Potentially Inappropriate Medications and Drug–Drug Interactions in Geriatrics Cardiac Patients Visiting to Tertiary Care Central Hospital of Nepal

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

Background and importancePatients with chronic kidney disease (CKD) are often characterised by the concomitance of multimorbidity, which could cause complex drug prescriptions that lead to a higher risk of incorrect...

BackgroundAppropriate prescribing is often challenging in geriatric patients due to age-related pharmacokinetic and pharmacodynamic alterations. Elderly patients with cardiovascular diseases are frequently prescribed multiple medications. Hence, it is imperative to investigate medication appropriateness, polypharmacy, and drug-drug interactions in these groups of patients.ObjectiveTo assess medication appropriateness using the 2019 American Geriatric Society Beers and Medication Appropriateness Index criteria, polypharmacy and drug-drug interactions among elderly ambulatory patients with cardiovascular diseases at Tikur Anbessa Specialized Hospital.MethodsA hospital-based retrospective cross-sectional study was conducted among 384 elderly (60 years and older) ambulatory patients with cardiovascular diseases between May 01-August 30, 2021. Data was collected from the patient’s medical record using a data abstraction tool. The data were entered and analyzed using the SPSS program. Descriptive and logistic regression models were used to present the findings.ResultsThe most frequent diagnosis was hypertension (78.4%) followed by ischemic heart disease (31.3%). Averagely, 4.4 ± 2 medications were prescribed per patient. More than half of (53.1%) the patients received polypharmacy. According to Beer’s and medication appropriateness index criteria, over one-third (28.1%) and the majority (95.1%) of the patients were prescribed potentially inappropriate medications, respectively. In addition, 53.1% and 90.1% of patients had polypharmacy, and were exposed to potential drug-drug interactions ranging from mild to major interactions, respectively. Further, polypharmacy was significantly associated with inappropriate medication prescribing.ConclusionThe study found that more than half of the patients got one or more potentially inappropriate medications in both criteria. The medication appropriateness index tool identified more potentially inappropriate medication than the Beers criteria. In addition, more than half of the patients got polypharmacy and had potential drug-drug interactions. Further, polypharmacy was significantly associated with inappropriate medication prescriptions. These findings highlight the need for interventions to improve appropriate prescribing practice among elderly patients.

The current study aims to evaluate the aptness of prescription in elderly along with looking out for polypharmacy, overprescribing and under prescribing in geriatric patients being treated at the tertiary care hospital. This is a retrospective record-based study, data was collected from 1st January 2017 to 31st December 2018 of all the patient which are falling in the inclusion criteria. Prescription appropriateness was assessed implementing 'Beers criteria'. Errors in prescription along with administration were checked by direct observation and analysis of prescriptions. Out of total 2,718 patients, 58.6 % were found to be males and 41.4 % were females. Most common comorbidities found were hypertension and coronary artery diseases (CAD). In the current study, 39 % of the prescription contained inappropriate medication and 11.20 % prescriptions were having adverse drug reaction. Error by attending nurse in prescription reading came out to be the most common error in thisstudy. Diclofenac was found to be the most commonly used inappropriate drug as per Beer's criteria. Clinicians should be more cautious when using drugs in old age patients.

BackgroundOlder patients affected with comorbidities often take a lot of potentially inappropriate drugs. This can cause side effects, hospitalization and even death.AimThe aim of the present study was to assess dangerous drug interactions and potentially inappropriate drugs administered to a sample of ambulatory and home care patients affected with dementia.Methods41 ambulatory outpatients and 53 home care patients affected with dementia were selected randomly between January 1st 2017 and December 31st 2019. They were visited at the Center for Cognitive Disorders and Dementia, Catanzaro Lido, Italy.Personal, clinical data and drugs taken were collected; comorbidities were assessed through CIRS, ADL, IADL, MMSE. Beers criteria were used in order to assess the potentially inappropriate drugs.ResultsOf 100 patients, 64 were women and 36 men, mean age 83,7 ± 4,9 and 82,1 years old ± 11,8 years old respectively. 50% of them were affected with mixed dementia, 13% Alzheimer’s dementia, 9% Parkinsonism, 10% depression with associated cognitive impairment, 18% dementia of other kind. Mean MMSE score was 15,99 ± 8,84. Each patient was taking 9,17 ± 3,31 drugs on the average, 56% of them 5‐9 drugs and 39% 10 drugs or more. 66% of patients was taking one inappropriate drugs or more, proton pump inhibitors (PPI) (51%), atypical and conventional antipsychotics (23% and 6% respectively), benzodiazepines, amiodarone, calcium antagonists (3%), tricyclic antidepressants and a‐blockers (2%), old generation anti‐histamine drugs (1%). 56% of them were taking a drug with anticholinergic properties.ConclusionsThe study shows a high percentage of drugs with anticholinergic properties, which can increase the risk for dementia or even worsen cognitive impairment. Furthermore, inappropriate drugs were stopped and changed with more tolerated compounds. PPI use was dramatically reduced. The study suggests the need for a careful check of treatment in every patient, and for personalizing treatment in older patients with dementia. A larger sample could bring more information to healthcare providers as well as the use of softwares for helping doctors to limit the risk for drug interactions.

9507 Background: Polypharmacy and inappropriate drug use are risk factors for adverse drug reactions (ADR) and poor compliance in older cancer patients. Drug evaluations in the past have not focused on this group. An evaluation of the prevalence of PIMs, pharmacist interventions, and the number and type of medications was performed. An educational component helped patients with drug management to increase adherence, avoid drug-drug and drug-disease interactions. Methods: A geriatric clinical pharmacist reviewed patient's medications, assessed understanding of their drugs, evaluated adherence, reviewed for PIMs (Beer's criteria), identified possible ADR and side effects, and provided detailed instructions. The pharmacist collaborated with the oncologist to determine appropriate therapy for the patient. Only patients over the age of 65 were eligible for this clinic. Consults were performed from March 2008 to June 2008, this includes new and follow up visits. An additional retrospective chart review was performed on 100 patients ≥ 65 years of age seen from July 2007 to November 2007. Results: There were 154 patients who underwent a prospective consultations; 74 yrs (65–91; 58% female). The interventions were: an alternative agent was recommended (31pts/20%), drug - drug interactions identified (15/10%), problems with adherence (58/37%), drugs discontinued (54/35%), additional medication (64/42%), dose change (17/11%), pain management (28/18%) and cost issues (19/12%). More then one issue was addressed during visits. In the retrospective study, median age 72 (65 - 90), 48% were females; medications: median 8 (range 0–23). Most common classes of medications were anti-hypertensives (52%), vitamins/herbals (46%), proton pump inhibitors (32%) and lipid lowering agents (29%). The prevalence of PIMs was 11%. The most common were propoxyphene, high doses of long-acting benzodiazepines and diphenhydramine. Conclusions: A geriatric medication management evaluation resulted in 50% of patients requiring specific interventions and identification of PIMs in 11% of patients. This type of intervention can optimize care by increasing adherence and avoiding adverse drug events and their serious sequelae. No significant financial relationships to disclose.

Indonesia is predicted to be in the top 10 largest geriatric populations in the world by 2050. One of the problems in the treatment of geriatric patients is the potential inappropriate medications (PIMs). The Beers criteria can be used to evaluate the prevalence of PIMs. This study aims to evaluate the potential incidence of inappropriate medication use in inpatient geriatric patients at RSUD Arjawinangun using update Beers criteria 2019 and analyze the relationship between the amount of medication used by geriatric patients and the incidence of PIMs. This kind of research is observational research with descriptive-analytical methods conducted retrospectively using a cross-sectional study design. The results of the study showed that of 42 geriatric patients aged >65 years, PIMs were found in 26 patients (59.09%) with a total of 44 PIMs. The incidence of PIMs, or medications that need to be avoided in general for geriatric patients were found in 54.55% of cases, drugs can still be used but with special attention, namely 43.18%, and drug interactions that must be avoided in geriatric patients. Hypertension drugs such as Amlodipine and the diuretic drug Furosemide are the most widely used, but these drugs have the potential to be inappropriate for use in geriatrics. The incidence of PIMs is correlated with the amount of medication used by geriatric patients, according to the results of the Pearson correlation analysis with a P value <0.001.

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.

All patients, especially elderly patients, those with certain pathologies, those with multimorbidity, or those who live in institutions, are exposed to polypharmacy. The prevalence of polypharmacy is high (18-30%) and the prevalence of excessive polypharmacy (10+ drugs) is 12%. Polypharmacy affects between 40% and 50% of all older adults. The incidence rate of polypharmacy is 20% person-years, ranging from 17% in individuals aged 65–74 years to 33% in those aged ≥95 years. From this point of view, polypharmacy seems to be a concept of quantity or volume of prescriptions. It can lead to serious adverse events related to a wide variety of drug-drug interactions (DDIs) and adverse drug reactions (ADRs): the frequency of ADR is 6% when a patient takes two medications, 50% when he takes five and almost 100% when he takes eight or more medications. Of every 100 courses of drug treatment, there are 20 adverse drug ADRs, between 5 and 25 of clinically observable DDIs and between 15 and 50 potential DDIs, which arrive to 100 in geriatric patients. But on the other hand, low-quality pharmacological care reports are not uncommon. About 60% of patients may be exposed to at least one potentially inappropriate medication: benzodiazepines, psychotropics, proton pump inhibitors, analgesics (including opiates), laxatives, NSAIDs, antacids, etc. Adverse health outcomes related to inappropriate medications for the population, and especially the elderly, include falls, strokes, delirium and death. The quantity of drugs as a defining concept of polypharmacy implies poor quality. The more drugs that are prescribed to a patient, not only there are more possibilities of inappropriate prescriptions or of little value, but even suitable prescriptions tend to lose their indication, and from a certain level of quantity or volume of prescriptions, the increase IDDs and ADRs makes their value decrease in such prescriptions, and they begin to be inappropriate and give rise to poor quality. In other words, there is no adequate and valuable polypharmacy; the high quantity originates low quality.

Polypharmacy can result in drug-drug interactions, severe side-effects, drug-disease interactions, inappropriate medication use in the elderly, and escalating costs. This study aims to evaluate nursing home residents' medication regimens using a rational drug use web assistant developed by researchers to mitigate unnecessary medication usage. This analytical, cross-sectional study included data from nursing home residents recently recorded in a training family health center. Sociodemographic information, medical conditions, and prescribed medications of all patients in the nursing home (n = 99) were documented. Medications were assessed using an artificial intelligence-aided rational drug use web assistant. Instances of inappropriate drug use and calculations of contraindicated drug costs were also recorded. The study revealed that 88.9% (n = 88) of patients experienced polypharmacy, with a mean value of 6.96 ± 2.94 drugs per patient. Potential risky drug-drug interactions were present in 89.9% (n = 89) of patients, contraindicated drug-drug interactions in 20.2% (n = 20), and potentially inappropriate drug use in 86.9% (n = 86). Plans to discontinue 83 medications were estimated to reduce total direct medication costs by 9.1% per month. After the assessment with the rational drug use web assistant, the number of drugs that patients needed to use and polypharmacy decreased significantly. This study concludes that the rational drug use web assistant application, which is more cost-effective than the traditional manual method, assisted by artificial intelligence, and integrated into healthcare services, may offer substantial benefits to family physicians and their geriatric patients.

Background:Geriatric psychiatry has yet to receive its due recognition in India. There is increasing evidence of a rise in morbidity, mortality, hospitalization, and loss of functional status related to common mental disorders in the elderly patients. Collaborative care approach, including a clinical pharmacist, is one of the possible approaches to cope with geriatric patients with psychiatric patients.Objective:The study aimed to assess the impact of pharmacotherapy management of geriatric patients in collaboration with pharmacist and psychiatrist.Materials and Methods:A prospective interventional study was conducted in the psychiatry outpatient department of a tertiary care hospital in Mysore over 6 months. Geriatric patients who were newly diagnosed with depression, bipolar affective disorder (BPAD) and alcohol dependency syndrome (ADS) were included in this study. The clinical pharmacist scrutinized the patients for their participation in the study. Included patients were followed up on monthly basis for up to 4 months. Pharmacotherapy management was provided to the enrolled patients. Interventions provided were discussed with the psychiatrist. Descriptive analysis was performed for categorical variables.Results:A total of 84 geriatric patients were enrolled in the study. Majority of the enrolled patients were female (n = 46, 54.7%). Nearly half of the patients were illiterate (n = 40, 47.6%) and unemployed (n = 38, 45.2%). Among the enrolled patients, half of the study participants were diagnosed with depression (63.09%) followed by BPAD (27.38%), Schizophrenia (7.14%), and ADS (2.38%). A total of 155 medication information services were provided to 84 patients including patient counseling (n = 84, 100%), pharmacist interventions (n = 48, 30.96%) and medication information (n = 23, 14.83%). Most of the interventions were adverse drug reactions followed by drug-drug interactions, failure to receive drugs, untreated indication, subtherapeutic dose, drug use without indication, and overdose. Majority of the interventions (n = 46, 95.8%) provided were accepted by the psychiatrist.Conclusion:The study findings indicate that pharmacotherapy management services provided by the clinical pharmacist in collaboration with the psychiatrist benefited the geriatric psychiatric patients.

Background: Pharmacotherapy in elderly patients has become a major concern due to their physiological changes, pharmacokinetic and pharmacodynamics variations and poly-pharmacy. In considering the global trend in population aging, we aim to evaluate the effect of “Beers Criteria” education on prescribing medications for elderly patients by General Practitioners (GPs). Methods: Thirty GPs with the highest number of prescriptions were included in this pilot study. All prescriptions written over a three-month period were considered, then prescriptions for geriatric patients were selected and evaluated. The GPs were trained using pamphlets and booklets which were prepared based on Beers 2015 explicit criteria. In order to evaluate the effect of education, appropriateness of prescriptions was analyzed before and 1 month following training. Results: Of 15,447 prescriptions selected during the first step, 1,281 prescriptions were related to geriatric patients in which the prevalence of inappropriate drug prescriptions was 37.3%. The most inappropriate medications identified were Bisacodyl, Alprazolam, and Hyoscyamine. While in the second step 1,055 of 15,154 prescriptions concerned the elderly and inappropriate drug prescription rate was noted as 23.6%. The most common inappropriate medications included Alprazolam, Amitriptyline, and Hyoscyamine. Based on our results, the prevalence of prescribing potentially inappropriate medications (PIMs) for elderly patients is high among GPs and educational interventions that raise awareness about “Beers Criteria” significantly reduce the prescribing PIMs. Conclusion: Given the importance of GP training programs in reducing inappropriate prescription rates among geriatric patients, it will be necessary for the National Committee of Rational Use of Drugs (NCRUD) to consider undertaking comprehensive educational strategies for reducing the prevalence of inappropriate medication use in elderly people.

Geriatric (elderly) patients generally require a number of drugs (polypharmacy) to cure health-related conditions that tend to occur Potentially Inappropriate Medication (PIM). Identification of PIM is very important to prevent Drug Related Problems (DRP). The purpose of the study was to identify the incidence of PIM using the Beers Criteria and STOPP Criteria and analyze the relationship between PIM risk factors and the incidence of PIM in geriatric patients at Wangaya Hospital, Denpasar City. This type of research is retrospective observational in a cross-sectional manner using simple random sampling techniques on all geriatric patients for the period 2023. Samples that met the inclusion criteria, namely geriatric patients aged ≥65 years in outpatient and inpatient facilities with geriatric patients who died and who were referred to other hospitals, were excluded from this study. Of the 354 samples, the prevalence of PIM in outpatient care was (4.23%) with the most common drugs being spironolactone (55.84%), Sulfonylureas (19.48%), and NSAIDs (6.49%) with Beers criteria. In hospitalization, (0.84%) with NSAIDs (25%), corticosteroids (25%), clopidogrel (25%), and antipsychotics (25%) with STOPP criteria. Based on the evaluation results, there was a very weak correlation between the number of drugs (p=0.000; r=0.199) and there was no relationship between the number of diagnoses (p=0.674) prescribed and the incidence of PIM. Based on this, it can be concluded that the greater the number of diseases and the number of drugs can increase the risk of PIM.

Proton Pump Inhibitors and Dementia

Background: Polypharmacy is common and increasing among geriatric patients. Polypharmacy has been strongly associated with drug-drug interactions (DDIs). Polypharmacy and DDIs represent potential health hazards for the elderly. Aim and Objective: This study aims to analyze the polypharmacy and associated potential DDIs (pDDIs) among geriatric patients. Materials and Methods: A total of 484 geriatric (age ≥65 years) patients, who have fulfilled the selection criteria, were included in the study. Polypharmacy was assessed from prescriptions. pDDI was assessed using computer-based checks online available on the internet. Results: A total of 111 patients (22.93%) were prescribed ≥6 drugs simultaneously – polypharmacy. Six patients were prescribed ≥10 drugs (hyperpolypharmacy) simultaneously. A total of 191 (39.46%) prescriptions have at least one pDDI – 98 (20.24%) prescriptions, 63 (13.02%) prescriptions, and 30 (6.20%) prescriptions have 1–2 pDDI, 3–5 pDDI, and ≥6 pDDI, respectively, with total pDDIs were 578. The statistically significant association has been found between the polypharmacy and pDDI (