Potentially inappropriate drug prescribing among first-visit elderly outpatients in Taiwan

STUDY OBJECTIVE: To determine the prevalence and risk factors of potentially inappropriate drug prescribing among first-visit elderly outpatients. DESIGN: Cross-sectional survey. SETTING: An urban tertiary care and academic medical center in southern Taiwan. PATIENTS: Eight hundred eighty-two patients aged 65 years or older who were prescribed drugs at their first visit to either the medical center's outpatient internal medicine clinic or family medicine clinic between March 1, 2001, and July 31, 2001. MEASUREMENTS AND MAIN RESULTS: Potentially inappropriate drug prescribing was assessed according to updated Beers criteria. Ninety-seven potentially inappropriate drugs were identified in 93 (10.5%) patients. The most common classes were sedative-hypnotics (18.6%) and muscle relaxants (17.5%). Twenty (20.6%) of these inappropriate drugs had a high severity potential according to the Beers criteria. Patients prescribed potentially inappropriate drugs were more likely to be prescribed several drugs versus those who were not prescribed potentially inappropriate drugs (4.0+/-1.9 vs 2.8+/-1.4, p<0.001). Multiple logistic regression analysis revealed an interaction between age and the number of prescribed drugs on the risk of having potentially inappropriate drugs prescribed. In patients who were prescribed four agents or less, the risk was not associated with increasing age; in those who were prescribed five drugs or more, the risk was positively associated with increasing age. CONCLUSION: Potentially inappropriate drug prescribing among first-visit elderly outpatients was relatively low. Increasing patient age combined with increased number of drugs prescribed was associated with increased risk of having potentially inappropriate drugs prescribed.     

Assessing potentially inappropriate prescribing in the elderly Veterans Affairs population using the HEDIS 2006 quality measure

BACKGROUND: Studies have found that 20% to 25% of older patients receive drugs identified as inappropriate by the 1997 Beers criteria. After the addition of 22 new drugs to the 2003 Beers criteria, the National Committee on Quality Assurance convened an expert consensus panel to identify which drugs from the 2003 Beers criteria should always be avoided in the elderly. The resulting list of drugs to avoid was added to the 2006 Health Plan Employer Data and Information Set (HEDIS) to measure the quality of prescribing for the elderly. OBJECTIVE: To use HEDIS 2006 criteria to determine the rate of potentially inappropriate prescribing in the elderly (PIPE) and to determine if patient risk factors are similar to those found using Beers criteria. METHODS: This cross-sectional database study identified older patients receiving drugs included in the HEDIS 2006 criteria using national data from the Veterans Health Administration. Patients aged 65 years or older on October 1, 1999, with at least 2 outpatient visit days during fiscal year 2000, ending September 30, or outpatient visits in fiscal years 1999 and 2000 were included (N=1,096,361). Multivariable logistic regression analyses stratified by gender identified patient characteristics associated with increased risk of HEDIS 2006 drug exposure. Since oral estrogens were considered appropriate at the time of this study, they were excluded from the list of HEDIS 2006 drugs. RESULTS: Overall, 19.6% of older veterans were exposed to HEDIS 2006 drugs. 23.3% of older veteran women and 19.2% of older veteran men. The most commonly prescribed HEDIS 2006 drugs were antihistamines (received by 9.0% of men and 10.7% of women), opioid analgesics (received by 4.6% of men and 5.8% of women), and skeletal muscle relaxants (received by 4.3% of men and 5.3% of women). Propoxyphene was the most commonly used HEDIS 2006 drug, received by 4.5% of men and 5.7% of women, followed by diphenhydramine, received by 3.5% of men and 4.7% of women, and hydroxyzine, received by 3.2% of both men and women. Patients receiving 10 or more medications of any type were at greatest risk of exposure. Men were 8.2 times more likely to receive at least 1 HEDIS 2006 drug than those taking 1 to 3 drugs of any type (95% confidence interval [CI], 8.0-8.4), while women were 9.6 times more likely (95% CI, 8.2-11.2). CONCLUSIONS: Even though we included a slightly different list of drugs to avoid, results for the HEDIS 2006 measure were similar to those of the 1997 Beers criteria. The HEDIS 2006 drugs are commonly prescribed, and there is a distinct need for direct evidence linking HEDIS 2006 PIPE exposure to adverse patient outcomes. To reduce PIPE, it seems necessary to provide additional evidence for clinicians through the conducting of a well-designed study to assess patient outcomes associated with PIPE exposure as defined by the HEDIS criteria.     

The treatment of chronic constipation in elderly people: an update

Constipation is a common problem in elderly persons, with prevalence ranging from 15% to 20% in the community-dwelling elderly population and up to 50% in some studies of nursing home residents. In these patients, constipation results from a combination of risk factors, such as reduced fibre and fluid intake, decreased physical activity resulting from chronic diseases and multiple medications. Despite the high prevalence of constipation, there is surprisingly little evidence available on which to base management decisions of this common condition.Increased fluid intake, regular physical activity and high fibre intake are usually proposed as first step nonpharmacological measures. However, adherence to these measures is limited and pharmacological treatment is frequently required. Data are too limited, especially in elderly persons, to formally recommend one class of laxatives over another or one agent over another within each class. However, bulk-forming and osmotic laxatives are usually recommended as first-line agents, even though data on their effectiveness are limited. The need to maintain good hydration is a limitation in the use of bulk-forming laxatives, in particular, in frail elderly patients. In these patients, polyethylene glycol, an osmotic agent, is an attractive alternative. In addition, it has been shown to relieve faecal impaction in frail patients with neurological disease. Its cost and potential danger in patients at high risk for aspiration is, however, a limitation. Stimulant laxatives are considered mainly as an intermittent treatment in patients who do not respond to bulk-forming or osmotic laxatives.Several promising compounds such as the new serotonin 5-HT4 receptor agonists (tegaserod, prucalopride) and neurotrophin-3 (NT3) have not been adequately tested in older individuals. They are not routinely used and their role in the management of constipation in these patients will be more precisely defined in the future. Other treatment options are available (acupuncture, biofeedback, botulinum toxin and surgery), but experience with these interventions in elderly patients is limited and their indications in this population remain to be clarified.Management of constipation in elderly persons depends largely on experience and beliefs. Several new compounds seem promising but will need to be specifically tested in this population before being recommended.     

Prevalence of inappropriate prescribing in primary care

Objective To describe the prevalence of inappropriate prescribing in primary care in Copenhagen County, according to the Medication Appropriateness Index (MAI) and to identify the therapeutic areas most commonly involved. Setting A cross-sectional study was conducted among 212 elderly ( >65 years) polypharmacy patients (five or more different medications) listed to 41 general practitioners (GPs) in the County of Copenhagen. Method Patients exposed to polypharmacy were identified via the database recording the drug subsidy system of Danish pharmacies. For each patient, data were collected on subsidised medications prescribed over 3 months by the patients’ own GPs. The GPs were asked to provide baseline information regarding the patients’ medical history and detailed information regarding the subsidised and non-subsidised medications prescribed to the patients. A MAI was scored for medication prescribed to the patients. Topical, dermatological medications and medications not used regularly were excluded. Results 212 patients were prescribed 1621 medications by their GPs at baseline. In all, 640 (39.5%) of the medications had one or more inappropriate ratings in the 10 criteria making up the MAI. The main part of the patients (94.3%) had one or more inappropriate ratings among their medications. A total of 12.3% of the medications were rated as ‘not indicated’, 6% were rated as ‘ineffective’, 6.7% were given in an incorrect dose, 0.7% were prescribed with incorrect directions, 1.3% had impractical directions, 0.7% of the drugs had clinically significant drug–drug interactions, 8.6% had clinically significant drug–disease/condition interactions, 3.1% were unnecessary duplications, 16.5% were given in an unacceptable duration and 27.1% of the medications were not the least expensive alternative. The therapeutic groups most commonly involved in inappropriate prescribing were medications for treatment of peptic ulcer, cardiovascular medications, anti-inflammatory medications, antidepressants, hypnotics and anti-asthmatics. Conclusion The overall prescribing quality in primary care in Copenhagen County, Denmark is good. However, the majority of patients used one or more medications with inappropriate ratings. The inappropriate prescribing relates to specific therapeutic groups and criteria, which should be targeted in future interventions.     

Combined intervention programme reduces inappropriate prescribing in elderly patients exposed to polypharmacy in primary care

Purpose  To evaluate the effect of a combined or a single educational intervention on the prescribing behaviour of general practitioners (GPs). The primary endpoint was effect on inappropriate prescribing according to the Medication Appropriateness Index (MAI). Methods  General practitioners were randomised to either (1) a combined intervention consisting of an interactive educational meeting plus feedback on participating patients’ medication, (2) a single intervention with an interactive educational meeting or (3) a control group (no intervention). Elderly (>65 years) patients exposed to polypharmacy (≥5 medications) were identified and approached for inclusion. Data on medications prescribed over a 3-month period were collected, and the GPs provided detailed information on their patients before and after the intervention. A pre- and post-MAI were scored for all medications. Results  Of the 277 GPs invited to participate; 41 (14.8%) volunteered. Data were obtained from 166 patients before and after the intervention. Medication appropriateness improved in the combined intervention group but not in the single intervention group. The mean change in MAI and number of medications was −5 [95% confidence interval (CI) −7.3 to −2.6] and −1.03 (95% CI −1.7 to −0.30) in the combined intervention group compared with the group with the educational meeting only and the no intervention group. Conclusions  A combined intervention consisting of an interactive educational meeting plus recommendations given by clinical pharmacologists/pharmacists concerning specific patients can improve the appropriateness of prescribing among elderly patients exposed to polypharmacy. This study adds to the limited number of well-controlled, randomised studies on overall medication appropriateness among elderly patients in primary care. Important limitations to the study include variability in data provided by participating GPs and a low number of GPs volunteering for the study. The trial is not registered in a publicly available database of clinical trials. The trial was conducted in a period prior to June 1, 2007.     

The prevention of maternal deaths: a continuing challenge

This report studies the principal causes of maternal death at Harare Maternity Hospital. In 1983 the maternal mortality rate for the greater Harare unit was 52/100,000 compared to 11.9/100,000 for England and Wales. Puerperal sepsis, hemorrhage, post-abortal sepsis and hypertensive disease accounted for 78.5% of the deaths. 12 of the deaths were due to puerperal sepsis, 8 of which had normal vaginal delivery and 4 were delivered by Caesarian section. 3 patients died within 48 hours of delivery. Hemorrhage was most commonly a result of ruptured uterus. Avoidable factors were considered present in all cases. Delay in diagnosis, availability of blood or performing laparotomy was evident in 4 of 5 who died from ruptured uterus; 2 were due to pulmonary edema from excessive transfusion, and 2 were attributable to the patient (refusal of transfusion, attempt to self abort.) Post-abortal sepsis occurred in 9 patients, most of whom were septicemic on admission. 8 patients died from hypertensive disease, 7 of which were eclamptic. Reduction in mortality has gone from 34% (1976) to 23.7% (1983) for puerperal sepsis and can be affected by encouraging patients to book for antenatal care. An observed increase in hemorrhagic deaths since 1976 may reflect a decreased staff-patient ratio at Harare Maternity Hospital. Post-abortal sepsis mortality has decreased from 32% (1976) to 17.7% (1983). Reduction in deaths from hypertensive disease necessitates prediction and early detection. Value of a post-mortem exam in all cases of maternal death is stressed.     

Potentially inappropriate prescribing in Canada relative to the US

OBJECTIVE: To explore the prescribing of potentially inappropriate drug therapy in Ontario, Canada where there is a restrictive drug formulary relative to the US where there is no single drug formulary. METHODS: A retrospective, cohort study using an administrative database (Ontario, Canada) compared with published survey results (US). All 1,088,680 community-dwelling adults >or=66 years of age in Ontario, Canada compared with published survey results from 2455 community-dwelling older adults in the US in 1996.Patterns of potentially inappropriate drug prescribing were compared between countries using a list of 33 potentially inappropriate drug therapies. These therapies were classified by an expert panel into three categories: (i) those to always avoid; (ii) those which are rarely appropriate; and (iii) those with only some indications to prescribe. RESULTS: Among the 33 potentially inappropriate drug therapies, 15 (45%) prescribed in the US were not available through Ontario's drug formulary. Potentially inappropriate drug therapies available through the Ontario Drug Benefit Plan (ODB) and also in the US were frequently prescribed in both Ontario and the US. Differences in prescribing patterns of individual drug therapies were noted between the two countries. Specifically, in the rarely appropriate category, diazepam, a long half-life benzodiazepine, was much more frequently dispensed in Ontario than in the US (3.18% vs 1.37%). In contrast, dextropropoxyphene, an opioid with a poor adverse event profile was more frequently prescribed in the US than in Ontario (6.21% vs 0.74%). CONCLUSION: Almost half of the potentially inappropriate drug therapies that are available in the US are unavailable from Ontario's drug formulary. Potentially inappropriate drug therapies that were available through the ODB were frequently prescribed in both countries. Alternative approaches that make information immediately accessible to physicians at the time they make prescribing decisions should be considered to improve prescribing practices.     

Treatment of inflammatory bowel disease in the elderly: an update

Inflammatory bowel disease (IBD) is most common in young adults, but it can also present in the elderly. Furthermore, with the aging of the population, the number of elderly patients with IBD is expected to grow. Other conditions, such as diverticulitis and ischaemic colitis, may be more common in the elderly and need to be considered in the differential diagnosis. Management of elderly patients with IBD follows the same principles as in younger patients, with a few exceptions. For patients with mild-to-moderate colitis, a 5-aminosalicylate drug is often used (sulfasalazine, olsalazine, mesalazine, balsalazide). Topical therapy may be sufficient for those with distal colitis, whereas an oral preparation is used for more extensive disease. In those with more severe or refractory symptoms, corticosteroids are used, although the elderly appear to be at increased risk for corticosteroid-associated complications. For patients with corticosteroid-dependent or corticosteroid-refractory disease, immunosuppression with azathioprine or mercaptopurine may help avoid surgery. In patients with Crohn's disease, a similar approach is followed, with the additional consideration that the formulation of drug used must ensure delivery of drug to the site of inflammation. In fistulising Crohn's disease, antibacterials, immunosuppressive drugs, infliximab and surgery are often used in combination. Controlled trials and clinical experience have shown that infliximab is a significant addition to the therapeutic armamentarium for patients with Crohn's disease.