An evaluation of the appropriateness of prescribing and frailty in elderly patients using STOPP criteria and Frailty Index in tertiary care teaching hospital

People above 65 years of age would amount to 10.7% of total population of India by 2021. India has acquired the label of ‘an ageing nation’ with 7.7% of its population being more than 60 years old. Geriatric patients are exposed to potentially inappropriate medications (PIMs) thus strategies to improve quality of life and safety of prescribing is needed. One such explicit criteria tool is ‘Screening Tool of Older person’s Potentially inappropriate Prescriptions’ (STOPP) criteria. For older individuals, frailty plays a decisive role. Frailty assessment is useful for identification of risk stratifications to assist in clinical decision makings. Hence, this study is aimed to assess the percentage of PIM using STOPP criteria and correlation between PIMS and Frailty Index (FI) in elderly patients in our setting. An observational study was done in 60 patients in department of medicine at tertiary care teaching hospital. Demographic details, diagnosis and current medications were recorded in Microsoft excel 2016. PIMs based on STOPP criteria version 2 and FI suggested by Searle et al. was calculated and analyzed. Spearman rank correlation test was used to check the correlation between FI and PIM. Out of 60 prescriptions, 21 prescriptions with PIM were found. Most common drugs prescribed as PIM were Aspirin, calcium, ceftriaxone, multivitamin B complex and furosemide. FI was analyzed by using 34 variables. Value of FI was between 0.03 to 0.17. Spearman Rank correlation test showed direct low degree of significant correlation between FI and PIM with correlation (r) value of 0.1602 (P value=0.02). 35% of prescriptions were having at least one PIM in our study and we found that there was direct association between FI and PIM which will help us to reduce potential medication errors, drug interactions and adverse reactions.

Indications for prescription and deprescription in multimorbid independently living elderly outpatients

Introduction Global trend to population ageing is associated with inevitable increase of polypharmacy in multimorbid elderly population. Purpose To estimate the level and structure of comorbidity and pharmacotherapy in independently living patients of different age groups with high and extreme cardiovascular risk, when observed in outpatient clinics Methods 282 consecutive patients of high cardiovascular risk have been enrolled. Inclusion criteria were: SCORE ≥5%, documented history of acute myocardial infarction (AMI), acute or transient cerebrovascular accident (CVD), coronary artery intervention, acute coronary syndrome (ACS), stable angina, intermittent claudication, type 2 diabetes mellitus (DM2) or type 1 DM with diabetic nephropathy, angiogram or ultrasound proved atherosclerotic plaques, total serum cholesterol level ≥8 mmol/L, blood pressure ≥180/110 mmHg and signed voluntary informed consent form. Current clinical conditions, pharmacologic treatment and indications for prescription and deprescription were studied. STOPP criteria for prescribing potentially non-recommended drugs in people over 65 years of age, START criteria for not prescribing necessary drugs in people over 65 years of age, non-recommended in elderly people over 65 drug list were used to assess polypharmacy. According to the WHO age classification, there were three groups: Group 1 (aged 45 to 59), Group 2 (aged 60 to 74) and Group 3 (aged 75 +). Results There were no differences in the frequency of statins administration (p=0.72) and antiplatelet agents (p=0.49) between 3 groups. Polypragmasia (administration of more than 5 drugs) was registered in 150 patients (53%) and was significantly more common in Group 3 (p=0.001). 48 cases of inadequate prescribing were registered in 46 (28%) elderly patients. 24 cases of prescribing potentially unacceptable medications for the elderly were reported. Conclusion Unavoidable polypragmasia was found in 53% multimorbid elderly patients. Irrational drug treatment was detected in 28% elderly patients STOPP criteria were met in 32.1% and START criteria were met in 30.4% cases. Polypragmasia being inevitable in elderly multimorbid patients, administration of any new medication should be performed after a thorough risk-benefits balance assessment. FUNDunding Acknowledgement Type of funding sources: None.

Polypharmacy in elderly patients with falls

Background: Falls in elderly–a multifactorial syndrome. One of the modifiable factors is polypharmacy. STOPP/START criteria are used for correction of polypharmacy in geriatrics.Aim: Assessment of the prevalence of polypharmacy, analysis and correction of pharmacotherapy using STOPP/START criteria in patients with falls.Materials and methods: The study included 655 patients hospitalized in the geriatric department over 60 years of age, who were divided into two groups. Group 1 (n=332, 50.7%)–patients with 1 or more falls, group 2 (n=323,49.3%)–patients without falls. The analysis of the received therapy before hospitalization was performed. After that, based on the indications, contraindications and STOPP/START criteria, drug therapy was corrected in patients with falls.Results: Patients of group 1 took 4.5±2.18 drugs, group 2–4.3±2.6. Polypharmacy was diagnosed in 150 (45.2%) patients with falls and in 122 (37.8%) patients without falls. Patients with falls were more likely to receive sleeping pills, NSAIDs. Univariate analysis showed that falls were associated with NSAIDs (OR 2.15, 95% CI 1.38–3.35, p=0.001) and sleeping pills (OR 2.03, 95% CI 1.02–4.02, p=0.047). An audit and correction of therapy was performed: in 108 (32.5%) patients the number of prescribed drugs was reduced. Patients with falls were prescribed statins, antidementia drugs, anticonvulsants and antidepressants as components of therapy for chronic pain syndrome, chondroitin sulfate and glucosamine sulfate for the treatment of osteoarthritis, calcium and antiresorbtive therapy, antianemic drugs, vitamin D. Antiplatelet agents, digoxin, sleeping pills and NSAIDs were less frequently prescribed. STOPP/START criteria and their frequency in patients with falls were analyzed. 141 cases of potentially non-recommended but prescribed medications were identified. STOPP criteria were for the administration of NSAIDs (n=53, 37.6%) and acetylsalicylic acid (n=62, 44%). There were 458 cases of potentially recommended but not prescribed medications. The most common START criteria were not for the administration of vitamin D and statins.Conclusion. Half of elderly patients with falls have polypharmacy. These patients are more likely to take sleeping pills and NSAIDs. STOPP criteria most often concerned the appointment of NSAIDs and acetylsalicylic acid, and the START criteria revealed the absence of the appointment of vitamin D and statins.

Prescription of Potentially Inappropriate Medication in Older Inpatients of an Internal Medicine Ward: Concordance and Overlap Among the EU(7)-PIM List and Beers and STOPP Criteria

Background: Age-related comorbidities prone older adults to polypharmacy and to an increased risk of potentially inappropriate medication (PIM) use. This work aims to analyze the concordance and overlap among the EU(7)-PIM list, 2019 Beers criteria, and Screening Tool of Older Person’s Prescriptions (STOPP) version 2 criteria and also to analyze the prevalence of PIM.Methods: A retrospective cohort study was conducted on older inpatients of an internal medicine ward. Demographic, clinical, and pharmacological data were collected, during March 2020. After PIM identification by the EU(7)-PIM list, Beers criteria, and STOPP v2 criteria, the concordance and overlap between criteria were analyzed. A descriptive analysis was performed, and all the results with a p-value lower than 0.05 were considered statistically significant.Results: A total of 616 older patients were included in the study whose median age was 85 (Q1–Q3) (78–89) years. Most of the older patients were male (51.6%), and the median (Q1–Q3) number of days of hospitalization was 17 (13–22) days. According to the EU(7)-PIM list, Beers criteria, and STOPP criteria, 79.7, 92.0, and 76.5% of older adults, respectively, used at least one PIM. A poor concordance (<63.4%) among criteria was observed. An association between PIM and the number of prescribed medicines was found in all applied criteria. Moreover, an association between the number of PIMs and diagnoses of endocrine, nutritional, and metabolic diseases, mental, behavioral, and neurodevelopmental disorders, and circulatory system diseases and days of hospitalization was observed according to Beers criteria, and that with diseases of the circulatory system and musculoskeletal system and connective tissue was observed according to STOPP criteria.Conclusion: Despite the poor concordance between the EU(7)-PIM list, 2019 Beers, and STOPP v2 criteria, this work highlights the need for more studies in inpatients to develop strategies to facilitate the identification of PIM to decrease the high prevalence of PIM in hospitalized patients. The poor concordance among criteria also highlights the need to develop new tools adapting the existing criteria to medical ward inpatients.

Potentially inappropriate medications (PIMs): frequency and extent of GP-related variation in PIMs: a register-based cohort study

ObjectivesPotentially inappropriate medications (PIMs) pose an increasing challenge in the ageing population. We aimed to assess the extent of PIMs and the prescriber-related variation in PIM prevalence.DesignNationwide register-based cohort study.SettingGeneral practice.ParticipantsThe 4.2 million adults listed with general practitioner (GP) clinics in Denmark (n=1906) in 2016.Main outcome measuresWe estimated the patients’ time with PIMs by using 29 register-operationalised STOPP criteria linking GP clinics and redeemed prescriptions. For each criterion and each GP clinic, we calculated ratios between the observed PIM time and that predicted by multivariate Poisson regressions on the patients. The observed variation was measured as the 90th/10th percentile ratios of these ratios. The extent of expectable random variation was assessed as the 90th/10th percentile ratios in randomly sampled GP populations (ie, the sampled variation). The GP-related excess variation was calculated as the ratio between the observed variation and sampled variation. The linear correlation between the observed/expected ratio for each of the criteria and the observed/expected ratio of total PIM time (for each clinic) was measured by Pearson’s rho.ResultsOverall, 294 542 individuals were exposed to 1 44 117 years of PIMs. The two most prevalent PIMs were long-term use (>3 months) of non-steroidal anti-inflammatory drugs (51 074 years of PIMs) or benzodiazepines (48 723 years of PIMs). These two criteria showed considerable excess variation of 2.33 and 3.05, respectively; for total PIMs, this figure was 1.65. For more than half of the criteria, we observed a positive correlation between the specific PIM and the sum of remaining PIMs.ConclusionsThis study documents considerable variations in the prescribing practice of GPs for certain PIMs. These findings highlight a need for exploring the causal explanations for such variations, which could be markers of suboptimal GP-prescribing strategies.

Long-acting benzodiazepines among the top predictors of Potentially Inappropriate Psychotropic (PIP) Medication

Background: There is limited information available on the use of PIP medication in older adults having psychiatric illness. Objective: To determine the prevalence of PIP medications, and assess its predictors in older adults with psychiatric illness. Methods: A cross-sectional study was carried out at a tertiary care hospital on 456 patients of either sex, with a median age of 65 years attending the psychiatry outpatient department. Evaluation of PIP medication was done using Beers criteria 2019 and STOPP criteria 2015. Bivariate logistic regression was used to find out the predictors of PIP prescribing. Results: Results of the study reflect that a staggering number of older adults, (more than 91% and 73%) out of total of 456 patients were prescribed with at least one PIP medication identified by Beers criteria and STOPP criteria, respectively. Long-acting benzodiazepine (LABZD) like clonazepam was identified as one of the most commonly prescribed PIP medications by both set of criteria. Further analysis revealed that older adults from rural background (Odds Ratio (OR) 2.60, 95% Confidence Interval (CI) 1.20-5.65; P=0.015), TCA (OR 0.30, 95% CI 0.12- 0.75; P= 0.010), LABZD (OR 33.72, 95% CI 11.27-100.85; P=<0.001), atypical antipsychotics (OR 22.35, 95% CI 5.31- 93.99; P= <0.001) use were most common predictors for PIP medication prescribing. Conclusion: The use of PIP medication is highly prevalent among older adults according to Beers criteria and STOPP criteria. The study reflects a more comprehensive and sturdy nature of Beer criteria as it significantly detects more PIP medication than STOPP criteria.

Potentially inappropriate medication use among elderly patients on follow-up at the chronic care clinic of a specialized teaching hospital in Ethiopia. A cross-sectional study

Background Elderly patients are prone to potentially inappropriate medication use (PIMU); its use have been associated with multiple adverse consequences. As a result, it is crucial to determine the magnitude and factors associated with PIMU. The present study was mainly aimed to determine and assess the magnitude and predictors of potentially inappropriate medications use in elderly patients on follow-up at the chronic care clinic of Jimma medical center. Methods A retrospective cross-sectional study was conducted involving 219 patients aged 65 years and above on treatment follow-up. Data was collected using checklist. The 2019 updated American Geriatric Society (AGS) Beers Criteria® and Screening Tool of Older People’s Potentially Inappropriate Prescriptions criteria and Screening Tool to Alert Doctors to Right Treatment (STOPP/START) criteria (version 2) were employed to assess PIMU. SPSS IBM (v22) was used for data entry and analysis. Categorical variables were described using frequency and percentage, whereas continuous variables were described using mean with standard deviation (SD) or median with interquartile range (IQR). Logistic regression was conducted to identify predictors of PIMU. Results The average number of medications prescribed per patient was 4.0 (IQR = 2.0). At least one PIMU was identified in 182 (83.1%) and 99 (45.2%) patients, based on Beers and STOPP criteria, respectively. Additionally, potential prescription omission (PPO) was observed in 24 (10.9%) patients. The risk of Beers PIMU was increased with age [AOR = 1.21, p < 0.001], hypertension [AOR = 4.17, p < 0.001], and Polypharmacy [AOR = 14.10, p < 0.001], while a decrease in the risk was noted in patients with a diagnosis of ischemic stroke [AOR = 0.133, p = 0.01] and asthma [AOR = 0.03, p < 0.001]. Using STOPP criteria, hypertension [AOR = 2.10, p = 0.04], diabetes mellitus [AOR = 2.26, p = 0.04], ischemic heart disease [AOR = 2.84, p = 0.04], peripheral neuropathy [AOR = 10.61, p < 0.001], and Polypharmacy [AOR = 6.10, p < 0.001] significantly increased the risk of PIMU. Conclusions Regardless of the screening tool used to assess, the present study revealed PIMU in the large proportion of the participants. Multiple medication use and certain disease condition had increased the probability of PIMU. Thus, it is imperative to use screening tools to review medications prescribed for each hospitalized elderly patients so as to reduce adverse consequences of PIMU.