Potentially Inappropriate Prescribing Among Older Adults in Slovakia: A Population-Based Study of Pre-Pandemic Trends

Potentially inappropriate medication (PIM) exposes patients to an increased risk of adverse outcomes. Many lists of explicit criteria provide guidance on identifying PIM and recommend alternative prescribing, but the complexity of available lists limits their applicability and the amount of data available on PIM prescribing. To determine PIM prevalence and the most frequently prescribed PIMs according to 6 well-known PIM lists and to develop a best practice synthesis for clinicians. This cross-sectional study used anonymized electronic health record data of Swiss primary care patients aged 65 years or older with drug prescriptions from January 1, 2020, to December 31, 2021, extracted from a large primary care database in Switzerland, the FIRE project. Data analyses took place from October 2022 to September 2023. PIM prescription according to PIM criteria operationalized for use with FIRE data. The primary outcomes were PIM prevalence (percentage of patients with 1 or more PIMs) and PIM frequency (percentage of prescriptions identified as PIMs) according to the individual PIM lists and a combination of all 6 lists. The PIM lists used were the American 2019 Updated Beers criteria, the French list by Laroche et al, the Norwegian General Practice Norwegian (NORGEP) criteria, the German PRISCUS list, the Austrian list by Mann et al, and the EU(7) consensus list of 7 European countries. This study included 115 867 patients 65 years or older (mean [SD] age, 76.0 [7.9] years; 55.8% female) with 1 211 227 prescriptions. Among all patients, 86 715 (74.8%) were aged 70 years or older, and 60 670 (52.4%) were aged 75 years or older. PIM prevalence among patients 65 years or older was 31.5% (according to Beers 2019), 15.4% (Laroche), 16.1% (NORGEP), 12.7% (PRISCUS), 31.2% (Mann), 37.1% (EU[7]), and 52.3% (combined list). PIM prevalence increased with age according to every PIM list (eg, according to Beers 2019, from 31.5% at age 65 years or older to 37.4% for those 75 years or older, and when the lists were combined, PIM prevalence increased from 52.3% to 56.7% in those 2 age groups, respectively). PIM frequency was 10.3% (Beers 2019), 3.9% (Laroche), 4.3% (NORGEP), 2.4% (PRISCUS), 6.7% (Mann), 9.7% (EU[7]), and 19.3% (combined list). According to the combined list, the 5 most frequently prescribed PIMs were pantoprazole (9.3% of all PIMs prescribed), ibuprofen (6.9%), diclofenac (6.3%), zolpidem (4.5%), and lorazepam (3.7%). Almost two-thirds (63.5%) of all PIM prescriptions belonged to 5 drug classes: analgesics (26.9% of all PIMs prescribed), proton pump inhibitors (12.1%), benzodiazepines and benzodiazepine-like drugs (11.2%), antidepressants (7.0%), and neuroleptics (6.3%). In this cross-sectional study of adults aged 65 or older, PIM prevalence was high, varied considerably depending on the criteria applied, and increased consistently with age. However, only few drug classes accounted for the majority of all prescriptions that were PIM according to any of the 6 PIM lists, and by considering this manageable number of drug classes, clinicians could essentially comply with all 6 PIM lists. These results raise awareness of the most common PIMs and emphasize the need for careful consideration of their risks and benefits and targeted deprescribing.

BackgroundThe use of potentially inappropriate medication (PIM) in population of older adults may result in adverse drug events (ADE) already after short term exposure, especially when it is prescribed to patients with chronic kidney disease (CKD). In order to limit ADE in the treatment of older adults PIM lists have been constructed as a source of information for healthcare professionals. The aim of this study was to estimate the utilization of PIM and incidence of ADE in older adults (≥70 years) with CKD.MethodsWe conducted a retrospective population-wide cohort study including patients from Lower Austria who were 70 years or older and diagnosed with CKD in the period from 2008 to 2011. Utilization of PIM was estimated from prescriptions filled by target population. We estimated risks of hospitalization due to ADE within 30 days after incident PIM prescription and compared them to a PIM-free control group by using marginal structural models (MSM).ResultsWe identified 11,547 patients (women: 50.6%, median age in 2008: 78 years) who fulfilled the inclusion criteria. In total 24.7 and 8.1% of all prescriptions from that period contained a medication with a substance listed in the EU (7)-PIM and AT-PIM list, respectively. Proton pump inhibitors and Ginkgo biloba were the most often prescribed PIMs in this population. 94.6 and 79.3% patients filled at least one EU(7)-PIM and AT-PIM prescription, respectively. Despite the relatively high utilization of PIM there was only a low incidence of clinically relevant ADE. No event type exceeded the threshold level of 1% in the analysis of risks of ADE after filling a prescription for PIM. Nevertheless, MSM analysis showed an increased risk for 11 drugs and reduced risk for 4 drugs.ConclusionsPIM prescription was common among older adults with CKD, however, only a small number of these drugs eventually led to hospitalization due to ADE within 30 days after incident PIM was filled. In the absence of a clinically important PIM-related increase in risk, an assessment of potential ADE severity to a PIM list by using a warning score system seems prudent.

Background:The European Union (EU)(7)-PIM (potentially inappropriate medication) list presents the most comprehensive and up-to-date tool for evaluation of PIM prescribing in Europe; however, several country-specific studies have documented lower specificity of this list on pharmaceutical markets of some countries. The aim of our study was to describe approval rates and marketing of PIMs stated by EU(7)-PIM criteria in six EU countries [in comparison with the American Geriatric Society (AGS) Beers 2015 criteria].Methods:Research teams of six EU countries (Czech Republic, Spain, Portugal, Serbia, Hungary and Turkey) participated in this study conducted by WG1b EU COST Action IS1402 group in the period October 2015–November 2018. Data on approval rates of PIMs and their availability on pharmaceutical markets have been obtained from databases of national drug-regulatory institutes and up-to-date drug compendia. The EU(7)-PIM list and AGS Beers 2015 Criteria (Section 1) were applied.Results:PIMs from EU(7)-PIM list were approved for clinical use more often than those from the AGS Beers 2015 criteria (Section 1). Approval rates for EU(7)-PIMs ranged from 42.8% in Serbia to 71.4% in Spain (for AGS criteria only from 36.4% to 65.1%, respectively). Higher percentages of approved PIMs were documented in Spain (71.4%), Portugal (67.1%) and Turkey (67.5%), lower in Hungary (55.5%), Czech Republic (50.2%) and Serbia (42.8%). The majority of approved PIMs were also currently marketed in all countries except in Turkey (19.8–21.7% not marketed PIMs) and less than 20% of PIMs were available as over-the-counter medications (except in Turkey, 46.4–48.1%).Conclusions:The EU(7)-PIM list was created for utilization in European studies; however, applicability of this list is still limited in some countries, particularly in Eastern and Central Europe. The EU project EUROAGEISM H2020 (2017–2021) that focuses on PIM prescribing and regulatory measures in Central and Eastern European countries must consider these limits.

Inappropriate prescribing puts older adults (≥65 years) at risk for adverse drug reactions [1]. Recently, a European list of potentially inappropriate medications (PIMs) was developed, the EU(7)-PIM list [2]. Experts from the seven participating countries (EE, NL, FI, ES, FR, SE, DE) screened their medication market for PIMs, using existing lists of explicit criteria [1, 3–5]. The experts developed the EU(7)-PIM list using a two-round Delphi panel. See Annex 1 for more details on the development and content. Our first aim was to check the Belgian market on the availability of potentially inappropriate medications as listed in the EU(7)-PIM list. Second, we studied the actual use of PIM products in a cohort of oldest old (≥80 years). To check the availability, we cross-referenced the official register of medications in Belgium (coded in Anatomical Therapeutic Chemical (ATC)) to the EU(7)-PIM list. Of the 275 active substances in the EU(7)-PIM list, 157 were available in Belgium. Of those, 139 products were only available on prescription. The seven medication classes in the EU(7)PIM list contain a total of 60 active substances in the ATC classification, of which 21 were available in Belgium (three antacid combinations and complexes, five proton-pump inhibitors, two iron supplements, four estrogens, and seven triptanes). The medication classes of antacids containing aluminium compounds, and quinine and derivates, were not available in Belgium as registered medications. To check the actual use of PIM products, we used the Belfrail-MED cohort of 503 Belgian community-dwelling oldest old (≥80 years, range 80–102 years) [6, 7]. See Annex 2 for more background on the Belfrail-Med cohort. For this, all prescribed, chronic medications with systemic action in this population were recorded, coded into ATC, and crossreferenced to the EU(7)-PIM list. In the oldest old, the mean number of medications was 5.4 (range 0–16). Of the possible 157 PIM products in Belgium, 77 were identified in this cohort. All five available medication classes were identified as well. In this cohort, 72.8 % of patients took at least one PIM product. Lorazepam was the most prescribed PIM product (10.7 % of patients) and proton pump inhibitors the most prescribed medication class (17.3 % of patients). See Annex 3 for background on the PIMs identified in Belgium. While scanning the Belgian medication market, we identified a few other potentially inappropriate medications, not considered in the EU(7)-PIM list, because possibly not available in the participating countries. See Annex 4 for possible additions to the EU(7)-PIM list. Also, PIM products available in combination products should be discussed. For instance, loperamide (A07DA03) is listed as a PIM product, but the combination of loperamide in the same dose with simethicone (A07DA53) is not. For the Belgian situation, there are 61 combinations containing a PIM product (see Annex 3). We encourage other European countries, not (yet) participating in the EU(7)-PIM list, to repeat this exercise to gain insights in remaining overlaps or gaps of PIMs available in each national medication market. We urge the authors of the EU(7)-PIM list to (1) explicitly list all active substances in the medication classes and (2) to address the problem of combinations containing PIMs. Also, (3) a procedure must be Electronic supplementary material The online version of this article (doi:10.1007/s00228-015-1947-3) contains supplementary material, which is available to authorized users.

Using two tools to identify Potentially Inappropriate Medications (PIM) in elderly patients in Southern Chile

Objective To understand the situation and influencing factors of potentially inappropriate medication(PIM) in elderly patients in outpatient and emergency departments in China. Methods Prescriptions for patients aged ≥65 years with complete prescribing information from 79 hospitals in six cities including Beijing, Shanghai, Guangzhou, Tianjin, Hangzhou and Chengdu from February 1st, 2014 to December 31st, 2014 were collected. All prescriptions for elderly patients of 10 working days in each quarter were collected and the basic information (including region, hospital grade, gender, age, department, and major disease/disease status) and medication information (including drug name, drug specification, drug dosage form, drug dose, and the number of combined drugs) were recorded. The situation and influencing factors of PIM in elderly patients based on the Chinese PIM list and 2012 Beers criteria were analyzed. Results A total of 2 962 232 prescriptions were collected, of them, 1 499 201 were for male patients and 1 463 031 ones for female patients. The ages were from 65 to 120 years and the average age was (75±7) years. The number of combined drugs were 1-15 and the average number was 2.2±1.5. According to the Chinese PIM list (Chinese list, including 72 drugs)and 2012 Beers criteria (Beers criteria, including 124 drugs and 100 of them were in the Chinese market), the detection proportion of prescriptions for elderly patients containing PIM in outpatient and emergency departments were 15.81%(468 228/2 962 232)and 9.16% (271 250/2 962 232), respectively (P<0.001); the detection proportion of PIM varieties in prescriptions were 90.28%(65/72)and 70.00% (70/100), respectively (P<0.001); the detection proportion of PIM varieties with high risks or high recommendation and high evidence levels were 85.71% (30/35) and 67.50% (27/40), respectively (P=0.065). The proportion of prescriptions with one inappropriate medication in all PIM prescriptions were 91.83%(429 977/468 228) and 92.79%(251 696/271 250), respectively. The top 10 drugs in PIM prescriptions were clopidogrel, estazolam, alprazolam, doxazosin, nicergoline, zolpidem, diclofenac, insulin, olanzapine, and warfarin according to the Chines PIM list, and estazolam, alprazolam, doxazosin, terazosin, zolpidem, diclofenac, meloxicam, olanzapine, clonazepam, and spironolactone according to 2012 Beers criteria. Multiple logistic regression analysis showed that the cities, hospital grade, gender, age, departments for treatment, the number of combined medica-tions, and disease or disease states were independent risk factors for PIM. The risks of PIM in patients with sleep disorder, depression, coronary heart disease, Alzheimer disease, prostate hyperplasia and arthritis or joint pain were higher than in patients with other diseases or disease status. Conclusions The prevalence of PIM use according to the Chinese PIM list and 2012 Beers criteria in elderly patients in outpatient and emergency departments in China were not optimistic. Risk factors of PIM use in elderly patients in China were the regional distribution, hospital grade, gender, age, the number of combined medications, department for treatment, and disease/disease status. Key words: Potentially inappropriate medication list; Elderly; China

Factors associated with the use of potentially inappropriate medications by older adults in primary health care: An analysis comparing AGS Beers, EU(7)-PIM List , and Brazilian Consensus PIM criteria.

Prescription of potentially inappropriate medication (PIM) in older adults is associated with poor clinical outcomes. The EU (7)-PIM list was created for the European market to improve pharmacotherapy in older adults.PurposeThis work aims to characterize the medication profile and assess the presence of PIM, using the EU (7)-PIM list in older adults’ residents at nursing homes.MethodsRetrospective data were collected from the anonymized nursing home records. After PIM identification, a descriptive analysis was performed, and a generalized linear model for dependent negative binomial-type variables was constructed to assess the risk of PIM.ResultsOf the 210 participants (mean age 85.10), 82.40% were polymedicated. PIM was observed in 86.4% participants (mean per patient = 2.30± 0.10). The most common PIM were proton pump inhibitors (n = 121, 57.62%), followed by anxiolytics (n = 96, 45.71%). 64.30% of all patients take 2–4 PIM and 5.80% take five or more PIM. The occurrence of PIM is influenced by the number of prescribed medicines (RR 1.14; 95% CI 1.1.-1.17) and the presence of digestive system diseases (RR 1.05; 95% CI 1.0–1.09).ConclusionThe high prevalence of PIM observations highlights the necessity of the implementation of guidelines to prevent PIM.

Systematic reviews were the perceived most important source of information for updating a potentially inappropriate medication list for the elderly: An online survey.

BackgroundThe use of potentially inappropriate medications (PIMs) are associated with negative health effects for older adults. The purpose of this study was to apply national register data to investigate the impact of hospitalisation to geriatric wards in Norway on the use of medications and PIMs, and to compare two explicit PIM identification tools.MethodsWe included 715 patients ≥65 years (mean 82.5, SD = 7.8) admitted to Norwegian geriatric wards in 2013 identified from The Norwegian Patient Registry, and collected their medication use from the Norwegian Prescription Database. Medication use before and after hospitalisation was compared and screened for PIMs applying a subset of the European Union (EU)(7)-PIM list and the Norwegian General Practice – Nursing Home (NORGEP-NH) list part A and B.ResultsThe mean number of medications increased from 6.5 (SD = 3.5) before to 7.5 (SD = 3.5) (CI:1.2–0.8, p < 0.001) after hospitalisation. The proportion of patients with PIMs increased from before to after hospitalisation according to the EU(7)-PIM list (from 62.4 to 69.2%, p < 0.001), but not according to The NORGEP-NH list (from 49.9 to 50.6%, p = 0.73). The EU(7)-PIM list and the NORGEP-NH list had more than 70% agreement on the classification of patients as PIM users.ConclusionsMedication use increased after hospitalisation to geriatric wards. We did not find that geriatric hospital care leads to a general improvement in PIM use after hospitalisation. According to a subset of the EU(7)-PIM list, PIM use increased after hospitalisation. This increase was not identified by the NORGEP-NH list part A and B. It is feasible to use health register data to investigate the impact of hospitalisation to geriatric wards on medication use and PIMs.

The aim of this study was to investigate the prevalence of potentially inappropriate medication (PIM) prescribing and its number-dependent association (PIM = 1, 2, ≥3) with all-cause hospitalizations, emergency department (ED) visits, and medication expenditures in Beijing, China. A retrospective cohort analysis was conducted to analyse PIM prescribing in community-dwelling older adults aged ≥65 years within the Beijing Municipal Medical Insurance Database (data from July to September 2016). The prevalence of PIMs was estimated based on the 2015 Beers Criteria. Logistic models were utilized to investigate the associations between PIM use and all-cause hospitalizations and ED visits. Generalized linear models with the logic link and gamma distribution were used to analyse associations between PIM use and medication expenditures. Among the 506 214 older adults, the prevalence of PIM was 38.07%. After adjusting for covariables, prescribing two and three or more PIMs was associated with increased risks of hospitalizations (PIM = 2: odds ratio [OR] 1.34, 95% confidence interval [CI]: 1.22-1.47; PIM ≥ 3: OR = 1.47, 95% CI: 1.32-1.63) and ED visits (PIM = 2: OR = 1.29, 95% CI 1.12-1.48; PIM ≥ 3: OR = 1.23, 95% CI: 1.04-1.44). Exposures to two and three or more PIMs were associated with higher medication expenditures for inpatient visits (PIM = 2: incidence rate ratio [IRR] = 1.08, 95% CI 1.01-1.16; PIM ≥ 3: IRR = 1.18, 95% CI: 1.08-1.28). Vasodilators were the most frequent PIM prescribing group among patients who were hospitalized or had to visit the ED. PIMs were prescribed at a high rate among community-dwelling older adults in Beijing. Two or more PIMs were associated with increased risks of hospitalizations, ED visits, and increased inpatient medication expenditures. Effective interventions are needed to target unnecessary and inappropriate medications in older adults.

Objective The aim of this study was to examine the prevalence of potentially inappropriate medication (PIM) use and its associated risk factors in community-dwelling older adults from five Central and Eastern European (CEE) countries. Materials and methods This secondary analysis of a cross-sectional survey, which was part of the Horizon 2020 EuroAgeism ESR7 project, was conducted between February 2019 and March 2020 in Bulgaria, Croatia, Czechia, Estonia, and Serbia. We enrolled older adults aged ≥65 years who visited community pharmacies to acquire medications. The prevalence of PIM use was determined by applying all 282 criteria from the EU(7)-PIM list. Risk and protective factors for PIM use were evaluated using multiple logistic regression. R software version 4.3.2 was used in statistical analysis. Results Most of the 2,155 participants were women (63.3%) and aged 65–74 years (64.8%). The overall PIM prevalence was 56.0% (95% confidence interval 53.8%–58.1%), ranging from 29.5% in Czechia to 70.0% in Croatia. The most commonly used PIMs were benzodiazepines (16.7% of all PIMs), followed by nonsteroidal anti-inflammatory drugs (14.3%), and proton pump inhibitors taken for more than 8 weeks (14.1%). Multiple logistic regression revealed that residence, increasing comorbidity burden, and polypharmacy were significant risk factors associated with PIM use in older adults. Conclusions Our findings demonstrate a high prevalence of PIM use among older patients from CEE countries and considerable cross-country differences, underscoring the need to improve medication prescribing for older adults to improve healthcare quality and patient outcomes.

Objective: The primary aim of this study was to evaluate, for the first time, the use of the EU-7 PIM List in identifying potentially inappropriate medications among older patients. Researchers have firmly established the connection between drug-related problems, which include increased morbidity and mortality rates and the heightened utilization of healthcare services. While previous studies have focused on methodologies for identifying potentially inappropriate medications in Bulgaria, further research is warranted to explore the applicability of the widely recognized EU(7)- PIM List. Materials and methods: A prospective review was conducted on patient prescriptions aligned with the National Health and Insurance Fund, explicitly focusing on patients aged over 65 years from a single pharmacy in Veliko Turnovo City, Bulgaria. The review spanned from November 2022 to April 2023. The prescriptions analyzed in this study exclusively comprised medications covered by the insurance fund. The pharmacy manager provided patient prescription data in a coded form, which included information on the patients’ age, corresponding medications, and accompanying ICD codes. Results: The study analyzed a sample of 255 patients. Healthcare providers prescribed 2,623 medications, and 61.96% of the patients had polypharmacy, taking more than five medications daily. Among the study population, 67% with polypharmacy had at least one PIM based on the EU (7)-PIM List criteria. In total, 173 potentially inappropriate medications (PIMs) were identified. The main PIMs were categorized into four groups: alimentary tract and metabolism, blood and blood-forming organs, cardiovascular system (CVS), and nervous system. Most PIMs (75.72%) were in the ATC cardiovascular system. Within the CVS category, 11 PIMs were associated with digoxin intake and 11 with antiarrhythmics such as propafenone, flecainide, and amiodarone. In addition, trimetazidine was linked to 9 PIMs, and centrally acting antiadrenergic agents had 22 PIMs, with moxonidine being the most prevalent (n=16). Peripherally acting agents were linked to 22 PIMs, primarily doxazosin. The study identified 24 PIMs related to diuretics, specifically spironolactone, and 18 PIMs related to selective calcium channel blockers such as verapamil. The antithrombotic agent category had the highest share, with 30 identified PIMs, including acenocoumarol, dabigatran, rivaroxaban, and apixaban. Furthermore, the examination of ICD codes confirmed that most PIMs occurred within CVS, with patients having ICD I11.0 and ICD I11.9 being associated with 40 and 47 PIMs, respectively. Conclusion: This study highlights many PIMs among patients with cardiovascular diseases. Using the EU (7)-PIM List as a pilot study demonstrates its effectiveness in managing adult patients’ conditions. Given the significant role of PIMs in deprescribing strategies for older patients with polypharmacy, there is a need for prescribers, educators, and drug regulatory institutions to show increased interest in regulatory measures and specific aspects related to PIM use. This is important because the demographic trend of population ageing continues, and organizations increasingly focus on the elderly population.

Potentially inappropriate medications (PIM) and resulting adverse health outcomes in older adults are a common occurrence. However, PIM prescriptions are still frequent for vulnerable older adults. Here, we sought to estimate the risk of hospitalization and emergency department (ED) visits associated with PIM prescriptions over different exposure periods and PIM drug categories. We used the National Health Insurance Service-Elderly Cohort Database (NHIS-ECDB) to construct the cohort and implemented a Self-Controlled Case Series (SCCS) method. Hospitalization or ED visits during the exposure and post-exposure periods were compared to those during the non-exposure period, and six PIM drug categories were evaluated. A conditional Poisson regression model was applied, and the risk of outcomes was presented as the incidence rate ratio (IRR). All potential time-varying covariates were adjusted by year. A total of 43,942 older adults aged ≥65 y who had at least one PIM prescription and the events of either hospitalization or ED visits between Jan 2016 and Dec 2019 were selected.. Mean days of each exposure period was 46 d (±123); risk was highest in exposure1 (1-7 d, 37.8%), whereas it was similar during exposure2 (15-28 d), and exposure3 (29-56 d) (16.6%). The mean number of total PIM drugs administered during the study period was 7.34 (±4.60). Both hospitalization and ED visits were significantly higher in both exposure (adjusted IRR 2.14, 95% Confidence Interval (CI):2.11-2.17) and post-exposure periods (adjusted IRR 1.41, 95% CI:1.38-1.44) in comparison to non-exposure period. The risk of adverse health outcomes was highest during the first exposure period (1-14 d), but decreased gradually over time. Among the PIM categories, pain medication was used the most, followed by anticholinergics. All PIM categories significantly increased the risk of hospitalization and ED visits, ranging from 1.18 (other PIM) to 2.85 (pain medication). Sensitivity analyses using the first incidence of PIM exposure demonstrated similar results. All PIM categories significantly increased the risk of hospitalization and ED visits, with the initial period of PIM prescriptions showing the highest risk. In subgroup analysis stratified by the number of medications, PIM effects on the risk of hospitalization and ED visits remained significant but gradually attenuated by the increased number of medications. Therefore, the development of deprescribing strategies to control PIM and polypharmacy collectively is urgent and essential.

Background and importanceThe population aged ≥65 years suffers multimorbidity associated with increasing use of potentially inappropriate medications (PIM). MultiCare, a longitudinal cohort study, collected data (eg, socioeconomic status, morbidities, drugs...