Appropriate prescribing in the elderly: an investigation of two screening tools, Beers criteria considering diagnosis and independent of diagnosis and improved prescribing in the elderly tool to identify inappropriate use of medicines in the elderly in primary care in Ireland

Background:  Elderly patients are particularly vulnerable to inappropriate prescribing, with increased risk of adverse drug reactions and consequently higher rates of morbidity and mortality. A large proportion of inappropriate prescribing is preventable by adherence to prescribing guidelines, suitable monitoring and regular medication review. As a result, screening tools have been developed to help clinicians improve their prescribing.
Objectives:  To compare identification rates of inappropriate prescribing in elderly patients in primary care using two validated screening tools: Beers' criteria and improved prescribing in the elderly tool (IPET); to calculate the net ingredient cost (NIC) per month (€) of the potentially inappropriate medicines in this population of patients.
Method:  A consecutive cohort of 500 patients 65 years of age and over were recruited prospectively from primary care over a 6 month period in a provincial town in Ireland. Patients' medical records (electronic and paper) were screened and all relevant information concerning current illnesses and medications was recorded on a standardized data collection form to which Beers' criteria [considering diagnosis (CD) and independent of diagnosis (ID)] and IPET tools were applied. The NIC was calculated from an edition of the Irish monthly index of medical specialities published concurrently with the data collection.
Results:  Beers' criteria identified a total of 69 medicines that were prescribed inappropriately (eight CD and 61 ID) in 65 patients (13%), costing €824·88 per month while IPET identified 63 potentially inappropriate medicines in 52 (10·4%) patients costing €381·28 per month.
Conclusions:  Potentially inappropriate medications are prescribed in a significant proportion of elderly people in primary care, with significant economic implications.     

Comparison of tools for the assessment of inappropriate prescribing in hospitalized older people

Rational, aims and objective The aim of the present study was to compare the ease of use and the capability of four approaches [Medication Appropriateness Index (MAI), the Beers' criteria 2003, the Improved Prescribing in the Elderly Tool (IPET) and Health Plan Employer Data and Information Set (HEDIS)] in assessing changes in medication appropriateness in elderly patients over a period of hospitalization. Methods A retrospective observational study in two hospitals in Northern Ireland using the four measures was undertaken, involving a cohort of 192 patients (aged > 65 years). Medication appropriateness assessments were made at three stages during the patients' hospital ‘journey’, that is, at admission, during their inpatient stay and at discharge. The identifying rates of inappropriate prescribing in elderly patients in hospital used validated screening tools: MAI, the Beers' criteria 2003, the IPET and HEDIS. Results The MAI was the most comprehensive approach but was also the most time consuming to apply. Data derived using the MAI indicated clearly that there was improved medication appropriateness over the three hospital stay stages (P < 0.001). Although this trend was also significant for the Beers' criteria 2003 (P < 0.05) and the IPET (P < 0.05) approaches, the HEDIS was unable to differentiate changes in appropriateness over time. There was a good correlation between data derived using the MAI and the Beers' criteria 2003 and the IPET approaches; this correlation was not evident for the HEDIS. Conclusions The MAI is the most convincing tool in evaluating medication appropriateness, but is very time consuming to apply. Beers' criteria 2003 and the IPET perform to an acceptable standard within the clinical setting and are more practical in their application. The HEDIS, although simplest to apply, does not have the sensitivity to measure change in appropriateness over time.     

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.     

Potentially inappropriate prescribing in elderly: assessing doctor knowledge,confidence and barriers

Introduction Inappropriate medication prescribing by doctors is an important preventable cause of morbidity and mortality in the elderly. This study investigates doctor knowledge about potentially inappropriate prescribing (PIP) in elderly, their confidence in prescribing for the elderly and explores perceived barriers. Methods Family and Internal Medicine resident and attending doctors at three teaching hospitals were asked to complete a survey. Six clinical vignettes based on the 2003 Beers criteria were used to evaluate doctor knowledge about medications to avoid in the elderly. Confidence in prescribing for the elderly and perceived barriers to appropriate prescribing in elderly was assessed using a 5‐point Likert scale. Results Eighty‐nine doctors completed the survey, for a response rate of 45%. Forty‐four per cent of surveyed doctors estimated that over 25% of their practice consisted of patients 65 years or older. When knowledge of PIP was assessed via vignettes, the mean correct response was 3.9 (SD: 1.1, min = 1, max = 6). Only 14% of those doctors scoring ≤4 vignettes correctly had used the Beers criteria for prescribing; 31% of the doctors answering ≥5 vignettes correctly had used the Beers criteria (P = 0.08). Overall, 75% of doctors felt confident about their prescribing irrespective of their knowledge scores. Seventy per cent of surveyed doctors cited at least seven different barriers to appropriate prescribing in elderly. Conclusions Many primary care doctors possess a poor knowledge of PIP and are unaware of prescribing guidelines such as the Beers criteria. Our survey indicates that doctor usage of the Beers criteria might correlate with improved judgement in prescribing for the elderly. Most doctors report multiple barriers to appropriate prescribing in the elderly. Lack of formal education about prescribing guidelines was the only barrier that correlated with the doctors' level of training.     

Inappropriate prescribing for older people admitted to an intermediate-care nursing home unit and hospital wards

Objective

To identify inappropriate prescribing among older patients on admission to and discharge from an intermediate-care nursing home unit and hospital wards, and to compare changes during stay within and between these groups.

Design

Observational study.

Setting and subjects

Altogether 400 community-dwelling people aged ≥ 70 years, on consecutive emergency admittance to hospital wards of internal medicine and orthopaedic surgery, were randomized to an intermediate-care nursing home unit or hospital wards; 290 (157 at the intermediate-care nursing home unit and 133 in hospital wards) were eligible for this sub-study.

Main outcome measures

Prevalence on admission and discharge of potentially inappropriate medications (Norwegian general practice [NORGEP] criteria) and drug–drug interactions; changes during stay.

Results

The mean (SD) age was 84.7 (6.2) years; 71% were women. From admission to discharge, the mean numbers of drugs prescribed per person increased from 6.0 (3.3) to 9.3 (3.8), p < 0.01. The prevalence of potentially inappropriate medications increased from 24% to 35%, p < 0.01; concomitant use of ≥ 3 psychotropic/opioid drugs and drug combinations including non-steroid anti-inflammatory drugs (NSAIDs) increased significantly. Serious drug–drug interactions were scarce both on admission and discharge (0.7%).

Conclusions

Inappropriate prescribing was prevalent among older people acutely admitted to hospital, and the prevalence was not reduced during stay at an intermediate-care nursing home unit specially designed for these patients.Key Words: Acute illness, drug–drug interactions, elderly, general practice, hospital, intermediate care unit, NORGEP screening tool, Norway, potentially inappropriate medicationsOlder people are at increased risk of adverse drug events. Screening tools may identify potentially inappropriate medications. Treatment in intermediate care units may possibly provide an opportunity for reducing inappropriate prescribing.

• Inappropriate prescribing was prevalent among community-dwelling older people on emergency admittance to hospitals in Bergen, Norway.
• Concomitant use of ≥ 3 psychotropic/opioid drugs and drug combinations including non-steroid anti-inflammatory drugs (NSAIDs) increased significantly during stay.
• Serious drug–drug interactions were scarce on admission and discharge.