Applying the 2003 Beers update to elderly Medicare enrollees in the Part D program

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.

Associations between sex, race/ethnicity, and age and the initiation of chronic high-risk medication in US older adults

BACKGROUND

High-risk medication use is associated with an increased risk of adverse events, but little is known about its chronic utilization by key demographic groups. We aimed to study the associations between age, sex, and race/ethnicity with new chronic use of high-risk medications in older adults.

METHODS

In this retrospective cohort study, we analyzed data from older adults aged ≥65 years enrolled in a national health insurer who started a high-risk medication between 2017 and 2022 across 16 high-risk medication classes. We used generalized estimating equations to estimate the associations between sociodemographic classifications and the onset of chronic high-risk medication use after initiation (≥90 days' supply across ≥2 fills within 180 days). We adjusted the analyses for sociodemographic and clinical patient characteristics and added three-way interaction terms for race/ethnicity, sex, and age to explore whether the outcome varied across different subgroups of race/ethnicity, age, and sex.

RESULTS

Across 2,751,069 patients (mean age: 74 years [SD = 7], 72% White, 60% Female), 406,075 (15%) became new chronic users of ≥1 high-risk medication. Compared to White older adults, Asian (RR = 0.81, 95% CI: 0.79-0.84), Black (RR = 0.92, 95% CI: 0.90-0.94), and Hispanic (RR = 0.85, 95% CI: 0.83-0.86) older adults had a lower risk of becoming new chronic users. Men had a higher risk compared to women (RR = 1.09, 95% CI: 1.08-1.10). Age was not significantly associated with new chronic high-risk medication use (≥75 years: RR = 1.00, 95% CI: 1.00-1.01). We observed differences across some medication classes, like benzodiazepines, first-generation antihistamines, and antimuscarinics for which non-White older adults were at a higher risk. The joint presence of specific age, sex, and race/ethnicity characteristics decreased the risk of becoming a new chronic user (e.g., Hispanic/Female/65-74 years: RR = 0.96, 95% CI: 0.94-0.99).

CONCLUSIONS

New chronic high-risk medication use varied across older adults by sociodemographic characteristics, suggesting the need to individualize medication optimization approaches and better understand how systematic barriers in access to health care may influence differences in high-risk medication use in older adults.

Potentially inappropriate prescribing (PIP) in older people and its association with socioeconomic deprivation-a systematic review and narrative synthesis

BACKGROUND

Potentially inappropriate prescribing (PIP) refers to the prescription of medications that carry a higher risk of adverse outcomes, such as drug interactions, falls, and cognitive impairment. PIP is of particular concern in older adults, and is associated with increased morbidity, mortality, and healthcare costs. Socioeconomic deprivation has been identified as a potential risk factor for PIP. However, the extent of this relationship remains unclear. This review aimed to synthesize the current literature on the association between PIP and socioeconomic status (SES) in older adults.

METHODS

A literature search was conducted using the databases Medline, Embase and CINAHL. A search strategy was developed to capture papers examining three key concepts: PIP, socioeconomic deprivation and older/elderly populations. Peer-reviewed quantitative research published between 1/1/2000 and 31/12/2022 was eligible for inclusion.

RESULTS

Twenty articles from 3,966 hits met the inclusion criteria. The sample size of included studies ranged from 668 to 16.5million individuals, with the majority from Europe (n = 8) and North America (n = 8). Most defined older patients as being 65 or over (n = 12) and used income (n = 7) or subsidy eligibility (n = 5) to assess SES. In all, twelve studies reported a statistically significant association between socioeconomic deprivation and an increased likelihood of experiencing PIP. Several of these reported some association after adjusting for number of drugs taken, or the presence of polypharmacy. The underlying reasons for the association are unclear, although one study found that the association between deprivation and higher PIP prevalence could not be explained by poorer access to healthcare facilities or practitioners.

CONCLUSION

The findings suggest some association between an older person's SES and their likelihood of being exposed to PIP. SES appears to be one of several factors that act independently and in concert to influence an older person's likelihood of experiencing PIP. This review highlights that prioritising older people living in socioeconomically-deprived circumstances may be an efficient strategy when carrying out medication reviews.

Risk of Potentially Inappropriate Medications in Adults With CKD: Findings From the Chronic Renal Insufficiency Cohort (CRIC) Study

RATIONALE & OBJECTIVE

Adults with chronic kidney disease (CKD) may be at increased risk of adverse effects from use of potentially inappropriate medications (PIMs). Our objective was to assess whether PIM exposure has an independent association with CKD progression, hospitalizations, mortality, or falls.

STUDY DESIGN

Retrospective observational study.

SETTING & PARTICIPANTS

Chronic Renal Insufficiency Cohort (CRIC) study; 3,929 adults with CKD enrolled 2003-2008 and followed prospectively until December 2011.

EXPOSURE

PIM exposure was defined as prescriptions for any medications to be avoided in older adults as defined by the 2015 American Geriatrics Society Beers Criteria.

OUTCOME

Hospitalization count, death, a composite kidney disease end point of CKD progression or initiation of kidney replacement therapy (KRT), KRT, and fall events assessed 1 year after PIM exposure.

ANALYTICAL APPROACH

Logistic regression and Poisson regression to estimate the associations of PIM exposure with each outcome.

RESULTS

The most commonly prescribed PIMs were proton pump inhibitors and α-blockers. In unadjusted models, any PIM exposure (compared to none) was associated with hospitalizations, death, and fall events. After adjustment, exposure to 1, 2, or≥3 PIMs had a graded association with a higher hospitalization rate (rate ratios of 1.09 [95% CI, 1.01-1.17], 1.18 [95% CI, 1.07-1.30], and 1.35 [95% CI, 1.19-1.53], respectively) and higher odds of mortality (odds ratios of 1.19 [95% CI, 0.91-1.54], 1.62 [95% CI, 1.21-2.17], and 1.65 [95% CI, 1.14-2.41], respectively). In a cohort subset reporting falls (n=1,109), prescriptions for≥3 PIMs were associated with an increased risk of falls (adjusted OR, 2.85 [95% CI, 1.54-5.26]). PIMs were not associated with CKD progression or KRT. Age did not modify the association between PIM count and outcomes.

LIMITATIONS

Measurement bias; confounding by indication.

CONCLUSIONS

Adults of any age with CKD who are prescribed PIMs have an increased risk of hospitalization, mortality, and falls with the greatest risk occurring after more than 1 PIM prescription.

Factors associated with potentially inappropriate medication use in community-dwelling older adults in the United States: a systematic review

OBJECTIVES

Potentially inappropriate medication (PIM) use in older adults is a prevalent problem associated with poor health outcomes. Understanding drivers of PIM use is essential for targeting interventions. This study systematically reviews the literature about the patient, clinician and environmental/system factors associated with PIM use in community-dwelling older adults in the United States.

METHODS

PRISMA guidelines were followed when completing this review. PubMed and EMBASE were queried from January 2006 to September 2017. Our search was limited to English-language studies conducted in the United States that assessed factors associated with PIM use in adults ≥65 years who were community-dwelling. Two independent reviewers screened titles and abstracts. Reviewers abstracted data sequentially and assessed risk of bias independently.

KEY FINDINGS

Twenty-two studies were included. Nineteen examined patient factors associated with PIM use. The most common statistically significant factors associated with PIM use were taking more medications, female sex, and higher outpatient and emergency department utilization. Only three studies examined clinician factors, and few were statistically significant. Fifteen studies examined system-level factors such as geographic region and health insurance. The most common statistically significant association was the south and west geographic region relative to the northeast United States.

CONCLUSIONS

Amongst older adults, women and persons on more medications are at higher risk of PIM use. There is evidence that increased healthcare use is also associated with PIM use. Future studies are needed exploring clinician factors, such as specialty, and their association with PIM prescribing.

Benzodiazepine and sedative-hypnotic use among older seriously Ill veterans: choosing wisely?

PURPOSE

The 2014 American Geriatrics Society's Choosing Wisely list cautions against the use of any benzodiazepines or other sedative-hypnotics (BSHs) as initial treatments for agitation, insomnia, or delirium in older adults. Because these symptoms are prevalent among hospitalized patients, seriously ill older adults are at risk of receiving these potentially inappropriate medications. The objectives of this study were to understand the extent to which potentially inappropriate BSHs are being used in hospitalized, seriously ill, older veterans and to understand what clinical and sociodemographic characteristics are associated with potentially inappropriate BSH use.

METHODS

We reviewed medical records of 222 veterans aged ≥65 years who were hospitalized in an acute care facility in the New York-New Jersey metropolitan region in fiscal years 2009 and 2010. Veterans had diagnoses of advanced cancer, chronic obstructive pulmonary disease, congestive heart failure, and/or HIV/AIDS and received inpatient palliative care. Associations among potentially inappropriate BSH use (BSHs for indications other than alcohol withdrawal and current generalized anxiety disorder or one-time use before a medical procedure) and clinical and sociodemographic characteristics were examined with multivariable logistic regression.

FINDINGS

One-fifth of the sample was prescribed a potentially inappropriate BSH during the index hospitalization during the study period (n = 47). The most commonly prescribed potentially inappropriate medications were zolpidem (n = 26 [11.7%]) and lorazepam (n = 19 [8.9%]). Hispanic ethnicity was significantly associated with prescription of potentially inappropriate BSHs among the entire sample (adjusted odds ratio [AOR] = 3.79; 95% CI, 1.32-10.88) and among patients who survived until discharge (n = 164; AOR = 5.28; 95% CI, 1.64-17.07). Among patients who survived until discharge, black patients were less likely to be prescribed potentially inappropriate BSHs than white patients (AOR = 0.35; 95% CI, 0.13-0.997), and patients who had past-year BSH prescriptions were more likely to be prescribed a potentially inappropriate BSH than patients without past-year BSH use.

IMPLICATIONS

The potentially inappropriate BSHs documented in our sample included short- and intermediate-acting benzodiazepines, medications that were not identified as potentially inappropriate for older adults until after these data were collected. Few long-acting benzodiazepines were recorded, suggesting that the older veterans in our sample were receiving medications according to the guidelines in place at the time of hospitalization. Clinicians may be able to reduce prescriptions of newly identified inappropriate BSHs by being aware of medications patients received before hospitalization and by being cognizant of racial/ethnic disparities in symptom management. Future studies should explore reasons for disparities in BSH prescriptions.