Polypharmacy and prescribing quality in older people

OBJECTIVES: To evaluate the relationship between inappropriate prescribing, medication underuse, and the total number of medications used by patients. DESIGN: Cross-sectional study. SETTING: Veterans Affairs Medical Center. PARTICIPANTS: One hundred ninety-six outpatients aged 65 and older who were taking five or more medications. MEASUREMENTS: Inappropriate prescribing was assessed using a combination of the Beers drugs-to-avoid criteria (2003 update) and subscales of the Medication Appropriateness Index that assess whether a drug is ineffective, not indicated, or unnecessary duplication of therapy. Underuse was assessed using the Assessment of Underutilization of Medications instrument. All vitamins and minerals, topical and herbal medications, and medications taken as needed were excluded from the analyses. RESULTS: Mean age was 74.6, and patients used a mean+/-standard deviation of 8.1+/-2.5 medications (range 5-17). Use of one or more inappropriate medications was documented in 128 patients (65%), including 73 (37%) taking a medication in violation of the Beers drugs-to-avoid criteria and 112 (57%) taking a medication that was ineffective, not indicated, or duplicative. Medication underuse was observed in 125 patients (64%). Together, inappropriate use and underuse were simultaneously present in 82 patients (42%), whereas 25 (13%) had neither inappropriate use nor underuse. When assessed by the total number of medications taken, the frequency of inappropriate medication use rose sharply from a mean of 0.4 inappropriate medications in patients taking five to six drugs, to 1.1 inappropriate medications in patients taking seven to nine drugs, to 1.9 inappropriate medications in patients taking 10 or more drugs (P<.001). In contrast, the frequency of underuse averaged 1.0 underused medications per patient and did not vary with the total number of medications taken (P=.26). Overall, patients using fewer than eight medications were more likely to be missing a potentially beneficial drug than to be taking a medication considered inappropriate. CONCLUSION: Inappropriate medication use and underuse were common in older people taking five or more medications, with both simultaneously present in more than 40% of patients. Inappropriate medication use is most frequent in patients taking many medications, but underuse is also common and merits attention regardless of the total number of medications taken.     

Improving medication use in newly admitted home healthcare patients: a randomized controlled trial

OBJECTIVES: To test the efficacy of a medication use improvement program developed specifically for home health agencies. The program addressed four medication problems identified by an expert panel: unnecessary therapeutic duplication, cardiovascular medication problems, use of psychotropic drugs in patients with possible adverse psychomotor or adrenergic effects, and use of nonsteroidal antiinflammatory drugs (NSAIDs) in patients at high risk of peptic ulcer complications. It used a structured collaboration between a specially trained clinical pharmacist and the patients' home-care nurses to improve medication use. DESIGN: Parallel-group, randomized controlled trial. SETTING: Two of the largest home health agencies in the United States. PARTICIPANTS: Study subjects were consenting Medicare patients aged 65 and older admitted to participating agency offices from October 1996 through September 1998, with a projected home healthcare duration of at least 4 weeks and at least one study medication problem. INTERVENTION: Qualifying patients were randomized to usual care or usual care with the medication improvement program. MEASUREMENTS: Medication use was measured during an in-home interview, with container inspection at baseline and at follow-up (between 6 and 12 weeks) by interviewers unaware of treatment assignment. The trial endpoint was the proportion of patients with medication use improvement according to predefined criteria at follow-up. RESULTS: There were 259 randomized patients with completed follow-up interviews: 130 in the intervention group and 129 with usual care. Medication use improved for 50% of intervention patients and 38% of control patients, an attributable improvement of 12 patients per 100 (95% confidence interval (CI) = 0.0-24.0, P =.051). The intervention effect was greatest for therapeutic duplication, with improvement for 71% of intervention and 24% of control patients, an attributable improvement of 47 patients per 100 (95% CI = 20-74, P =.003). Use of cardiovascular medications also improved more frequently in intervention patients: 55% vs 18%, attributable improvement 37 patients per 100 (95% CI = 9-66, P =.017). There were no significant improvements for the psychotropic medication or NSAID problems. There was no evidence of adverse intervention effects: new medication problems, more agency nurse visits, or increased duration of home health care. CONCLUSIONS: A program congruent with existing personnel and practices of home health agencies improved medication use in a vulnerable population and was particularly effective in reducing therapeutic duplication.     

How to Use the American Geriatrics Society 2015 Beers Criteria—A Guide for Patients,Clinicians, Health Systems,and Payors

The Beers Criteria are a valuable tool for clinical care and quality improvement but may be misinterpreted and implemented in ways that cause unintended harms. This article describes the intended role of the 2015 American Geriatrics Society (AGS) Beers Criteria and provides guidance on how patients, clinicians, health systems, and payors should use them. A key theme underlying these recommendations is to use common sense and clinical judgment in applying the 2015 AGS Beers Criteria and to remain mindful of nuances in the criteria. The criteria serve as a “warning light” to identify medications that have an unfavorable balance of benefits and harms in many older adults, particularly when compared with pharmacological and nonpharmacological alternatives. However, there are situations in which use of medications included in the criteria can be appropriate. As such, the 2015 AGS Beers Criteria work best not only when they identify potentially inappropriate medications, but also when they educate clinicians and patients about the reasons those medications are included and the situations in which their use may be more or less problematic. The criteria are designed to support, rather than supplant, good clinical judgment.     

Potentially inappropriate prescriptions to Brazilian older people with Alzheimer disease: A cross-sectional study

Older adults are the leading users of medications, where this can be associated with a high number of potentially inappropriate medications (PIMs) and of potentially inappropriate prescribing (PIP) and consequent harm to health. No Brazilian study evaluating potentially inappropriate prescribing in older patients with Alzheimer''s disease (AD) was found. This study determined and analyzed the prevalence of PIP and PIM prescribed for older people with AD.A cross-sectional study was carried out at the Specialty Drugs Pharmacy in the city of Sorocaba, São Paulo State, Brazil. The MEDEX system provided the register in older people with AD and data were collected during interviews with patients and/or caregivers between June and September 2017. The PIMs were identified according to the 2019 Beers Criteria. The association between PIMs and independent variables was analyzed by Poisson regression.This study included 234 older patients with AD. The prevalence of PIP prescribed was 66.7% (n = 156). Of the 1073 medications prescribed, 30.5% (n = 327) were inappropriate with most affecting the central nervous system or cardiovascular, particularly quetiapine (12.8%) and acetylsalicylic acid (11.6%), respectively. Around 45.2% of the PIMs should be avoided in older people, especially sertraline (14.2%) and clonazepam (7.4%). After adjusted analysis, the PIMs were associated with the diagnosis of depression (P = 0.010) and the number of comorbidities (P = 0.005).There was a high number of PIMs among older people, a substantial number of which should have been avoided in this population. Health care professionals can apply these findings to improve safety in the use of medications for treating patients with AD.     

Alternative Medications for Medications in the Use of High‐Risk Medications in the Elderly and Potentially Harmful Drug–Disease Interactions in the Elderly Quality Measures

The National Committee for Quality Assurance (NCQA) and the Pharmacy Quality Alliance (PQA) use the American Geriatrics Society (AGS) Beers Criteria to designate the quality measure Use of High‐Risk Medications in the Elderly (HRM). The Centers for Medicare and Medicaid Services (CMS) use the HRM measure to monitor and evaluate the quality of care provided to Medicare beneficiaries. NCQA additionally uses the AGS Beers Criteria to designate the quality measure Potentially Harmful Drug–Disease Interactions in the Elderly. Medications included in these measures may be harmful to elderly adults and negatively affect a healthcare plan's quality ratings. Prescribers, pharmacists, patients, and healthcare plans may benefit from evidence‐based alternative medication treatments to avoid these problems. Therefore the goal of this work was to develop a list of alternative medications to those included in the two measures. The authors conducted a comprehensive literature review from 2000 to 2015 and a search of their personal files. From the evidence, they prepared a list of drug‐therapy alternatives with supporting references. A reference list of nonpharmacological approaches was also provided when appropriate. NCQA, PQA, the 2015 AGS Beers Criteria panel, and the Executive Committee of the AGS reviewed the drug therapy alternatives and nonpharmacological approaches. Recommendations by these groups were incorporated into the final list of alternatives. The final product of drug‐therapy alternatives to medications included in the two quality measures and some nonpharmacological resources will be useful to health professionals, consumers, payers, and health systems that care for older adults.     

American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults

Potentially inappropriate medications (PIMs) continue to be prescribed and used as first-line treatment for the most vulnerable of older adults, despite evidence of poor outcomes from the use of PIMs in older adults. PIMs now form an integral part of policy and practice and are incorporated into several quality measures. The specific aim of this project was to update the previous Beers Criteria using a comprehensive, systematic review and grading of the evidence on drug-related problems and adverse drug events (ADEs) in older adults. This was accomplished through the support of The American Geriatrics Society (AGS) and the work of an interdisciplinary panel of 11 experts in geriatric care and pharmacotherapy who applied a modified Delphi method to the systematic review and grading to reach consensus on the updated 2012 AGS Beers Criteria. Fifty-three medications or medication classes encompass the final updated Criteria, which are divided into three categories: potentially inappropriate medications and classes to avoid in older adults, potentially inappropriate medications and classes to avoid in older adults with certain diseases and syndromes that the drugs listed can exacerbate, and finally medications to be used with caution in older adults. This update has much strength, including the use of an evidence-based approach using the Institute of Medicine standards and the development of a partnership to regularly update the Criteria. Thoughtful application of the Criteria will allow for (a) closer monitoring of drug use, (b) application of real-time e-prescribing and interventions to decrease ADEs in older adults, and (c) better patient outcomes.     

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.     

Potentially inappropriate medication use by elderly persons in U.S. Health Maintenance Organizations, 2000-2001

OBJECTIVES: To determine rates of potentially inappropriate medication use in elderly persons in managed care plans in the United States in 2000-2001. DESIGN: Cross-sectional study using automated medication-dispensing data. SETTING: Ten geographically distributed health maintenance organizations (HMOs). PARTICIPANTS: One hundred fifty-seven thousand five hundred seventeen members aged 65 years and older enrolled in one of the HMOs. MEASUREMENTS: Prevalence of use of 33 potentially inappropriate medications from January 1, 2000 through June 30, 2001. RESULTS: In 2000-2001, 28.8% (95% confidence interval=28.6-29.1) of elderly individuals received at least one of 33 potentially inappropriate medications. This rate ranged from 23.0% to 36.5% across the 10 HMOs. Approximately 5% of elderly patients received at least one of the 11 medications classified by an expert panel as "always avoid," 13% received at least one of the eight medications that would rarely be considered appropriate, and 17% received at least one of the 14 medications that have some indications but are often misused. Overall, rates of use of these medications were greater in women (32.4%) than in men (24.2%). At least 1% of elderly members received belladonna alkaloids (2.3%), dicyclomine (1.1%), or hyoscyamine (1.2%), each of which multiple expert panels have classified as always inappropriate in patients aged 65 years and older. Seven percent of elderly members received propoxyphene, an analgesic medication considered rarely appropriate in the elderly and a drug that has a long history of limited efficacy and potential for toxicity. CONCLUSION: Recent rates of potentially inappropriate medication use by elderly HMO members were at least as great as in a 1996 national sample. This study highlights the need to understand more fully the rationale behind the continued use of these medications.     

老年人不宜使用的药物

不适当药物的使用是导致老年人发病和死亡的一个重要原因。文章介绍了国际上广泛应用的两个老年人用药指南。Beers标准介绍了48种药物在老年人中应避免使用或限量使用和20种老年人特定病症不宜使用药物的理由及危害等级。加拿大标准介绍了38种药物在老年人中应避免使用,并对老年人不适当处方行为提出了替代治疗方案。推广两个指南的应用,将有利于改善老年人不适当药物应用的局面,使老年人少受药物不良反应的危害。     

American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults

The 2015 American Geriatrics Society (AGS) Beers Criteria are presented. Like the 2012 AGS Beers Criteria, they include lists of potentially inappropriate medications to be avoided in older adults. New to the criteria are lists of select drugs that should be avoided or have their dose adjusted based on the individual's kidney function and select drug–drug interactions documented to be associated with harms in older adults. The specific aim was to have a 13‐member interdisciplinary panel of experts in geriatric care and pharmacotherapy update the 2012 AGS Beers Criteria using a modified Delphi method to systematically review and grade the evidence and reach a consensus on each existing and new criterion. The process followed an evidence‐based approach using Institute of Medicine standards. The 2015 AGS Beers Criteria are applicable to all older adults with the exclusion of those in palliative and hospice care. Careful application of the criteria by health professionals, consumers, payors, and health systems should lead to closer monitoring of drug use in older adults.     

Criteria for high-risk medication use in Thai older patients

Many older patients have multiple diseases that require high-risk drug use, which may cause serious adverse effects. Criteria for the use of these drugs in older people are vital to the prevention of adverse events. This study aimed to develop explicit criteria for determining high-risk medication use in Thai older patients. It was conducted using a Delphi technique with the three-round survey of 16 geriatric medicine (GM) experts. A structured questionnaire with 56, 93, and 95 statements were devised for Rounds 1, 2, and 3, respectively. In each statement, the panelists were requested to confirm a high-risk drug in Round 1, and to rate on a 5-point Likert scale and classify the high-risk medication use in Rounds 2 and 3. The results showed that 77 practice statements (81.1%) that embraced the use of high-risk medications with potential adverse reactions, drug-disease interactions, and drug-drug interactions were agreed by the expert panel. A total of 23 statements (29.9%) were categorized as Groups 1-3 and the rest remained unclassified. Most high-risk medications were utilized in the central nervous system, musculoskeletal system, and cardiovascular system. Further studies are warranted to evaluate the criteria in terms of prescribing and monitoring medication use in older patients.     

Utilization and Spending on Potentially Inappropriate Medications by US Older Adults with Multiple Chronic Conditions using Multiple Medications

BackgroundThe utilization of potentially inappropriate medications (PIMs) in older adults can lead to adverse events and increased healthcare costs. Polypharmacy, the concurrent utilization of multiple medications, is common in older adults with multiple chronic conditions.ObjectiveTo investigate the utilization and costs of PIMs in multimorbid older adults with polypharmacy over time.MethodsThis retrospective cross-sectional study used linked Medicare claims and electronic health records from seven hospitals/medical centers in Massachusetts (2007-2014). Participants were ≥65 years old, had ≥2 chronic conditions (to define multimorbidity), and used drugs from ≥5 pharmaceutical classes for ≥90 days (to define polypharmacy). Chronic conditions were defined using the Chronic Conditions Indicator from the Agency for Health Research and Quality. PIMs were defined using the American Geriatrics Society 2019 version of the Beers criteria. We calculated the percentage of patients with ≥1 PIMs and the percentages of patients using different types of PIMs. We used logistic regression analyses to test the odds of taking ≥1 PIMs. We calculated mean costs spent on PIMs by dividing the costs spent on PIMs by the total medication cost.Results≥69% of patients used ≥1 PIM. After adjusting for healthcare utilization, chronic conditions, medication intake, and demographic factors, female sex (2014: Odds ratio (OR)=1.27, 95%CI 1.25-1.30), age (2014: OR=0.92, 95%CI 0.90-0.93), and Hispanic ethnicity (2014: OR=1.41, 95%CI 1.27-1.56) were associated with PIM use. Gastrointestinal drugs and central nervous system drugs were the most commonly-used PIMs. In patients using ≥1 PIM, >10% of medication costs were spent on PIMs.ConclusionThe utilization of PIMs in US older adults with multimorbidity and polypharmacy is high.     

Does Incorporating Medications in the Surveyors' Interpretive Guidelines Reduce the Use of Potentially Inappropriate Medications in Nursing Homes?

OBJECTIVES: To quantify the association between including specific medications deemed potentially inappropriate in the surveyors' interpretive guidelines for nursing homes and the prevalence of use. DESIGN: Quasi-experimental. SETTING: One thousand one hundred forty-one nursing homes in four U.S. states. PARTICIPANTS: Residents living in one of the included nursing homes in operation during 1997 (before Beers; n=130,250) and 2000 (after Beers; n=164,889). INTERVENTION: Inclusion of specific medications deemed potentially inappropriate in the surveyors' interpretive guidelines for nursing homes. MEASUREMENTS: Logistic regression models adjusting for clustering effects of residents residing in homes provided estimates of the relationship between the survey process and use of any medications targeted as potentially inappropriate as part of the survey process, as well as those deemed inappropriate but not included. RESULTS: The use of any potentially inappropriate medication decreased from 42.5% in 1997 to 39.8% in 2000. After adjustment for resident characteristics, residents were less likely to receive any potentially inappropriate medication (odds ratio (OR)=0.85, 95% confidence interval (95% CI)=0.84-0.87), those considered high-severity drugs (those with a high likelihood of a clinically significant adverse event) (OR=0.67, 95% CI=0.65-0.69), or Beers' medications not included in the surveyors' guidelines (OR=0.76, 95% CI=0.74-0.79) in 2000 than in 1997 after the changes to the drug regulations and interpretive guidelines. CONCLUSION: Targeting specific drugs in the surveyor's interpretive guidelines as a method to reduce potentially inappropriate medication use may not produce desired gains in medication-use quality improvement. Alternative strategies for nursing homes should be evaluated.     

Quality improvement toward decreasing high-risk medications for older veteran outpatients

OBJECTIVES: To examine the effectiveness of a quality improvement program to decrease prescribing of high-risk medications.
DESIGN: Single cohort, pre- and postintervention.
SETTING: Regional network of Department of Veterans Affairs medical facilities.
PARTICIPANTS: Outpatient veterans aged 65 and older who received one or more high-risk medications and the prescribing clinicians.
INTERVENTION: A two-stage intervention was implemented. First, a real-time warning message to prescribers appeared whenever one of the high-risk drugs was ordered; second, a personally addressed letter from the Chief Medical Officer asking prescribers to consider discontinuing the high-risk medication along with a copy of the Beers criteria article, a list of suggested alternatives to high-risk medications, and a list of older patients receiving the high-risk medications who had upcoming appointments with these prescribers.
MEASUREMENTS: The primary outcome was the absence of prescribed high-risk medications for all patients in the cohort during the postintervention period. For a subgroup of the cohort whose prescribers received the second-stage intervention, an additional outcome was the absence of prescribed high-risk medications within the subgroup.
RESULTS: Two thousand seven hundred fifty-three unique patients were identified in the cohort; 1,396 (50.7%) had high-risk medications discontinued, resulting in a significant decrease in the number of patients prescribed high-risk medications from the preintervention period to the postintervention period ( P <.001). Of the 801 patients in the subgroup, 72.0% (n=577) had high-risk medications discontinued ( P <.001).
CONCLUSION: This multimethod intervention significantly decreased prescribing of high-risk medications to older patients. Further studies are needed to confirm the findings.