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

Prevalence of potentially inappropriate medications according to STOPP-Frail criteria in nursing home residents, the SHELTER study

OBJECTIVE

The aim of this study was to determine the prevalence of potentially inappropriate medications (PIMs) in nursing home residents across eight countries and investigate differences between residents with and without cognitive impairment, as well as those with and without life expectancy of six months or less.

METHODS AND DEIGN

The study utilized the second edition of the STOPP-Frail criteria to operationalize PIMs in the baseline assessment of nursing home residents participating in the Services and Health for Elderly in Long TERm care (SHELTER) project. The data were collected between 2009 and 2012. The project was conducted in eight countries: Czech Republic, England, Finland, France, Germany, Italy, the Netherlands, and Israel. Cognitive impairment was measured by the cognitive performance scale (CPS). The presence of end-stage disease with a life expectancy of six months or less was recorded. The study included residents aged 60 years or older who underwent a valid medication assessment.

RESULTS

Among the 3,832 eligible residents, 87.9% had at least one PIM. Specifically, 24.3%, 23.5%, 18.8%, and 19.3% of residents had one, two, three, and four or more PIMs, respectively. On average, each person was prescribed 2.16 PIMs. Cognitively impaired residents (n = 1999) had an average of 1.96 PIMs (SD 1.49) per person, while residents with a low CPS score (n = 1783) had an average of 2.40 PIMs (SD 1.57) per person, showing a statistically significant difference (P < 0.001). Similarly, NH residents with life expectancy of six months or less had an average of 1.66 PIMs (SD 1.30), whereas those without had an average of 2.17 PIMs (SD 1.55) (p < 0.001). The average number of PIMs varied across countries, ranging from 3.23 in Finland to 2.15 in the UK (P < 0.001). Anti-platelets and aspirin were the most prescribed PIMs, accounting for over 38.0% of prescriptions.

CONCLUSIONS

This study highlights the high prevalence of PIMs among nursing home residents. However, PIMs were somewhat lower in residents with cognitive impairment and life expectancy of six months or less. Efforts must continue to improve the rationale behind prescribing practices in nursing homes.

Under-Prescription of Drugs in the Elderly Population of Western Romania: An Analysis Based on STOPP/START Version 2 Criteria

Background/Objectives: Numerous European countries, including Romania, are facing the concern of rapid ageing of their populations. Moreover, Romania's life expectancy ranks among the lowest in the European Union. In light of this, it is imperative that the assessment of medication-related harm be given national priority in order to secure and enhance pharmacotherapy and the medical act. In this study, we sought to describe and evaluate the under-prescribing practices among the Romanian elderly population. Methods: We conducted a cross-sectional study in urban areas of two counties in Western Romania (Timis and Arad) from November 2017 to February 2019. We collected chronic electronic prescriptions issued for elderly patients (>65 years old) with chronic conditions. The medication was prescribed by generalist or specialist physicians for periods ranging between 30 and 90 days. To assess inappropriate prescribing behaviours, a multidisciplinary team of specialists applied the Screening Tool of Older Persons' Prescriptions/Screening Tool to Alert to Right Treatment (STOPP/START) v.2 criteria to the collected prescriptions. Results: Within the 1498 prescriptions included in the study, 57% were issued to females, the mean age was 74.1 ± 6.95, and the average number of medicines per prescription was 4.7 ± 1.51. The STOPP criteria most commonly identified were the (1) long treatment duration (23.6%) and (2) prescription of neuroleptics (14.6%) or zopiclone (14.0%) as medications that increase the risk of falls. According to START criteria, the following medicines were under-prescribed: (1) statins (47.4%), (2) beta-blockers (24.5%), (3) antiresorptive therapy (10.0%), and (4) β2-agonists and muscarinic antagonists for chronic obstructive pulmonary disease (COPD) (4.5%). Within our study group, the prevalence of potentially inappropriate medications was 18.58%, whereas the prevalence of potential prescribing omissions was 49.2%. Conclusions: To decrease medication-related harm and morbid-mortality, and to increase the quality of life for elderly people in Romania, immediate actions are needed from national authorities. These actions include reinforcing primary care services, providing periodic training for physicians, implementing medication review services by pharmacists, and utilising electronic health records at their full capacity.

Application of STOPP/START criteria in older patients in primary care using RStudio®

OBJECTIVES

To estimate the frequency of potentially inappropriate prescribing (PIP) in outpatients according to STOPP/START criteria, and to identify risk factors. For this purpose, an algorithm was developed and validated in RStudio® based on the information collected in the electronic prescription.

METHODS

The data corresponds to dispensations from two pharmacies in Spain made to patients over 18 years, over 4 years. For the analysis, only patients aged ≥ 65 years who are targeted by the STOPP/START criteria are included. The statistical programming language RStudio® was used to develop the algorithm. The STOPP criteria used as models for the implementation of the method were L2 and B12. A logistic regression analysis was performed.

RESULTS

A total of 15,601 treatment plans were obtained from 2312 patients ≥ 65 years (56% women), of whom 46.6% had polypharmacy (≥ 5 drugs) and 9.3% had excessive polypharmacy (≥ 10 drugs). In this group, PIPs were detected in 57% of patients and in 38% of their treatment plans; of these PIPs the most common were those related to the use of benzodiazepines for more than 28 days (D5 criterion) in 25.9% of patients, followed by the use of opioids prescribed without an associated laxative (L2 criterion) in 13.8% and finally, drugs duplication (A3 criterion) in 5.7%. The most numerous duplications related to criterion A3 were benzodiazepines (39%) and non-steroidal anti-inflammatory drugs (37.4%).

CONCLUSIONS

The method developed and validated in RStudio® with different STOPP criteria allows us to analyse the pharmacological treatment of many patients using different databases and to identify those at risk of suffering a PIP according to the STOPP criteria. Our results indicate a high prevalence of PIPs in patients ≥ 65 years, with polypharmacy being the most common risk factor affecting PIP.

Racial and ethnic disparities in potentially inappropriate medication use in patients with dementia

INTRODUCTION

Racial and ethnic disparities in potentially inappropriate medication (PIM) use among older adults with dementia are unclear.

METHODS

Data were drawn from the baseline visits of participants who were ≥60 years old and diagnosed with dementia in the National Alzheimer's Coordinating Center Uniform Data Set (NACCUDS) recruited from National Institute on Aging (NIA)-funded Alzheimer's Disease Research Centers (ADCs) throughout the United States. PIM utilization was evaluated using the 2019 American Geriatrics Society Beers Criteria for PIM Use in Older Adults. We estimated the association between race and ethnicity and the following outcomes and estimation models: (1) any PIM use, any PIM in each drug class, and any PIM best avoided in dementia patients using logistic regression models, (2) total number of medications, total number of PIMs, and anticholinergic burden scale (ACBS) using Poisson or negative binomial regression models, and (3) proportion of total medications that were PIMs using generalized linear models (GLM).

RESULTS

Compared to White participants, Black, Hispanic, and Asian participants reported taking fewer total medications (incidence rate ratio [IRR] ± standard error[SE] = 0.903 ± 0.017, 0.875 ± 0.021, and 0.912 ± 0.041, respectively, all p < 0.01). Asian participants were less likely to be exposed to any PIM (odds ratio [OR] ± SE = 0.619 ± 0.118, p < 0.05). Compared to White participants, Black participants were less likely to be exposed to benzodiazepine (OR ± SE = 0.609 ± 0.094, p < 0.01) and antidepressant (OR ± SE = 0.416 ± 0.103, p < 0.001) PIMs, but greater antipsychotic (OR ± SE = 1.496 ± 0.204, p < 0.01), cardiovascular (OR ± SE = 2.193 ± 0.255, p < 0.001), and skeletal muscle relaxant (OR ± SE = 2.977 ± 0.860, p < 0.001) PIMs. Hispanic participants were exposed to greater skeletal muscle relaxant PIMs and had lower anticholinergic burden. Asian participants were exposed to fewer benzodiazepine PIMs.

DISCUSSION

Significant racial and ethnic disparities in exposure to PIMs and PIMs by medication category in dementia research participants who have access to dementia experts found in the study suggest that disparities may be wider in the larger community.

Potentially Inappropriate Medication: A Pilot Study in Institutionalized Older Adults

Institutionalized older adults often face complex medication regimens, increasing their risk of adverse drug events due to polypharmacy, overprescribing, medication interactions, or the use of Potentially Inappropriate Medications (PIM). However, data on medication use and associated risks in this population remain scarce. This pilot study aimed to characterize the sociodemographic, clinical and pharmacotherapeutic profiles, and the use of PIM among institutionalized elders residing in Residential Structures for Elderly People (ERPI) in the Faro municipality, located in the Portuguese region of the Algarve. We conducted a cross-sectional study in a non-randomized sample of 96 participants (mean age: 86.6 ± 7.86 years) where trained researchers reviewed medication profiles and identified potentially inappropriate medications using the EU(7)-PIM list. Over 90% of participants exhibited polypharmacy (≥5 medications), with an average of 9.1 ± 4.15 medications per person. About 92% had potential drug interactions, including major and moderate interactions. More than 86% used at least one potentially inappropriate medication, most commonly central nervous system drugs. This pilot study demonstrates that institutionalized older adults may be at high risk of potential medication-related problems. Implementing comprehensive medication review programs and promoting adapted prescribing practices are crucial to optimize medication use and improve the well-being of this vulnerable population.

The Role of a Clinical Pharmacist in the Identification of Potentially Inadequate Drugs Prescribed to the Geriatric Population in Low-Resource Settings Using the Beers Criteria: A Pilot Study

Population aging is a global phenomenon. Each country in the world faces an increased number of older persons in the total population. With aging, a high prevalence of multiple chronic diseases occurs, leading to the use of complex therapeutic regimens and often to polypharmacy. Potentially inappropriate medication (PIM) is a medicine prescribed to a patient for whom the risks outweigh the benefits. Today, several tools are used to evaluate the use of pharmacotherapy in older adults, one of them is the 2019 AGS Beers Criteria. In this prospective, pilot study, we aimed to investigate if the number of PIMs in elderly patients would be significantly reduced if a clinical pharmacist performed a pharmacotherapy review. The study included 66 patients over 65 years of age who were hospitalized at the 1200-bed university hospital. The intervention was conducted by a clinical pharmacist who reviewed the patients' pharmacotherapy and provided written suggestions to physicians. The pharmacotherapy was again reviewed at the patients' discharge from the hospital. A total number of 204 PIMs were identified in the pharmacotherapy of the study population. At discharge, the number of PIMs decreased to 67. A total of 67% of the pharmacist's suggestions were accepted by the physicians. The pharmacist's intervention led to significant decrease in the number of PIMs on patients' discharge letters.

Potentially inappropriate medication prescribing based on 2019 Beers criteria and the impact of pharmacist intervention in elderly patients with kidney diseases: A report from Iran

Background and Aims

A potentially inappropriate medication (PIM) is a pharmaceutical agent that poses a greater risk of harm than potential benefit to elderly patients. This study aimed to detect PIMs and their risk factors in hospitalized elderly patients with kidney disease.

Methods

This cross-sectional study assessed medication orders of elderly patients (≥65 years old) with kidney diseases admitted to the hospital. In the first 6 months, we retrospectively evaluated all medications to identify PIMs according to the 2019 Beers criteria. In the second phase, a clinical pharmacist prospectively evaluated all medications and suggested modifications as needed. Data were analyzed to determine risk factors for prescribing PIMs.

Results

Based on our evaluation of 258 patients, we observed that the utilization of PIMs was prevalent among the study population. Of the total patients evaluated, 273 instances of PIM use were identified, with only 23.3% of patients not having any PIMs. Notably, proton pump inhibitors and benzodiazepines were the most frequently prescribed PIMs. The risk of experiencing a PIM was significantly amplified by a higher degree of polypharmacy, with odds approximately 2.68 times higher (p < 0.01). Several factors were found to be associated with an increased likelihood of having a PIM, including being male, undergoing hemodialysis, having chronic kidney disease or other comorbidities, and having an extended hospital stay. The second phase of study, in terms of addressing these issues, physicians adhered to 67.5% of the 120 recommendations made by pharmacists regarding the discontinuation of PIM usage.

Conclusion

High prevalence of PIMs was detected in our study population. Preventing medication-associated harms in the elderly can reduce the financial burden imposed on healthcare systems. Therefore, routine evaluation of medications with clinical pharmacists and/or implementation of computerized medication decision support systems is recommended to prevent PIMs use.

Factors affecting the medication literacy of older adults and targeted initiatives for improvement: a cross-sectional study in central China

Introduction

This study explored the state of rational drug use among older adults in central China, aiming to unveil factors influencing their medication literacy and proposing targeted improvement measures.

Methods

A cross-sectional study involving 454 participants aged 60 and above was conducted in Hubei province between February 1 and May 30, 2023, with data collected through face-to-face interviews by pharmacists. Multiple logistic regression analysis was conducted to determine factors that affected medication literacy.

Results

Of the 412 valid questionnaires, findings revealed inadequate knowledge of rational drug use among older adults in central China. Those who fully understood (105, 25.49%, OR = 9.349, p < 0.001, 95%CI = 3.884-22.502) or partially understood (228, 55.34%, OR = 3.295, p = 0.002, 95%CI = 1.548-7.013) drug instructions exhibited significantly higher medication literacy than those who did not understand (79, 19.17%). Subsequent research revealed a lack of awareness in reading drug instructions or difficulty in understanding them. Most older adults seldom heard of but exhibited high acceptance of medication guidance services.

Discussion

In conclusion, the ability to comprehend drug instructions significantly influenced the medication literacy of older adults. Initiatives such as revising age-appropriate drug instructions could effectively enhance rational drug use among this demographic.

Rationalizing prescription via deprescribing in oncology practice

OBJECTIVE

To provide an integrated approach for deprescribing practice in oncology setting.

DATA SOURCES

The data on deprescribing in oncology settings has been retrieved from the PubMed, Scopus and Google Scholar. We used "deprescribing," "potentially inappropriate medication" and "cancer" as a keyword for the conducting general search. The articles relevant to guidelines or tools used to deprescribe in cancer care were included.

DATA SUMMARY

The nature of cancer, its treatment strategies, adverse effects of therapy and multimorbidity impact negatively on quality of life (QoL). Further, they invite polypharmacy which puts the patient at higher risk of drug-related problems like drug interactions, adverse drug reactions and addition of potentially improper medications, etc. In older adults with cancer, the incidence of potentially inappropriate medications (PIMs) was between 41% and 52%. Over the decades, multiple strategies have been developed to assess the appropriateness of therapy. One such approach is deprescribing. OncPal and oncoSTRIP (Systematic Tool to Reduce Inappropriate Prescribing) are the cancer specific guidelines whereas BEERs criteria, Screening Tool to Alert to Right Treatment/Screening Tool of Older Person's Prescriptions criteria (START/STOPP criteria), medication appropriateness index (MAI) are the cancer nonspecific tools to identify PIM among cancer patients. Here, we provided an integrative approach and algorithm for deprescribing in oncology setting which includes patient and caregiver goals, life expectancy (LE), review of medications, determining medication appropriateness, assessment of time to benefit (TTB), symptomatic and asymptomatic care, identifying medications to cease, implementation of the plan, monitoring and reviewing.

CONCLUSION

Deprescribing in oncology setting is a novel and effective patient-centric approach to counteract the use of PIM, which helps to mitigate polypharmacy, drug-drug interactions, and adverse effects.

Potentially inappropriate medication and frailty in older adults: A systematic review and meta-analysis

OBJECTIVES

The purpose of this study was to systematically assess existing studies to demonstrate the association between potentially inappropriate medication (PIM) and frailty.

DESIGN

Systematic review and meta-analysis.

METHODS

We searched major electronic databases (PubMed, Web of Science, the Cochrane Library, Embase, CINHAL, PsycInfo, China National Knowledge Infrastructure, China Biology Medicine disk, Weipu, and Wanfang) from their inception until February 25, 2023 (data updated on May 4, 2023), for observational studies investigating PIM and frailty. I2 was used to measure the heterogeneity between studies quantitatively. A random effect model calculated pooled effect size owing to high heterogeneity. Subgroup analysis was conducted to explore sources of heterogeneity. Additionally, the studies' quality was evaluated using the Newcastle Ottawa Scale (a modified Newcastle Ottawa Scale was used to evaluate cross-sectional studies).

RESULTS

Twenty-four studies were included for systematic review, 14 of which were included in the meta-analysis. After pooling the effect size, the odds ratio with PIM as the dependent variable was 1.12 (95%CI: 1.01-1.25), and that with frailty as the dependent variable was 1.75 (95%CI: 1.25-2.43), indicating a bidirectional association between PIM and frailty.

CONCLUSIONS

PIM and frailty interact with each other and have a bidirectional association, thus providing additional information for early clinical identification and prevention of frailty, and medication safety management.

Potentially inappropriate medication use and associated factors in residents of long-term care facilities: A nationwide cohort study

Background: Residents in long-term care (LTC) facilities (LTCFs) may have multimorbidity and be unable to self-administer medication. Thus, due to the risk of potentially inappropriate medications (PIMs), epidemiological studies on PIM use and its associated factors should be conducted to ensure safe medication use for residents in LTCFs. Objective: We evaluated PIM use among residents of LTCF and the associated factors in residents of LTCFs in Korea using a nationwide database. Methods: This cross-sectional study used the Korea National Health Insurance Service Senior Cohort (KNHIS-SC) database 2.0 of the National Health Insurance Service (NHIS), a single public insurer in Korea. We analyzed older adults aged ≥65 years who were residents of LTCFs in 2018, using the KNHIS-SC database. The 2019 American Geriatrics Society (AGS) Beers criteria was used for PIM identification. The prevalence of PIM use was defined as the proportion of LTCF residents who received PIM prescriptions at least once. We evaluated the frequency of prescriptions, including PIMs, and determined the most frequently used PIMs. We also conducted a multivariable logistic regression analysis to identify the factors associated with PIM use. Results: The prevalence of PIM among the LTCF residents was 81.6%. The prevalence of PIM was 74.9% for LTC grades 1 or 2 (high dependence) and 85.2% for LTC grades 3-5 (low dependence). Quetiapine was the most frequently prescribed PIM, followed by chlorpheniramine. The low dependence level was significantly associated with PIM use (odds ratio of LTC grades 3-5: 1.49, 95% confidence interval 1.32-1.68, reference: LTC grades 1 or 2); moreover, the number of medical institutions visited, and medications emerged as primary influencing factors. Conclusion: Most LTCF residents were vulnerable to PIM exposure. Furthermore, exposure to PIMs is associated with LTC grade. This result highlights the need for comprehensive medication management of LTCF residents.

Extended Pharmacist Assessment of Medication Safety for Nursing Home Residents—A Cross-Sectional and Prospective Study

In the routine pharmacist’s medication review in ambulatory care and nursing homes in Germany, clinical diagnoses are often insufficiently considered as they are frequently not accessible to pharmacists and their electronic support tools. This may leave a significant proportion of medication-related problems (MRP) undetected and unresolved. Moreover, limited and incomplete data may promote spurious alerts of low clinical relevance. In order to assess the impact of improved data availability, we conducted a study (German Clinical Trials Register DRKS00025346) to evaluate the impact of an extended pharmacist’s medication review, made possible by diagnosis data being routinely available to the pharmacist. At six nursing homes in the Nuremberg metropolitan area, 338 patients treated by 32 physicians were enrolled. A pharmacist’s medication review, considering only the medication data, identified 114 potential MRPs, and additional consideration of diagnoses further identified 69 potential MRPs. The physicians adapted the therapy in response to 69.9% of alerts. The observed gain in MRP identified indicates that efforts should be intensified to facilitate and improve consideration of drug–diagnosis-related MRP by improving data sharing and communication between pharmacists and physicians caring for nursing home residents.