Prevalence Of Potentially Inappropriate Medication In The Older Adult Population Within Primary Care In Portugal: A Nationwide Cross-Sectional Study

Polypharmacy and potentially inappropriate prescribing of benzodiazepines in older nursing home residents

INTRODUCTION

Previous research has raised concerns about high prevalence of drug-related problems, polypharmacy and inappropriate benzodiazepine prescribing in nursing homes (NHs) and confirmed lack of studies from Central and South-Eastern Europe. The aim of our study was to determine the prevalence and characteristics of polypharmacy, hyperpolypharmacy and inappropriate benzodiazepine prescribing in NH residents in Croatia.

METHODS

Data from 226 older NH residents from five Croatian NHs were collected using the InterRAI Long-Term Care Facilities assessment form. The prevalence and determinants of polypharmacy/hyperpolypharmacy and patterns of inappropriate benzodiazepine prescribing were documented.

RESULTS

The prevalence of polypharmacy (49.6%) and hyperpolypharmacy (25.7%) among NH residents was high. In our study, 72.1% of NH residents were prescribed at least one psychotropic agent, 36.7% used 2-3 psychotropics and 6.6% used 4+ psychotropics. Among benzodiazepine users (55.8%), 28% of residents were prescribed benzodiazepines in higher than recommended geriatric doses, 75% used them for the long term and 48% were prescribed concomitant interacting medications. The odds of being prescribed polypharmacy/hyperpolypharmacy were significantly higher for older patients with polymorbidity (6+ disorders, proportional odds ratio (POR) = 19.8), type II diabetes (POR = 5.2), ischemic heart disease (POR = 4.6), higher frailty (Clinical Frailty Scale (CFS ≥5); POR = 4.3) and gastrointestinal problems (POR = 4.8).

CONCLUSIONS

Our research underscores the persistent challenge of inappropriate medication use and drug-related harms among older NH residents, despite existing evidence and professional campaigns. Effective regulatory and policy interventions, including the implementation of geriatrician and clinical pharmacy services, are essential to address this critical issue and ensure optimal medication management for vulnerable NH populations.

Comparing AGS Beers 2019, STOPP version 2, and EU(7)-PIM list in Portuguese older adults in primary health care

PURPOSE

This study aims to identify PIM prevalence in older adults according to the 2019 Beers criteria, Screening Tool of Older Person's Prescriptions version 2 (STOPP v2) criteria, and the Portuguese EU(7)-PIM list and also to analyze the concordance between these criteria.

METHODS

A retrospective study was conducted among 1200 Portuguese older adults (≥ 65 years old), users of primary health care. Demographic, clinical, and pharmacological data were collected concerning the period between April 2021 and August 2022. A comparative analysis was performed between the three PIM identification criteria, and the concordance was determined according to the Lin concordance correlation coefficient.

RESULTS

The mean age was 76.3 (SD 7.7) years old and 57.6% of the older adults were females. Our findings indicate varying prevalence rates among these criteria with 63.8% (95% CI 61.0-66.6%), 66.8% (95% CI 64.1-69.5%), and 50.1% (95% CI 47.2-53.0%) of the older adults take at least one PIM according to the EU(7)-PIM list, Beers 2019, and STOPP v2 criteria, respectively. The highest prevalence observed was for proton pump inhibitors according to EU(7)-PIM list (30.1%, 95% CI 27.6-32.9) and Beers criteria (30.1%, 95% CI 27.6-32.9) and alprazolam according to STOPP v2 criteria (10.1%, 95% CI 8.4-11.9%). A poor concordance between criteria was observed (< 0.834). The highest concordance coefficient was found between the EU(7)-PIM list and the Beers criteria (0.833), and the lowest between the EU(7)-PIM list and STOPP criteria (0.735).

CONCLUSION

This study reveals varying prevalence rates of PIM in older adults, as assessed by different criteria, and highlights the need for targeted interventions and improved prescribing practices. In the future, studies should focus on the occurrence of negative outcomes in older adults associated with PIM consumption.

Effectiveness and cost-effectiveness of a collaborative deprescribing intervention of proton-pump-inhibitors on community-dwelling older adults: Protocol for the C-SENIoR, a pragmatic non-randomized controlled trial

INTRODUCTION

Worldwide, demographic ageing is a major social, economic and health challenge. Despite the increase in life expectancy, elderly often live with multiple chronic conditions, exposing them to multiple medications. Concerns have been raised about the growing issue of inappropriate long-term usage of proton-pump inhibitors (PPI), which have been associated with adverse outcomes and increased healthcare costs. Deprescribing is a recommended intervention to reduce or withdraw medicines that might be causing harm or might no longer be of benefit. This protocol details a trial to assess the effectiveness and cost-effectiveness of a collaborative deprescribing intervention of PPI among community-dwelling elderly, involving community pharmacists and general practitioners.

METHODS AND ANALYSIS

A pragmatic, multicentre, two-arm, non-randomised controlled trial of a structured PPI collaborative deprescribing intervention in the primary care setting with a 6-month follow-up will be conducted. Patients must be 65 years old or older, live in the community and have been using PPI for more than 8 weeks. We hypothesize that the intervention will reduce the PPI usage in the intervention group compared to the control group. The primary outcome is the successful discontinuation or dose decrease of any PPI, defined as a statistically significant absolute 20% reduction in medication use between the intervention and control groups at 3- and 6-month follow-ups. An economic evaluation will be conducted alongside the trial. This study was approved by the Ethics Research Committee of Nova Medical School, NOVA University of Lisbon and by the Ethics Committee from the Local Health Unit Alto Minho, Portugal.

DISCUSSION

This pragmatic trial will provide evidence on the effectiveness and cost-effectiveness of a patient-centred collaborative deprescribing intervention in the community setting in Portugal. It will also inform improvements for the development of future multi-faceted interventions that aim to optimise medication for the community-dwelling elderly.

CLINICAL TRIAL REGISTRATION

ISRCTN 49637686.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

Evaluation of deprescription by general practitioners in elderly people with different levels of dependence: cross-sectional study

BACKGROUND

Polypharmacy is easily achieved in elderly patients with multimorbidity and it is associated with a higher risk of potentially inappropriate medication use and worse health outcomes. Studies have shown that deprescription is safe, however, some barriers have been identified. The aim of this study was to analyse Portuguese General Practitioners (GP) deprescription's attitudes using clinical vignettes.

METHODS

Cross-sectional study using an online survey with 3 sections: demographic and professional characterization; two clinical vignettes with an elderly patient with multimorbidity and polypharmacy in which the dependency level varies; barriers and factors influencing deprescription. Frequencies, means, and standard deviations were calculated to describe the GPs. Analysis of the deprescription attitude, globally and for each drug, for each clinical vignette applying the McNeemar's test.

RESULTS

A sample of 396 GP was obtained with a mean age of 38 years, most of them female. A statistically significant difference (p < 0.01) was observed in deprescribing according to the patient dependency level, with more GPs (80.4% versus 75.3%) deprescribing in the most dependent patient. A statistically significant difference was found for all drugs except for antihypertensive drugs. All medications were deprescribed more often in dependent patients except for anti-dementia drugs. More than 70% of the participants considered life expectancy and quality of life as "very important" factors for deprescription and more than 90% classified the existence of guidelines and the risks and benefits of medication as "very important" or "important". In the open question, the factors most reported by the GP were those related to the patient (52,9%).

CONCLUSIONS

This is the largest study on this topic carried out in Portugal using clinical vignettes, with a representative sample of Portuguese GP. The level of dependence significatively influenced the deprescription attitude of Portuguese GPs. The majority of the GPs classified the quality of life, life expectancies, potential negative effects and the existence of guidelines as "very important" or "important" while deprescribing. It is important to develop and test deprescribing in real life studies to analyze if these attitudes are the same in daily practice.

Magnitude and Determinants of Long-term Use of Proton Pump Inhibitors Among Portuguese Older Adults in Primary Health Care

PURPOSE

Proton Pump Inhibitors (PPIs) have been associated with several adverse effects of particular concern in older populations. Their use for a period longer than 8 weeks is not recommended for older adults. Strategies to discontinue PPIs have been offered; however, their use remains high. This study aims to characterize PPI use in Portuguese older people and to identify the factors associated with potentially inappropriate use.

METHODS

A cross-sectional study was conducted on 1200 randomly selected older adults (≥65 years of age), users of primary health care facilities in the Regional Health Administration (Administração Regional de Saúde of Centro [ARSC]) of Portugal between April 2021 and August 2022. Data concerning their characteristics and PPI use were provided by the Shared Services of the Health Ministry (Serviços Partilhados do Ministério da Saúde) and collected retrospectively. Associations between independent variables and PPI use were investigated by logistic regression analysis.

FINDINGS

Of the older adults, 37.92% were receiving PPIs and 78.68% of them were taking them for a longer period than recommended; 49.79% were taking PPIs without having any digestive system-related disease. Multivariate analysis showed that the prolonged use of PPIs was not associated with any specific pattern, although inappropriate PPI use is high among Portuguese older adults.

IMPLICATIONS

Long-term PPI use in older adults is widespread and does not fit any particular patient profile; therefore, cross-cutting educational interventions should be designed independently of the patient's pathologic condition or treatment.

[Prevalence of Outpatient Use of Medicines by the Elderly Population in Portugal: A Cross-Sectional Study]

INTRODUCTION

Like in other countries, the age pyramid in Portugal has been changing considerably, with a substantial increase in the size of the older population and a significant reduction in the number of young people. With aging, co-occurrence of several conditions becomes frequent, often leading to the use of multiple medications (polypharmacy). Polypharmacy in the older population is particularly relevant considering the physiological changes of the ageing process, which increase the risk of drug interactions, poor adherence to treatment, and adverse drug reactions, especially in the oldest-old population (85 years or older). As the size of the older population is likely to increase significantly, it is important to characterize the pattern of medicines' use by the elderly while also identifying cases of polypharmacy in order to obtain evidence that can be used to develop specific measures to tackle the high prevalence of use and its associated risks. To this end, the aim of this study was to characterize medication use by older individuals in Portugal.

METHODS

Cross-sectional study with data from the National Health System's Control and Monitoring Center on reimbursed medicines that were prescribed and dispensed to individuals aged 65 years or older in 2019 in all community pharmacies of the Portuguese mainland. We performed a demographic and geographic analysis of the data by international nonproprietary name and therapeutic group. The number of reimbursed packages and the number of reimbursed packages per capita were the metrics used (data from Instituto Nacional de Estatística).

RESULTS

A higher consumption of medicines was observed in women, increasing with age, except in the oldest olds, in which the sex difference tended to shrink. Use per capita showed an opposite trend, with the oldest-old men surpassing the oldest-old women (mean reimbursed packages: 55.5 in men versus 55.1 in women). In women, consumption was led by cardiovascular medicines (31%), followed by central nervous system medications (30%) and antidiabetics (13%); in men, 37% of TOP 10 consumption was due to cardiovascular medications, antidiabetics (16%) and drugs for benign prostatic hypertrophy (14%).

CONCLUSION

In the elderly, there were sex differences in the pattern of medicines' use, and there were also significant age-related differences in 2019. To the best of our knowledge, our study is the first nationwide analysis of reimbursed medicines' consumption data in the elderly, which is essential to characterize the use of medicines in this age group in Portugal.

The Prevalence of Potentially Inappropriate Prescribing in Two Family Health Units in Portugal

OBJECTIVE

Polypharmacy and potentially inappropriate prescribing (PIP) are growing concerns in the ageing population. They carry the risk of increasing adverse effects, medical interactions, and difficulties managing the medication. Few studies in Portugal evaluate the prevalence of polypharmacy and PIP in primary care. No previous studies in the primary care setting in Portugal have been conducted using the European Union (EU)(7)-PIM (potentially inappropriate medication) list tool. In this study, we aimed to estimate the prevalence of polypharmacy and PIP in two family health units in Portugal.  Methods: To answer this question, we enrolled a sample of 361 elderly patients from two family health units in a descriptive observational transversal study. We randomly selected patients, consulted their prescription records in the previous 12 months, and applied the EU(7)-PIM list tool, validated for the Portuguese population. The data was then analyzed using descriptive and inferential statistics and the Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp., Version 24.0, Armonk, NY).

RESULTS

Our results showed a prevalence of 79.8% of polypharmacy in the elderly population and 73.4% of PIP. These values are higher than predicted in the literature, but different screening tools have been used among papers. The mean number of prescribed drugs per patient was nine in one unit and seven in the other, and the mode was eleven per patient. The most identified PIP-associated drugs were proton pump inhibitors in 46.4% of the patients in one unit and 43.7% in the other. We also found a statistically significant higher prevalence of PIP and polypharmacy in females and patients over 75 years.

CONCLUSION

From a prevalence perspective, we found higher-than-expected prevalences of PIP and polypharmacy in our population. Contributing factors might be a higher ageing index in the Portuguese population, modern practices using combination therapy, and the use of a screening tool that does not take into account the personal clinical history of patients. Further limitations involve only including patients with follow-up in the units studied. Even so, it suggests both PIP and polypharmacy as concerns to address, and we will strive to educate both health teams on PIP, polypharmacy, and deprescribing. We also emphasize the need to widen the study to other family health units.

Potentially Inappropriate Medication Use Among Older Patients with Diabetes in a Chinese Community

BACKGROUND

Potentially inappropriate medications (PIMs) are frequently prescribed to older people with diabetes. This study aimed to assess the prevalence of PIM use in older people with diabetes and identify potential risk factors influencing the development of PIM use.

METHODS

This was a cross-sectional study conducted in an outpatient setting in Beijing, China, using Chinese criteria. The prevalence of PIM use, polypharmacy, and comorbidities in older adults with diabetes in an outpatient setting was measured. Logistic models were employed to investigate the association among polypharmacy, comorbidities, and PIM use.

RESULTS

The prevalence of PIM use and polypharmacy was 50.1% and 70.8%, respectively. The most common comorbidities were hypertension (68.0%), hyperlipemia (56.6%), and stroke (36.3%), and the top three inappropriately used medications were insulin (22.0%), clopidogrel (11.9%), and eszopiclone (9.81%). Age (OR 1.025; 95% CI 1.009, 1.042), the number of diagnoses (OR 1.172; 95% CI 1.114, 1.232), coronary heart disease (OR 1.557; 95% CI 1.207, 2.009), and polypharmacy (OR 1.697; 95% CI 1.252, 2.301) were associated with PIM use.

CONCLUSIONS

Given the higher rate of PIM use among older adults with diabetes, strategies and interventions targeting this population are needed to minimize PIM use.

Potentially inappropriate medication uses and associated factors among elderly primary health care clinics attendees: A call to action

BACKGROUND

Polypharmacy is a significant risk factor for using potentially inappropriate medication (PIM), which is using drugs with more risks than benefits, especially for elders. This study aimed to estimate the prevalence of PIM using Beers Criteria, polypharmacy, and their related risk factors.

METHODS

A descriptive cross-sectional study was conducted in West Bank primary health care clinics (PHC)from December 2021 to March 2022. Data were collected from PHC clinic attendees aged 65 and above via an interviewer-administered questionnaire and a review of their medical records. We used the Beers Criteria 2019 update to identify PIM and performed a multivariable analysis to determine its associated factors.

RESULTS

The study included 421 older people (197 men and 224 women) with an average age of 73.6 years. The prevalence of polypharmacy was 75.1% (95%CI: 70.6%-79.1%), with an average of six medications dispensed per patient. On the other hand, PIM was identified among 36.8% of the study participants (CI:95%CI: 32.2%- 41.6%). Sulfonylureas were the most common (24.2%) reported PIM, followed by peripheral alpha-blockers (4.3%), non-steroidal anti-inflammatory drugs (3.1%), proton pump inhibitors (2.9%), and central nervous system medications (2.1%). Hyperpolypharmacy (> 10 drugs) [aOR = 4.1, 95%CI: 1.6-10.7], polypharmacy [aOR = 2.8, 95%CI: 1.4-5.4], and Diabetes [aOR = 3.5, 95%CI: 2.0-6.0] are the main associated factors of PIM.

CONCLUSION

This study found that over one-third of the older people attending PHC clinics have PIM, with polypharmacy and Diabetes being the main predicting variables. Improving physicians' awareness of clear and specific PIM lists can reduce the number of PIM prescribed and decrease their impact.

The impact of including a medication review in an integrated care pathway: A pilot study

AIM

The objective of the present study was to measure the impact of the intervention of combining a medication review with an integrated care approach on potentially inappropriate medications (PIMs) and hospital readmissions in frail older adults.

METHODS

A cohort of hospitalized older adults enrolled in the French PAERPA integrated care pathway (the exposed cohort) was matched retrospectively with hospitalized older adults not enrolled in the pathway (unexposed cohort) between January 1st, 2015, and December 31st, 2018. The study was an analysis of French health administrative database. The inclusion criteria for exposed patients were admission to an acute care department in a general hospital, age 75 years or over, at least three comorbidities or the prescription of diuretics or oral anticoagulants, discharge alive and performance of a medication review.

RESULTS

For the study population (n = 582), the mean ± standard deviation age was 82.9 ± 4.9 years, and 380 (65.3%) were women. Depending on the definition used, the overall median number of PIMs ranged from 2 [0;3] on admission to 3 [0;3] at discharge. The intervention was not associated with a significant difference in the mean number of PIMs. Patients in the exposed cohort were half as likely to be readmitted to hospital within 30 days of discharge relative to patients in the unexposed cohort.

CONCLUSION

Our results show that a medication review was not associated with a decrease in the mean number of PIMs. However, an integrated care intervention including the medication review was associated with a reduction in the number of hospital readmissions at 30 days.

Potentially inappropriate medication in long-term care wards of a veteran hospital in Taiwan: Investigation using a spreadsheet-based rapid assessment tool

BACKGROUND

Multimorbidity and polypharmacy increase in the aging population and are accompanied by the use of potentially inappropriate medications (PIMs) and adverse drug events (ADEs). This study developed a rapid assessment tool to investigate PIM use among patients in long-term care wards.

METHODS

We retrospectively collected the data of patients in long-term care wards of a veteran hospital in Taiwan between July 2019 and June 2020. The patients with chronic diseases and medications were selected. The data, including gender, age, diagnosis, and medications, were deidentified. Nonchronic disease diagnosis and short-term and topical use medications were excluded. We used Microsoft Excel (Microsoft Corporation, Redmond, Washington, USA) and the 2019 version of the Beers Criteria to establish a rapid assessment tool. The correlations between the prevalence of PIM use and age, the number of diagnoses, and the number of medications were analyzed using SPSS version 23.

RESULTS

A total of 176 patients were included in this study, of which 76.7% (n = 135) were male and 23.3% (n = 41) were female. The average age of men was 82.1 years and that of women was 83.4 years. The average number of diagnoses for men was 5.5, and that for women was 7.3. The average number of medications for men was 5.8, and that for women was 6.5. The prevalence of PIM use was 59.1% (n = 104). Logistic regression revealed that the prevalence of PIM use may be associated with the number of medications ( p < 0.001; odds ratio = 1.378). Decision tree analysis revealed that patients who simultaneously used more than four medications exhibited a higher risk of PIM.

CONCLUSION

PIM use is a key factor causing ADEs among older adults. Therefore, comprehensive assessment of PIM use is necessary. This study designed a rapid assessment tool to simultaneously integrate and evaluate medications. Future studies may investigate the effectiveness of the proposed assessment tool.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusion

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

Translation, cross-cultural adaptation and validation of the revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire to Portuguese: Older adults version

BACKGROUND

Deprescribing is a patient-centered approach to managing inappropriate polypharmacy that faces several barriers, including patients' attitudes and beliefs about medications that need to be considered. For this purpose, the revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire is a helpful instrument, but until now, there is no Portuguese version.

OBJECTIVES

To translate and validate the rPATD questionnaire (older adults version) to Portuguese.

METHODS

The rPATD questionnaire was translated and cross-culturally adapted using forward-backward translation and pre-testing. A cross-sectional study with 192 older adults aged ≥65 years taking at least 1 regular medication was conducted for validity assessment. Participants were recruited by convenience sampling in 3 Portuguese outpatient rehabilitation medicine clinics. Psychometric properties were evaluated through face and content validity; construct validity, by assessing structural validity through exploratory factor analysis, hypotheses testing, including concurrent validity and cross cultural validity; reliability with internal consistency; and item-total correlation. Floor and ceiling effects were examined.

RESULTS

The exploratory factor analysis (EFA) revealed a 4-factor structure that explains 51.08% of the total variance, as in the original rPATD. These 4 factors are related to the level of involvement in medication management, beliefs in the appropriateness of medication, perceived burden of medication, and concerns about stopping medications. Factor loadings ranged from 0.226 to 0.800; 2 items scored <0.3, and no cross-loading was found. The exclusion of the 2 items loading <0.3 in the EFA showed no significant improvement in factor loading or internal consistency, so the item structure was maintained. In hypothesis testing, 78% of the correlations were correctly predicted. The 4 factors internal consistency was generally acceptable, with Cronbach's alpha ranging from 0.638 to 0.830. The item-total correlation ranged between 0.223 and 0.7.

CONCLUSION

The Portuguese rPATD questionnaire for older adults presents globally good or acceptable psychometric properties.

Assessment of Potentially Inappropriate Medications Using the EU (7)-PIM List, in a Sample of Portuguese Older Adults' Residents in Nursing Homes

Abstract

Prescription of potentially inappropriate medication (PIM) in older adults is associated with poor clinical outcomes. The EU (7)-PIM list was created for the European market to improve pharmacotherapy in older adults.

Purpose

This work aims to characterize the medication profile and assess the presence of PIM, using the EU (7)-PIM list in older adults’ residents at nursing homes.

Methods

Retrospective data were collected from the anonymized nursing home records. After PIM identification, a descriptive analysis was performed, and a generalized linear model for dependent negative binomial-type variables was constructed to assess the risk of PIM.

Results

Of the 210 participants (mean age 85.10), 82.40% were polymedicated. PIM was observed in 86.4% participants (mean per patient = 2.30± 0.10). The most common PIM were proton pump inhibitors (n = 121, 57.62%), followed by anxiolytics (n = 96, 45.71%). 64.30% of all patients take 2–4 PIM and 5.80% take five or more PIM. The occurrence of PIM is influenced by the number of prescribed medicines (RR 1.14; 95% CI 1.1.-1.17) and the presence of digestive system diseases (RR 1.05; 95% CI 1.0–1.09).

Conclusion

The high prevalence of PIM observations highlights the necessity of the implementation of guidelines to prevent PIM.

Prevalence of potentially inappropriate medications based on the STOPPFrail criteria in frail older patients with limited life expectancy: a cross-sectional study

BACKGROUND

The recently developed Screening Tool of Older Persons' Prescriptions in Frail adults with a limited life expectancy (STOPPFrail) criteria can be helpful for screening medications (PIMs), but it is yet to be widely used in clinical practice. Herein, we aimed to investigate the prevalence of PIMs based on the STOPPFrail criteria (STOPPFrail-PIM) among frail older adults with limited life expectancy admitted to the geriatric center.

METHODS

This was a retrospective cross-sectional study conducted in the geriatric center at an academic tertiary care hospital in Korea. We evaluated frail older adults with limited life expectancy who received comprehensive geriatric assessment (CGA) admitted between 1 January, 2019 and 30 June, 2020. Frail older adults with limited life expectancy were identified by geriatricians with retrospective records and the prevalence of STOPPFrail-PIMs was analysed by trained pharmacists. Descriptive analysis, t-test, and chi-square test were conducted using IBM SPSS software version 25.0.

RESULTS

Among 504 older adults who underwent CGA after admission, 171 frail older adults with limited life expectancy were identified by geriatricians and included in the study. An average of 11.3 ± 4.7 medications were administered regularly to each patient before admission. Overall, 97.1% (166/171) had at least one STOPPFrail-PIM, and the mean number of STOPPFrail-PIM was 4.2 ± 2.8. Drugs without clear clinical indication (A2) were the most frequent pre-admission STOPPFrail-PIM, followed by lipid-lowering therapies (B1) and neuroleptic antipsychotics (D1). The number of STOPPFrail-PIM was significantly lower at discharge than that at admission, with the decrease being the highest for A2 at 94.7%.

CONCLUSIONS

Most frail older adults with limited life expectancy had at least one STOPPFrail-PIM at admission, and the rate of STOPPFrail-PIM decreased significantly at discharge after the geriatric multidisciplinary team care. Further studies are needed to investigate the association between the use of STOPPFrail-PIM and adverse consequences in frail older adults.

Adverse Drug Reactions and Potentially Inappropriate Medication in Older Patients: Analysis of the Portuguese Pharmacovigilance Database

Criteria have been developed to identify potentially inappropriate medications that can enhance adverse reactions, highly prevalent in older patient’s therapy. This study aimed to identify potentially inappropriate medications within the adverse drug reactions reported in the Portuguese pharmacovigilance system, characterizing the reports where inappropriate medications were identified. INFARMED, I.P. provided all adverse drug reactions reported from January to December 2019 in 65-year-old and older patients. Adverse drug reactions were characterized according to the System Organs Classes, seriousness, and medications with the Anatomical Therapeutical Classification. Potentially inappropriate medications were identified by applying the EU-(7)-PIM and the Beers criteria. A p value < 0.05 was considered statistically significant. From the 2337 reports considered for the analysis, PIMs were found in 12.8% of these, and 64.7% of all adverse reaction reports were classified as serious. Within the group of reports including at least one PIM, 71.4% were classified as serious, with hospitalization the most common criteria (35.1%). From the 3170 suspected medicines identified, 10.6% were classified as PIMs. Amiodarone was the most frequent PIM identified in the study (10.1%). Reports including at least one PIM were more associated with a higher number of ADRs (p = 0.025) reported in the same record, higher number of suspected medicines identified (p < 0.001), seriousness (p = 0.005), and hospitalization (p < 0.001). Potentially inappropriate medications are important enhancers of serious adverse drug reactions, increasing the likelihood of hospitalizations. This reinforces the importance of improving medication appropriateness in the older population.

The Prevalence of Polypharmacy and Potentially Inappropriate Medications and Its Relationship with Cognitive Status in Portuguese Institutionalized Older Adults: A Cross-Sectional Study

The aim of this study was to evaluate the prevalence of polypharmacy and potentially inappropriate medications (PIMs) in a population of older adults living in nursing homes. Furthermore, we also intended to assess the possible association between polypharmacy, potentially inappropriate medications and cognitive impairment in institutionalized older adults. A cross-sectional study analyzed data from 193 nursing home residents in the district of Viseu, Portugal, between September 2018 and June 2019, with a mean age of 82.4 ± 6.2 years (ranging from 65 to 95 years old); 72.5% (n = 140) were female participants. Major polypharmacy was presented in 80.8% of the study population, who took 7.6 ± 3.3 drugs per day. Using the Beers Criteria, we found that 79.3% took PIMs. There was a positive association between polypharmacy and PIM (p < 0.001), showing that higher medicines intake increased the number of PIMs. Polypharmacy was not associated with the functionality of the older adults to perform activities of daily living, but was associated with cognitive impairment. The older adults with lower scores on the Mini Mental State Examination (MMSE) took more drugs (p = 0.039) and used more PIM (p < 0.001). Moreover, patients taking five or more prescription drugs per day (major polypharmacy) consuming any psychiatric, gastrointestinal or oral antidiabetic agents (regardless of whether they were considered potentially inappropriate or not) had higher odds of displaying cognitive impairment than those who did not (p < 0.05). Older adult residents of the studied nursing homes were potentially affected by polypharmacy and inappropriate polypharmacy. This observation reveals the need to adopt and implement strategies that make drug therapy more adequate and safer for older adults.

Potentially inappropriate medication prescribing among elderly patients with cardiovascular diseases

Background/Aim. The growing number of older adults means higher medicine utilization. The aim of the study was to determine the frequency and identify risk factors of potentially inappropriate medication (PIM) in the elderly population with cardiovascular diseases. Methods. The retrospective, cross-sectional study was performed in 2018, and the relevant data were collected during the period from January 2016 to December 2017. The study sample included 1,500 patients over 65 years with cardiovascular disease who had medical records at the Institute for Gerontology and Palliative Care, Belgrade. Assessment of PIM was done by standard international criteria such as the American Geriatrics Society 2015 updated Beers Criteria for PIM use in older adults. Results. PIM frequency in the elderly population was 70.3%. In relation to gender, it was more frequent in female elders. The mean number of prescribed drugs was similar for 2016 and 2017, 7.2 and 7.3, respectively. The most common were: medium-acting benzodiazepines (70.9%), central ? blockers (23.98%), and antipsychotics (typical and atypical) (20.94%). The most common comorbidity was noted in a group labeled with the International Disease Classification I00-I99, which includes heart and blood vessel diseases [n = 2,658 (36.9%)]. The most common diagnoses belonged to the subgroups I10-I15 [hypertensive diseases, n = 1,298 (18%)], I20-I25 [ischemic heart diseases n = 542 (7.5%)], I30-I52 [other forms of heart disease, n = 705 (9.8%)], I60-I69 [cerebrovascular diseases, n = 94 (1.3%)], and I80- I89 [diseases of veins, lymph vessels, and lymph nodes n = 12 (0.17%)]. The risk factors for PIM were: polypharmacy, gender, nicotine use, cognitive status, nutrition state, and the number of diseases registered in the study sample. Conclusion. Cardiovascular diseases in the elderly population are associated with a high prevalence of PIM. Creating health recommendations for prescribing drugs to the elderly that would emphasize these factors could reduce the prevalence of PIM in this population.

Prevalence and Factors that Influence Potentially Inappropriate Medication Use among Thai Elderly in Primary Care Settings

Background

Older age increases the likelihood of chronic diseases and polypharmacy with the likelihood of potentially inappropriate medications (PIMs) in secondary and tertiary care levels, but in the primary care settings of Thailand there still is a need for more evidence. This study aimed to examine the prevalence of PIM in primary care settings, and to identify factors that influence the use of PIM.

Methods

A cross-sectional retrospective study was conducted in 2017. Eight primary care units from four regions of Thailand were randomly selected. People aged ≥ 60 years in the eight units were studied as participants. The List of Risk Drugs for Thai Elderly (LRDTE) was used as the reference. Multivariate logistic regression was carried out to identify factors that influence.

Results

A total of 4,848 patients aged ≥60 years with 20,671 prescriptions were studied. The mean age was 70.7±8.3 years for males, and 61.2% for females. A little more than 5% (5.1%) had ≥ 3 chronic diseases and 15.0% received polypharmacy (≥5 medications). The prevalence of prescriptions with PIMs was 65.9%. The most frequent PIMs were antidepressants: amitriptyline (28.1%), antihistamines: dimenhydrinate (22.4%) and chlorpheniramine maleate (CPM) (11.2%); and Benzodiazepines: lorazepam (6.5%). Three factors that significantly influenced prescribing of PIMs were polypharmacy (adjusted OR 3.51; 95% CI 2.81-4.32), having ≥3 chronic diseases (adjusted OR 1.44; 95% CI 1.04-2.01), and age ≥75 years (adjusted OR 1.18; 95% CI 1.01-1.38).

Conclusion

More than two-thirds of elderly Thai patients in the primary care settings were prescribed PIMs. Multidisciplinary prescription review and PIM screening in patients aged ≥75 years who have ≥3 chronic diseases or polypharmacy should be implemented in primary care and supportive computerized PIMs alert system is needed.

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.

Effectiveness of polypharmacy reduction policy in Japan: nationwide retrospective observational study

Background Polypharmacy is an important global health issue. In Japan, an amended policy has been implemented since April 2016 to offer incentives that allow claiming a payment of approximately 22.5 US$ per patient to hospitals and clinics that succeed to reduce two or more medications. However, there is no evidence on the nationwide effectiveness of polypharmacy reduction policy. Aim To evaluate the effectiveness of the polypharmacy reduction policy in Japan using nationwide outpatient prescription fee reimbursement claims data in Open Data of the National Database of Health Insurance Claims and Specific Health Checkups of Japan. Method This nationwide retrospective observational study was conducted over 3 years (April 2015 to March 2018). The primary outcome was the polypharmacy reduction ratio calculated by the polypharmacy proportion. Factors associated with policy effectiveness were identified by performing a multiple linear regression analysis using independent variables. Results After implementing the new policy, a 7.3 % polypharmacy reduction ratio was observed, particularly in the elderly (8.2 %). Multiple linear regression analysis revealed that the proportion of elderly residents (aged ≥65 years), number of hospitals per 100,000 residents, and number of clinics per 100,000 residents were statistically significantly associated with this reduction. Conclusion The polypharmacy reduction policy indicated an association with polypharmacy reduction in Japan. The proportion of elderly residents and availability of hospitals and clinics are important factors to enhance the effectiveness of the polypharmacy reduction policy.

Potentially inappropriate medication use in elderly patients treated in intensive care units: A cross-sectional study using 2019 Beers, STOPP/v2 Criteria and EU(7)-PIM List

OBJECTIVE

To determine the prevalence of and the risk factors for Potentially Inappropriate Medication (PIM), the drug groups most commonly evaluated as PIMs in elderly patients in the ICUs by using 2019 Beers Criteria, STOPP version 2 (v2) Criteria and EU(7)-PIM List. The relation between mortality rate and length of ICU stay with PIMs was also examined.

METHODS

This was a cross sectional study conducted on patients aged ≥65 years, treated in ICUs (n = 139) between June 8, 2020, and January 11, 2021. Patients' demographic characteristics, clinical data and laboratory findings about the drugs used were collected prospectively. PIMs were evaluated according to each of the criteria applied. Relationship of dependent and independent variables was evaluated using chi-square analysis, t-test and logistic regression analysis. P < .05 was considered statistically significant.

RESULTS

The number of patients with at least 1 PIM according to three criteria was 118 (84.9%) (80.6%, 59.7%, 48.2%, Beers, STOPP/v2 and EU(7)-PIM List, respectively). In the univariate analysis, receiving renal replacement therapy and high number of drugs were the covariates that significantly affected the presence of PIM according to all three criteria (P < .05). Combined use of anxiolytics and opioids in Beers Criteria (58.3%), antipsychotics (26.6%) in STOPP/v2 Criteria, and antiarrhythmics (23.7%) in EU(7)-PIM List were the drugs that caused PIM at most. No relationship was found between the presence of PIM and mortality. The length of ICU stay was determined significantly longer in the presence of PIM according to Beers Criteria (P = .028).

CONCLUSIONS

In this study, the prevalence of PIM was determined higher in elderly patients in ICU. Our results supported that 2019 Beers Criteria for ICU patients seems to be more directive in detecting PIMs and determining the prognosis. Reducing the number of drugs administered may be the first step to decrease PIMs in elderly patients in ICU and to maintain the treatment safely.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Elderly Patients in Primary Care are Still at Risks of Receiving Potentially Inappropriate Medications

Background

Most older adults with comorbidities in primary care clinics use multiple medications and are at risk of potentially inappropriate medications (PIMs) prescription.

Objective

This study examined the prevalence of polypharmacy and PIMs using Thai criteria for PIMs.

Methods

This study was a retrospective cross-sectional study. Data were collected from electronic medical records in a primary care clinic in 2018. Samples were patients aged ≥65 years old with at least 1 prescription. Variables included age, gender, comorbidities, and medications. The list of risk drugs for Thai elderly version 2 was the criteria for PIMs. The prevalence of polypharmacy and PIMs were calculated, and multiple logistic regression was conducted to examine associations between variables and PIMs.

Results

Of 2806 patients, 27.5% and 43.7% used ≥5 medications and PIMs, respectively. Of 10 290 prescriptions, 47% had at least 1 PIM. The top 3 PIMs were anticholinergics, proton-pump inhibitors, and nonsteroidal anti-inflammatory drugs (NSAIDs). Polypharmacy and dyspepsia were associated with PIM prescriptions (adjusted odds ratio 2.48 [95% confident interval or 95% CI 2.07-2.96] and 3.88 [95% CI 2.65-5.68], respectively).

Conclusion

Prescriptions with PIMs were high in the primary care clinic. Describing unnecessary medications is crucial to prevent negative health outcomes from PIMs. Computer-based clinical decision support, pharmacy-led interventions, and patient-specific drug recommendations are promising interventions to reduce PIMs in a primary care setting.

Patient- and Prescriber-Related Factors Associated with Potentially Inappropriate Medications and Drug-Drug Interactions in Older Adults

We aimed to evaluate the prevalence of potentially inappropriate medication (PIM) use and drug–drug interactions (DDIs) in older adults and their associated factors. This cross-sectional study used National Health Insurance data of older adults in South Korea. The 2015 AGS Beers Criteria were used to classify PIM use and DDIs. The associations of PIM use and DDIs with patient- and prescriber-related factors were evaluated using multiple logistic regression. Of the older adults who received at least one outpatient prescription (N = 1,277,289), 73.0% and 13.3% received one or more prescriptions associated with PIM use or DDIs, respectively. Chlorphenamine was most commonly associated with PIM, followed by diazepam. Co-prescriptions of corticosteroids and NSAIDs accounted for 82.8% of DDIs. Polypharmacy and mainly visiting surgeons or neurologists/psychiatrists were associated with a higher likelihood of prescriptions associated with PIM use or DDIs. Older age, high continuity of care (COC), and mainly visiting a hospital were associated with a lower likelihood of PIM use or DDIs. Prescriptions associated with PIM use and DDIS were more frequent for low COC patients or those who mainly visited clinics; therefore, patients with these characteristics are preferred intervention targets for reducing prescriptions associated with PIM use and DDIs.

Epidemiology and associated factors of polypharmacy in older patients in primary care: a northern Italian cross-sectional study

Background

A precondition for developing strategies to reduce polypharmacy and its well-known harmful consequences is to study its epidemiology and associated factors. The objective of this study was to analyse the prevalence of polypharmacy (defined as ≥8 prescribed drugs), of potentially inappropriate medications (PIMs) and major drug-drug interactions (DDIs) among community-dwelling general practice patients aged ≥75 years and to identify characteristics being associated with polypharmacy.

Methods

This cross-sectional study is derived from baseline data (patients’ demographic/biometric characteristics, diagnoses, medication-related data, cognitive/affective status, quality of life) of a northern-Italian cluster-RCT. PIMs and DDIs were assessed using the 2012 Beers criteria and the Lexi-Interact® database. Data were analysed using descriptive methods, Wilcoxon rank-sum tests, Fisher’s exact tests and Spearman correlations.

Results

Of the eligible patients aged 75+, 13.4% were on therapy with ≥8 drugs. Forty-three general practitioners and 579 patients participated in the study. Forty five point nine percent of patients were treated with ≥1 Beers-listed drugs. The most frequent PIMs were benzodiazepines/hypnotics (19.7% of patients) and NSAIDs (6.6%). Sixty seven point five percent of patients were exposed to ≥1 major DDI, 35.2% to ≥2 major DDIs. Antithrombotic/anticoagulant medications (30.4%) and antidepressants/antipsychotics (23.1%) were the most frequently interacting drugs. Polypharmacy was significantly associated with a higher number of major DDIs (Spearman’s rho 0.33, p < 0.001) and chronic conditions (Spearman’s rho 0.20, p < 0.001), higher 5-GDS scores (thus, lower affective status) (Spearman’s rho 0.12, p = 0.003) and lower EQ-5D-5L scores (thus, lower quality of life) (Spearman’s rho − 0.14, p = 0.001). Patients’ age/sex, 6-CIT scores (cognitive status), BMI or PIM use were not correlated with the number of drugs.

Conclusions

The prevalence of polypharmacy, PIMs and major DDIs was considerable. Results indicate that physicians should particularly observe their patients with multiple conditions, reduced health and affective status, independently from other patients’ characteristics. Careful attention about indication, benefit and potential risk should be paid especially to patients on therapy with specific drug classes identified as potentially inappropriate or prone to major DDIs in older persons (e.g., benzodiazepines, NSAIDs, protonic pump inhibitors, antithrombotics/anticoagulants, antidepressants/antipsychotics).

Trial registration

The cluster-RCT on which this cross-sectional analysis is based was registered with Current Controlled Trials Ltd. (ID ISRCTN: 38449870) on 2013-09-11.

Utilization and Spending on Potentially Inappropriate Medications by US Older Adults with Multiple Chronic Conditions using Multiple Medications

BACKGROUND

The utilization of potentially inappropriate medications (PIMs) in older adults can lead to adverse events and increased healthcare costs. Polypharmacy, the concurrent utilization of multiple medications, is common in older adults with multiple chronic conditions.

OBJECTIVE

To investigate the utilization and costs of PIMs in multimorbid older adults with polypharmacy over time.

METHODS

This retrospective cross-sectional study used linked Medicare claims and electronic health records from seven hospitals/medical centers in Massachusetts (2007-2014). Participants were ≥65 years old, had ≥2 chronic conditions (to define multimorbidity), and used drugs from ≥5 pharmaceutical classes for ≥90 days (to define polypharmacy). Chronic conditions were defined using the Chronic Conditions Indicator from the Agency for Health Research and Quality. PIMs were defined using the American Geriatrics Society 2019 version of the Beers criteria. We calculated the percentage of patients with ≥1 PIMs and the percentages of patients using different types of PIMs. We used logistic regression analyses to test the odds of taking ≥1 PIMs. We calculated mean costs spent on PIMs by dividing the costs spent on PIMs by the total medication cost.

RESULTS

≥69% of patients used ≥1 PIM. After adjusting for healthcare utilization, chronic conditions, medication intake, and demographic factors, female sex (2014: Odds ratio (OR)=1.27, 95%CI 1.25-1.30), age (2014: OR=0.92, 95%CI 0.90-0.93), and Hispanic ethnicity (2014: OR=1.41, 95%CI 1.27-1.56) were associated with PIM use. Gastrointestinal drugs and central nervous system drugs were the most commonly-used PIMs. In patients using ≥1 PIM, >10% of medication costs were spent on PIMs.

CONCLUSION

The utilization of PIMs in US older adults with multimorbidity and polypharmacy is high.

Potentially Harmful Medication Use Among Medicare Patients with Heart Failure

BACKGROUND

The unintentional prescribing of medications harmful for patients with heart failure (HF) remains an ongoing problem. The American Heart Association published a scientific statement detailing a list of medications that may worsen or exacerbate a patient's HF. The use of potentially harmful medications has not been studied in Medicare patients with HF.

OBJECTIVE

The aim of this study was to assess the prevalence of prescribing these harmful medications in a Medicare-enrolled medication therapy management (MTM)-eligible population with HF and to identify the characteristics associated with this potentially harmful prescribing.

METHODS

This cross-sectional analysis involved utilization of a national MTM provider's database for the 2018 calendar year. Eligible patients were included if they were Medicare enrolled, MTM eligible, and with International Classification of Disease 9/10 codes for HF. Counts and percentages were used to describe the prevalence of potentially harmful medication use and prescribing, by physician specialty. Exploratory logistic regression assessed the relationship between unique patient characteristics and potentially harmful prescribing.

RESULTS

A total of 13,250 patients were included, of whom 7017 (53%) were prescribed at least one potentially harmful medication. The most frequently prescribed medications in this cohort were nonsteroidal anti-inflammatory drugs (NSAIDs; 3357, 25%), dipeptidyl peptidase-4 (DPP4) inhibitors (3117, 24%), and non-dihydropyridine calcium channel blockers (CCBs; 936, 7%). A logistic regression found female sex, increasing polypharmacy, years qualified for MTM, higher poverty level, number of prescribers, and number of pharmacies were associated with potentially harmful medication prescribing. Of 17,548 potentially harmful medications encountered in a 4-month span, 9433 (54%) were prescribed by physician primary care providers.

CONCLUSIONS

Over one-half of patients with HF were prescribed one or more potentially harmful medication(s). Automated monitoring of prescription claims and implementation of alerts in electronic health records in primary care is warranted to reduce potentially harmful medication use among Medicare MTM-eligible patients.

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.

Hypertension and Drug Adherence in the Elderly

Hypertension is highly prevalent after the age of 65 years affecting more than 60% of individuals in developed countries. Today, there is sufficient evidence from clinical trials that treating elderly subjects with hypertension with antihypertensive medications has a positive benefit/risk ratio even in very elderly patients (>80 years). In recent years, partial or total non-adherence has been recognized as major issues in the long-term management of hypertension in all age categories. However, whether non-adherence is more frequent in hypertensive patients older than 65 years or not is still a matter of debate and the common belief is that adherence is lower in older than in younger patients. Are clinical data supporting this belief? In this brief review, we discuss the topic of drug adherence in elderly in the context of the medical treatment of hypertension. Studies show that drug adherence is actually better in patients aged 65 to 80 years when compared to younger hypertensive patients (<50 years). However, in very old patients (>80 years) the prevalence of non-adherence does increase. In this patients' group, there are specific risk factors for non-adherence such as cognitive ability, depression, and health believes, in addition to classical risk factors for non-adherence. One important aspect in the elderly is the prescription of potentially inappropriate medications that will interfere with the adherence to necessary treatments. In this context, an interesting new concept was developed few years ago, i.e., the process of deprescribing. Thus, today, in addition to conventional guidelines recommendations (use of single pill combinations, individualization of treatments), the evaluation of cognitive abilities, the regular assessment of potentially inappropriate medications, and the process of deprescribing appear to be three new additional steps to improve drug adherence in the elderly and thereby ameliorate the global management of hypertension.