METHODS: A systematic review of published and unpublished studies were carried out. Included studies described the development of explicit criteria for PIM use in older adults and provided a list of medications that should be considered inappropriate. PubMed, Medline, EMBASE, Cochrane CENTRAL, CINAHL, PsycINFO, and Scopus searches were conducted. The PIMs were analyzed according to the general conditions, disease-specific conditions, and drug-drug interaction classes. The qualities of the included studies were assessed using a nine-point evaluation tool. The kappa agreement index was used to evaluate the level of agreement between the identified explicit PIM tools.
RESULTS: The search yielded 1206 articles, and 15 studies were included in our analysis. Thirteen criteria were identified in East Asia and two in South Asia. Twelve out of the 15 criteria were developed using the Delphi method. We identified 283 PIMs independent of medical conditions and 465 disease-specific PIMs. Antipsychotics were included in most of the criteria (14/15), followed by tricyclic antidepressants (TCAs) (13/15), antihistamines (13/15), sulfonylureas (12/15), benzodiazepines (11/15), and nonsteroidal anti-inflammatory drug (NSAIDs) (11/15). Only one study fulfilled all the quality components. There was a low kappa agreement (k = 0.230) between the included studies.
CONCLUSION: This review included 15 explicit PIM criteria, which most listed antipsychotics, antidepressants, and antihistamines as potentially inappropriate. Healthcare professionals should exercise more caution when dealing with these medications among older patients. These results may help healthcare professionals in Asian nations to create regional standards for the discontinuation of potentially harmful drugs for elderly patients.
AIMS: This study determined the use of potentially inappropriate medications according to frailty status using the Beers Criteria 2019, identified medications that should be flagged as potentially inappropriate and harmful depending on individual health factors, and determined the association between frailty and PIMs, adjusted for characteristics associated with PIMs.
METHODS: This prospective longitudinal study included 9355 participants aged 77-82 years at baseline (2003). Frailty was measured using the FRAIL (fatigue, resistance, ambulation, illness and loss of weight) scale. Generalised estimating equations using log-binomial regressions determined the association between frailty and risk of using PIMs.
RESULTS: Among participants who were frail and non-frail at baseline, the majority used ≥ 3 PIMs (74.2% and 58.5%, respectively). At 2017, the proportion using ≥ 3 PIMs remained constant in the frail group (72.0%) but increased in the non-frail group (66.0%). Commonly prescribed medications that may be potentially inappropriate in both groups included benzodiazepines, proton-pump inhibitors and non-steroidal anti-inflammatory drugs, and risperidone was an additional contributor in the non-frail group. When adjusted for other characteristics, frail women had a 2% higher risk of using PIMs (RR 1.02; 95% CI 1.01, 1.03).
CONCLUSION: Given that the majority of frail women were using medications that may have been potentially inappropriate, it is important to consider both frailty and PIMs as indicators of health outcomes, and to review the need for PIMs for women aged 77-96 years who are frail.
DESIGN: Pragmatic multicenter stepped-wedge cluster randomized controlled trial.
SETTING AND PARTICIPANTS: Residents across 4 nursing homes in Singapore were included if they were aged 65 years and above, and taking 5 or more medications.
METHODS: The intervention involved a 5-step deprescribing intervention, which involved a multidisciplinary team-care medication review with pharmacists, physicians, and nurses (in which pharmacists discussed with other team members the feasibility of deprescribing and implementation using the Beers and STOPP criteria) or to an active waitlist control for the first 3 months.
RESULTS: Two hundred ninety-five residents from 4 nursing homes participated in the study from February 2017 to March 2018. At 6 months, the deprescribing intervention did not reduce falls. Subgroup analysis showed that intervention reduced fall risk scores within the deprescribing-naïve group by 0.18 (P = .04). Intervention was associated with a reduction in mortality [hazard ratio (HR) 0.16, 95% confidence interval 0.07, 0.41; P
METHODS: A systematic search was conducted in four databases from inception until April 30, 2021 as well as search of citation of included articles. Studies that reported patients' and/or their caregivers' attitude towards deprescribing quantitatively were included. All studies were independently screened, reviewed, and data extracted in duplicates. Patients and caregivers willingness to deprescribe their regular medication was pooled using random effects meta-analysis of proportions.
RESULTS: Twenty-nine unique studies involving 11,049 participants were included. All studies focused on the attitude of the patients towards deprescribing, and 7 studies included caregivers' perspective. Overall, 87.6% (95% CI: 83.3 to 91.4%) patients were willing to deprescribe their medication, based upon the doctors' suggestions. This was lower among caregivers, with only 74.8% (49.8% to 93.8%) willing to deprescribe their care recipients' medications. Patients' or caregivers' willingness to deprescribe were not influenced by study location, study population, or the number of medications they took.
DISCUSSION: Most patients and their caregivers were willing to deprescribe their medications, whenever possible and thus should be offered a trial of deprescribing. Nevertheless, as these tools have a poor predictive ability, patients and their caregivers should be engaged during the deprescribing process to ensure that the values and opinions are heard, which would ultimately improve patient safety. In terms of limitation, as not all studies may published the methods and results of measurement they used, this may impact the methodological quality and thus our findings. OPEN SCIENCE FRAMEWORK REGISTRATION: https:// osf.io/fhg94.
OBJECTIVE: This systematic review sought to identify DRPs due to medication misadventures, including adverse drug reactions (ADRs), and use of inappropriate medications, among patients with dementia or cognitive impairments.
METHODS: The included studies were retrieved from the electronic databases PubMed and SCOPUS, and a preprint platform (MedRXiv) which were searched from their inception through August 2022. The English-language publications that reported DRPs among dementia patients were included. The JBI Critical Appraisal Tool for quality assessment was used to evaluate the quality of studies included in the review.
RESULTS: Overall, 746 distinct articles were identified. Fifteen studies met the inclusion criteria and reported the most common DRPs, which comprised medication misadventures (n = 9), such as ADRs, inappropriate prescription use, and potentially inappropriate medication use (n = 6).
CONCLUSION: This systematic review provides evidence that DRPs are prevalent among dementia patients, particularly the older people. It indicates that medication misadventures such as ADRs and inappropriate drug use, as well as potentially inappropriate medications, are the most prevalent DRPs among older people with dementia. Due to the small number of included studies, however, additional studies are required to improve comprehension about the issue.
METHODS: This cross-sectional study included data from 344 older (173 inpatients and 171 outpatients) patients, aged 60 years and above, through validated questionnaires. Medication appropriateness was assessed via Medication Appropriateness Index (MAI) tool, whereas Beers and Screening Tool of Older Person's Potentially Inappropriate Prescribing (STOPP) criteria were used to evaluate PIMs and potentially inappropriate prescribing (PIP), respectively. The Drug Burden Index (DBI) and polypharmacy, as well as PROs, included Groningen Frailty Indicator (GFI), Katz Index of Independence in Activities of Daily Living (Katz ADL) and Older People's Quality of Life (OPQOL) were also evaluated.
RESULTS: Overall, inpatients received significantly higher medications (6.90 ± 2.70 vs 4.49 ± 3.20) than outpatients. A significantly higher proportion of inpatients received at least one PIM (65% vs 57%) or PIP (57.4% vs 17.0%) and higher mean MAI score (1.76 ± 1.08 and 1.10 ± 0.34) and DBI score (2.67 ± 1.28 vs 1.49 ± 1.17) than outpatients. Inpatients had significantly higher total OPQOL (118.53 vs 79.95) and GFI score (5.44 vs 3.78) than outpatients. We only found significant correlations between GFI and DBI and total OPQOL and the number of PIMs.
CONCLUSIONS: Proportions of PIMs and DBI exposure were significantly higher in an inpatient setting. No significant correlations between exposures to inappropriate medications or drug burden and PROs were observed.
METHODS: The study was conducted using a self-administered questionnaire. Knowledge of PIMs was assessed using 10 clinical vignettes based on the 2015 Beers Criteria. Practice behaviour towards older customers was assessed using 10 items with a 5-point Likert scale. Descriptive and inferential statistics were used to analyse the data.
RESULTS: A total of 277 community pharmacists participated in the study. Only 27.1% of the pharmacists were aware of Beers Criteria, and of these, only 37.3% were aware of the latest 2015 update. The respondents demonstrated moderate knowledge of PIMs with a mean total score of 5.46 ± 1.89 out of a maximum of 10. Pharmacists who were aware of Beers Criteria had significantly higher scores (6.31 vs 5.14, P
Methods: A cross-sectional study using a validated 20-item questionnaire was conducted among physicians (n=78) and clinical pharmacists (n=45) working in the medical wards of two tertiary hospitals in Malaysia. Knowledge was assessed by six clinical vignettes which were developed based on Beers criteria and the STOPP/START criteria. Other domains of the study were investigated using a four-point or five-point Likert scale.
Results: Of the 82 participants who completed the questionnaire, 65% were physicians, 90.2% had never received training in geriatric medicine, and 70.8% estimated that 25% or more of their patients were elderly. Only six participants (7.3%) had ever used STOPP/START or Beers criteria when prescribing for elderly patients, and 60% of the respondents had never heard of either one of those criteria. The mean score (SD) for the knowledge part was 3.65 (1.46) points, and only 27 participants (22.9%) scored more than four out of a possible six points. Overall, 34% of the participants rated themselves as confident in prescribing for elderly patients, and this was significantly associated with their knowledge score (P=0.02). The mean number (SD) of barriers cited per participant was 6.88 (2.84), with polypharmacy being the most cited barrier.
Conclusions: The majority of the participants had inadequate knowledge and low confidence regarding recommending medications for elderly patients. Continuing education on geriatric pharmacotherapy may be of value for the hospital physicians and pharmacists.
METHODS: We prospectively studied older patients (n = 301) admitted to three urban, public-funded hospitals. We scrutinized their medical records and used STOPP-START (Screening Tool to Alert Prescribers to Right Treatment) criteria to determine PIM and potential prescribing omissions (PPO) respectively- together these constitute IP. Prescriptions with PIM(s) were subjected to a pharmacist medication review, aimed at detecting cases of ADE(s). The vetted cases were further assessed by an expert consensus panel to ascertain: i) causality between the ADE and hospitalization, using, the World Health Organization Uppsala Monitoring Centre criteria, and, ii) whether the ADEs were avoidable (using Hallas criteria). Finally, percentages of PIM-associated ADEs that were both preventable and linked to hospitalization were calculated.
RESULTS: IP prevalence was 58.5% (n = 176). A majority (49.5%, n = 150) had moderate to severe degree of comorbidities (Charlson Comorbidity Index score ≥ 3). Median age was 72 years. Median number of medications was 6 and 30.9% (n = 93) had ≥8 medications. PIM prevalence was 34.9% (117 PIMs, n = 105) and PPO 37.9% (191 PPOs, n = 114). Most PIMs and PPOs involved overuse of aspirin and underuse of both antiplatelets and statins respectively. With every increase in the number of medications prescribed, the likelihood of PIM occurrence increased by 20%, i.e.1.2 fold (OR 1.20, 95% CI: 1.1-1.3). Among the 105 patients with PIMs, 33 ADEs (n = 33); 31 ADEs (n = 31) considered "causal" or "contributory" to hospitalization; 27 ADEs (n = 27) deemed "avoidable" or "potentially avoidable"; and 25 PIM-associated ADEs, preventable, and that induced hospitalization (n = 25), were identified: these equated to prevalence of 31.4%, 29.5%, 25.7%, and 23.8% respectively. The most common ADEs were masked hypoglycemia and gastrointestinal bleed. With every additional PIM prescribed, the odds for ADE occurrence increased by 12 folds (OR 11.8, 95% CI 5.20-25.3).
CONCLUSION: The majority of the older patients who were admitted to secondary care for acute illnesses were potentially exposed to IP. Approximately a quarter of the patients were prescribed with PIMs, which were plausibly linked with preventable ADEs that directly caused or contributed to hospitalization.
Methods: This is a before-and-after study that took place in a tertiary Malaysian hospital. Discharge medications of patients ≥65 years old were reviewed to identify PIMs/PPOs using version 2 of the STOPP/START criteria. The prevalence and pattern of PIM/PPO before and after the intervention were compared. The intervention targeted the physicians and clinical pharmacists and it consisted of academic detailing and a newly developed smartphone application (app).
Results: The study involved 240 patients before (control group) and 240 patients after the intervention. The prevalence of PIM was 22% and 27% before and after the intervention, respectively (P = 0.213). The prevalence of PPO in the intervention group was significantly lower than that in the control group (42% Vs. 53.3%); P = 0.014. This difference remained statistically significant after controlling for other variables (P = 0.015). The intervention was effective in reducing the two most common PPOs; the omission of vitamin D supplements in patients with a history of falls (P = 0.001) and the omission of angiotensin converting enzyme inhibitor in patients with coronary artery disease (P = 0.03).
Conclusions: The smartphone app coupled with academic detailing was effective in reducing the prevalence of PPO at discharge. However, it did not significantly affect the prevalence or pattern of PIM.
Objective: The objective of this study was to investigate the prevalence and pattern of medications associated with geriatric syndromes (MAGSs) among the discharged elderly patients (≥65 years old).
Materials and Methods: This is a cross-sectional study that was conducted at a Malaysian teaching hospital from October to December 2018. The discharge medications of geriatric patients were reviewed to identify MAGSs using Beers criteria, Lexicomp drug information handbook, and the United States Food and Drug Administration (USFDA) drug inserts. Chi-square test was used to compare MAGS prescribed between categories. Spearman's rank-order correlation was used to test the correlation between the presence of MAGS and the number of discharge medications. A binomial logistic regression was applied to determine the predictors of prescribing MAGSs.
Results: A total of 400 patients (mean ± standard deviation [SD] age, 72.0 ± 5.0 years) were included, and 45.3% of them were females. The most common diseases were hypertension followed by diabetes mellitus. The mean ± SD number of discharge medications per patient was 4.2 ± 2.5. The MAGSs were prescribed in 51.7% of the patients, and 54 patients were discharged with more than one MAGSs. The most commonly prescribed MAGSs were opioid analgesics, vasodilators, and β-blockers, which are associated with falls, depression, and delirium. Polypharmacy was found in 138 patients, and it was significantly associated with the presence of MAGSs (P < 0.001). No significant differences were found in prescribing MAGSs based on the patients' gender, race, and age.
Conclusion: The prescribing of MAGSs occurred in half of the discharged elderly patients. Physicians should be aware of the medications that are associated with special side effects in the elderly patients, and should switch to safer alternatives when possible.