Model to Minimize Inappropriate Medications in the Elderly

Abstract

Scott et al1Scott I.A. Gray L.C. Martin J.H. Mitchell C.A. Minimizing inappropriate medications in older populations: a 10-step conceptual framework.Am J Med. 2012; 125: 529-537Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar have designed an elegant and precise model to examine and rationalize drug use in older people. I have a few comments on step 1 (ascertain current drug use). I suggest the following actions: (1) Examine the dates on each medication container. If the current date is June 12, 2012, and the patient claims to be using spironolactone, why does the patient have a 30-day supply of spironolactone dispensed on December 23, 2011? (2) Examine the patient name on each medication container. Is the patient taking a medication prescribed for her husband? (3) Examine medication containers for double-dipping, for example, one container for Antenex 5 mg 30 tablets (diazepam 5 mg) and another for Apo-diazepam 5 mg 30 tablets (diazepam 5 mg) both dispensed on the same day. (4) Question the prescribing doctor for drugs of abuse. Why does the patient have a container of oxycodone slow-release (OxyContin) 20 mg twice daily prescribed by Doctor A on June 7 (28 tablets) and another by Dr B on June 9 (28 tablets)? (5) Ask for inhalers, eye drops, skin creams, and nasal sprays. Some patients do not consider these as medications. (6) Ask the patient for his/her method of dispensing weekly drugs, such as alendronate, monthly drugs such as risedronate 150 mg monthly, or avoiding certain days (eg, avoid folic acid on the day of methotrexate). (7) Phone the patient's pharmacy for a list of dates of dispensing. (8) Test drug levels when appropriate (eg, theophylline level in the rare patient who uses this old drug). I applaud the authors' suggestion to investigate out-of-pocket expenses for medications. One of the most common examples of this is the use of olanzapine or quetiapine for elderly patients with dementia who have restlessness or agitation. Many prescribers use these drugs despite the facts that (1) they are not funded in certain countries such as Australia for dementia (only for schizophrenia and bipolar disease); (2) there is no good evidence to suggest they are more effective than drugs funded for behavioral and psychologic symptoms of dementia, such as risperidone; and (3) extrapyramidal side effects of risperidone in those with behavioral and psychologic symptoms of dementia are low with dosages of 0.5 to 1.5 mg daily. Perhaps the authors would consider adding a step 11 for patients who are reluctant to take medications; this might be negotiating which drugs to continue and which to stop. I have just published a short article2Regal P. Reducing polypharmacy Don Quixote style.Intern Med J. 2012; 42: 1273Crossref PubMed Scopus (1) Google Scholar about Don Quixote attacking imaginary enemies such as preventative drugs in older people. The following drug classes are imaginary enemies with uncommon adverse effects that are virtually always reversible: angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, calcium carbonate once daily, folic acid, inhaled anticholinergics for chronic obstructive pulmonary disease, inhaled steroids for asthma or chronic obstructive pulmonary disease, strontium ranelate, thiamine in alcohol abuse, and vitamin D. Minimizing Inappropriate Medications in Older Populations: A 10-step Conceptual FrameworkThe American Journal of MedicineVol. 125Issue 6PreviewThe increasing burden of harm resulting from the use of multiple drugs in older patient populations represents a major health problem in developed countries. Approximately 1 in 4 older patients admitted to hospitals are prescribed at least 1 inappropriate medication, and up to 20% of all inpatient deaths are attributable to potentially preventable adverse drug reactions. To minimize this drug-related iatrogenesis, we propose a quality use of medicine framework that comprises 10 sequential steps: 1) ascertain all current medications; 2) identify patients at high risk of or experiencing adverse drug reactions; 3) estimate life expectancy in high-risk patients; 4) define overall care goals in the context of life expectancy; 5) define and confirm current indications for ongoing treatment; 6) determine the time until benefit for disease-modifying medications; 7) estimate the magnitude of benefit versus harm in relation to each medication; 8) review the relative utility of different drugs; 9) identify drugs that may be discontinued; and 10) implement and monitor a drug minimization plan with ongoing reappraisal of drug utility and patient adherence by a single nominated clinician. Full-Text PDF