Inappropriate prescribing for the elderly: beers criteria-based review

OBJECTIVE: To review currently available literature applying the Beers criteria for inappropriate medication use in the elderly to prescribing practices in various settings. DATA SOURCE: Key words including inappropriate, Beers, medication, prescribing, elderly, geriatric, and criteria were used to search MEDLINE records from January 1992 to June 1999. DATA EXTRACTION: Eight relevant studies were found that applied the Beers criteria in various healthcare settings. DATA SYNTHESIS: Each study was examined for methodologic issues, criteria used, prevalence, nature and extent of inappropriate medication use, and factors associated with their use. Despite the methodologic differences, the review revealed some consistent patterns across healthcare settings. This review has shown that: (1) most of the researchers modified the Beers criteria to examine inappropriate medication use in the elderly; (2) studies using patient-based prevalence showed that between nearly one in four (23.5%) and one in seven (14.0%) elderly patients received an inappropriate medication as defined by either the Beers list of 20 inappropriate medications or the Modified Beers list; (3) the majority of these patients received one inappropriate agent; and (4) long-acting benzodiazepines, dipyridamole, propoxyphene, and amitriptyline were among the most frequently prescribed inappropriate medications. Univariate analyses indicated that women, patients >80 years old, and Medicaid patients appeared to receive more inappropriate medications than others; however, multivariate analyses found that only a higher number of medications was consistently associated with inappropriate medication use. CONCLUSIONS: Inappropriate prescribing or use trends are noteworthy because they were observed despite methodologic differences. The findings can be instrumental in developing targeted interventions to influence future prescribing practices. More research is needed to address the national trends and healthcare impact of inappropriate drug use in the elderly.     

Inappropriate prescribing in older residents of Australian care homes

What is known and objective: The incidence of inappropriate prescribing is higher amongst the older age group than the younger population. Inappropriate prescribing potentially leads to drug‐related problems such as adverse drug reactions. We aimed to determine the prevalence of inappropriate prescribing in residents of Tasmanian (Australia) residential care homes using Beers and McLeod criteria. Methods: Patient demographics, medical conditions and medications were collected from medical records. The patients who fulfilled either Beers or McLeod criteria were identified and the characteristics of these patients were then compared. Results: Data for 2345 residents were collected between 2006 and 2007. There were 1027 (43·8%) patients prescribed at least one inappropriate medication. Beers criteria identified more patients (828 patients, 35·3%) as being prescribed inappropriate medication compared with McLeod criteria (438 patients, 18·7%). Patients taking psychotropic medication/s, more than six medications or diagnosed with five or more medical conditions were more likely to be prescribed an inappropriate medication (P < 0·001). The most frequently identified inappropriate medications included benzodiazepines, amitriptyline, oxybutynin and non‐steroidal anti‐inflammatory drugs. What is new and conclusion: Inappropriate prescribing, as defined by either Beers criteria or McLeod criteria, is relatively common in Australian nursing homes. The prevalence of inappropriate prescribing, and factors influencing it, are consistent with other countries. Both Beers and McLeod criteria are a general guide to prescribing, and do not substitute for professional judgment.     

Concerns and beliefs about medicines and inappropriate medications: An internet-based survey on risk factors for self-reported adverse drug events among older adults

Background: Adverse drug events (ADEs), which can be especially problematic in older adults, often can be prevented by detecting potential risk factors. Sociopsychological factors such as concerns and beliefs about medicines (patients' anxieties about the harmful effects of prescribed medications) may also be risk factors related to self-reported ADEs, even when considering clinical variables such as receiving an inappropriate medication.Objectives: This study was designed to quantify the use of inappropriate medications among older adult outpatients and to determine whether an association exists between the use of inappropriate medications, concerns and beliefs about medicines, and self-reported ADEs.Methods: This cross-sectional, Internet-based survey of Medicare beneficiaries was conducted in 2007. Harris Interactive®, a New York-based marketing research firm, invited participants from their online panel who were ≥65 years of age, residents of the United States, and enrolled in the Medicare health plan to participate in the survey. The updated Beers criteria and a modified version of the Assessing Care of Vulnerable Elders quality indicators were used to determine the appropriateness of medications. Respondents' concerns about their medicines were assessed using items from a validated scale such as “Having to take medicines worries me” and “I sometimes worry about the long-term effects of my medicines.” To establish self-reported ADEs, respondents were asked, “Did you see a doctor about any side effects, unwanted reactions, or other problems from medicines you were taking in the past year?”Results: Of the 1024 panelists who responded to the survey, 874 provided all of the information required for analysis. The respondents who were included in the analyses ranged in age from 65 to 94 years; 56.6% were female, 94.4% were white, and 20.3% self-reported an ADE. The frequency of patients receiving either an inappropriate medication or a medication that failed a quality indicator was 45.8%. Stronger concerns and beliefs about medicines (odds ratio [OR] = 1.57; 95% CI, 1.02–2.39; P = 0.04) and having more symptoms (OR = 2.26; 95% CI, 1.22–4.22; P = 0.01) were significantly related to self-reporting of ADEs, whereas receiving an inappropriate medication (OR = 1.03; 95% CI, 0.65–1.64) and the number of medications received (OR = 1.28; 95% CI, 0.52–3.13) were not.Conclusions: Stronger concerns and beliefs about medicines and having more symptoms were significantly related to self-reporting of ADEs. Receiving an inappropriate medication and the number of medicines received were not significantly related.     

Recent advances in geriatrics: drug-related problems in the elderly

OBJECTIVE: To review recent articles examining drug-related problems in the elderly and comment on their potential impact on geriatric pharmacy practice. DATA SOURCES: Six articles published in 1997 and 1998. DATA SYNTHESIS: One study estimated that the cost of drug-related morbidity and mortality with the services of consultant pharmacists was $4 billion, compared with $7.6 billion without the services of consultant pharmacists. A study of ambulatory elderly patients with polypharmacy documented that 35% reported experiencing at least one adverse drug event within the previous year. Another study of ambulatory elderly found that in those with discontinued medications, adverse drug withdrawal events were uncommon. Two studies, one from Canada and one from the US, describe the development, by consensus, of explicit criteria for defining and identifying inappropriate drug use in the elderly (i.e., drugs to avoid, drugs with dose limits, drug-drug and drug-disease interactions). Finally, a modified Delphi survey of an expert panel reached consensus on 18 potential risk factors for drug-related factors in long-term care facility residents. CONCLUSIONS: Drug-related problems are considerable for elderly patients. Data from published studies should provide some guidance for today's practitioners as well as direction regarding future research.     

Potentially inappropriate medication use in elderly Japanese patients

Background: Modified Beers criteria for elderly Japanese patients were developed in 2008 by consensus among 9 experts to reflect regional clinical practice and available medications in Japan. Since then, many physicians and pharmacists have expressed interest in obtaining more information about the criteria and alternative drug choices.Objective: This study examined the incidence, health care utilization, and costs associated with potentially inappropriate medications (PIMs) in elderly patients based on the modified Beers criteria.Methods: A retrospective, observational cohort study was conducted using health insurance claims data in Japan. The study population included elderly patients aged ≥65 years who had at least 2 pharmacy claims in separate months over a 1-year period (April 2006 through March 2007). Use of the PIMs was identified using the modified criteria, and 1-year incidence rates were calculated for the total study population and for subgroups stratified by age and sex. A logistic regression model was used to examine demographic and clinical characteristics associated with PIMs. Health care utilization rates and costs were also analyzed and compared between patients with and without PIMs using generalized linear models. All models included dummy variables indicating age category, female sex, hospitalization, polypharmacy, index month, and number of Elixhauser comorbidities to adjust for potential confounders.Results: Among 6628 elderly patients, 71.2% (4721/6628) were female and 62.9% (4167/6628) were aged 65 to 74 years; 43.6% (2889/6628) were prescribed at least one PIM. The most commonly used PIMs were histamine-2 blockers (20.5% [1356/6628]), benzodiazepines (11.4% [756/6628]), and anticholinergics and antihistamines (7.9% [526/6628]). No significant differences in incidence rates were observed based on age or sex. Inpatient service use, polypharmacy, and comorbidities of peptic ulcer, depression, and cardiac arrhythmias were significant predictors of PIM use while controlling for other factors. PIM users had significantly higher hospitalization risk (1.68-fold), more outpatient visit days (1.18-fold), and higher medical costs (33% increase) than did nonusers.Conclusions: In a group of elderly Japanese patients, 43.6% used at least one PIM over a 1-year period in this study. PIM use was associated with greater health care utilization rates and costs.     

Real-time pharmacy surveillance and clinical decision support to reduce adverse drug events in acute kidney injury: a randomized, controlled trial

OBJECTIVES: Clinical decision support (CDS), such as computerized alerts, improves prescribing in the setting of acute kidney injury (AKI), but considerable opportunity remains to improve patient safety. The authors sought to determine whether pharmacy surveillance of AKI patients could detect and prevent medication errors that are not corrected by automated interventions. METHODS: The authors conducted a randomized clinical trial among 396 patients admitted to an academic, tertiary care hospital between June 1, 2010 and August 31, 2010 with an acute 0.5 mg/dl change in serum creatinine over 48 hours and a nephrotoxic or renally cleared medication order. Patients randomly assigned to the intervention group received surveillance from a clinical pharmacist using a web-based surveillance tool to monitor drug prescribing and kidney function trends. CDS alerting and standard pharmacy services were active in both study arms. Outcome measures included blinded adjudication of potential adverse drug events (pADEs), adverse drug events (ADEs) and time to provider modification or discontinuation of targeted nephrotoxic or renally cleared medications. RESULTS: Potential ADEs or ADEs occurred for 104 (8.0%) of control and 99 (7.1%) of intervention patient-medication pairs (p=0.4). Additionally, the time to provider modification or discontinuation of targeted nephrotoxic or renally cleared medications did not differ between control and intervention patients (33.4 hrs vs. 30.3 hrs, p=0.3). CONCLUSIONS: Pharmacy surveillance had no incremental benefit over previously implemented CDS alerts.     

Comprehensive medication therapy management: identifying and resolving drug-related issues in a community pharmacy

OBJECTIVE: The aim of this study was to characterize comprehensive medication therapy management (MTM) involving a community pharmacy and local physicians by describing the drug-related issues encountered, identifying which medication types were associated with these issues, and listing the actions taken by physicians and pharmacists to address them. METHODS: In the MTM program studied, community pharmacists and physicians worked together to manage the drug therapy of ambulatory Iowa Medicaid recipients dispensed > or =4 medications for chronic conditions by a community pharmacy. After initial assessment, pharmacists made written recommendations to the patient's physician, and the physicians subsequently responded. Data were extracted from pharmacy records for patients who made > or =1 visit during the first 2 years of the program. Collected data included patient demographics, number of chronic conditions and medications at enrollment, type and number of drug-related issues, medication category, pharmacist recommendations, and physician acceptance of recommendations. RESULTS: Data were gathered for 150 patients. The mean (SD) age was 54.4 (19.4) years and 74.0% were female. They were taking a mean (SD) of 9.3 (4.6) medications and had a mean (SD) of 6.1 (3.1) medical conditions at enrollment. A total of 886 drug-related issues were classified into 7 categories: inappropriate adherence (25.9%), needs additional therapy (22.0%), wrong drug (13.2%), unnecessary drug therapy (12.9%), adverse drug reaction (11.1%), dose too low (9.7%), and dose too high (5.3%). Overall, physicians accepted 313 (47.4%) of the 659 recommendations to alter drug therapy made by pharmacists, with the highest rates of agreement to stop or change a medication (50.3% and 50.0%, respectively) and the lowest rate of agreement to start a new medication (41.7%). CONCLUSION: The MTM program showed that drug therapy for ambulatory patients taking multiple medications to treat chronic conditions can be improved through collaboration between physicians and community pharmacists.     

Potentially inappropriate prescribing for the elderly: effects of geriatric care at the patient and health care system level

BACKGROUND: Many studies have identified patient characteristics associated with potentially inappropriate prescribing in the elderly (PIPE), however, little attention has been directed toward how health care system factors such as geriatric care may affect this patient safety issue. OBJECTIVE: This study examines the association between geriatric care and PIPE in a community dwelling elderly population. RESEARCH DESIGN: Cross-sectional retrospective database study. SUBJECTS: Veterans age > or =65 years who received health care in the VA system during Fiscal Years (FY99-00), and also received at medications from the Veterans Administration in FY00. MEASURES: PIPE was identified using the Zhan adaptation of the Beers criteria. Geriatric care penetration was calculated as the proportion of patients within a facility who received at least 1 geriatric outpatient clinic or inpatient visit. ANALYSES: Logistic regression models with generalized estimating equations were used to assess the relationship between geriatric care and PIPE after controlling for patient and health care system characteristics. RESULTS: Patients receiving geriatric care were less likely to have PIPE exposure (odds ratio, 0.64; 95% confidence interval, 0.59-0.73). There was also a weak effect for geriatric care penetration, with a trend for patients in low geriatric care penetration facilities having higher risk for PIPE regardless of individual geriatric care exposure (odds ratio, 1.14; 95% confidence interval, 0.99-1.30). CONCLUSIONS: Although geriatric care is associated with a lower risk of PIPE, additional research is needed to determine if heterogeneity in the organization and delivery of geriatric care resulted in the weak effect of geriatric care penetration, or whether this is a result of low power.     

Implementation of ward-based clinical pharmacy services in Belgium--description of the impact on a geriatric unit

BACKGROUND: Patient-centered clinical pharmacy services are still poorly developed in Europe, despite their demonstrated advantages in North America and the UK. Reporting European pilot experiences is, therefore, important to assess the usefulness of clinical pharmacy services in this specific context. OBJECTIVE: To report the results of the first implementation of Belgian clinical pharmacy services targeting patients at high risk of drug-related problems. METHODS: An intervention study was conducted by a trained clinical pharmacist providing pharmaceutical care to 101 patients (mean age 82.2 y; mean +/- SD number of prescribed drugs 7.8 +/- 3.5) admitted to an acute geriatric unit, over a 7 month period. All interventions to optimize prescribing, and their acceptance, were recorded. An external panel (2 geriatricians, 1 clinical pharmacist) assessed the interventions' clinical significance. Persistence of interventions after discharge was assessed through telephone calls. RESULTS: A total of 1066 interventions were made over the 7 month period. The most frequent drug-related problems underlying interventions were: underuse (15.9%), wrong dose (11.9%), inappropriate duration of therapy (9.7%), and inappropriate choice of medicine (9.6%). The most prevalent consequences were to discontinue a drug (24.5%), add a drug (18.6%), and change dosage (13.7%). Acceptance rate by physicians was 87.8%. Among interventions with clinical impact, 68.3% and 28.6% had moderate and major clinical significance, respectively. Persistence of chronic treatment changes 3 months after discharge was 84%. CONCLUSIONS: Involving a trained clinical pharmacist in a geriatric team led to clinically relevant and well-accepted optimization of medicine use. This initiative may be a springboard for further development of clinical pharmacy services.     

Adverse outcomes associated with inappropriate drug use in nursing homes

BACKGROUND: Little empirical evidence exists regarding the influence and outcomes of inappropriate medication use among elderly nursing home residents. OBJECTIVE: To identify the prevalence of inappropriate medication use among elderly patients in Georgia nursing homes using the Beers criteria and identify the relationship between inappropriate drug use and the likelihood of an adverse health outcome. METHODS: A cohort design was used to review 1117 patient medical records in 15 Georgia nursing homes with a high risk of polypharmacy. Prevalence of inappropriate medication use among elderly patients, as defined by the Beers criteria, was estimated. The adverse health outcomes of hospitalizations, emergency department visits, or deaths were identified from Medicaid claims data. RESULTS: A total of 519 (46.5%) patients received at least one inappropriate medication and 143 (12.8%) patients experienced at least one adverse health outcome. Logistic regression revealed that the total number of medications taken (OR 1.139, 95% CI 1.105 to 1.173) significantly increased the likelihood of receiving an inappropriate drug, while having a diagnosis of "dementia" (OR 0.748, 95% CI 0.565 to 0.991) decreased the likelihood. Inappropriate medication use increased the likelihood of experiencing at least one adverse health outcome more than twofold (OR 2.34, 95% CI 1.61 to 3.40). Propoxyphene use alone was significantly associated with the occurrence of an adverse health outcome (OR 2.39, 95% CI 1.54 to 3.71). CONCLUSIONS: Inappropriate drug use was common in our study cohort. Inappropriate use of medication in the elderly, particularly propoxyphene, is associated with a higher risk of adverse health outcomes.     

Conflicts and concordance between measures of medication prescribing quality

BACKGROUND: Several instruments commonly are used to assess the quality of medication prescribing. However, little is known about the relationship between these instruments or the concordance of their quality assessments when applied to the same group of patients. METHODS: We assessed 3 indicators of prescribing quality in a cohort of 196 veterans age 65 and older who were taking 5 or more medications. These 3 indicators assessed whether each patient was (1) taking any medication from the drugs-to-avoid criteria of Beers et al, (2) taking any medication with a score of 3 or more on the Medication Appropriateness Index (MAI), and/or (3) taking 9 or more medications (polypharmacy). Kappa statistics were used to assess agreement between measures. RESULTS: Mean age was 74.6 years, and patients used a mean of 8.1 medications. Six percent of drugs were rated inappropriate by the Beers drugs-to-avoid criteria, whereas 23% of drugs received an MAI score of 3 or more. Overall agreement between these metrics was 78%, little more than expected by chance (kappa statistic 0.14, P<0.01). At the level of the patient, the proportion of subjects taking one or more inappropriate drugs was 37% by drugs-to-avoid criteria and 82% by MAI, whereas 37% had polypharmacy of >or=9 drugs. Prescribing was classified as inappropriate by all 3 metrics in 18% of patients and as appropriate by all 3 metrics in 13%. Together, this level of agreement was slightly better than chance (3-way kappa statistic 0.08, P=0.03). Agreement remained low in sensitivity analyses using different cutoffs for the Beers criteria, a range of thresholds for MAI scores, and different definitions of polypharmacy, with kappa statistics相似文献   

北京市社区老年人潜在不适当用药的调查分析

目的 调查北京市社区老年人潜在不适当用药(potentially inappropriate medication,PIM)现状.方法 采用自我报告方式,收集北京市社区215名老年人用药信息,根据2019版美国老年人PIM标准(Beers criteria for PIM use in older adults,Beers标准)和中国老年人潜在不适当用药判断标准(中国PIM标准)评价并做描述性分析.结果 根据2019版Beers标准发现66人(30.7%)存在84例次PIM,其中中枢神经系统药物(36例次)、血液系统药物(14例次)、内分泌系统药物(11例次)导致的PIM最多;采用中国PIM标准发现53人(24.7%)存在73例次PIM,前三位分别为:中枢神经系统药物(31例次),血液系统药物(17例次),解热、镇痛、抗炎与抗风湿药(17例次).结论 社区老年人PIM发生率较高,特别是中枢神经系统和血液系统用药需要引起关注.Beers标准和中国PIM标准可相互补充,且需不断更新完善.     

Potentially inappropriate medication prescribing in outpatient practices: Prevalence and patient characteristics based on electronic health records

Background: Some older adults receive potentially inappropriate medications (PIMs), increasing their risk for adverse events. A literature search did not find any US multicenter studies that measured the prevalence of PIMs in outpatient practices based on data from electronic health records (EHRs), using both the Beers and Zhan criteria.Objectives: The aims of the present study were to compare the prevalence of PIMs using standard drug terminologies at 2 disparate institutions using EHRs and to identify characteristics of elderly patients who have a PIM on their active-medication lists.Methods: This cross-sectional study of outpatients' active-medication lists from April 1, 2006, was conducted using data from 2 outpatient primary care settings: Intermountain Healthcare, Salt Lake City, Utah (center 1), and the Cleveland Clinic, Cleveland, Ohio (center 2). Data were included from patients who were aged ≥65 years at the time of the last office visit and had ≥2 documented clinic visits within the previous 2 years. The primary end point was prevalence of PIMs, measured according to the 2002 Beers criteria or the 2001 Zhan criteria.Results: Data from 61,251 patients were included (36,663 women, 24,588 men; center 1: 37,247 patients; center 2: 24,004). A total of 8693 (23.3%) and 5528 (23.0%) patients at centers 1 and 2, respectively, were documented as receiving a PIM as per the Beers criteria; this difference was not statistically significant. Per the Zhan criteria (P < 0.001), these values were 6036 (16.2%) and 4160 (17.3%). Eight of the most common PIMs were the same at both institutions, with propoxyphene and fluoxetine (once daily) being the most prescribed. Female sex, polypharmacy (≥6 medications), and multiple primary care visits were significantly associated with PIM prescribing.Conclusions: In this analysis of data from elderly patients at 2 outpatient centers, a small set of 8 medications accounted for the majority of PIMs at both centers, irrespective of geographic and demographic variations. Female sex, polypharmacy, and number of primary care visits were significantly associated with PIM prescribing. In this analysis of data from elderly patients at 2 outpatient centers, a small set of 8 medications accounted for the majority of PIMs at both centers, irrespective of geographic and demographic variations.