Evaluation of Psychotropic Drug Interactions and Inappropriate Use in Older Adults: A Cross-sectional Study

2019 AGS Beers Criteria for older adults

Antiplatelet and anticoagulant (collectively called antithrombotics) use remains ubiquitous in older adults due to well-established benefits in treating atherosclerotic and thromboembolic disease. It is unclear whether these benefits outweigh the risk of traumatic hemorrhage in older adults with elevated fall risk. Emergency department (ED) providers are well-positioned to identify opportunities to deprescribe likely inappropriate antithrombotics following an emergency visit for a fall. The objective was to determine the prevalence of likely inappropriate antithrombotic use among older adults on antithrombotics presenting to an ED with a fall. This was a secondary analysis of a prospective cohort study of older adults presenting to an ED with a fall enrolled from 2020 to 2021 in a pharmacist-led medication reconciliation program at a southeastern academic ED. We utilized the Medication Appropriateness Index (MAI) to assess antithrombotic appropriateness, categorized: appropriate (MAI = 0), potentially inappropriate (MAI = 1-2), and likely inappropriate (MAI ≥ 3). 171 out of 514 enrolled patients who presented with a fall to the ED were on an antithrombotic. Their mean age was 81.2 years (std dev 9.2) and 66.1% were female (113/171; 95% CI: 58.6%-72.8%). The median MAI score was 2 (IQR: 2-4). Potentially inappropriate or likely inappropriate use was observed in 82.5% (141/171; 95% CI: 76.0%-87.5%) of participants. Aspirin had the highest prevalence of likely inappropriate use at 60% (59/98; 95% CI: 50%-69%), while P2Y12 inhibitors, warfarin, and direct oral anticoagulants had prevalence of likely inappropriate use at 53% (8/15; 95% CI: 27%-78%), 30% (3/10; 95% CI: 8%-67%), and 29% (21/72; 95% CI: 20%-41%), respectively. There was a high prevalence of likely inappropriate antithrombotic use among older adults presenting to the ED with a fall. While aspirin had the highest rate of likely inappropriate use, all antithrombotics had 30% or greater rates of likely inappropriate use. An ED encounter presents a critical opportunity to evaluate the appropriateness of antithrombotic use in patients who have fallen.

Potentially inappropriate medication (PIM) use is one of the main drug-related problems encountered in older adults. It is associated with adverse drug events, morbidity, mortality, increased economic costs, and negative effects on the quality of life that requires strict monitoring of prescriptions in older adults. Thus, the study aimed to assess potentially inappropriate medication use and its determinants among older adults. A cross-sectional study was conducted among all outpatient prescriptions dispensed to older adults (aged 65 years and above) in six community chain pharmacies in Asmara, Eritrea. Data were collected retrospectively, between June 16 and July 16, 2023. PIMs were detected using the 2023 American Geriatric Society (AGS) Beers Criteria®. Descriptive statistics and logistic regression analysis were performed using IBM SPSS® (Version-26.0). A total of 2680 outpatient prescriptions dispensed to older adults were included in this study. The prevalence of PIM among prescriptions was 18.1% (95% CI: 16.7, 19.6). Moreover, a total of 470 medications were found to be avoided in older adults. The most commonly prescribed PIMs were sulfonylureas (27.2%) and substituted alkylamines (16.2%). The prevalence of prescriptions containing medications to be used with caution in older adults was 13.2% (95% CI: 12.0, 14.5). Age (Adjusted Odds Ratio (AOR))=0.98, 95% CI: 0.97, 0.99), polypharmacy (AOR=2.77, 95% CI: 1.49, 5.15), and general practitioner prescriber (AOR=1.38, 95% CI: 1.11, 1.70) were significantly associated with PIMs. A considerable number of ambulatory older adults were exposed to PIMs which require a close attention by policymakers, program managers, and healthcare professionals.

To determine the association between inappropriate medication use and self-reported adverse drug effects (ADEs). Prospective cohort study with three annual mailed surveys. Population-based sample of Iowa Medicare beneficiaries. Cohort members (n5626) with established mobility disability and complete pharmacy dispensing records, continuous Medicare eligibility, and survey data. The number of unique drug ingredients dispensed and inappropriate use were assessed for the year before the ADE survey. Inappropriate medication use was defined according to published criteria: contraindicated drugs for elderly people, drug-disease interactions (constructed from linked Medicare claims), drug-drug interactions, and therapeutic duplications. An ADE was defined from the following question: "In the past 12 months, have you experienced an unwanted effect or side effect of a medication?" Of respondents to the ADE survey, 22.0% reported having experienced an ADE in the past year, and 322 (51.4%) received at least one potential inappropriate medication. Factors associated univariately with ADE self-report were number of medications, number of mobility limitations, any inappropriate medication use, and each of the individual domain appropriateness indicators, as well as number of different domains of inappropriate use. The adjusted odds ratio for developing an ADE was 2.14 (95% confidence interval=1.26-3.65) for those with inappropriate use versus no inappropriate use. Efforts to reduce ADEs by reducing medication inappropriateness should be encouraged as a complement to efforts focused on reducing the number of medications prescribed.

Osteoarthritis (OA) is a degenerative arthritis affecting over 30 million Americans most of whom are over 65 years or older. Its clinical management is complicated by several disease- and treatment-specific factors. These include the co-occurrence of cardiovascular and gastrointestinal disorders (CV-GID), the inappropriate use of non-steroidal anti-inflammatory drugs (NSAID) to manage pain, and the risk of certain age-related chronic conditions like Alzheimer’s disease and related dementia (ADRD). Moreover, older adults with OA are at a higher risk of CV-GID, inappropriate NSAID use, and ADRD. Additionally, these factors can also affect one another in both a positive and a negative way. For example, the long-term use of NSAID has been shown to increase the risk for cardiovascular and gastrointestinal disorders. On the other hand, their use has been shown to decrease the risk of ADRD in some studies. NSAID use is disproportionately higher among older adults, so the benefits or risks associated with such use should be taken into account while making treatment decisions. However, there is a gap in our understanding of the clinical and demographic factors that increase the risk of co-occurring CV-GID, inappropriate NSAID use, and ADRD in older adults with OA. This dissertation pursued three related aims to fill this knowledge gap: 1) identify the leading predictors of CV-GID; 2) identify the leading predictors of inappropriate NSAID use; and 3) examine whether duration of NSAID use is a leading predictor of ADRD and how other factors affect this relationship using a combination of machine learning techniques. All three aims used a retrospective, longitudinal, cohort study design using de-identified commercial health insurance insurance claims data from Optum De-identified Clinformatics Data Mart for years 2015 through 2017. OA was identified from these data using a combination of International Classification of Disease – 9th Revision and 10th Revision (ICD-9 and ICD-10) codes. Using a random forest classifier, we identified age, cardiac arrhythmia, and the duration of opioid use to be the top three leading predictors of CV-GID in our study cohort. In the second aim, we found that around 13% of older adults with OA were prescribe NSAIDs not in accordance with their CV and GI risk profile (i.e. inappropriate NSAID use). Using an eXtreme Gradient Boosting classifier and Shapley Additive eXplanations, we found durations of non-selective and selective NSAID use to be the top two predictors of inappropriate NSAID use. Older adults with low CV and high GI or

Background Sleep disorders such as insomnia may occur in old age, potentially leading to z-hypnotic use. However, few studies have explored older adults’ self-reported sleep concerns in relation to z-hypnotic use. We aim to examine this relationship. Methods We conducted a cross-sectional study using a web-based questionnaire to assess sleep disturbances and medication use (z-hypnotics, benzodiazepines, and opioid analgesics) among 5,194 older adults through 21 GPs in southeast Norway. The main outcome, inappropriate z-hypnotic use, was defined as self-reported use for ≥4 weeks at ≥ three times per week. We used descriptive statistics and exploratory logistic regression mixed-effects models for data analysis. Results Among the 687 patients included in the study, 22% (N = 153) reported sleep disturbances. Of these, 84% (N = 575) did not use z-hypnotics, while 16% (N = 112) used z-hypnotics, 63% (N = 71) of these used them inappropriately. (≥4 weeks, ≥ three times per week). Patients with sleep disturbances (OR: 12.1, CI: 6.77 − 21.6, p < 0.001), trouble falling or staying asleep (OR: 14.6, CI: 5.04–42.0, p < 0.001), and multiple reasons for disturbances (pain, overthinking, or a family death) (OR: 3.58, CI: 1.85–6.93, p < 0.001) had higher odds of inappropriate z-hypnotic use compared to those with no or occasional disturbances. Men had lower odds (OR: 0.54, CI: 0.30–0.97, p = 0.039) than women. GP prescribing was not associated with inappropriate use, but men had lower odds (OR: 0.34, CI: 0.14–0.84, p = 0.020) when prescribed by male GPs compared to women prescribed by female GPs. Conclusion A high proportion of patients used z-hypnotics inappropriately. This inappropriate use was associated with experienced sleep disturbances, particularly trouble falling asleep, trouble staying asleep, and multiple reasons for sleep disturbances. The prescribing GP was not significantly associated with inappropriate use.

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.

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.

Updated Beers Criteria: A more comprehensive guide to medication safety in older adults

ObjectivesLittle is known about the inappropriate use of proton pump inhibitors (PPIs) and how mild cognitive impairment (MCI) and high comorbid burden relate to the inappropriate prescribing of PPIs. Therefore, the current study aimed to examine these associations among community-dwelling older adults in Jordan. MethodThis cross-sectional study was conducted on 215 community-dwelling older adults from three local healthcare centers located in Irbid, Jordan. Data about PPI use, including the name of medication, dose, frequency, duration, and indication, were collected retrospectively from a review of the participating older adults’ medication cards for November and December 2019. The collected data were evaluated based on the Food and Drug Administration (FDA) guidelines. MCI was measured using the Arabic version of the Montreal Cognitive Assessment, and comorbid burden was measured using the Cumulative Illness Rating Scale for Geriatrics. ResultsForty-seven percent of the participants were found to have taken a PPI, with 68 % having taken one for a longer period than recommended by the FDA. Older adults with MCI or high comorbid burden were found to be more susceptible than other older adults to the long-term use of PPIs. The logistic regression revealed that MCI is a statistically significant predictor of inappropriate PPI use (p < 0.001). ConclusionInappropriate PPI use is common among community-dwelling older adults in Jordan, with a significantly higher prevalence of inappropriate PPI use in people with MCI than in people with normal cognitive abilities. Future intervention studies are highly recommended to encourage optimal prescribing of PPIs for community-dwelling older adults.

Background Considering the vulnerability of older adults to adverse drug reactions, medications with strong anticholinergic properties are considered potentially inappropriate for this population. This study aims to characterize older adults’ profile of anticholinergics use and to identify the factors associated with their potentially inappropriate use. Research design and methods A retrospective study was conducted on 1200 older adults in primary health care centers of Portugal between April 2021 and August 2022. Potentially inappropriate use was assessed according to the 2023 Beers criteria. Logistic regression analyses were performed to determine associations between independent variables and potentially inappropriate use. Results A 8.9% (95% CI 0.074–0.107) of the older adults were exposed to one or more potentially inappropriate anticholinergics, and amitriptyline was the most used (2.0%). Multivariate analysis revealed that use was associated with a higher mean number of medications (OR 1.173, 95% CI 1.115–1.234), diagnoses of depression (OR 2.889, 95% CI 1.785–4.674) and psychiatric disorders (OR 1.654, 95% CI 1.003–2.729). Conclusions This study underscores the importance of vigilance in prescribing anticholinergic medications to older adults, particularly those with higher medication burdens and mental health diagnoses. By identifying factors associated with potentially inappropriate use, healthcare providers can better tailor medication regimens to mitigate risks and optimize the well-being of older adults.

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...

Beers revised: Drugs not to use in older adults

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.

Older adults are more likely to suffer from the adverse effects of digoxin. Studies have described the inappropriate use of digoxin in various populations. The objective of this study was to determine the correlates of inappropriate digoxin use in older heart failure patients. We studied older hospitalized heart failure patients with documented left ventricular (LV) function evaluation and electrocardiography. Digoxin use was considered inappropriate if patients had preserved LV systolic function (ejection fraction greater > or =40%) or if they had no atrial fibrillation (AF). We compared baseline patient characteristics by indication for digoxin and tested statistical significance using Pearson's chi-square analysis and Student's t tests. Using logistic regression, we determined the correlates of inappropriate use and initiation of digoxin. Subjects (N = 603) had a mean age of 79 (+/-7) years; 59% were women, and 18% were African American. A total of 376 patients (62%) were discharged on digoxin, and 223 (37%) had no indication for its use. Half of the patients without an indication for digoxin received the drug. Of 132 patients without an indication and not already on digoxin, 38 (29%) were initiated on it. After adjustment for various patient and care characteristics, prior digoxin use (adjusted odds ratio [OR] 11.47, 95% confidence interval [CI] 5.72-23.02) and pulse > or =100/min (adjusted OR 2.33, 95% CI 1.10-4.94) were associated with inappropriate digoxin use. Pulse > or =100/min was also associated with inappropriate initiation of the drug (adjusted OR 2.95, 95% CI 1.28-6.78). Inappropriate use of digoxin was common and was associated with prior use. Tachycardia was associated with inappropriate use and initiation. Electrocardiography and echocardiography should be performed in all older heart failure patients. Digoxin therapy should not be initiated or continued in patients without any evidence of LV systolic dysfunction or chronic AF.