Potentially inappropriate medication prescribing in the elderly: Is the Beers Criteria relevant in the Emergency Department today?

Geriatric Emergency Medication Safety Recommendations (GEMS-Rx): Modified Delphi Development of a High-Risk Prescription List for Older Emergency Department Patients

STUDY OBJECTIVE

Half of emergency department (ED) patients aged 65 years and older are discharged with new prescriptions. Potentially inappropriate prescriptions contribute to adverse drug events. Our objective was to develop an evidence- and consensus-based list of high-risk prescriptions to avoid among older ED patients.

METHODS

We performed a modified, 3-round Delphi process that included 10 ED physician experts in geriatrics or quality measurement and 1 pharmacist. Consensus members reviewed all 35 medication categories from the 2019 American Geriatrics Society Beers Criteria and ranked each on a 5-point Likert scale (5=highest) for overall priority for avoidance (Round 1), risk of short-term adverse events and avoidability (Round 2), and reasonable medical indications for high-risk medication use (Round 3).

RESULTS

For each round, questionnaire response rates were 91%, 82%, and 64%, respectively. After Round 1, benzodiazepines (mean, 4.60 [SD, 0.70]), skeletal muscle relaxants (4.60 [0.70]), barbiturates (4.30 [1.06]), first-generation antipsychotics (4.20 [0.63]) and first-generation antihistamines (3.70 [1.49]) were prioritized for avoidance. In Rounds 2 and 3, hypnotic "Z" drugs (4.29 [1.11]), metoclopramide (3.89 [0.93]), and sulfonylureas (4.14 [1.07]) were prioritized for avoidability, despite lower concern for short-term adverse events. All 8 medication classes were included in the final list. Reasonable indications for prescribing high-risk medications included seizure disorders, benzodiazepine/ethanol withdrawal, end of life, severe generalized anxiety, allergic reactions, gastroparesis, and prescription refill.

CONCLUSION

We present the first expert consensus-based list of high-risk prescriptions for older ED patients (GEMS-Rx) to improve safety among older ED patients.

Adverse Drug Event Prevention and Detection in Older Emergency Department Patients

Older adults are given therapies to enhance the quality and longevity of life, but with the benefits of medication therapy also comes the potential for adverse drug events (ADEs). Avoiding ADEs has become a national health priority with substantial impact on health outcomes and health care costs. The presence of multimorbidity, changes in physiologic function, and polypharmacy make older adults more vulnerable to medication-related ADEs. Use of interactive support tools in the form of geriatric-friendly medication order sets and geriatric consultations along with pharmacist-led medication review and optimization are imperative to decrease the occurrence of ADEs and unnecessary prescribing cascades.

Challenges and opportunities in creating a deprescribing program in the emergency department: A qualitative study

BACKGROUND

As the population of older adults increases, appropriate deprescribing becomes increasingly important for emergency geriatric care. Older adults represent the sickest patients with chronic medical conditions, and they are often exposed to high-risk medications. We need to provide an evidence-based, standardized deprescribing program in the acute care setting, yet the evidence base is lacking and standardized medication programs are needed.

METHODS

We conducted a qualitative study with the goal to understand the perspective of healthcare workers, patients, and caregivers on deprescribing high-risk medications in the context of emergency care practices, provider preferences, and practice variability, along with the facilitators and barriers to an effective deprescribing program in the emergency department (ED). To ensure rich, contextual data, the study utilized two qualitative methods: (1) a focus group with physicians, advanced practice providers, nurses, pharmacists, and geriatricians involved in care of older adults and their prescriptions in the acute care setting; (2) semi-structured interviews with patients and caregivers involved in treatment and emergency care. Transcriptions were coded using thematic content analysis, and the principal investigator (S.L.) and trained research staff categorized each code into themes.

RESULTS

Data collection from a focus group with healthcare workers (n = 8) and semi-structured interviews with patients and caregivers (n = 20) provided evidence of a potentially promising ED medication program, aligned with the vision of comprehensive care of older adults, that can be used to evaluate practices and develop interventions. We identified four themes: (1) Challenges in medication history taking, (2) missed opportunities in identifying high-risk medications, (3) facilitators and barriers to deprescribing recommendations, and (4) how to coordinate deprescribing recommendations.

CONCLUSIONS

Our focus group and semi-structured interviews resulted in a framework for an ED medication program to screen, identify, and deprescribe high-risk medications for older adults and coordinate their care with primary care providers.

Balancing Vision With Pragmatism: The Geriatric Emergency Department Guidelines-Realistic Expectations From Emergency Medicine and Geriatric Medicine

BACKGROUND

In 2014, the Geriatric Emergency Department (GED) Guidelines were published and endorsed by four major medical organizations. The multidisciplinary GED Guidelines characterized the complex needs of the older emergency department (ED) patient and current best practices, with the goal of promoting more cost-effective and patient-centered care. The recommendations are extensive and most EDs then and now have neither the resources nor the hospital administrative support to provide this additional service.

DISCUSSION

At the 2021 American Academy of Emergency Medicine's Scientific Assembly, a panel of emergency physicians and geriatricians discussed the GED Guidelines and the current realities of EDs' capacity to provide best practice and guideline-recommended care of GED patients. This article is a synthesis of the panel's presentation and discussion. With the substantial challenges in providing guideline-recommended care in EDs, this article will explore three high-impact GED clinical conditions to highlight guideline recommendations, challenges, and opportunities, and discuss realistically achievable expectations for non-GED-accredited institutions.

CONCLUSIONS

In 2014, the GED Guidelines were published, describing the current best practices for GED patients. Unfortunately, most of the EDs worldwide do not provide the level of service recommended by the GED Guidelines. The GED Guidelines can best be termed aspirational for U.S. EDs at the present time.

Exposure reasons, other substance use, and medical outcomes of poison control center cases aged 50+ involving opioids, 2015-2020

CONTEXT

Rates of prescription opioid (PO) prescribing and filling remain high, and illicit opioid (IO) use has increased among late middle-aged and older adults. Research on PO and IO poisoning and their impacts among these age groups is needed.

METHODS

Data came from 2015 to 2020 poison control center cases aged 50+ (N = 83,135). We used χ2 tests to examine changes over the study period in the numbers of PO and IO cases, type of opioids used, exposure reasons, and medical outcomes. We fit multinomial logistic regression models to examine the associations of medical outcomes with exposure reasons and other medication/substance involvement.

RESULTS

Between 2015/2016 and 2020, the numbers and shares of PO-only cases steadily declined, but IO cases, with or without PO, nearly tripled, constituting almost 10% of all PCC opioid cases aged 50+ in 2020. The rates of intentional misuse/abuse increased among both PO-only and IO (with/without PO) cases during the study period, and the death rate among IO cases sharply increased in 2020. Compared to adverse reactions or other unintentional exposures, intentional misuse/abuse and suspected suicides were associated with significantly higher risks of serious outcomes (e.g., risk of death from intentional misuse/abuse: RRR = 22.11, 95% CI = 16.74-29.20 in PO-only cases and RRR = 6.95, 95% CI = 2.37-20.39 in IO cases with/without PO). The use of most other medications and substances was also significantly associated with serious outcomes.

DISCUSSION

Among older adults, medical outcomes in opioid poisoning cases have become more serious in recent years as intentional misuse/abuse became more common. Opioid use disorder treatment should be readily available and accessible, and alternatives to PO prescribing should be considered.

CONCLUSIONS

Among individuals aged 50+, PO poisoning cases decreased, but IO cases increased sharply from 2015 to 2020 with concomitant increases in intentional misuse/abuse and serious medical outcomes.

Geriatric emergency department revisits after discharge with Potentially Inappropriate Medications: A retrospective cohort study

OBJECTIVE

To determine whether Potentially Inappropriate Medications (PIMs) prescribed in an academic emergency department (ED) are associated with increased ED revisits in older adults.

METHODS

A retrospective chart review of Medicare beneficiaries 65 years and older, discharged from an academic ED (January 2012 - November 2015) with any PIMs versus no PIMs. PIMs were defined using Category 1 of the 2015 Updated Beers criteria. Primary outcomes, obtained from a Medicare database linked to hospital ED subjects, were ED revisits 3 and 30 days from index ED discharge. Adjusted multiple logistic regression was used with entropy balance weighted covariates: Age in years, Gender, Race, Number of discharge medications, Charlson Comorbidity Index (CCI) score, Emergency Severity Index scores (ESI), Chief Complaint, Medicaid status, and prior 90 Day ED visits.

RESULTS

Over the study period, there were a total of 7,591 Medicare beneficiaries 65+ discharged from the ED with a prescription; 1,383 (18%) received one or more PIMs. ED revisits in 30 days were fewer for the PIMs cohort (12% PIMs vs 16% no PIMs, OR 0.79, 95% CI 0.65 - 0.95, P value <0.005). Hospital admissions in 30 days were fewer for the PIMs cohort (4 PIMs vs 7% no PIMs, OR 0.75, 95% CI 0.56 - 1.00, P value <0.005). In addition to PIMs, covariate risk factors associated with ED revisits in 30 days included comorbidity severity, history of prior ED revisits, chief complaint, and Medicaid status. Risk factors associated with hospitalization in 30 days included those plus age and emergency severity index, but not race nor ethnicity.

CONCLUSIONS

Patients discharged from the ED receiving potentially inappropriate medications as defined by Category 1 of the 2015 updated Beers criteria had lower odds of revisiting the ED within 30 days of index visit. Sociodemographic factors such as gender and race did not predict ED revisits or hospital admissions. Clinical characteristics predicted ED revisits and hospital admissions, the strongest risk being increasing Charlson Comorbidity Index score followed by triage acuity and chief complaint. Future studies are needed to delineate the implications of our findings.

Potentially Inappropriate Medication Usage in Older Adults in a Tertiary Academic Medical Center Emergency Department

BACKGROUND

The Beers Criteria® medications are potentially inappropriate medications (PIMs) recommended by the American Geriatric Society to be avoided or used with caution in adults 65 years and older. The usage of PIMs in the emergency department (ED) setting is not well characterized.

OBJECTIVES

The purpose of this study is to evaluate the usage of PIMS in the ED.

METHODS

This is a single center retrospective observational study of a random sample of patients aged 65 and older who presented to the ED during a 6-month timeframe. The primary outcome was the incidence of ED readmissions in patients administered or prescribed a PIM compared with patients who were not prescribed or administered a PIM. Secondary outcomes included ED length of stay (LOS) and hospital admission.

RESULTS

Out of 192 patients, there was a total of 58 patients (30.2%) in the PIM group and 134 patients (69.8%) in the No PIM group. ED re-presentation within 30 days occurred in 10 patients (17%) in the PIM group vs 26 patients (19%) in the No PIM group (p = 0.88). The median ED LOS was 227 minutes vs 208 minutes (p = 0.1679). Hospital admission within 30 days occurred in 4 patients (7%) in the PIM group and 13 patients (10%) in the No PIM group (p = 0.725).

CONCLUSIONS

This analysis did not show statistically significant differences between patients who received a PIM compared to those who received an alternative medication with regard to re-presentation, admission, and ED LOS. ED LOS trended towards being longer in the PIM group.

Potentially Inappropriate Prescriptions to Older Patients in Emergency Departments in South Korea: A Retrospective Study

Purpose

The purpose of this study was to evaluate the incidence of the administration of potentially inappropriate medications (PIMs) and the potential drug–drug interactions (pDDIs) in older patients in emergency departments (EDs) over a 12-month period and to identify the factors associated with the administration of PIMs.

Patients and Methods

This retrospective study was conducted using the electronic medical records from two university-affiliated teaching hospitals in South Korea. ED visit cases of patients aged 65 and older from January 1, 2013, to December 31, 2013, were included in the analysis. Among the medications administered in ED, PIMs or pDDIs were identified using a drug utilization review program available in Korea.

Results

During the study period, a total of 13,002 ED visit cases were reported from 10,686 patients. The proportion of ED visit cases with any PIM was 79.2% and the average number of PIMs was 2.7 (range, 1–17). The most commonly administered PIMs that were contraindicated or should have been used with caution were ketorolac (41.3%) and metoclopramide (10.3%), respectively. Multivariate regression analysis indicated that female patients (p = 0.012), patients with more than six drugs in the ED (p < 0.001), and visits longer than 300 minutes (p = 0.026) were significantly associated with PIM administration in the ED. Potential DDIs between the medications administered in EDs were observed in 20.5% of total visit cases, with ketorolac being the most frequently reported drug in contraindicated drug combinations.

Conclusion

This study demonstrated a high incidence of the administration of PIMs and medications with pDDIs in older patients in EDs and revealed the characteristics that are significantly associated with an increased risk of PIM administration. Healthcare providers in EDs should consider the risk of administering PIMs or medications with pDDIs, especially when treating older patients.

Potentially Inappropriate Medication Combination with Opioids among Older Dental Patients: A Retrospective Review of Insurance Claims Data

BACKGROUND

Opioid prescribing by dentists for older patients receiving medications with potential contraindications and the subsequent impact on acute care outcomes is not well described.

OBJECTIVES

Our objective of this paper was to evaluate the use of potentially inappropriate medication combinations (PIMCs) involving opioids prescribed by dentists according to the Beers Criteria and risks of 30-day emergency department (ED) visits and all-cause hospitalization among commercially insured dental patients ages 65 years and older.

METHODS

We conducted a retrospective cohort study of 40,800 older dental patient visits in which opioids were prescribed between 2011 and 2015 using the IBM MarketScan databases. Data collection from dental, medical, and pharmacy claims included information on the concurrent use of PIMCs and outcomes of all-cause acute care utilization over the 30-day period after dental encounters.

RESULTS

For the overall cohort, the median age was 69 years, and 45% were women. The prevalence of PIMCs per Beers Criteria was 10.4%. A total of 947 all-cause acute care events were observed in the 30 days post-dental visit. Patients with PIMCs involving opioids prescribed by dentists according to the Beers Criteria had higher rates of acute care use (3.3% vs 2.2%, p<0.001), which were associated with an increased risk of all-cause acute care utilization (adjusted risk ratio [RR] 1.23, 95% confidence interval [CI] 1.02-1.48). A dose-response relationship was seen with increasing oral morphine equivalents prescribed and increased acute care utilization (p<0.001).

CONCLUSION

A significant proportion of older patients receiving opioids at dental visits use psychotropic medications that in combination should be avoided according to the American Geriatric Society Beers Criteria.