High rate of potentially inappropriate medication use in older people: a case-control study.

Annually, 172 million fall events cause temporary or permanent impairment in older adults, and this number is increasing. Contributing factors that increase the risk for falls include age, polypharmacy, and malnutrition. This study evaluated medications mainly included in the EU(7)-PIM (potentially inappropriate medication) list. From March 21, 2022, to July 6, 2022, 945 patients who experienced a fall and visited the Department of Emergency Medicine at the Albert Szent-Györgyi Health Centre of the University of Szeged in Hungary. Data from 886 patients were collected (study group). The control group included 1364 patient data collected from three general practice in Hungary. The use of ≥ 2 EU(7)-PIM drugs was found to be associated with increased risk for falls (adjusted odds ratio [AOR], 1.38; 95% confidence interval [CI] 1.01-1.88). Piracetam (AOR, 1.81; 95% CI, 1.28-2.57) and trimetazidine (AOR, 1.62; 95% CI, 1.17-2.24) were associated with increased risk for falls. Doxazosin was associated with a low risk for falls (AOR, 0.59; 95% CI, 0.41-0.86). Tiapride (AOR, 3.54; 95% CI, 1.75-7.17), gliclazide (AOR, 1.57; 95% CI, 1.02-2.43), and vinpocetine (AOR, 1.95; 95% CI, 1.29-2.95) are not included in the EU(7)-PIM list; however, they are associated with increased risk for falls. Long-acting benzodiazepines (AOR, 1.79; 95% CI, 1.20-2.68), antidepressants (AOR, 1.89; 95% 95% CI, 1.37-2.61), serotonin-norepinephrine reuptake inhibitor (AOR, 2.82; 95% CI, 1.41-5.67; p < 0.01), and selective serotonin reuptake inhibitor (AOR, 1.88; 95% CI, 1.24-2.85) were also associated with increased risk for falls. However, Z-drugs were associated with a low risk for falls (AOR, 0.57; 95% CI, 0.36-0.92). With the help of this tool, trimetazidine and piracetam are filtered as EU(7)-PIM drugs associated with increased risk for falls.

Risk of Mortality Associated with Potentially Inappropriate Medication Use Including Opioids in Older Adults.

INTRODUCTION AND OBJECTIVE: As the population ages, understanding the potential risks associated with inappropriate medication use becomes increasingly important. Given the lack of studies in this area, our objective was to study the risk of mortality associated with potentially inappropriate medication use involving opioids in community-dwelling older adults. METHODS: Data came from a longitudinal study on older adults aged ≥ 65 years recruited in primary care clinics between 2011 and 2013 with an average follow-up of 4.25 years. Older adults were excluded if they used an opioid or had a malignant tumor diagnosis in the year before the study survey. A nested case-control within a cohort of older adults with at least one opioid claim during follow-up was used to evaluate the risk of all-cause mortality. Four controls per case were matched on follow-up time using risk-set sampling, i.e., while still at risk of death when their matched case died. The risk of mortality was estimated using conditional logistic regression analyses. Exposure to potentially inappropriate medication use involving opioids, defined using the Beers 2019 criteria, was assessed from provincial drug claims data in the 0-90 days before death. RESULTS: In a cohort of 472 community-dwelling older adults with an incident episode of opioid use, there were 40 cases matched to 160 controls. Exposure to inappropriate medication use involving opioids in the 90 days before death was associated with an increased risk of mortality (odds ratio 6.81, 95% confidence interval 1.69-27.47), after adjusting for potential confounders. CONCLUSIONS: Exposure to inappropriate medication use involving opioids in the 90 days before death is associated with an increased risk of mortality in older adults. These findings can be used to encourage safer pain management strategies in older adults.

[Polypharmacy in older people].

After the publication of the guidelines about the safe drug therapy for older people in 2015 by the Japan Geriatrics Society, the risk of polypharmacy has become popular. Older people are likely to have multimorbidity, resulting in the use of multiple drugs. This not only increases the frequency of side effects, but also increase confusion and difficulty in medication management and adherence. Polypharmacy is the problem related to these complicated drug therapies and will increase by age. It is necessary to review drugs and resolve polypharmacy without making comorbid conditions worth. To carry out effective medication reviews, the guidance established by the Ministry of Health, Labor and Welfare introduced that geriatric assessment is essential for those with polypharmacy, since not only all medical conditions, but also physical and cognitive functions, medications, living environment, and caregivers should be taken into consideration when discontinuing drugs. When tapering, potentially inappropriate medications (PIMs) should be always the targets, and PIMs drug lists such as the Beers criteria and STOPP/START became very popular in overseas. Even after the reductions, careful attention should be paid to changes in the patient's condition. For drugs that are continued, continuous checks are required to ensure compliance with patients' medication adherence. There are many possible reasons for poor medication adherence, and it will be difficult to improve unless we identify what the cause is in each patient, and making the prescriptions simple may be necessary.

Patterns of inappropriate prescribing and clinical characteristics in patients at admission to an acute care of the elderly unit.

PURPOSE: Inappropriate prescribing (IP) is common among the elderly and is associated with adverse health outcomes. The role of different patterns of IP in clinical practice remains unclear. The aim of this study is to analyse the characteristics of different patterns of IP in hospitalized older adults. METHODS: This is a prospective observational study conducted in the acute care of elderly (ACE) unit of an acute hospital in Barcelona between June and August 2021. Epidemiological and demographic data were collected, and a comprehensive geriatric assessment (CGA) was performed on admitted patients. Four patterns of inappropriate prescribing were identified: extreme polypharmacy (10 or more drugs), potentially inappropriate medications (PIMs), potential prescribing omissions (PPOs) and anticholinergic burden. RESULTS: Among 93 admitted patients (51.6% male, mean age of 82.83), the main diagnosis was heart failure (36.6%). Overprescribing patterns (extreme polypharmacy, PIMs, PPOs and anticholinergic burden) were associated with higher comorbidity, increased dependence on instrumental activities of daily living (IADL) and greater prevalence of dementia. Underprescribing (omissions) was associated with important comorbidity, residence in nursing homes, an increased risk of malnutrition, higher social risk and greater frailty. Comparing different patterns of IP, patients with high anticholinergic burden exhibited more extreme polypharmacy and PIMs. In the case of omissions, no association was identified with other IP patterns. CONCLUSIONS: We found statistically significant association between patterns of inappropriate prescribing and clinical and CGA variables such as comorbidity, dependency, dementia or frailty. There is a statistically significant association between patterns of overprescribing among patients admitted to the ACE unit.

Association of Potentially Inappropriate Medication Classes with Mortality Risk Among Older Adults Initiating Hemodialysis.

BACKGROUND AND OBJECTIVE: Older adults initiating dialysis have a high risk of mortality and that risk may be related to potentially inappropriate medications (PIMs). Our objective was to identify and validate mortality risk associated with American Geriatrics Society Beers Criteria PIM classes and concomitant PIM use. METHODS: We used US Renal Data System data to establish a cohort of adults aged ≥ 65 years initiating dialysis (2013-2014) and had no PIM prescriptions in the 6 months prior to dialysis initiation. In a development cohort (40% sample), adjusted Cox proportional hazards models were performed to determine which of 30 PIM classes were associated with mortality (or "high-risk" PIMs). Adjusted Cox models were performed to assess the association of the number of "high-risk" PIM fills/month with mortality. All models were repeated in the validation cohort (60% sample). RESULTS: In the development cohort (n = 15,570), only 13 of 30 PIM classes were associated with a higher mortality risk. Compared with those with no "high-risk" PIM fills/month, patients having one "high-risk" PIM fill/month had a 1.29-fold (95% confidence interval 1.21-1.38) increased risk of death; those with two or more "high-risk" PIM fills/month had a 1.40-fold (95% confidence interval 1.24-1.58) increased risk. These findings were similar in the validation cohort (n = 23,569). CONCLUSIONS: Only a minority of Beers Criteria PIM classes may be associated with mortality in the older dialysis population; however, mortality risk increases with concomitant use of "high-risk" PIMs. Additional studies are needed to confirm these associations and their underlying mechanisms.

Potentially inappropriate medication use is associated with increased risk of incident disability in healthy older adults.

BACKGROUND: Efforts to minimize medication risks among older adults include avoidance of potentially inappropriate medications (PIMs). However, most PIMs research has focused on older people in aged or inpatient care, creating an evidence gap for community-dwelling older adults. To address this gap, we investigated the impact of PIMs use in the ASPirin in Reducing Events in the Elderly (ASPREE) clinical trial cohort. METHODS: Analysis included 19,114 community-dwelling ASPREE participants aged 70+ years (65+ if US minorities) without major cardiovascular disease, cognitive impairment, or significant physical disability. PIMs were defined according to a modified 2019 AGS Beers Criteria. Cox proportional-hazards regression models were used to estimate the association between baseline PIMs exposure and disability-free survival, death, incident dementia, disability, and hospitalization, with adjustment for sex, age, country, years of education, frailty, average gait speed, and comorbidities. RESULTS: At baseline, 7396 (39% of the total) participants were prescribed at least one PIM. Compared with those unexposed, participants on a PIM at baseline were at an increased risk of persistent physical disability (adjusted hazard ratio [HR] 1.47, 95% confidence interval [CI] 1.21, 1.80) and hospitalization (adjusted HR 1.26, 95% CI 1.20, 1.32), but had similar rates of disability-free survival (adjusted HR 1.02; 95% CI 0.93, 1.13) and death (adjusted HR 0.92, 95% CI 0.81, 1.05). These effects did not vary by polypharmacy status in interaction analyses. PIMs exposure was associated with higher risk of disability followed by hospitalization (adjusted HR 1.92, 95% CI 1.25, 2.96) as well as vice versa (adjusted HR 1.54, 95% CI 1.15, 2.05). PPIs, anti-psychotics and benzodiazepines, were associated with increased risk of disability. CONCLUSIONS: PIMs exposure is associated with subsequent increased risk of both incident disability and hospitalization. Increased risk of disability prior to hospitalization suggests that PIMs use may start the disability cascade in healthy older adults. Our findings emphasize the importance of caution when prescribing PIMs to older adults in otherwise good health.

Development and Implementation of a Pharmacist-Led Proton Pump Inhibitor Deprescribing Algorithm in a Geriatric Ambulatory Office.

Background The American Geriatrics Society 2019 Updated Beers Criteria© recommends avoiding scheduled use of proton pump inhibitors (PPIs) for greater than eight weeks in older people because of potential risk of bone loss and fractures and Clostridioides difficile infection. There are limited studies evaluating the effectiveness of deprescribing PPIs in this patient population. Objective The purpose of this study was to evaluate the implementation of a PPI deprescribing algorithm in a geriatric ambulatory office on the appropriateness of PPI use in older people. Methods This single-center study evaluated PPI use in a geriatric ambulatory office pre- and post-implementation of a deprescribing algorithm. Participants included all patients 65 years of age or older and a documented PPI on their home medication list. The PPI deprescribing algorithm was developed by the pharmacist using components of the published guideline. The primary outcome was the percentage of patients on a PPI with a potentially inappropriate indication before and after implementation of this deprescribing algorithm. Results At baseline, 228 patients were treated with a PPI, and 64.5% (n = 147) of patients were treated for a potentially inappropriate indication. Of the 228 patients, 147 patients were included in the primary analysis. Potentially inappropriate use of PPI significantly decreased after implementation of a deprescribing algorithm from 83.7% to 44.2% in the cohort of patients who were eligible for deprescribing (difference 39.5%; P < 0.0001). Conclusion Potentially inappropriate PPI use in older adults decreased after implementation of a pharmacist-led deprescribing initiative, supporting the role of pharmacists on interdisciplinary deprescribing teams.

A combination of Beers and STOPP criteria better detects potentially inappropriate medications use among older hospitalized patients with chronic diseases and polypharmacy: a multicenter cross-sectional study.

BACKGROUND: Research on potentially inappropriate medications (PIM) and medication-related problems (MRP) among the Chinese population with chronic diseases and polypharmacy is insufficient. OBJECTIVES: This study aimed to investigate the prevalence of PIM and MRP among older Chinese hospitalized patients with chronic diseases and polypharmacy and analyze the associated factors. METHODS: A retrospective cross-sectional study was conducted in five tertiary hospitals in Beijing. Patients aged ≥ 65 years with at least one chronic disease and taking at least five or more medications were included. Data were extracted from the hospitals' electronic medical record systems. PIM was evaluated according to the 2015 Beers criteria and the 2014 Screening Tool of Older Persons' Prescriptions (STOPP) criteria. MRPs were assessed and classified according to the Helper-Strand classification system. The prevalence of PIM and MRP and related factors were analyzed. RESULTS: A total of 852 cases were included. The prevalence of PIM was 85.3% and 59.7% based on the Beers criteria and the STOPP criteria. A total of 456 MRPs occurred in 247 patients. The most prevalent MRP categories were dosages that were too low and unnecessary medication therapies. Hyperpolypharmacy (taking ≥ 10 drugs) (odds ratio OR 3.736, 95% confidence interval CI 1.541-9.058, P = 0.004) and suffering from coronary heart disease (OR 2.620, 95%CI 1.090-6.297, P = 0.031) were the influencing factors of inappropriate prescribing (the presence of either PIM or MRP in a patient). CONCLUSION: PIM and MRP were prevalent in older patients with chronic disease and polypharmacy in Chinese hospitals. More interventions are urgently needed to reduce PIM use and improve the quality of drug therapies.

Potentially inappropriate medication in long-term care wards of a veteran hospital in Taiwan: Investigation using a spreadsheet-based rapid assessment tool.

BACKGROUND: Multimorbidity and polypharmacy increase in the aging population and are accompanied by the use of potentially inappropriate medications (PIMs) and adverse drug events (ADEs). This study developed a rapid assessment tool to investigate PIM use among patients in long-term care wards. METHODS: We retrospectively collected the data of patients in long-term care wards of a veteran hospital in Taiwan between July 2019 and June 2020. The patients with chronic diseases and medications were selected. The data, including gender, age, diagnosis, and medications, were deidentified. Nonchronic disease diagnosis and short-term and topical use medications were excluded. We used Microsoft Excel (Microsoft Corporation, Redmond, Washington, USA) and the 2019 version of the Beers Criteria to establish a rapid assessment tool. The correlations between the prevalence of PIM use and age, the number of diagnoses, and the number of medications were analyzed using SPSS version 23. RESULTS: A total of 176 patients were included in this study, of which 76.7% (n = 135) were male and 23.3% (n = 41) were female. The average age of men was 82.1 years and that of women was 83.4 years. The average number of diagnoses for men was 5.5, and that for women was 7.3. The average number of medications for men was 5.8, and that for women was 6.5. The prevalence of PIM use was 59.1% (n = 104). Logistic regression revealed that the prevalence of PIM use may be associated with the number of medications ( p < 0.001; odds ratio = 1.378). Decision tree analysis revealed that patients who simultaneously used more than four medications exhibited a higher risk of PIM. CONCLUSION: PIM use is a key factor causing ADEs among older adults. Therefore, comprehensive assessment of PIM use is necessary. This study designed a rapid assessment tool to simultaneously integrate and evaluate medications. Future studies may investigate the effectiveness of the proposed assessment tool.

Drug-drug interactions in nursing home residents: analysis from the COME-ON trial.

BACKGROUND: as a result of the high prevalence of polypharmacy in nursing homes (NHs), nursing home residents (NHRs) are exposed to numerous drug-drug interactions (DDIs) that can lead to adverse drug effects, and increased morbidity and mortality. OBJECTIVES: to evaluate (i) the prevalence of DDIs among NHRs and its evolution over time, and (ii) factors associated with a favourable evolution. DESIGN: posthoc analysis of the COME-ON study, a cluster-randomised controlled trial aiming at reducing potentially inappropriate prescriptions in NHs, through the implementation of a complex intervention. SETTING AND SUBJECTS: 901 NHRs from 54 Belgian NHs. METHODS: DDIs were identified using a validated list of 66 potentially clinically relevant DDIs in older adults. We defined a favourable evolution at 15 months as the resolution of at least one DDI present at baseline, without the introduction of any new DDI. Factors associated with a favourable evolution were analysed using multivariable logistic regression. RESULTS: at baseline, 475 NHRs (52.7%) were exposed to at least 1 DDI and 225 NHRs (25.0%) to more than one DDI. Most common DDI was 'Concomitant use of at least three central nervous system active drugs'. At 15 months, we observed a 6.3% absolute decrease in DDI prevalence in intervention group, and a 1.0% absolute increase in control group. The intervention, older age and private NH ownership were significantly associated with a favourable DDI evolution. CONCLUSION: a high prevalence of DDI in Belgian NHs was observed, but the COME-ON intervention was associated with a favourable evolution over time.

Clinical Pharmacist Intervention Reduces Potentially Inappropriate Prescriptions in a Geriatric Perioperative Care Unit Dedicated to Hip Fracture.

INTRODUCTION: Clinical pharmacist (CP) intervention improves drug prescription by identifying potentially inappropriate prescriptions (PIPs). Geriatric perioperative care units (UPOGs) provide enhanced care for patients with hip fracture, including drug prescription. However, it is not known whether adding a CP intervention in a UPOG decreases the number of PIPs. This study aimed to evaluate the effect of a CP intervention, combining an implicit and an explicit method, on the number of PIPs in a UPOG. METHODS: This single centre before-after-control-impact study recruited patients aged over 75 years admitted to a UPOG for a hip fracture. The "control group" ("before period") received usual care including two medication reconciliations, one at admission and one at discharge. The "intervention group" ("after period") received usual care and a CP intervention including two medication reconciliations, a medication review with two tools, STOPP/START and Medication Appropriateness Index, and a meeting between a CP and geriatricians. PIPs were assessed in both groups by STOPP/START and Medication Appropriateness Index and compared from hospital admission to discharge. RESULTS: A total of 209 patients were included, 150 in the control group and 59 in the intervention group (mean age: 87.2 ± 5.9 years). The number of PIPs decreased in both groups from hospital admission to discharge (p < 0.001). The number of PIPs, potentially inappropriate medications, and potential prescribing omissions decreased more in the intervention group than in the control group (adjusted intervention effect: -2.46 (95% CI: -2.63; -2.24); -1.13 (95% CI: -1.27; -0.98); and -1.35 (95% CI: -1.52; -1.18), respectively, p < 0.001 for all). DISCUSSION/CONCLUSION: A CP intervention with an explicit and implicit method improved prescriptions in a UPOG. Further randomized studies are necessary to evaluate the effect of a CP intervention on adverse drug events, health costs, and mortality.

Impact of Potentially Inappropriate Medications on Kidney Function in Chronic Kidney Disease: Retrospective Cohort Study.

INTRODUCTION: Chronic kidney disease (CKD) represents a major public health burden. Potential inappropriate medications (PIMs) are common in patients with CKD. However, its impact on kidney outcomes has not been adequately elucidated for middle-aged patients. This study aimed to clarify the prescription status of PIMs for middle-aged patients with CKD and its effect on kidney function decline. METHODS: Using an administrative claims database in Japan, a retrospective cohort study was conducted among Japanese patients with CKD (aged 20-74) who underwent annual health check-ups at least three times between April 2008 and December 2020. PIM exposure was defined as medications to be avoided in older adults as defined by the 2019 American Geriatrics Society Beers Criteria. The association between the number of prescribed PIMs and the decline in estimated glomerular filtration rate (eGFR) was examined using logistic regression models adjusted for clinical characteristics and laboratory variables. RESULTS: A total of 43,143 patients with CKD (mean age 57 years, median eGFR: 52 mL/min/1.73 m2) were analyzed, and approximately 40% of the patients were prescribed one or more PIMs. The most commonly prescribed PIMs were pain medications (18.5%), followed by gastrointestinal medications (9.8%), central nervous system medications (8.6%), and cardiovascular medications (8.6%). After adjustment, exposure to 2 or ≥3 PIMs was associated with an increased risk of 30% eGFR decline (adjusted odds ratio 1.71 [95% confidence interval, 1.24-2.37] and 1.65 [95% confidence interval, 1.08-2.52], respectively) as compared to the control group. CONCLUSION: This study showed that middle-aged patients with CKD who were prescribed ≥2 PIM had an increased risk of progression of CKD. Further studies are needed to analyze whether deprescribing steps contribute to reduce PIM prescriptions and prevent CKD progression.

Socio-demographic differences in polypharmacy and potentially inappropriate drug use among older people with different care needs and in care settings in Stockholm, Sweden.

AIMS: Polypharmacy and potentially inappropriate medications (PIM) are risk factors for negative health outcomes among older people. This study aimed to investigate socio-demographic differences in polypharmacy and PIM use among older people with different care needs in a standard versus an integrated care setting. METHODS: Population-based register data on residents aged ⩾65 years in Stockholm County based on socio-demographic background and social care use in 2014 was linked to prescription drug use in 2015. A logistic regression analysis was used to estimate socio-demographic differences in polypharmacy and PIM, adjusting for education, age group, sex, country of birth, living alone, morbidity and dementia by care setting based on area and by care need (i.e. independent, home help or institutionalised). RESULTS: The prevalence of polypharmacy and PIM was greater among home-help users (60.4% and 11.5% respectively) and institutional residents (74.4% and 11.9%, respectively). However, there were greater socio-demographic differences among the independent, with those with lower education, older age and females having higher odds of polypharmacy and PIM. Morbidity was a driver of polypharmacy (odds ratio (OR)=1.19, confidence interval (CI) 1.16-1.22) among home-help users. Dementia diagnosis was associated with reduced odds of polypharmacy and PIM among those in institutions (OR=0.78, CI 0.71-0.87 and OR 0.52, CI 0.45-0.59, respectively) and of PIM among home-help users (OR=0.53, 95% CI 0.42-0.67). CONCLUSIONS: Polypharmacy and PIM were associated with care needs, most prevalent among home-help users and institutional residents, but socio-demographic differences were most prominent among those living independently, suggesting that municipal care might reduce differences between socio-demographic groups. Care setting had little effect on inappropriate drug use, indicating that national guidelines are followed.

Uso ambulatorio de medicamentos potencialmente inapropiados en adultos mayores usuarios de la RAP Metropolitana de ASSE durante 2019 / Potentially inappropriate medication use in older adults assisted as outpatients in ASSE's Metropolitan RAP (Primary Health Care) during 2019 / Uso ambulatorial de medicamentos potencialmente inapropriados em idosos usuários da RAPE Metropolitana da ASSE durante 2019

Introducción: los adultos mayores son una población de riesgo para el desarrollo de reacciones adversas a los medicamentos. Los medicamentos potencialmente inapropiados son aquellos que representan mayores riesgos que beneficios en este grupo etario. Se cuenta con herramientas de apoyo a la prescripción en geriatría que permiten identificar a estos medicamentos y mediante la aplicación de estudios de utilización de medicamentos, podemos describir o analizar el uso de los mismos en una población. Objetivos: reconocer disponibilidad de medicamentos potencialmente inapropiados para adultos mayores en la RAP metropolitana de ASSE durante 2019 y establecer un diagnóstico de situación de consumo de los mismos durante ese año. Método: se realizó un análisis del vademécum institucional mediante la aplicación de los Criterios de Beers 2019 y dos escalas de riesgo anticolinérgico para identificar medicamentos potencialmente inapropiados. Posteriormente se realizó un estudio de utilización de los medicamentos identificados, mediante datos de dispensación de farmacia entre el 1 de enero y 31 de diciembre de 2019. El consumo se expresó en Dosis Diarias Definidas por cada 1000 adultos mayores-año (DHD). Resultados: se identificaron 16 medicamentos potencialmente inapropiados, de los cuales los más usados fueron clonazepam (DHD 69), quetiapina (65,6), alprazolam (DHD 43,7), flunitrazepam (DHD 42,7) y zolpidem (DHD 36,4). Conclusiones: la aplicación de herramientas explícitas facilita la identificación de medicamentos potencialmente inapropiados para adultos mayores y se evidenció un consumo elevado de los mismos durante el año 2019 a expensas de derivados benzodiazepínicos y quetiapina.

Introduction: older adults are at higher risk for developing adverse drug reactions. Potentially inappropriate medications are drugs that have more risks than benefits in this age group. There are a number of tools to support the prescription of medication in geriatrics that allow the identification of these medications, and by applying studies developed on the use of medications we may describe or analyze their impact on a given population. Objectives: to recognize availability of potentially inappropriate medications in older adults in ASSE's Metropolitan RAP during 2019 and to draw conclusions about the current situation in terms of the consumption of this kind of medications. Method: an institutional analysis of medications available in each healthcare provided was conducted through the application of Beers Criteria 2019, and two anticholinergic risk scales were used to identify potentially inappropriate medications. Subsequently, the use of the medications identified was studied by applying pharmacy dispensing data between January 1 and December 31, 2019. Consumption was expressed in defined daily doses every 1000 adults per year (DHD). Results: 16 potentially inappropriate medications were identified, the most widely used of which were clonazepam (DHD 69), quetiapine (65.6), alprazolam (DHD 43.7), flunitrazepam (DHD 42.7) and zolpidem (DHD 36.4). Conclusions: Applying explicit tools makes it easier to identify potentially inappropriate medications for older adults. An increased consumption of these kinds of drugs was noticed during 2019, as a result of benzodiazepine derivatives and quetiapine.

Introdução: os idosos são uma população de risco para o desenvolvimento de reações adversas a medicamentos. Medicamentos potencialmente inapropriados são aqueles que apresentam maiores riscos do que benefícios nessa faixa etária. Existem ferramentas de apoio à prescrição em geriatria que permitem identificar esses medicamentos e, por meio da aplicação de estudos de utilização de medicamentos, descrever ou analisar seu uso em uma população. Objetivos: reconhecer a disponibilidade de medicamentos potencialmente inapropriados para idosos na RAP metropolitana da ASSE durante o ano de 2019 e estabelecer um diagnóstico de consumo durante esse ano. Método: o formulário institucional foi analisado utilizando os Critérios de Beers 2019 e duas escalas de risco anticolinérgico para identificar medicamentos potencialmente inapropriados. Posteriormente, foi realizado um estudo de consumo dos medicamentos identificados, através dos dados de dispensação da farmácia entre 1 de janeiro e 31 de dezembro de 2019. O consumo foi expresso em Doses Diárias Definidas por 1000 idosos-ano (DHD). Resultados: foram identificados 16 medicamentos potencialmente inapropriados, sendo clonazepam (DHD 69), quetiapina (65,6), alprazolam (DHD 43,7), flunitrazepam (DHD 42,7) e zolpidem (DHD 36,4) os mais utilizados Conclusões: a aplicação de ferramentas explícitas facilita a identificação de medicamentos potencialmente inapropriados para idosos; foi observado um alto consumo dos mesmos em detrimento dos derivados benzodiazepínicos e da quetiapina durante o período do estudo.

Prevalence of potentially inappropriate medications and association with comorbidities in older adults with diabetes in an outpatient visitation setting.

Aims: Potentially inappropriate medications had been found associated with adverse drug events such as falls, emergency department admissions and hospital readmissions. There is lack of information about the prevalence of potentially inappropriate medications and associated chronic conditions in older patients with diabetes in China. This study aimed to assess the prevalence of potentially inappropriate medications in older adults with diabetes in an outpatient visitation setting and the association with polypharmacy due to comorbidities. Materials and methods: This was a 3-year repeated cross-sectional study which conducted in outpatient setting of 52 hospitals in Shenzhen, China, using 2019 Beers criteria. The prevalence of potentially inappropriate medications, polypharmacy and comorbidities in older adults with diabetes in an outpatient setting was expressed as percentages. Logistic models were used to investigate the association between potentially inappropriate medication exposure and age, sex, polypharmacy and comorbidities. Results: Among the 28,484 older adults with diabetes in 2015, 31,757 in 2016 and 24,675 in 2017, the prevalence of potentially inappropriate medications was 43.2%, 44.88% and 42.40%, respectively. The top five potentially inappropriate medications were diuretics (20.56%), benzodiazepines (13.85%), androgens (13.18%), non-steroidal anti-inflammatory drugs (12.94%) and sulfonylureas (6.23%). After adjustment for age and polypharmacy, the probability of potentially inappropriate medication exposure was associated with chronic gastrointestinal diseases, followed by osteoarthritis and rheumatoid arthritis, chronic pulmonary disease, chronic kidney disease, tumor, dementia, chronic liver disease, hypertension, cardiovascular disease, cerebrovascular disease and hyperlipemia. Conclusion: Potentially inappropriate medications were common in older patients with diabetes in an outpatient visitation setting. Higher probability of potentially inappropriate medication exposure was associated with the comorbidity chronic gastrointestinal diseases as well as osteoarthritis and rheumatoid arthritis. To ensure that iatrogenic risks remain minimal for older adults with diabetes, the clinical comorbidities should be considered.

Deprescripción en personas mayores: es el momento de pasar a la acción / Deprescription in old people: It's time to take action

El uso de fármacos conlleva innegables beneficios en las personas mayores, pero no está exento de efectos indeseables. La deprescripción es el proceso de revisión sistemática de la medicación con el objetivo de lograr la mejor relación riesgo-beneficio en base a la mejor evidencia disponible. Este proceso es especialmente importante en mayores polimedicados, sobretratados, frágiles, con enfermedades terminales y en el final de la vida.La deprescripción debe hacerse de forma escalonada, estableciendo un seguimiento estrecho por si aparecen problemas tras la retirada. En la toma de decisiones es muy importante contar con la opinión del paciente y de los cuidadores, valorando los objetivos del tratamiento según la situación clínica, funcional y social del enfermo.Existen múltiples herramientas para facilitar a los clínicos la tarea de seleccionar qué fármacos deprescribir (criterios Beers, STOPP-START…). Los grupos farmacológicos más susceptibles de intervención son: antihipertensivos, antidiabéticos, estatinas, benzodiacepinas, antidepresivos, anticolinérgicos, anticolinesterásicos y neurolépticos.(AU)

The use of drugs has undeniable benefits to the elderly, but it is not exempt from undesirable effects. Deprescription is the process of systematic medication review with the target of achieving the best risk-benefit ratio based on the best available evidence. This process is especially important for polymedicated elderly patients as well as those overtreated, frail, terminally ill and at the end of life.The deprescription must be done in stages, establishing a close follow-up in case problems appear after withdrawal. In the decision-making process, it is very important to consider the patient and caregivers opinion, assessing the objectives of the treatment according to the clinical, functional and social situation of the patient.There are multiple tools to make it easier for clinicians to select which drugs to deprescribe (Beers criteria, STOPP-START…). The most susceptible to intervention pharmacological groups are: antihypertensives, antidiabetics, statins, benzodiazepines, antidepressants, anticholinergics, anticholinesterase agents, and neuroleptics.(AU)

Prescribing cascades: we see only what we look for, we look for only what we know.

Prescribing cascades are increasingly recognized since they were described in the mid-1990s. Cascades are more likely in older people with multimorbidity and associated polypharmacy where multiple medications can induce a variety of side effects that manifest with various non-specific symptoms that may be misidentified as new geriatric syndromes such as falls, dizziness and new-onset incontinence. Geriatricians encounter medication side effects frequently and will usually consider if an older patient presenting with new symptoms could be experiencing an adverse drug reaction or event. However, most medications prescribed to multimorbid older patients are initiated and continued by prescribers without specialist geriatric training who may not detect medication-induced morbidity. Therefore, novel approaches to the detection and management of prescribing cascades in older people are needed. Currently, the knowledge base surrounding prescribing cascades in older people is evolving towards better methods for cascade detection and secondary prevention. However, the large number of cascades described in the literature, the wide-ranging symptomatology of cascades and the rapidly increasing number of multimorbid older people at risk of cascades represent major challenges for prescribers. Furthermore, prospective prevalence studies of prescribing cascades in older people are lacking. To detect and correct prescribing cascades during routine medication review in multimorbid older people, awareness of cascades is essential. Prescribing cascade awareness in turn requires novel explicit ways of defining cascades to facilitate their rapid detection and correction during medication review. Given that prescribing cascades represent another aspect of inappropriate prescribing (IP), explicit cascades criteria should be integrated with other explicit IP criteria.

Clinical relevance of potentially inappropriate medications and potential prescribing omissions according to explicit criteria-a validation study.

PURPOSE: To investigate the clinical relevance of potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs), and to evaluate the association between PIMs/PPOs and inadequate drug treatment. METHODS: PIMs/PPOs, concordantly identified by two physicians applying the STOPP/START criteria, the EU(7)-PIM list, and a Swedish set in 302 consecutive older primary care patients, were assessed regarding clinical relevance for the specific patient. The physicians determined, in consensus, whether an action related to the medication was medically justified prior to the next regular consultation. If so, the drug treatment was categorised as inadequate, and if not, the treatment was considered adequate. RESULTS: In all, 259 (86%) patients had 1010 PIMs/PPOs, 150 (15%) of which, in 81 (27%) patients, were assessed as clinically relevant (kappa: 0.26). A total of 75 (50%) clinically relevant PIMs and PPOs were prioritised for medical action before the next regular consultation. Action-requiring clinically relevant PIMs most often concerned acetylsalicylic acid (ASA) for primary prevention (four out of 68 patients on ASA). The corresponding PPOs concerned beta-blockers in ischaemic heart disease (four out of 61 patients with this condition). When an overall medical perspective was applied, 164 (63%) out of 259 patients with PIMs/PPOs were assessed as having adequate treatment. In adjusted logistic regression, number of PIMs and/or PPOs and number of drugs were associated with inadequate drug treatment. CONCLUSION: One in seven PIMs/PPOs may be clinically relevant, half of these not of priority for medical action. Cautious interpretation is warranted when PIMs/PPOs are used as outcome measures.