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Inappropriate Drug Prescription at Nursing Home Admission
JAMDA 13 (2012) 83.e9e83.e15
JAMDA journal homepage: www.jamda.com
Original Study
Inappropriate Drug Prescription at Nursing Home Admission Fermín García-Gollarte MD a, *, José Baleriola-Júlvez MD b, Isabel Ferrero-López MD c, Alfonso J. Cruz-Jentoft MD, PhD d a
Grupo Ballesol, Universidad Católica de Valencia, Valencia, Spain Centro de Atención Primaria Vall de Uixó, Castellón, Universidad Católica de Valencia, Spain c Hospital Pare Jofré, Valencia, Spain d Servicio de Geriatría, Hospital Universitario Ramón y Cajal, Madrid, Spain b
a b s t r a c t Keywords: Drug use nursing homes appropriateness geriatric pharmacotherapy
Background: Inappropriate prescriptions are common in older people admitted to nursing homes. Commonly used instruments to detect potential inappropriate prescriptions have limitations that have precluded wide use, and new instruments are needed. Objective: The goal of this study was to determine the value of the Screening Tool of Older Person’s potentially inappropriate Prescriptions/Screening Tool to Alert doctors to the Right, ie appropriate, indicated Treatment (STOPP-START) criteria and the Australian criteria to detect potentially inappropriate drug prescriptions in older people on admission to nursing home care. Methods: Cross-sectional study of 100 consecutive patients (mean age 84.7 7.5 years, 80% women) admitted to 6 assisted living nursing homes, with systematic review of prescriptions used at the time of nursing home admission using the STOPP-START and the Australian criteria looking for potentially inappropriate drug treatments. Results: Using the STOPP criteria, 79% of the subjects showed at least one potentially inappropriate prescription. Omissions of potentially appropriate drugs were found by the START criteria in 74% of them. The Australian criteria detected at least one potential problem in 95% of the sample. The number of subjects with 2 or more problems detected was highest using the Australian criteria (72%). The most frequent potentially inappropriately used drugs detected were proton-pump inhibitors, benzodiazepines, antipsychotic drugs, and anticholinergic drugs; many cases of duplicate medications and drug interactions were also detected. Underuse of statins and aspirin in patients with high cardiovascular risk, and of calcium and vitamin D in osteoporosis was also frequent. Conclusions: A high number of potentially inappropriate drug prescriptions can be detected at the time of admission to nursing home care by the use of systematic instruments. Both STOPP-START criteria and the Australian criteria performed well in this setting. The impact of this detection on health outcomes and costs should be assessed before they can be widely recommended. Published by Elsevier Inc. on behalf of the American Medical Directors Association, Inc.
Polypharmacy and the prescription of inappropriate medications are frequent in older people, a population with high levels of comorbidity, functional impairment, and social dependency.1,2 Age-associated changes in homeostasis, pharmacokinetics, and pharmacodynamics also contribute to errors in drug prescriptions that are responsible for adverse drug reactions, increased mortality, and repeated hospitalizations, all frequent events in institutionalized individuals.3e7 A drug is considered to be inappropriate for a particular condition when the risk of adverse effects is higher than the
The authors have declared no conflicts of interest. * Address correspondence to Fermín García-Gollarte, MD, Grupo Ballesol, Universidad Católica de Valencia, C/ Gobernador Viejo, 25, 46003 Valencia, Spain. E-mail address: [email protected] (F. García-Gollarte).
expected benefits, when there are therapeutic alternatives with better safety or efficacy, when there is a high risk of drug interaction, when duplicate medications are prescribed, or when the duration of a treatment is longer than needed. Nonprescription of medications that could be potentially beneficial but are not used for unjustified reasons, such as advanced age, is also considered inappropriate.8,9 However, it may be an oversimplification to believe that polypharmacy is a paradigm of inappropriate prescription in geriatric care without a deeper knowledge of risk-benefit patterns in the use of medication in older individuals.10 According to the Spanish Consejo General de Farmacéuticos, use of drugs by people older than 65 years has increased from 56.3% of total prescription costs in the National Health System in 1986 to 73.3% in 2008.11 Pharmaceutical expenditure has risen to 21%
1525-8610/$ - see front matter Published by Elsevier Inc. on behalf of the American Medical Directors Association, Inc. doi:10.1016/j.jamda.2011.02.009
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of total expenditure on health in Spain ($561 per capita in 2007).12 Improving drug prescription to tailor it to individual needs of older subjects is complex, and many different approaches are being been explored.13e15 Systematic and regular review of prescriptions using standardized procedures could be a sensible and inexpensive way both to improve actual prescriptions and to educate future prescriptions.16 Increasing evidence on the relevance of inappropriate prescriptions (IPs) in health and quality of life has renewed interest in adapting pharmacological treatments to the characteristics of older people, as well as defining and developing protocols, scales, and criteria that may foster better prescriptions.17 The most frequently used methods for the detection of potentially inappropriate prescriptions are the Beers criteria,18,19 the IPET (Improved Prescribing in the Elderly Tool),20 the MAI (Medication Appropriateness Index),21 and the ACOVE (Assessing Care of Vulnerable Elder) project.22,23 However, most of these methods have some deficiencies and drawbacks that have prevented them from being widely adopted, so new criteria are still been developed with the aim of detecting a wider range of problems.24 In this context, the STOPP-START (Screening Tool of Older Person’s potentially inappropriate Prescriptions/Screening Tool to Alert doctors to the Right, ie, appropriate, indicated Treatment) criteria were developed in Ireland and adopted by the European Union Geriatric Medicine Society25 and translated into many European languages.26e29 A group of experts from Australia also produced, in 2006, a new prescribing indicators tool based on frequent health problems, on medications frequently prescribed by physicians in that country, and on the most frequent reasons for medical visits and hospitalizations.30 Older people living in nursing homes have specific prescription characteristics and needs, but most studies on potentially inappropriate prescriptions have used Beers criteria.31e34 Only recently have STOPP-START criteria been explored in different care levels25,35; no data are available on the use of the Australian criteria in nursing homes. The goal of this study was to determine the value of the STOPP-START criteria and the Australian criteria to detect potentially inappropriate drug prescriptions in older people on admission to nursing home care.
Methods This was a cross-sectional study of a convenience sample of all 106 patients older than 65 years who were admitted in 2008 to 6 skilled nursing homes of the same company in Valencia, Spain, with systematic review of all drugs that had been prescribed and were used at the time of nursing home admission, using the STOPPSTART criteria and the Australian criteria. Age, gender, functional status (Barthel),36 mental status (Global Deterioration Scale),37 transfer location (from home, hospital, or a different nursing home), and number of prescribed medications were also registered. Nursing homes where the study was performed offer aroundthe-clock multidisciplinary care by multiprofessional teams that include physicians, nurses, therapists, and psychologists, in adapted facilities. Thus, they would be defined in some countries as skilled nursing facilities. Data were gathered by a physician with experience in the care of older persons, who was first trained in the correct use of both scales, and had no responsibility in patient care. A second physician, with expertise in geriatric prescription, provided both the training and feedback, and resolved any discrepancy about the interpretation of any criteria. Prescription data were obtained from computerized medical records; all the nursing homes used the same software. These were completed by a careful review of reports
from the primary care physician or the hospital where the subject was transferred from. The STOPP-START criteria have 2 parts: the STOPP section has 65 indicators that show frequent potentially inappropriate prescriptions in older individuals. The START section lists 22 indicators on appropriate evidence-based prescriptions that should be used to treat frequent conditions. The Australian criteria identify 48 prescribing indicators, consisting mainly of optimum as well as potentially inappropriate medication choices for a large number of common medical conditions in older people. All subjects or their legal proxies signed an informed consent form. The study was approved by the Ethics Committee of the Hospital de la Plana, Castellón, Spain. Statistical analysis was carried out with SPSS (Statistical Package for the Social Sciences) software (IBM Corporation, Somer, NY). Results Data were available from 100 subjects: 5 refused to sign consent and 1 was found to be younger than 65 years. Mean age was 84.7 7.5 years (79% were older than 80 years). Subjects were mostly women (80%), with a high degree of severe functional deterioration (42%); 23% had severe cognitive impairment. The average number of prescription drugs used was 6.49 per subject (Table 1). Mean time needed to fill both the STOPP-START scale and the Australian scale was close to 3 minutes. Thirty-seven (56.9%) of the 65 items listed in the STOPP criteria detected potential prescription problems; 21 (95.4%) of the 22 items of the START criteria, and 43 (89.5%) of the 48 items of the Australian score were also able to detect potential problems. Using the STOPP criteria, 79% of the subjects showed at least one potentially inappropriate prescription. Omissions of potentially appropriate drugs were found by the START criteria in 74% of subjects. The Australian criteria detected at least one potential problem in 95% of the sample. The number of subjects with 2 or more potential problems detected was higher using the Australian criteria (72%) than with the STOPP (33%) or START (25%) criteria (P < .001) (Table 2). The most frequent potentially inappropriate prescription detected by the STOPP criteria was the use of a proton-pump inhibitor (PPI) without a clear indication (52%) (Table 3). Other frequent findings were the use of benzodiazepines (35%) and antipsychotic drugs (26%) in patients with a history of falls, prolonged use of long-acting benzodiazepines (13%), and the use of antipsychotics for sleep induction (23%). In 9% of the subjects, duplicate medications were detected, in most cases central nervous system active drugs. START criteria look for omissions of potentially needed drugs. The most frequent problem detected was not using vitamin D and Table 1 Characteristics of the Subjects Age, mean SD Admitted from Home Hospital Nursing home Barthel Index >60 45e60 <45 GDS Reisberg 1e3 4e5 6e7 Number of drugs, mean SD GDS, Global Deterioration Scale.
84.7 7.5 years 58% 33% 9% 39% 19% 42% 52% 25% 23% 6.49 2.86
F. García-Gollarte et al. / JAMDA 13 (2012) 83.e9e83.e15 Table 2 Performance of the STOPP-START and the Australian Criteria in the Detection of Potentially Inappropriate Prescriptions in 100 Subjects Admitted to 6 Nursing Homes
No problems detected One criterion Two criteria More than 2 criteria
STOPP
START
Australian
21 24 22 33
26 36 13 25
5 13 10 72
calcium in patients with osteoporosis (34%), and nonprescription of statins (21%) and aspirin (18%) in cardiovascular conditions where benefits have been well established, in many cases in subjects with diabetes (Table 4).
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The most frequent potential prescription problems detected by the Australian criteria were the prolonged use of benzodiazepines (48%) and the use of psychotropic drugs in subjects with a history of falls (42%) or anticholinergic drugs in dementia (25%) (Table 5). Again, insufficient treatment to prevent osteoporosis (35%), and underuse of statins (30%) were prominent findings. Interactions were detected in 36% of patients, and 30% had significant changes in medications in the preceding 3 months, putting them at risk of further problems.
Discussion Inappropriate drug prescription is a frequent and serious problem among older people. In this study we used both the
Table 3 Potentially Inappropriate Prescriptions Detected by STOPP Criteria* A. Cardiovascular system , Digoxin at a long-term dose >125 mg/d with impaired renal function , Loop diuretic for dependent ankle edema only, ie, no clinical signs of heart failure , Loop diuretic as a first-line monotherapy for hypertension , Thiazide diuretic with a history of gout , Use of diltiazem or verapamil with NYHA class III or IV heart failure , Calcium channel brokers with chronic constipation , Dipiridamol as monotherapy for cardiovascular secondary prevention , Aspirin at dose >150 mg/d , Aspirin with no history of coronary, cerebral, or peripheral vascular symptoms or occlusive event , Aspirin, clopidogrel, dipyridamole, or warfarin with concurrent bleeding disorder B. Central nervous system and psychotropic drugs , Tricyclic antidepressants with dementia , TCAs with constipation , TCAs with an opiate or calcium channel blocker , Long-term long-acting benzodiazepines, and benzodiazepines with long-acting metabolites , Long-term neuroleptics as long-term hypnotics , Long-term neuroleptics in those with parkinsonism , Prolonged use of first-generation antihistaminics C. Gastrointestinal system , Diphenoxilate, loperamide, or codeine phosphate for treatment of diarrhea of unknown cause , Prochlorperazine or metochlopramide with parkinsonism , Proton pump inhibitor for peptic ulcer disease at full therapeutic dosage for >8 weeks D. Respiratory system , Systemic corticosteroids instead of inhaled corticosteroids for maintenance therapy in moderate to severe chronic obstructive pulmonary disease E. Musculoskeletal system , Nonsteroidal anti-inflammatory drug with moderate to severe hypertension , NSAID with heart failure F. Urogenital system , Bladder antimuscarinic drugs with dementia , Vesical antimuscarinic medication in chronic constipation , Alpha-blockers in males with frequent incontinence , Alpha-blockers with long term urinary catheter in situ G. Endocrine system , Beta-blockers in those with diabetes mellitus and frequent hypoglycemic episodes H. Drugs that adversely affect fallers , Benzodiazepines , Neuroleptic drugs , First-generation antihistamines , Vasodilator drugs with persistent postural hypotension , Long-term opiates in those with recurrent falls I. Analgesic drugs , Use of long-term powerful opiates , ie, morphine or fentanyl, as first-line therapy for mild to moderate pain , Regular opiates for more than 2 weeks in those with chronic constipation without concurrent use of laxatives , Long term opiates in those with dementia unless indicated in palliative care or management of moderate/severe chronic pain syndrome J. Duplicate drug classes , Peripheral vasodilators , Psychopharmaceuticals in same group (sedatives, antidepressants, neuroleptics) , Diuretics , Antihypertensives in the same group , Platelet drugs , Calcium supplements , Analgesics STOPP, screening tool of older person’s potentially inappropriate prescriptions. * Only those criteria found in at least one subject are listed.
2 7 3 1 1 7 1 7 7 1 2 1 1 13 23 4 1 2 1 52 1
1 1 3 1 1 1 2 35 26 1 8 7 1 6 3 4 9 2 3 2 1 1
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Table 4 Potentially Inappropriate Prescriptions Detected by START Criteria* A. Cardiovascular system , Warfarin in the presence of chronic atrial fibrillation , Aspirin in the presence of chronic atrial fibrillation, where warfarin is contraindicated , Aspirin or clopidogrel with a documented history of atherosclerotic coronary, cerebral, or peripheral vascular disease in patients with sinus rhythm , Antihypertensive therapy where systolic blood pressure is consistently >160 mm Hg , Statin therapy with a documented history of coronary, cerebral, or peripheral vascular disease, where the patient remains independent for ADL and life expectancy >5 years , Angiotensin-converting enzyme inhibitor with chronic heart failure , ACE inhibitor following acute myocardial infarction , b-blocker with chronic stable angina B. Respiratory system , Regular inhaled b2-agonist or anticholinergic agent for mild to moderate asthma or COPD , Inhaled corticosteroid for moderate/severe asthma or COPD, where predicted forced expiratory volume is <50% C. Central nervous system , L-DOPA in idiopathic Parkinson’s disease with definite functional impairment and resultant disability , Antidepressant drug in the presence of moderate/severe depressive symptoms lasting at least 3 months D. Gastrointestinal system , Fiber supplements for chronic, symptomatic diverticular disease with constipation E. Musculoskeletal System , Disease-modifying antirrheumatic drug with active moderate/severe rheumatoid disease lasting >12 weeks , Calcium and vitamin D supplement in patients with known osteoporosis F. Endocrine system , Metformin with type 2 diabetes metabolic syndrome , ACE inhibitor or angiotensin receptor blocker in diabetes with nephropathy , Antiplatelet therapy in diabetes mellitus with coexisting major cardiovascular risk factors , Statin therapy in diabetes mellitus if coexisting major cardiovascular risk factors present
5 1 18 13 21 9 4 3 3 2 1 4 3 1 34 4 6 11 12
ADL, activities of daily living; COPD, chronic obstructive pulmonary disease; START, screening tool to alert doctors to the right indicated treatment. * Only those criteria found in at least one subject are listed.
STOPP-START criteria and the Australian system in an older population, at the moment of admission to a nursing home, to evaluate their usefulness as a systematic means to detect potentially inappropriate prescription at this time. The Australian tool has not yet been properly validated. Although more than half of our subjects were admitted directly from their homes, and therefore were cared for by their primary care physician before admission, it is important to note that a high percentage (33%) entered immediately after hospital discharge. Potentially inappropriate prescriptions were present in both populations at similar rates. Patients included were representative of assisted nursing home patients (very old age, mostly women, severe disability) and were taking a large number of drugs (6.49), close to that found in similar studies.38,39 The rates of potentially inappropriate prescriptions found by either criterion were higher than rates found in other studies. Beers criteria have been reported to detect different rates of potentially inappropriate prescription in different care settings, ranging from 13% to 48%.40e47 In a study carried out in Ireland using the STOPP criteria in a population of 1329 patients in primary care, potentially inappropriate prescription was found in 17% to 24% of subjects.41 Another recent study from Spain compared potentially inappropriate prescription using STOPP criteria in 3 care settings (primary care, nursing homes, and hospitals) and found rates of 36% in primary care, 50% in nursing homes, and 54% in hospitalized older patients, with different prescription profiles in each setting.34 Our higher rates could be explained because our subjects were in the transition from one care setting to another, and polypharmacy and drug problems have been shown to be predictors of nursing home admission.48 Excessive use of psychoactive drugs is a problem in our country and in others,49 which may be explained by an underdeveloped mental health primary care network, poor access to nondrug treatments, and by poor general practitioner education in this area. This finding would highlight the importance of performing a systematic search of drug-related problems at nursing home admission. The use of START criteria to detect potential omissions showed similar findings. A study in 600 hospitalized patients from different
countries found omissions in about 58% of the cases, with wide variability.50 Omission can be as high as 48% in patients sent to geriatric outpatient clinics51; in primary care, START criteria detected problems in 20% to 26% of the cases.41 Again, we found higher rates (74%) of nonuse of potentially indicated drugs, which might also be related to the need for nursing home care. It is also possible that physicians prescribing to these patients had found compliance problems, or had decided that disability or limited life expectancy contraindicated such drugs. Although STOPP-START criteria have different tables for potentially inappropriate use and inappropriate omission of medications, the Australian criteria include both in an undivided list, which may explain a higher rate of detection of problems. STOPP-START and Australian criteria have some degree of overlap, but together were able to detect a high number of potential prescription problems across a wide range of health conditions. As criteria are based on consensus and interpretation of available evidence, some apparent contradictions may arise when comparing them. To be reproducible, each list of criteria has to be used literally. Thus, there are only 6 events of "regular opiates for more than 2 weeks in those with chronic constipation without concurrent use of laxatives" in STOPP and 8 events in the Australian tool of "patients taking an opioid without prophylactic treatment for constipation," meaning that in 2 subjects opiates were used for less than 2 weeks. Another example is the 21 events of "statin therapy with a documented history of coronary, cerebral, or peripheral vascular disease, where the patient remains independent for ADL and life expectancy >5 years" in START versus 30 Australian tool events of "patient at high risk of a cardiovascular event is not taking a statin," which means that some patients were considered to be at high cardiovascular risk not having a documented story of the listed diseases. These discrepancies would have to be discussed by the promoters of the criteria, looking for the highest consistency when possible. It should also be remembered that a potential medication problem cannot be considered a real problem until a clinician determines if the prescription is right or wrong for that individual patient in that precise situation.
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Table 5 Potentially Inappropriate Prescriptions Detected by the Australian System , , , , , , , , , ,
Patient taking an antihypertensive is not at his or her target blood pressure Patient at high risk of a cardiovascular event is not taking an HMG-CoA reductase inhibitor Patient with IHD or a history of MI is not taking a b-blocker Patient with IHD or history of MI is not taking an antiplatelet agent unless taking an oral anticoagulant Patient with heart failure is not taking a b-blocker Patient with heart failure is not taking an ACE inhibitor or ARB Patient with heart failure is taking medications that may exacerbate heart failure Patient with heart failure or hypertension is taking high sodium-containing medications Patient with atrial fibrillation is not taking an oral anticoagulant Patient with a history of non-hemorrhagic stroke or transient ischemic attack is not taking an antiplatelet agent unless taking an anticoagulant , Patient with risk factors for myopathy is taking 40 mg/d of simvastatin or atorvastatin , Patient with cardiovascular disease is taking an NSAID , Patient with type 2 diabetes and hypertension and albuminuria is not taking an ACE inhibitor or ARB , Patient with diabetes at high risk of a cardiovascular event is not taking an antiplatelet agent unless taking an anticoagulant , Patient with diabetes is taking a medication that may increase or decrease blood glucose concentrations , Patient taking metformin for diabetes has not had the dose adjusted for creatinine clearance , Patient with osteoarthritis pain interfering with activities of daily living has not been trialled on paracetamol 2e4 g/d , Patient taking analgesic has pain that interferes with daily activities , Patient taking an opioid is not taking prophylactic treatment for constipation , Patient with risk factors for impaired renal function is taking an NSAID , Patient is concurrently taking an ACE inhibitor or ARB, diuretic, and NSAID , Patient with sleep disturbance or anxiety has been taking benzodiazepine for >4 weeks , Patient with depression is taking anticholinergic-type antidepressants , Patient with a history of falls is taking psychotropic medications , Patient taking an SSRI is concurrently taking medications known to increase the risk of gastrointestinal bleeding , Patient taking an SSRI is currently taking other medications that may contribute to serotonin toxicity , Patient with dementia is receiving anticholinergic medication , Patient is taking more than one medication with anticholinergic activity , Patient using a proton-pump inhibitor is taking a medication that may cause dyspepsia , Patient with chronic obstructive pulmonary disease is taking benzodiazepines , Patient with asthma using an inhaled long acting beta agonist is not using an inhaled corticosteroid , Patient using a salbutamol or terbutaline inhaler more than 3 times per week for reversible airways disease has not been prescribed an inhaled corticosteroid , Patient with asthma is taking a medication that may worsen asthma , Female patient with recurrent urinary tract infections has not been prescribed intravaginal estrogen , Patient with an upper respiratory tract infection is receiving antibacterials , Patient with osteoporosis who is not receiving at least 600 IU of vitamin D daily from dietary sources is not receiving supplementation with vitamin D , Patient with osteoporosis who is not receiving at least 1200 mg of calcium daily from dietary sources is not receiving calcium supplementation , Patient with osteoporosis is not receiving anti-osteoporotic medication , Patient has not received influenza and pneumococcal vaccination , Patient has significant medication interactions , Patient has had a significant change in medications in the previous 90 days
12 30 9 5 6 9 1 2 5 6 2 3 4 11 3 2 9 3 8 1 2 48 7 62 4 1 25 9 11 5 3 2 5 2 1 5 4 34 1 36 30
ACE, angiotensin-converting enzyme; ARB, adrenergic receptor binder; IHD, ischemic heart disease; MI, myocardial infarction; NSAID, nonsteroidal anti-inflammatory drug; SSRI, selective serotonin reuptake inhibitor.
It is worth noting the high number of potentially inappropriate prescriptions found in the use of psychotropic drugs in this population with both instruments, which is not unexpected.52,53 Specific instruments are being developed for improving quality of prescription of this group of drugs.54e57 The second area that may need improvement is the management of cardiovascular risk. The use of duplicate medications is a frequent problem (15% of admissions) that is amenable to be solved with the appropriate use of computer aids,58 and the same is true for relevant interactions. The high unjustified consumption of PPI and the low prescription of calcium and vitamin D in a high-risk population are also worth mentioning.59,60 This study is being followed by an ongoing intervention study, where 40 skilled nursing homes have been randomized to receive a targeted structured educational intervention on appropriate drug prescription, with regular updates and support; outcomes will include not only a better prescription profile, but also some geriatric problems (falls, delirium) and the use of resources (hospitalizations, emergency room visits). Some methodological shortcomings of this study should be considered. Subject selection was not randomized (all consecutive admissions along a period were included). Only physicians, but not
pharmacists, were involved in the review of prescriptions, and no computer-based prescription tool was used. The methods used were not aiming to validate the 2 prescription tools used, and neither of the tools include a mechanism to verify if a potentially inappropriate prescription is in fact inappropriate and leads to poor outcomes. Careless use of drugs in older people may be dangerous. Although in many cases drug use is beneficial to treat medical conditions in old age, adverse drug reactions may increase the burden of suffering and costs of care. A higher number of drugs does not always imply better health care,61 and sound research in geriatric patients is urgently needed so as to have better grounds for clinical decision making.62 Nursing home admission may be a good time to review and improve medication regimens, and nursing home physicians may benefit from training programs on appropriate prescription. The use of computerassisted prescription may also be beneficial. The use of systematic instruments to detect potential prescription problems both on admission and on a regular basis would have to be explored, and its impact on health outcomes and costs would have to be assessed before they can be widely recommended.
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We have shown that both STOPP-START criteria and Australian criteria are good candidates for future research in this area. References 1. Salgado A, Ruipérez I, Sepúlveda D. Valoración geriátrica integral: Conceptos generales. Beneficios de la intervención. Grupos de riesgo. In: Salgado A, Guillén F, Ruipérez I, editors. Manual de Geriatría. 3rd ed. Barcelona: Masson; 2002. p. 223e229. 2. Cepeda O, Morley J. Polypharmacy, is this another disease? In: Pathy J, Sinclair A, Morley J, editors. Principles and Practice of Geriatric Medicine 4th ed. Chichester, UK: John Wiley & Sons; 2006. p. 329e346. 3. Hanlon JT, Schmader KE, Koronkowski MJ, et al. Adverse drug events in high risk older outpatients. J Am Geriatr Soc 1997;45:945e948. 4. Klarin I, Wimo A, Fastbom J. The association of inappropriate drug use with hospitalisation and mortality. Drugs Aging 2005;22:69e82. 5. Ackermann RJ, Meyer von Bremen GB. Reducing polypharmacy in the nursing home: An activist approach. J Am Board Fam Pract 1995;8:195e205. 6. Beers MH, Fingold SF, Ouslander JG, et al. Characteristics and quality of prescribing by doctors practicing in nursing homes. J Am Geriatr Soc 1993;41: 802e807. 7. Nguyen JK, Fouts MM, Kotabe SE, et al. Polypharmacy as a risk factor for adverse drug reactions in geriatric nursing home residents. Am J Geriatr Pharmacother 2006;4:36e41. 8. Rochon PA, Gurwitz JH. Prescribing for seniors: Neither too much nor too little. JAMA 1999;282:113e115. 9. Avorn J, Gurwitz JH, Rochon P. Principles of pharmacology. In: Cassel CK, Leipzig RM, Cohen HJ, editors. Geriatric Medicine: An Evidence-based Approach. 4th ed. New York: Springer; 2002. p. 65e81. 10. Gurwitz JH. Polypharmacy. A new paradigm for quality drug therapy in the elderly. Arch Intern Med 2004;164:1957e1959. 11. Consejo General de Colegios Oficiales de Farmacéuticos. Estadísticas Sanitarias. Available at: http://www.portalfarma.com/pfarma/taxonomia/general/gp0000 16.nsf/voDocumentos/120C1F228EDEF914C125764E00352390/$File/estadisti cas_sanitarias.pdf 2008. Accessed September 12, 2010. 12. OECD Statistics. Available at: http://www.oecd.org/publications/0,3353,en_ 2649_201185_1_1_1_1_1,00.html. Accessed August 22, 2010. 13. Lewis L. Reduce polypharmacy and boost appropriate drug use. J Am Med Dir Assoc 2001;2:H36eH37. 14. Spinewine A, Schmader KE, Barber N, et al. Appropriate prescribing in elderly people: How well can it be measured and optimised? Lancet 2007;370: 173e184. 15. De Smet P, Denneboom W, Kramers C, et al. A composite screening tool for medication reviews of outpatients. General issues with specific examples. Drugs Aging 2007;24:733e760. 16. Straand J, Fetveit A, Rognstad S, et al. A cluster-randomized educational intervention to reduce inappropriate prescription patterns for elderly patients in general practicedThe Prescription Peer Academic Detailing (Rx-PAD) study [NCT00281450]. BMC Health Serv Res 2006;6:72. 17. Tangiisuran B, Wright J, Van der Cammen T, et al. Adverse drug reactions in elderly: Challenges in identification and improving preventative strategies. Age Ageing 2009;38:358e359. 18. Beers MH, Ouslander JG, Rollingher I, et al. Explicit criteria for determining inappropriate medication use in nursing home residents. Arch Intern Med 1991;151:1825e1832. 19. Fick DM, Cooper JW, Wade WE, et al. Updating the Beers criteria for potentially inappropriate medication use in older adults: Results of a US consensus panel of experts. Arch Intern Med 2003;163:2716e2724. 20. Naugler CT, Brymer C, Stolee P, et al. Development and validation of an improved prescribing for the elderly tool. Can J Clin Pharmacol 2000;7: 103e107. 21. Hanlon JT, Schmader KE, Samsa GP, et al. A method for assessing drug therapy appropriateness. J Clin Epidemiol 1992;45:1045e1051. 22. Shekelle PG, MacLean CH, Morton SC, et al. Acove quality indicators. Ann Intern Med 2001;135:653e667. 23. Knight EL, Avorn J. Quality indicators for appropriate medication use in vulnerable elders. Ann Intern Med 2001;135:703e710. 24. Barry PJ, Gallagher P, Ryan C. Inappropriate prescribing geriatric patients. Curr Psychiatry Rep 2008;10:37e43. 25. Gallagher P, Ryan C, Byrne S, et al. STOPP (Screening Tool of Older Persons Prescriptions) and START (Screening Tool to Alert Doctors to Right Treatment): Consensus validation. Int J Clin Pharmacol Ther 2008;46: 72e83. 26. Gallagher P, O’Mahony D. STOPP (Screening Tool of Older Persons potentially inappropriate Prescriptions): Application to acutely ill elderly patients and comparison with Beers’ criteria. Age Ageing 2008;37: 673e679. 27. Delgado Silveira E, Muñoz García M, Montero Errasquin B, et al. Prescripción inapropiada de medicamentos en los pacientes mayores. Los criterios STOPP/ START. Rev Esp Geriatr Gerontol 2009;44:273e279. 28. Lang PO, Hasso Y, Belmin J, et al. STOPP-START: Adaptation en langue francaise d’un outil de detection de la prescription medicamente use inapproprièe chez la personne agèe. Can J Public Health 2009;100:426e431.
29. Topinková E, Mádlová P, Fialová D, et al. Nova evidence-based kriteria pro posouzeni vhodnosti lekoveho rezimu u senioru. Kriteria STOPP (Screening Tool of Older Person’s Prescriptions) a START (Screening Tool to Alert doctors to Right Treatment). Vnitr Lek 2008;54:1161e1169. 30. Basger BJ, Chen TF, Moles RJ. Inappropriate medication use and prescribing indicators in elderly Australians: Development of a prescribing indicators tool. Drugs Aging 2008;25:777e793. 31. Sicras Mainar A, Peláez-de-Loño, Castellá R, et al. Eficacia de una intervención en la adecuación del uso de medicamentos en centros residenciales geriátricos. Resultados a los tres años de su implantación. Rev Esp Geriatr Gerontol 2007; 42:5e15. 32. Gongora L, Puche E, García J, Luna JD. Prescripciones inapropiadas en ancianos institucionalizados. Rev Esp Geriatr Gerontol 2004;39:19e24. 33. Dhalla IA, Anderson GM, Mamdani MM, et al. Inappropriate prescribing before and after nursing home admission. J Am Geriatr Soc 2002;50: 995e1000. 34. Beers MH, Ouslander JG, Fingold SF, et al. Inappropriate medication prescribing in skilled-nursing facilities. Ann Intern Med 1992;117:684e689. 35. Conejos Miquel MD, Sánchez-Cuervo M, Delgado-Sivera E, et al. Potentially inappropriate drug prescription in older subjects across health care settings. European Geriatric Medicine 2010;1:9e14. 36. Mahoney FI, Barthel DW. Functional evaluation: The Barthel Index. Md State Med J 1965;4:61e65. 37. Reisberg B, Ferris SH, de Leon MJ, et al. The global deterioration scale for assessment of primary degenerative dementia. Am J Psychiatry 1982;139: 1136e1139. 38. Kaufman DW, Kelly JP, Rosenberg L, et al. Recent patterns of medication use in the ambulatory adult population of the United States: The Slone survey. JAMA 2002;287:337e344. 39. IMSERSO-SEGG. Atención a personas mayores que viven en residencias. Protocolos de intervención psicosocial y sanitaria. Madrid: Ministerio de Trabajo y Asuntos Sociales; 1998. 40. Ryan C, O’Mahony D, Kennedy J, et al. 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 identity inappropriate use of medicines in elderly in primary care in Ireland. J Clin Pharm Ther 2009;34:369e376. 41. Buck MD, Atreja A, Bunker CP, et al. Potentially inappropriate medication prescribing in outpatient practices: prevalence and patient characteristics based on electronic health records. Am J Geriatr Pharmacother 2009;7:84e92. 42. Carey IM, De Wilde S, Harris T, et al. What factors predict potentially inappropriate primary care prescribing in older people? Analysis of UK primary care patient record database. Drugs Aging 2008;25:693e706. 43. Cárdenas-Valladolid J, Mena-Mateo J, Cañada-Dorado MM, et al. Implantación y mejora de un programa de atención al mayor polimedicado en un área de atención primaria. Rev Calid Asist 2009;24:24e31. 44. Hosia-Randell HM, Muurinen SM, Pitkälä KH. Exposure to potentially inappropriate drugs and drug-drug interactions in elderly nursing home residents in Helsinki, Finland: A cross-sectional study. Drugs Aging 2008;25: 683e692. 45. Zuckerman IH, Hernandez JJ, Gruber-Baldini AL, et al. Potentially inappropriate prescribing before and after nursing home admission among patients with and without dementia. Am J Geriatr Pharmacother 2005;3: 246e254. 46. Perri M, Menon AM, Deshpande AD, et al. Adverse outcomes associated with inappropriate drug use in nursing homes. Ann Pharmacother 2005;39: 405e411. 47. Tulner LR, Frankfort SV, Gijsen GJ, et al. Drug-drug interactions in a geriatric outpatient cohort: Prevalence and relevance. Drugs Aging 2008;25: 343e355. 48. Frazier SC. Health outcomes and polypharmacy in elderly individuals: An integrated literature review. J Gerontol Nurs 2005;31:4e11. 49. Lang PO, Hasso Y, Dramé M, et al. Potentially inappropriate prescribing including under-use amongst older patients with cognitive or psychiatric comorbidities. Age Ageing 2010;39:373e381. 50. Barry PJ, Gallagher P, Ryan C, et al. START (Screening Tool to Alert doctors to the Right Treatment): An evidence-based screening tool to detect prescribing omissions in elderly patients. Age Ageing 2007;36:632e638. 51. Montero-Errasquin B, Sánchez-Cuervo M, Sánchez-Castellano M, et al. Inappropriate prescription in geriatric outpatients: A comparison of two instruments [abstract]. J Nutr Health Aging 2008;12:585. 52. Tinetti M. Preventing falls in elderly persons. N Engl J Med 2003;348:42e49. 53. Gray SL, LaCroix AZ, Hanlon JT, et al. Benzodiazepine use and physical disability in community dwelling older adults. J Am Geriatr Soc 2006;54: 224e230. 54. Westbury J, Jackson S, Gee P, et al. An effective approach to decrease antipsychotic and benzodiazepine use in nursing homes: the RedUSe project. Int Psychogeriatr 2010;22:26e36. 55. Donovan JL, Kanaan AO, Thomson MS, et al. Effect of clinical decision support on psychotropic medication prescribing in the long-term care setting. J Am Geriatr Soc 2010;58:1005e1007. 56. Patterson SM, Hughes CM, Crealey G, et al. An evaluation of an adapted U.S. model of pharmaceutical care to improve psychoactive prescribing for nursing home residents in Northern Ireland (Fleetwood Northern Ireland Study). J Am Geriatr Soc 2010;58:44e53.
F. García-Gollarte et al. / JAMDA 13 (2012) 83.e9e83.e15 57. Dahl LJ, Wright R, Xiao A, et al. Quality improvement in long term care: The psychotropic assessment tool (PAT). J Am Med Dir Assoc 2008;9:676e683. 58. van der Sijs H, Mulder A, van Gelder T, et al. Drug safety alert generation and overriding in a large Dutch university medical centre. Pharmacoepidemiol Drug Saf 2009;18:941e947. 59. Ntaios G, Chatzinikolaou A, Kaiafa G, et al. Evaluation of use of proton pump inhibitors in Greece. Eur J Intern Med 2009;20:171e173.
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60. Kamel HK. Underutilization of calcium and vitamin D supplements in an academic long-term care facility. J Am Med Dir Assoc 2004;5: 98e100. 61. Grady D, Redberg RF. Less is more: How less health care can result in better health. Arch Intern Med 2010;170:749e750. 62. Cherubini A, Del Signore S, Ouslander J, et al. Fighting against age discrimination in clinical trials. J Am Geriatr Soc 2010;58:1791e1796.
JAMDA journal homepage: www.jamda.com
Original Study
Inappropriate Drug Prescription at Nursing Home Admission Fermín García-Gollarte MD a, *, José Baleriola-Júlvez MD b, Isabel Ferrero-López MD c, Alfonso J. Cruz-Jentoft MD, PhD d a
Grupo Ballesol, Universidad Católica de Valencia, Valencia, Spain Centro de Atención Primaria Vall de Uixó, Castellón, Universidad Católica de Valencia, Spain c Hospital Pare Jofré, Valencia, Spain d Servicio de Geriatría, Hospital Universitario Ramón y Cajal, Madrid, Spain b
a b s t r a c t Keywords: Drug use nursing homes appropriateness geriatric pharmacotherapy
Background: Inappropriate prescriptions are common in older people admitted to nursing homes. Commonly used instruments to detect potential inappropriate prescriptions have limitations that have precluded wide use, and new instruments are needed. Objective: The goal of this study was to determine the value of the Screening Tool of Older Person’s potentially inappropriate Prescriptions/Screening Tool to Alert doctors to the Right, ie appropriate, indicated Treatment (STOPP-START) criteria and the Australian criteria to detect potentially inappropriate drug prescriptions in older people on admission to nursing home care. Methods: Cross-sectional study of 100 consecutive patients (mean age 84.7 7.5 years, 80% women) admitted to 6 assisted living nursing homes, with systematic review of prescriptions used at the time of nursing home admission using the STOPP-START and the Australian criteria looking for potentially inappropriate drug treatments. Results: Using the STOPP criteria, 79% of the subjects showed at least one potentially inappropriate prescription. Omissions of potentially appropriate drugs were found by the START criteria in 74% of them. The Australian criteria detected at least one potential problem in 95% of the sample. The number of subjects with 2 or more problems detected was highest using the Australian criteria (72%). The most frequent potentially inappropriately used drugs detected were proton-pump inhibitors, benzodiazepines, antipsychotic drugs, and anticholinergic drugs; many cases of duplicate medications and drug interactions were also detected. Underuse of statins and aspirin in patients with high cardiovascular risk, and of calcium and vitamin D in osteoporosis was also frequent. Conclusions: A high number of potentially inappropriate drug prescriptions can be detected at the time of admission to nursing home care by the use of systematic instruments. Both STOPP-START criteria and the Australian criteria performed well in this setting. The impact of this detection on health outcomes and costs should be assessed before they can be widely recommended. Published by Elsevier Inc. on behalf of the American Medical Directors Association, Inc.
Polypharmacy and the prescription of inappropriate medications are frequent in older people, a population with high levels of comorbidity, functional impairment, and social dependency.1,2 Age-associated changes in homeostasis, pharmacokinetics, and pharmacodynamics also contribute to errors in drug prescriptions that are responsible for adverse drug reactions, increased mortality, and repeated hospitalizations, all frequent events in institutionalized individuals.3e7 A drug is considered to be inappropriate for a particular condition when the risk of adverse effects is higher than the
The authors have declared no conflicts of interest. * Address correspondence to Fermín García-Gollarte, MD, Grupo Ballesol, Universidad Católica de Valencia, C/ Gobernador Viejo, 25, 46003 Valencia, Spain. E-mail address: [email protected] (F. García-Gollarte).
expected benefits, when there are therapeutic alternatives with better safety or efficacy, when there is a high risk of drug interaction, when duplicate medications are prescribed, or when the duration of a treatment is longer than needed. Nonprescription of medications that could be potentially beneficial but are not used for unjustified reasons, such as advanced age, is also considered inappropriate.8,9 However, it may be an oversimplification to believe that polypharmacy is a paradigm of inappropriate prescription in geriatric care without a deeper knowledge of risk-benefit patterns in the use of medication in older individuals.10 According to the Spanish Consejo General de Farmacéuticos, use of drugs by people older than 65 years has increased from 56.3% of total prescription costs in the National Health System in 1986 to 73.3% in 2008.11 Pharmaceutical expenditure has risen to 21%
1525-8610/$ - see front matter Published by Elsevier Inc. on behalf of the American Medical Directors Association, Inc. doi:10.1016/j.jamda.2011.02.009
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of total expenditure on health in Spain ($561 per capita in 2007).12 Improving drug prescription to tailor it to individual needs of older subjects is complex, and many different approaches are being been explored.13e15 Systematic and regular review of prescriptions using standardized procedures could be a sensible and inexpensive way both to improve actual prescriptions and to educate future prescriptions.16 Increasing evidence on the relevance of inappropriate prescriptions (IPs) in health and quality of life has renewed interest in adapting pharmacological treatments to the characteristics of older people, as well as defining and developing protocols, scales, and criteria that may foster better prescriptions.17 The most frequently used methods for the detection of potentially inappropriate prescriptions are the Beers criteria,18,19 the IPET (Improved Prescribing in the Elderly Tool),20 the MAI (Medication Appropriateness Index),21 and the ACOVE (Assessing Care of Vulnerable Elder) project.22,23 However, most of these methods have some deficiencies and drawbacks that have prevented them from being widely adopted, so new criteria are still been developed with the aim of detecting a wider range of problems.24 In this context, the STOPP-START (Screening Tool of Older Person’s potentially inappropriate Prescriptions/Screening Tool to Alert doctors to the Right, ie, appropriate, indicated Treatment) criteria were developed in Ireland and adopted by the European Union Geriatric Medicine Society25 and translated into many European languages.26e29 A group of experts from Australia also produced, in 2006, a new prescribing indicators tool based on frequent health problems, on medications frequently prescribed by physicians in that country, and on the most frequent reasons for medical visits and hospitalizations.30 Older people living in nursing homes have specific prescription characteristics and needs, but most studies on potentially inappropriate prescriptions have used Beers criteria.31e34 Only recently have STOPP-START criteria been explored in different care levels25,35; no data are available on the use of the Australian criteria in nursing homes. The goal of this study was to determine the value of the STOPP-START criteria and the Australian criteria to detect potentially inappropriate drug prescriptions in older people on admission to nursing home care.
Methods This was a cross-sectional study of a convenience sample of all 106 patients older than 65 years who were admitted in 2008 to 6 skilled nursing homes of the same company in Valencia, Spain, with systematic review of all drugs that had been prescribed and were used at the time of nursing home admission, using the STOPPSTART criteria and the Australian criteria. Age, gender, functional status (Barthel),36 mental status (Global Deterioration Scale),37 transfer location (from home, hospital, or a different nursing home), and number of prescribed medications were also registered. Nursing homes where the study was performed offer aroundthe-clock multidisciplinary care by multiprofessional teams that include physicians, nurses, therapists, and psychologists, in adapted facilities. Thus, they would be defined in some countries as skilled nursing facilities. Data were gathered by a physician with experience in the care of older persons, who was first trained in the correct use of both scales, and had no responsibility in patient care. A second physician, with expertise in geriatric prescription, provided both the training and feedback, and resolved any discrepancy about the interpretation of any criteria. Prescription data were obtained from computerized medical records; all the nursing homes used the same software. These were completed by a careful review of reports
from the primary care physician or the hospital where the subject was transferred from. The STOPP-START criteria have 2 parts: the STOPP section has 65 indicators that show frequent potentially inappropriate prescriptions in older individuals. The START section lists 22 indicators on appropriate evidence-based prescriptions that should be used to treat frequent conditions. The Australian criteria identify 48 prescribing indicators, consisting mainly of optimum as well as potentially inappropriate medication choices for a large number of common medical conditions in older people. All subjects or their legal proxies signed an informed consent form. The study was approved by the Ethics Committee of the Hospital de la Plana, Castellón, Spain. Statistical analysis was carried out with SPSS (Statistical Package for the Social Sciences) software (IBM Corporation, Somer, NY). Results Data were available from 100 subjects: 5 refused to sign consent and 1 was found to be younger than 65 years. Mean age was 84.7 7.5 years (79% were older than 80 years). Subjects were mostly women (80%), with a high degree of severe functional deterioration (42%); 23% had severe cognitive impairment. The average number of prescription drugs used was 6.49 per subject (Table 1). Mean time needed to fill both the STOPP-START scale and the Australian scale was close to 3 minutes. Thirty-seven (56.9%) of the 65 items listed in the STOPP criteria detected potential prescription problems; 21 (95.4%) of the 22 items of the START criteria, and 43 (89.5%) of the 48 items of the Australian score were also able to detect potential problems. Using the STOPP criteria, 79% of the subjects showed at least one potentially inappropriate prescription. Omissions of potentially appropriate drugs were found by the START criteria in 74% of subjects. The Australian criteria detected at least one potential problem in 95% of the sample. The number of subjects with 2 or more potential problems detected was higher using the Australian criteria (72%) than with the STOPP (33%) or START (25%) criteria (P < .001) (Table 2). The most frequent potentially inappropriate prescription detected by the STOPP criteria was the use of a proton-pump inhibitor (PPI) without a clear indication (52%) (Table 3). Other frequent findings were the use of benzodiazepines (35%) and antipsychotic drugs (26%) in patients with a history of falls, prolonged use of long-acting benzodiazepines (13%), and the use of antipsychotics for sleep induction (23%). In 9% of the subjects, duplicate medications were detected, in most cases central nervous system active drugs. START criteria look for omissions of potentially needed drugs. The most frequent problem detected was not using vitamin D and Table 1 Characteristics of the Subjects Age, mean SD Admitted from Home Hospital Nursing home Barthel Index >60 45e60 <45 GDS Reisberg 1e3 4e5 6e7 Number of drugs, mean SD GDS, Global Deterioration Scale.
84.7 7.5 years 58% 33% 9% 39% 19% 42% 52% 25% 23% 6.49 2.86
F. García-Gollarte et al. / JAMDA 13 (2012) 83.e9e83.e15 Table 2 Performance of the STOPP-START and the Australian Criteria in the Detection of Potentially Inappropriate Prescriptions in 100 Subjects Admitted to 6 Nursing Homes
No problems detected One criterion Two criteria More than 2 criteria
STOPP
START
Australian
21 24 22 33
26 36 13 25
5 13 10 72
calcium in patients with osteoporosis (34%), and nonprescription of statins (21%) and aspirin (18%) in cardiovascular conditions where benefits have been well established, in many cases in subjects with diabetes (Table 4).
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The most frequent potential prescription problems detected by the Australian criteria were the prolonged use of benzodiazepines (48%) and the use of psychotropic drugs in subjects with a history of falls (42%) or anticholinergic drugs in dementia (25%) (Table 5). Again, insufficient treatment to prevent osteoporosis (35%), and underuse of statins (30%) were prominent findings. Interactions were detected in 36% of patients, and 30% had significant changes in medications in the preceding 3 months, putting them at risk of further problems.
Discussion Inappropriate drug prescription is a frequent and serious problem among older people. In this study we used both the
Table 3 Potentially Inappropriate Prescriptions Detected by STOPP Criteria* A. Cardiovascular system , Digoxin at a long-term dose >125 mg/d with impaired renal function , Loop diuretic for dependent ankle edema only, ie, no clinical signs of heart failure , Loop diuretic as a first-line monotherapy for hypertension , Thiazide diuretic with a history of gout , Use of diltiazem or verapamil with NYHA class III or IV heart failure , Calcium channel brokers with chronic constipation , Dipiridamol as monotherapy for cardiovascular secondary prevention , Aspirin at dose >150 mg/d , Aspirin with no history of coronary, cerebral, or peripheral vascular symptoms or occlusive event , Aspirin, clopidogrel, dipyridamole, or warfarin with concurrent bleeding disorder B. Central nervous system and psychotropic drugs , Tricyclic antidepressants with dementia , TCAs with constipation , TCAs with an opiate or calcium channel blocker , Long-term long-acting benzodiazepines, and benzodiazepines with long-acting metabolites , Long-term neuroleptics as long-term hypnotics , Long-term neuroleptics in those with parkinsonism , Prolonged use of first-generation antihistaminics C. Gastrointestinal system , Diphenoxilate, loperamide, or codeine phosphate for treatment of diarrhea of unknown cause , Prochlorperazine or metochlopramide with parkinsonism , Proton pump inhibitor for peptic ulcer disease at full therapeutic dosage for >8 weeks D. Respiratory system , Systemic corticosteroids instead of inhaled corticosteroids for maintenance therapy in moderate to severe chronic obstructive pulmonary disease E. Musculoskeletal system , Nonsteroidal anti-inflammatory drug with moderate to severe hypertension , NSAID with heart failure F. Urogenital system , Bladder antimuscarinic drugs with dementia , Vesical antimuscarinic medication in chronic constipation , Alpha-blockers in males with frequent incontinence , Alpha-blockers with long term urinary catheter in situ G. Endocrine system , Beta-blockers in those with diabetes mellitus and frequent hypoglycemic episodes H. Drugs that adversely affect fallers , Benzodiazepines , Neuroleptic drugs , First-generation antihistamines , Vasodilator drugs with persistent postural hypotension , Long-term opiates in those with recurrent falls I. Analgesic drugs , Use of long-term powerful opiates , ie, morphine or fentanyl, as first-line therapy for mild to moderate pain , Regular opiates for more than 2 weeks in those with chronic constipation without concurrent use of laxatives , Long term opiates in those with dementia unless indicated in palliative care or management of moderate/severe chronic pain syndrome J. Duplicate drug classes , Peripheral vasodilators , Psychopharmaceuticals in same group (sedatives, antidepressants, neuroleptics) , Diuretics , Antihypertensives in the same group , Platelet drugs , Calcium supplements , Analgesics STOPP, screening tool of older person’s potentially inappropriate prescriptions. * Only those criteria found in at least one subject are listed.
2 7 3 1 1 7 1 7 7 1 2 1 1 13 23 4 1 2 1 52 1
1 1 3 1 1 1 2 35 26 1 8 7 1 6 3 4 9 2 3 2 1 1
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Table 4 Potentially Inappropriate Prescriptions Detected by START Criteria* A. Cardiovascular system , Warfarin in the presence of chronic atrial fibrillation , Aspirin in the presence of chronic atrial fibrillation, where warfarin is contraindicated , Aspirin or clopidogrel with a documented history of atherosclerotic coronary, cerebral, or peripheral vascular disease in patients with sinus rhythm , Antihypertensive therapy where systolic blood pressure is consistently >160 mm Hg , Statin therapy with a documented history of coronary, cerebral, or peripheral vascular disease, where the patient remains independent for ADL and life expectancy >5 years , Angiotensin-converting enzyme inhibitor with chronic heart failure , ACE inhibitor following acute myocardial infarction , b-blocker with chronic stable angina B. Respiratory system , Regular inhaled b2-agonist or anticholinergic agent for mild to moderate asthma or COPD , Inhaled corticosteroid for moderate/severe asthma or COPD, where predicted forced expiratory volume is <50% C. Central nervous system , L-DOPA in idiopathic Parkinson’s disease with definite functional impairment and resultant disability , Antidepressant drug in the presence of moderate/severe depressive symptoms lasting at least 3 months D. Gastrointestinal system , Fiber supplements for chronic, symptomatic diverticular disease with constipation E. Musculoskeletal System , Disease-modifying antirrheumatic drug with active moderate/severe rheumatoid disease lasting >12 weeks , Calcium and vitamin D supplement in patients with known osteoporosis F. Endocrine system , Metformin with type 2 diabetes metabolic syndrome , ACE inhibitor or angiotensin receptor blocker in diabetes with nephropathy , Antiplatelet therapy in diabetes mellitus with coexisting major cardiovascular risk factors , Statin therapy in diabetes mellitus if coexisting major cardiovascular risk factors present
5 1 18 13 21 9 4 3 3 2 1 4 3 1 34 4 6 11 12
ADL, activities of daily living; COPD, chronic obstructive pulmonary disease; START, screening tool to alert doctors to the right indicated treatment. * Only those criteria found in at least one subject are listed.
STOPP-START criteria and the Australian system in an older population, at the moment of admission to a nursing home, to evaluate their usefulness as a systematic means to detect potentially inappropriate prescription at this time. The Australian tool has not yet been properly validated. Although more than half of our subjects were admitted directly from their homes, and therefore were cared for by their primary care physician before admission, it is important to note that a high percentage (33%) entered immediately after hospital discharge. Potentially inappropriate prescriptions were present in both populations at similar rates. Patients included were representative of assisted nursing home patients (very old age, mostly women, severe disability) and were taking a large number of drugs (6.49), close to that found in similar studies.38,39 The rates of potentially inappropriate prescriptions found by either criterion were higher than rates found in other studies. Beers criteria have been reported to detect different rates of potentially inappropriate prescription in different care settings, ranging from 13% to 48%.40e47 In a study carried out in Ireland using the STOPP criteria in a population of 1329 patients in primary care, potentially inappropriate prescription was found in 17% to 24% of subjects.41 Another recent study from Spain compared potentially inappropriate prescription using STOPP criteria in 3 care settings (primary care, nursing homes, and hospitals) and found rates of 36% in primary care, 50% in nursing homes, and 54% in hospitalized older patients, with different prescription profiles in each setting.34 Our higher rates could be explained because our subjects were in the transition from one care setting to another, and polypharmacy and drug problems have been shown to be predictors of nursing home admission.48 Excessive use of psychoactive drugs is a problem in our country and in others,49 which may be explained by an underdeveloped mental health primary care network, poor access to nondrug treatments, and by poor general practitioner education in this area. This finding would highlight the importance of performing a systematic search of drug-related problems at nursing home admission. The use of START criteria to detect potential omissions showed similar findings. A study in 600 hospitalized patients from different
countries found omissions in about 58% of the cases, with wide variability.50 Omission can be as high as 48% in patients sent to geriatric outpatient clinics51; in primary care, START criteria detected problems in 20% to 26% of the cases.41 Again, we found higher rates (74%) of nonuse of potentially indicated drugs, which might also be related to the need for nursing home care. It is also possible that physicians prescribing to these patients had found compliance problems, or had decided that disability or limited life expectancy contraindicated such drugs. Although STOPP-START criteria have different tables for potentially inappropriate use and inappropriate omission of medications, the Australian criteria include both in an undivided list, which may explain a higher rate of detection of problems. STOPP-START and Australian criteria have some degree of overlap, but together were able to detect a high number of potential prescription problems across a wide range of health conditions. As criteria are based on consensus and interpretation of available evidence, some apparent contradictions may arise when comparing them. To be reproducible, each list of criteria has to be used literally. Thus, there are only 6 events of "regular opiates for more than 2 weeks in those with chronic constipation without concurrent use of laxatives" in STOPP and 8 events in the Australian tool of "patients taking an opioid without prophylactic treatment for constipation," meaning that in 2 subjects opiates were used for less than 2 weeks. Another example is the 21 events of "statin therapy with a documented history of coronary, cerebral, or peripheral vascular disease, where the patient remains independent for ADL and life expectancy >5 years" in START versus 30 Australian tool events of "patient at high risk of a cardiovascular event is not taking a statin," which means that some patients were considered to be at high cardiovascular risk not having a documented story of the listed diseases. These discrepancies would have to be discussed by the promoters of the criteria, looking for the highest consistency when possible. It should also be remembered that a potential medication problem cannot be considered a real problem until a clinician determines if the prescription is right or wrong for that individual patient in that precise situation.
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Table 5 Potentially Inappropriate Prescriptions Detected by the Australian System , , , , , , , , , ,
Patient taking an antihypertensive is not at his or her target blood pressure Patient at high risk of a cardiovascular event is not taking an HMG-CoA reductase inhibitor Patient with IHD or a history of MI is not taking a b-blocker Patient with IHD or history of MI is not taking an antiplatelet agent unless taking an oral anticoagulant Patient with heart failure is not taking a b-blocker Patient with heart failure is not taking an ACE inhibitor or ARB Patient with heart failure is taking medications that may exacerbate heart failure Patient with heart failure or hypertension is taking high sodium-containing medications Patient with atrial fibrillation is not taking an oral anticoagulant Patient with a history of non-hemorrhagic stroke or transient ischemic attack is not taking an antiplatelet agent unless taking an anticoagulant , Patient with risk factors for myopathy is taking 40 mg/d of simvastatin or atorvastatin , Patient with cardiovascular disease is taking an NSAID , Patient with type 2 diabetes and hypertension and albuminuria is not taking an ACE inhibitor or ARB , Patient with diabetes at high risk of a cardiovascular event is not taking an antiplatelet agent unless taking an anticoagulant , Patient with diabetes is taking a medication that may increase or decrease blood glucose concentrations , Patient taking metformin for diabetes has not had the dose adjusted for creatinine clearance , Patient with osteoarthritis pain interfering with activities of daily living has not been trialled on paracetamol 2e4 g/d , Patient taking analgesic has pain that interferes with daily activities , Patient taking an opioid is not taking prophylactic treatment for constipation , Patient with risk factors for impaired renal function is taking an NSAID , Patient is concurrently taking an ACE inhibitor or ARB, diuretic, and NSAID , Patient with sleep disturbance or anxiety has been taking benzodiazepine for >4 weeks , Patient with depression is taking anticholinergic-type antidepressants , Patient with a history of falls is taking psychotropic medications , Patient taking an SSRI is concurrently taking medications known to increase the risk of gastrointestinal bleeding , Patient taking an SSRI is currently taking other medications that may contribute to serotonin toxicity , Patient with dementia is receiving anticholinergic medication , Patient is taking more than one medication with anticholinergic activity , Patient using a proton-pump inhibitor is taking a medication that may cause dyspepsia , Patient with chronic obstructive pulmonary disease is taking benzodiazepines , Patient with asthma using an inhaled long acting beta agonist is not using an inhaled corticosteroid , Patient using a salbutamol or terbutaline inhaler more than 3 times per week for reversible airways disease has not been prescribed an inhaled corticosteroid , Patient with asthma is taking a medication that may worsen asthma , Female patient with recurrent urinary tract infections has not been prescribed intravaginal estrogen , Patient with an upper respiratory tract infection is receiving antibacterials , Patient with osteoporosis who is not receiving at least 600 IU of vitamin D daily from dietary sources is not receiving supplementation with vitamin D , Patient with osteoporosis who is not receiving at least 1200 mg of calcium daily from dietary sources is not receiving calcium supplementation , Patient with osteoporosis is not receiving anti-osteoporotic medication , Patient has not received influenza and pneumococcal vaccination , Patient has significant medication interactions , Patient has had a significant change in medications in the previous 90 days
12 30 9 5 6 9 1 2 5 6 2 3 4 11 3 2 9 3 8 1 2 48 7 62 4 1 25 9 11 5 3 2 5 2 1 5 4 34 1 36 30
ACE, angiotensin-converting enzyme; ARB, adrenergic receptor binder; IHD, ischemic heart disease; MI, myocardial infarction; NSAID, nonsteroidal anti-inflammatory drug; SSRI, selective serotonin reuptake inhibitor.
It is worth noting the high number of potentially inappropriate prescriptions found in the use of psychotropic drugs in this population with both instruments, which is not unexpected.52,53 Specific instruments are being developed for improving quality of prescription of this group of drugs.54e57 The second area that may need improvement is the management of cardiovascular risk. The use of duplicate medications is a frequent problem (15% of admissions) that is amenable to be solved with the appropriate use of computer aids,58 and the same is true for relevant interactions. The high unjustified consumption of PPI and the low prescription of calcium and vitamin D in a high-risk population are also worth mentioning.59,60 This study is being followed by an ongoing intervention study, where 40 skilled nursing homes have been randomized to receive a targeted structured educational intervention on appropriate drug prescription, with regular updates and support; outcomes will include not only a better prescription profile, but also some geriatric problems (falls, delirium) and the use of resources (hospitalizations, emergency room visits). Some methodological shortcomings of this study should be considered. Subject selection was not randomized (all consecutive admissions along a period were included). Only physicians, but not
pharmacists, were involved in the review of prescriptions, and no computer-based prescription tool was used. The methods used were not aiming to validate the 2 prescription tools used, and neither of the tools include a mechanism to verify if a potentially inappropriate prescription is in fact inappropriate and leads to poor outcomes. Careless use of drugs in older people may be dangerous. Although in many cases drug use is beneficial to treat medical conditions in old age, adverse drug reactions may increase the burden of suffering and costs of care. A higher number of drugs does not always imply better health care,61 and sound research in geriatric patients is urgently needed so as to have better grounds for clinical decision making.62 Nursing home admission may be a good time to review and improve medication regimens, and nursing home physicians may benefit from training programs on appropriate prescription. The use of computerassisted prescription may also be beneficial. The use of systematic instruments to detect potential prescription problems both on admission and on a regular basis would have to be explored, and its impact on health outcomes and costs would have to be assessed before they can be widely recommended.
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