A predictive model of inappropriate use of medical tests and medications in Bronchiolitis

Objective: This study was designed to study the inappropriate medication utilization in patients aged 65 years or older residing in a long term care facility; to examine patterns in the use of inappropriate medications during the stay in the facility; and to determine predictors of inappropriate medication use. Design: Retrospective, cross-sectional study. Methods: We used the Systematic Assessment of Geriatric Drug Use via Epidemiology (SAGE) database that includes data from all Medicaid/Medicare certified nursing homes located in 5 US states. We examined data collected with the federally mandated Minimum Data Set along with the sociodemographic, clinical and treatment information during the period October 1995 to September1996 (n =44,562). Measurements: Inappropriate medication was defined according to Beers' criteria. Use of inappropriate medication was determined at admission and at ninety days. We calculated incidence of discontinuation, initiation, and continuance of these medications over the ninety-day period in the nursing home. A logistic regression model provided estimates of Odds Ratio (OR) for the predictors of inappropriate use of drugs. Results: Thirty-three percent of the residents were receiving at least one inappropriate medication on admission to the long-term care facility. Of the 29,082 remaining in long term care facility ninety days after admission, 16% on an inappropriate medication at admission had the medication discontinued, while 18% of non-users at admission initiated an inappropriate agent during the 90 days, a net result of 39% using an inappropriate agent at 90 days. The number of medications taken by the patient, race, age and level of cognitive impairment were found to be associated with the use of inappropriate medications. Discussion: Overall use of inappropriate medication increased significantly during the first 90 days of residence in a long-term care facility. Inappropriate use of long acting benzodiazepines and analgesics was of particular concern. These findings highlight the need for careful patient medication regimen assessment and medication prescribing upon long term care admission.

Inappropriate medication use is a major problem for the elderly. Although increasing attention has been paid to inappropriate prescription medication use, most previous research has been limited to the investigation of prevalence and trends. Few studies provide the empirical evidence for the adverse effect of inappropriate medication use on health outcomes at the national level. This study is the first attempt to assess the relationship between inappropriate prescription use and health status for the elderly in the United States. Based on the 1996 Medical Expenditure Panel Survey, inappropriate medication use in a national representative elderly population was first identified using Beers criteria. A survey type of ordered probit model was then estimated to quantify the effect of inappropriate drug use on patient self-perceived health status measured using a five-point scale (poor, fair, good, very good, and excellent). After controlling for a set of possible confounding factors, it was found that individuals using inappropriate medications in Round 1 were more likely than those not using inappropriate medications to report poorer health status in Round 2. Other risk factors for poor health status include a higher number of prescriptions, being black, having low education, and having one or more chronic diseases. This study provides strong evidence of a significant adverse effect of inappropriate medication use on patient health status. These findings lend partial support to the use of Beers criteria in assessing the quality of prescribing and the appropriateness of medication use in the elderly population.

2019 AGS Beers Criteria for older adults

Instruments to Identify Prescription Medication Misuse, Abuse, and Related Events in Clinical Trials: An ACTTION Systematic Review

Little empirical evidence exists regarding the influence and outcomes of inappropriate medication use among elderly nursing home residents. To identify the prevalence of inappropriate medication use among elderly patients in Georgia nursing homes using the Beers criteria and identify the relationship between inappropriate drug use and the likelihood of an adverse health outcome. A cohort design was used to review 1117 patient medical records in 15 Georgia nursing homes with a high risk of polypharmacy. Prevalence of inappropriate medication use among elderly patients, as defined by the Beers criteria, was estimated. The adverse health outcomes of hospitalizations, emergency department visits, or deaths were identified from Medicaid claims data. A total of 519 (46.5%) patients received at least one inappropriate medication and 143 (12.8%) patients experienced at least one adverse health outcome. Logistic regression revealed that the total number of medications taken (OR 1.139, 95% CI 1.105 to 1.173) significantly increased the likelihood of receiving an inappropriate drug, while having a diagnosis of "dementia" (OR 0.748, 95% CI 0.565 to 0.991) decreased the likelihood. Inappropriate medication use increased the likelihood of experiencing at least one adverse health outcome more than twofold (OR 2.34, 95% CI 1.61 to 3.40). Propoxyphene use alone was significantly associated with the occurrence of an adverse health outcome (OR 2.39, 95% CI 1.54 to 3.71). Inappropriate drug use was common in our study cohort. Inappropriate use of medication in the elderly, particularly propoxyphene, is associated with a higher risk of adverse health outcomes.

Inappropriate use of medications has become an international cause for concern in geriatric patients, who are at high risk of drug-related morbidity. This study is the first attempt to determine the prevalence of inappropriate drug use in elderly Lebanese outpatients, using community pharmacy data, and to identify factors that predict potentially inappropriate drug intake in this population. Records of elderly patients aged > or =65 years were selected from different community pharmacies. Each patient profile was reviewed and to confirm patient record information, in-person interviews were conducted with elderly patients between November 2004 and May 2005 by qualified pharmacists. Based on a literature review describing guidelines for the inappropriate use of medications in the elderly, courses of therapy were assessed and classified as either appropriate or inappropriate. Courses of therapy that were judged inappropriate were further classified according to the specific area of inappropriate use (i.e. Beers' criteria, duplicate therapy, indication, dose, dose frequency including missing doses, duration and discontinuation of therapy, adverse effects, drug-drug and/or drug-disease interactions, and poor memory). Statistical analyses were performed to estimate the prevalence of inappropriate medication use and to identify potentially predictive factors of such use arising from patients' sociodemographic characteristics, health factors and drug regimen intake. A total of 350 elderly patient profiles were reviewed, from which 277 evaluable records were obtained. More than half (59.6%) of the patients taking drugs at the time of the study were taking at least one inappropriate medication. Inappropriate medication use was most frequently identified in terms of Beers' criteria (22.4%), missing doses (18.8%) or incorrect frequency of administration of drugs (13.0%). Factors predicting potentially inappropriate drug intake included female sex (65.7% vs 53.3% for males, p = 0.03) and alcohol intake (p = 0.007). There were also significant associations between the likelihood of use of an inappropriate drug and (i) increased number of medical illnesses (p < 0.00002); and (ii) consumption of an over-the-counter drug (OTC) and/or prescription drug (p = 0.048 and p = 0.0035, respectively). The likelihood of use of an inappropriate drug was higher again when patients concurrently used both OTC and prescription drugs (p < 0.0002). The present study is the first to describe and assess inappropriate medication use by elderly outpatients in the Lebanese community setting. With increasing availability of newer and more appropriate medications, use of potentially inappropriate drugs may decrease. Pharmacists have a major role to play in counselling patients about the importance of appropriate drug use.

IntroductionPolypharmacy refers to the concurrent use of multiple medications, while inappropriate drug use occurs when patients take more medications than necessary or use drugs without proper indication. The elderly are...

Elderly with mental health conditions usually use multiple medications, which predisposes them to inappropriate use of medications, which is defined as medications that should be avoided due to their risk; this outweighs their benefit given that safer alternatives are available. This study aimed to examine potentially inappropriate medication use among older patients with anxiety disorder. This study used a cross-sectional retrospective study design using twelve months of data extracted from the Electronic Health Record (EHR) database for older adults diagnosed with anxiety disorder and treated in the ambulatory care setting. Potentially inappropriate medications (PIMs) use was evaluated using the 2019 Beers criteria. Descriptive statistics were used to describe the sample. Pearson's chi-square tests (for categorical variables) and t-tests (for continuous variables) were utilized to measure the differences in independent variables between patients with and without PIMs. Binary logistic regression was used to examine the associations between PIMs use and identify potential factors for PIMs use among older adults with anxiety disorder. Analyses were performed using the Statistical Analysis Software version 9.4 (SAS® 9.4). The study sample includes 371 older adults (age ≥ 65 years) with anxiety disorder; their average age was (72.1 ± 5.8) years. PIMs use was highly prevalent among older adults with anxiety (66.6%). About 35.6% of the study sample used one PIM, 22.6% used two PIMs, and 8.4% used three PIMs. The most frequently prescribed PIMs were NSAIDs and gastrointestinal agents. The adjusted regression analysis found that PIMs use was less likely among men than women. In addition, PIMs use was more likely among women with diabetes, cancer, and polypharmacy. Future studies on strategies and interventions rationing PIMs use in older adults with anxiety disorder are necessary given the high prevalence of PIMs and polypharmacy within this population.

Introduction: This study aims to evaluate potentially inappropriate medication (PIM) use, the association of PIM use, and activities of daily living in 65 years and older home care patients. Method: The study included 322 patients aged 65 and over who applied to Home Care Unit. Consent was obtained from those who agreed to participate in the study. A questionnaire containing demographic data, drug use information, and Katz Daily Living Activities Index was used which was prepared by the researcher in this study. The drugs used by the patients were evaluated according to the 2015 Beers criteria and inappropriate active substances were detected. The data were defined by statistical analyzes such as mean, percentage, standard deviation, and frequency. Chi-squared test and Student's t-test were used in the analysis. The significance level was accepted as p&amp;lt;0.05. Results: The mean age of the patients was 80.2±8.2 years, and 63.4% (n=204) were female. 70.5% (n=227) of the elderly have three or more chronic diseases. The most common diseases were hypertension (56.2%), diabetes (30.0%), and heart failure (29.8%). 79.2% (n=255) of the group uses four or more drugs. 83.3% (n=260) of the patients get help to use the drugs. 51.6% (n=166) of the patients were fully dependent on activities of daily living and 3.4% (n=11) were fully independent, the level of dependency increases with age (p&amp;lt;0.05). The PIM rate was 61.5% in patients. PIM use was found to be significantly higher in those with more disease, in those who used more drugs, and in females (p&amp;lt;0.05). No relationship was found between inappropriate medication use and addiction level. Conclusion: In this study, it was found that more than half of home care patients aged 65 and over had inappropriate drug use. It was determined that inappropriate medication use increased with polypharmacy, and polymorbidity, and there was no correlation between addiction levels.

Polypharmacy and inappropriate medication use in older adults is a major public health problem associated with morbidity and mortality. Aging is associated with metabolic changes and decreased drug clearance, increased drug-drug interactions, prescribing cascades, and potentially inappropriate medication (PIM) use. The purpose of this study was to evaluate the association between a common geriatric syndromes and PIM use among older adults. Study participants were recruited among patients admitted to Istanbul Medical School Geriatrics outpatient clinic between June 2000 and June 2014 and were evaluated retrospectively by a geriatrician using the patients' records according to Beers 2012 criteria. Among the 667 enrolled patients, 421 (63.1%) were women and 246 (36.9%) were men. The use of PIM was not associated with age or sex. Polypharmacy (OR 4.86, 95% CI 3.25-7.27, p < 0.001), malnutrition (OR 2.69, 95% CI 1.52-4.76, p = 0.001), depression (OR 2.61, 95% CI 1.7-3.95, p < 0.001), presence of fall in the previous year (OR 2.24, 95% CI 1.51-3.32, p < 0.001), and dementia (OR 1.69, 95% CI 1.08-2.65, p = 0.021) were independently associated with the use of PIM. The results of our study suggest that PIM use is independently associated with presence of polypharmacy, malnutrition, depression, falls and dementia in older outpatients. Identifying the association of inappropriate medication use with common geriatric syndromes in older people can help to prevent, delay, and reduce PIM use and related adverse health outcomes.

To determine the prevalence and patient-specific predictors of the use of 10 presumptively inappropriate medications used to treat medical conditions among nursing home residents, and to use this information to examine alternative screening strategies using computerized assessment data to identify residents who are at high risk of receiving inappropriate medications. Retrospective, cross-sectional study. All persons residing in all 252 nursing homes in two states during the last 6 months of 1991 (N = 21,884). Data were from Minimum Data Set Plus (MDS+) assessments, gathered as part of the Health Care Financing Administration (HCFA) Multistate Nursing Home Casemix and Quality Demonstration Project. The MDS+ is an expanded version of the federally mandated Minimum Data Set (MDS) that includes additional information on medications and their doses and schedules (frequency, standing vs prn). The reliability of the MDS has been demonstrated previously. Medications were defined as inappropriate using explicit criteria from published literature. Outcome measures were the standing use of each or any of 10 presumptively inappropriate medications used to treat medical (rather than psychiatric or behavioral) conditions. Potential predictors of inappropriate medication use included patient demographic characteristics, payer, a proxy measure for length of stay and admission source, functional status, number of standing medications, and state. A total of 12% of residents were prescribed one or more of 10 presumptively inappropriate medications on a standing basis, a figure that differed substantially between states (14.0% vs 7.4% (P < .001)). The most prevalent inappropriate medications were dipyridamole (5.4% of residents), amitriptyline (3.3%), and methyldopa (1.8%). Among patients receiving 0 to 3, 4 to 6, and 7+ medications, 5%, 12%, and 19%, respectively, were receiving at least one inappropriate medication. In multivariate logistic regression analyses, the strongest predictors of inappropriate medication use were state and the total number of standing medications prescribed. Including other statistically significant predictors of inappropriate medication use (age > 65 years, never having been married, severe functional limitations, being a long-stay patient, and medical diagnosis) did not substantially improve the overall predictive ability of the model. A substantial proportion of nursing home residents receives presumptively inappropriate medications to treat medical conditions. Selecting persons prescribed large numbers of medications for further review may be the most efficient method for nursing home or pharmacy personnel to identify residents at high risk of receiving inappropriate medications. Extensive additional information on residents' characteristics, although widely available through the Minimum Data Set, does not significantly improve the ability to identify residents receiving inappropriate medications for medical conditions. State-specific policies or provider practices also influence the likelihood of presumptively inappropriate medication use among nursing home residents and deserve further investigation.

Potentially Inappropriate Medication Use and Polypharmacy Before and After Admission to Internal Medicine for Older Patients

Potentially inappropriate medication use among the elderly in an outpatient setting has been widely reported. However, the potential association between inappropriate medication use and adverse outcomes is seldom examined. To identify the prevalence, risk factors for and adverse outcomes of potentially inappropriate medication use in ambulatory elderly patients with chronic diseases. Data for this observational cohort study consisted of computerized claims from a tertiary medical centre in Taiwan to the Bureau of National Health Insurance. Consecutive ambulatory elderly patients aged > or = 65 years who received long-term (3-month) prescriptions for treatment of a chronic disease were recruited from 1 to 31 March 2005. The cohort included 5741 elderly patients who received 7538 long-term prescriptions. Patients who required repeat prescriptions were able to be given the same prescription if their conditions were stable. The prevalence of potentially inappropriate medication use and the incidence of adverse outcomes, including emergency visits, hospitalizations and mortality, were documented for up to 6 months after the first day the patient was recruited. Beers' 2002 criteria were used to determine the potential inappropriateness of prescribed medications. Associations between potentially inappropriate medications and adverse outcomes were examined by multivariate logistic regression analyses controlling for possible confounding factors. The prevalence of potentially inappropriate medication use was 23.7% in the studied hospital. The most frequently prescribed potentially inappropriate medications of high severity (i.e. having a high likelihood of being associated with an adverse effect that was clinically significant) were amiodarone, chlorzoxazone, bisacodyl, nifedipine and amitriptyline. Logistic regression analysis revealed that female sex, advanced age, number of chronic diseases and number of medications taken all significantly increased the likelihood of receiving potentially inappropriate medications. The incidence of adverse outcomes in patients with potentially inappropriate medication use in the studied hospital was 25.1%. Multivariate logistic regression analysis revealed that potentially inappropriate medication use was significantly associated with hospitalization. Potentially inappropriate medication use is not a rare event in elderly patients and is associated with higher risk of hospitalization in this age group. In order to reduce the possibility of prescribing inappropriate medications, and therefore to reduce the consequent risk of hospitalization, more attention should be paid when prescribing drugs to, in particular, older female patients with multiple chronic illnesses that require treatment with multiple medications.

Criteria for potentially inappropriate medication use among elderly patients have been used in the past decade in large US epidemiological surveys to identify populations at risk and specifically target risk-management strategies. In contrast, in Europe little information is available about potentially inappropriate medication use and is based on small studies with uncertain generalizability. To estimate the prevalence and associated factors of potentially inappropriate medication use among elderly home care patients in European countries. Retrospective cross-sectional study of 2707 elderly patients receiving home care (mean [SD] age, 82.2 [ 7.2] years) representatively enrolled in metropolitan areas of the Czech Republic, Denmark, Finland, Iceland, Italy, the Netherlands, Norway, and the United Kingdom. Patients were prospectively assessed between September 2001 and January 2002 using the Minimum Data Set in Home Care instrument. Prevalence of potentially inappropriate medication use was documented using all expert panels criteria for community-living elderly persons (Beers and McLeod). Patient-related characteristics independently associated with inappropriate medication use were identified with a multiple logistic regression model. Combining all 3 sets of criteria, we found that 19.8% of patients in the total sample used at least 1 inappropriate medication; using older 1997 criteria it was 9.8% to 10.9%. Substantial differences were documented between Eastern Europe (41.1% in the Czech Republic) and Western Europe (mean 15.8%, ranging from 5.8% in Denmark to 26.5% in Italy). Potentially inappropriate medication use was associated with patient's poor economic situation (adjusted relative risk [RR], 1.96; 95% confidence interval [CI], 1.58-2.36), polypharmacy (RR, 1.91; 95% CI, 1.62- 2.22), anxiolytic drug use (RR, 1.82; 95% CI, 1.51-2.15), and depression (RR, 1.29; 95% CI, 1.06-1.55). Negatively associated factors were age 85 years and older (RR, 0.78; 95% CI, 0.65-0.92) and living alone (RR, 0.76; 95% CI, 0.64-0.89). The odds of potentially inappropriate medication use significantly increased with the number of associated factors (P<.001). Substantial differences in potentially inappropriate medication use exist between European countries and might be a consequence of different regulatory measures, clinical practices, or inequalities in socioeconomic background. Since financial resources and selected patient-related characteristics are associated with such prescribing, specific educational strategies and regulations should reflect these factors to improve prescribing quality in elderly individuals in Europe.

Introduction: At present, 7.2% of the population in Singapore is in the geriatric age group, which will increase to 18.4% in the year 2030. The frailest segment of the geriatric population live in nursing homes. They suffer from multiple co-morbidities requiring multiple medication use. Polypharmacy and inappropriate medication use have been considered as quality indicators for nursing home care. As no data of these indicators are available in Singapore, this study was planned to assess the prevalence of polypharmacy and inappropriate medication use in Singapore nursing homes. Materials and Methods: A total of 454 residents in the geriatric age group residing in 3 randomly selected nursing homes were involved in the study. Case notes were reviewed for demographic information, clinical history and medication use. The data were analysed for polypharmacy (5 or more medication orders) and inappropriate medication use (based on established criteria). Results: Residents were on an average of 5.32 medications. Polypharmacy and inappropriate medication use were seen in 266 (58.6%) and 318 (70.0%) residents, respectively. There was significant association between polypharmacy and inappropriate medication use [P &lt;0.001, χ2 = 82.56 at 95% confidence interval (CI)]. The most common medication-related problems were the use of medication without proper indication (n = 302), significant potential for adverse drug reactions (n = 281) and drug interactions (n = 141). Conclusion: The prevalence of polypharmacy and inappropriate medication use is high in Singapore nursing homes. Current practice of medication use in the nursing homes may lead to significant adverse drug reactions and drug interactions. A multidisciplinary approach involving geriatricians, nursing home physicians, nurses and pharmacists may potentially reduce polypharmacy and inappropriate medication use in Singapore nursing homes.