Medication Use Quality and Safety in Older Adults: 2018 Update

Improving the quality of medication use and medication safety is an important priority for prescribers who care for older adults. The objective of this article was to identify key articles from 2018 that address these issues. In addition, we selected four of these articles to annotate, critique, and discuss their broader implications for clinical practice. The first study highlights a cluster‐randomized trial that utilized a pharmacist‐led education‐based intervention delivered to both patients and physicians to deprescribe four types of inappropriate medications (sedative‐hypnotics, first‐generation antihistamines, selective nonsteroidal anti‐inflammatory drugs, and glyburide). The second study, a nested case‐control study using data from within the UK Clinical Practice Research Datalink, examined the association between anticholinergic exposure, overall and by anticholinergic medication class, and dementia risk in 40 770 older adults. The third study, a longitudinal cohort study of 1028 Swedish older adults, examined the association between antihypertensive medications and incident dementia. The last study was a randomized, double‐blind, placebo‐controlled trial that investigated the effect of daily low‐dose aspirin (100 mg) for primary prevention on cardiovascular events and major hemorrhage in 19 144 community‐dwelling older adults. Collectively, this current article provides insight into the pertinent topics of medication use quality and safety in older adults and helps raise awareness about optimal prescribing in older adults. J Am Geriatr Soc 67:2458–2462, 2019     

Medication Use Quality and Safety in Older Adults: 2019 Update

Improving the quality of medication use and medication safety are important priorities for prescribers who care for older adults. The objective of this article was to identify four exemplary articles with this focus in 2019. We selected high-quality studies that moved the field of research forward and were not merely replication studies. The chosen articles cover domains related to aspects of suboptimal prescribing and medication safety. The first study used a nationally representative sample of Medicare beneficiaries to examine the continuation of medications with limited benefit in patients admitted for cancer and non-cancer diagnoses in hospice (domain: potentially inappropriate medications). The second study, a retrospective cohort study of older adults in Ontario, Canada, assessed the association between prescribing oral anticoagulants in an emergency department relative to not prescribing anticoagulants in the emergency department and their persistence at 6 months (domain: underuse of medications). The third study, a cluster randomized trial in Quebec, Canada, evaluated the effect of conducting electronic medication reconciliation on several outcomes including adverse drug events and medication discrepancies (domain: medication safety). Lastly, the fourth study, a retrospective study using national inpatient and outpatient Veteran Health Administration combined with clinical and Medicare Claims data, examined the effects of intensification of antihypertensive medications on older adults' likelihood for hospital re-admission and other important clinical outcomes (domain: medication safety). Collectively, this review succinctly highlights pertinent topics related to promoting safe use of medications and promotes awareness of optimizing older adults' medication regimens.     

Complex and Potentially Harmful Medication Patterns in Heart Failure with Preserved Ejection Fraction

BackgroundComplex medication regimens, often present in heart failure with preserved ejection fraction, may increase the risk of adverse drug effects and harm. We sought to characterize this complexity by determining the prevalence of polypharmacy, potentially inappropriate medications, and therapeutic competition (where a medication for 1 condition may worsen another condition) in 1 of the few dedicated heart failure with preserved ejection fraction programs in the United States.MethodsWe conducted chart review on 231 patients with heart failure with preserved ejection fraction seen in the University of Michigan's Heart Failure with Preserved Ejection Fraction Clinic between July 2016 and September 2019. We recorded: 1) standing medications to determine the presence of polypharmacy, defined as ≥10 medications; 2) potentially inappropriate medications based on the 2016 American Heart Association Scientific Statement on drugs that pose a major risk of causing or exacerbating heart failure, the 2019 Beers Criteria update, or a previously described list of medications associated with geriatric syndromes; and 3) competing conditions and subsequent medications that could create therapeutic competition.ResultsThe prevalence of polypharmacy was 74%, and the prevalence of potentially inappropriate medications was 100%. Competing conditions were present in 81% of patients, of whom 49% took a medication that created therapeutic competition.ConclusionIn addition to confirming that polypharmacy was highly prevalent, we found that potentially inappropriate medications and therapeutic competition were also frequently present. This supports the urgent need to develop patient-centered approaches to mitigate the negative effects of complex medication regimens endemic to adults with heart failure with preserved ejection fraction.     

Tools to reduce polypharmacy

The reduction in polypharmacy and avoidance of inappropriate medications is a common goal in the care of older persons, regardless of setting. While multidisciplinary teams and regular medication reconciliation and review can identify and reduce medication-related problems, tools to decrease the use of high-risk/low benefit medications can help the individual clinician to improve prescribing. Numerous criteria, tools, algorithms, and scoring systems have been developed for use in a wide range of areas from long-term care to the outpatient setting, and some may not be applicable to individual situations. Not all medication review instruments have been adequately validated, and the tools we have presented have varying levels of evidence to support their use. Clinicians also need to be aware of regulatory, policy, and guideline issues that may impact the use of certain criteria for optimum prescribing. Ultimately, optimizing prescribing by reducing polypharmacy and avoiding inappropriate medications is a highly individualized process for each patient, and clinicians will have to use extensive clinical judgment in using the tools presented here.     

Medications in long-term care: when less is more

Attention has been drawn to the potential risks of several medications in the long-term care setting. Most of these medications deemed as inappropriate affect the central nervous system and are indicated only for select populations with specific conditions. Many of these drugs are prescribed without clear indications and continued indefinitely without critical decision-making about the potentially salutary effects of discontinuing medications. This article describes the increasing awareness of potentially inappropriate prescribing in the long-term care setting and reviews the rationale for why various types of medications are deemed inappropriate, with a focus on agents that affect central nervous system functioning.     

Electronic prescribing and other forms of technology to reduce inappropriate medication use and polypharmacy in older people: a review of current evidence

This review provided an overview of the current evidence in relation to the use of e-prescribing and other forms of technology, such as CDSS, to reduce inappropriate prescribing in older people. The evidence indicates that various types of e-prescribing and CDSS interventions have the potential to reduce inappropriate prescribing and polypharmacy in older people, but the magnitude of their effect varies according to study design and setting. There was significant heterogeneity in the studies reported in terms of study designs, intervention design, patient settings, and outcome measures with patient outcomes seldom reported. Widespread diffusion of these interventions has not occurred in any of the health care settings examined. Overall, health care providers report being satisfied with e-prescribing systems and see the systems as having a positive impact on the safety of their prescribing practices, yet the problem of overriding or ignoring alerts persists. The problem of large numbers of inaccurate and insignificant alerts and this issue, along with the other barriers that have been identified, warrant further investigation.     

Medication adherence to multidrug regimens

Despite the fact that medication adherence has been extensively described in the literature over the last several decades, a quote by Becker and Maiman from over 35 years ago best captures the current state of our understanding: “Patient compliance[sic adherence] has become the best documented, but least understood, health behavior.” Future research is greatly needed to identify and translate safe and effective interventions into routine clinical practice to improve adherence. Only then can we begin to make significant improvements to the medication use process and, in turn, the health of older adults.