Medication use quality and safety in older adults: 2022 update

Improving the quality of medication use and medication safety are important priorities for healthcare providers who care for older adults. The objective of this article was to identify four exemplary articles with this focus in 2022. We selected high-quality studies from an OVID search and hand searching of major high impact journals that advanced the field of research forward. The chosen articles cover domains related to deprescribing, medication safety, and optimizing medication use. The MedSafer Study, a cluster randomized clinical trial in Canada, evaluated whether patient specific deprescribing reports generated by electronic decision support software resulted in reduced adverse drug events in the 30 days post hospital discharge in older adults (domain: deprescribing). The second study, a retrospective cohort study using data from Premier Healthcare Database, examined in-hospital adverse clinical events associated with perioperative gabapentin use among older adults undergoing major surgery (domain: medication safety). The third study used an open-label parallel controlled trial in 39 Australian aged-care facilities to examine the effectiveness of a pharmacist-led intervention to reduce medication-induced deterioration and adverse reactions (domain: optimizing medication use). Lastly, the fourth study engaged experts in a Delphi method process to develop a consensus list of clinically important prescribing cascades that adversely affect older persons' health to aid clinicians to identify, prevent, and manage prescribing cascades (domain: optimizing medication use). Collectively, this review succinctly highlights pertinent topics related to promoting safe use of medications and promotes awareness of optimizing older adults' medication regimens.     

Medication use quality and safety in older adults: 2020 update

Improving the quality of medication use and medication safety are important priorities for prescribers who care for older adults. The objective of this article was to identify four exemplary articles with this focus in 2020. We selected high-quality studies that moved the field of research forward and were not merely replication studies. The chosen articles cover domains related to deprescribing, medication safety, and optimizing medication use. The first study, a noninferiority randomized clinical trial in England, evaluated whether antihypertensive medication reduction is possible without significant changes in systolic blood pressure control or adverse events over the 12-week follow-up (domain: deprescribing). The second study, a prospective cohort study of women at Kaiser Permanente Southern, California, examined the association between bisphosphonate use and atypical femur fracture (domain: medication safety). The third study examined the effectiveness and safety of a multifaceted antimicrobial stewardship and quality improvement initiative in reducing unnecessary antimicrobial use for unlikely cystitis cases in noncatheterized residents in 25 nursing homes across the United States (domain: optimizing medication use). Lastly, the fourth study, a population-based cohort study in the United Kingdom, examined the association of tramadol use with risk of hip fracture (domain: medication safety). Collectively, this review succinctly highlights pertinent topics related to promoting safe use of medications and promotes awareness of optimizing older adults' medication regimens.     

Risk factors for adverse drug events among older adults in the ambulatory setting

OBJECTIVES: To gather information on patient-level factors associated with risk of adverse drug events (ADEs) that may allow focus of prevention efforts on patients at high risk. DESIGN: Nested case-control study. SETTING: Large multispecialty group practice in New England. PARTICIPANTS: All Medicare enrollees cared for by a multispecialty group practice during 1 year (N=30,397 person-years from July 1, 1999, through June 30, 2000). For each patient with an ADE, a control was randomly selected. MEASUREMENTS: Data were abstracted from medical records on age, sex, comorbidities, and medication use at the time of the event. RESULTS: ADEs were identified in 1,299 older adults. Independent risk factors included being female and aged 80 and older. There were dose-response associations with the Charlson Comorbidity Index and number of scheduled medications. Patients taking anticoagulants, antidepressants, antibiotics, cardiovascular drugs, diuretics, hormones, and corticosteroids were at increased risk. In the analysis of preventable ADEs, the dose-response relationship with comorbidity and number of medications remained. Patients taking nonopioid analgesics (predominantly nonsteroidal antiinflammatory drugs and acetaminophen), anticoagulants, diuretics, and anti-seizure medications were at increased risk. CONCLUSION: Prevention efforts to reduce ADEs should be targeted toward older adults with multiple medical conditions or taking multiple medications, nonopioid analgesics, anticoagulants, diuretics, and antiseizure medications.     

Clin-STAR corner: Practice changing advances in prescribing for geriatric emergency department patients

Reducing adverse drug events among older adults in heterogeneous and often chaotic emergency department (ED) settings requires a multidisciplinary approach. Recent research evaluates the impact of multicomponent protocols designed to reduce ED physician prescribing of potentially inappropriate medications (PIMs), including transdisciplinary training and leveraging electronic health records to provide real-time alternative safer pharmaceuticals while providing personalized feedback to prescribers. Most new research is not randomized trial data. Although this current research does not consistently demonstrate a reduction in the prescribing of PIMs, these studies provide a foundation for emergency medicine healthcare teams, geriatricians, and pharmacists to collaborate with health informatics to continue advancing the frontiers of safer medication prescribing during episodes of acute care.     

Medication Use Quality and Safety in Older Adults: 2018 Update

Improving the quality of medication use and medication safety is an important priority for prescribers who care for older adults. The objective of this article was to identify key articles from 2018 that address these issues. In addition, we selected four of these articles to annotate, critique, and discuss their broader implications for clinical practice. The first study highlights a cluster‐randomized trial that utilized a pharmacist‐led education‐based intervention delivered to both patients and physicians to deprescribe four types of inappropriate medications (sedative‐hypnotics, first‐generation antihistamines, selective nonsteroidal anti‐inflammatory drugs, and glyburide). The second study, a nested case‐control study using data from within the UK Clinical Practice Research Datalink, examined the association between anticholinergic exposure, overall and by anticholinergic medication class, and dementia risk in 40 770 older adults. The third study, a longitudinal cohort study of 1028 Swedish older adults, examined the association between antihypertensive medications and incident dementia. The last study was a randomized, double‐blind, placebo‐controlled trial that investigated the effect of daily low‐dose aspirin (100 mg) for primary prevention on cardiovascular events and major hemorrhage in 19 144 community‐dwelling older adults. Collectively, this current article provides insight into the pertinent topics of medication use quality and safety in older adults and helps raise awareness about optimal prescribing in older adults. J Am Geriatr Soc 67:2458–2462, 2019     

Adverse drug events resulting from patient errors in older adults

OBJECTIVES: To characterize the types of patient-related errors that lead to adverse drug events (ADEs) and identify patients at high risk of such errors. DESIGN: A subanalysis within a cohort study of Medicare enrollees. SETTING: A large multispecialty group practice. PARTICIPANTS: Thirty thousand Medicare enrollees followed over a 12-month period. MEASUREMENTS: Primary outcomes were ADEs, defined as injuries due to a medication, and potential ADEs, defined as medication errors with the potential to cause an injury. The subset of these events that were related to patient errors was identified. RESULTS: The majority of patient errors leading to adverse events (n=129) occurred in administering the medication (31.8%), modifying the medication regimen (41.9%), or not following clinical advice about medication use (21.7%). Patient-related errors most often involved hypoglycemic medications (28.7%), cardiovascular medications (21.7%), anticoagulants (18.6%), or diuretics (10.1%). Patients with medication errors did not differ from a comparison group in age or sex but were taking more regularly scheduled medications (compared with 0-2 medications, odds ratio (OR) for 3-4 medications=2.0, 95% confidence interval (CI)=0.9-4.2; OR for 5-6 medications=3.1, 95% CI=1.5-7.0; OR for >or=7 medications=3.3, 95% CI=1.5-7.0). The strongest association was with the Charlson Comorbidity Index (compared with a score of 0, OR for a score of 1-2=3.8, 95% CI=2.1-7.0; OR for a score of 3-4=8.6, 95% CI=4.3-17.0; OR for a score of >or=5=15.0, 95% CI=6.5-34.5). CONCLUSION: The medication regimens of older adults present a range of difficulties with the potential for harm. Strategies are needed that specifically address the management of complex drug regimens.     

The quality of pharmacotherapy in older veterans discharged from the emergency department or urgent care clinic

OBJECTIVES: To determine the prevalence and type of suboptimal pharmacotherapy that older veterans discharged from the emergency department (ED) or urgent care clinic (UCC) receive and to examine factors associated with suboptimal pharmacotherapy in this population. DESIGN: Retrospective, cohort study. SETTING: An academically affiliated Department of Veterans' Affairs (VA) Medical Center. PARTICIPANTS: Four hundred twenty-one veterans aged 65 and older who were prescribed a new medication at the time of discharge from the ED or UCC. MEASUREMENTS: The primary dependent variable, suboptimal pharmacotherapy, was a composite measure defined as one or more drug-related problems, based on drugs-to-avoid criteria, drug-drug interactions, drug-disease interactions, and failure to satisfy an explicit quality indicator for prescribing or medication monitoring. RESULTS: A total of 757 drugs were prescribed to the 421 patients at the time of discharge from the ED or UCC (mean number+/-standard deviation per patient 1.65+/-1.1). The most frequently prescribed medications were nonsteroidal antiinflammatory drugs (n=59), opioid analgesics (n=47), and fluoroquinolone antibiotics (n=46). Overall, 134 (31.8%) subjects were found to have suboptimal pharmacotherapy with regard to their discharge medications; 49 (11.6%) were prescribed a drug to avoid, 53 (12.6%) received a drug that introduced a new drug-drug interaction, 24 (5.7%) were given a drug that introduced a drug-disease interaction, and 74 (17.6%) did not have a quality indicator satisfied (61% of these evaluated prescribing and 39% evaluated medication monitoring). No consistent associations between patient or visit characteristics and suboptimal pharmacotherapy were identified in multivariable models. CONCLUSION: A substantial number of older adults discharged from the ED or UCC may be at risk for adverse events due to suboptimal prescribing and inadequate medication monitoring. Further study is needed to examine the relationship between suboptimal pharmacotherapy and adverse clinical outcomes.     

Causes of Therapeutic Errors in Older Adults: Evaluation of National Poison Center Data

OBJECTIVES: To evaluate the reasons for unintentional therapeutic errors in older adults, the types of medications most frequently involved, and the medical outcomes related to these adverse drug events.
DESIGN: Retrospective analysis of American Association of Poison Control Center's National Poison Data System (NPDS).
SETTING: NPDS collects data from all U.S. poison centers. Data from 2002 to 2006 were examined.
PARTICIPANTS: Cases involving adults aged 65 and older with a potentially toxic exposure due to unintentional therapeutic errors.
MEASUREMENTS: Hazard factor analysis was conducted to identify medications that pose risk in this population.
RESULTS: There were 140,786 older adults with reported therapeutic errors, of which 49,320 cases were followed to a known medical outcome. A major effect or death occurred in 596 cases (1.2% of cases with known medical outcome). The most common reasons for therapeutic errors were inadvertently took or given medication twice, wrong medication taken or given, and other incorrect dose. The reasons associated with the highest rate of major effect or death were drug interaction, health professional or iatrogenic error, and more than one product containing same ingredient. Certain medication classes such as analgesics, anticoagulants, anticonvulsants, asthma therapies, psychotherapeutics, and some cardiovascular agents were associated with high hazard factors.
CONCLUSION: Poison center data can be used to evaluate therapeutic errors in older adults to identify reasons associated with frequently reported errors, as well as reasons and medications involved with errors that result in serious outcomes. Knowing the reasons why they occur can aid in developing strategies for decreasing unintentional errors in older adults.     

Polypharmacy, adverse drug-related events, and potential adverse drug interactions in elderly patients presenting to an emergency department

STUDY OBJECTIVES: We sought to document the degree of polypharmacy, the frequency of adverse drug-related events (ADREs) leading to emergency department presentation that were recognized by emergency physicians, and the frequency of potential adverse drug interactions (PADIs) in medication regimens of elderly patients in the ED. METHODS: We conducted a retrospective chart review on 300 randomly selected ED visits made by patients 65 years of age and older between January 1 and December 31, 1998. ADREs were defined according to a standardized algorithm. PADIs were identified by using the drug interaction database PharmVigilance. RESULTS: After excluding 17 patient visits with inadequate documentation, 283 were left for review. Of these, 257 (90.8%) patients were taking 1 or more medications (prescribed or over the counter). The number of medications consumed ranged from 0 to 17 and averaged 4.2 (SD+/-3.1) drugs per patient. ADREs accounted for 10.6% of all ED visits in our patient group. The most frequently implicated classes of medications were nonsteroidal anti-inflammatory drugs, antibiotics, anticoagulants, diuretics, hypoglycemics, beta-blockers, calcium-channel blockers, and chemotherapeutic agents. Thirty-one percent of all patients in our group had at least 1 PADI in their medication list. Among patients who presented because of an ADRE, 50% had at least 1 PADI in their medication list that was unrelated to the ADRE with which they presented. CONCLUSION: ADREs are an important cause of ED presentation in the elderly. PADIs are found in a significant proportion of medication lists. Emergency physicians must be vigilant in monitoring elderly patients for medication-related problems.     

Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts

BACKGROUND: Medication toxic effects and drug-related problems can have profound medical and safety consequences for older adults and economically affect the health care system. The purpose of this initiative was to revise and update the Beers criteria for potentially inappropriate medication use in adults 65 years and older in the United States. METHODS: This study used a modified Delphi method, a set of procedures and methods for formulating a group judgment for a subject matter in which precise information is lacking. The criteria reviewed covered 2 types of statements: (1) medications or medication classes that should generally be avoided in persons 65 years or older because they are either ineffective or they pose unnecessarily high risk for older persons and a safer alternative is available and (2) medications that should not be used in older persons known to have specific medical conditions. RESULTS: This study identified 48 individual medications or classes of medications to avoid in older adults and their potential concerns and 20 diseases/conditions and medications to be avoided in older adults with these conditions. Of these potentially inappropriate drugs, 66 were considered by the panel to have adverse outcomes of high severity. CONCLUSIONS: This study is an important update of previously established criteria that have been widely used and cited. The application of the Beers criteria and other tools for identifying potentially inappropriate medication use will continue to enable providers to plan interventions for decreasing both drug-related costs and overall costs and thus minimize drug-related problems.     

Potential adverse drug interactions in the emergency room. An issue in the quality of care

STUDY OBJECTIVE: To determine how often emergency department physicians prescribe medications that can adversely interact with other medications that their patients are already taking, which patients are at highest risk for potential adverse reactions, and which medications most frequently lead to adverse interactions. DESIGN: Survey of elderly persons and other adults seeking care at an emergency department. PATIENTS: Four-hundred twenty-four randomly selected adults seeking care at a university-affiliated hospital emergency department. MEASUREMENTS AND MAIN RESULTS: We evaluated 424 randomly selected visits to a hospital emergency department made by 186 persons over age 65 and 238 younger adults; all of the subjects were discharged without hospital admission. Forty-seven percent of visits led to added medication, and in 10% of the visits in which at least one medication was added, a new medication added a potential adverse interaction. The interactions were determined by a computer program, were reviewed using explicit criteria, and were excluded if of uncertain or trivial clinical significance, rare, or not established for that specific drug. The number of medications used at presentation was the best predictor of whether a potential interaction would be introduced. CONCLUSIONS: In the emergency departments studied, a medication history was recorded on every patient and was available to physicians, but physicians did not routinely screen for potential drug interactions. Further safeguards are needed to protect patients from receiving medications that could produce adverse interactions.     

Analgesic use in the emergency department

The relief of pain is one of the most common reasons for seeking care in an emergency department. We conducted a retrospective chart review to see whether children received analgesic treatment similar to that of adults with the same acute, painful conditions. Charts of 112 pediatric patients from the Children's Hospital of Philadelphia ED and 156 patients from the Medical College of Pennsylvania ED were reviewed. Patient ages ranged from a few months to 97 years. All patients had acute pain due to sickle cell crises (20%), lower-extremity fractures (31%), or second- or third-degree burns (49%). Hospitalization was required in 15% of cases. In the ED, 60% of patients with painful conditions received no pain medication at all. When medications were given, they were usually narcotics. Children (aged 19 years or younger) were much less likely to receive pain medications than adults (P = .001). Those less than 2 years old received analgesics less often than older children (P less than .01). Senior citizens (aged 65 years or older) received analgesics as often as other adults. On discharge from the ED, 55% of all patients had no pain medications prescribed; and children were less likely than adults to receive analgesics at discharge (P less than .001). Pediatricians and emergency physicians are reluctant to use analgesics for children in pain. The data suggest that these physicians need additional education about management of acute pain.     

Outcomes of pain in frail older adults with dementia

OBJECTIVES: To describe the outcomes of pain in cognitively impaired older adults in a Program of All-inclusive Care for older people (PACE) setting and to determine whether pain and psychotropic drug use, behavioral disturbances, hospital, nursing facility, and emergency department use, or mortality increases with the level of pain reported. DESIGN: Retrospective review of an observational cohort of patients with dementia. SETTING: A first-generation PACE program located in Portland, Oregon. Patients with the diagnosis of dementia had been assessed for pain in a prior study. PARTICIPANTS: One hundred fifty-four cognitively impaired subjects. MEASUREMENTS: Standardized pain assessments were administered to cognitively impaired subjects between June and October 1998. After the pain assessment, information about mortality and healthcare use, including use of medication, was collected and analyzed. Subjects who reported moderate to severe pain were compared with demented subjects who reported no or mild pain. RESULTS: There were no differences in patient characteristics (age, sex, functional limitations, disruptive behaviors, and incontinence), medications (pain and psychotropic), use (hospital, nursing home, or emergency department visit), or mortality by level of pain alone or by levels of pain and dementia together. CONCLUSIONS: The study did not demonstrate that a single point-in-time measurement of pain in demented persons was associated with an increased rate of behavioral problems, narcotic use, or hospital or emergency department use over the following year. Prospective studies are needed that measure pain over time to determine more accurately the relationship between pain and negative outcomes in dementia.     

Quality of pharmacotherapy and outcomes for older veterans discharged from the emergency department

OBJECTIVES: To determine whether suboptimal pharmacotherapy increases the risk of adverse outcomes in older adults discharged from the emergency department (ED).
DESIGN: Retrospective, cohort study.
SETTING: Academically affiliated Veterans Affairs Medical Center.
PARTICIPANTS: Nine hundred forty-two veterans aged 65 and older discharged from the ED.
MEASUREMENTS: The primary independent variable, suboptimal pharmacotherapy, was based on drugs-to-avoid criteria, drug–drug interactions, drug–disease interactions, or failure to satisfy explicit quality indicators (QIs). An adverse outcome was defined as one or more repeat ED visits or hospitalizations or death within 90 days of ED discharge.
RESULTS: Four hundred twenty-one patients were prescribed a new medication at ED discharge. Of these, 134 (31.8%) had suboptimal pharmacotherapy; 49 (11.6%) were prescribed a drug to avoid, 53 (12.6%) received a drug that introduced a new drug–drug interaction, 24 (5.7%) were given a drug that introduced a drug–disease interaction, and 74 (17.6%) did not have a QI satisfied. Overall, 320 patients (34.0%) experienced an adverse outcome within 90 days. Multivariable analyses suggested a trend toward greater risk of adverse outcomes in patients with suboptimal pharmacotherapy (hazard ratio=1.32, 95% confidence interval=0.95, 1.84).
CONCLUSION: A substantial number of older male veterans discharged from the ED may be at risk for adverse events due to suboptimal prescribing and inadequate medication monitoring. Efforts to improve the quality of pharmacotherapy in this vulnerable population are warranted.