Trends in prescriptions and factors associated with discontinuation of potentially inappropriate medications in elderly patients with advanced cancer at the end of life: A retrospective cohort study

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

Background and Aim: Polypharmacy and potentially inappropriate medication (PIM) use in older populations (65+ years) have not yet been investigated by meta-analyses in developing countries. This systematic literature review and meta-analysis aimed to investigate the prevalence of polypharmacy and PIM use and major risk factors associated with PIM prescribing in older adults in Ethiopia. Methods: We searched PubMed/MEDLINE, Scopus, Embase, and Google Scholar databases to identify relevant studies published between January 1990 and October 2020. Observational studies reporting the prevalence and association of risk factors with polypharmacy and PIM use in the older population were meta-analyzed. A multilevel meta-analysis was conducted to pool the prevalence estimates, and the risk of PIM use was reported as a relative risk (RR) with a 95% confidence interval (CI). Results: We identified by systematic literature review 404 articles. Of those, 8 studies fulfilled inclusion criteria, comprising a total sample of 2,608 participants. The overall prevalence of polypharmacy and PIM use pooled by meta-analysis in the Ethiopian older population was 33 and 37%, respectively. The risk factors of PIM use were analyzed in the meta-analysis (particularly polymorbidity, polypharmacy, gender, and older age), and only older age of 65+ (RR: 1.71, 95% CI: 1.16–2.51) was significantly associated with PIM use. Conclusion: This first meta-analysis from a developing country revealed a high prevalence of polypharmacy and PIM use in the Ethiopian older population. There was no awareness about the risk of PIMs in patients with polypharmacy and polymorbidity, and older age significantly predicted PIM use. Interventions ensuring rational geriatric pharmacotherapy are essential in developing countries in order to reduce the expected burden of PIM-related geriatric morbidity, higher costs, and mortality.

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

Prevalence of potentially inappropriate medication in hospitalized elderly patients by using explicit criteria

To examine the association between potentially inappropriate medications (PIMs) use and the hospitalization rate in elderly Thai patients. In this retrospective cohort study, we collected the electronic medical data of elderly patients aged 60years and older who visited the outpatient department (OPD) at Thammasat University Hospital in Thailand in 2015. The patients were categorized into PIM and non-PIM users according to the Beers 2019 criteria. We calculated descriptive statistics for demographic variables. We also examined the association between PIM use and various different factors with hospitalization rate during follow-up using log-binomial regression. We calculated the relative risk for association between PIM use and other factors with the hospitalization rate. We collected data for a total of 32,261 patients. The majority of participants were female (59.65%) and had a mean age of 70.21years (SD = 7.88). Overall, 63.98% of the patients (n = 20,641) were PIM users and 49.45% (n = 15,952) received polypharmacy (≥ 5 medications). The most common PIM prescription was proton-pump inhibitors, which were 27.51% of all medications prescribed. We found that PIM use increased the risk of hospitalization by 1.31 times (adjusted RR = 1.31, 95% CI: 1.21-1.41, p-value < 0.001). Other factors associated with a higher rate of hospitalizations included older age, male gender, polypharmacy, and a higher number of OPD visits. PIMs were commonly prescribed to the elderly in the OPD, and were significantly associated with subsequent hospitalization. The provision of an alternative drug list can help physicians avoid prescribing PIMs to the elderly. If PIMs prescription is unavoidable, physicians should closely monitor patients for drug-related problems and deprescribe PIMs when they are no longer indicated.

BackgroundSeveral classifications to identify and avoid use of potentially inappropriate medications (PIMs) in the elderly have been published. To what extent these classifications match each other and whether there are differences in the prevalence of PIM use at admission, during the inpatient stay and at discharge are largely unreported.ObjectivesTo determine the PIM prevalence in elderly patients at a university hospital, with a special focus on different classification systems and the chronological sequence, and to examine a possible association between PIM use and the reason for admission, as well as severe side effects and consequences of PIM use during hospitalization.MethodsOn the basis of the criteria provided by FORTA (Fit for the Aged), PRISCUS (Latin for ‘time-honoured’) and STOPP (Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions), medication in patients over the age of 65 years was screened retrospectively within four point prevalence analyses at admission, during the inpatient stay and at discharge. Evaluation of a possible association between PIM use and the primary diagnosis or severe side effects during hospitalization was performed according to an analysis using the World Health Organization Uppsala Monitoring Centre system for standardized case causality assessment.ResultsOf 200 patients, 176 (88 %) received at least one PIM at admission, during the inpatient stay and/or at discharge (116 patients according to FORTA, 113 according to PRISCUS and 138 according to STOPP). When the PIM prevalence was compared between the three different sets of criteria, STOPP identified significantly more patients receiving PIMs than FORTA (P = 0.022) and PRISCUS (P = 0.010). At the patient level and at the drug level, the use of PIMs increased during the inpatient stay; however, the PIM prevalence was similar at admission and at discharge, both at the patient level and at the drug level.ConclusionMedication is rated significantly differently by FORTA, PRISCUS and STOPP. In addition, a significant rise in prescribing of PIMs during the inpatient stay illustrates that a reduction in PIM use during the inpatient stay is essential, as it is known that avoiding PIM use in older adults is one strategy to decrease the risk of adverse events.Electronic supplementary materialThe online version of this article (doi:10.1007/s40801-016-0085-2) contains supplementary material, which is available to authorized users.

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.

Potentially inappropriate medications (PIMs) are prevalent in older adults with dementia and subsequent falls or fall-related injuries. The present study determined the risk of falls or fall-related injuries associated with PIM use in older adults with dementia. The National Health Insurance Service-Elderly Cohort Database 2.0 (NHIS-ECDB2.0) was used for this self-controlled case series (SCCS) study. This study included 1430 participants who went through exposure and non-exposure periods of PIM application among patients with dementia and experienced outcome events of falls or fall-related injuries between January 2016 and December 2019. The incidence of falls or fall-related injuries during the exposure and post-exposure periods was compared with that during the non-exposure period. Beers Criteria were used to define PIMs in patients with dementia. Negative binomial regression was conducted. The incidence rate ratio (IRR) was used to determine the risk of falls or fall-related injuries. During the exposure periods in which falls or fall-related injuries occurred, the mean number of PIMs among patients with dementia was 3.76 (SD = 2.99), and the most commonly used PIMs among patients with dementia were first-generation antihistamines (n = 283; 59.1%). Compared to the non-exposure period, the adjusted IRR during the exposure period was 1.57 (95% CI = 1.39-1.76). The risk of falls or fall-related injuries was increased when PIM use in patients with dementia was initiated (1-14days: IRR = 2.76, 95% CI = 2.31-3.28; 15-28days: IRR = 1.95, 95% CI = 1.48-2.56; ≥ 29days: IRR = 1.17, 95% CI = 1.01-1.35). Especially, an increased risk of falls or fall-related injuries was associated with greater PIM use among patients with dementia. Among older adults with dementia, PIMs significantly increase the risk of falls and fall-related injuries. Therefore, strategies should be developed to manage PIM prescriptions in patients with dementia to prevent falls.

Potentially inappropriate medication (PIM) is suggested to give rise to adverse drug events. To study this suggestion for elderly psychiatric patients, an observational analysis related prescription of PRISCUS PIMs and drug-induced side effects in old aged (≥65 years) psychiatric inpatients and outpatients under conditions of everyday pharmacotherapy. Request forms from a therapeutic drug monitoring (TDM) survey and medical files were screened for medication to identify PIMs of the PRISCUS list and assessed using the Udvalg for Kliniske Undersøgelser (UKU) side effect rating scale. From 914 TDM request forms, data were available for 168 patients (64.3 % female). Patients (mean ± SD age 73.0 ± 5.5 years) received by mean 6.4 ± 3.9 drugs per day. More than half of them (53.0 %, n = 89) had at least one PIM, inpatients 0.9 ± 0.8 and outpatients 0.5 ± 0.7. Predominant PIMs were hypnotic drugs (69 %) in inpatients and antipsychotic drugs (35.6 %) in outpatients. The number of PIMs correlated with the total number of drugs administered per day (Spearman correlation coefficient 0.225, p < 0.01, CI 95 %). Side effects were documented for 106 patients (63 %). Severity of side effects did not correlate significantly (p > 0.05) with number of PIMs. However, only 6 of 77 patients who took no PRISCUS PIMs but 2 of 3 patients who took 3 PRISCUS PIMs exhibited severe side effects. Though the prevalence for PIMs and side effects was high in old aged psychiatric inpatients and outpatients, PIMs could not be identified as major determinants of overall unwanted side effects. Nevertheless, prescription of PIMs should be minimized, especially of hypnotic drugs, to improve safety.

Older adults initiating dialysis have a high risk of mortality and that risk may be related to potentially inappropriate medications (PIMs). Our objective was to identify and validate mortality risk associated with American Geriatrics Society Beers Criteria PIM classes and concomitant PIM use. We used US Renal Data System data to establish a cohort of adults aged ≥ 65years initiating dialysis (2013-2014) and had no PIM prescriptions in the 6months prior to dialysis initiation. In a development cohort (40% sample), adjusted Cox proportional hazards models were performed to determine which of 30 PIM classes were associated with mortality (or "high-risk" PIMs). Adjusted Cox models were performed to assess the association of the number of "high-risk" PIM fills/month with mortality. All models were repeated in the validation cohort (60% sample). In the development cohort (n = 15,570), only 13 of 30 PIM classes were associated with a higher mortality risk. Compared with those with no "high-risk" PIM fills/month, patients having one "high-risk" PIM fill/month had a 1.29-fold (95% confidence interval 1.21-1.38) increased risk of death; those with two or more "high-risk" PIM fills/month had a 1.40-fold (95% confidence interval 1.24-1.58) increased risk. These findings were similar in the validation cohort (n = 23,569). Only a minority of Beers Criteria PIM classes may be associated with mortality in the older dialysis population; however, mortality risk increases with concomitant use of "high-risk" PIMs. Additional studies are needed to confirm these associations and their underlying mechanisms.

BACKGROUND:Potentially inappropriate medications (PIMs) are a major concern in geriatric care. The primary objective of our study was to assess the prevalence of PIMs prescribed for older persons attending outpatient setting of two teaching hospitals in Kerala state in South India, where the population is aging.MATERIALS AND METHODS:A cross-sectional study was carried out in two teaching hospitals in Kerala. Four hundred consecutive outpatient medical records of patients aged 65 years and above were selected. The current medications of the patients were analyzed to identify PIMs by the Beers criteria 2015. Polypharmacy and hyperpolypharmacy were defined as 5–9 medications and ≥10 medications, respectively. Chi-square test was done to identify demographic variables and the pattern of health-care facility use associated with PIM prescription. Binary logistic regression was performed to adjust for confounding associations.RESULTS:The prevalence of PIMs prescription was 34.0% (95% confidence interval: 29.4%–38.6%) and that of polypharmacy and hyperpolypharmacy was 45.8% and 13.5%, respectively. The common PIMs were proton-pump inhibitors, benzodiazepines, peripheral α-1 blockers, and first-generation antihistamines. Inpatient admission, visits to the emergency department, multiple diagnoses, polypharmacy, and hyperpolypharmacy were associated with PIM prescription (P < 0.05). Age, gender, number of outpatient visits, and specialist consultation were not associated with PIM prescription. Polypharmacy (adjusted odds ratio [aOR] =2.11) and hyperpolypharmacy (aOR = 5.55) had independent association with PIM prescription (P < 0.05).CONCLUSION:PIM prescription appears to be common in teaching hospitals in Kerala. Polypharmacy and hyperpolypharmacy in older people should trigger a review of medication to reduce the use of PIM.

Potentially inappropriate medication (PIM) use is an important and preventable safety concern in the care of elderly patients and has been associated with adverse drug reactions, hospitalization, and mortality. Although PIM use for the elderly is a common and serious public health issue worldwide, there are few studies examining PIM use in the ambulatory care setting in Korea. To examine the prevalence and risk factors of PIM use from ambulatory care visits by elderly patients covered by National Health Insurance (NHI) in Korea, the nationwide prescription claims data of elderly patients' ambulatory care visits in 2006 were analyzed. Potentially inappropriate prescriptions were identified using extensive criteria that included Beers', Zhan's, and Canadian criteria. In 2006, 3,770,978 elderly patients received 40,995,267 prescriptions. 36.7% of the total prescriptions for elderly patients who visited ambulatory care clinics were identified as PIM use. Findings in this study indicated that the strongest risk factors for PIM prescriptions were the number of drugs prescribed and visit characteristics. Therefore, it is necessary to develop the explicit criteria of PIM prescription in Korea that can be included in the Drug Utilization Review (DUR) system, which is expected to lead to more appropriate and judicious prescribing.

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...

To assess the changes in use of potentially inappropriate medication (PIM) as defined by the 2015 Beers criteria, the EU(7)-PIM, and the PRISCUS list over a 6-year period and to identify determinants for current and future PIM use with a particular focus on geriatric syndromes. In a German cohort of 2878 community-dwelling adults aged ≥ 60years, determinants of the use of ≥ 1 PIM were identified in multivariable logistic regression (cross-sectional analysis) and weighted generalized estimating equation models (longitudinal analysis). Prevalences for Beers, EU(7), and PRISCUS PIM were 26.4, 37.4, and 13.7% at baseline and decreased to 23.1, 36.5, and 12.3%, respectively, 6years later. Unadjusted prevalences in participants with any geriatric syndrome (frailty, co-morbidity, functional, or cognitive impairment) were approximately twice as high as in robust older adults. In multivariable analyses, cognitive impairment was statistically significantly associated with the use of PIM of all three criteria in the cross-sectional (odds ratio (OR) point estimates 1.90-2.21) but not in the longitudinal models. In contrast, frailty, co-morbidity, and functional impairment were statistically significantly associated with the use of PIM of at least one of the three criteria in both models. However, the associations varied for the PIM criteria, and in the longitudinal analysis, associations were only statistically significant for Beers PIM (ORs [95% confidence intervals]: frailty (2.23 [1.15, 4.31]), co-morbidity by five total co-morbidity score points (1.21 [1.05, 1.38]), and functional impairment (1.51 [1.00, 2.27]). Other statistically significant determinants of the incidence of PIM (any definition) were female sex, age, coronary heart disease, heart failure, biomarkers of the metabolic syndrome, and history of ulcer, depressive episodes, hip fracture, or any cancer. Older adults with frailty, co-morbidity, cognitive, and functional impairment had higher odds of taking PIM or getting a PIM prescription in the future (exception: cognitive impairment). Physicians should be especially cautious when prescribing drugs for these patients who are particularly susceptible to adverse reactions.

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.