Application of the Beers Criteria to Alternate Level of Care Patients in Hospital Inpatient Units

Background:

The Beers criteria were developed to help in identifying potentially inappropriate medications (PIMs) for elderly patients. These medications are often associated with adverse events and limited effectiveness in older adults. Patients awaiting an alternate level of care (ALC patients) are those who no longer require acute care hospital services and are waiting for placement elsewhere. They are often elderly, have complex medication regimens, and are at high risk of adverse events. At the time of this study no studies had applied the Beers criteria to ALC patients in Canadian hospitals.

Objectives:

To determine the proportion of ALC patients receiving PIMs and the proportion experiencing selected PIM-related adverse events.

Methods:

A retrospective chart review of ALC patients 65 years of age or older was performed to identify PIMs and the occurrence of selected adverse events (specifically central nervous system [CNS] events, falls, bradycardia, hypoglycemia, seizures, insomnia, gastrointestinal bleeding, and urinary tract infections). A logistic regression model with a random intercept for each patient was constructed to estimate odds ratios and probabilities of adverse events.

Results:

Fifty-two ALC patients were included in the study. Of these, 48 (92%) were taking a PIM. Of the 922 adverse events evaluated, 407 (44.1%) were associated with a regularly scheduled PIM. Among patients who were taking regularly scheduled PIMs, there was a significantly increased probability of an adverse CNS event and of a fall (p < 0.001 for both). The most common PIM medication classes were first-generation antihistamines (24 [46%] of the 52 patients), antipsychotics (21 patients [40%]), short-acting benzodiazepines (15 patients [29%]), and nonbenzodiazepine hypnotics (14 patients [27%]).

Conclusions:

A high proportion of ALC patients were taking PIMs and experienced an adverse event that may have been related to these drugs. These findings suggest that the ALC population might benefit from regular medication review and monitoring to prevent or detect adverse events.     

Influence of Admission to a Tertiary Care Hospital after a Fall on Use of Potentially Inappropriate Medications among Older Patients

Background:

Each year, about one-third of individuals over the age of 65 years will experience a fall, and half of these will experience a subsequent fall in the following year. The use of potentially inappropriate medications (PIMs) is an important factor contributing to increased fall risk in geriatric patients.

Objective:

To determine the proportion of patients over the age of 65 admitted to orthopedics and general medicine services with diagnosis of a fall who experienced a change in the total number or dosage of PIMs, as defined by the Beers criteria, upon discharge from hospital.

Methods:

This retrospective observational study involved patients admitted to a tertiary care hospital with diagnosis of a fall between January 1 and December 31, 2011. Those aged 65 years or older with at least one PIM on admission were eligible for inclusion. Data analysis included χ² and Fisher testing, as well as multivariate analysis.

Results:

A total of 148 patients were included, of whom 63 (43%) had an overall change in the dosage or number of PIMs during their hospital stay. Forty patients (27%) had an overall reduction in the dosage or number of PIMs upon discharge from hospital, whereas 23 (16%) experienced an overall increase in the dosage or total number of PIMs. The mean number (± standard deviation) of PIMs decreased during the hospital stay, from 1.6 ± 0.8 on admission to 1.4 ± 0.9 on discharge (p = 0.03). Benzodiazepines were the class of PIMs most frequently discontinued or reduced in dosage.

Conclusion:

One-quarter of patients admitted with falls had de-escalation of PIMs upon hospital discharge. Although dosage reduction or drug discontinuation may not be appropriate for all patients, a standardized approach to medication review during the hospital stay and improved prescriber education and awareness of PIM use among elderly individuals are warranted.     

Potentially inappropriate medications in geriatric outpatients with polypharmacy: application of six sets of published explicit criteria

AIM

Our aim was to compare the practicability of six different potentially inappropriate medication (PIM) criteria in geriatric outpatients with polypharmacy.

METHODS

We analysed baseline data from the Medication Safety Review Clinic in Taiwanese Elders (MSRC-Taiwan) study. The prevalence and correlates of PIMs were determined on the basis of criteria developed in the USA, Canada, France, Norway, Ireland and Thailand. The percentage of PIMs considered as drug-related problems and the problem-solving rate are reported.

RESULTS

In the 193 participants, the prevalence of PIM varied from 24 to 73%. Application of the criteria revealed that a high number of chronic medications was a common risk factor for having at least one PIM. Of the 1713 medications reviewed, 5.6–14.8% were considered PIMs. Only 30–40% of the identified PIMs were reported as drug-related problems by the MSRC team experts. Criteria with a higher number of statements and a higher percentage of local market/institution drug availability tended to detect more PIMs.

CONCLUSIONS

The prevalence of PIM varied significantly when different criteria were applied. Caution should be exercised in applying PIM criteria developed in other regions when medication availability in the local market is limited.     

Factors associated with potentially inappropriate medications use by the elderly according to Beers criteria 2003 and 2012

Background Potentially inappropriate medications (PIMs) should be avoided by the elderly because they possess a significant high risk for this population when a safer alternative is available. Therefore, the identification of prevalence and factors associated with PIMs should be considered as they provide valuable information that can be used to develop strategies to ensure patients’ safety. Objective To identify the prevalence and the clinical and socioeconomic–demographic factors that may be associated with PIMs use in the elderly, according to Beers criteria 2003 and its updated version 2012. And, as a secondary objective, a comparison between both criteria was performed. Setting Pharmacy of the Basic Health District Unit of the western district of Ribeirão Preto. Methods This cross-sectional observational study was conducted with the elderly, assisted by the Brazilian public health system. Data from patients were collected through a structured interview form. Beers criteria 2003 and 2012 were used to classify PIMs. The association between PIMs used and independent variables were analyzed by odds ratios. The differences between PIMs use according to Beers criteria 2003 and 2012 were analyzed by McNemar’s test and the agreement by kappa coefficient. Main outcome measure Prevalence and factors associated with PIMs use in Brazilian elderly outpatients. Results One thousand elderly patients were interviewed. High prevalence of PIMs use was observed, 48.0 and 59.2 % according to Beers criteria 2003 and 2012, respectively. The factors associated with PIMs use, common for both criteria, are female gender, self-medication, use of over the counter drugs, complaints related to adverse drug event, psychotropic medication, polypharmacy and some categories of drugs. PIMs use is different between Beers criteria 2003 and 2012 (McNemar’s test, p < 0.01), although a substantial agreement between these classifications was observed (kappa coefficient 0.635, 95% confidence intervals (0.588, 0.681). Conclusions Our study showed a high prevalence of PIMs use, which is associated with various clinical and social–demographic factors. When comparing both criteria through McNemar’s test, PIMs use was considered different. The differences may have occurred because medications with high prevalence of use in Brazil were included in Beers criteria 2012 .     

Inappropriate benzodiazepine use in older adults and the risk of fracture

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

• Benzodiazepine use increases the risk of fracture in the elderly.
• It is controversial which conditions of use are most risky, e.g. use of short- or long-acting benzodiazepines, dose and duration of use.
• The well-known Beers criteria include statements about inappropriate benzodiazepine use in elderly and the risk of fracture, but their clinical value has never been tested in an outcome study.

WHAT THIS STUDY ADDS

• Inappropriate benzodiazepine use according to the Beers criteria is not associated with an increased risk of fracture.
• Daily dose and duration of use is associated with higher risk of fracture, not the type of benzodiazepine prescribed as the Beers criteria state.

AIMS

The Beers criteria for prescribing in elderly are well known and used for many drug utilization studies. We investigated the clinical value of the Beers criteria for benzodiazepine use, notably the association between inappropriate use and risk of fracture.

METHODS

We performed a nested case–control study within the Rotterdam Study, a population-based cohort study in 7983 elderly. The proportion of ‘inappropriate’ benzodiazepine use according to the Beers criteria was compared between fracture patients and controls. ‘Inappropriate’ use for elderly implies use of some long-acting benzodiazepines and some intermediate/short-acting ones exceeding a suggested maximum daily dose. Also, alternative criteria were applied to compare the risk of fracture. Cases were defined as persons with incident fracture between 1991 and 2002 who were current benzodiazepine users on the fracture date. Controls were matched on fracture date and were also current benzodiazepine users.

RESULTS

The risk of fracture in ‘inappropriate’ benzodiazepine users according to the Beers criteria was not significantly different from ‘appropriate’ users [odds ratio (OR) 1.07, 95% confidence interval (CI) 0.72, 1.60]. However, a significantly higher risk of fracture was found in ‘high dose’ users and a longer duration of use (14–90 days), irrespective of the type of benzodiazepine (OR 3.45, 95% CI 1.38, 8.59).

CONCLUSIONS

These findings suggest that inappropriate benzodiazepine use according to the Beers criteria is not associated with increased risk of fracture. Daily dose and longer duration of use (>14 days) is associated with higher risk of fracture, irrespective of the type of benzodiazepine prescribed.     

依据Beers标准评价门诊老年患者潜在性不适当用药

目的:提高处方质量,促进合理用药,保障医疗安全。方法:以Beers(2012年版)标准为主要依据,对我院3 012例老年患者进行潜在性不适当用药(PIM)评价分析。结果:根据Beers标准判断,共有162例(5.4%)至少发生了1种PIM,其中129例(4.6%)使用了老年人避免使用的药物;46例(1.5%)使用了老年人慎用的药物;13例(8.0%)存在2种PIM情况;354例(11.8%)发生了Beers标准未包括的PIM;尚未发现与诊断或疾病状态相关的PIM。结论:Beers标准是专业判断的重要补充,门诊老年患者PIM需要综合评价标准。     

依据Beers标准评价老年患者不合理用药

目的：关注老年患者用药安全,促进合理用药。方法：以Beers（2012年版）标准为主要依据。对我院3012位老年患者进行潜在性不合理用药（PIM）评价分析。结果：根据Beers标准判断,共有162例（5.4%）至少发生了一种PIM,其中129例（4.6%）使用了老年人应避免使用的药物,46例（1.5%）使用了老年人应慎用的药物,13例存在两种PIM情况。354例（11.8%）发生了Beers标准未包括的PIM。尚未发现与诊断或疾病状态相关的潜在性不适当用药。结论：Beers标准是专业判断的重要补充,门诊老年患者潜在不当用药需要综合评价标准。     

Potentially inappropriate drug use in older people: a nationwide comparison of different explicit criteria for population-based estimates

Aims

The aim was to investigate the prevalence of potentially inappropriate medication use among older people in Sweden according to five different published sets of explicit criteria from Europe and the US.

Methods

This was a nationwide cross-sectional, register-based study across the whole of Sweden in 2008. All individuals aged 65 years and older were included (n = 1 346 709, both community-dwelling and institutionalized persons). We applied all drug-specific criteria included in the 2012 Beers Criteria, the Laroche’s list, the PRISCUS list, the NORGEP criteria and the Swedish National Board of Health and Welfare criteria. The main outcome was the potentially inappropriate drug use according to each set of criteria, separately and combined. Multivariate logistic regression models were used to identify individual factors associated with the use of potentially inappropriate drugs.

Results

The prevalence of potentially inappropriate medication use varied between the explicit criteria from 16% (NORGEP criteria) to 24% (2012 Beers criteria). Overall, 38% of the older people were exposed to potentially inappropriate drug use by at least one of the five sets of criteria. While controlling for other possible covariates, female gender, institutionalization and polypharmacy were systematically associated with inappropriate drug use, regardless of the set of explicit criteria we considered.

Conclusion

Although explicit criteria for inappropriate drug use among older people have been reported to be quite different in their content, they provide similar measures of the prevalence of potentially inappropriate drug use at the population level.