Potentially Inappropriate Prescribing in a Falls Clinic Using the STOPP & START Criteria

Background Potentially inappropriate prescribing which may lead to adverse drug events and linked to polypharmacy is becoming increasingly common in older patients. Objective This study applied the STOPP/START criteria to a clinical registry to determine the burden and profile of potentially inappropriate prescribing among patients attending a falls clinic. Setting University of Malaya Medical Centre Falls Clinic Method Data of individuals aged ≥ 65 years referred to the falls and syncope clinic were extracted from the falls registry. Potentially inappropriate prescribing was determined with the STOPP/START version 2 criteria. The relationship between potentially inappropriate prescribing with polypharmacy (≥ 5 medications), comorbidities and clinical variables were determined using Pearson’s chi-square and potential confounders adjusted for with multivariate regression. Main outcome measure Potentially inappropriate medicines and/or omitted medicines using STOPP/START criteria Results Data from 421 individuals, aged 77.8 ± 6.7 years and 53.4% women, were included. Potentially inappropriate prescribing was present in 311 (74%). Potentially inappropriate medicines use accounted for 84.6% of the 325 prescriptions. 361/659 instances (54.8%) were falls-risk-increasing drugs, with vasodilators (49.3%) being the main potentially inappropriate medicine identified. Of the 177/421 with polypharmacy, 169/177 (95.5%) were exposed to ≥ one potentially inappropriate medicine. 129 instances of potentially omitted medicines were observed in 109 prescriptions (25.9%). Conclusion STOPP/START criteria are useful to identify potentially inappropriate prescribing at the falls and syncope clinic. This finding has important implications for medication review strategies at falls clinic. Future research should determine whether identifying potentially inappropriate prescribing may reduce adverse falls outcomes among patients in this setting.

Operacionalização para Portugal da Lista EU(7)-PIM para Identificação de Medicamentos Potencialmente Inapropriados nos Idosos

Introduction: In 2015, the EU(7)-PIM List was published, which identifies potentially inappropriate medicines in older patients and resulted from a consensus of experts from seven European countries. Portugal was not part of this group, so it was not originally adapted to the Portuguese reality. With this work, we intend to elaborate a list of potentially inappropriate medicines adapted to the reality of medicines marketed in Portugal, through the operationalization of the EU(7)-PIM List for the national reality and to evaluate the adequacy of its use for clinical practice.Material and Methods: Search, in INFARMED’s Infomed database, of drugs that are included in the EU(7)-PIM List that have marketing authorization, and analysis of possible new drugs for inclusion in the list. The tool adapted to the Portuguese reality was applied to a sample of 1089 outpatient, polymedicated older patients from 38 primary care units in Central Portugal.Results: The final PIM list adapted to the Portuguese reality includes 184 potentially inappropriate medicines (from these, 178 are active substances, five are classes of drugs, and one corresponds to the sliding scale therapeutic scheme used in insulin therapy). Of 1089 polymedicated older patients, 83.7% took at least one drug included in the final potentially inappropriate medicines list or belonging to one of the groups included in the list, and, on average, each patient took 1.74 (IQR 1 – 2).Discussion: Even though the availability of drugs on the market is quite diverse, the EU(7)-PIM List has been used in several European countries. With this study, we operationalized the European list for the Portuguese reality, which will enable its application in clinical practice.Conclusion: The list drawn up is a useful tool for the identification of potentially inappropriate medicines, easy to use in clinical practice and research.

Aplicação dos Critérios de Beers de 2015 Operacionalizados para Portugal em Pessoas Idosas Institucionalizadas: Um Estudo Transversal

Introduction: The consumption of potentially inappropriate medicines is high among institutionalized elderly, predisposing to potential drug interactions, adverse drug events, risk of iatrogenic cascade, increased morbidity and mortality and health costs. Medication review is a promising strategy for therapeutic optimization, although scarcely documented in Portugal. The aim of this study was to characterize, using explicit criteria, the existence of potentially inappropriate medicines, among institutionalized elderly, and to calculate the eventual cost savings, with their discontinuation.Material and Methods: Descriptive and cross-sectional study conducted in three residential homes for the elderly, from different geographic regions, based on a random sample of 33 health records. In order to characterize the existence of potentially inappropriate medicines, we used the 2015 Beers criteria, revised by the American Geriatrics Society and in the Portuguese version.Results: On average, 11 drugs are prescribed to elderly residents of three residential structures for the elderly. All health records contain potentially inappropriate medicines (mean 4.8 ± 2.0 per resident), with anxiolytics (17.7%), antidepressants (17.7%) and antipsychotics (15.8%) being the most prevalent. Its reduction would result in an average monthly savings of €9.6 per resident.Discussion: The consumption of potentially inappropriate medicines is higher than the literature describes, and the cost of medicines is high. The involvement of nurses in the process of drug management and reconciliation, in coordination with the physician, could be an effective strategy. This is the first study using the latest Portuguese version of the Beers criteria, which makes the comparability of the results difficult.Conclusion: The consumption of potentially inappropriate medicines is high, which suggest the need for adoption of improvement measures.

Quality of prescribing predicts hospitalisation in octogenarians: life and living in advanced age: a cohort study in New Zealand (LiLACS NZ)

Background Prescribing for older people is complex, and many studies have highlighted that appropriate prescribing in this cohort is not always achieved. However, the long-term effect of inappropriate prescribing on outcomes such as hospitalisation and mortality has not been demonstrated. The aim of this study was to determine the level of potentially inappropriate prescribing (PIP) for participants of the Life and Living in Advanced Age: A Cohort Study in New Zealand (LiLACS NZ) study at baseline and examine the association between PIP and hospitalisation and mortality at 12-months follow-up. Methods PIP was determined using STOPP/START. STOPP identified potentially inappropriate medicines (PIMs) prescribed, START identified potential prescribing omissions (PPOs). STOPP/START were applied to all LiLACS NZ study participants, a longitudinal study of ageing, which includes 421 Māori aged 80–90 years and 516 non-Māori aged 85 years. Participants’ details (e.g. age, sex, living arrangements, socioeconomic status, physical functioning, medical conditions) were gathered by trained interviewers. Some participants completed a core questionnaire only, which did not include medications details. Medical conditions were established from a combination of self-report, review of hospital discharge and general practitioner records. Binary logistic regression, controlled for multiple potential confounders, was conducted to determine if either PIMs or PPOs were associated with hospital admissions and mortality (p < 0.05 was considered significant). Results Full data were obtained for 267 Māori and 404 non-Māori. The mean age for Māori was 82.3(±2.6) years, and 84.6(±0.53) years for non-Māori. 247 potentially inappropriate medicines were identified, affecting 24.3% Māori and 28.0% non-Māori. PIMs were not associated with 12-month mortality or hospitalisation for either cohort (p > 0.05; adjusted models). 590 potential prescribing omissions were identified, affecting 58.1% Māori and 49.0% non-Māori. PPOs were associated with hospitalisation (p = 0.001 for Māori), but were not associated with risk of mortality (p > 0.05) for either cohort within the 12-month follow-up (adjusted models). Conclusion PPOs were more common than PIMs and were associated with an increased risk of hospitalisation for Māori. This study highlights the importance of carefully considering all indicated medicines when deciding what to prescribe. Further follow-up is necessary to determine the long-term effects of PIP on mortality and hospitalisation.