Inappropriate medication use and prescribing indicators in elderly Australians: development of a prescribing indicators tool

BACKGROUND: Evidence-practice gaps, adverse medication-related incidents and unplanned medical admissions to hospital are common in elderly Australians. Many prescribing indicator tools designed to address some of these problems have been reported in the literature, the most common of which is the Beers list of inappropriate medications in the elderly. However, many of these tools are not appropriate for the Australian healthcare environment without modification and validation, and there appears to be a need for a tool based on Australian data. OBJECTIVE: To develop a list of prescribing indicators for elderly (aged >65 years) Australians based on the most frequent medications prescribed to Australians, and the most frequent medical conditions for which elderly Australians consult medical practitioners. METHOD: The most common reasons for elderly Australians to seek or receive healthcare were cross-referenced with the 50 highest-volume Pharmaceutical Benefits Scheme medications prescribed to Australians in 2006 to develop prescribing indicators in the elderly using Australian medication and medical condition information resources. RESULTS: Forty-eight prescribing indicators were identified, consisting mainly of optimum as well as inappropriate medication choices for a large number of common medical conditions in the elderly. CONCLUSION: A prescribing indicators tool was developed. This tool is envisaged as forming an important part of the medication review process, which is aimed at addressing the common problem of adverse medication-related events in elderly Australians.     

Alprazolam-reinforced medication use in outpatients with anxiety

The reinforcing effects of alprazolam were investigated in 14 patients who had generalized anxiety or panic disorder, but were not current users/abusers of other psychoactive substances. Using a double-blind outpatient choice procedure, color-coded alprazolam (0.5 mg) and placebo capsules were provided to patients for use ‘as needed’ in the treatment of anxiety symptoms. Comparisons of alprazolam and placebo during a 2 week sampling period in which placebo and alprazolam were available sequentially revealed no significant differences on measures of medication usage or anxiety levels, although alprazolam did increase subjective ratings of drug effects/side effects. During a 4 week choice period, alprazolam was strongly preferred over placebo in 11 out of 14 patients indicating that alprazolam functioned as a reinforcer. Medication usage ranged from zero to 4.0 mg alprazolam in a day. Variations in daily medication-use were positively correlated with anxiety level fluctuations for a majority of patients. For a majority of patients, the results indicate that alprazolam functioned as a reinforcer without accompanying signs of abuse or addiction.     

中国老年门诊患者潜在不适当用药现状系统评价

目的:了解中国老年门诊患者潜在不适当用药的现状及相关影响因素。方法:系统搜索中国生物医学文献服务系统(Sino Med)、中国知网(CNKI)、万方数据库、Pub Med、Embase和Web of Science的相关文献(截至2017年9月),纳入研究为横断面研究,研究对象是中国老年门诊患者,并且使用了潜在不适当用药的筛查工具,数据分析采用STATA软件。结果:共纳入文献16篇,其中有11篇研究使用了Beers标准(2012版),5篇使用了中国PIM目录;根据Beers标准,PIM的总体发生率为14.8%(95%CI:13.2%~16.4%)。根据中国PIM目录,PIM的总体发生率为23.2%(95%CI:19.3%~27.1%)。相关影响因素包括性别、年龄、用药种类和合并疾病种类。常见的不适当用药的药物种类:苯二氮类药物、甲氧氯普胺、螺内酯、非甾体抗炎药、胺碘酮和氯吡格雷。结论:虽然中国老年门诊患者PIM的发生率相对较低,但是应该引起医疗机构的重视;合理使用潜在不适当用药筛查工具,促进老年门诊患者合理用药。     

Frequency and risk factors of potentially inappropriate medication use in a community-dwelling elderly population: results from the 3C Study

Objective To estimate the frequency of potentially inappropriate medication use among community-dwelling elderly subjects and to identify socio-demographic factors associated with this use.Methods Data were collected in the Three-City Study, a French longitudinal study on vascular factors and cognitive decline. The study population was composed of 9,294 subjects aged 65 years and older, living in the community. Inappropriate medication use was assessed using a list derived from the Beers criteria by a panel of French experts.Results Nearly 40% of the participants used at least one potentially inappropriate medication: 23.4% used cerebral vasodilators, 9.2% long-acting benzodiazepines and 6.4% drugs with anticholinergic properties. Excluding cerebral vasodilators from the list, the frequency of potentially inappropriate medication use was 21.7%. This use was significantly more frequent among women, older subjects and poorly educated subjects. Adjusted analyses showed that these associations could not be explained by a confounding effect of medical factors. Compared with 13.0% of men with a high educational level, 27.9% of women with a low educational level used at least one potentially inappropriate medication (odds ratio=2.0; 95% confidence interval: 1.7–2.3).Conclusion This study is the first attempt to evaluate the frequency of potentially inappropriate medication use in the elderly French population. Female gender and low socio-economic characteristics reduced the chances of receiving optimal pharmacotherapy. The proportion of elderly subjects receiving potentially inappropriate medication was higher than shown in previous studies. This is mainly explained by differences in the use of cerebral vasodilators.     

本院老年门诊患者潜在不适当用药评估分析

目的分析老年门诊患者潜在不适当用药(PIMs)的临床特征及危险因素。方法采用横断面调查的方法,收集本院老年科门诊年龄≥60岁患者的人口学、临床诊断、用药情况、药物不良反应(ADRs)、认知功能、用药依从性等资料,以Beers标准对PIMs进行评估分析。比较有和无PIMs患者的各项资料差异,logistic回归分析法分析PIMs与危险因素的相关性。结果共纳入1 187例患者,年龄(79.8±7.3)岁,PIMs发生率为25.02%(297/1187)。PIMs组患者年龄[(82.8±7.4)岁vs.(78.6±7.1)岁]、共患病种数(4.2±1.0 vs.3.2±1.0)、用药种数(11.0±2.6 vs.7.9±2.3)、认知功能损害比例(42.1%vs.12.1%)及ADRs发生率(30.3%vs.6.6%)均高于无PIMs组(P<0.05或P<0.01),而用药依从性良好比例低于无PIMs组(86.2%vs.95.2%,P<0.05)。Logistic分析显示年龄>70岁、共患病≥2种、用药种数≥10种、认知功能损害与PIMs呈显著正相关(P<0.01),良好的用药依从性与PIMs呈显著的负相关(P<0.01)。结论老年门诊患者发生PIMs的比例较高,PIMs患者出现ADRs的风险也大。除高龄、共患病种数、用药种数等因素外,认知功能损害也是PIMs的独立危险因素,而良好的用药依从性可减少老年门诊患者发生PIMs的风险。     

老年心血管病患者潜在性不适当用药及影响因素分析

目的:评价某院老年心血管病患者药物潜在不适当应用情况,并对其影响因素进行分析。方法:抽取某院2015年10月到2016年8月的老年心血管病例,以2014年版STOPP/START标准为依据,对年龄在65岁及以上的出院患者潜在不适当用药(PIM)进行评价,并采用多因素Logistic回归分析确定其影响因素。结果:通过病例筛选纳入514份病例,患者平均年龄(77.44±8.48)岁,平均罹患疾病数(5.93±2.34)种,联合用药总数(16.84±8.89)种;其中涉及2014年版STOPP标准不适当用药190例次,START标准处方遗漏419例次。单因素卡方分析提示,年龄(P=0.022)、罹患疾病数(P=0.041)、联合用药数(P=0.000)、心血管疾病史(P=0.001)及是否接受抗栓治疗(P=0.000)与PIM的发生具有相关性,且差异具有显著性(P<0.05);多因素Logistic回归分析提示稳定型心绞痛(OR=2.543,P=0.025),心房颤动(OR=2.304,P=0.024),冠状动脉粥样硬化(OR=2.659,P=0.005),联合用药数(≥10)(OR=1.040,P=0.026)及接受抗栓治疗(OR=3.037,P=0.007)的患者均会增加潜在不适当用药的风险,采用拟合的Logistic回归预测模型对入选病例预测总的预测正确率为74.5%。结论:老年心血管疾病患者发生潜在不适当用药是稳定型心绞痛、心房颤动、冠状动脉粥样硬化,联合用药数(≥10)及接受抗栓治疗多因素相互影响的结果。基于相关危险因素的PIM预防有助于减少不良事件的发生,促进临床合理用药。     

天津市某三甲医院门诊患者用药行为风险KAP调查及影响因素研究

目的:了解天津医科大学总医院门诊患者在用药行为上存在的具体问题,分析影响安全用药知识、态度和行为的相关因素,为有针对性地开展合理用药宣教提供方向.方法:以纸质问卷形式,对该院门诊患者进行知-信-行(knowledge-attitudes-practices,KAP)调查,采用Excel软件对问卷进行整理和汇总,采用t检...     

Perceived medication use challenges and coping strategies among medical outpatients in Nigeria

Background The use of medicines is an action that involves a change in behaviour and it is a complex construct involving reciprocal interactions between social, environmental and cognitive factors. This is particularly true when a patient uses medicines for asymptomatic chronic conditions, requiring life-long use. Objective To identify patient-perceived medication use challenges, determine the coping strategies used and investigate the relationship between patient-perceived challenges and self-initiation of coping strategies. Setting A premier 900-bed tertiary/teaching hospital located in Ibadan, Nigeria. Method Ten pharmacists conducted cross-sectional medication use interviews for a random sample of 324 medical outpatients in 4 weeks (25th October–19th November 2006). Main outcome measure Patient-perceived challenges with prescribed medications, self-initiated coping strategies used and relationship between patient-perceived challenges and self-initiation of coping strategies Results Eighty-one percent (324) of the random sample of 400 patients consented and completed the interview. Of these, 50.3 % were males while 49.7 % were females with mean age (SD) of 51.5 (17.6) and 52.1 (17.4) years respectively. The most frequent diagnoses were hypertension (53 %) and type-2 diabetes + hypertension (14.5 %). Two hundred and twenty-four patients reported one or more perceived challenges. Of these, 43.8 % were 65 years or older and about half reported at least 3 challenges. The majority (95.6 %) of patients who reported perceived challenges initiated one or more coping strategies without the knowledge of their physicians or pharmacists. Of 100 patients who did not report any perceived challenge, 43 % admitted initiating strategies to maintain perceived “cure” of their medical conditions. Self-initiation and use of coping strategies was far more likely among patients who reported perceived challenges (OR: 28.4, 95 % CI 26.1–30.5). The number of coping strategies reported appeared strongly related to the number of perceived challenges (r = 0.91, p < 0.001). Conclusion Perceived challenges associated with the use of prescribed medications and self-initiation of coping strategies appeared considerable among medical outpatients at a major teaching hospital in Nigeria. The risk of unauthorised initiation and use of varieties of coping strategies without the knowledge of clinicians was very high among patients who reported at least one perceived challenge.     

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.     

Comparison of the prevalence and nature of potentially inappropriate medication use in geriatric outpatients between tertiary and community healthcare settings: a multicenter cross-sectional study

International Journal of Clinical Pharmacy - Background Geriatric outpatients with polypharmacy have a high risk of potentially inappropriate medication (PIM) use. Aim To identify differences in...     

基于Beers标准的门诊心内科老年患者潜在性不适当用药分析

目的调查我院门诊心内科老年患者潜在性不适当用药情况。方法以Beers标准(2012版)为主要依据,对我院4 320例门诊心内科老年患者的潜在性不适当用药进行分析。结果依据Beers标准,334例(7.73%)存在与药物相关的潜在性不适当用药,40例(0.93%)存在与疾病或状态相关的潜在性不适当用药,301例(6.97%)使用了老年慎用的药物;根据药学专业知识,判断出不适当用药359例(8.31%)。结论 Beers标准在评估老年患者潜在性不适当用药方面有重要的参考价值,但不能替代专业判断,需根据医院及患者实际情况进行综合分析。