Potentially Inappropriate Medications Are Associated with Increased Healthcare Utilization and Costs

Mortality among individuals with chronic kidney disease based on the 2012 and 2021 KDIGO blood pressure targets

The 2021 Kidney Disease: Improving Global Prognosis (KDIGO) guidelines set a target systolic blood pressure (SBP) of 120 mmHg for chronic kidney disease (CKD) patients. This paper aims to compare mortality outcomes in CKD patients following the 2021 KDIGO guidelines versus the 2012 KDIGO guidelines. We used the National Health and Nutrition Examination Survey (NHANES) database to categorize CKD patients into four groups: "above 2021 KDIGO only", "above 2012 KDIGO only", "above both targets" and "controlled with both targets". We compared differences in all-cause and cardiovascular deaths among these groups. In total, 10,612 CKD patients from the 2001-2018 NHANES database were identified. Subsequently, 2,226 patients lacking mortality information and 1,157 without crucial laboratory data were excluded. 7,229 CKD patients were enrolled, with 50.67% above both targets, 27.1% controlled within both targets, 1.01% above the 2012 KDIGO target, and 21.22% only above the 2021 KDIGO target. In multivariate analyses, the risk of all-cause mortality was not statistically significant (hazard ratio (HR): 0.91, 95% confidence interval (CI): 0.8-1.02, P = 0.11) for patients above the 2021 KDIGO target only compared to those controlled with both targets. Similar results were found for cardiovascular deaths. The 2021 KDIGO guidelines did not differentiate high-risk CKD populations in terms of all-cause death and cardiovascular death, compared with the 2012 KDIGO guidelines.

Utilization of potentially inappropriate sedative-hypnotic and atypical antipsychotic medications among elderly individuals with insomnia and Alzheimer's disease

STUDY OBJECTIVES

This study assessed the utilization of potentially inappropriate medications (PIM) including oral sedative-hypnotic and atypical antipsychotic (OSHAA), healthcare resource utilization (HCRU), and costs among elderly individuals with insomnia and in the subpopulation with Alzheimer's disease (AD) who also had a diagnosis of insomnia.

METHODS

Using a claims database containing International Classification of Diseases, 10th Revision (ICD-10) codes, the cohort included individuals aged ≥ 65 with incident insomnia (EI, N = 152 969) and AD insomnia subpopulation (ADI, N = 4888). The proportion of patients utilizing atypical antipsychotics or oral sedative-hypnotic medications, namely z-drugs, benzodiazepines, doxepin, dual orexin receptor antagonists (DORAs), and melatonin agonists, were assessed. Inappropriate OSHAA utilization was defined as per the American Geriatrics Society (AGS) Beers criteria. Multivariable models were utilized to compare HCRU and costs between PIM-OSHAA and no PIM-OSHAA groups.

RESULTS

Among the EI cohort, z-drugs (13.39%) were the most commonly utilized OSHAA, and in the ADI cohort, it was AAPs (29.97%). PIM-OSHAA was utilized by 20% of the EI and 35% of the ADI cohorts. Patients with PIM-OSHAA use among the EI cohort had a higher annualized adjusted mean HCRU (pharmacy visits: 31.21 vs. 23.68; ambulatory and outpatient visits: 18.55 vs. 16.85) and costs, primarily due to medical costs (mean total cost: $36 676.08 vs. $31 346.54) compared to those without.

CONCLUSIONS

Substantial utilization of PIM-OSHAA was observed in EI and ADI cohorts. PIM-OSHAA use was associated with higher HCRU and costs. These findings underscore the importance of appropriate treatment strategies for insomnia in the elderly population especially in those with concurrent AD.

Racial and Ethnic Differences in Potentially Inappropriate Medication Use Among Medicare Beneficiaries

Importance

Older Medicare beneficiaries are susceptible to receiving potentially inappropriate medications (PIMs), where the risks outweigh the benefits. Racial and ethnic differences in PIM use may perpetuate health disparities and disproportionately lead to costly adverse drug events for some groups.

Objective

To examine associations of race and ethnicity with PIM use among older Medicare beneficiaries.

Design, Setting, and Participants

This cross-sectional study used nationwide Medicare Part D Event files, fee-for-service claims, and Medicare Advantage (MA) encounter data among Medicare beneficiaries 65 years or older with Part D prescription drug coverage. The study population included random samples of 20% of traditional Medicare (TM) beneficiaries and 50% of MA enrollees from January 1, 2016, to December 31, 2019. Analysis was conducted from May 28 to September 16, 2024.

Exposure

Race and ethnicity.

Main Outcomes and Measures

Linear probability models were estimated for outcomes of (1) high-risk medication use among older adults, (2) potentially harmful drug-disease interactions in patients with dementia, and (3) potentially harmful drug-disease interactions in patients with a history of falls.

Results

The study sample included 21 193 170 patients with 32 199 587 beneficiary-year observations (mean [SD] age, 75.5 [7.3] years; 18 936 697 [58.8%] female; 983 513 [3.1%] Asian or Pacific Islander, 3 190 515 [9.9%] Black, 2 710 930 [8.4%] Hispanic, and 25 314 629 [78.6%] White). Compared with White beneficiaries, the rates of high-risk medication use were 1.7 [95% CI, -1.8 to -1.6] percentage points lower for Asian or Pacific Islander beneficiaries, 3.4 [95% CI, -3.4 to -3.3] percentage points lower for Black beneficiaries, and 0.6 [95% CI, -0.6 to -0.5] percentage points lower for Hispanic beneficiaries. Similarly, White beneficiaries had the highest rates of potentially harmful drug-disease interactions among those with dementia as well as those with a history of falls. The pattern of racial and ethnic differences was similar in analyses stratified by enrollment in TM or MA plans. However, the differences between White individuals and other groups were smaller in MA than in TM plans for all comparisons.

Conclusions and Relevance

In this cross-sectional study of 32 199 587 Medicare beneficiary-years from 2016 to 2019, White Medicare beneficiaries had consistently higher rates of PIM use compared with other racial and ethnic groups. The observed differences may be partially explained by racial and ethnic differences in overall prescription drug use and suggest the need to reduce PIM use in all racial and ethnic groups.

Potentially inappropriate medications for geriatric patients in Bahrain: prevalence, predictors, and implications for practice

BACKGROUND

The global increase in the older adult population necessitates a comprehensive understanding of medication management to mitigate the risks associated with potentially inappropriate medications (PIMs). These medications are of particular concern due to their association with adverse drug reactions, increased hospitalization, and increased healthcare costs. This study aimed to determine the prevalence and risk factors associated with PIM use among older adult patients attending primary health care centers in Bahrain.

METHODS

This cross-sectional study was conducted in 2022 in 27 primary healthcare centers across Bahrain. The study included patients aged 65 years or older. A computer based simple random sample was obtained, and the Beers criteria 2023 was utilized to assess medication appropriateness. Anonymous data was retrieved from electronic medical records and analyzed via univariate, and logistic regression analyses.

RESULTS

Among the 595 older adult patients studied, the average age was 71.7 years, with 54.5% (n = 324) being female. Most of the patients were married (70.8%, n = 421). More than half of the patients (51.3%, n = 305) received at least one PIM, with gliclazide (37%, n = 113), pantoprazole (29.8%, n = 91), and rabeprazole (27.9%, n = 85) being the most prevalent prescribed PIM. Univariate analyses revealed that PIM rates were significantly higher among females (p = 0.001) and patients with comorbidities such as diabetes mellitus (p < 0.001), essential hypertension (p < 0.001), and hyperlipidaemia (p < 0.001). Logistic regression analysis revealed that age (OR = 1.09, p < 0.001), female sex (OR = 1.645, p = 0.012), and diabetes mellitus (OR = 1.696, p = 0.029) were significant predictors of PIM use.

CONCLUSION

This study highlights the significant burden of PIM use among older adult patients in Bahrain, with more than half of the participants receiving at least one PIM. These findings underscore the urgent need for targeted interventions, particularly among female patients, those with chronic conditions such as diabetes mellitus, and patients taking five or more medications. These insights contribute to the broader understanding of geriatric pharmacotherapy and offer a foundation for policy development aimed at optimizing medication safety in aging populations.

Managing medication in very old age: A qualitative study among Faroese nonagenarians

BACKGROUND

Currently, people generally live longer, and consequently, the number of older people experiencing periods of multimorbidity and the need for medication will increase. Managing multiple medications can be a complex and challenging task, especially for older people who may experience a decline in their cognitive and physical abilities. The aim of this study was to gather knowledge on how home-dwelling people who are 90 years or older manage their daily medication, what strategies they use, and what challenges they experience regarding medication. This knowledge is necessary for providing support and care for the oldest old regarding their medication management in daily living.

METHOD

Semi-structured interviews were conducted with 10 men and women aged 91-97 years who were part of the Faroese Nonagenarian Study conducted in 2021. The analysis was conducted by using thematic analysis as suggested by Braun and Clarke.

RESULTS

We identified three important themes for understanding how the oldest-old citizens manage medication and the challenges and worries that they sometimes experience. These themes were managing medication in daily living, challenges regarding medication management, and worries among the participating older people and their relatives. The majority of the participants received automated dose dispensing (ADD) services, which they considered a great help. In addition, they developed personal strategies to manage their medication. However, the changing colour and shape of tablets caused concern among the participants, and concern about side effects were not always taken seriously by their general practitioners.

CONCLUSION

In addition to personal strategies, ADD services helped the participants manage medications in daily living. However, user involvement and regular counselling with their doctors appeared to be insufficient and, in some cases, absent. This study points to the necessity of strengthening user involvement by providing sufficient and regular counselling about medication between healthcare providers and people of very old age.

Medication reviews in hospitalised patients for reduced hospital readmission and mortality. Systematic review, meta-analysis and meta-regression of RCTs

Efforts to reduce preventable medication-related harm through medication reviews have increased, but interventions often yield null-results regarding clinical outcomes. We conducted a systematic literature search in four data bases and summarised the available evidence from randomised controlled trials (RCTs) comparing medication reviews and usual care in hospitalised patients regarding hospital readmissions and all-cause mortality by random-effects meta-analyses. Effect size differences by methodological study differences were of special interest. The meta-analysis of all 24 trials on hospital readmissions, including 12,539 participants, showed a statistically significant 8 % decrease in hospital readmissions (risk ratio (RR) [95 % confidence interval]: (0.92 [0.88-0.97], p = 0.002). The number of patient contacts was the most prominent effect modifier in meta-regression (p = 0.003) and the effect of medication reviews was approximately twice as strong (15 %) in 11 trials with 2 or more patient contacts (0.85 [0.78-0.92], p < 0.001). No statistically significant reduction in all-cause mortality was observed in a meta-analysis of all 22 trials with data for this outcome (0.95 [0.86-1.04], p = 0.24), including 12,350 participants. The method of mortality assessment was identified as an effect modifier by meta-regression (p = 0.01). A meta-analysis of 10 trials with complete mortality ascertainment via registries or primary care data showed a significantly 19 % reduced mortality (0.81 [0.70-0.94], p < 0.01). In conclusion, medication reviews reduce the risk of hospital readmission and might also reduce all-cause mortality. Comprehensive mortality assessment was essential for successful trials. Clinical guidelines should recommend medication reviews with multiple patient contacts, involving pharmacists, either for repeated medication reviews or to improve adherence.

Patient-Related Factors Associated With the Initiation of Potentially Inappropriate Medication in Home Care: An Observational Study Based on Resident Assessment Instrument Data

BACKGROUND

The harmful outcomes of potentially inappropriate medications (PIMs) are highlighted among multimorbid older home care clients using several medicines. The aim of this study was to identify patient-related factors associated with the initiation of PIMs.

METHODS

This register-based study used Resident Assessment Instrument-Home Care (RAI-HC) assessments (n = 6176) from year 2014 to 2015. PIMs were identified according to the Beers criteria. Generalised estimating equations were used to identify factors associated with the initiation of PIMs.

FINDINGS

A total of 228 (11.3%) clients initiated PIMs during the follow-up (mean 13 months). Factors associated with higher odds to initiate PIMs were higher education (OR = 1.36, 95% CI 1.02-1.82), cognitive impairment (OR = 1.70, 1.02-2.82), reduced social interaction (OR = 1.50, 1.06-2.13), independent activity outdoors (OR = 1.72, 1.18-2.51), diabetes (OR = 1.47, 1.12-1.94), Parkinson's disease (OR = 3.42, 1.86-6.27) and longer interval between RAI assessments (OR = 1.09 per month, 1.02-1.18).

CONCLUSIONS

Incidence of PIMs among home care clients was common. The results help healthcare professionals to focus more attention on clients more susceptible to PIM prescribing. Preventing PIM use is essential, especially among older adults with cognitive impairment, to prevent further decline of health status and admission to long-term care.

Prescribing rate, healthcare utilization, and expenditure of older adults using potentially inappropriate medications in China: A nationwide cross-sectional study

BACKGROUND

The use of potentially inappropriate medications (PIMs) is a major concern for medication safety as it may entail more harm than potential benefits for older adults. This study aimed to explore the prescribing rate, healthcare utilization, and expenditure of older adults using PIMs in China.

METHODS

A cross-sectional analysis was conducted using a national representative database of all medical insurance beneficiaries across China, extracting ambulatory visit records of adults aged 65 years and above between 2015 and 2017. Descriptive analysis was conducted to measure the rate of patients exposed to PIM, prescribing rate of each PIM, average annual outpatient visits per patient, average total medication costs for each visit, average annual cost of PIMs for each patient, and average annual medication costs for each patient. Generalized linear model with logit link function and binomial distribution was used to examine the adjusted associations between PIMs and independent variables.

RESULTS

In total, 845,278 (33.2%) participants were identified to be exposed to at least one PIM. Patients aged 75-84 years (38.1%) and ≥85 years (37.9%) were more likely to be prescribed with PIMs. Beneficiaries of the Urban Employee Basic Medical Insurance (UEBMI) and living in eastern and southern regions were more frequently prescribed with PIMs. Compared with patients without PIM exposure (7.5 visits, drug cost of RMB 1545.0 Yuan), patients with PIM exposure showed higher adjusted average annual number of outpatient visits (10.7 visits, β = 3.228, 95% confidence interval [CI] = 3.196-3.261) and higher annual drug costs (RMB 2461.8 Yuan, Coef. = 916.864, 95% CI = RMB 906.292-927.436 Yuan).

CONCLUSIONS

The results showed that the use of PIM among older adults was common in China. This study suggests that it represents a clear target, pending multidimensional efforts, to promote rational prescribing for older adults.

The co-occurrence of multimorbidity and polypharmacy among middle-aged and older adults in Canada: A cross-sectional study using the Canadian Longitudinal Study on Aging (CLSA) and the Canadian Primary Care Sentinel Surveillance Network (CPCSSN)

BACKGROUND

There is an increasing prevalence of multiple conditions (multimorbidity) and multiple medications (polypharmacy) across many populations. Previous literature has focused on the prevalence and impact of these health states separately, but there is a need to better understand their co-occurrence.

METHODS AND FINDINGS

This study reported on multimorbidity and polypharmacy among middle-aged and older adults in two national datasets: the Canadian Longitudinal Study on Aging (CLSA) and the Canadian Primary Care Sentinel Surveillance Network (CPCSSN). Using consistent methodology, we conducted a cross-sectional analysis of CLSA participants and CPCSSN patients aged 45 to 85 years as of 2015. When multimorbidity was defined as two or more conditions, the prevalence was 66.7% and 52.0% in the CLSA and CPCSSN cohorts, respectively. The prevalence of polypharmacy was 14.9% in the CLSA cohort and 22.6% in the CPCSSN cohort when defined as five or more medications. Using the same cut-points, the co-occurrence of multimorbidity and polypharmacy was similar between the two cohorts (CLSA: 14.3%; CPCSSN: 13.5%). Approximately 20% of older adults (65 to 85 years) were living with both multimorbidity and polypharmacy (CLSA: 21.4%; CPCSSN: 18.3%), as compared to almost 10% of middle-aged adults (45 to 64 years) living with this co-occurrence (CLSA: 9.2%; CPCSSN: 9.9%). Across both cohorts and age groups, females had consistently higher estimates of multimorbidity, polypharmacy and the co-occurrence of multimorbidity and polypharmacy.

CONCLUSIONS

This study found that multimorbidity and polypharmacy are not interchangeable in understanding population health needs. Approximately one in five older adults in the CLSA and CPCSSN cohorts were living with both multimorbidity and polypharmacy, double the proportion in the younger cohorts. This has implications for future research, as well as health policy and clinical practice, that aim to reduce the occurrence and impact of multimorbidity and unnecessary polypharmacy to enhance the well-being of aging populations.

Assessing the prevalence of anticholinergic and sedative medications to avoid in older adults from the French Health Data System

BACKGROUND

In older people, medications with anticholinergic or sedative properties are associated with falls, frailty, and functional and cognitive impairment. These medications are often described as a subset of potentially inappropriate medications (PIMs). We examined the prevalence of anticholinergic or sedative medications to avoid in older people in France in 2023.

METHODS

This cross-sectional study used anonymized data from a large electronic healthcare database, the French National Health Data System (Système National des Données de Santé, SNDS). All people aged 65 years or older from January 1, 2023, to December 31, 2023, were included in this study. Dispensations of anticholinergic and sedative medications were identified according to PIM criteria (2023 American Geriatrics Society Beers Criteria and REMEDI[e]S tool). The prevalence of anticholinergic or sedative medications was assessed for the study population and by age (65-84 and 85 or older) and living place (home and institutionalized patients) subgroups in terms of number and percentage of patients.

RESULTS

This study included 16,938,152 patients aged 65 years or older (55% women). Among all patients, 79.8% were aged between 65 and 84 years and 20.2% were aged 85 years or older. Most patients lived at home (97.0%), and 3.0% were institutionalized. The prevalence of anticholinergic or sedative medications was 32.8% among all patients, 32.3% among 65-84 patients, and 34.8% among 85 or older patients, 32.1% among home patients, and 54.5% among institutionalized patients. The most commonly dispensed anticholinergic or sedative medications were oxazepam (5.27%), alprazolam (5.27%), zopiclone (4.85%), bromazepam (4.23%), metopimazine (2.88%), paroxetine (2.70%), nefopam (2.57%), and hydroxyzine (2.17%).

CONCLUSIONS

This study highlighted that anticholinergic and sedative medications to avoid in older people are still frequently prescribed despite the development and regular updating of PIM criteria. Future studies are needed to assess whether this has led to worsened outcomes among older adults who utilized these medications, and new initiatives should be developed to further promote deprescribing by prescribers and pharmacists.

The cost of potentially inappropriate medications for older adults in Canada: A comparative cross-sectional study

BACKGROUND

Potentially inappropriate medications (PIMs) are medications whereby the harms may outweigh the benefits for a given individual. Although overprescribed to older adults, their direct costs on the healthcare system are poorly described.

METHODS

This was a cross-sectional study of the cost of PIMs for Canadians aged 65 and older, using adapted criteria from the American Geriatrics Society. We examined prescription claims information from the National Prescription Drug Utilization Information System in 2021 and compared these with 2013. The overall levels of inflation-adjusted total annual expenditure on PIMs, average cost per quarterly exposure, and average quarterly exposures to PIMs were calculated in CAD$.

RESULTS

Exposure to most categories of PIMs decreased, aside from gabapentinoids, proton pump inhibitors, and antipsychotics, all of which increased. Canadians spent $1 billion on PIMs in 2021, a 33.6% reduction compared with 2013 ($1.5 billion). In 2021, the largest annual expenditures were on proton pump inhibitors ($211 million) and gabapentinoids ($126 million). The quarterly amount spent on PIMs per person exposed decreased from $95 to $57. In terms of mean cost per person, opioids and antipsychotics were highest ($138 and $118 per exposure). Some cost savings may have occurred secondary to an observed decline of 16.4% in the quarterly rate of exposure to PIMs (from 7301 per 10,000 in 2013 to 6106 per 10,000 in 2021).

CONCLUSIONS

While expenditures on PIMs have declined in Canada, the overall cost remains high. Prescribing of some seriously harmful classes of PIMs has increased and so directed, scalable interventions are needed.

Potentially Inappropriate Medication in Older Persons With Dementia: Does a Migration Background Matter?

OBJECTIVES

Previous research in the general population shows more potentially inappropriate medications (PIMs) among persons with a migration background compared with persons without a migration background. This study investigated the association between non-Western (nw) migration background (MB) and dementia-specific PIMs in older adults with dementia in the Netherlands.

DESIGN

Cohort study using routinely recorded electronic health records and administrative data.

SETTING AND PARTICIPANTS

Electronic health record data of general practitioners from the NIVEL-Primary Care Database, were linked to registries managed by Statistics Netherlands (2013-2014). A total of 9055 community-dwelling older adults with dementia were included, among whom 294 persons had an nw-MB from Africa, South America, or Asia, based on their country of birth.

METHODS

We determined the presence of dementia-specific PIM prescriptions and compared this between persons with an nw-MB and without an MB, using logistic regression analysis adjusted for follow-up time, age, registered sex, and total number of prescriptions. Interaction effects of potentially relevant covariates were tested. The 3 largest nw-MB groups in the Netherlands were analyzed separately.

RESULTS

Dementia-specific PIMs were less frequently prescribed to persons with an nw-MB compared to persons without an MB with a dementia diagnosis [30.6% vs 34.4%, odds ratio (OR) 0.71, 95% CI 0.54-0.92], with especially less often a benzodiazepine prescription in the group with an nw-MB, compared to persons without an MB (15.0% vs 19.3%, OR 0.61, 95% CI 0.43-0.84). Dementia duration, living alone, household income, and degree of urbanization did not influence the associations.

CONCLUSIONS AND IMPLICATIONS

Among older adults with dementia in the Netherlands, persons with an nw-MB had less often a dementia-specific PIM prescription compared to persons without an MB. Whether this difference is a reflection of better quality of care, higher professional uncertainty, or less recognition of (mental) health problems in persons with an nw-MB and dementia, needs further investigation.

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.

Association between potentially inappropriate medications prescription and health-related quality of life among US older adults

BACKGROUND

Potentially inappropriate medications (PIMs) are associated with worse health outcomes among older adults. Our objective was to examine the association between PIM prescription and health-related quality of life (HRQoL) among older adults in the United States using nationally representative data.

METHODS

This was a retrospective study utilizing 2011-2015 Medical Expenditure Panel Survey (MEPS) data. Community dwelling US adults aged 65 years or older were included. A qualified definition operationalized from the 2019 American Geriatrics Society Beers Criteria® was used to define exposure to PIMs during the study period. The Physical Component Summary (PCS) and Mental Component Summary (MCS) of the Medical Outcomes Study 12-Item Short Form Health Survey (SF-12) were used to measure HRQoL. Survey-weighted linear regression models were constructed to investigate the association between PIM exposure and participants' PCS and MCS scores. Analyses were stratified across three age cohorts (65-74, 75-85, and ≥85 years).

RESULTS

Unadjusted analysis showed poorer scores in the PIM exposed group for both PCS and MCS (all p < 0.001). PIM exposure was associated with poorer PCS scores across all age groups with those aged 65-74 years (adjusted regression coefficient = -1.60 [95% CI = -2.27, -0.93; p < 0.001]), those 75-84 years (adjusted regression coefficient: -1.49 [95% CI = -2.45, -0.53; p = 0.003]), and those 85 years and older (adjusted regression coefficient = -1.65 [95% CI = -3.03, -0.27; p = 0.02]). PIM exposure was also associated with poorer MCS scores in participants aged 65-74 years (adjusted regression coefficient = -0.69 [95% CI = -1.16, -0.22; p = 0.004]) and 85 years and older (adjusted regression coefficient = -2.01 [95% CI = -3.25, -0.78; p = 0.002]).

CONCLUSIONS

Our results suggest that patients' exposure to PIMs is associated with poorer HRQoL. Further work is needed to assess whether interventions to deprescribe PIMs may help to improve patients' HRQoL.

The 2023 American Geriatrics Society Updated Beers Criteria® Application in Low- and Middle-Income Countries: A Walk-through

The 2023 update of the American Geriatrics Society Beers Criteria® provides a comprehensive set of guidelines for optimizing medication use in older people. While this update is based on a rigorous review of evidence from clinical trials and research studies published between 2017 and 2022, its application in low- and middle-income countries (LMICs) may present unique challenges and considerations. LMICs often face different health care realities compared with high-income countries, such as limited access to medications, varying prescribing practices, and resource constraints. As a result, the Beers Criteria® 2023 update, which includes the addition, deletion, and revision of medicines based on new evidence, may not be entirely applicable or feasible in these settings. This commentary aims to explore the implications of the 2023 Beers Criteria® update for LMICs, highlighting the need for context-specific adaptations and strategies to optimize medication use and improve health outcomes for older people in resource-limited settings.

Impact of comprehensive medication reviews on potentially inappropriate medication discontinuation in Medicare beneficiaries

BACKGROUND

The use of potentially inappropriate medications (PIMs) is associated with increased risk of hospitalizations and emergency room visits and varies by racial and ethnic subgroups. Medicare's nationwide medication therapy management (MTM) program requires that Part D plans offer an annual comprehensive medication review (CMR) to all beneficiaries who qualify, and provides a platform to reduce PIM use. The objective of this study was to assess the impact of CMR on PIM discontinuation in Medicare beneficiaries and whether this differed by race or ethnicity.

METHODS

Retrospective cohort study of community-dwelling Medicare Part D beneficiaries ≥66 years of age who were eligible for MTM from 2013 to 2019 based on 5% Medicare fee-for-service claims data linked to the 100% MTM data file. Among those using a PIM, MTM-eligible CMR recipients were matched to non-recipients via sequential stratification. The probability of PIM discontinuation was estimated using regression models that pooled yearly subcohorts accounting for within-beneficiary correlations. The most common PIMs that were discontinued after CMR were reported.

RESULTS

We matched 24,368 CMR recipients to 24,368 CMR non-recipients during the observation period. Median age was 74-75, 35% were males, most were White beneficiaries (86%-87%), and the median number of PIMs was 1. In adjusted analyses, CMR receipt was positively associated with PIM discontinuation (adjusted relative risk [aRR]: 1.26, 95% CI: 1.20-1.32). There was no evidence of differential impact of CMR by race or ethnicity. The PIMs most commonly discontinued after CMR were glimepiride, zolpidem, digoxin, amitriptyline, and nitrofurantoin.

CONCLUSIONS

Among Medicare beneficiaries who are using a PIM, CMR receipt was associated with PIM discontinuation, suggesting that greater CMR use could facilitate PIM reduction for all racial and ethnic groups.

Variability in the prevalence of inappropriate medication use among older adults: A review highlighting the importance of screening methods and database types

AIMS

The global older population is growing rapidly, and the rise in polypharmacy has increased potentially inappropriate medication (PIM) encounters. PIMs pose health risks, but detecting them automatically in large medical databases is complex. This review aimed to uncover PIM prevalence in individuals aged 65 years or older using health databases and emphasized the risk of underestimating PIM prevalence due to underutilization of detection tools.

METHODS

This study conducted a broad search on the Medline database to identify articles about the prevalence of PIMs in older adults using various databases. Articles published between January 2010 and June 2023 were included, and specific criteria were applied for study selection. Two literature reviews conducted before our study period were integrated to obtain a perspective from the 1990s to the present day. The selected papers were analysed for variables including database type, screening method, adaptations and PIM prevalence. The study categorized databases and original screening tools for clarity, examined adaptations and assessed concordance among different screening methods.

RESULTS

This study encompassed 48 manuscripts, covering 58 sample evaluations. The mean prevalence of PIMs within the general population aged over 65 years was 27.8%. Relevant heterogeneity emerged in both the utilized databases and the detection methods. Adaptation of original screening tools was observed in 86.2% (50/58) of cases. Half of the original screening tools used for assessing PIMs belonged to the simple category. About a third of the studies employed less than half of the original criteria after adaptation. Only three studies used over 75% of the original criteria and more than 50 criteria.

CONCLUSIONS

This extensive review highlights PIM prevalence among the older adults, emphasizing method intricacies and the potential for underestimation due to data limitations and algorithm adjustments. The findings call for enhanced methodologies, transparent algorithms and a deeper understanding of intricate rules' impact on public health implications.

Potentially inappropriate medication on communitydwelling older adults: Longitudinal analysis using the International Mobility in Aging Study

Introduction

Medications are a fundamental part of the treatment of multiple pathologies. However, despite their benefits, some are considered potentially inappropriate medications for older people given their safety profile. Epidemiological data differences related to potentially inappropriate medications make it difficult to determine their effects on elderly people.

Objective

To estimate the prevalence and types of potentially inappropriate medications using the 2019 Beers Criteria® in a cohort of adults older than 65 years.

Materials and methods

We performed an observational, multicenter, retrospective, longitudinal study of a four-year follow-up of potentially inappropriate medications in community-dwelling older adults.

Results

We followed 820 participants from five cities for four years (2012-2016) and evaluated them in three different moments (m1 = 2012, m2 = 2014, and m3 = 2016). The average age was 69.07 years, and 50.9% were women. The potentially inappropriate medication prevalence in the participants was 40.24%. The potentially inappropriate medications' mean among the studied subjects in the first moment was 1.65 (SD = 0.963), in the second was 1.73 (SD = 1.032), and in the third was 1.62 (SD = 0.915). There were no statistical differences between measurements (Friedman test, value = 0.204). The most frequent potentially inappropriate medications categories were gastrointestinal (39.4%), analgesics (18.8%), delirium-related drugs (15.4%), benzodiazepines (15.2%), and cardiovascular (14.2%).

Conclusions

About half of the population of the community-dwelling older adults had prescriptions of potentially inappropriate medications in a sustained manner and without significant variability over time. Mainly potentially inappropriate medications were gastrointestinal and cardiovascular drugs, analgesics, delirium-related drugs, and benzodiazepines.

Deprescribing in older adults with polypharmacy

Polypharmacy is common in older adults and is associated with adverse drug events, cognitive and functional impairment, increased healthcare costs, and increased risk of frailty, falls, hospitalizations, and mortality. Many barriers exist to deprescribing, but increased efforts have been made to develop and implement deprescribing interventions that overcome them. This narrative review describes intervention components and summarizes findings from published randomized controlled trials that have tested deprescribing interventions in older adults with polypharmacy, as well as reports on ongoing trials, guidelines, and resources that can be used to facilitate deprescribing. Most interventions were medication reviews in primary care settings, and many contained components such as shared decision making and/or a focus on patient care priorities, training for healthcare professionals, patient facing education materials, and involvement of family members, representing great heterogeneity in interventions addressing polypharmacy in older adults. Just over half of study interventions were found to perform better than usual care in at least one of their primary outcomes, and most study interventions were assessed over 12 months or less.

Potentially Inappropriate Medications in Hospitalized Older Patients in Tabuk, Saudi Arabia Using 2023 Beers Criteria: A Retrospective Multi-Centric Study

Purpose

Older persons are frequently prescribed several medications; therefore, inappropriate medication prescriptions are common. Prescribing potentially inappropriate medications (PIMs) poses a serious risk and hence, we aimed to assess the PIMs in older patients in Tabuk, using the 2023 Beers criteria.

Patients and Methods

A retrospective cross-sectional study was carried out, including older persons ≥65 years of age admitted in two government hospitals from June 2022 to May 2023, and prescribed with five or more medications. PIMs were assessed using the 2023 Beers criteria. Descriptive analysis was performed for the categorical and continuous variables. Logistic regression was used to assess the influence of age, gender, number of medications and comorbidities on PIMs using SPSS version 27.

Results

The study included 420 patients. The mean age of the participants was 75.52 ± 8.70 years (range, 65-105 years). There was a slightly higher proportion of females (52%). The prevalence of PIMs was 81.43%, where 35.41% were prescribed one PIM, 26.48% were prescribed two PIMs, and 17.32% were prescribed three PIMs. The proportion of medications considered potentially inappropriate among older patients was 70.11%, and proton pump inhibitors were the most commonly prescribed medication (52.99%). The proportion of medications to be used with caution was 19.55%, with diuretics being the most frequently administered medication (91.43%). Gender and comorbidity did not influence PIMs, but age and number of medications significantly influenced the likelihood of PIMs.

Conclusion

PIMs are prevalent among older people and are significantly associated with age and multiple medications. Caution should be exercised while prescribing medications to older persons. Frequent audits should be performed to assess PIMs, and clinicians should be informed of the same to avoid serious outcomes associated with PIMs. Interventions designed to reduce PIM need to be initiated.

Polypharmacy, Potentially Inappropriate Medications, and Dysphagia in Older Inpatients: A Multi-Center Cohort Study

BACKGROUND

Although the relationship between medication status, symptomatology, and outcomes has been evaluated, data on the prevalence of polypharmacy and potentially inappropriate medications (PIMs) and the association of polypharmacy and PIMs with swallowing function during follow-up are limited among hospitalized patients aged ≥65 years with dysphagia.

METHODS

In this 19-center cohort study, we registered 467 inpatients aged ≥65 years and evaluated those with the Food Intake LEVEL Scale (FILS) scores ≤8 between November 2019 and March 2021. Polypharmacy was defined as prescribing ≥5 medications and PIMs were identified based on the 2023 Updated Beers Criteria. We applied a generalized linear regression model to examine the association of polypharmacy and PIMs with FILS score at discharge.

RESULTS

We analyzed 399 participants (median age, 83.0 years; males, 49.8%). The median follow-up was 51.0 days (interquartile range, 22.0-84.0 days). Polypharmacy and PIMs were present in 67.7% of and 56.1% of patients, respectively. After adjusting for covariates, neither polypharmacy (β = 0.05; 95% confidence interval [CI], -0.04-0.13, p=0.30) nor non-steroidal anti-inflammatory medications (β = 0.09; 95% CI, -0.02-0.19; p=0.10) were significantly associated with FILS score at discharge.

CONCLUSION

The results of this study indicated a high proportion of polypharmacy and PIMs among inpatients aged ≥65 years with dysphagia. Although these prescribed conditions were not significantly associated with swallowing function at discharge, our findings suggest the importance of regularly reviewing medications to ensure the appropriateness of prescriptions when managing older inpatients.

Association between changes in potentially inappropriate medication use and adverse outcomes during hospitalization in older adults: A retrospective study

PURPOSE

To evaluate the association between the change in the number of PIMs in older adults during hospitalization and adverse outcomes.

METHODS

This retrospective cohort study was conducted in the internal medicine wards of a tertiary teaching hospital between May and December 2017. 3,460 patients (77.5±8.4 years, 60.4% male) were enrolled, and 206 patients died during hospitalization. PIMs were defined using the Beers Criteria as suggested by the American Geriatrics Society. Adverse outcomes studied were functional decline (a loss in 1 or more activities of daily living from admission to discharge), prolonged length of stay (LOS) (≥14 days), and mortality.

RESULTS

2258 patients (65.3%) had increasing PIMs during hospitalization. They tended to be younger (77.0±8.3 versus 78.5±8.5 years, p<0.001) and had lower numbers of PIMs at admission (0.4±0.8 versus 0.8±1.1, p<0.001). Increasing PIM use was strongly associated with greater functional decline (aOR 1.36, 95%CI 1.01-1.67, p=0.005), prolonged LOS (aOR 3.47, 95%CI 2.71-4.44, p<0.001) and higher mortality rate (aOR 2.68, 95%CI 1.75-4.12, p<0.001), even after adjusting for all covariates. We observed a strong association between adverse outcomes and increasing PIMs in older adults during hospitalization (p for trend <0.001).

CONCLUSIONS

Older adults with increasing PIMs during hospitalization were at greater risk for functional decline, prolonged LOS, and mortality, especially in those with three or more PIMs. Further studies are needed to better understand the complex interactions and to evaluate the effectiveness of intervention programs to lower PIM number and improve discharge outcomes for patients who had increasing PIM use during hospitalization.

Transitions of Care: Strategies for Medication Optimization and Deprescribing in Older Adults

Older adults have an increased risk of adverse drug events related to polypharmacy and potentially inappropriate medication (PIM) use. These patients are even more vulnerable as they transition through different health care settings. In 2023, the American Geriatrics Society published an updated version of the Beers Criteria®, providing updated guidance on identifying and managing PIMs. Nurses and nurse practitioners play important roles in medication management across the continuum of care. The current article aims to illustrate key concepts regarding medication safety and deprescribing for older adult patients during transitions of care. [Journal of Gerontological Nursing, 49(12), 5-10.].

Health care system costs related to potentially inappropriate medication use involving opioids in older adults in Canada

BACKGROUND

Older adults are at risk of potentially inappropriate medication use given polypharmacy, multimorbidity, and age-related changes, which contribute to the growing burden associated with opioid use. The objective of this study was to estimate the costs of health service utilization attributable to opioid use and potentially inappropriate medication use involving opioids in older adults in a public health care system.

METHODS

The sample included 1201 older adults consulting in primary care, covered by the public drug plan, without a cancer diagnosis and opioid use in the year before interview. Secondary analyses were conducted using two data sources: health survey and provincial administrative data. Health system costs included inpatient and outpatient visits, physician billing, and medication costs. Unit costs were calculated using annual financial and activity reports from 2013-2014, adjusted to 2022 Canadian dollars. Opioid use and potentially inappropriate medication use involving opioids were identified over 3 years. Generalized linear models with gamma distribution were employed to model 3-year costs associated with opioid use and potentially inappropriate medication use involving opioids. A phase-based approach was implemented to provide descriptive results on the costs associated with each phase: i) no use, ii) opioid use, and iii) potentially inappropriate medication use involving opioids.

RESULTS

Opioid use and potentially inappropriate medication use involving opioids were associated with adjusted 3-year costs of $2,222 (95% CI: $1,179-$3,264) and $8,987 (95% CI: $7,370-$10,605), respectively, compared to no use. In phase-based analyses, costs were the highest during inappropriate use.

CONCLUSIONS

Potentially inappropriate medication use involving opioids is associated with higher costs compared to those observed with opioid use and no use. There is a need for more effective use of health care resources to reduce costs for the health care system.

Potentially inappropriate medications and polypharmacy in the older population: A nationwide cross-sectional study in France in 2019

AIM OF THE STUDY

To assess the prevalence of potentially inappropriate medications (PIMs) and polypharmacy in adults aged 75 years and over in France in 2019 based on data from the French health insurance claims database, at the national level and by region.

METHODS

We conducted a cross-sectional study in French adults aged 75 years or over in 2019. We assessed the prevalence of seventeen PIM criteria adapted from the 2015 Beers and STOPP lists, as well as cumulative polypharmacy. Polypharmacy (5 to 9 drugs) and hyper-polypharmacy (≥10 drugs) were defined as the average number of drugs dispensed per quarter. The regional analysis used the age- and sex-standardized prevalence.

RESULTS

Of 6,707,897 older adults, 39.6% were exposed to at least one PIM in 2019, 46.7% were exposed to polypharmacy (5 to 9 drugs), and 25.2% to hyper-polypharmacy (≥10 drugs). Benzodiazepine PIMs were the most frequent (26.9%), followed by atropinic PIMs (8.3%), non-steroidal anti-inflammatory PIMs (7.8%), concomitant use of three or more central nervous system-active drugs (7.3%), and antihypertensive PIMs (6.0%). There was a gradient in the level of exposure to PIMs according to the level of polypharmacy for every PIM category. We observed regional variations in PIM prevalence, from 36.5% in Pays-de-la-Loire to 44.8% in Hauts-de-France in mainland France.

CONCLUSION

These results show that PIMs concerned more than one in three older adults after age 75 years in France in 2019 and support the need to secure medication use in this population. The reasons for geographic variations in PIM prevalence should be investigated in further studies.

Gender Differences in Potentially Inappropriate Medication Use among Older Adults

BACKGROUND

Use of potentially inappropriate medication (PIMs) is a prominent concern that leads to significant medication-related issues among older adults. Notably, older women tend to utilize more medicines than men; older women frequently take more drugs. In addition, some evidence suggests that prescription PIMs vary by gender. This study examines the gender-based variation in prescribing PIM among older adults in Saudi Arabia.

METHODS

A cross-sectional retrospective analysis of electronic medical records from a large hospital in Saudi Arabia was carried out. Patients over the age of 65 who received ambulatory treatment were included in the study. The utilization of PIM was assessed based on Beers criteria. Descriptive statistics and logistic regression were employed to describe patterns of PIM utilization and identify factors associated with their use. All statistical analyses were performed using Version 9.4 of the Statistical Analysis Software (SAS^® 9.4).

RESULTS

The study comprised 4062 older people (age 65) who visited ambulatory care clinics; the average age was (72.6 ± 6.2) years. The majority of the study sample was women (56.8%). Among older adults, 44.7% of older men and 58.3% of older women reported having PIMs that should be avoided, indicating a higher prevalence of PIMs among women compared to men. In terms of the PIM categories used, women had a much higher utilization rate of cardiovascular and gastrointestinal drugs than men. In men, the use of PIMs was frequently associated with hypertension, ischemic heart disease, asthma, osteoarthritis, and cancer, while in women PIM use was associated with age, dyslipidemia, chronic kidney disease, and osteoporosis.

CONCLUSIONS

This study revealed sex differences in PIM prescribing among older adults; PIM use is more common among women. Sex differences exist in clinical and socioeconomic characteristics and factors related to using potentially inappropriate medications. This study revealed essential areas that could be targeted by further interventions to improve drug-prescribing practices among older adults at risk of PIM.

Explicit potentially inappropriate medications criteria for older population in Asian countries: A systematic review

BACKGROUND

Explicit potentially inappropriate medications (PIM) criteria are commonly used to identify and deprescribe potentially inappropriate prescriptions among older patients. Most of these criteria were developed specifically for the Western population, which might not be applicable in an Asian setting. The current study summarizes the methods and drug lists to identify PIM in older Asian people.

METHODS

A systematic review of published and unpublished studies were carried out. Included studies described the development of explicit criteria for PIM use in older adults and provided a list of medications that should be considered inappropriate. PubMed, Medline, EMBASE, Cochrane CENTRAL, CINAHL, PsycINFO, and Scopus searches were conducted. The PIMs were analyzed according to the general conditions, disease-specific conditions, and drug-drug interaction classes. The qualities of the included studies were assessed using a nine-point evaluation tool. The kappa agreement index was used to evaluate the level of agreement between the identified explicit PIM tools.

RESULTS

The search yielded 1206 articles, and 15 studies were included in our analysis. Thirteen criteria were identified in East Asia and two in South Asia. Twelve out of the 15 criteria were developed using the Delphi method. We identified 283 PIMs independent of medical conditions and 465 disease-specific PIMs. Antipsychotics were included in most of the criteria (14/15), followed by tricyclic antidepressants (TCAs) (13/15), antihistamines (13/15), sulfonylureas (12/15), benzodiazepines (11/15), and nonsteroidal anti-inflammatory drug (NSAIDs) (11/15). Only one study fulfilled all the quality components. There was a low kappa agreement (k = 0.230) between the included studies.

CONCLUSION

This review included 15 explicit PIM criteria, which most listed antipsychotics, antidepressants, and antihistamines as potentially inappropriate. Healthcare professionals should exercise more caution when dealing with these medications among older patients. These results may help healthcare professionals in Asian nations to create regional standards for the discontinuation of potentially harmful drugs for elderly patients.

Considering pharmacoequity when deprescribing potentially inappropriate medications

This editorial comments on the article by Niznik et al. in this issue.

Potentially inappropriate medications use in a psychiatric elderly care hospital: A cross-sectional study using Beers criteria

Background and Aims

Potentially inappropriate medications (PIMs) carry risks that outweigh any potential benefits when compared to safer or more effective alternative treatments. Adverse drug events are more likely to occur in older adults with psychiatric diseases due to multimorbidity, polypharmacy, and age-related changes in drug pharmacokinetics and pharmacodynamics. The aim of this study was to assess the prevalence and risk factors of PIM use in an aged care hospital's psychogeriatric division, using the American Geriatrics Society Beers criteria 2019.

Methods

This cross-sectional study was conducted on all current inpatients, having a mental disorder and aged ≥65 years, in one elderly care hospital in Beirut, from March to May 2022. Medications, sociodemographic and clinical characteristics were collected from patients' medical records. PIMs were evaluated based on Beers criteria 2019. Independent variables were described using descriptive statistics. Factors associated with PIM use were identified by bivariate analysis followed by binary logistic regression. A two-sided p value <0.05 was considered statistically significant.

Results

The study included 147 patients, with a mean age of 76.3 years, 46.9% of them having schizophrenia, 68.7% using 5 or more drugs and 90.5% taking at least 1 PIM. The most prescribed PIMs were antipsychotics (40.2%), anticholinergics (16%), and antidepressants (7.8%). PIM use was significantly associated with polypharmacy (AOR = 20.88, 95% CI: 1.22-357.87, p = 0.04) and anticholinergic cognitive burden (ACB) score (AOR = 7.25, 95% CI: 1.13-46.52, p = 0.04).

Conclusion

PIMs were highly prevalent among hospitalized Lebanese psychiatric elderly. Polypharmacy and ACB score were the determinants of PIM use. A multidisciplinary medication review led by a clinical pharmacist could reduce PIM use.

Predictors of Receipt of Comprehensive Medication Reviews in Older Adults

BACKGROUND

Polypharmacy is highly prevalent among older adults. This study's purpose was to provide nationally representative estimates of self-reported comprehensive medication review (CMR) receipt among older adults and describe factors associated with their receipt, as CMRs are available through the Medicare Part D program.

METHODS

This cross-sectional study used data from the National Poll on Healthy Aging (NPHA), a nationally representative online survey of community-dwelling adults aged 50-80, administered in December 2019. Participants included older adults aged 65-80 with any health insurance (n = 960). Outcomes were self-reported CMR receipt, awareness of CMR insurance coverage, and interest in a future CMR with a pharmacist. Sociodemographic and health-related variables were included. Descriptive statistics and multivariable logistic regression with NPHA population sampling weights were used.

RESULTS

Among older adults on 2 or more prescription medications, only 20.8% had received a CMR while 34.3% were interested in a future CMR. Among individuals who had not received a CMR, most (83.4%) were unaware their insurance might cover a CMR. Factors associated with higher odds of receiving a CMR included taking 5 or more prescription medications (adjusted odds ratio [AOR] = 2.6, 95% CI: 1.59-4.38) and reporting food insecurity (AOR = 2.9, 95% CI: 1.07-7.93). Having fair or poor self-reported physical health was associated with lower odds of receiving a CMR (AOR = 0.49, 95% CI: 0.25-0.97).

CONCLUSIONS

Most older adults on 2 or more prescription medications with health insurance had not received a CMR and many were interested in one. Targeted strategies to increase older adults' awareness and receipt of CMRs are warranted.

Potentially inappropriate medications in geriatric blood or marrow transplantation (BMT) survivors: A BMT Survivor Study report

BACKGROUND

Blood or marrow transplantation (BMT) is increasingly offered to older individuals with hematologic malignancies. The high prevalence of chronic health conditions in such individuals necessitates use of multiple medications. Beers Criteria represent a list of potentially inappropriate medications (PIMs) shown to increase the risk of health problems in the elderly. We sought to determine the prevalence and predictors of PIM use in older BMT survivors and identify associations with health problems.

METHODS

Study participants were drawn from the BMT Survivor Study, a cohort study of patients transplanted at three US transplant centers between 1974 and 2014 and surviving ≥2 years. For this report, the survivors were aged ≥65 years. Siblings served as a comparison group. Participants self-reported sociodemographics, chronic health conditions, and medication use. Logistic regression analyses identified predictors of PIM use and associations with health problems.

RESULTS

Overall, PIM use was comparable between BMT survivors (49.4%) and siblings (49.3%) (odds ratio [OR] = 0.9; 95% CI, 0.7-1.2); however, BMT survivors were more likely to use >1 PIM (17.4% vs. 12.4%; OR = 1.5; 95% CI, 1.01-2.4) and central nervous system-related PIMs (8.3% vs. 4.3%; OR = 2.18; 95% CI, 1.17-4.09). Predictors of PIM use included presence of severe/life-threatening chronic health conditions (OR = 1.5; 95% CI, 1.1-2.0), and chronic graft versus host disease (OR = 1.7; 95% CI, 1.1-2.7). Survivors taking >1 PIM reported more issues with vertigo (OR = 2.3; 95% CI, 1.1-4.7), balance (OR = 2.6; 95% CI, 1.7-4.1), faintness/dizziness (OR = 2.8; 95% CI, 1.8-4.6), and personal care (OR = 4.5; 95% CI, 1.4-14.8).

CONCLUSIONS

This study shows the health problems associated with PIM use and identifies vulnerable populations at higher risk for PIM use, providing evidence for caution in using PIMs in high-risk populations.

The association of potentially inappropriate medications, polypharmacy and anticholinergic burden with readmission and emergency room revisit after discharge: A hospital-based retrospective cohort study

AIMS

While certain drug-use indicators are known to be associated with clinical outcomes, the relationship is unclear for some highly prevalent conditions in in patients aged ≥65 years. We examine correlations between 3 drug-use indicators and postdischarge healthcare services use by older patients according to the presence of dementia, advanced age and frailty.

METHODS

This retrospective cohort study analysed data collected from hospital electronic health records between April and December 2017. Potentially inappropriate medications (PIMs) and anticholinergic burden were assessed using the 2015 Beers Criteria and anticholinergic cognitive burden scale (ACBS) score. Minor and major polypharmacy were defined as the use of 5-9 and ≥10 drugs, respectively. Outcomes were set as emergency room revisits and readmissions at 1, 3 and 6 months postdischarge. The correlation between drug-use indicators and outcomes was analysed by multivariable logistic regression.

RESULTS

The final cohort included 3061 patients for the analysis, and 2930, 2671 and 2560 patients were followed up to 1, 3 and 6 months after discharge. After controlling for confounders, all 3 drug-use indicators were significantly associated with readmission and emergency room revisits except for the relationship between PIMs and readmission within 6 months. These associations were significantly observed among patients without dementia, aged >80 years and with frailty.

CONCLUSION

PIMs, polypharmacy and anticholinergic burden are common at discharge and correlate with future use of healthcare services. In older patients, the absence of dementia, advanced age and frailty should be given extra consideration with regard to medication safety.

Enhancing the quality of prescribing practices for older adults discharged from the emergency department in Rhode Island

BACKGROUND

We sought to examine the effectiveness of the Enhancing the Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department (EQUiPPED) medication safety program in three emergency departments (EDs) within the largest health system in Rhode Island (RI) with funding through a quality incentive payment by a private insurance partner.

METHODS

This study utilized a quasi-experimental interrupted time series design to implement EQUiPPED, a three-prong intervention aimed at reducing potentially inappropriate medication (PIM) prescriptions to 5% or less per month. We included clinicians who prescribed medications to older ED patients during the pre-and post-intervention periods from July 2018 to January 2021. We determined the monthly rate of PIM prescribing among older adults discharged from the ED, according to the American Geriatrics Society Beers Criteria, using Poisson regression.

RESULTS

247 ED clinicians (48% attendings [n = 119], 27% residents [n = 67], 25% advanced practice providers [n = 61]) were included in EQUiPPED, of which 92% prescribed a PIM during the study period. In the pre-implementation period (July 2018-July 2019) the average monthly rate of PIM prescribing was 9.30% (95% CI: 8.82%, 9.78%). In the post-implementation period (October 2019-January 2021) the PIM prescribing rate decreased significantly to 8.62% (95% CI: 8.14%, 9.10%, p < 0.01). During pre-implementation, 1325 of the 14,193 prescribed medications were considered inappropriate, while only 1108 of the 13,213 prescribed medications in post-implementation were considered inappropriate. The greatest reduction was observed among antihistamines, skeletal muscle relaxants, and benzodiazepines.

CONCLUSIONS

EQUiPPED contributed to a modest improvement in PIM prescribing to older adults among clinicians in these RI EDs even in the midst of the COVID-19 pandemic. The quality incentive funding model demonstrates a successful strategy for implementation and, with greater replication, could shape national policy regarding health care delivery and quality of care for older adults.

Physicians’ Knowledge, Altitudes, and Perceived Barriers of Inappropriate Prescribing for Older Patients in Shanghai, China

Background: Inappropriate medication use is common around the world, particularly among older patients, and, despite potentially being preventable, often leads to adverse clinical and economic outcomes. However, there is a dearth of information regarding this prominent issue in China.

Objectives: To evaluate the extent to which the physician can correctly identify potentially inappropriate medication (PIM) in older patients and to understand physicians’ attitudes towards improving PIM knowledge.

Methods: An online, cross-sectional survey was conducted anonymously among practicing physicians in China from November through December 2020. Knowledge of PIM was accessed using seven clinical vignettes covering a wide variety of therapeutic areas. Source of information and perceived barriers regarding PIM were also evaluated. We performed the ordinary least square regression analysis to understand the potential factors related to physicians’ knowledge of PIM.

Results: A total of 597 study participants were included in the analysis. More than half of them had never heard of any screening tool for PIMs (n = 328, 54.9%) and the most frequently acknowledged tool was the China PIM Criteria (n = 259, 43.4%). For the seven clinical vignettes testing physicians’ knowledge on the medications that should be generally avoided in older patients, the mean score was 2.91 points out of 7 (SD: 1.32), with the median score of three points (IQR: 2–4). Only one-third of the respondents were feeling confident when prescribing for older patients (n = 255, 35.08%). Package inserts have been used as the major source of PIM information (always, n = 177, 29.65%; frequently, n = 286, 47.91%). Perceived barriers to appropriate prescribing include polypharmacy (n = 460, 77.05%), lack of formal education on prescribing for the older patients (n = 428, 71.69%).

Conclusion: In this online survey evaluating physicians’ ability to detect PIM for older patients, approximately 40% of PIM were recognized, suggesting an insufficient level of knowledge about appropriate prescribing.

Risk factors for potentially inappropriate medication use in older adults: a cohort study

BACKGROUND

Much of the knowledge on the use of potentially inappropriate medications (PIM) in older adults is derived from cross-sectional studies, with little known about the risk factors over time.

AIM

Longitudinal analysis was applied to estimate the occurrence and risk factors of PIM use among older adults in a 10-year follow-up.

METHOD

Longitudinal study with 418 older adult residents of a capital city of Central-West Brazil. The PIM were classified according to the Beers criteria 2019. The usage rate was calculated at baseline (2008) and at the 10-year follow-up moment (2018). Analysis of predictors (sociodemographic, self-rated health, hospitalization, number of comorbidities, polypharmacy, diabetes, hypertension, hypercholesterolemia and nutritional status) was performed using Generalized Estimating Equation (GEE) models.

RESULTS

Mean age at baseline was 70.6 years (SD 7.1) and 76% were women; 221 older adults took part in the follow up. The rate of PIM use was 50.4% at baseline and 57.5% at the 10-year follow-up. Multiple analysis showed that PIM use in the cohort was statistically higher in the older adults with a history of hospitalization (RR_adj 1.20; 95% CI 1.01-1.40), with three or more diseases (RR_adj 1.41; 95% CI 1.14-1.74), with polypharmacy (RR_adj 1.81; 95% CI 1.47-2.24) and with diabetes mellitus (RR_adj 1.24; 95% CI 1.05-1.47).

CONCLUSION

A high level of potentially inappropriate medication use was observed, reaching 50% of the older adults, with a 7% increase in the prevalence over the 10-year follow-up period. Hospitalization, multimorbidities, polypharmacy and diabetes mellitus were associated with the use of these medications. Interventions for surveillance of the deprescribing process need to be encouraged to avoid potential harm caused by the use of medications.

The Effectiveness of Interventions to Evaluate and Reduce Healthcare Costs of Potentially Inappropriate Prescriptions among the Older Adults: A Systematic Review

Potentially inappropriate prescribing (PIP) is associated with an increased risk of adverse drug reactions, recognized as a determinant of adherence and increased healthcare costs. The study's aim was to explore and compare the results of interventions to reduce PIP and its impact on avoidable healthcare costs. A systematic literature review was conducted according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement guidelines. PubMed and Embase were queried until February 2021. Inclusion criteria followed the PICO model: older patients receiving PIP; Interventions aimed at health professionals, structures, and patients; no/any intervention as a comparator; postintervention costs variations as outcomes. The search strategy produced 274 potentially relevant publications, of which 18 articles met inclusion criteria. Two subgroups were analyzed according to the study design: observational studies assessing PIP frequency and related-avoidable costs (n = 10) and trials, including specific intervention and related outcomes in terms of postintervention effectiveness and avoided costs (n = 8). PIP prevalence ranged from 21 to 79%. Few educational interventions carried out to reduce PIP prevalence and avoidable costs resulted in a slowly improving prescribing practice but not cost effective. Implementing cost-effective strategies for reducing PIP and clinical and economic implications is fundamental to reducing health systems' PIP burden.

Healthcare Costs Associated with Potentially Inappropriate Medication Prescribing Detected by Computer Algorithm Among Older Patients

INTRODUCTION

Potentially inappropriate medication prescribing (PIP) among older patients is associated with an increased risk of adverse events and hospitalization, and sometimes increased healthcare costs.

OBJECTIVE

The aim of this study was to explore the association between healthcare costs and PIP exposure among older patients.

METHODS

Analyses were conducted using data from the Multidomain Alzheimer Preventive Trial (MAPT). A computer algorithm was constructed to detect PIP based on various different explicit criteria-based tools, and the results were expressed in number of medication-related potential non-compliances (MRNCs). A prescription was considered potentially inappropriate if there were one or more MRNCs. We performed a cost analysis from the French National Health Insurance perspective, and also performed a multivariate analysis to identify the association between healthcare costs and PIP (number of MRNCs).

RESULTS

The computer algorithm analyzed medication prescribing from included patients (N = 1525 aged 75.3 ± 4.4 years; 64% women [n = 978]). PIP was associated with increased total healthcare costs and non-medication healthcare costs after adjusting for potential confounders. We also noted that healthcare costs tended to increase with the number of MRNCs. The mean additional healthcare costs were €517, €921, and €1669 per patient and year for patients with one or two MRNCs, three or four MRNCs, and five or more MRNCs, respectively, in comparison with patients with appropriate medication prescriptions.

CONCLUSION

These observations led us to conclude that interventions focused on reducing PIP could result in savings.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00672685.

Optimizing Older Adults' Medication Use

This article is the third in a series, Supporting Family Caregivers in the 4Ms of an Age-Friendly Health System, published in collaboration with the AARP Public Policy Institute as part of the ongoing Supporting Family Caregivers: No Longer Home Alone series. The 4Ms of an Age-Friendly Health System (What Matters, Medication, Mentation, and Mobility) is an evidence-based framework for assessing and acting on critical issues in the care of older adults across settings and transitions of care. Engaging the health care team, including older adults and their family caregivers, with the 4Ms framework can help to ensure that every older adult gets the best care possible, is not harmed by health care, and is satisfied with the care they receive. The articles in this series present considerations for implementing the 4Ms framework in the inpatient hospital setting and incorporating family caregivers in doing so. Resources for both nurses and family caregivers, including a series of accompanying videos developed by AARP and the Rush Center for Excellence in Aging and funded by The John A. Hartford Foundation, are also provided. Nurses should read the articles first, so they understand how best to help family caregivers. Then they can refer caregivers to the informational tear sheet-Information for Family Caregivers-and instructional videos, encouraging them to ask questions. For additional information, see Resources for Nurses.

Number-dependent association of potentially inappropriate medications with clinical outcomes and expenditures among community-dwelling older adults: a population-based cohort study

AIM

To investigate the prevalence of potentially inappropriate medication (PIM) prescribing and its number-dependent association (PIM=1, 2, ≥3) with all-cause hospitalizations, emergency department (ED) visits, and medication expenditures in Beijing, China.

METHOD

A retrospective cohort analysis was conducted to analyze PIM prescribing in community-dwelling older adults aged ≥ 65 years within the Beijing Municipal Medical Insurance Database (data from July to September 2016). The prevalence of PIMs was estimated based on the 2015 Beers Criteria. Logistic models were utilized to investigate the associations between PIM use and all-cause hospitalizations and ED visits. Generalized linear models with the logic link and gamma distribution were used to analyze associations between PIM use and medication expenditures.

RESULTS

Among the 506,214 older adults, the prevalence of PIM was 38.07%. After adjusting for covariables, prescribing 2 and ≥3 PIMs was associated with increased risks of hospitalizations (PIM=2: OR 1.34, 95%CI: 1.22-1.47; PIM≥3: OR=1.47, 95%CI: 1.32-1.63) and ED visits (PIM=2: OR = 1.29, 95%CI 1.12-1.48; PIM≥3: OR=1.23, 95%CI: 1.04-1.44). Exposures of 2 and ≥3 PIMs were associated with higher medication expenditures for inpatient visits (PIM=2: incidence rate ratio IRR = 1.08, 95%CI 1.01-1.16; PIM≥3: IRR=1.18, 95%CI: 1.08-1.28). Vasodilators were the most frequent PIM prescribing group among patients who ended with hospitalizations or ED visits.

CONCLUSIONS

PIMs were prescribed at a high rate among community-dwelling older adults in Beijing. PIMs ≥2 were associated with increased risks of hospitalizations, ED visits, and increased inpatient medication expenditures. Effective interventions are needed to target unnecessary and inappropriate medications in older adults.

Potentially Inappropriate Medications Use among Older Adults with Comorbid Diabetes and Hypertension in an Ambulatory Care Setting

OBJECTIVE

This study aims to estimate the prevalence of PIMs use and its associated factors among older adults with comorbid diabetes and hypertension.

METHODS

A cross-sectional retrospective study was used, including 1,853 older adults (age ≥65 years) with diabetes and hypertension who visited an ambulatory care setting. The study objectives were to estimate the prevalence and factors associated with PIMs use based on the 2019 American Geriatric Society (AGS) Beers criteria.

RESULTS

Almost one out of two individuals had PIMs used, with the average number of medications taken being seven. The most commonly prescribed PIMs were the use of gastrointestinal and endocrine medications. High risk of PIMs use was among those with ischemic heart disease, anxiety, and polypharmacy.

CONCLUSIONS

Given the higher PIMs use among older adults with diabetes and hypertension comorbidities, tailored strategies and interventions to minimize PIMs use in this population are warranted.

Development of video animations to encourage patient-driven deprescribing: A Team Alice Study

OBJECTIVE

Patient-driven deprescribing initiatives aim to increase patient knowledge and strengthen self-advocacy skills. This article describes the development of three animated videos designed to educate older adults about unsafe prescribing and medication harm, based on the actionable lessons from the death, by polypharmacy, of an older adult in our community.

METHODS

Using a community based participatory research approach (CBPR), members of three senior centers (n = 53) and the Deprescribing Partnership of Western New York (n = 30) were recruited and participated in two rounds of focus groups to guide the video development.

RESULTS

Stakeholder input led to changes in content, wording, and visual presentation. The final versions of the videos emphasize the following messages (1) "New medications and what you should know about the risks", (2) "What you should do when a doctor tells you never to take a certain medication", (3) "What you should know about medications when you are in the hospital."

CONCLUSION

The study highlights the successful process of using CBPR to develop a series of videos designed to provide information on the risks of polypharmacy, and empower older adults to advocate for themselves.

PRACTICE IMPLICATIONS

Animated educational videos are a novel strategy to address medication harm in older adults. This research is a critical first step to increasing patient-led discussions that reduce the incidence of medication harm and inappropriate medication use among older adults.

Potentially inappropriate medications use and its associated factors among geriatric patients: a cross-sectional study based on 2019 Beers Criteria

The aims of this study were to estimate the prevalence of potentially inappropriate medications (PIMs) in a community-dwelling Jordanian population of geriatrics according to the 2019 American Geriatrics Society Beers Criteria, to identify the most used PIMs and factors independently associated with PIMs use.

This was an observational, descriptive, cross-sectional study. The sample population included 386 participants. Data were collected by face-to-face interviews. A total of 2894 medications were evaluated. The prevalence of patients using at least one PIM was 49.2%. The most used PIMs were proton pump inhibitors (24.6%) and long-acting sulfonylurea (20.5%). Participants who had diabetes mellitus, peptic ulcer, or irritable bowel syndrome had significantly higher numbers of PIMs.

The use of PIMs was high in Jordanian geriatric patients. The results of this study might help healthcare providers to detect high-risk patients and reconsider the necessity of using PIMs to decrease the risk of adverse drug events.

Prevalence and direct costs of potentially inappropriate prescriptions in France: a population-based study

BACKGROUND

Potentially inappropriate prescriptions (PIPs) in the older population remain a growing public health concern due to the many associated adverse events increasing healthcare service use and health costs. This study aimed to assess the prevalence and direct costs of PIPs in older adults aged ≥65 years in France.

METHODS

A population-based cross-sectional study was conducted in 2017 using a representative sample of the French national healthcare reimbursement system database. PIPs were defined using the French REMEDI[e]S tool. Overall reimbursed direct costs and by PIP category were extrapolated to the French older population.

RESULTS

The overall PIP prevalence was estimated at 56.7% (95% CI: 56.4-57.0). Medications with an unfavorable benefit/risk ratio had the highest prevalence (34.0%, 95% CI: 33.7-34.3). Direct costs associated with PIPs represented 6.3% of the total reimbursed medication costs in 2017 (€507 million). Drug duplications were the main contributors to these costs (39.2% of the total reimbursed PIP costs, €199 million) and among all PIPs, proton pump inhibitors (>8 weeks) were the most expensive PIPs (€152 million).

CONCLUSIONS

PIP prevalence is still high among French older adults, with substantial direct costs. Large-scale interventions targeting the most prevalent and/or costly PIPs are needed to reduce their clinical and economic impacts.