Inappropriate Medications and Older People

OPINION

Inappropriate Medications and Older People: Has Anything Changed Over Time? Carlos H Rojas-Fernandez

Ann Pharmacother 2003;37:1142-4. Published Online, 16 Jun 2003, www.theannals.com DOI 10.1345/aph.1D093

A study conducted in 1996 demonstrated that 21% of community-dwelling elderly patients in the US received at least 1 inappropriate medication according to the 1997 Beers criteria.1 Avorn commented that “…the sensation of déjà vu is always unsettling….”2 Nonetheless, I believe that déjà vu can help move things forward and effect positive change. I outline here the evolution of the literature regarding inappropriate medication prescribing for older people, discuss the merits of the report by Gray et al.,3 and speculate where this area of research and practice is going.

See also page 988, DOI 10.1345/aph.1C365.

The concept of inappropriate medication prescribing for older people has received much attention over the years. Indeed, documented rates of inappropriate prescribing have ranged from 5% to 40%, depending on the setting and criteria used.4 These findings are not surprising, since the high rate of chronic disease in this population leads to a disproportionate consumption of medications: about 35% of all drug expenditures are attributable to older people, despite the fact that they account for approximately 13% of the population.5,6 Furthermore, salient age-related changes in pharmacokinetics and pharmacodynamics and the high prevalence of frailty in this population place them at high risk for adverse drug events including hospitalizations, functional decline, nursing home placement, and death.7 Author information provided at the end of the text.

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The first version of Beers’ list of inappropriate medications for older nursing home residents was published in 1991.8 While the list was not without its critics, it became widely used for research purposes and by regulators in attempts to define, quantify, and presumably rectify the pervasive problem of inappropriate prescribing. A revised list was published in July 1997 that could be applied to drug use by older people regardless of where they resided and could also be used for research purposes in clinical practice and by regulators.9 In the same year, Canadian investigators also published an explicit list of inappropriate prescribing practices that would serve a similar purpose.10 These methods proved useful and are relatively simple (they require little information about the patients and their medications). However, their main limitation is that, in studies of inappropriate medication use, the prevalence of the problem appears to be underestimated for reasons discussed here. In that regard, the groundbreaking work of Hanlon et al.11 was a timely and welcome addition to research methodology in this area. Those investigators carefully designed and tested the Medication Appropriateness Index (MAI).12 This 10-item instrument went beyond an explicit and limited list of inappropriate medications by assessing important clinical constructs: Is there an indication for the drug in question? Are there dosage concerns? Are there concerns with the directions? Does therapeutic duplication exist? Other important domains were also assessed. Limitations of this method included its requirement for detailed clinical information, the time needed to assess a patient’s drug regimen, and its implicit nature. Nevertheless, the MAI improved the way in which drug use patterns in older people were (and continue to be) studied. One study used this method to evaluate medication use in older ambulatory patients and found that 74% of the drugs prescribed to the sample produced ≥1 medication-related problems.13 Using a modified MAI, another study found that 82% of older hospitalized people took ≥1 inappropriate drugs.14

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Another aspect of medication use in older people that came to the limelight in the 1990s was the underuse of medications in older people.15 This issue was recently reviewed in an article that thoughtfully discussed the broader, more clinically relevant concept of suboptimal prescribing for older patients.16 Under this broader concept, salient constructs to consider are (1) overuse of medications (i.e., “usual” polypharmacy) or new drugs to treat symptoms of a “new” disease when, in fact, these symptoms are unrecognized drug toxicity, (2) inappropriate medication use (e.g., drugs whose risk–benefit profile is unfavorable, such as diphenhydramine), and (3) underuse of medications (e.g., an indication exists, but no drug is prescribed or the dose is not titrated to desired effect, such as not prescribing warfarin for a patient with atrial fibrillation). It appears then, that a thoughtful evolution has occurred over the past decade or so, whereby concepts of and methods with which to measure the quality of medication prescribing for older people have changed. Presumably, these changes will shed further light on the problem and, as mentioned above, improve prescribing for older people. What, then, does the report by Gray et al. tell us about the current state of affairs? Two hundred and eight residents of community residential care (CRC) facilities who were either newly admitted or recently converted to Medicaid funding between April 1998 and March 1999 were included in their study. The objectives were to (1) describe the prevalence of inappropriate medication use in CRC at baseline, (2) describe the 1-year incidence of inappropriate medication use, and (3) examine correlates of inappropriate drug use. Using in-person interviews with trained personnel and state databases, the investigators collected detailed demographic, functional, cognitive, and medical information (i.e., list of drugs used). The outcome measure of inappropriate medication use was the Beers’ criteria that were published in 1997 with some minor modifications. One main finding of the study was that the absolute number of inappropriate medications was 75, which were taken by 22% of residents in the sample or, stated another way, among those taking inappropriate agents, the average was 1.2 per person. Of the 22% of residents using inappropriate medications at baseline, 81% used only 1 inappropriate drug and 55% used an agent classified as severe (e.g., doxepin, long half-life benzodiazepines). Another finding showed that the subsequent 1-year incidence of at least 1 inappropriate drug being used in this sample was 44% for new and existing users combined. For subjects who were not using such drugs at baseline (n = 217), the incidence rate was 1 inappropriate medication/1000 person-days. The authors concluded that inappropriate drug use is common among residents of CRC facilities and that comprehensive review of medications may be beneficial for older adults taking multiple medications in these settings. They also made the astute observation that future research should be focused on a more comprehensive review of suboptimal prescribing in older adults in these settings. The latter point is perhaps the most important message to pharmacists who endeavor to improve the care of all older www.theannals.com

patients, regardless of where they reside. Moreover, it speaks to the fact that we need to strongly consider moving away from only using lists of “bad drugs” or the number of drugs as sole measurement instruments for inappropriate medication use in older people. Such a statement is supported by the fact that, despite the wealth of studies documenting so-called inappropriate medication use in older people, the impact of inappropriate prescribing on health outcomes in older people at the population level is still unclear. Indeed, a recent study suggests that criteria that are solely based on such drug lists (i.e., Beers’ list) do not predict significant associations between the use of these drugs and negative functional outcomes.17 However, when these investigators combined this list with drug utilization review criteria, a significant association between inappropriate medication use and basic self care was documented and pronounced among patients with drug– drug or drug– disease interactions. In fact, in a recent review of suboptimal prescribing in older people, the authors noted that, despite the documented “successes” of decreasing inappropriate medication use by methods such as computer feedback and formulary restrictions, the impact of such strategies on morbidity and mortality has not been reported.16 Indeed, many of the medications included in “drugs to avoid” lists as in Beers’ criteria are seldom prescribed in clinical practice today, and so using only such lists as quality indicators is quite limiting. For example, none of the newer antidepressants or medications for osteoporosis are included in these lists. Thus, if a patient is receiving a subtherapeutic dose of an antidepressant, such an event would not be captured by “drugs to avoid” lists. Similarly, if a patient with osteoporosis has no contraindications to the use of bisphosphonates (with robust efficacy against vertebral and nonvertebral fractures) and is only offered calcitonin (only proven against vertebral fractures), such undertreatment would also not be captured. Clearly there is much more to the picture than simply bad drugs. We should nonetheless not be complacent about the use of these drugs since they can be quite toxic in this population and, clearly, better alternatives currently exist. With the aforementioned considerations in mind, we should consider the following when reviewing Gray et al.’s study: 1. The data collection period was recent (i.e., 1998–99), yet the proportion of subjects prescribed inappropriate drugs was high (22% at baseline). Clearly, educational efforts aimed at healthcare professionals are necessary at this most basic level of geriatric clinical pharmacology (i.e., identifying drugs that are undesirable). 2. Although potentially inappropriate medication use has been well documented in other settings, it is always timely and important to explore the prevalence of such problems in settings where research is lacking, as the authors have done, report them, and hopefully edge us along in steps aimed at improving drug use for older people. 3. The updated Beers’ criteria were published in July 1997; therefore, their uptake by clinicians by the time


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the data were collected by Gray et al. was likely not very high, possibly inflating the prevalence of inappropriate drug use. Various methods may be used to assess medication appropriateness in older people, each with its pros and cons. Nevertheless, it is necessary that more comprehensive methods be adopted in this important area of geriatric pharmacotherapy. This is exemplified by methods that can be used in research settings or in teaching facilities11 or the more recently introduced ACOVE (Assessing Care of Vulnerable Elders) project, which can be used even in healthcare systems that only maintain paper records.18 Furthermore, increased education of healthcare professionals in basic geriatric pharmacotherapy concepts must be a priority for medical, pharmacy, and nursing schools so that the next generation of healthcare providers begin their careers with the proper context for optimal medication use in this vulnerable population. Along the same lines, continuing education efforts should also include programs in geriatric pharmacotherapy since, in some cases, a practicing clinician’s knowledge of even basic concepts of geriatric pharmacotherapy can be very limited despite significant advances in science in this area over the past 2 decades.19,20 Additionally, education for consumers should also be considered, especially in this era of direct-to-consumer advertising of medications. For example, pharmacists could become involved in community senior groups or senior fairs and provide important education that would help older people to become more informed about drugs to avoid, untreated indications, and other common problems. Lastly, and perhaps most important, truly collaborative relationships between prescribers and pharmacists need to be further developed and strengthened if we are to play an active and important role in improving medication use in older people. Carlos H Rojas-Fernandez PharmD BCPP, at time of writing, Assistant Professor, Pharmacy Practice; Director, Geriatric Pharmacy Residency Program, School of Pharmacy, Texas Tech University, Health Sciences Center, Amarillo, TX; now, Neuroscience Medical Science Manager, Bristol-Myers Squibb, Washington, DC, 108 Winter Walk Dr., Gaithersburg, MD 20878-7801, FAX 301/330-1795, Email [email protected] Reprints: Carlos H Rojas-Fernandez PharmD BCPP

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References 1. Zhan C, Sangl J, Bierman AS, Miller MR, Friedman B, Wickizer SW, et al. Potentially inappropriate medication use in the community-dwelling elderly: findings from the 1996 Medical Expenditure Panel Survey. JAMA 2001;286:2823-9. 2. Avorn J. Improving drug use in elderly patients: getting to the next level. JAMA 2001;286:2866-8. 3. Gray SL, Hedrick SC, Rhinard EE, Sales AE, Sullivan JH, Tornatore JB, et al. Potentially inappropriate medication use in community residential care facilities. Ann Pharmacother 2003;37:988-93. DOI 10.1345/aph.1C365 4. Aparasu RR, Mort JR. Inappropriate prescribing for the elderly: Beers criteria–based review. Ann Pharmacother 2000;34:338- 46. DOI 10.1345/ aph.19006. 5. Levit K, Cowan C, Braden B, Stiller J, Sensenig A, Lazenby H. National health expenditures in 1997: more slow growth. Health Affairs 1998;17: 99-110. 6. Rathore SS, Mehta SS, Boyko WL Jr, Schulman KA. Prescription medication use in older Americans: a national report card on prescribing. Fam Med 1998;30:733-9. 7. Owens NJ, Fretwell MD, Willey C, Murphy SS. Distinguishing between the fit and frail elderly and optimising pharmacotherapy. Drugs Aging 1994;4:47-55. 8. Beers MH, Ouslander JG, Rollingher I, Reuben DB, Brooks J, Beck JC. Explicit criteria for determining inappropriate medication use in nursing home residents. Arch Intern Med 1991;151:1825-32. 9. Beers MH. Explicit criteria for determining potentially inappropriate medication use by the elderly. Arch Intern Med 1997;157:1531-6. 10. McLeod PJ, Huang AR, Tamblyn R, Gayton DG. Defining inappropriate practices in prescribing for elderly people: a national consensus panel. CMAJ 1997;156:385-91. 11. Hanlon JT, Schmader KE, Samsa GP, Weinberger M, Uttech KM, Lewis IK, et al. A method for assessing drug appropriateness. J Clin Epidemiol 1992;45:1045-51. 12. Samsa GP, Hanlon JT, Schmader KE, Weinberger M, Clipp EC, Uttech KM, et al. A summated score for the medication appropriateness index: development and assessment of clinimetric properties including content validity. J Clin Epidemiol 1994;47:891-6. 13. Schmader K, Hanlon JT, Weinberger M, Landsman PB, Samsa GP, Lewis I, et al. Appropriateness of medication prescribing in ambulatory elderly patients. J Am Geriatr Soc 1994;42:1241-7. 14. Ruscin JM, Owens NJ, Fried TP. Use of a modified medication appropriateness index to assess the quality of medication prescribing in very old acutely ill patients (abstract). Pharmacotherapy 1995;15:57. 15. Rochon PA, Gurwitz JH. Prescribing for seniors: neither too much nor too little. JAMA 1999;282:113-5. 16. Hanlon JT, Schmader KE, Ruby CM, Weinberger M. Suboptimal prescribing in older inpatients and outpatients. J Am Geriatr Soc 2001;49: 200-9. 17. Hanlon JT, Fillenbaum GG, Kuchibhatla M, Artz MB, Boult C, Gross CR, et al. Impact of inappropriate drug use on mortality and functional status in representative community dwelling elders. Med Care 2002;40: 166-76. 18. Wenger NS, Shekelle P, Davidoff F, Mulrow C. Quality indicators for assessment of vulnerable elders. Ann Intern Med 2001;135:641-758. 19. Rojas-Fernandez CH, Slattum PW, Hanlon JT, Howard KA. A pilot study of pharmacist’s knowledge of essential geriatric pharmacotherapy concepts. Consult Pharm 2002;17:962-71. 20. Ferry ME, Lamy PP, Becker LA. Physician’s knowledge of prescribing for the elderly. J Am Geriatr Soc 1985;33:616-23.


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