Development of a nomogram for predicting the risk of potentially inappropriate medication use in older adults: A retrospective cross-sectional study.

P from all practice settings are likely familiar with the American Geriatric Society’s (AGS) Beers Criteria of Potentially Inappropriate Drugs, last published in 20121 and recently revised and updated in 2015.2 The AGS Beers Criteria—Beers Criteria for short—have proven useful in identifying drugs to potentially avoid in older adults, to reduce adverse drug events and drug-related problems, and to improve medication selection and overall medication safety in older adults. The Beers Criteria are designed for use in any clinical setting and can also be used as an educational quality measure and research tool. The latest version of the Beers Criteria uses a more comprehensive, systematic review and grading of evidence.

Older adults are generally characterized as patients who may be at an increased risk for adverse drug events because of altered pharmacokinetics, increased exposure to multiple concomitant medications, and comorbid conditions. In 1991, Mark Beers, MD, and colleagues published criteria listing "potentially inappropriate medications" for older patients. Updates to these criteria were subsequently published in 1997, 2003, and earlier this year in the Journal of the American Geriatrics Society . The revised 2012 version heralds a new partnership between an interdisciplinary panel of experts and the American Geriatrics Society.

2019 AGS Beers Criteria for older adults

Inappropriate medications are often used in older adults despite their unfavourable risk-to-benefit profile. Although many of the medications in the American Geriatrics Society (AGS) Beers list are potentially inappropriate because of their anticholinergic properties, little is known regarding the nature and extent of potentially inappropriate anticholinergic medication use in older adults. To determine the prevalence of, and factors associated with, potentially inappropriate anticholinergic medication use in the older population. A retrospective, cross-sectional study was conducted, involving older adults (aged 65 years and older), using 2009-2010 Medical Expenditure Panel Survey (MEPS) data. The 2012 AGS Beers Criteria were used to define potentially inappropriate anticholinergic medications on the basis of the list of medications to avoid using in older adults irrespective of the diagnosis. Descriptive analyses were used to examine the nature and extent of potentially inappropriate anticholinergic medication use. Multivariable logistic regression within the conceptual framework of the Andersen Behavioral Model was used to identify the factors associated with potentially inappropriate anticholinergic use in older adults. According to the MEPS, there were 78.60 million older adults in the USA; an estimated 7.51 million (9.56 %) of these older adults used potentially inappropriate anticholinergic medications in 2009-2010. The most frequently used potentially inappropriate anticholinergics were cyclobenzaprine, promethazine, amitriptyline, hydroxyzine and dicyclomine. Multivariable regression analyses revealed that female sex, residing in the South and the presence of anxiety disorder increased the likelihood of receiving potentially inappropriate anticholinergic medications, whereas older adults aged 75-84 or ≥ 85 years, and those with over 15 years of education, had a decreased likelihood of receiving potentially inappropriate anticholinergic medications. The study found that approximately one in ten older adults used potentially inappropriate anticholinergic medications. Several predisposing, enabling and need factors were associated with the use of potentially inappropriate anticholinergic medications. Concerted efforts are needed to optimize potentially inappropriate anticholinergic medication use in older adults.

Optimizing Medication Use in Older Adults

Background The elderly population is often in continuous use of several medications and is more subject to the "iatrogenic triad" of polypharmacy, potentially inappropriate medication use and drug-drug interactions. However, few studies have investigated these three factors concomitantly. Purpose To assess the prevalence and inter-relationship of potentially inappropriate medication (PIM) use, polypharmacy and drug-drug interactions in older adults, together with their associated factors. Setting city of Juiz de Fora, Brazil. Methods a cross-sectional, observational and door-to-door epidemiologic study in community-dwelling older adults was conducted. Main outcome measure The primary outcomes were polypharmacy, inappropriate medication use (2012 Beers and 2015 STOPP criteria) and drug-drug interactions. Associated factors were also investigated using bivariate and multivariate analyses. Results a total of 368 (92%) older adults were in continuous use of at least one drug. There was a high prevalence of polypharmacy (44.6%), drug-drug interaction (72.3%) and PIMs byBeers (42.1%) and PIMs bySTOPP (46.2%). Analysis of the inter-relationship of the criteria (polypharmacy, PIMs STOPP and drug-drug interactions) revealed that 108 (29.3%) of the older adults had all three criteria concomitantly and multivariate analysis showed that frailty and having a caregiver were associated with this "iatrogenic triad". Conclusion A high prevalence of iatrogenic effectsfrom drugs was found in the older adults assessed. One in every three elderly participants of the study had all three iatrogenic criteria concomitantly, highlighting the major public health impact of this problem. The results of this study can serve to inform new preventive and educational strategies for health professionals.

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.

The American Geriatrics Society (AGS) Beers Criteria® (AGS Beers Criteria®) for Potentially Inappropriate Medication (PIM) Use in Older Adults is widely used by clinicians, educators, researchers, healthcare administrators, and regulators. Since 2011, the AGS has been the steward of the criteria and has produced updates on a regular cycle. The AGS Beers Criteria® is an explicit list of PIMs that are typically best avoided by older adults in most circumstances or under specific situations, such as in certain diseases or conditions. For the 2023 update, an interprofessional expert panel reviewed the evidence published since the last update (2019) and based on a structured assessment process approved a number of important changes including the addition of new criteria, modification of existing criteria, and formatting changes to enhance usability. The criteria are intended to be applied to adults 65 years old and older in all ambulatory, acute, and institutionalized settings of care, except hospice and end-of-life care settings. Although the AGS Beers Criteria® may be used internationally, it is specifically designed for use in the United States and there may be additional considerations for certain drugs in specific countries. Whenever and wherever used, the AGS Beers Criteria® should be applied thoughtfully and in a manner that supports, rather than replaces, shared clinical decision-making.

The American Geriatrics Society (AGS) Beers Criteria® (AGS Beers Criteria®) for Potentially Inappropriate Medication (PIM) Use in Older Adults are widely used by clinicians, educators, researchers, healthcare administrators, and regulators. Since 2011, the AGS has been the steward of the criteria and has produced updates on a 3-year cycle. The AGS Beers Criteria® is an explicit list of PIMs that are typically best avoided by older adults in most circumstances or under specific situations, such as in certain diseases or conditions. For the 2019 update, an interdisciplinary expert panel reviewed the evidence published since the last update (2015) to determine if new criteria should be added or if existing criteria should be removed or undergo changes to their recommendation, rationale, level of evidence, or strength of recommendation. J Am Geriatr Soc 67:674-694, 2019.

Adverse drug reactions are a common cause of potentially avoidable harm, particularly in older adults. To evaluate the feasibility and efficacy of a pilot multifactorial intervention to reduce potentially inappropriate medication (PIM) use in older adults. We conducted a phase 2, feasibility, open-label study in the ambulatory setting of an integrated healthcare network in Buenos Aires, Argentina. We recruited primary care physicians (PCPs) and measured PIM use in a sample of their patients (65years or older). Educational workshops for PCPs were organized with the involvement of clinician champions. Practical deprescribing algorithms were designed based on Beers criteria. Automatic email alerts based on specific PIMs recorded in each patient's electronic health record were used as a reminder tool. PCPs were responsible for deprescribing decisions. We randomly sampled 879 patients taking PIMs from eight of the most commonly used drug classes at our institution and compared basal (6months prior to the intervention) and final (12months after) prevalence of PIM use using a test of proportions. There was a significant reduction (p < 0.05) in all drug classes evaluated. Non-Steroidal Anti-Inflammatory Drugs (basal prevalence 5.92%; final 1.59%); benzodiazepines (10.13%; 6.94%); histamine antagonists (7.74%; 3.07%); opioids (2.16%; 1.25%); tricyclic antidepressants (8.08%; 4.10%); muscle relaxants (7.74%; 3.41%), anti-hypertensives (3.53%; 1.82%) and oxybutynin (2.96%; 1.82%). The absolute reduction in the overall prevalence was 8.5 percentage points (relative reduction of 51.4%). This multifactorial intervention is feasible and effective in reducing the use of potentially inappropriate medication in all drug classes evaluated.

BackgroundMultimorbidity, polypharmacy, and potentially inappropriate medication use in older adults are prevalent and affect their quality of life. This study investigates the interrelationship between potentially inappropriate medication use, comorbidity, and quality of life among older adults in Iran.MethodsThis cross-sectional study was conducted on 500 older adults in Isfahan City, Iran. The Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, a health-related quality-of-life questionnaire for older adults, and the Charlson Comorbidity Index were used to gather data.ResultsOur findings related to older adults living in the Isfahan community showed that the prevalence of PIM was 61.6%, and the most common drug category was painkillers. The average quality of life score was (0.86 ± 0.08), and the worst category was related to sleep status. The average score of the CCI was 3.63 ± 1.40, with the most frequent diseases being hyperlipidemia, hypertension, and diabetes. After adjusting for confounding variables, a negative relationship between CCI (B = -0.009 [SE = 0.0027], P < 0.001) and PIM (B = -0.03 [SE = 0.007], P < 0.001) with quality of life was observed.ConclusionPotentially inappropriate medication uses and comorbidities are high in our older population, and these variables are negatively associated with quality of life in this population. There are few family physicians trained in geriatrics in Iran. Policymakers should pay attention to these issues.

Commentary on the New American Geriatric Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults

The 2 most widely used explicit criteria regarding inappropriate medication use in older adults are the American Geriatrics Society's Beers Criteria and the Screening Tool of Older People's Prescriptions/Screening Tool to Alert to Right Treatment (STOPP/START). Both documents were updated recently. They are important educational tools that highlight medications for which risks of use may often exceed benefits in older adults and situations in which potentially appropriate medications should be considered for use. The application of these tools has the potential to significantly affect patient care. Thus, it is important for clinicians to be familiar with both documents.

Potentially inappropriate medication (PIM) use is prevalent in older adults and is associated with adverse events, hospitalisation and mortality. We assessed the patterns and associations of PIM use in older adults with mild-to-moderate Alzheimer's Disease (AD), who may represent a particularly vulnerable group. Analysis of data from NILVad, an 18-month Randomised Control Trial of Nilvadapine in mild-to-moderate AD. The v2 STOPP criteria were applied in duplicate to identify PIM use. Associations between PIM use and adverse events/unscheduled healthcare visits in addition to the associations between PIM use and AD progression were evaluated. 448 older adults with mild-to-moderate AD from 23 centres in nine European countries. Of 448 participants (mean age: 72.56 ± 8.19years), over half (55.8%) were prescribed a PIM with 30.1% being prescribed 2+ PIMs. The most frequent PIMs were (i) long-term benzodiazepines (11.6% N = 52/448), (ii) selective serotonin reuptake inhibitors without appropriate indication (11.1% N = 50/448), and (iii) Proton-Pump Inhibitors (PPIs) without appropriate indication (10.7% N = 48/448). Increasing number of PIMs was associated with a greater risk of adverse events (IRR 1.17, 1.13-1.19, P < 0.001), serious adverse events (IRR 1.27; 1.17-1.37, P < 0.001), unscheduled hospitalisations (IRR 1.16, 1.03-1.30, P = 0.016) and GP visits (IRR 1.22, 1.15-1.28, P < 0.001). PIM use was not associated with dementia progression. PIM use is highly prevalent in mild-to-moderate AD and is associated with adverse events and unscheduled healthcare utilisation. Further attention to de-prescribing in this vulnerable group is warranted.

Older adults with dementia are at high risk for drug-related adverse outcomes. While much is known about potentially inappropriate medication use in older adults, its prevalence and characteristics among those with dementia are not as well elucidated. We conducted a literature review to examine the prevalence of potentially inappropriate medication use among home-dwelling older adults with dementia. Our secondary aim was to determine the most frequently implicated medications and factors associated with potentially inappropriate medication use. MEDLINE, EMBASE, CINAHL, and International Pharmaceutical Abstracts were searched between 1946 and 2014 for articles that referenced potentially inappropriate medication use and types of dementia. One reviewer screened all titles and abstracts from the initial search and full-text articles after the initial screen for eligibility, then 2 reviewers independently abstracted data from included studies. Searches yielded 81 articles, of which 7 met inclusion criteria. Prevalence of potentially inappropriate medication use varied from 15% to 46.8%. No single drug or drug class was reported consistently across all studies as the most frequent potentially inappropriate medication, but anticholinergics and benzodiazepines, drugs that affect cognition, were among the most common medications or pharmacological classes listed. Older adults with dementia may be particularly vulnerable to potentially inappropriate medications because of cognitive impairment from their condition and the greater likelihood of experiencing adverse events from medications. Given this population's greater susceptibility to adverse events, more intense medication and patient monitoring may be warranted, especially among those taking anticholinergics and benzodiazepines, as these drugs can contribute to cognitive impairment.