RELEVANCE

This systematic review shows that almost one-half of nursing home residents are exposed to potentially inappropriate medications and suggests an increase prevalence over time. Effective interventions to optimize drug prescribing in nursing home facilities are, therefore, needed.

Potentially Inappropriate Medications in the Elderly in Korean Long-Term Care Facilities

Background

Elderly residents of long-term care facilities are more vulnerable to being prescribed inappropriate medications because of the high incidence of co-medication in this population resulting from the presence of multiple chronic diseases and also age-related changes in pharmacokinetics and pharmacodynamics.

Objective

We evaluated the frequency of potentially inappropriate medications and factors influencing their frequency.

Methods

A retrospective cross-sectional study was conducted in 20 long-term care facilities located in the northwest regions of South Korea for 824 patients aged 65 years and older who were assessed between January and February of 2012. Potentially inappropriate medications were identified using the 2012 American Geriatric Society’s Beers Criteria. We assessed the relationship between the frequency of potentially inappropriate medications prescribed and patient age, sex, co-medications, comorbidity, activities of daily living, length of stay, grade of long-term care insurance for seniors, and the bed size and business type of the long-term care facility.

Results

Of the 529 participants who satisfied our inclusion criteria, 308 (58.2 %) had received at least one inappropriate medication according to the 2012 Beers Criteria. The most frequently prescribed classes of inappropriate medications were central nervous system drugs (58.7 %), anti-cholinergics (21.2 %), and cardiovascular medications (10.8 %). The most commonly used drugs were quetiapine (28.4 %), chlorpheniramine (15.8 %), risperidone (6.5 %), and zolpidem (5.8 %). Inappropriate medication use was associated with the number of co-medications and long-term care insurance grade 3, which means less dependence and a requirement of low-level care.

Conclusions

Central nervous system drugs (58.7 %) were the most prescribed class of inappropriate medications. Quetiapine was the drug most often given inappropriately (28.4 %). There was a relationship between inappropriate medication use and the number of co-medications. The frequency of inappropriate medication prescriptions was higher among patients whose long-term care insurance for seniors was grade 3, which means less dependence and a requirement of low-level care.

Potentially inappropriate prescribing among older people in the United Kingdom

Background

Potentially inappropriate prescribing (PIP) in older people is associated with increases in morbidity, hospitalisation and mortality. The objective of this study was to estimate the prevalence of and factors associated with PIP, among those aged ≥70 years, in the United Kingdom, using a comprehensive set of prescribing indicators and comparing these to estimates obtained from a truncated set of the same indicators.

Methods

A retrospective cross-sectional study was carried out in the UK Clinical Practice Research Datalink (CPRD), in 2007. Participants included those aged ≥ 70 years, in CPRD. Fifty-two PIP indicators from the Screening Tool of Older Persons Potentially Inappropriate Prescriptions (STOPP) criteria were applied to data on prescribed drugs and clinical diagnoses. Overall prevalence of PIP and prevalence according to individual STOPP criteria were estimated. The relationship between PIP and polypharmacy (≥4 medications), comorbidity, age, and gender was examined. A truncated, subset of 28 STOPP criteria that were used in two previous studies, were further applied to the data to facilitate comparison.

Results

Using 52 indicators, the overall prevalence of PIP in the study population (n = 1,019,491) was 29%. The most common examples of PIP were therapeutic duplication (11.9%), followed by use of aspirin with no indication (11.3%) and inappropriate use of proton pump inhibitors (PPIs) (3.7%). PIP was strongly associated with polypharmacy (Odds Ratio 18.2, 95% Confidence Intervals, 18.0-18.4, P < 0.05). PIP was more common in those aged 70–74 years vs. 85 years or more and in males. Application of the smaller subset of the STOPP criteria resulted in a lower PIP prevalence at 14.9% (95% CIs 14.8-14.9%) (n = 151,598). The most common PIP issues identified with this subset were use of PPIs at maximum dose for > 8 weeks, NSAIDs for > 3 months, and use of long-term neuroleptics.

Conclusions

PIP was prevalent in the UK and increased with polypharmacy. Application of the comprehensive set of STOPP criteria allowed more accurate estimation of PIP compared to the subset of criteria used in previous studies. These findings may provide a focus for targeted interventions to reduce PIP.

Prevalence and determinants of use of potentially inappropriate medications in elderly inpatients: a prospective study in a tertiary healthcare setting

AIM

To determine the prevalence and predictors of potentially inappropriate medications (PIM) prescribing in elderly inpatients using the modified American Geriatrics Society (AGS) updated Beers criteria 2012 and comparing it with the Beers criteria 2003.

METHODS

The prospective observational study was carried out between September 2011 and May 2012 at a public teaching hospital. Elderly inpatients aged ≥60 years were included. Multivariate logistic regression analysis was used to determine the predictors of PIM prescribing.

RESULTS

The results were based on data of 502 patients; more than half (60%) were males and 66% were aged between 60-69 years with a mean (standard deviation [SD]) of 68 (7) years. Mean (SD) number of diagnoses and medications were three (1) and nine (4), respectively. A total of 81 (16%) patients were prescribed with at least ≥1 PIM according to modified AGS updated Beers criteria 2012, compared with 11% according to Beers criteria 2003. On multivariate regression, important predictors for PIM prescribing were found to be age ≥80 years (odds ratio [OR] 2.46, 95% confidence interval (CI) 1.27-3.12; P = 0.03), male sex (OR 1.35, 95% CI 1.06-1.84; P = 0.03), more than three diagnoses (OR 2.47, 95% CI 1.59-3.39; P = 0.04), ≥6 medications prescribed (OR 1.16, 95% CI 1.02-1.35; P = 0.03) and ≥10 days of hospital stay (OR 1.59, 95% CI 1.09-2.31; P = 0.02).

CONCLUSIONS

The results show that PIM prescribing is common among hospitalized elderly Indian patients. It is feasible to reduce this practice through the provision of appropriate unbiased information to healthcare professionals.

Prescribing in care homes: the role of the geriatrician

Large numbers of frail elderly people spend some time of their lives in care homes. Increasing age is associated with altered physiology, multiple diagnoses and complex comorbidity, and polypharmacy. Those living in care homes often take larger numbers of medications than those who live in the community and the risk of morbidity as a direct or indirect result of medications is high. Many methods have been suggested to revise the number and type of medications prescribed for individuals at risk of adverse drug reactions (ADRs), both in the community and in hospital with variable success and implementation. Assessment of prescribed and nonprescribed medications by pharmacists, nurses and general practitioners all have a role in optimizing therapeutics with evidence that improved prescribing can reduce the risk of ADRs. In conjunction with these professionals, community geriatricians undertaking a comprehensive geriatric assessment can reduce the number of medications prescribed or optimize therapy where there may be underprescribing (e.g. in depression), thereby reducing the overall risk of hospital admission ADRs.

Clinical and demographic factors associated with antimuscarinic medication use in older hospitalized patients

BACKGROUND

Antimuscarinic drug prescribing scoring systems might better identify patients at risk of adverse drug reactions. The recently developed Anticholinergic Risk Scale (ARS) score is significantly associated with the number of antimuscarinic side effects in older outpatients. We sought to identify the clinical and demographic patient-level correlates of the ARS, including a modified version adjusted for daily dose, in elderly hospitalized patients.

METHODS

Clinical and demographic patient characteristics known to be associated with antimuscarinic prescribing, ARS and dose-adjusted ARS scores, and full medication exposure on admission were recorded in 362 consecutive patients (aged 83.6 ± 6.6 years) admitted to 2 geriatric units (NHS Grampian, Aberdeen, Scotland, UK) between February 1, 2010 and June 30, 2010.

RESULTS

Each year of increasing age was associated with reduced number of antimuscarinic drugs (incidence rate ratio [IRR], 0.963; 95% confidence interval [CI], 0.948-0.980; P < 0.001), non-antimuscarinic drugs (IRR, 0.991; 95% CI, 0.985-0.997; P = 0.006), and total number of drugs (IRR, 0.988; 95% CI, 0.983-0.994; P < 0.001). Multivariate Poisson regression showed that increasing age and history of dementia were negatively associated with the ARS score (IRR, 0.97; 95% CI, 0.94-0.99; P = 0.001 and IRR, 0.62; 95% CI, 0.41-0.92; P = 0.019, respectively). By contrast, institutionalization (IRR, 1.32; 95% CI, 1.00-1.74; P = 0.050), Charlson comorbidity index (IRR, 1.06; 95% CI, 1.01-1.11; P = 0.015), and total number of non-antimuscarinic drugs (IRR, 1.13; 95% CI, 1.08-1.18; P < 0.001) were all positively associated with the ARS score. Similar results were observed for the dose-adjusted ARS score.

CONCLUSION

Institutionalization, comorbidities, and non-antimuscarinic polypharmacy show independent positive associations with the ARS and dose-adjusted ARS scores in older hospitalized patients. Increasing age and dementia are negatively associated with the ARS score.

Prevalence of potentially inappropriate prescribing in an acutely ill population of older patients admitted to six European hospitals

PURPOSE

Potentially inappropriate prescribing is common in older people presenting to hospital with acute illness in Ireland. The aim of this study was to determine if this phenomenon is unique to Ireland or whether it is a more widespread problem in hospitals across Europe.

METHODS

Prospective data were collected from 900 consecutive older patients admitted to six university teaching hospitals (150 patients per centre) in Geneva (Switzerland), Madrid (Spain), Oostende (Belgium), Perugia (Italy), Prague (Czech Republic) and Cork (Ireland). Age, gender, comorbidity, cognitive status, prescription medicines taken before admission and baseline haematological, biochemical and electrocardiographic data were recorded. STOPP and Beers' criteria were applied to detect potentially inappropriate medicines (PIMs). START criteria were applied to detect potentially inappropriate prescribing omissions (PPOs).

RESULTS

The overall PIM prevalence rate was 51.3% using STOPP criteria, varying from 34.7% in Prague to 77.3% in Geneva, and 30.4% using Beer's criteria, varying from 22.7% in Prague to 43.3% in Geneva. Using START criteria, the overall PPO prevalence rate was 59.4%, ranging from 51.3% in Cork to 72.7% in Perugia. Polypharmacy predicted the presence of PIMs using STOPP criteria [with >10 medications: odds ratio (OR)  7.22, 95% confidence interval (CI) 4.30-12.12, p < 0.001] and Beers' criteria (with >10 medications: OR 4.87, 95% CI 3.00-7.90, p < 0.001). Increasing co-morbidity (Charlson Index ≥2) and age ≥85 years significantly predicted PPOs.

CONCLUSION

Potentially inappropriate drug prescribing and the omission of beneficial drugs are highly prevalent in acutely ill hospitalized older people in six European centres.

Impact of a pharmaceutical care model for non-institutionalised elderly: results of a randomised, controlled trial

Objectives

To measure the impact of a community-based geriatric pharmaceutical care model on specific process measures.

Methods

The model was evaluated using a prospective, randomised, controlled study design. Clients who self-presented or were referred by Home Care were eligible if they were 65 years of age or older, non-institutionalised, taking two or more prescribed or non-prescribed medications, and willing to provide signed informed consent. A pharmacist conducted a comprehensive drug therapy review on test clients, then addressed issues with the client and/or the client's physician, with follow-up as required. Measurements included number of drugs, drug knowledge, adherence to therapy, cost of prescribed medicines, and number of reported symptoms obtained from a home medication history conducted by trained volunteers, the provincial prescription claims database, and response to a physician survey.

Setting

The pharmaceutical care model was situated within a community-based interdisciplinary health clinic targeting non-institutionalised elderly.

Key findings

One hundred and thirty-five clients were randomised to test (n=69) or control (n=66). A mean of 14.4 (SD 4.6) potential or actual issues were identified in test clients. Ninety-four per cent of physicians agreed with at least one of the pharmacist's recommendations but only 230 of 794 recommendations by the pharmacist (29 per cent) resulted in a change. There was no difference in overall number of prescribed or over-the-counter medications, drug costs, symptoms reported, drug knowledge or medication adherence between test and control groups post-intervention.

Future research

Further research is needed to identify barriers to changing drug use behaviour and facilitating acceptance of pharmaceutical care in the community.

Potentially inappropriate drug prescriptions and risk of hospitalization among older, Italian, nursing home residents: the ULISSE project

BACKGROUND

Potentially inappropriate medications in older patients increase the risk of adverse drug events, which are an important cause of hospital admission and death among hospitalized patients. Little information is available about the prevalence of potentially inappropriate drug prescriptions (PIDPs) and the related health adverse outcomes among nursing home (NH) residents.

OBJECTIVE

To estimate the prevalence of PIDPs and the association with adverse outcomes in NH residents.

METHODS

A total of 1716 long-term residents aged >or=65 years participating in the ULISSE (Un Link Informatico sui Servizi Sanitari Esistenti per l'anziano [A Computerized Network on Health Care Services for Older People]) project were evaluated using a standardized comprehensive geriatric assessment instrument, i.e. the interResident Assessment Instrument Minimum Data Set. A thorough evaluation of residents' drug use, medical diagnoses and healthcare resource utilization was performed. A PIDP was defined according to the most recent update of the Beers criteria.

RESULTS

Almost one out of two persons (48%) had at least one PIDP and almost one out of five had two or more PIDPs (18%). Residents with a higher number of PIDPs had a higher likelihood of being hospitalized. Compared with residents without PIDPs, those with two or more PIDPs at baseline had a higher probability of being hospitalized (hazard ratio 1.73; 95% CI 1.14, 2.60) during the following 12 months. Risk of PIDP was positively associated with the total number of drugs and diseases, but negatively with age. PIDPs defined according to specific conditions (n = 780; 55%) were slightly more frequent than PIDPs based on single medications irrespective of specific indication (n = 639; 45%).

CONCLUSIONS

PIDP is a significant problem among Italian NH residents. There is an urgent need for intervention trials to test strategies to reduce inappropriate drug use and its associated adverse health outcomes.

"Meds Are a Real Tricky Area": Examining Medication Management and Regulation in Assisted Living

Medication management is among the most commonly cited reasons for moving to assisted living and is closely associated with resident quality of care and life. Yet the issue has received little research attention. Using data from the statewide study, "Job Satisfaction and Retention of Direct Care Staff in Assisted Living," this article examines medication management policies and practices across 45 facilities in Georgia. Guided by principles of Grounded Theory Method, we analyzed qualitative data from surveys with 370 direct care workers (DCWs) and in-depth interviews with 41 DCWs and 44 administrators. Our analysis showed that medication managers vary widely in their backgrounds, positions, and training, largely based on home size and resources. Despite identifying common dimensions of the medication management process, we found variation in procedures and regulatory compliance based on facility, staff, and resident factors. Our findings relate to and extend existing work and have practice and research implications.

Potentially inappropriate medication in elderly hospitalized patients

Balanced and safe prescribing is difficult to achieve in frail older adults with multiple comorbid diseases. This issue is of particular concern, especially in elderly hospitalized patients because hospitalization exposes such individuals to an increased risk of adverse drug reactions (ADRs). The avoidance of medications that are considered to be inappropriate is among the interventions for treatment options in elderly patients. A potentially inappropriate medication (PIM) is a drug in which the risk of an adverse event outweighs its clinical benefit, particularly when there is a safer or more effective alternative therapy for the same condition. Explicit criteria have been developed to identify PIMs and among these, Beers' criteria are the most frequently applied in the literature. However, evidence suggests that such criteria cannot easily be applied to elderly hospitalized people in European countries; approximately 20% of drugs listed in Beers' criteria are rarely prescribed or are not available in Europe, and Beers' listed PIMs are not associated with inhospital mortality, length of hospital stay and/or ADRs in Italian studies. On the contrary, ADRs can contribute to accelerated functional decline in elderly hospitalized patients independently of the use of Beers' listed PIMs. Therefore, we will review the evidence pertaining to the application of Beers' criteria in elderly hospitalized patients, while focusing on Italian studies that have investigated the role of PIMs as potential predictors of negative hospital outcomes. In addition, we will also review the available evidence regarding new European criteria on identifying PIMs, because clinical application in elderly hospitalized Europeans is still under investigation.

Inappropriate drug prescriptions among older nursing home residents: the Italian perspective

Older people take up a large proportion of health care, including drugs, and evidence shows that drug prescribing to this group is often inappropriate. Negative consequences of potential inappropriate drug prescription (PIDP) include adverse drug events, high healthcare service utilization and high costs for the patients and society. Although nursing home residents are the most vulnerable persons exposed to PIDP, few observational studies have investigated the prevalence, the factors associated with and the consequences of PIDP. Epidemiological studies assessing PIDP mainly based on the Beers' criteria showed that approximately half of US and Canadian nursing home residents have at least one PIDP in this setting. The most frequent inappropriate prescriptions concern neuroleptics and long-term benzodiazepines. Nursing home residents aged 80 years or more, those taking a low number of drugs, cognitive or communication problems are less exposed to PIDP compared with residents younger than 80 years, living in facilities with a high number of beds and a lower registered nurse-to-resident ratio. In European countries, the prevalence of PIDP among older nursing home residents was comparable to or higher than that observed in US and Canadian nursing homes. To date, the issue of PIDP has never been investigated in a representative sample of Italian nursing home residents. In a preliminary study performed by our group in 496 nursing home residents randomly selected from 40 nursing homes in Umbria, the prevalence of residents taking at least one or two inappropriate medications was 28% and 7%, respectively. The prevalence of PIDP considering diagnosis (18%) as well as those regardless of diagnosis (17%), as determined by Beers' criteria, were equally distributed in older Italian nursing home residents and no difference was found between sexes. Overall, this review reveals that the prevalence of PIDP is high in both North American and European nursing homes and highlights the urgent need for intervention trials testing strategies to reduce the health and social burden of PIDP.

An Examination of the Health Profile, Service Use and Care Needs of Older Adults in Residential Care Facilities

Private, unregulated residential care facilities have become an increasingly important component of the continuum of housing and care for frail older adults in Canada. To date, this growing segment of the older population has received very little research attention. This study involved an in-depth examination of the functional/health profile, patterns of service use, and medical/care needs of a representative sample of 178 older adults in residential care facilities in the City of Ottawa. The results indicate great diversity in resident and facility profiles in this setting and confirm earlier impressions that special care units in the residential care sector have become increasingly close to being unlicensedpseudo-nursing homes. Despite the heavy burden of care, the evidence suggests that the care needs of the majority of residents are adequately met in the residential care environment. The results can inform future research, case finding, educational, and policy planning initiatives in this setting.

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.

Transferring knowledge about human subjects protections and the role of institutional review boards in a community-based participatory research project

Among the first tasks in a collaboration between Tufts University and community organizations in Somerville, MA, was designing an interview instrument to assess occupational health needs among immigrant workers. Human subjects protections was a critical issue, but community partners were not well informed about the need for such protections or the role of the institutional review board (IRB). During research meetings, members of the team from Tufts trained community collaborators to work with research participants and organized a presentation by a key university IRB administrator. We present findings from the process evaluation of this project and suggest ways to (1) assess community partners' understanding about working with research volunteers, (2) train collaborators, and (3) involve IRBs.

Factors associated with use of medications with potential to impair cognition or cholinesterase inhibitors among Alzheimer's disease patients

BACKGROUND

The aim of this study was to use a signal detection method to examine the prevalence of, and patient characteristics associated with, medication with potential to impair cognition and cholinesterase inhibitor use in patients with Alzheimer's disease.

METHODS

A cross-sectional study was conducted of 1,954 patients with a diagnosis of probable or possible Alzheimer's disease. Concurrent medications were measured, specifically: (1) a medication with potential to impair cognition or (2) a cholinesterase inhibitor. Predictor variables included age, gender, ethnic group, education, age of symptom onset, number of prescriptions, number of medical diagnoses, Mini-Mental State Examination (MMSE), Blessed-Roth Dementia Rating Scale (BRDRS), probable versus possible AD diagnosis.

RESULTS

Fifteen percent of the Alzheimer's disease patients were on a medication with potential to impair cognition, and 44% were on a cholinesterase inhibitor. Patient characteristics associated with the prescription of a medication with potential to impair cognition included total number of prescription medications, low education, low MMSE, older age, reported lack of vitamin use, and more medical diagnoses. Patient characteristics associated with the prescription of a cholinesterase inhibitor included reported use of vitamins, the total number of prescription medications, fewer medical diagnoses, lower age of symptom onset, and higher education.

CONCLUSIONS

Determining the patient characteristics associated with the prescription of a medication with potential to impair cognition can help clinicians identify patients who are at risk for drug-related morbidity. Patient characteristics unassociated with dementia appear to influence the prescription of cholinesterase inhibitors. Signal detection analysis is well suited to this type of research.

Magnitude of potentially inappropriate prescribing in Germany among older patients with generalized anxiety disorder

Background

Several medications commonly used to treat generalized anxiety disorder (GAD) have been designated "potentially inappropriate" for use in patients aged ≥65 years because their risks may outweigh their potential benefits. The actual extent of use of these agents in clinical practice is unknown, however.

Methods

Using a database with information from encounters with general practitioners (GP) in Germany, we identified all patients, aged ≥65 years, with any GP office visits or dispensed prescriptions with a diagnosis of GAD (ICD-10 diagnosis code F41.1) between 10/1/2003 and 9/30/2004 ("GAD patients"). Among GAD-related medications (including benzodiazepines, tricyclic antidepressants [TCAs], selective serotonin reuptake inhibitors, venlafaxine, hydroxyzine, buspirone, pregabalin, and trifluoperazine), long-acting benzodiazepines, selected short-acting benzodiazepines at relatively high dosages, selected TCAs, and hydroxyzine were designated "potentially inappropriate" for use in patients aged ≥ 65 years, based on published criteria.

Results

A total of 975 elderly patients with GAD were identified. Mean age was 75 years, and 72% were women; 29% had diagnoses of comorbid depression. Forty percent of study subjects received potentially inappropriate agents – most commonly, bromazepam (10% of all subjects), diazepam (9%), doxepin (7%), amitriptyline (5%), and lorazepam (5%). Twenty-three percent of study subjects received long-acting benzodiazepines, 10% received short-acting benzodiazepines at relatively high doses, and 12% received TCAs designated as potentially inappropriate.

Conclusion

GPs in Germany often prescribe medications that have been designated as potentially inappropriate to their elderly patients with GAD – especially those with comorbid depressive disorders. Further research is needed to ascertain whether there are specific subgoups of elderly patients with GAD for whom the benefits of these medications outweigh their risks.

Potentially inappropriate medications and functional decline in elderly hospitalized patients

OBJECTIVES

To verify whether the use of potentially inappropriate medications (PIMs) is associated with loss of independence in elderly in-patients by promoting adverse drug reactions (ADRs).

DESIGN

Prospective observational study.

PARTICIPANTS

Five hundred six patients aged 65 and older admitted to 11 acute care medical wards.

MEASUREMENTS

In-hospital loss of one or more activities of daily living (ADLs) and three or more ADLs. PIMs were identified according to diagnosis-independent Beers criteria and ascertained by study physicians based on daily review of medical and nurse records. The relationship between risk factors and outcomes was assessed using logistic regression.

RESULTS

Overall, 104 patients (20.6%) were taking at least one PIM at the time of admission (baseline users), and 49 (9.7%) were newly prescribed at least one PIM during their hospital stay. The loss of one or more ADLs occurred in 9.6% of baseline users, 16.3% of new users, and 8.5% of nonusers (P=.21) and that of three or more ADLs in 7.7% of baseline users, 12.2% of new users, and 4.8% of nonusers (P=.10). The lack of association was confirmed after correction for potential confounders, including ADRs. The occurrence of ADRs was strongly associated with both outcomes (odds ratio (OR)=7.80, 95% confidence interval (CI)=3.53-17.3 for the loss of > or =1 ADLs; OR=3.98, 95% CI=1.50-10.5 for the loss of > or =3 ADLs), but PIMs caused only six of 106 ADRs.

CONCLUSIONS

ADRs to any drugs more than the use of PIMs might be associated with functional decline in elderly hospitalized patients, but because the power of this study was too limited to definitively exclude a direct relationship between PIMs and functional decline, this merits further investigation.

Types, prevalence, and potential clinical significance of medication administration errors in assisted living

OBJECTIVES

To describe the types and potential clinical significance of medication administration errors in assisted living (AL).

DESIGN

Cross-sectional observational study.

SETTING

This study was conducted in 12 AL settings in three states (Oregon, Washington, and New Jersey).

PARTICIPANTS

Participants included 29 unlicensed assistive personnel and 510 AL residents.

MEASUREMENTS

Medication administration observations, chart review, and determination of rates, types, and potential clinical significance of errors using standardized methodology.

RESULTS

Of 4,866 observations, 1,373 errors were observed (28.2% error rate). Of these, 70.8% were wrong time, 12.9% wrong dose, 11.1% omitted dose, 3.5% extra dose, 1.5% unauthorized drug, and 0.2% wrong drug. Excluding wrong time, the overall error rate dropped to 8.2%. Of the 1,373 errors, three were rated as having potential clinical significance.

CONCLUSION

A high number of daily medications are given in AL. Wrong time accounted for the majority of the errors. The bulk of the medications are low risk and routine; to promote optimal care delivery, clinicians need to focus on high-risk medications and residents with complex health problems.

Medication inappropriateness for older adults receiving hospice care: a pilot survey

OBJECTIVE

To test the feasibility and reliability of a tool and methodology for evaluating expert clinicians' perceptions about the application of the Beers criteria in hospice.

DESIGN

A pilot survey.

SETTING

A national medication therapy management provider specializing in hospice care.

PARTICIPANTS

Thirty-five participants from a multidisciplinary panel were invited to complete the survey. They were selected to represent acute, long-term care, and community practice settings with various levels of experience and judgment.

INTERVENTION

Respondents were asked to complete the survey by rating their agreement or disagreement with the inappropriateness of the medications or medication classes for hospice patients, using a five-point Likert scale from strongly agree (1) to strongly disagree (5), with the midpoint (3) expressing equivocation.

MAIN OUTCOME MEASURES

Feasibility as measured by the percentage of returned and completed surveys. A secondary aim was to measure inter-rater reliability and response.

RESULTS

Twenty-four clinicians (69%) completed the survey, including 13 clinical pharmacists, 6 nurses, and 5 physicians. Twenty-nine responses (2%) were furnished by imputation methods. The intraclass correlation for medication inappropriateness for hospice patients was 0.89 (0.81-0.95), indicating "good" inter-rater reliability. Short-acting benzodiazepines, gastrointestinal antispasmodics, anticholinergics, and antihistamines were considered appropriate for use in older hospice patients, but they are considered inappropriate according to the Beers criteria.

CONCLUSION

We established a viable methodology for evaluating clinician judgment about medication inappropriateness in older hospice patients. Some medications routinely considered to be inappropriate may be appropriate at end of life; different criteria may be needed to determine medication inappropriateness in hospice care.

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.

Impact of inappropriate drug use on physical performance among a frail elderly population living in the community

OBJECTIVE

The criteria for inappropriate drug use developed by Beers have been widely used in drug utilization reviews to assess the quality of prescribing, but there is still inconclusive evidence that these criteria can impact on patient outcomes. The aim of the present study was to evaluate the relationship between the use of inappropriate drugs and measures of physical performance, muscle strength and functional status in an elderly population (80+ years).

METHODS

Data are from the baseline evaluation of 364 subjects enrolled in the ilSIRENTE study, a prospective cohort study performed in a mountain community living in the Sirente geographic area (L'Aquila, Abruzzo) in Central Italy. Physical performance was assessed using the physical performance battery score (SPPB), which is based on three timed tests: 4-m walking speed, balance and chair stand tests. Muscle strength was measured by hand grip strength. Inappropriate drug use was defined by the 2003 Beers criteria. Analyses of covariance were performed to evaluate the relationship of inappropriate drugs with physical function.

RESULTS

In the unadjusted model, all of the physical performance, muscle strength and functional measures showed significant associations with inappropriate drug use. Following adjustment for potential confounders, which included age, gender, physical activity level, cognitive performance scale, comorbidity, lung diseases and diabetes, these associations were still statistically significant for the physical performance battery score [non-users inappropriate drugs: 7.0; standard error (SE): 0.1; users inappropriate drugs: 6.1; SE: 0.2; p = 0.007] The 4-m walking speed, physical performance battery score and Total Activities of Daily Living (ADL) scale score showed worsening results among subjects using two inappropriate medications compared with subjects using one inappropriate drug or none at all.

CONCLUSIONS

The use of inappropriate medication (as defined by Beers 2003 criteria) was found to be common among the elderly Italian study cohort living in the community. Our results suggest that among old-old subjects the use of inappropriate drugs is associated with impaired physical performance.

Is inappropriate medication use a major cause of adverse drug reactions in the elderly?

AIM

To study the occurrence of adverse drug reactions (ADRs) linked to inappropriate medication (IM) use in elderly people admitted to an acute medical geriatric unit.

METHODS

All the elderly people aged > or = 70 years admitted to the acute medical geriatric unit of Limoges University hospital (France) over a 49-month period were included, whatever their medical condition. For all the patients, clinical pharmacologists listed the medications given before admission and identified the possible ADRs. The appropriateness of these medications and the causal relationship between drugs (either appropriate or not) and ADRs were evaluated.

RESULTS

Two thousand and eighteen patients were included. The number of drugs taken was 7.3 +/- 3.0 in the patients with ADRs and 6.0 +/- 3.0 in those without ADRs (P < 0.0001). Sixty-six percent of the patients were given at least one IM prior to admission. ADR prevalence was 20.4% among the 1331 patients using IMs and 16.4% among those using only appropriate drugs (P < 0.03). In only 79 of the 1331 IM users (5.9%) were ADRs directly attributable to IMs. The IMs most often involved in patients with ADRs were: anticholinergic antidepressants, cerebral vasodilators, long-acting benzodiazepines and concomitant use of two or more psychotropic drugs from the same therapeutic class. Using multivariate analysis, after adjusting for confounding factors, IM use was not associated with a significant increased risk of ADRs (odds ratio 1.0, 95% confidence interval 0.8, 1.3).

CONCLUSION

Besides a reduction in the number of drugs given to the elderly, a good prescription should involve a reduction in the proportion of IMs and should take into consideration the frailty of these patients.

Pharmaceutical use among older adults: using administrative data to examine medication-related issues

Medication use is recognized as the least expensive, most cost-effective health care intervention. In older adults this is especially important, as they are the largest consumer of prescription medications. We describe the use of a linked data set including pharmaceutical, medical, and hospital claims to examine pharmaceutical use in the population of older adults and then give several examples of its application. Indicators to describe the population's overall use of medication and the appropriate use of specific medication have been developed. Indicators of appropriate use are characterized using the dispensation of benzodiazepines to older adults.We have found that a significant proportion of new users of benzodiazepines are still prescribed a long-acting version (over 10%), signifying potential inappropriate use. The data are also able to describe some significant outcomes from the use of pharmaceuticals such a death, fracture, and population-based clinical measures where available.

Medication-related problems in the elderly : defining the issues and identifying solutions

The elderly population is at great risk for medication-related problems as a result of age-related physiological changes, the presence of multiple chronic diseases and conditions, and the types and numbers of prescription and nonprescription medications they consume.Medication-related problems have received international attention. In the US, as many as 200,000 people may die of medication-related problems each year. Studies from other developed nations where patients have access to medications have determined that various types of medication-related problems occur in the elderly population in health care environments ranging from nursing homes to community dwelling settings.A variety of initiatives have been developed in an attempt to reduce the likelihood of medication-related problems in the elderly. The role that a pharmacist can play in identifying and preventing the negative health outcomes and costs of medication-related problems is being increasingly recognised. Indeed, numerous studies have now documented the positive impact that pharmacists can have in this area, and ongoing research is being conducted. With the growing numbers of elderly, and the increase in the numbers and types of medications available, it is imperative that awareness of medication-related problems be increased and that further initiatives be developed to optimise the positive outcomes of drug therapy in the elderly.

Prescribing to older ED patients

The purpose of this article is to assist emergency physicians in selecting safe and effective drug therapy for seniors. Because safer alternatives exist, medications on the Beers list of potentially inappropriate medications should generally be avoided. We also review risks associated with several classes of medications: nonsteroidal anti-inflammatory drugs, benzodiazepines, and anticholinergic medications. They are associated with adverse outcomes when taken by older adults and should be used with caution. We also address the use of opioid medications in seniors. Although they are not without risk, opioids are generally safe with slow titration, precautions, and a bowel regimen to prevent constipation. Prescribers should also consider the need for estimating creatinine clearance when prescribing medications that require dosage adjustment in the setting of renal insufficiency. Two areas in need of research are identifying the proper dosing and safety of medications in seniors and prescribing with electronic decision support to assist in prescribing decisions.

Nurse delegation of medication administration for older adults in assisted living

Assisted living (AL) is a relatively new form of long-term care that offers residents personal care services and more independence in a home-like environment. Introduced to the United States in the 1980s, AL is changing the conventional thinking about how to care for frail older adults. One important issue to explore is registered nurse (RN) delegation to unlicensed assistive personnel (UAP), particularly for medication administration. This study provides a national perspective on medication delivery in AL settings from the perspectives of state Board of Nursing (BON) executives. Qualitative interviews using semi-structured interview guides were conducted with BON executives to validate a legal summary of AL regulations and nurse practice acts, and to identify nursing issues pertaining to medication management in AL across the United States. In this study, there was considerable variation across states regarding medication administration and the role of both the RN and the UAP. BON executives displayed a range of knowledge about nursing practice issues in AL, with many reporting low familiarity with this setting. Mechanisms for systematic review of quality of delegation were not in place. Medication administration and nurse delegation were dynamic issues, with practice and policy evolving concurrently. This study highlights the limited articulation of policies between agencies and across states in the important and growing setting of assisted living. Nurses have the opportunity to shape this evolving practice arena and to enhance awareness of the professional and clinical issues inherent in working with UAP in medication delivery.

Quality of Medication Records and Use of Pharmacy Resources in Community Residential Care Facilities

Background:

In community residential care (CRC) facilities, medication administration is often performed by unlicensed personnel with minimal knowledge in medication use. Medication management is one of the top 3 quality-of-care issues facing these facilities.

Objective:

To examine the type of medication assistance residents received, determine the proportion of facilities that used pharmacy resources, and examine the quality of facility medication records in CRC facilities (eg, adult family homes, adult residential care, assisted living facilities).

Methods:

Baseline in-person interviews were conducted with 349 residents and 299 facility providers in the Puget Sound region of Washington. Information was also obtained from facility medication records at enrollment and state databases. A pharmacist determined quality of the records using a standardized form.

Results:

The average resident was a 78-year-old white female taking 7 drugs. Medication records that were computer generated were significantly less likely to have misspelled names of drugs and errors in or absence of dose, directions for use, and route of administration. Overall, 26.3% of facilities reported that a consultant pharmacist reviewed residents' medication lists, 52.0% reported the use of preprinted lists, and 75.6% received prepackaged medications from the pharmacy. Adult family homes, the smallest facility type, were the least likely to use pharmacy-related services.

Conclusions:

The quality of handwritten medication records was a concern in CRC facilities. These facilities may benefit from services offered by pharmacies that may enhance medication management, many of which were underutilized.

Prevalence of inappropriate medication using Beers criteria in Japanese long-term care facilities

Background

The prevalence and risk factors of potentially inappropriate medication use among the elderly patients have been studied in various countries, but because of the difficulty of obtaining data on patient characteristics and medications they have not been studied in Japan.

Methods

We conducted a retrospective cross-sectional study in 17 Japanese long-term care (LTC) facilities by collecting data from the comprehensive MDS assessment forms for 1669 patients aged 65 years and over who were assessed between January and July of 2002. Potentially inappropriate medications were identified on the basis of the 2003 Beers criteria.

Results

The patients in the sample were similar in terms of demographic characteristics to those in the national survey. Our study revealed that 356 (21.1%) of the patients were treated with potentially inappropriate medication independent of disease or condition. The most commonly inappropriately prescribed medication was ticlopidine, which had been prescribed for 107 patients (6.3%). There were 300 (18.0%) patients treated with at least 1 inappropriate medication dependent on the disease or condition. The highest prevalence of inappropriate medication use dependent on the disease or condition was found in patients with chronic constipation. Multiple logistic regression analysis revealed psychotropic drug use (OR = 1.511), medication cost of per day (OR = 1.173), number of medications (OR = 1.140), and age (OR = 0.981) as factors related to inappropriate medication use independent of disease or condition. Neither patient characteristics nor facility characteristics emerged as predictors of inappropriate prescription.

Conclusion

The prevalence and predictors of inappropriate medication use in Japanese LTC facilities were similar to those in other countries.

Use of Inappropriate Medications and Their Prognostic Significance Among In-Hospital and Nursing Home Patients with and without Dementia in Finland

BACKGROUND

Although the Beers criteria have been frequently utilised to describe the use of inappropriate medications in various elderly populations, less is known about the use of such medications among patients with dementia, and nor have many studies dealt with their impact on mortality or use of healthcare services. This study examines the use of inappropriate drugs and their impact on mortality and use of health services among Finnish elderly nursing home and hospital patients. Patients with dementia were studied as a special subgroup.

METHODS

A total of 425 patients consecutively admitted to seven Finnish nursing homes and two hospitals in 1999-2000 were examined. Details of all medications prescribed and administered were retrieved from medical records and coded according to the Beers 1997 criteria. Mortality data as well as days in acute hospital were obtained from central registers and all area hospitals during 2 years of follow-up.

RESULTS

The entire population was old and frail (mean age 86 years, 82% females), 60% had dementia and 36.2% received at least one potentially inappropriate drug (PID). No differences existed in the proportion of users of PIDs among those 60% of patients with dementia compared with those without. The most common PID was temazepam, with 14% of all patients on high doses. Other commonly used PIDs were oxybutynin and dipyridamole. Amitriptyline was more commonly used among patients without dementia (4.7%) compared with those with dementia (0.8%). Nevertheless, in this very old and frail study population, use of inappropriate drugs did not predict mortality or use of health services.

CONCLUSION

Use of PIDs is common in nursing homes and hospitals in Finland but has no impact on mortality or hospital admissions. Use of high-dose temazepam as a hypnotic accounted for most of the high use of PIDs.

Inappropriate medication prescribing in community-dwelling elderly people living in Iran

OBJECTIVES

To determine the prevalence of inappropriate medication prescribing in Middle Eastern community-dwelling elderly persons, and to determine factors associated with inappropriate prescribing.

METHODS

Prescriptions from 3,000 elderly-patient visits (> or =65 years) to physicians in Isfahan, Iran were collected between September and December 2002; only the first patient visit was considered in the study. Inappropriate prescriptions were defined according to Beers' explicit criteria (1997). The presence of at least one drug-drug interaction (DDI) and at least one drug-class duplication within each patient visit was also determined. Multivariate analyses were performed to determine factors associated with receiving at least one inappropriate medication. These factors included age, gender, number of prescribed medications per visit, DDIs, duplications, and physician's number of years of experience. Similar analyses were performed to determine whether these factors were associated with a composite index (defined as having at least one of the following: receiving at least one inappropriate prescription, DDI, or duplication).

RESULTS

The mean age of our cohort was 72.6 (+/-5.7) years, and 1,735 (57.8%) were females. A total of 829 (27.6%) patients received at least one inappropriate prescription, 285 (9.5%) had at least one DDI during the visit, and 746 (24.9%) had at least one duplication during the visit. The three most inappropriately prescribed medication classes were antihistamines (29%), non-steroidal anti-inflammatory agents (23%) and benzodiazepines (16%). In multivariate analyses, the number of prescribed medications per visit was the only factor significantly associated with receiving at least one inappropriate prescription (OR 1.24; 95%CI: 1.16-1.32); analyses using the composite index as outcome gave similar results (OR: 1.70; 95%CI: 1.60-1.80).

CONCLUSION

Our findings indicate a high prevalence of inappropriate prescribing in elderly patients. Given the potential severity of this problem, further steps need to be implemented to prevent this occurrence.

Dextropropoxyphene: safety and efficacy in older patients

Dextropropoxyphene, alone or in combination with acetaminophen (paracetamol), is among the most frequently prescribed opioid analgesics in the elderly in the US despite the American Geriatric Society recommendation that its use should be restricted. However, this recommendation is based on expert opinion in an apparent absence of data. Accordingly, we conducted a literature search which identified nine studies that reported efficacy and safety data for dextropropoxyphene in predominantly older patients (> or = 55 years of age). These studies were evaluated to assess the efficacy and safety of dextropropoxyphene compared with other opioids and to evaluate whether safety and tolerability differed in older versus younger patients. The efficacy of dextropropoxyphene appeared to be similar to that of other analgesics, and its safety was comparable to that of other opioid analgesics. Although the adverse event profile suggests that elderly patients might have more frequent gastrointestinal and CNS complaints than younger patients treated with dextropropoxyphene, the frequency of reports appears similar to that of other opioids. The incidences of dizziness and somnolence were not significantly greater in older patients (1-2% and 0-21%, respectively) than in younger patients (8% and 13%, respectively). The absence of clinical studies directly addressing the safety and tolerability of dextropropoxyphene in elderly patients (>65 years of age) versus younger patients encumbers assessment of the validity of restricting its use in the elderly. Careful outcomes research is needed to assess the effectiveness and safety of dextropropoxyphene in older patients and to develop evidence-based risk/benefit prescribing criteria for use of this drug in this age group.

Evaluation of Nationally Mandated Drug Use Reviews to Improve Patient Safety in Nursing Homes: A Natural Experiment

OBJECTIVES

To test whether nationally required drug use reviews reduce exposure to inappropriate medications in nursing homes.

DESIGN

Quasi-experimental, longitudinal study.

SETTING

Data source is the 1997-2000 Medicare Current Beneficiary Survey, a nationally representative survey of Medicare beneficiaries.

PARTICIPANTS

Nationally representative population sample of 8 million nursing home (NH) residents (unweighted n=2,242) and a comparative group of 2 million assisted living facility (ALF) residents (unweighted n=664).

MEASUREMENTS

Prevalence and incident use of 38 potentially inappropriate medications compared before and after the policy: 32 restricted for all NH residents and six for residents with certain conditions. Inappropriate medications were stratified by potential for legitimate exceptions: always avoid, rarely appropriate, or some acceptable indications.

RESULTS

In July 1999, the Centers for Medicare and Medicaid Services (CMS) mandated expansions to the drug use review policy for nursing home certification. Using explicit criteria, surveyors and consultant pharmacists must evaluate resident records for potentially inappropriate medication exposures and related adverse drug reactions. Nursing homes in noncompliance may receive citations for deficient care. Before the CMS policy, 28.8% (95% confidence interval (CI)=27.3-30.3) of Medicare beneficiaries in NHs and 22.4% (95% CI=19.8-25.0) in ALFs received potentially inappropriate medications. Nearly all prepolicy use came from medications with some acceptable indications: 23.4% in NHs (95% CI=20.4-26.4) and 18.0% in ALFs (95% CI=15.6-20.4). After the policy, exposures in NHs declined to 25.6% (95% CI=24.1-27.1, P<.05), but similar declines occurred in ALFs (19.0%, 95% CI=16.7-21.3, nonsignificant). Postpolicy use of inappropriate medications with exempted indications remained high, and more than half was incident use: 20.6% of NH residents (95% CI=19.0-22.0) and 15.6% of ALF residents (95% CI=15.2-15.7). Use of drugs that are restricted with certain diseases increased 33% in NHs between 1997 and 2000 (from 9.3% to 13.2%; P<.05). Multivariate results detected no postpolicy differences in inappropriate drug use between long-term care facilities with mandatory drug use reviews and those without.

CONCLUSION

Some postpolicy declines were noted in NH use of potentially inappropriate medications, but the decrease was uneven and could not be attributed to the national drug use reviews. This study is the first evaluation of the CMS policy, and it highlights the unclear effectiveness of drug use reviews to improve patient safety in NHs even though state and federal agencies have widely adopted this strategy.

Impact of inappropriate drug use among hospitalized older adults

OBJECTIVE

Criteria for inappropriate drug use developed by Beers have been widely used in drug utilization reviews as the basis for educational materials and to assess the quality of prescribing. However, there is inconclusive evidence that these criteria can impact on patient outcomes. The objective of this study was to evaluate the impact of inappropriate drug use on all-cause mortality, adverse drug reactions (ADRs) and length of stay among in-hospital patients.

METHODS

We performed a retrospective, cohort study on 5,152 patients aged 65 years or older admitted to 81 hospitals in Italy between 1997 and 1998. Inappropriate drug use was defined by 2003 Beers criteria. Outcomes of the study were: (a) in-hospital mortality; (b) incidence of ADR occurring during hospital stay; (c) length of hospital stay 13 days or more.

RESULTS

The mean age of 5,152 participants was 78.8 years (standard deviation = 8.4 years), and 2,463 (47.8%) were men. During hospital stay, 1,475 (28.6% of the study sample) patients received one or more inappropriate drugs. After adjusting for potential confounders, use of inappropriate drugs was not associated significantly with either mortality [odds ratio (OR) 1.05; 95% confidence intervals (CI): 0.75-1.48], ADR (OR 1.20; 95% CI: 0.89-1.61) or length of stay 13 days or more (OR 1.09; 95% CI: 0.95-1.25).

CONCLUSIONS

This study did not show any significant effect of inappropriate drug use defined by Beers 2003 criteria on health outcomes among hospitalized older adults. Further studies conducted in different settings, using additional health outcomes and alternate measures of inappropriate drug use, are needed.

Adverse Outcomes Associated with Inappropriate Drug Use in Nursing Homes

BACKGROUND:

Little empirical evidence exists regarding the influence and outcomes of inappropriate medication use among elderly nursing home residents.

OBJECTIVE:

To identify the prevalence of inappropriate medication use among elderly patients in Georgia nursing homes using the Beers criteria and identify the relationship between inappropriate drug use and the likelihood of an adverse health outcome.

METHODS:

A cohort design was used to review 1117 patient medical records in 15 Georgia nursing homes with a high risk of polypharmacy. Prevalence of inappropriate medication use among elderly patients, as defined by the Beers criteria, was estimated. The adverse health outcomes of hospitalizations, emergency department visits, or deaths were identified from Medicaid claims data.

RESULTS:

A total of 519 (46.5%) patients received at least one inappropriate medication and 143 (12.8%) patients experienced at least one adverse health outcome. Logistic regression revealed that the total number of medications taken (OR 1.139, 95% CI 1.105 to 1.173) significantly increased the likelihood of receiving an inappropriate drug, while having a diagnosis of “dementia” (OR 0.748, 95% CI 0.565 to 0.991) decreased the likelihood. Inappropriate medication use increased the likelihood of experiencing at least one adverse health outcome more than twofold (OR 2.34, 95% CI 1.61 to 3.40). Propoxyphene use alone was significantly associated with the occurrence of an adverse health outcome (OR 2.39, 95% CI 1.54 to 3.71).

CONCLUSIONS:

Inappropriate drug use was common in our study cohort. Inappropriate use of medication in the elderly, particularly propoxyphene, is associated with a higher risk of adverse health outcomes.

Prevalence and correlates of potentially inappropriate prescribing among ambulatory older patients in the year 2001: Comparison of three explicit criteria

OBJECTIVES

The aims of this study were to determine the prevalence of prescribing potentially inappropriate medications (PIMs) based on the 2002 Beers criteria among ambulatory patients aged > or =65 years, to compare PIM prevalence rates based on the 1997 Beers criteria and Zhan criteria with the rate obtained using the 2002 Beers criteria, and to examine patient, provider, and visit characteristics associated with receiving a PIM.

METHODS

Retrospective analysis was conducted of the year-2001 public-use data files of the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey. The 2002 Beers criteria 1997 Beers criteria, and Zhan criteria were used to determine presence of PIMs. Multivariate logistic regression was performed to identify patient, visit, and provider characteristics associated with receiving a PIM.

RESULTS

A total of 7243 ambulatory visits by individuals aged > or =65 years with > or =1 prescription were projected to an estimated 157 million such ambulatory visits. An estimated 21 million visits (13.4%) involved PIMs based on the 2002 Beers criteria, compared with 13.9 million visits (8.8%) based on the 1997 Beers criteria and 6.6 million visits (4.2%) based on the Zhan criteria. An additional 7.2 million visits (4.6%) by eligible patients involved medications defined by the Zhan criteria as having some indications but often being misused. After adjusting for other factors, visits made in metropolitan areas (odds ratio [OR], 2.42 195% Cl, 1.14-5.12) or by referred patients (OR, 2.28 195% CI, 1.43-3.61) were more likely to involve a PIM. Compared with visits involving 1 medication, those involving 2 (OR, 2.39 [95% CI, 1.30-4.41]), 3 (OR, 7.01 [95% Cl, 3.42-14.35]), or > or =4 medications (OR, 7.35 [95% Cl, 4.44-12.17]) were more likely to be associated with a PIM.

CONCLUSIONS

Prevalence of PIMs among ambulatory patients aged > or =65 years is high. The most frequently prescribed PIMs and positive risk factors warrant greater attention from a policy perspective.

The Association of Inappropriate Drug Use with Hospitalisation and Mortality

BACKGROUND AND OBJECTIVE

Inappropriate prescribing is an important and possibly preventable risk factor for adverse drug reactions (ADRs) in the elderly, and hospital-based studies have shown that a large proportion of admissions is a result of ADRs. However, little is known about how inappropriate drug use (IDU) affects the elderly at the population level. The aim of this study was to explore possible associations of IDU with acute hospitalisation and mortality in an elderly population during 3 years of follow-up.

PATIENTS AND METHODS

Data from a rural, population-based, longitudinal cohort study within the Kungsholmen Project, Sweden, were used. 785 participants, > or=75 years of age, had complete data on drug use and selected covariates collected during baseline investigation from 1995 to 1998, and were included in the study. Hospitalisation and mortality data during 3 years after inclusion were collected. IDU was assessed at baseline using consensus-based criteria applicable to available data (derived from Beers' criteria, Canadian criteria and clinical indicators of drug-related morbidity in older adults) with the addition of potentially dangerous drug duplication and additional potentially hazardous drug-drug interactions. IDU was defined as presence of at least one inappropriate drug regimen according to the study criteria. Logistic regression and proportional hazard models were used, respectively, to study the association of IDU with hospitalisation and mortality.

RESULTS

Drugs were used on a regular or 'as needed' basis by 91.6% of the study population, with a mean of 4.4 drugs per person. IDU was common, with a prevalence of 18.6% and was associated with increased risk of at least one acute hospitalisation in community-living elderly, after adjustment for age, sex, education, comorbidity, dependency in activities of daily living (ADL) and smoking. The odds ratio was 2.72 (95% CI 1.64, 4.51). No association with mortality was found, after adjustment for age, sex, housing, education, comorbidity, ADL-dependency, smoking and body mass index.

CONCLUSION

Polypharmacy and IDU are common among the elderly and IDU is associated with acute hospitalisation in community-living elderly. Although causality cannot be established with this study design, the results are consistent with the high prevalence of drug-related hospital admissions found in hospital-based studies. Our results indicate that it is desirable with current knowledge, to reduce IDU through information to physicians and careful prescribing.

Prevalence, correlates, and associated outcomes of potentially inappropriate psychotropic use in the community-dwelling elderly

BACKGROUND

Previous applications of the Beers criteria have shown significant prescribing of potentially inappropriate psychotropic agents for the community-dwelling elderly. However, there is limited information at the national level on potentially inappropriate psychotropic use, the characteristics of elderly persons at risk, and the impact of this inappropriate use on health care outcomes.

OBJECTIVE

This study addressed the prevalence, correlates, and associated outcomes of potentially inappropriate psychotropic use among community-dwelling elderly persons in the United States who were receiving psychotropic medications.

METHODS

Data from the 1996 Medical Expenditure Panel Survey (MEPS) were employed to examine the use of psychotropic medications that generally should be avoided in the elderly and those that should be avoided in elderly patients with certain preexisting conditions, as defined by the Beers criteria. The MEPS sampling weights were used to derive national estimates. Cross-sectional data were analyzed by multivariate analyses to examine the correlates and associated health care outcomes (health care utilization, economic, and humanistic) of potentially inappropriate psychotropic use in the elderly.

RESULTS

An estimated 2.30 million community-dwelling elderly persons received potentially inappropriate psychotropic medications in 1996. This represented 7.14% of all community-dwelling elderly persons and 37.86% of all community-dwelling elderly persons using psychotropic agents; 32.94% of those taking psychotropic drugs received agents that were generally inappropriate, and 10.21% received agents that were inappropriate in the presence of specific conditions. The rates of potentially inappropriate psychotropic use in those receiving antidepressant, antianxiety, and sedative/hypnotic agents were 50.93%, 31.84%, and 23.49%, respectively. Multivariate analyses showed that correlates of potentially inappropriate psychotropic use in the elderly were age <75 years and use of multiple psychotropic agents. After controlling for predisposing, enabling, and need factors, no association was found between the use of potentially inappropriate psychotropic medications and differences in health care utilization, economic, or humanistic outcomes.

CONCLUSIONS

The study findings suggest that although the use of potentially inappropriate psychotropic medications is common among the community-dwelling elderly who are prescribed psychotropic agents, the unfavorable risk-benefit ratio of these inappropriate medications does not appear to influence broad measures of health care utilization, costs, or quality of life in this population.

Update on drug-related problems in the elderly

BACKGROUND

Although pharmacotherapy for the elderly can treat diseases and improve well-being, its benefits can be compromised by drug-related problems.

OBJECTIVE

This article reviews recent publications concerning drug-related problems in the elderly, as well as articles describing the development of 3 sets of quality indicators for medication use in the elderly.

METHODS

Relevant articles were identified through a search of MEDLINE (2002-March 2003) for articles on drug-related problems, inappropriate prescribing, and adverse drug events in the elderly.

RESULTS

The review included 7 articles published in 2002 and 2003. A study in ambulatory elderly persons reported that approximately 5.0% of patients had > or =1 adverse drug event within the previous year. Another study found that approximately 20.0% of ambulatory elderly persons used > or =1 inappropriate drug, as defined by drug utilization review (DUR) criteria, with drug-disease interactions and duration of use being the most common drug-related problems. A third study involving elderly individuals in assisted living facilities found that 16.0% used > or =1 inappropriate drug, as defined by the Beers criteria. Another study examined whether inappropriate drug use, as defined by the Beers or DUR criteria, was associated with death or a decline in functional status; it found that only use of drugs defined as inappropriate by DUR criteria (particularly those drugs associated with drug-drug or drug-disease interactions) was associated with a decline in the ability to perform basic self-care. Three studies, 1 from the United States, 1 from the United Kingdom, and 1 from Canada, described consensus development of quality indicators for drug use in the elderly, including drugs to avoid, maximum daily dose, drug duplication, limits on duration of use, drug-drug and drug-disease interactions, need for drug monitoring, underuse of necessary drugs to treat or prevent common problems, and inappropriate drug-administration technique.

CONCLUSIONS

Drug-related problems are common in elderly patients. Data from recently published studies provide guidance to practitioners and directions for future research.

Inappropriate Medication Administration to the Acutely Ill Elderly: A Nationwide Emergency Department Study, 1992–2000

OBJECTIVES

To determine the national rate and trend of inappropriate medication administration to elderly emergency department (ED) patients. Secondary objectives were to identify risk factors for receiving an inappropriate medication and to determine whether administration is sometimes justified based on diagnosis.

DESIGN

Retrospective analysis of ED visits in the 1992-2000 National Hospital Ambulatory Medical Care Survey. Inappropriate medications identified using Beers' 1997 explicit criteria.

SETTING

EDs of U.S. noninstitutionalized general and short-stay hospitals.

PARTICIPANTS

ED survey patients aged 65 and older.

MEASUREMENTS

Magnitude and rate of administration of 36 medications.

RESULTS

Inappropriate medications were administered in an estimated 16.1 million (95% confidence interval (CI)=14.9-17.3 million) or 12.6% (95% CI=11.6-13.5%) of elderly ED visits from 1992 to 2000. The rate of inappropriate administration was unchanged throughout the study period (P=.40). Six drugs accounted for 70.8% of inappropriate administration: promethazine (22.2%), meperidine (18.0%), propoxyphene (17.2%), hydroxyzine (10.3%), diphenhydramine (7.1%), and diazepam (6.0%). In multivariate analysis, number of ED medications was the strongest predictor, with an odds ratio for two to three medications of 6.0 (95% CI=5.3-6.7) and for four to six medications of 8.1 (95% CI=7.2-9.2). Diagnoses indicating potentially appropriate uses of these medications were rarely present. For example, only 42.4% of patients receiving diphenhydramine and 7.4% receiving hydroxyzine were diagnosed with an allergic process.

CONCLUSION

Elderly ED patients are frequently administered inappropriate medications. Potentially appropriate uses of generally inappropriate drugs cannot account for such administrations. Inappropriate administration rates remain unchanged despite the 1997 publication of explicit criteria.

Drug therapy in the elderly

Drug dosage in the elderly requires an understanding of the age-dependent changes in drug disposition and sensitivity. The most important pharmacokinetic alteration is a decline in renal function, the elderly should therefore be treated as renally insufficient patients. Metabolic clearance is primarily reduced with drugs that display high hepatic extraction, whereas the metabolism of drugs with low hepatic extraction usually is not diminished. The reduction of metabolic clearance is especially pronounced in malnourished or frail patients. The water content of the aging body decreases, the fat content rises. Hence the distribution volume of hydrophilic drugs may be reduced in the elderly, resulting in increased plasma concentrations. In contrast, the distribution volume of liphophilic drugs is increased, their plasma concentrations may decrease. Intestinal absorption of most drugs is not altered in the elderly. Aside of these pharmacokinetic changes, one of the characteristics of old age is a progressive decline in counterregulatory (homeostatic) mechanisms. Therefore, drug effects are attenuated less, the responses are usually stronger than in younger subjects, the rate and intensity of adverse effects are higher. Examples of drug actions augmented is this manner are postural hypotension with agents that lower blood pressure, dehydration and electrolyte disturbances in response to diuretics, bleeding complications with oral anticoagulants, hypoglycemia with antidiabetics, and gastrointestinal irritation with non-steroidal anti-inflammatory drugs. The brain is an especially sensitive drug target in old age. Psychotropic drugs, anticonvulsants, and centrally acting antihypertensives may impede intellectual function and motor coordination. Hence drugs should be used restrictively in geriatric patients.