Assessment of Drug Therapy in Geriatric Patients Using Beer s Criteria

Transcription

1 Original Article Assessment of Drug Therapy in Geriatric Patients Using Beer s Criteria RJ Lihite *, M Lahkar **, S Roy * Abstract Aim: Inappropriate medication use (IMU) in the elderly population has long been an issue of healthcare quality along with over and under-use of medications. Therefore, this study aimed to determine the prevalence and also the predictors of inappropriate prescribing (IP) for elderly inpatients. Method: The prospective interventional study was conducted to evaluate the quality of geriatric pharmacotherapy in a tertiary care centre of a government hospital. Data of 502 patients were used to carry out the analysis by using modified Beer s Criteria (2003). Results: The analysis of data for appropriateness of drug therapy showed that 6.9% of the 502 patients received at least 1 inappropriate medication. Out of 35 inappropriate prescriptions, the most frequent was digoxin (48.6%) followed by nifedipine (11.4%), bisacodyl (5.7%). Drug identified according to the second list of inappropriate medications was NSAIDs. Conclusion: Inappropriateness of medication use in elderly inpatients increased with advanced age, increase in number of medications, number of diagnoses and length of hospitalization. In more than half of the cases, clinician agreed that the provided information about inappropriate medication was clinically significant and the given suggestions were accepted. (Journal of The Indian Academy of Geriatrics, 2010; 6: ) Introduction Sickness is as natural as the process of ageing. Since time unknown diseases have been associated with old age. Thus have begun man s pursuit of healing and health. Today, when science has conquered the unimaginable, disease free world still remains elusive. Advancement in medical science marked by the wonder drugs, new state-of-art medical techniques and equipments has improved the quality of life of elderly and increased the life expectancy. However, like two sides of a same coin, these medical facilities also have few shortcomings. For example, a drug given to elicit therapeutic effect may cause side effects. Drug therapy is necessary to treat acute illness, maintain current health and prevent *NIPER, Guwahati, **Chief Academic Coordinator, NIPER Guwahati & Head, Department of Pharmacology, Gauhati Medical College, Guwahati Address for correspondence: Dr (Mrs) M Lahkar, Head, Department of Pharmacology, Gauhati Medical College,Guwahati r.lihite@yahoo.com further decline. However, optimizing drug therapy for older patients is challenging and sometimes it can do more harm than good. This is because people over the age of 65 years have a higher prevalence of chronic illnesses, disabilities and dependency than those <65 years. They are more likely to be on medications than younger people. They are often taking several drugs to treat concomitant disease processes. Hence elderly patient constitute a special group requiring special concern. India comprises approximately 16% of the world population and it is reasonable to believe that we will have a large number of elderly patients. 1 A World Health Organization (WHO) report has projected that the elderly population of the world will cross the one billion mark by the year 2020 and by that time, over 700 million elderly people will be living in developing countries. 2 Appropriateness in healthcare has been defined as the outcomes of process of decision making that maximizes net health gains within society s available resources. 3 Inappropriate medication use (IMU) in the elderly population has

2 156 Journal of The Indian Academy of Geriatrics, Vol. 6, No. 4, December, 2010 long been an issue of healthcare quality along with over and under-use of medications. 4 Such IMU can be expected to affect both well being and use of health-care service. This subject has gained attention among health care researchers, providers and policy makers. The effort to reduce IMU in elderly patients is likely to have a substantial impact upon reducing drug-related morbidity. It is important that elderly people should not be taken as a burden on society but rather as an asset. 5 The assessment of suitability of pharmacotherapy aims to modify the existing geriatric care practice(s). This is possible only when age-related problems are studied well and problems related to pharmacotherapy are identified. This will lead to improvement in the existing geriatric pharmacotherapy practice. The results of the earlier studies done in the same setting had shown that the prevalence rate of IMU in elderly patients was 17.51% according to updated Beers Criteria. 6-8 Therefore, this study aimed to determine the prevalence and also the predictors of inappropriate prescribing (IP) for elderly inpatients. Methodology Study design and setting: To achieve the objectives, a prospective interventional study was carried out in an inpatient setting of the Gauhati Medical College and Hospital, Guwahati after the approval of the Institutional Human Ethics Committee. The patients were recruited from 14 wards. Out of these 6 were male medicine units, 6 female medicine units and 2 cardiology male & female units. Patients: Patients were recruited in the study as per the criteria given below. Inclusion criteria a. 60 years or above, patients of either gender. b. Number of drugs prescribed more than one. c. One or more concurrent diseases. Exclusion criteria Incomplete information regarding patient Data collection: The prescriptions were studied using chart review method. The data was collected from prescriptions and medicine charts of the patients. For each patient, a study form was completed at the time of admission and updated daily until the patient was discharged. Assessment using Beer s criteria: Each prescription was checked individually for inappropriate drug prescribing by using Modified Updated Beers Criteria In 2002, US expert panel updated the previously established Beers criteria and included newer drugs and incorporated new knowledge of drug product and clinical evidence. According to the updated Beers criteria 2003, 48 medications or classes of medications should be avoided regardless of condition or disease in elderly and it also lists 20 diseases and the medications to be avoided in elderly. This has led to two lists of inappropriate medications: one of medications deemed to be inappropriate regardless of the disease condition being treated and the other of medications whose use would be inappropriate in patients with certain diseases. The criterion used in this study is known as modified updated Beers Criteria 2003 because of the modifications done for the Indian setting. These modifications are: 1. The cut off age considered in this study was 60 years instead of age 65 years or more. 2. Some medications which were banned after 2002 by the Drug Controller General India (DCGI) were removed from the list for eg. reserpine, propoxyphene and cimetidine etc. A prescription is known to be inappropriate if it contains one or more drugs included in Beers list of inappropriateness. Feedback: Suggestions were given to the clinical pharmacologist and consultants for inappropriate medications. Statistical analysis: All the data was presented as average ± SEM and percentages. Relative risk (RR) was used to assess IMU by comparing inappropriate with AMU. The confidence interval (CI) and RR was calculated for determining the predictors of IMU. Results Analysis of IMU using modified Beer s criteria The analysis of data for appropriateness of drug therapy showed that 6.9% (n=35) of the 502 patients received at least 1 inappropriate medication. Out of 35 inappropriate prescriptions, the most frequently used inappropriate medications identified were digoxin (48.6%) followed by nifedipine (11.4%), bisacodyl (5.7%) etc. A drug identified according to the second list of inappropriate medications was NSAIDs (Table 1).

3 Assessment of Drug Therapy in Geriatric Patients Using Beer s Criteria 157 Table 1. Prevalence of inappropriate medicine use by Beer s Criteria 2003 (n =35). Independent of diagnosis(1 st LIST) Name of Drugs Severity No. of patients Digoxin low 17 (48.6%) Nifedipine high 4 (11.4%) Bisacodyl high 2 (5.7%) Indomethacin high 2 (5.7%) Dicyclomine high 2 (5.7%) Ketorolac high 2 (5.7%) Nitrofurantoin high 2 (5.7%) Promethazine high 1 (2.8%) Amiodarone high 1 (2.8%) Chlorpheniramine high 1 (2.8%) Dependent on Diagnosis (2 ND LIST) Name of Drugs Severity No. of patients NSAIDs high 1 (2.8%) Predictors of IMU: The presence of certain factors increased the likelihood of IMU. These risk factors associated with inappropriate medications were divided into two groups of variables. Sociodemographic characteristics consisting of age, gender and clinical variables comprising of number of medications prescribed number of diagnoses and length of hospitalization. The RR was calculated for determining the predictors of IMU (Table 2). Table 2. Predictors of IMU using modified updated Beer s Criteria Variable Total (n) Patients with IMU Patients with AMU Prevalence of IMU All % OR (95% CI * ) Age % 1 (reference) % 0.75( ) % 0.71( ) Sex Female % 1 (reference) Male % 1.40( ) No. of % 1 (reference) medication % 1.17( ) % 1.32( ) Length % 1 (reference) of stay % 1.38( ) % 1.44( ) No. of % 1 (reference) diagnosis % 0.37( ) % 0.33( ) Feedback from clinicians: A total of 35 inappropriate medications were noted in this study. There were several inappropriate medications which were repeatedly noted in different patients during the period of study. The prevalence of inappropriate medications were reported and feedback obtained from 51 clinicians and clinical pharmacologists practicing in the medicine and cardiology ward of the hospital (Table 3). Out of 51, 62.74% clinicians agreed that therapeutic drug monitoring (TDM) should be done % clinicians found monitoring of adverse drug reaction (ADR) would be helpful and 54.90% clinicians accepted that specific laboratory test should be indicated (Fig 1). Table 3. Clinician s (n=51) response for various types of suggestions. Suggestions Accepted Not accepted TDM should be done Monitoring for ADR should be done Specific laboratory test should be indicated Monitor for efficacy of drug should be involved Further information required for taking decision about clinical implication of provided information Rescheduling of drug administration should be done Avoid concurrent use of drugs 9 42 Use drugs with caution 6 45 Others 4 47 TDM = Therapeutic drug monitoring ADR = Adverse drug reaction Fig. 1. Clinician s (n=51) response for various types of suggestions. Discussion Inappropriate medication use: IMU is a major, common health problem in older people. IMU among the elderly in other countries has been

4 158 Journal of The Indian Academy of Geriatrics, Vol. 6, No. 4, December, 2010 well-documented with the estimated prevalence ranging from 11% to 43%. The finding of this study also confirmed the prevalence of IMU in elderly inpatients in a tertiary care centre. The inappropriateness was found to be 6.97% by using Modified Updated Beer s Criteria The prevalence of IP as shown in this study was lower than the rates reported in different countries. Varying prevalence of IP is reflected from the studies conducted around the world; 32% (n=191) in Ireland in 2007, 23.7% (n=5741) in Taiwan in 2008, 43.5% (n=212) in Israel in 2009, 33% (n=965756) in Canada in 2007 and 21% (n=1669) in Japan in The difference in the prevalence of IMU in different countries can be attributed to diverse demographic characteristics of patients, varying disease characteristics, difference in prescribing patterns, physician specialties, sample size and pharmaceutical market of the various countries. In this study the most commonly prescribed inappropriate drugs were digoxin (48.6%) followed by nifedipine (11.4%) and bisacodyl (5.7%). Similar pattern of inappropriateness was observed in the Taiwanese medical setting where amiodarone, bisacodyl and nifedipine were the most frequently prescribed potentially inappropriate medications of high severity. A study conducted to assess the risk of digoxin toxicity in elderly patient reported that out of 2030 patients on digoxin, total of 34 hospitalizations occurred due to toxicity. 14 The second list of IP according to the Beers was drugs, whose dose should not be exceed maximum dose and drugs which are to be avoided in specific disease condition. NSAIDs should be avoided as they may exacerbate existing ulcer disease or create new ulcer. One study has found that important risk factors for the development of gastrointestinal complications in patients taking NSAIDs include: increasing age, concomitant use of anticoagulation therapy, previous gastrointestinal events and concomitant use of corticosteroids. The risk of gastrointestinal complications in NSAID users over the age of 65 years is increased approximately fold when compared with younger patients. 15 Predictors of inappropriate medication use: Two categories of predictors were determined, i.e. socio-demographic variables consisting of age and gender and continuous clinical variables like number of medications, number of diagnoses and length of hospitalization. 16,17 According to the findings of this study, older men were more likely than older women to receive inappropriate medications. It was found that patients prescribed with larger number of medications were more likely to receive inappropriate medications. 18 Patients prescribed with more than 10 medications were found to have more prevalence of inappropriate medication than those who were prescribed less than 10 medications. Number of diagnoses also had significant impact on the IP. This may be explained by a simple example that as the number of diagnosis increases, number of medications to treat each particular disease condition also increases which ultimately leads to polypharmacy and IMU. 19 Hence this study suggests that polypharmacy is common and is significantly associated with IP. Similarly, length of hospitalization also contributed to IMU. The patients staying for more than ten days were twice more likely to receive inappropriate medication than patients staying for less than ten days. Feedback Feedback was recorded from 51 clinicians and clinical pharmacologists about their opinion regarding inappropriate medication from the medicine and cardiology wards. In more than half of the cases clinicians agreed that the provided information about inappropriate medication was clinically significant and the given suggestions were accepted. The results of this study reflect the need to update the clinicians on the pharmacotherapy of the elderly patients. This could be done by providing continuous feedback to them on the pharmacotherapy of elderly patients. References 1. Mandavi, Tiwari P. Profile of pharmacotherapy in elderly Indian patients: Preliminary findings. Int J Risk Safety Medicin 2006; 18: World Health Organization/ South East Asia Region. [Home page on the internet]. Health of the elderly: Healthy aging. Agenda for the coming century. New Delhi. 3. Aronson J. Rational prescribing, appropriate prescribing. Br J Clin Pharmacol 2004; 57: Hanlon J, Schmader K, Ruby C, Weinberger M. Suboptimal prescribing in older inpatients and outpatients. J Am Geriatr Soc 2001; 49: Help age India. [Homepage on the internet].the Indian ageing scenario. New Delhi. [Updated on 2003, cited on 17 th June 2010]. Available from: URL: http//: 6. Jhawar K. A study to detect inappropriate drug use and promote appropriate drug use in elderly [M.

5 Assessment of Drug Therapy in Geriatric Patients Using Beer s Criteria 159 Pharm. Thesis]. National Institute of Pharmaceutical Education & Research (NIPER), S.A.S. Nagar; Padmavathi R. Drug optimization in geriatric patients [M. Pharm. Thesis]. National Institute of Pharmaceutical Education & Research (NIPER), S.A.S. Nagar; Mandavi. Appropriateness of geriatric pharmacotherapy [M. Pharm. Thesis]. National Institute of Pharmaceutical Education & Research (NIPER), S.A.S. Nagar; Gallagher P, Barry P, O Mahony D. Inappropriate prescribing in the elderly. J Clin Pharm Ther 2007; 32: Lin HY, Liao CC, Cheng SH, et al. Association of potentially inappropriate medication use with adverse outcomes in ambulatory elderly patients with chronic diseases: experience in a Taiwanese medical setting. Drugs Aging 2008; 25: Mansur N, Weiss A, Beloosesky Y. Is there an association between inappropriate prescription drug use and adherence in discharged elderly patients? Ann Pharmacother 2009; 43: Bierman AS, Pugh MJ, Dhalla I, et al. Sex differences in inappropriate prescribing among elderly veterans. Am J Geriatr Pharmacother 2007; 5: Satoko N, Yukari Y, Naoki I. Prevalence of inappropriate medication using beers criteria in Japanese long- term care facilities. BMC Geriatr 2006; 6: Haynes K, Hennessy S, Localio AR, et al. Increased risk of digoxin toxicity following hospitalization. Pharmacoepidemiol Drug Saf Available from: URL: 15. Dubois R, Melmed G, Henning J, Laine L. Guidelines for the appropriate use of non-steroidal anti-inflammatory drugs, cyclo-oxygenase-2-specific inhibitors and proton pump inhibitors in patients requiring chronic anti-inflammatory therapy. Aliment Pharmacol Ther 2004; 19: Mandavi, Tiwari P, Kapur V. Inappropriate drug prescribing identified among Indian elderly hospitalized patients. Int J Risk Safety Medicine 2007; 19: Pugh MJ, Hanlon JT, Zeber JE, et al. Assessing potentially inappropriate prescribing in the elderly veterans affairs population using the HEDIS 2006 quality measure. J Manag Care Pharm 2006; 12: Bushardt RL, Massey EB, Simpson TW, et al. Polypharmacy: misleading, but manageable. Clin Interv Aging 2008; 3: Wawruch M, Zikavska M, Wsolova L, et al. Perception of potentially inappropriate medication in elderly patients by Slovak physicians. Pharmacoepidemiol Drug Saf 2006; 10: From Editor s Desk.. Dear Readers, 1. We have decided to publish activities of IAG and various chapters, academic achievements and honor of members, and brief comments about JIAG. Please send relevant details on regular basis. 2. A large number of copies are being returned back by courier for want of correct contact details. We request you to update your postal address, contact numbers and ID quoting your registration number with Indian Academy of Geriatrics. 3. Website of journal is being updated. You are requested to send suggestions. 4. We invite you to submit articles for publication in JIAG. Please consult guidelines for authors published in this issue of journal. Regards and good wishes Editorial Team

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