Potentially inappropriate anticholinergic drug use among older adults in primary healthcare: prevalence and determinants

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.

2019 AGS Beers Criteria for older adults

Musculoskeletal disorders are frequently associated with pain in older adults, and the use of inappropriate analgesics drugs is common. Understanding the patterns and factors of inappropriate analgesic use may help reduce its prevalence among older adults with chronic musculoskeletal pain. This cross-sectional study evaluated 215 older adults aged ≥ 60 years who experienced chronic musculoskeletal pain and used oral medication to relieve pain within the previous 3 months. Participants were recruited through home visits using the community health register in Ban Phru, Hat Yai District, Songkhla Province (Southern Thailand) between July and December 2023. Analgesic use was determined by directly inspecting the drugs that participants were taking within the previous 3 months, regardless of whether they were prescribed or self-purchased. The name, dose, and source of each medication were recorded and cross-checked with the 2023 American Geriatrics Society Beers Criteria to identify potentially inappropriate drugs. This approach enabled differentiation into three patterns of inappropriate analgesic drug use: potentially inappropriate medication use, overtreatment, and undertreatment. Factors associated with the inappropriate use of analgesic drugs were analysed using multivariate logistic regression analysis. Inappropriate analgesic drug use was prevalent in 66.5%. Regarding the prevalence rates by pattern, potentially inappropriate, overtreatment, and undertreatment were prevalent in 71.3%, 24.5%, and 33.6%, respectively. Non-prescribed polypharmaceutical packs (adjusted odds ratio [aOR] [95% confidence interval {CI}] = 11.45 [3.32, 72.15], P < 0.001) and pain interfering with enjoyment of life (aOR [95% CI] = 1.16 [1.04, 1.30], P = 0.007) were significantly associated with inappropriate analgesic drug use. Inappropriate analgesic use was common, affecting 66.5% of community-dwelling older adults with chronic musculoskeletal pain. Non-prescribed polypharmaceutical packs and pain interference were significant predictors of inappropriate use. These findings underscore the influence of inappropriate self-medication, suggesting the need for greater attention from healthcare providers to promote safe and rational analgesic use in this population.

Potentially inappropriate anticholinergic medication use in older adults with dementia

Magnitude and Determinants of Long-term Use of Proton Pump Inhibitors Among Portuguese Older Adults in Primary Health Care

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...

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

Inappropriate drug use is one of the risk factors for adverse drug reactions in the elderly. We hypothesised that, in elderly patients, geriatricians are more aware of potentially inappropriate medications (PIMs) and may replace or stop PIMs more frequently compared with internists. We therefore evaluated and compared the prevalence of PIMs as well as anticholinergic drug use throughout hospital stay in elderly patients admitted to a medical or geriatric ward. In this retrospective cross-sectional study, 800 patients aged > or =65 years admitted to a general medical or geriatric ward of a 700-bed teaching hospital in Switzerland during 2004 were included. PIMs were identified using the Beers criteria published in 2003. The prevalence of anticholinergic drug use was assessed based on drug lists published in the literature. The prevalence of use of PIMs that should generally be avoided was similar in medical and geriatric inpatients both at admission (16.0% vs 20.8%, respectively; p = 0.08) and at discharge (13.3% vs 15.9%, respectively; p = 0.31). In contrast to medical patients, the reduction in the prevalence of use of PIMs between admission and discharge in geriatric patients reached statistical significance (p < 0.05). Overall, the three most prevalent inappropriate drugs/drug classes were amiodarone, long-acting benzodiazepines and anticholinergic antispasmodics. At admission, the prevalence of use of PIMs related to a specific diagnosis was not significantly different between patients hospitalised to a medical or a geriatric ward (14.0% vs 17.5%, respectively; p = 0.17), as compared with the significant difference evident at hospital discharge (11.7% vs 23.7%, respectively; p < 0.001). This was largely because of a higher prescription rate of platelet aggregation inhibitors in combination with low-molecular-weight heparins and benzodiazepines in patients with a history of falls and syncope. The proportions of patients taking anticholinergic drugs in medical and geriatric patients at admission (13.0% vs 17.5%, respectively; p = 0.08) and discharge (12.2% vs 16.5%, respectively; p = 0.10) were similar. Inappropriate drug use as defined by the Beers criteria was common in both medical and geriatric inpatients. Compared with internists, geriatricians appear to be more aware of PIMs that should generally be avoided, but less aware of PIMs related to a specific diagnosis, and of the need to avoid anticholinergic drug use. However, the results of this study should be interpreted with caution because some of the drugs identified as potentially inappropriate may in fact be beneficial when the patient's clinical condition is taken into consideration.

US Physician Adherence to Standards in Asthma Pharmacotherapy Varies by Patient and Physician Characteristics

Suspected inappropriate use of prescription and non-prescription drugs among requesting customers: A Saudi community pharmacists’ perspective

Invited Commentary on ‘Effect of the Affordable Medicines Facility--malaria (AMFm) on the availability, price, and market share of quality-assured artemisinin-based combination therapies in seven countries: a before-and-after analysis of outlet survey data’, Tougher et al., Lancet, 2012. The war on drugs conjures images of drug enforcement agencies battling to stem the tide of illegal narcotics coming from South American drug cartels. But a second drug war is underway, and the public health stakes are even higher. This is the trade in counterfeit, sub-standard, and inappropriate medications that plague low and middle-income countries. By some estimates, 33% of medications in poor countries are counterfeit or substandard, and the market for these is estimated at an astonishing 40 billion US dollars per year, rivaling revenues from big pharma.1 The consequences of inappropriate drug use are particularly injurious to public health. In recent years, artemisinin monotherapy for acute malaria has emerged as a particularly malignant challenge to global malaria control efforts. The sequential introduction and use of antimalarials, including chloroquine, sulfadoxine-pyrimethamine, mefloquine, and others, was quickly followed by the emergence of Plasmodia resistant to each of these agents.2 Facing a resurgence of malaria in many parts of the world and fewer and fewer effective treatment options remaining, the malaria community adopted the strategy of combining antimalarial drugs. The most common approach has been to combine a highly potent but short-acting artemisinin with a long acting second agent into ‘artemisinin combination therapies’ (ACTs). As predicted, ACTs have proven highly effective for treating acute uncomplicated malaria.3 Unfortunately, this strategy is now jeopardized by the inappropriate use of artemisinin monotherapies, which have flooded the market in many parts of the world. These are poorly effective due to the short half-life of artemisinins, need to take a more prolonged 5 to 7 day course (which is often not completed), and high risk of relapse from partially treated cases of malaria.4 More importantly, monotherapy increases the risk of artemisinin resistance, which ultimately degrades ACT effectiveness. In short, the inappropriate use of artemisinin by itself undermines a cornerstone of our strategy for malaria case management, and the consequences could be catastrophic. But what to do? The problem, as with the war on narcotics, is that where there is demand, there is a private sector market eager to supply. Moreover, in the same way that our war on narcotics has largely failed by trying to interfere with the supply side, there is little optimism that trying to combat the problem of inappropriate artemisinin use through regulation will be effective. To address this challenge, the Global Fund to Fight AIDS, Tuberculosis and Malaria approved an innovative initiative in 2008, the Affordable Medicines Facility for malaria (AMFm).5 This financing mechanism involved three elements: price reductions of quality-assured ACTs, subsidies for consumers, and interventions to promote rational antimalarial use. The overarching goal of AMFm was to subsidize ACTs in the public and private sectors and thereby drive artemisinin monotherapy and substandard antimalarials out of the marketplace. Rather than trying to block the supply of inappropriate artemesinin monotherapy use, AMFm fought fire with fire, by aggressively subsidizing the ACTs at costs below artemisinin monotherapy, thereby eliminating a competitive market advantage. Tougher and her colleagues were commissioned to provide an independent, external evaluation of the AMFm strategy. They used before-and-after comparisons of price, availability, and market share in eight national-level pilot programs in seven countries.6 Their results were impressive. Overall, the volume of ACT use increased significantly in all but two pilot sites. Conversely, use of monotherapy fell sharply in Nigeria and Zanzibar, the two pilot sites where monotherapy had exceeded 5% at baseline. Moreover, Tougher et al documented a large increase in private drug sellers who elected to start stocking ACTs at the expense of artemisinin monotherapies. In fact, the preferential use or adoption of ACTs was most notable among private drug sellers, whose diversity and financial self-interest previously had posed a significant barrier to reducing inappropriate drug use. It is also relevant that the public sector of four countries purchased AMFm-subsidized ACTs from the private sector in order to avoid stockouts. This innovative financing mechanism stands as a textbook example of the effectiveness of harnessing market forces to promote public health, and should be studied and replicated in other contexts.

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.

Drugs with anticholinergic properties have harmful effects among frail older people and they may antagonize the effects of cholinesterase inhibitors (ChEIs). However, their association with psychological well-being has not been studied. To determine (1) the prevalence of the use of anticholinergic drugs, ChEIs, or their combination among older adults in residential care facilities and their association with psychological well-being, and (2) the association of anticholinergic drugs with an individual's psychological well-being. In 2007, all older adults (N = 1475) living in residential care facilities in the cities of Helsinki and Espoo, Finland, were assessed in a cross-sectional study. A trained nurse retrieved data on demographic factors, regularly administered medications, and diagnoses from medical charts. Psychological well-being was assessed using 6 questions concerning life satisfaction, zest for life, plans for the future, feeling needed, and feeling depressed or lonely, and a psychological well-being score was created (range 0-1). Residents taking anticholinergic drugs (n = 613) were significantly younger, used more drugs, and were more often on ChEIs compared with nonusers (n = 862). There was no significant difference in Charlson comorbidity index, stage of cognition, or dependence on activities of daily living between the users or nonusers of anticholinergic drugs. The anticholinergic drug users had significantly lower psychological well-being scores compared with the nonusers. Of the participants, 10.7% used ChEIs and anticholinergic drugs concomitantly. In logistic regression analysis where age, sex, comorbidities, and use of ChEIs were used as covariates, lower psychological well-being was associated with the use of anticholinergic drugs (OR 1.40; 95% CI 1.00 to 1.94; p = 0.048). Concomitant use of anticholinergic drugs and ChEIs is common among older adults. The use of anticholinergic drugs is associated with poor psychological well-being.

A - 101 Anticholinergic Drug Use in Older Adults with Dementia: a Systematic Review

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.