Potentially Inappropriate Medications in Elderly Patients: Prevalence at Admission and Changes During Hospital Stay

Potentially Inappropriate Medications in Elderly Patients: Prevalence at Admission and Changes During Hospital Stay

Background

Polypharmacy in the Elderly 40% seniors are using 5-9 different classes of medications 15% 85+ using 15+ medication classes Drug Use Among Seniors on Public Drug Programs in Canada. CIHI 2014

Adverse Drug Events in Elderly 20% of all hospitalizations in elderly related to severe ADE s= cost of $36 million / year in Canada 35% community dwelling elderly=1 ADE/ year

Potentially Inappropriate Medication Use in the Elderly 10-15% of seniors use inappropriate medications Drug Use Among Seniors on Public Drug Programs in Canada. CIHI 2014

Objective Estimate the prevalence of potentially inappropriate CNS medications upon admission and describe changes made during the hospital stay among patients 65 years of age and older

Methods

Data Sources & Measured Variables Community Drug List Discharge Prescription Patient demographics, health care service utilization, drug dispensations 1 year Hospital stay Admission to Hospital Discharge from Hospital RAMQ Health Services & Prescription Claims Electronic Medication Reconciliation software

Electronic Medication Reconciliation Software- Right Rx Provincial Drug Repository & Master Provider Registry Hospital Pharmacy System Side by side view of community and hospital medications Standardized, printable, barcoded forms across institutions Alignment of matching medications Meets all Accreditation Canada requirements

Electronic Medication Reconciliation Software- Right Rx

Example of Patient Drug Changes Drug A Drug A STOP Drug B NEW Drug C Drug C MODIFY Drug D Drug D CONTINUE Drugs present at admission In hospital medications Drug changes at discharge

Discharge Prescription Total number of medications continued from the community=5 Total number of community medications stopped=1 Total number of new medications=7 Total number of medications at discharge= 12

Study cohort Admitted to MG & RVH 1 October 2014-31 February 2016 65+ years of age Admitted from community or long term care Intervention patients with finalized e-prescription At least 1 CNS PIM 1 year Hospital stay Continuous RAMQ coverage Admission to Hospital N=2,328 patients Discharge from Hospital N=194 patients

Identification of Potentially Inappropriate Central Nervous System Medications- Modified STOPP Criteria Prolonged use of benzodiazepines (> 4 weeks) Prolonged use of antipsychotics (> 4 weeks) Prolonged use of TCA s (> 4 weeks) Use of first-generation antihistamines

Cohort Characteristics 2,328 patients Mean age 77 (SD 8) 44% female 67% 2+ chronic conditions 18% 7+ unique prescribers in year prior to admission 23% visiting more than 1 unique pharmacy in year prior to admission 9 medications on average per patient

CNS PIMs Present at Admission 5% 1% 650/2,328 (28%) patients had at least 1 CNS PIM =total of 628 CNS PIMs 22% Number of CNS PIMS per patient 72% 0 PIMs 1 PIM 2 PIMs 3+ PIMs

Predicting Presence of CNS PIMs at Admission No PIMs (n=1678) At least one PIM (n=650) Adjusted OR Male 1014 (77.0) 303 (23.0) Reference Female 664 (65.7) 347 (34.3) 1.69 (1.40-2.06) Number of distinct pharmacies prior to admission, mean(sd) 1.4 (0.74) 1.5 (0.82) 1.17 (1.03-1.32) 0 137 (100) 0 (-) 1 1026 (72.0) 400 (28.1) 2 377 (67.8) 250 (38.5) 3+ 138 (8.2) 225 (34.6) Number of distinct prescribers prior to admission, mean (SD) 4.3 (3.4) 5.8 (3.6) 0.98 (0.94-1.01) 0-2 567 (84.9) 101 (15.1) 3-7 864 (69.6) 378 (30.4) 7+ 247 (59.1) 171 (40.1) Number of chronic conditions, mean (SD) 2.2 (2.7) 2.7 (3.0) 1.03 (0.99-1.06) 0 542 (74.3) 188 (25.8) 1 320 (74.6) 109 (25.4) 2 317 (72.9) 118 (27.1) 3+ 499 (30.0) 235 (36.2) Number of admission medications, mean (SD) 8.1 (5.6) 12.6 (5.6) 1.15 (1.12-1.17) 0-4 488 (93.8) 33 (6.3) 5-9 567 (76.5) 174 (23.5) 10-14 383 (62.8) 227 (37.2) 15+ 240 (52.6) 216 (47.4)

Classes of CNS PIMs Present at Admission 4% 7% Benzodiazepines Antipsychotics Antihistamines 31% 58% TCA's

Changes made to CNS PIMs Present at Admission All CNS PIMs Benzodiazepines Antipsychotics Antihistamines Stop Modify Continue TCA's 0 20 40 60 80 100 Percent of Reconciliation Actions

True Stops and Therapeutic Substitutions All CNS PIMs Benzodiazepines Antipsychotics Antihistamines True stop Therapeutic substitution Modify Continue TCA's 0 20 40 60 80 100 Percent of Reconciliation Actions

Conclusions & Future Research

Conclusions High prevalence treatment with CNS PIMs at admission Benzodiazepines most common Majority of CNS PIMs not discontinued during hospitalization Demonstrates usability of data from electronic medication reconciliation software

Next steps Determine prevalence of all STOPP medications at admission Evaluate patient, physician and system level factors associated with deprescribing of PIMs Determine whether de-prescription of PIMs associated with improved health outcomes post-discharge

Acknowledgements Co-authors Dr. Robyn Tamblyn Dr. Aude Motulsky Dr. Todd Lee Maria- Teresa Moraga Funding Source Canadian Institutes of Health Research Doctoral Award - Frederick Banting and Charles Best Canada Graduate Scholarships

Thank you! Daniala Weir PhD candidate Department of Epidemiology, Biostatistics and Occupational Health McGill University daniala.weir@mail.mcgill.ca