Inappropriate medication prescribing in homebound older adults

Changes in Polypharmacy and Potentially Inappropriate Medications in Homebound Older Adults in Japan, 2015-2019: a Nationwide Study

BACKGROUND

With rising worldwide population aging, the number of homebound individuals with multimorbidity is increasing. Improvement in the quality of home medical care (HMC), including medications, contributes to meeting older adults' preference for "aging in place" and securing healthcare resources.

OBJECTIVE

To evaluate the changes in drug prescriptions, particularly potentially inappropriate medications (PIMs), among older adults receiving HMC in recent years, during which measures addressing inappropriate polypharmacy were implemented, including the introduction of clinical practice guidelines and medical fees for deprescribing.

DESIGN

A cross-sectional study.

PARTICIPANTS

Using data from the national claims database in Japan, this study included older adults aged ≥ 75 years who received HMC in October 2015 (N = 499,850) and October 2019 (N = 657,051).

MAIN MEASURES

Number of drugs, prevalence of polypharmacy (≥ 5 regular drugs), major drug categories/classes, and PIMs according to Japanese guidelines were analyzed. Random effects logistic regression models were used to evaluate the differences in medications between 2015 and 2019, considering the correlation within individuals who contributed to the analysis in both years.

KEY RESULTS

The number of drugs remained unchanged from 2015 to 2019 (median: 6; interquartile range: 4, 9). The prevalence of polypharmacy also remained unchanged at 70.0% in both years (P = 0.93). However, the prescription of some drugs (e.g., direct oral anticoagulants, new types of hypnotics, acetaminophen, proton pump inhibitors, and β-blockers) increased, whereas others (e.g., warfarin, vasodilators, H2 blockers, acetylcholinesterase inhibitors, and benzodiazepines) decreased. Among the frequently prescribed PIMs, benzodiazepines/Z-drugs (25.6% in 2015 to 21.1% in 2019; adjusted odds ratio: 0.52) and H2 blockers (11.2 to 7.3%; 0.45) decreased, whereas diuretics (23.8 to 23.6%; 0.90) and antipsychotics (9.7 to 10.5%; 1.11) remained unchanged.

CONCLUSIONS

We observed some favorable changes but identified some continuous and new challenges. This study suggests that continued attention to medication optimization is required to achieve safe and effective HMC.

Medication-Related Problems and Their Intervention in the Geriatric Population: A Review of the Literature

In order to implement the principles of providing clinically and economically effective care, the current state of healthcare must be evaluated, and challenges must be addressed. As part of a physician's role in such a context, one tool consists of identifying medication-related problems (MRPs) and accordingly implementing best practices and innovative strategies to improve patient healthcare outcomes. The geriatric population is expected to have passed through the natural ageing process and experienced several physiological and biological changes that impact their bodies and lives. In the presence of geriatric syndromes and the increased number of medications consumed, the risk of MRPs such as polypharmacy, potentially inappropriate medication (PIM), adverse events, drug-drug interactions, and risk of non-adherence increases. Different interventions that focus on practical and perceptual barriers have been studied, and different tools to define clinically important prescribing problems relating to PIM have been established. The Beers Criteria and STOPP (Screening Tool of Older Persons' Prescriptions)/START (Screening Tool to Alert to Right Treatment) criteria are the most widely used sets of explicit PIM criteria; however, they are still limited in Saudi Arabia. These tools should be considered in clinical settings to improve healthcare outcomes in the geriatric population, and the clinical relevance of enhancing medication should also be explored from the point of view of both the patient and healthcare practitioners.

Risk of Polypharmacy and Its Outcome in Terms of Drug Interaction in an Elderly Population: A Retrospective Cross-Sectional Study

The simultaneous use of multiple drugs-termed 'polypharmacy'-is often required to manage multiple physiological and biological changes and the interplay between chronic disorders that are expected to increase in association with ageing. However, by increasing the number of medications consumed, the risk of undesirable medication reactions and drug interactions also increases exponentially. Hence, knowledge of the prevalence of polypharmacy and the risk of potentially serious drug-drug interactions (DDIs) in elderly patients should be considered a key topic of interest for public health and health care professionals. Methods: Prescription and demographic data were collected from the electronic files of patients who were aged ≥ 65 years and attended Al-Noor Hospital in Makkah, Saudi Arabia, between 2015 and 2022. The Lexicomp^® electronic DDI-checking platform was used to evaluate the patients' medication regimens for any potential drug interactions. Results: A total of 259 patients were included in the study. The prevalence of polypharmacy among the cohort was 97.2%: 16 (6.2%) had minor polypharmacy, 35 (13.5%) had moderate polypharmacy, and 201 (77.6%) had major polypharmacy. Of the 259 patients who were taking two or more medications simultaneously, 221 (85.3%) had at least one potential DDI (pDDI). The most frequently reported pDDI under category X that should be avoided was the interaction between clopidogrel and esomeprazole and was found in 23 patients (18%). The most frequently reported pDDI under category D that required therapeutic modification was the interaction between enoxaparin and aspirin, which was found in 28 patients (12%). Conclusions: It is often necessary for elderly patients to take several medications simultaneously to manage chronic diseases. Clinicians should distinguish between suitable, appropriate and unsuitable, inappropriate polypharmacy, and this criterion should be closely examined when establishing a therapeutic plan.

Polypharmacy in the Homebound Population

The number of homebound elders has risen dramatically in the past decade and was accelerated by the Sars-Cov-2 COVID-19 pandemic. These individuals generally have 5 or more chronic conditions, take 6 or more medications, and are at elevated risk for functional decline. Polypharmacy constitutes a major burden for these individuals, putting them at risk for medication nonadherence, medication errors, medication interactions, and reduced quality of life. A team-based approach may help these elders manage medications more effectively.

Factors Associated with Having Home Care Physicians as an Integrated Source of Medications for Chronic Conditions Among Homebound Patients

BACKGROUND

Inappropriate management of medications is a major threat to homebound patients with chronic conditions. Despite many efforts in improving medication reconciliation in ambulatory and inpatient settings, little research has focused on home care settings. In 2016, Taiwan initiated the Integrated Home Health Care programme, which was intended to reduce potentially inappropriate medication management and risks of uncontrolled polypharmacy through the integration of different medication sources for chronic conditions among homebound patients. This study investigated factors associated with having home care physicians as an integrated source of medications for chronic conditions among homebound patients.

METHODS

This retrospective cohort study enrolled 3,142 community-dwelling homebound patients from Taipei City Hospital. Homebound patients' adherence to using home care physicians as an integrated source of chronic condition medications was defined as having all prescriptions for their chronic conditions prescribed by a single home care physician for at least six months. Both patient and home care physician characteristics were analysed. Multivariable logistic regression was applied.

RESULTS

Of the 3,142 patients with chronic conditions, 1,002 (31.9%) had consistently obtained all medications for their chronic illnesses from their home care physicians for 6 months and 2,140 (68.1%) had not. The most common chronic diseases among homebound patients were hypertension, diabetes mellitus, dementia, cerebrovascular disease, and constipation. Oldest-old patients with poor functional status, fewer daily medications, no co-payment exemption, and no recent inpatient experience were more likely to adhere to this medication integration system. In addition, patients whose outpatient physicians were also their home care physicians were more likely to adhere to the system.

CONCLUSION

The finding suggests that building trust and enhancing communication among homebound patients, caregivers, and home care physicians are critical. Patient and provider variations highlight the need for further improvement and policy modification for medication reconciliation and management in home care settings. The improvement in medication management and care integration in home care settings may reduce misuse and polypharmacy and improve homebound patients' safety.

Polypharmacy is Associated with Diabetic Foot Ulcers in Type 2 Diabetes mellitus

Objectives: This observational study aimed to investigate the relationship between polypharmacy and the existence of diabetic foot ulcers in patients with type 2 diabetes. Methods: Patients with T2DM with and without diabetic foot ulcers who presented to the endocrinology outpatient clinic between August 2020 and November 2021 were involved in the study. Overall, five hundred and twelve patients with T2DM (293 patients with diabetic foot ulcer and 219 patients without diabetic foot ulcer) were included. The exclusion criteria were pregnancy, lactation, type 1 diabetes, patients under 18 years and over 65 years of age, and history of malignancy. The information of drugs administered, demographic and clinical data were obtained from the patient files. The Wagner score was used to evaluate the severity of ulcers. Results: The comparison of the two groups revealed that patients with diabetic foot ulcers had significantly higher rates of diabetic retinopathy (p = 0.017). The patients with diabetic foot ulcers who had polypharmacy had significantly higher rates of hypertension, ischaemic heart disease, diabetic retinopathy, and complaints of diabetic neuropathy (P < 0.001, P < 0,001, p = 0.021 and P = 0.004, respectively). In the binary logistic regression analyses, polypharmacy was independently associated with diabetic foot ulcers in all models. Conclusion: Polypharmacy should be seriously concerned in type 2 diabetes mellitus in patients with diabetic foot ulcers and polypharmacy was related to diabetic foot ulcers.

Characterization of potentially inappropriate medications use in Indian elderly population and their impact on quality of life using Beers criteria

Background

Methods

Results

Conclusion

PRN Medicines Management for Older People with Long-Term Mental Health Disorders in Home Care

Older people with long-term mental health conditions who receive care in their own home are vulnerable to the inappropriate use of medications and polypharmacy given their underlying health conditions and comorbidities. Inappropriate use of pro re nata (PRN) medications in these older people can enhance their suffering and have negative consequences for their quality of life and well-being, leading to readmission to healthcare settings and the increased cost of health care. This narrative review on published international literature aims at improving our understanding of medicines management in home care and how to improve PRN medication use among older people with long-term health conditions in their own home. Accordingly, the improvement of PRN medicines management for these older people requires the development of an individualised care plan considering ‘reduction of older people’s dependence on PRN medications’, ‘empowerment of family caregivers’, and ‘support by healthcare professionals.’ PRN medication use should be reduced through deprescription and discontinuation strategies. Also, older people and their family caregivers should be encouraged to prioritize the use of non-pharmacologic methods to relieve physical and psychological problems. Besides the empowerment of family caregivers through role development, education and training about PRN medications, and involvement in decision-making, they need support by the multidisciplinary network in terms of supervision, monitoring, and home visits.

Patterns of self-medication in Qassim Province, Saudi Arabia: A cross-sectional study

BACKGROUND

Selling medicines in pharmacies without a prescription is a common practice in the Kingdom of Saudi Arabia. The aim of this study was to determine the attitudes about and prevalence of non-prescribed medication for those attending community pharmacies in Qassim Province, Saudi Arabia.

METHODS

This is a cross-sectional survey based study that was designed and administered to individuals attending four community pharmacies in the main cites of Qassim Province, Saudi Arabia to obtain Over The Counter (OTC) drug use, exposure to health education, awareness of risks, important causes, and side-effects.

RESULTS

Approximately 75% of 109 individuals attending the studied pharmacies purchased non-prescribed medicines. Most participants (80%) had read the drug pamphlets and followed the instructions for use. The most common reasons for buying non-prescribed medicines were repetition of a previous prescription by a healthcare provider (30.3%), belief that the disease was minor (26.6%), convenience of pharmacist prescription (19.3%), and the low cost and shortness of time to attend health services. The most commonly used drugs were analgesics (18.3%) followed by anti-allergic medications and antibiotics, and the least commonly used drugs were laxatives and anti-diarrheal medications. There were no significant differences in the purchase of non-prescribed drugs with respect to age, gender, and educational level. Only 9% of respondents were opposed to buying non-prescribed drugs and 34% were willing to use them only when necessary.

CONCLUSIONS

There was a high prevalence of non-prescribed medicine purchase from community pharmacies in the study area. Education efforts are needed to change this behavior.

Interventions to deprescribe potentially inappropriate medications in the elderly: Lost in translation?

WHAT IS KNOWN AND OBJECTIVE

Use of potentially inappropriate medications (PIMs) remains common in older adults, despite the easy availability of screening tools such as the Beers and Screening Tool of Older Person's Prescriptions (STOPP) criteria. Multiple published studies have implemented these screening tools to encourage deprescribing of PIMs, with mixed results. Little is known about the reasons behind the success or failure of these interventions, or what could be done to improve their impact. Implementation science (IS) provides a set of theories, models and frameworks to address these questions. The goal of this study was to conduct a focused narrative review of the deprescribing literature through an IS lens-to determine the extent to which implementation factors were identified and the intermediate steps in the intervention were measured. A better understanding of the existing literature, including its gaps, may provide a roadmap for future research.

METHODS

PubMed search from 2000-2019 using appropriate MeSH headings.

INCLUSION CRITERIA

controlled trials or prospective cohort studies intended to reduce PIMs in the elderly that used hospitalizations and/or emergency department visits as outcome measures. Studies were reviewed to identify potential implementation factors (known as determinants), using the Consolidated Framework for Implementation Research (CFIR) as a guide. In addition, intermediate outcomes were extracted.

RESULTS AND DISCUSSION

Of the 548 reviewed abstracts, 14 studies met the inclusion criteria and underwent detailed analysis. Of the 14 studies, 10 acknowledged potential implementation determinants that could be mapped onto CFIR. The most commonly identified determinant was the degree of pharmacist integration into the medical team (seven of 14 studies), which mapped onto the CFIR construct of 'networks and communication'. Several important CFIR constructs were absent in the reviewed literature. Intermediate measures were captured by 12 of the 14 reviewed papers, but the choice of measures was inconsistent across studies.

WHAT IS NEW AND CONCLUSION

In recent high-quality studies of deprescribing interventions, we found limited acknowledgement of factors known to be important to successful implementation and inconsistent reporting of intermediate outcomes. These findings indicate missed opportunities to understand the factors underlying study outcomes. As a result, we run the risk of rejecting worthwhile interventions due to negative results, when the correct interpretation might be that they failed in implementation. In other words, they were 'lost in translation'. Studies that rigorously examine and report on the implementation process are needed to tease apart this important distinction.

Failure to Reach a Consensus in Polypharmacy Definition: An Obstacle to Measuring Risks and Impacts-Results of a Literature Review

INTRODUCTION

The risk of polypharmacy is on the rise in most industrialized countries, threatening to burden their health systems. Although many definitions exist and numerous concepts are found in literature as synonyms, the phenomenon of polypharmacy remains poorly defined. The aim of this literature review is to provide an overview of available definitions of polypharmacy, to analyse their convergences and divergences and to discuss the consequences on the assessment of the problem.

METHODS

A literature review was conducted to identify all published systematic reviews on definitions of polypharmacy available via Scopus and Pubmed databases. The Assessment of Multiple Systematic Reviews (AMSTAR) tool was used to appraise the methodological quality of the selected reviews. Available definitions and other characteristics were extracted; summarised in a table and analysed.

RESULTS

Six systematic reviews were identified. They were published between 2000 and 2018. Three focussed on definitions of polypharmacy in the elderly; two in the general population and one in children. The strategy adopted in reviews is more rigorous in the most recent ones. However, they remain, at best, partially exhaustive. The definitions found in the literature used two main approaches, either (i) quantitative, applying varying thresholds and types of polypharmacy based on the number of medications being taken by the patient (ii) qualitative, based on the clinical indications and effects of a given drug regimen, with a growing number of characteristics to describe polypharmacy. The term "inappropriate" is increasingly associated with polypharmacy especially in studies that aimed to use this definition to identify possible solutions for healthcare providers in the field related to aging.

CONCLUSION

This review confirms a high variability and an evolution in the approaches defining "polypharmacy" in the absence of a consensus following standardized criteria. That makes it very difficult to estimate and measure the outcomes associated with this phenomenon.

Meeting the Mental Health Needs of the Homebound: A Psychiatric Consult Service Within a Home-Based Primary Care Program

The growing population of homebound adults increasingly receives home-based primary care (HBPC) services. These patients are predominantly frail older adults who are homebound because of multiple medical comorbidities, yet they often also have psychiatric diagnoses requiring mental health care. Unfortunately, in-home psychiatric services are rarely available to homebound patients. To address unmet psychiatric need among the homebound patients enrolled in our large academic HBPC program, we piloted a psychiatric in-home consultation service. During our 16-month pilot, 10% of all enrolled HBPC patients were referred for and received psychiatric consultation. Depression and anxiety were among the most common reasons for referral. To better meet patients' medical and psychiatric needs, HBPC programs need to consider strategies to incorporate psychiatric services into their routine care plans.

Inappropriate prescribing among older persons in primary care: protocol for systematic review and meta-analysis of observational studies

INTRODUCTION

Inappropriate prescribing has a significant impact on older persons in primary care. Previous reviews on inappropriate prescribing included a heterogeneous range of populations and may not be generalisable to primary care. In this study we aim to conduct a comprehensive systematic review and meta-analysis of the prevalence, risk factors and adverse outcome associated with inappropriate prescribing, specifically among older persons in primary care.

METHODS AND ANALYSIS

We will search PubMed, Embase, CINAHL, Web of Science, Scopus, PsycINFO and references of other review articles for observational studies related to the keywords 'older persons', 'primary care' and 'inappropriate prescribing'. Two reviewers will independently select the eligible articles. For each included article, the two reviewers will independently extract the data and assess the risk of bias using the Newcastle-Ottawa Scale. If appropriate, meta-analyses will be performed to pool the data across all the studies. In the presence of heterogeneity, meta-regression and subgroup analyses will also be performed. The quality of the evidence will be assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

ETHICS AND DISSEMINATION

The results will be disseminated through conference presentations and peer-reviewed publications. They will provide consolidated evidence to support informed actions by policymakers to address inappropriate prescribing in primary care, thus reducing preventable and iatrogenic risk to older persons in primary care.

TRIAL REGISTRATION NUMBER

CRD42016048874.

Patients Aged 80 Years or Older are Encountered More Potentially Inappropriate Medication Use

Background:

Polypharmacy and potentially inappropriate medications (PIMs) are prominent prescribing issues in elderly patients. This study was to investigate the different prevalence of PIM use in elderly inpatients between 65–79 years of age and 80 years or older, who were discharged from Geriatric Department in West China Hospital.

Methods:

A large-scale cohort of 1796 inpatients aged 65 years or over was recruited. Respectively, 618 patients were 65–79 years and 1178 patients were 80 years or older. Updated 2012 Beers Criteria by the American Geriatric Society was applied to assess the use of PIM among the investigated samples.

Results:

A review of the prescribed medications identified 686 patients aged 80 years or older consumed at least one PIM giving a rate of 58.2%. Conversely, 268 (43.4%) patients aged 65–79 years consumed at least one PIM (χ² = 40.18, P < 0.001). Patients aged 80 years or older had higher hospitalization expenses, length of stay, co-morbidities, medical prescription, and mortality than patients aged 65–79 years (all with P < 0.001). Patients aged 80 years or older were prescribed with more benzodiazepines, drugs with strong anticholinergic properties, megestrol, antipsychotics, theophylline, and aspirin. In multiple regression analysis, PIM use was significantly associated with female gender, age, number of diagnostic disease, and number of prescribed medication.

Conclusions:

The finding from this study revealed that inpatients aged 80 years or older encountered more PIM use than those aged 65–79 years. Anticholinergic properties, megestrol, antipsychotics, theophylline, and aspirin are medications that often prescribed to inpatients aged 80 years or older. Doctors should carefully choose drugs for the elderly, especially the elderly aged 80 years or older.

Polypharmacy Cut-Off for Gait and Cognitive Impairments

BACKGROUND

Polypharmacy is a well-established risk factor for falls, and these are one of the major health problems that affect the quality of life as people age. However, the risk of mobility and cognitive impairments consecutive to polypharmacy has been little addressed, despite the association between these adverse outcomes and falls. Moreover, the rare polypharmacy cut-offs were all but one arbitrarily determined.

OBJECTIVE

Studying relationships between polypharmacy and both mobility and cognitive impairments, and statistically determining a cut-off point in the number of medicinal molecule beyond which polypharmacy has deleterious consequences with respect to mobility and cognitive impairment.

METHODS

We enrolled 113 community-dwelling adults aged 55 years and older with a fall history, with or without injury, in the previous year. We carefully collected information about daily medicinal molecules taken. We assessed basic mobility and global cognition with the Time-Up-and-Go and the Montreal Cognitive Assessment (MoCA) test, respectively (clinicaltrials.gov NCT02292316).

RESULTS

Timed-Up and Go test and MoCA scores were both significantly correlated with the number of molecule, used. Receiver Operating Characteristic curves indicate, with high prediction (p < 0.002), that daily consumption of five or more molecules is associated with risk for both impaired mobility and global cognition. These relationships were independent of the number of comorbidities and of the pharmacological class.

CONCLUSION

Community-dwelling adults aged 55 years and older who take five or more daily medicinal molecules are at high risk for both mobility and cognitive impairments. Physicians and patients should be aware of these new findings, especially when there are multiple prescribers involved in the care of the patient.

Drug Prescribing in the Elderly Receiving Home Care

BACKGROUND

To compare the prevalence of potentially inappropriate medications (PIMs) using the 2012 and 2003 Beers Criteria in frail older patients receiving home health care services (HHS), and to explore the correlates of PIMs based on the 2012 Beers criteria.

MATERIALS AND METHODS

A total of 145 older patients (mean age, 80.9 ± 7.6 years) with Barthel scale ≤ 60 receiving regular HHS from a university hospital between January 2013 and June 2013 were retrospectively enrolled. The 2003 and 2012 Beers criteria were used separately to detect PIMs. Logistic regressions, receiver-operating-characteristic curve analyses and number needed to harm were used, where appropriate.

RESULTS

The 2012 Beers Criteria identified more PIM cases than did the 2003 Beers Criteria (66.9% versus 55.9%, P < 0.05). Multivariate analysis revealed that PIM identified by the 2012 Beers Criteria was associated with an increased number of medications prescribed (P = 0.019) and the presence of psychiatric diseases (P = 0.001). Moreover, the area under the receiver-operating-characteristic curve for the number of drugs to predict the risk of PIM was 0.674 (P < 0.001) with the optimal cutoff value of 6 medications. After adjusting for age, sex, Charlson comorbidity index and psychiatric disorders, patients taking ≥6 drugs (adjusted odds ratio, 2.33; adjusted number needed to harm, 3.93; P < 0.05) had a significantly higher risk for PIM than those taking <6 drugs.

CONCLUSIONS

Our data showed that the 2012 Beers Criteria was more sensitive in detecting PIMs than the 2003 Beers Criteria. Furthermore, frail older patients receiving HHS with polymedication and with psychiatric illnesses had higher risk of PIM when using the 2012 criteria. The number of medications prescribed could be a useful index for risk stratification, and at the same time help physicians to be aware of the high risk for PIM when prescribing 6 or more drugs to frail older adults during in-home visits.

The Medication Management Model: An Effective Tool for Home Health Providers

Home health patients are at substantial risk for medication problems and errors. A medication management model designed specifically for use by home health agencies proved effective in a recent study conducted by Vanderbilt University: Medication use improved in 50% of intervention participants compared with 38% of controls. The model uses a structured collaboration between a clinical pharmacist and a home health nurse. It can help providers meet federal standards for medication review and improve clinical outcomes by identifying and preventing medication errors in their patients. This article presents findings from the study and strategies for implementation so other home health providers can adopt the model for use in their practices.

Substance abuse among older adults

Although the myth that older adults do not use mood-altering substances persists, evidence suggests that substance use among older adults has been underidentified for decades. The baby boom generation is unique in its exposure to, attitudes toward, and prevalence of substance use-causing projected rates of substance use to increase over the next twenty years. Given their unique biological vulnerabilities and life stage, older adults who misuse substances require special attention. Prevalence rates of substance use and misuse among older adults, methods of screening and assessment unique to older adults, and treatment options for older adults are reviewed.

Pharmaceuticals safety practices-a comparative pilot study

INTRODUCTION

The safety of medicine is essential for the safety of patients. Inappropriate drug storage, expiration dates, sharing prescription drugs, self medication habits and misuse of some drugs are contributing factors affecting medication safety. One or more of these factors may lead to serious health complications and even death.

OBJECTIVES

The purpose of this study was to highlight the common errors and pharmaceutical malpractices that people usually engage in on a daily basis and to correlate these to culture, gender and educational levels. This may spread awareness in an easy and understandable manner and provide certain guidelines to drug consumers ensuring that pharmaceutical preparations are used correctly and safely.

METHODS

Two hundred questionnaires were randomly distributed in two countries; Saudi Arabia and India. The collected data were statistically analyzed.

OUTCOMES AND CONCLUSION

Results showed that alarming percentages of various participants were using pharmaceuticals inappropriately due to carelessness, unawareness or intentional mistakes. Therefore, active participation by health care professionals is essential for the prevention of drug misuse. Increasing population awareness about self medication, products expiration, pharmaceuticals labels and optimum storage conditions would minimize the adverse effects and may even be life saving.

Inappropriate use of psychotropic drugs in older individuals: implications for practice

Frailty at old age and institutionalization in nursing homes are often associated with multiple chronic diseases (multimorbidity) requiring multiple medications (polypharmacy). Among these chronic conditions, mental health problems (e.g., dementia, depression and insomnia) are common. Psychotropic drugs are frequently used as a treatment approach for these conditions, and the prevalence of their use is high among community-dwelling older adults, but even higher in nursing homes. Furthermore, within the problem of polypharmacy and inappropriate prescribing, psychotropic drugs (defined in this article as antipsychotics, benzodiazepines and antidepressants) constitute a significant proportion. The use of psychotropics in older adults remains controversial given the risk of adverse effects, in contrast to the limited effectiveness. Guidelines advise a thorough risk–benefit analysis before the initiation of psychotropics, in addition to time-limited use and discontinuation. In the future, serious efforts should be undertaken to tackle the burden of inappropriate psychotropic prescribing in older adults by incorporating a multidisciplinary approach and by offering credible alternatives.

Antimuscarinic treatment in overactive bladder: special considerations in elderly patients

Overactive bladder is a common condition that increases in prevalence in association with age. Antimuscarinic therapy remains the mainstay of pharmacological treatment for the condition, and there is an increasing body of evidence that supports the use of these drugs. Despite this, and because of concerns about associated adverse effects, older people are less likely to receive active treatment for their condition. This review considers some of the factors that need to be taken into account when using these medications.

Antimuscarinic treatment in overactive bladder: special considerations in elderly patients

Overactive bladder is a common condition that increases in prevalence in association with age. Antimuscarinic therapy remains the mainstay of pharmacological treatment for the condition, and there is an increasing body of evidence that supports the use of these drugs. Despite this, and because of concerns about associated adverse effects, older people are less likely to receive active treatment for their condition. This review considers some of the factors that need to be taken into account when using these medications.

Évaluation de l’usage à risque des benzodiazépines chez les personnes âgées : facteurs de risque et impacts

L’usage à risque de la benzodiazépine (BZD), fréquent chez les aînés, est un problème souvent sous-estimé. Cet article présente une recension des écrits qui explore ce profil de consommation problématique sur les plans biologique, psychologique et environnemental. Les auteurs constatent qu’il y un manque de consensus et de validité quant à la description du phénomène. Ils discutent de certains facteurs qui contribuent à l’usage à risque des BZD chez les aînés : des habitudes de prescriptions et des attitudes parfois laxistes des médecins ; les attitudes des aînés envers la maladie mentale et la façon dont se manifestent leurs symptômes ; les difficultés dans l’évaluation de l’anxiété et de la dépression des aînés. En conclusion, les auteurs proposent que la recherche s’intéresse à des méthodes intégratives pour l’évaluation de l’usage à risque de la BZD chez les aînés.

Medication Assessments by Care Managers Reveal Potential Safety Issues in Homebound Older Adults

Background

Over-the-counter (OTC) medications, benzodiazepines, and barbiturates are not covered under many Medicare drug benefit plans; hence, their use by homebound older adults is largely unreported. Furthermore, the tiered design of Medicare drug formularies may in fact promote the use of older but potentially inappropriate medications. Little is known about the use of these medications in the homebound older adult population.

Objective:

To determine the prevalence of the use by homebound older adults of OTC drugs, dietary supplements (vitamins, minerals, and herbal products), Part D-excluded medications (benzodiazepines and barbiturates), and potentially inappropriate medications (according to Beers criteria).

Methods:

Patients were enrollees in a home and community-based Medicaid waiver provider. All clients were older than 65 and were dually eligible for Medicare and Medicaid. All clients met Florida Medicaid's medical and financial criteria for nursing home placement. The medication list was obtained by geriatric care managers during a home assessment.

Results:

A total of 3911 older adults (mean [SD] age 83.6 [8.0] years) were taking an average of 9.9 [4.8] drugs. Of these individuals. 74.5% were using an OTC medication, 41.9% were using a dietary supplement, 29.6% were using a benzodiazepine or barbiturate, and 25.2% were using at least 1 potentially inappropriate medication.

Conclusions:

Based on data gathered by a geriatric care management assessment, we found that most of the homebound older adults enrolled in our study used medications not included in their Medicare drug benefit. The use of potentially inappropriate medications was also common in this population. Future drug safety initiatives involving the elderly will benefit from engaging care managers in identifying and addressing the potential hazards posed by commonly used prescribed and nonprescribed medications.

National study of injury‐increasing analgesics in the elderly

Purpose

The purpose of this paper is to identify the probability of the occurrence of an analgesic medication injury when controlling for potential risk factors, as well as gain a better understanding of which risk factors appear more problematic.

Design/methodology/approach

Cross‐sectional retrospective review of 2004 Centers for Medicare and Medicaid Service Medicaid Pharmacy claims data. Logistic regression analysis performed to examine the risk of injury‐related emergency room (ER) visits following the use of analgesics controlling for potential risk factors.

Findings

Methadone, an agent to treat severe pain, and propoxyphene, an agent to treat non‐severe pain, are problematic opioids in the elderly. White origin, male gender, and increased disease burden are potential risk factors influencing injury‐related ER visits for elderly analgesic recipients. Increased age in the elderly is a potential risk factor for severe pain analgesics; decreased age for non‐severe pain analgesics.

Research limitations/implications

The study uses administrative data which, by its nature, makes conducting outcomes research on inappropriate medication use problematic. A number of confounders are present.

Practical implications

Appropriate drug therapy in an elderly patient is complicated by age‐related changes in pharmacokinetics as well as chronic disorders that affect drug response. Knowing of additional risk factors that may place the patient at greater odds of having an adverse outcome should improve prescribing practices.

Originality/value

The findings add to the literature by identifying problematic risk factors associated with injury among elderly recipients of analgesics.

Inappropriate prescribing in an elderly population: findings from a South African public sector survey

Objective

To quantify the extent of potentially inappropriate prescribing among elderly patients seen at public sector primary health care facilities and old age homes in a South African urban setting.

Method

Cross-sectional survey of the prescription charts of patients aged 65 years or older, using a list of potentially inappropriate medicines in elderly patients, modified from that established by Beers and further developed by consensus.

Setting

A provincial government chronic prescription pharmacy servicing public sector primary health care clinics and old age homes in the Durban metropole.

Key findings

Of the 6,410 prescriptions that were reviewed, 1,926 (30.0%) included at least one medication listed as potentially inappropriate in the elderly. The median number of chronic medications prescribed per patient was 4 (range 1 to 11). Although the prevalence of potentially inappropriate prescribing in patients receiving medication at primary health care clinics (29.7%) was similar to the prevalence in those resident in old age homes (31.8%), this difference was shown to be significant upon multivariate analysis. Age was not found to be a predictor of inappropriate prescribing. An association was found between sex and inappropriate prescribing, with female sex being associated with a greater degree of potentially inappropriate prescribing.

Conclusion

This study has shown that 30% of elderly patients were prescribed at least one potentially inappropriate medicine. Women were more likely than men to be prescribed potentially inappropriate medicines.

Adverse events experienced by homecare patients: a scoping review of the literature

PURPOSE

The paper summarizes the results of a scoping review that focused on the occurrence of adverse events experienced by homecare patients.

DATA SOURCES

The literature search covered published and grey literature between 1998 and 2007. Databases searched included: MEDLINE, EMBASE, CINAHL and EBM REVIEWS including the Cochrane Library, AGELINE, the National Patient Safety Foundation Bibliography, Agency for Healthcare Research and Quality and the Patient Safety Net bibliography.

STUDY SELECTION

Papers included research studies, review articles, policy papers, opinion articles and legal briefs. Inclusion criteria were: (i) homecare directed services provided in the home by healthcare professionals or caregivers; (ii) addressed a characteristic relevant to patient experienced adverse events (e.g. occurrences, rates, definitions, prevention or outcomes); and (iii) were in English. Data extraction A pool of 1007 articles was reduced to 168 after analysis. Data were charted according to six categories: definitions, rates, causes, consequences, interventions and policy.

RESULTS

Eight categories emerged: adverse drug events, line-related, technology-related, infections and urinary catheters, wounds, falls, studies reporting multiple rates and other. Reported overall rates of adverse events ranged from 3.5 to 15.1% with higher rates for specific types. Few intervention studies were found. Adverse events were commonly associated with communication problems. Policy suggestions included the need to improve assessments, monitoring, education, coordination and communication.

CONCLUSION

A standardized definition of adverse events in the homecare setting is needed. Prospective cohort studies are needed to improve estimates and intervention studies should be undertaken to reduce the risk that homecare patients will experience adverse events.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Appropriate prescribing in the elderly: an investigation of two screening tools, Beers criteria considering diagnosis and independent of diagnosis and improved prescribing in the elderly tool to identify inappropriate use of medicines in the elderly in primary care in Ireland

BACKGROUND

Elderly patients are particularly vulnerable to inappropriate prescribing, with increased risk of adverse drug reactions and consequently higher rates of morbidity and mortality. A large proportion of inappropriate prescribing is preventable by adherence to prescribing guidelines, suitable monitoring and regular medication review. As a result, screening tools have been developed to help clinicians improve their prescribing.

OBJECTIVES

To compare identification rates of inappropriate prescribing in elderly patients in primary care using two validated screening tools: Beers' criteria and improved prescribing in the elderly tool (IPET); to calculate the net ingredient cost (NIC) per month (euro) of the potentially inappropriate medicines in this population of patients.

METHOD

A consecutive cohort of 500 patients 65 years of age and over were recruited prospectively from primary care over a 6 month period in a provincial town in Ireland. Patients' medical records (electronic and paper) were screened and all relevant information concerning current illnesses and medications was recorded on a standardized data collection form to which Beers' criteria [considering diagnosis (CD) and independent of diagnosis (ID)] and IPET tools were applied. The NIC was calculated from an edition of the Irish monthly index of medical specialities published concurrently with the data collection.

RESULTS

Beers' criteria identified a total of 69 medicines that were prescribed inappropriately (eight CD and 61 ID) in 65 patients (13%), costing euro824.88 per month while IPET identified 63 potentially inappropriate medicines in 52 (10.4%) patients costing euro381.28 per month.

CONCLUSIONS

Potentially inappropriate medications are prescribed in a significant proportion of elderly people in primary care, with significant economic implications.

The Use of Anticholinergic Medications in Homebound Elderly Patients with Dementia

OBJECTIVE

Identify the number of homebound older adults admitted to a home-based health care agency in 2003 with a diagnosis of dementia. Compare the use of anticholinergic medications in older adults with a diagnosis of dementia to a matched comparison group without a diagnosis of dementia.

DESIGN

Retrospective, cohort study.

SETTING

Home health care agency in the eastern part of Washington State serving the homebound.

PARTICIPANTS

Homebound subjects 60 years of age or older with or without a diagnosis of dementia.

INTERVENTIONS

N/A.

MAIN OUTCOME MEASURES

Number of homebound subjects with a diagnosis of dementia. Comparison of those in the group diagnosed with dementia (n = 50) to a matched cohort in the group with no dementia diagnosis (n = 50) in regard to use of drugs with anticholinergic activity.

RESULTS

From a population of 1,746 patients served in 2003 who met the study criteria, 107 (6.1%) patients had a diagnosis of dementia. Of these, 50 were studied. Of the subjects with dementia, 62% were prescribed a drug with anticholinergic activity, compared with 80% of subjects without dementia. Fewer patients in the study group were prescribed anticholinergic drugs than in the comparison group. The primary drugs with anticholinergic activity cited most often were olanzapine, hydroxyzine, and mirtazapine.

CONCLUSION

Drugs with anticholinergic activity are used frequently in an older homebound population, irrespective of a dementia diagnosis.

Reasons given by homebound older adults living in a large midwestern city for taking or not taking vitamin and mineral supplements

The prevalence of vitamin and mineral supplement usage in a group of homebound older adults in a large Midwestern city and their motivation for supplement use or nonuse were evaluated. Sixty-one selected homebound individuals 60 years and older from three assistance programs for older adults participated in the study. Forty-seven percent reported taking vitamin or mineral supplements, and of these 93% were taking a multivitamin supplement. Most participants received their information regarding supplements from a health care professional, generally a physician. For those not taking supplements, the most common reason given was the absence of a prescription/recommendation. For those taking supplements, the most common reason given was that supplements were prescribed/recommended.

Applying the 2003 Beers update to Medicaid/Medicare enrollees

Purpose

The purpose of this paper is to examine rates of potentially inappropriate prescribing in a population dually eligible for Medicare and Medicaid using the new 2003 Fick update, which revises the previous 1997 Beers list.

Design/methodology/approach

Cross sectional retrospective review of 2003 Centers for Medicare and Medicaid Service (CMS) Medicaid Pharmacy claims data. Claims data submitted for outpatient and nursing home residents for elderly enrollees dually eligible for Medicare and Medicaid were analyzed. Potentially inappropriate drug use was assessed using the 2003 Fick update to the previous 1997 Beers list. Inappropriate use was identified based on these criteria for drugs independent of diagnosis.

Findings

Of enrollees with drug use, 34 percent received an inappropriate drug per the 1997 Beers list; 47 percent per the 2003 Fick update. Hispanics had the highest percentage of drug recipients receiving an inappropriate drug in the Northeast region per the 2003 Fick update. Within therapeutic category, the number of inappropriate genitourinary products dispensed to total genitourinary products ranked the highest at 20 percent per the 2003 Fick update.

Practical implications

This study examines variations in Beers drug use in the elderly dually eligible Medicare and Medicaid population in 2003 by applying the 2003 Fick et al. update of the 1997 Beers list to one of the nation's largest sources of person‐specific data on prescribed drugs. Inappropriate use was identified for drugs independent of diagnosis. Of enrollees with drug use, 34 percent received an inappropriate drug per the 1997 Beers list; 47 percent per the 2003 Fick update. Within therapeutic category, the number of inappropriate genitourinary products dispensed to total genitourinary products ranked the highest at 20 percent per the 2003 Fick update. The paper's findings provide evidence that the potential use of inappropriate drugs in Hispanics should be considered separately from other ethnicity groups.

Originality/value

A markedly higher rate of potentially inappropriate drug use in the elderly Medicaid population exists following the Fick update. These findings provide evidence that the potential use of inappropriate drugs in Hispanics should be considered separately from other ethnicity groups. By comparing drug use based on therapeutic category, genitourinary products were found to have the highest potential for inappropriate prescribing.

Assessing Advance Directives in the Homebound Elderly

We studied the prevalence of specific barriers that prevent indigent homebound older adults from obtaining advance directives and tested the effectiveness of clinical reminders for lowering the number of clients without advance directives. Case managers interviewed 1569 clients to determine whether they had an advance directive. All 530 clients without advance directives were contacted 3 months later to determine if advance directives had been obtained. Clients who still did not have advance directives were asked to list 1 or more reasons they did not have advance directives. About 57.8% of the barriers identified may reflect reluctance on the part of clients to address their own mortality. Reminders by the case managers were ineffective at lowering the number of homebound older adults without advance directives. Further studies are needed to identify and design strategies for convincing this population of homebound elderly to establish advance directives.

Characteristics associated with four potential medication problems among older adults in Medicaid waiver services

OBJECTIVE

To identify characteristics associated with four potential medication problems among older adults at risk for nursing home placement.

DESIGN

Cross-sectional survey.

SETTING

Three sites of California's Multipurpose Senior Services Program (MSSP), a Medi-Cal waiver care management program.

PARTICIPANTS

Six hundred fifteen dual-eligible, functionally impaired, community-dwelling adults aged 65 years and older enrolled in MSSP between June 2004 and January 2006.

INTERVENTION

Medication screening using the Home Health Criteria that include medication use and clinical risk factors.

MAIN OUTCOME MEASURES

Demographic and health characteristics associated with four problem types: 1) unnecessary therapeutic duplication, 2) psychotropic medication use with concurrent falls or confusion, 3) cardiovascular medication problems, and 4) use of nonsteroidal anti-inflammatory drugs (NSAIDs) with risk of peptic ulcer complications. Independent measures included age, gender, race/ethnicity, living arrangement, number of medications, health status, and utilization.

RESULTS

Each problem type was associated with different characteristics, as identified by logistic regression modeling. Increased number of medications was associated with therapeutic duplication (odds ratio [OR] = 1.27; confidence interval [CI] 1.20-1.35; P < 0.001) and problematic psychotropic medication use (OR = 1.15; CI 1.08-1.22; P < 0.001). Psychotropic use was also associated with emergency department, hospital, or skilled nursing admission in the previous year (OR = 1.86; CI 1.15-3.00; P = 0.012), living with someone (OR = 0.57; CI 0.34-0.95; P = 0.032), and new care management enrollment (OR = 1.99; CI 1.22-3.24; P = 0.006). New enrollment was also associated with cardiovascular medication problems (OR = 2.15; CI 1.32-3.51; P = 0.002). There were no significant characteristics associated with NSAID problems (not shown).

CONCLUSION

Unique predictors of potential medication problems highlight the need for systematic medication screening and treatment planning. These should include medication therapy management for vulnerable community-dwelling elders (upon enrollment for care management) and for those taking multiple medications. Funding mechanisms via Medicare Part D (prescription drug program) should be explored in this population to increase identification of medication problems and their resolution.

Assessing multiple medication use with probabilities of benefits and harms

OBJECTIVE

A quantitative framework to assess harms and benefits of candidate medications in the context of drugs that a patient is already taking is proposed.

METHOD

Probabilities of harms and benefits of a given medication are averaged to yield a utility value. The utility values of all medications under consideration are combined as a geometric mean to yield an overall measure of favorability. The grouping of medications yielding the highest favorability value is chosen.

RESULTS

Five examples of choosing between widely used candidate medications demonstrate the feasibility of the proposed framework.

DISCUSSION

The framework proposed provides a simple method for considering the trade-offs involved in prescribing multiple medications. It can be adapted to include additional parameters representing severity of condition, prioritization of outcomes, patient preferences, dosages, and medication interactions. Inconsistent reporting in the medical literature of data about benefits and harms of medications, dosages, and interactions constitutes its primary limitation.

Pharmacokinetic and pharmacodynamic alterations in the geriatric patient

Adverse drug events (ADEs) are all too common in older patients. Although there are multiple causes for the ADEs in the elderly, alterations in pharmacokinetics (PK) and pharmacodynamics (PD) are frequent culprits. These alterations in PK and PD may be part of the normal aging process. Older patients often develop significant drug-related problems when alterations in PK and PD are not appropriately accounted for in prescribing and monitoring of medications. Clinically, the most significant PK changes that occur in aging are renal elimination and metabolism of drugs. In general, renal function declines with aging, necessitating dosage adjustments for drugs with renal-elimination pathways. The ability of the liver to metabolize certain drugs may also decline as a consequence of the aging process. From a PD standpoint, exaggerated responses are frequent, and often it is the side effects of medications that become exaggerated, rather than the therapeutic effects. Drugs affecting the central nervous system are particularly prone to PD alterations. Because of the PK and PD changes, vigilant monitoring of both therapeutic and adverse effects is mandatory in older patients. Based on PK and PD differences between middle-aged and elderly patients, there are certain medications that should almost always be avoided in older people. In addition, because older people tend to use more medications, the incidence of drug-drug interactions becomes more prevalent. Most of the drug-drug interactions that adversely impact older people involve both PK and PD mechanisms. Pharmacists and all prescribers must have a sound understanding of PK and PD effects of medications used in older people to provide optimal care and avoid preventable drug-related problems.

Analysis of drug–drug interactions (DDIs) in nursing homes in Central Taiwan

With the progressive aging of the population, the long-term nursing care and drug safety for the elderly are gradually gaining attention. In Taiwan, nursing homes are the main institutes helping society or families take care of elderly people suffering from diseases. The aim of this study was to assess the prescribed medications of nursing home residents, the occurrence of DDIs and the association between the number of drugs and DDIs with a view to reinforce drug safety for the elderly. The findings of this study showed that the mean number of medications per resident was 5.74+/-2.4. Of the 323 samples, 81 (25.1%) had experienced DDIs, 63 (64.95%) were of moderate and 7 (7.2%) of major severity. The findings also showed that the number of potential DDIs increased as the number of medications used per residents increased. The residents with nine or more medications tended to have more DDIs, in comparison to those with one or two medications. The odds ratio (OR) was 11.389, which had reached statistical significance in difference. Therefore, to reduce potential DDIs, the number of medications for the senior people with chronic diseases should be properly controlled.

Comparison of persistence rates of acetylcholine-esterase inhibitors in a state Medicaid program

OBJECTIVE

To compare levels of persistency between cholinesterase inhibitors (ChEIs) among a Medicaid patient population of older adults.

METHODS

Survival analysis was used to assess differences in discontinuation between ChEIs (donepezil versus rivastigmine and galantamine), and for difference in patient gender, age, race, and care setting.

RESULTS

Rates of discontinuation increased from 42.7% (95% CI = 39.9-45.5) at 12 months to 84.8% (95% CI = 82.3-87.3) at 24 months. In multivariate models, no significant difference in discontinuation existed prior to 365 days. However, patients dispensed donepezil were less likely to discontinue as compared with users of the other two ChEIs after the first year (RR = 0.70; CI = 0.499-0.983; p < 0.04). Patients of white race were less likely to discontinue (RR = 0.549; 95% CI = 0.43-0.82; p = 0.0015), while gender, care setting, and age were not associated with discontinuation.

CONCLUSIONS

One-year persistence rates were similar between different ChEIs. Among patients persisting with ChEI medication for at least 12 months, users of donepezil were slightly more likely to continue to persist at 24 months. Nearly half of patients failed to persist with ChEI therapy for at least 12 months. Our findings underscore the limitations of the ChEI medications and the urgent need for effective and tolerable therapeutic options for patients having dementia.

Inappropriate prescribing in older people

Optimal prescribing is critical to the goals of geriatric medicine of curing disease, eliminating or reducing symptoms, and improving functioning. However, prescribing decisions in older people are often complex. There is marked heterogeneity in health status and functional capacity amongst older people, who range from fit, active, independent individuals to those who are physically and mentally frail, with limited physiological reserve. Age-related changes in physiology affect drug pharmacokinetics and pharmacodynamics, and together with various pathological processes, increase the risk of adverse drug events (ADEs). This risk is heightened by prescription of multiple medications to treat multiple co-morbidities. Consequently, balancing safety and quality of prescribing for older people with appropriate treatment of all co-morbidities can be challenging.