Prescribing In Elderly Patients Research Articles

Are potentially inappropriate and anticholinergic medications being prescribed for institutionalized elderly subjects?

The PAAPI project (Optimising Inappropriate Prescriptions in the Elderly) is a multi-disciplinary approach put in place by the Toulouse Pharmacovigilance Centre (CRPV) in order to improve drug prescribing practice in nursing homes. The aim of this study was to analyse the association between polypharmacy, frequency of prescriptions for potentially inappropriate medications (PIMs) and the anticholinergic burden of prescriptions in elderly patients from the PAAPI cohort. We carried out a retrospective study on residents of 24 nursing homes (EHPAD) participating in the PAAPI programme between 1er January 2017 and 31 December. Resident's Data were collected in a single review in a random day. Drug prescriptions were analysed quantitatively and qualitatively. PIMs and anticholinergic drugs were identified by the list EU(7)PIM and the Duran scale, respectively. The total anticholinergic burden was calculated by adding the anticholinergic scores of each drug. We classified the drugs into three categories: no anticholinergic burden (burden=0), low anticholinergic burden (≥1≤3) or high anticholinergic burden (burden>3). A total of 1191 residents living were included, and we analysed 8869 drug prescription lines. The average age of the residents was 87.0±8.3years, and the majority (71.5%) were female. Nearly half of the residents (49.6%, n=67) having a prescription with a high anticholinergic burden were taking more than 9 drugs (Fisher exact test P<0.05). All the prescriptions with more than 5 PIMs (n=23) had an anticholinergic burden>0, with the majority (65.2%, n=15) having a high anticholinergic burden (Kruskal-Wallis test, P<0.0001). In this cohort, 88% (n=539) of prescriptions with a low anticholinergic burden and 100% (n=135) of prescriptions with a high anticholinergic burden included at least one PIM. According to our study, the anticholinergic burden of prescriptions given to residents in the PAAPI cohort is associated with the prescription of PIMs and with polypharmacy. Optimizing the use of medicines remains essential in this population, given the harmful properties of these drugs. It would also be useful for the list of anticholinergic drugs to be updated as new medicines come onto the market.

Potentially harmful drug prescription in elderly patients with heart failure with reduced ejection fraction.

AimsThis study aimed to evaluate the prescription frequency of potentially harmful prescription drugs as defined in current heart failure guidelines among elderly patients with a diagnosis of heart failure with reduced ejection fraction and their association with clinical outcomes.Methods and resultsWe used the Centers for Medicare & Medicaid Services data from a nationally representative 5% sample for the years 2014–2016 to identify patients admitted to acute care hospitals with a primary diagnosis of heart failure with reduced ejection fraction. The primary exposure was filling a prescription for a potentially harmful drug. Potentially harmful drug fills were treated as a time‐dependent covariate to examine their association on readmission and mortality. A total of 8993 patients met study criteria. Potentially harmful drugs were prescribed in 1077 (11.9%) patients within 90 days of discharge from the heart failure hospitalization. Non‐steroidal anti‐inflammatory agents were the most frequently prescribed potentially harmful drug (6.7%) followed by calcium channel blockers (4.7%), thiazolidinedione (0.59%), and select antiarrhythmic (0.33%). Factors independently associated with potentially harmful drug prescription were female gender, Hispanic ethnicity, severe obesity, among others. In the multivariable Cox model, the prescription of a potentially harmful drug was associated with an increased risk of readmission (hazard ratio 1.14; 95% confidence interval 1.05–1.23, P < 0.001). Among drug subgroups, only calcium channel blockers were associated with an increased risk of readmission (hazard ratio 1.225; 95% confidence interval 1.085–1.382, P = 0.0011).ConclusionsIn elderly patients discharged with a primary diagnosis of heart failure with reduced ejection fraction on guideline‐directed medical therapy, prescription of a potentially harmful drug was frequent. Calcium channel blockers were associated with an increased risk of readmission.

Insomnia in the elderly: reported reasons and their associations with medication in general practice in Denmark

Objective: The aim of this study was to investigate reasons for insomnia symptoms and their associations with sleep medication prescription in elderly patients in general practice.Design: Over a period of 20 weekdays, general practitioners (GPs) recorded reasons and treatment for insomnia symptoms. Patient characteristics and outcomes were analysed using descriptive statistics. Logistic regression was used to analyse the associations between reasons for insomnia symptoms and prescription.Setting: General practices in the Region of Southern Denmark.Subjects: Consultations (n = 405) with patients older than 65 years presenting with insomnia symptoms.Main outcome measures: Reasons for insomnia symptoms and sleep medication prescription.Results: The most commonly reported reasons for insomnia symptoms were somatic illness (34%) and psychiatric diagnosis (29%). Having a psychiatric diagnosis or multiple reported reasons for insomnia increased the odds for prescription (odds ratio (OR) 4.60, 95% confidence interval (CI) 2.41-9.90 and OR 2.10, CI 1.03-4.28), whereas being first consultation regarding insomnia symptoms decreased the odds (OR 0.17, CI 0.10-0.30). A total of 80% received a prescription, most frequently of Z-hypnotics (49%). About half (52%) of the patients consulting their GP for the first time with insomnia symptoms received a prescription.Conclusion: Somatic and psychiatric diseases were the most commonly reported reasons for insomnia symptoms in the elderly, suggesting a high prevalence of comorbid insomnia. Regardless of reason, a majority of the consultations resulted in prescription of sleep medication with potential serious adverse effects. This indicates that there is still room for improving the management of insomnia among older adults. Key PointsAlthough insomnia is common in the elderly, little is known about its reasons and their associations with prescription patterns. The most commonly reported reasons for insomnia symptoms in the elderly are psychiatric diagnosis and somatic illness. According to guidelines, sleep medication with potential serious adverse effects is prescribed too frequently to elderly patients. An effort should be made to identify and optimally treat comorbid insomnia, which appears to be prevalent in older adults.

Potentially Inappropriate Prescriptions in Ambulatory Elderly Patients Living in Rural Areas of Romania Using STOPP/START (Version 2) Criteria.

BackgroundRational use of medications and monitoring of prescriptions in elderly patients is important to decrease the number and duration of hospitalizations, emergency medical consultations, mortality, as well as medical costs.PurposeTo identify potentially inappropriate medications (PIMs) and potential prescription omissions (PPOs), and determine their prevalence based on the Screening Tool of Older Persons’ potentially inappropriate Prescriptions (STOPP) v2 criteria and Screening Tool to Alert doctors to Right Treatment (START) v2 criteria for patients aged >65 years.MethodsThis cross-sectional study was conducted in two rural counties in Romania based on electronic prescriptions for chronic conditions (EPCCs) issued from 30 days to 90 days by a specialist or general practitioner. Collected EPCCs were evaluated by an interdisciplinary team of specialists based on 26 STOPP v2 criteria and 10 START v2 criteria.ResultsPIM prevalence was 25.80% and PPO prevalence was 41.72% for 646 EPCCs. The mean age of patients was 75 years and the mean number of drugs per EPCC was four. The most frequently identified PIMs were treatment duration (6.65%), theophylline administration (5.72%), drug indication (4.64%), cyclo-oxygenase-2 non-steroidal anti-inflammatory drugs (1.39%), and zopiclone prescription (0.77%). Statins (24.76%), beta-blockers (8.04%), and beta-2 agonist/antimuscarinic bronchodilators (5.88%) were the most frequently identified PPOs.ConclusionPPOs were more prevalent than PIMs for elderly populations living in the two rural counties in Romania we studied. Health practitioners (family physicians, specialists, and pharmacists) should focus on prophylactic and curative considerations when prescribing agents to decrease the morbidity and mortality of elderly rural Romanian patients.

Antibiotics prescription and guidelines adherence in elderly: impact of the comorbidities

BackgroundAlthough the interest of antibiotics is well known, antibiotics prescription is associated with side effect, especially in patients with multiples comorbidities. One way to reduce the incidence of side effects is to respect antibiotics prescriptions guidelines. Our objective was to investigated the factors associated with guidelines adherence in elderly patients with multiples comorbidities.MethodsFrom October 2015 to December 2016, antibiotics prescription and guidelines adherence were analyzed in two post-acute care and rehabilitation services of a 2600-bed, university-affiliated center.ResultsOne hundred and twenty-eight patients were included, fifty-nine (46%) patients had antibiotics prescription according to guidelines. In Multivariable logistic regression analysis, prescription of 2 antibiotics or more (OR = 0.168, 95% IC = 0.037–0.758, p < 0.05), 85 years of age and more (OR = 0.375, 95% IC = 0.151–0.931, p < 0.05) and the Charlson comorbidity index score (OR = 0.750, 95% IC = 0.572–0.984, p < 0.05) were negatively associated with antibiotics prescriptions according to guidelines.ConclusionsHigh comorbidity in the elderly was negatively associated with the guidelines adherence of antibiotiсs prescriptions. These criteria should be considered to optimize antibiotics prescriptions in elderly patients.

Oral anticoagulant prescribing in elderly patients above and below age 80 with atrial fibrillation .

Oral anticoagulation is efficient to prevent ischemic stroke in atrial fibrillation (AF), but in very old patients, physicians always remain cautious to use anticoagulants concerning the bleeding risk. This research aims to investigate the current situation of oral anticoagulation therapy in very old (≥ 80 years) AF patients. We carried out a cross-sectional study in an urban area in China from 2014 to 2016. Characteristics of the very old patients (age ≥80 years) and the younger patients (age < 80 years) were compared. Logistic analysis was used to estimate the association between oral anticoagulation therapy and CHA2DS2-VASc score. A total of 1,000 AF patients were enrolled; 306 were very old patients, and 694 were younger patients. In the very old group, 48.0% were women, and the average age was 84.12±3.62 years. In the younger group, 35.3% were women, and the average age was 66.92±9.02 years. CHA2DS2-VASc score was 2.8±1.7 in the younger group and 4.5±1.5 in the very old group (p< 0.001). The proportion of oral anticoagulation was low in patients with AF (31.8%) and even lower in very old patients compared to younger patients (24.5 vs. 35.0%, p=0.004). Moreover, oral anticoagulation therapy was strongly associated with CHA2DS2-VASc scores only in the younger group, but not in the very old group, which means the very old patients were not treated with oral anticoagulation according to their elevated CHA2DS2-VASc scores. Anticoagulants were underused in AF patients, particularly in very old patients. Evidence is accumulating that the very old patients could still benefit from anticoagulants so that physicians should not exclude such patients from anticoagulation only because of their older age.

Positive impact of clinical pharmacist interventions on antipsychotic use in patients on excessive polypharmacy evidenced in a retrospective cohort study

Abstract Objectives Although antipsychotic prescribing in elderly patients using polypharmacy has not been studied in well-designed clinical trials and meta-analyses, there is an urgent need to monitor prescribing practice in this population. One of the possible approaches to optimize pharmacotherapy may be the involvement of clinical pharmacists (CPs). The aim of this research was to examine whether the involvement of a CP can improve treatment guidelines adherence and change the total number of medications per patient in older patients who are treated with excessive polypharmacy that includes antipsychotics. Methods This cohort retrospective study included older patients (65 years or older) treated with at least one antipsychotic and excessive polypharmacy (10 or more medications concurrently) between 2012 and 2014 in primary care. The main outcome measures were antipsychotic treatment guidelines’ adherence and the total number of medications per patient after the CP’s interventions. Only interventions including antipsychotics were studied in detail (i.e., discontinuation, switching, initiation, dose adjustment, change of another medication because of a drug-related problem). Data on diagnoses, patient pharmacotherapy and the CP’s interventions were obtained from clinical records and medical reviews. Age and acceptance of the CP’s interventions were used as predictive factors for antipsychotic treatment guidelines’ adherence. Results Forty-nine patients were included. The CP suggested 21 different interventions of which nine (42.8%) were accepted by the general practitioners. The number of medications that patients received decreased after the CP’s interventions (N of medications before: 15.4; N of medications after: 12.0, p &lt; 0.05). The acceptance of the CP’s recommendations, but not age, improved antipsychotic treatment guidelines’ adherence (p = 0.041). Conclusions These results show that a collaborative care approach including a CP in primary care significantly improved the adherence to treatment guidelines. The results also support the implementation of this service in the Slovenian healthcare system, although more studies are needed.

Impact of an intervention program to improve potentially inappropriate prescription in hospitalized elderly patients

Introduction and objectivesPotentially inappropriate prescription (PIP) is common in elderly people. It has become a global public health problem due to its association with adverse drug effects (ADE), increased morbidity and mortality, emergency care visits and resource use. The main aim of this study was to determine whether the use of a notification program of PIP in elderly patients admitted in the hospital led to a reduction of their prescription. MethodA quasi-experimental before–after study was conducted. PIP were identified by using Beers (2012 update) and STOPP-START criteria (2008 version). An individualized report on PPI was prepared and the effect of this intervention was evaluated. Results174 patients were included who presented 284 PIP. 54% (153) of the recommendations were accepted. Barthel index was the only variable that proved to contribute to the presence of PIP modifications. The patients whose PIP drugs were modified were significantly more dependent (p=.005), presented cognitive impairment (p=.001) and were more institutionalized (p=.039) than those without any modifications. There were fewer readmissions, emergency care visits and mortality within six months after intervention comparing patients with and without PIP modifications, but without significant differences. 32 ADE were detected, 29 related with PIP drugs. Adverse events were significantly associated with PIP drugs, versus other medications (p<.001), odds ratio 242.5 (95% CI: 56.9–1023.6). ConclusionsReview of medication in elderly patients, along with the use of tools that help in the identification of dangerous drugs, entail a reduction of inadequate prescription and significantly contribute to the continuous improvement of chronic medication in elders.

Preoperative chronic beta-blocker prescription in elderly patients as a risk factor for postoperative mortality stratified by preoperative blood pressure: a cohort study

Background: Recent data suggest that beta blockers are associated with increased perioperative risk in hypertensive patients. We investigated whether beta blockers were associated with an increased risk in elderly patients with raised preoperative arterial blood pressure. MethodsWe conducted a propensity-score-matched cohort study of primary care data from the UK Clinical Practice Research Datalink (2004–13), including 84 633 patients aged 65 yr or over. Conditional logistic regression models, including factors that were significantly associated with the outcome, were constructed for 30-day mortality after elective noncardiac surgery. The effects of beta blockers (primary outcome), renin–angiotensin system (RAS) inhibitors, calcium-channel blockers, thiazides, loop diuretics, and statins were investigated at systolic and diastolic arterial pressure thresholds. ResultsBeta blockers were associated with increased odds of postoperative 30-day mortality in patients with systolic hypertension (defined as systolic BP >140 mm Hg; adjusted odds ratio [aOR]: 1.92; 95% confidence interval [CI]: 1.05–3.51). After excluding patients for whom prior data suggest benefit from perioperative beta blockade (patients with prior myocardial infarction or heart failure), rather than adjusting for them, the point estimate shifted slightly (aOR: 2.06; 95% CI: 1.09–3.89). Compared with no use, statins (aOR: 0.35; 95% CI: 0.17–0.75) and thiazides (aOR: 0.28; 95% CI: 0.10–0.78) were associated with lower mortality in patients with systolic hypertension. ConclusionsThese data suggest that the safety of perioperative beta blockers may be influenced by preoperative blood pressure thresholds. A randomised controlled trial of beta-blocker withdrawal, in select populations, is required to identify a causal relationship.

Impacto de un programa de intervención destinado a la mejora de la prescripción potencialmente inapropiada en pacientes ancianos hospitalizados

Introduction and objectivesPotentially inappropriate prescription (PIP) is common in elderly people. It has become a global public health problem due to its association with adverse drug effects (ADE), increased morbidity and mortality, emergency care visits and resource use. The main aim of this study was to determine whether the use of a notification program of PIP in elderly patients admitted in the hospital led to a reduction of their prescription. MethodA quasi-experimental before-after study was conducted. PIP were identified by using Beers (2012 update) and STOPP-START criteria (2008 version). An individualized report on PPI was prepared and the effect of this intervention was evaluated. Results174 patients were included who presented 284 PIP. 54% (153) of the recommendations were accepted. Barthel index was the only variable that proved to contribute to the presence of PIP modifications. The patients whose PIP drugs were modified were significantly more dependent (p=0.005), presented cognitive impairment (p=0.001) and were more institutionalized (p=0.039) than those without any modifications. There were fewer readmissions, emergency care visits and mortality within six months after intervention comparing patients with and without PIP modifications, but without significant differences. 32 ADE were detected, 29 related with PIP drugs. Adverse events were significantly associated with PIP drugs, versus other medications (p<0.001), odds ratio 242.5 (CI95%: 56.9-1023.6). ConclusionsReview of medication in elderly patients, along with the use of tools that help in the identification of dangerous drugs, entail a reduction of inadequate prescription and significantly contribute to the continuous improvement of chronic medication in elders.

Evaluation of a collaborative care approach between general practitioners and clinical pharmacists in primary care community settings in elderly patients on polypharmacy in Slovenia: a cohort retrospective study reveals positive evidence for implementation

BackgroundThe population of developed countries is aging, leading to an increase in the use of medication in daily practice, which can lead to serious treatment costs and irrational polypharmacy. A collaborative care approach, such as providing medication review service provided by a clinical pharmacist (CP), is a possible way to reduce drug-related problems and irrational polypharmacy. The aim of this study was to determinate whether a CP’s medication review service can improve the quality of drug prescribing in elderly patients treated with polypharmacy in primary care.MethodsIn a retrospective observational medical chart review study, patients aged 65 years or more in the period 2012–2014 who received 10 or more medications concomitantly and who were screened by a CP were included. Data on pharmacotherapy and CPs’ interventions were obtained from the patients’ medical records (non-electronic chart review). Potential drug-drug interactions (pDDIs) were determined with Lexicomp Online™ 3.0.2. Only potential X-type DDIs (pXDDIs) were included. Potentially inappropriate medications in the elderly (PIMs) were identified using the PRICUS list.ResultsNinety-one patients were included. The CPs suggested 625 interventions, of which 304 (48.6%) were accepted by the general practitioners (GPs). After adopting the CPs’ interventions, the number of total medications decreased by 11.2% (p < 0.05) and the number of pXDDIs decreased by 42% (p < 0.05). The number of clinically important pXDDIs decreased by 50% (3 cases). The number of prescribed PIMs decreased by 20% (p = 0.069). The acceptance of CP’s recommendations reduced the number of pXDDIs (p < 0.05) and improved the adherence to heart failure treatment guidelines.ConclusionsA collaborative care approach offering a CP medication review service significantly improved the quality of pharmacotherapy by reducing the total number of medications and pXDDIs. The results support the implementation of this service in the Slovenian healthcare system.

Retrospective evaluation of statin prescription in the elderly.

Statins are one of the most commonly prescribed medications in Australia. Although the cardioprotective effects of statins are well documented, questions remain regarding their risk-benefit profile in elderly adults, especially those with limited life expectancies. To describe the prevalence and pattern of statin use in elderly patients admitted to a General Medicine Unit. We retrospectively reviewed medical records of patients aged ≥80 years who were admitted to the General Medical Unit at Monash Medical Centre between 1 January 2015 and 30 June 2015. Patients receiving statin therapy prior to admission were identified and included. Data including patient demographics, indication for statin, comorbidities, co-prescription of interacting medications, presence of muscle-related toxicity and any change to statin prescription were collected and described. Of 852 patients admitted to hospital, 359 (42%) were taking statins prior to admission. Statins were used for the secondary prevention of cardiovascular disease in 63% of patients and for primary prevention in 24%. Most patients were taking high- (16%) or medium-intensity statins (78%); 46% of patients were co-prescribed medications with the potential to increase the risk of statin toxicity. Statins were discontinued in 16% of patients; however, the majority of patients had no change to their statin prescription. Muscle-related toxicity was documented in 4% of patients. Statin use and the co-prescription of potentially interacting medications are common in elderly adults admitted to hospital. Statin prescription in elderly patients with multiple comorbidities is rarely reviewed unless directly relevant to their admission diagnosis.

Effect of a computerized decision support system on potentially inappropriate medication prescriptions for elderly patients in Thailand

The prescription of potentially inappropriate medication (PIM) is a global issue associated with increased adverse drug events, mortality, and health care expenditure. Computerized decision support system (CDSS) for the detection of PIM is a novel alert system in Thailand for reducing PIM prescriptions. The aim of this study was to evaluate the effect of a CDSS on PIM prescriptions for elderly patients in Thai community hospitals. The study design comprised two phases with a duration of 12months each: pre-CDSS implementation (October 2015-March 2016) and post-CDSS implementation (October 2016-March 2017). Medical services and prescription claims data from four hospitals were used to calculate the prevalence of PIM prescriptions among elderly patients aged 60years and older. Chi-square tests were used to analyse changes in PIM prescriptions across hospitals post CDSS. The overall prevalence of PIM prescriptions post-CDSS implementation significantly decreased from 87.7% to 74.4%. The severity of mild and moderate PIMs was significantly reduced from 71.9% to 49.0% and from 64.5% to 48.7%, respectively. All hospitals had only one severe PIM, which was hyoscine. It was reduced from 4.7% to 1.5%, but the change was not significant (P=0.74). The proportion of frequently prescribed PIMs in all PIM levels was significantly decreased, regardless of existing alternative medications. Specific CDSS for PIM in community hospital setting was associated with a reduction of PIM prescription in elderly patients. This CDSS can change physician's prescription behaviour to avoid inappropriate medications.

Evaluation of Potential Drug-Drug Interactions with Medications Prescribed to Geriatric Patients in a Tertiary Care Hospital.

Background and Objectives The drugs most commonly implicated in major potential interactions are those used in the day-to-day clinical management of elderly patients with chronic diseases. This study is planned to evaluate the profile of drug-drug interactions in the medications prescribed to elderly population and also to identify the possible predictors for potential drug-drug interactions in the elderly. Methods This cross-sectional study included patients aged above 60 years with a minimum of two drugs in the prescriptions. Data were collected from medical prescriptions and patients' medical records. The data collected included demographic characteristics such as age, gender, height, weight, educational status, socioeconomic status, medical history, and medications prescribed. The prescriptions were analyzed for the potential drug interactions using Lexi-Interact™ Online, an online software to check drug-drug interactions. Results A total of 209 patients were included in the study, among them 104 (49.8%) were males and 105 (50.2%) were females. The mean number of medications received was 6.53 ± 2.15 per prescription. Around 138 (66%) patients received more than six medications. The mean number of potential drug interactions seen in the prescription of these patients was 3.17 ± 2.78. Around 18.2% patients had more than five drug interactions. Major drug interactions were observed in 21.42% of cases. Around 3.02% of drug interactions belonged to risk category X, i.e., to be avoided. Logistic regression analysis showed that age above 70 years was associated with the presence of drug interactions. Increased number of medication was independently associated with the occurrence of drug interactions. The presence of drug interactions was not associated with increased number of comorbidities. Conclusion A significant number of potential drug-drug interactions were seen in the prescriptions of elderly patients. Increasing age and polypharmacy were identified as the predictors of potential drug interactions.

Predictors of new oral anticoagulant drug initiation as opposed to warfarin in elderly adults: a retrospective observational study in Southern Italy.

AimThe aim of this study was to assess the predictive role of age, gender, and number and type of co-treatments for new oral anticoagulant (NOAC) vs warfarin prescription in elderly patients naïve for the aforementioned drugs.Materials and methodsData collected in the period from January 1, 2014, to December 31, 2014, in Caserta Local Health Unit administrative databases (Campania Region, Italy) were screened to identify new users of oral anticoagulants (OACs) who were 75 years or older and whose OAC prescriptions amounted to >90 days of treatment. Age, gender, and number and type of concomitant medications at the time of first OAC dispensation were retrieved. Multivariable logistic regression analysis was used to assess the role of the aforementioned predictors for NOAC initiation as opposed to warfarin.ResultsOverall, 2,132 incident users of OAC were identified, of whom 967 met all inclusion criteria. In all, 490 subjects (50.7%) received an NOAC and 477 (49.3%) received warfarin. Age >75 years was positively associated with lower odds of NOAC initiation (OR: 0.969, 95% CI: 0.941–0.998, P=0.038). Similarly, multiple concomitant medication was negatively associated with NOAC initiation compared to warfarin (OR [five to nine drugs] group: 0.607, 95% CI: 0.432–0.852, P=0.004; OR [ten+ drugs] group: 0.372, 95% CI: 0.244–0.567, P<0.001). Prior exposure to platelet aggregation inhibitor drugs was associated with the initiation of NOACs (OR: 3.474, 95% CI: 2.610–4.625).ConclusionAge and multiple co-medication were negatively associated with NOAC initiation.

Case analysis of inappropriate prescription in elderly patients

老年人群用药数量多，不合理用药常见，可引起药物不良反应等严重后果。老年患者潜在不合理用药的Beers标准(Beers Criteria)是常用的药物核查工具，在识别潜在不合理用药问题、降低不合理用药引起的相关问题和治疗费用等方面发挥了积极作用。针对不合理用药的现状，采用Beers标准，分心血管系统、中枢神经系统、内分泌代谢系统、消化系统对一些常见的临床不合理用药情况结合病例进行分析，以期为临床提供合理用药参考。

Prevalence and predictors of tricyclic antidepressant use among elderly Koreans in primary-care and specialty clinics.

Tricyclic antidepressants (TCAs) are prescribed with caution in the elderly due to diverse side effects. We analyzed the patterns of TCA use in elderly patients in primary-care and specialty clinics and investigated factors influencing TCA prescriptions. Elderly patients (≥65 years old) prescribed antidepressants in primary-care clinics in 2013 were included from the Health Insurance Review and Assessment Service-Aged Patient Sample (HIRA-APS). Prevalence of TCA prescriptions was assessed by insurance coverage status, clinical specialty, and region. Multiple logistic regression analysis was performed to compute odds ratios (ORs) and 95% confidence intervals (CIs) for factors associated with TCA prescriptions. TCAs and selective serotonin reuptake inhibitors (SSRIs) comprised 45.2% and 15.0% of all antidepressant prescriptions, respectively. TCAs comprised 61.5% and 20.7% of antidepressant prescriptions for pain and depression, respectively. Patients aged ≥85 years were less likely to be treated with TCAs (OR 0.81, 95% CI 0.79-0.84) than those aged 65-69 years. The odds for being prescribed TCAs were higher for patients residing in cities (OR 1.20, 95% CI 1.18-1.23), treated in nonpsychiatric clinics (OR 5.64, 95% CI 5.53-5.76), and those covered by Veteran's Health (OR 1.62, 95% CI 1.37-1.90) when compared to patients residing in the Seoul metropolitan area, treated in psychiatric clinics, or covered by National Health Insurance, respectively. The prescriptions of TCAs with pain diagnoses were much higher than prescriptions for depression (OR 1.87, 95%CI 1.82-1.93). Compared with a 2005 report, the prevalence of TCA prescriptions in elderly patients in Korea has decreased substantially, but remains high. Various efforts should be considered to reduce TCA prescriptions in the elderly. .

Quality of direct oral anticoagulant prescribing in elderly patients with non-valvular atrial fibrillation: results from a large urban health system.

Non-valvular atrial fibrillation (NVAF) is common in older adults. Oral anticoagulation is indicated to reduce the risk of stroke and systemic embolism, but it also poses a risk of bleeding, particularly in the elderly. Direct oral anticoagulants (DOACs) provide an alternative to warfarin and their use in the treatment of AF is growing. We conducted a retrospective cohort study to assess the quality of DOAC prescribing in elderly patients with NVAF in a large academic health system and to compare practice with consensus best practice recommendations. We searched the electronic medical record for patients ≥ 65years of age who were newly initiated on a DOAC for AF from January 2013 through December 2015. Patient and provider characteristics, baseline laboratory investigations, concomitant medications, and interval to first follow-up were recorded. 192 patients met eligibility criteria. The most commonly prescribed DOACs were rivaroxaban (65%) and apixaban (26%). Despite consensus recommendations that patients have a baseline creatinine, complete blood cell count, and coagulation studies prior to DOAC initiation, these tests were not performed in 18, 31, and 67% of patients, respectively. Consensus recommendations also suggest a follow-up visit within 1month of DOAC initiation. However, only 39% of patients had a return visit within 6 weeks and 43% did not have follow-up within 12weeks. DOAC prescribing in elderly patients with NVAF frequently fell short of quality standards. Interventions to enhance the quality of DOAC prescribing in this high-risk population are needed.

Influence of hospitalization on potentially inappropriate prescribing among elderly patients in a Malaysian community

Purpose : To compare the prevalence and type of potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) on admission and discharge of patients, and to determine the associated predictors. Methods : This was a prospective observational study conducted in the multidisciplinary medical and surgical units of Hospital Tengku Ampuan Afzan (HTAA), Malaysia. The medications of patients who had been admitted to the hospital from community-dwelling settings were reviewed to identify PIMs/PPOs using version 2 of STOPP/START criteria. A logistic regression model was applied to detect the risk factors associated with PIM or PPO at discharge. Results : Among the 300 patients involved in the study, the prevalence of PIMs was 27 % upon admission, which decreased to 22.3 % at discharge (p = 0.014) with PIMs pertaining to increasing the risk of physical falls in elderly people being the most common for pre- and post-hospitalization. The prevalence of PPOs was 47.6 % upon admission, which increased to 48 % at discharge (p = 0.99), with the omission of musculoskeletal medications being the most common PPOs at admission and discharge. Having a PIM at discharge was associated with the number of discharge medications and the history of falls, whereas having a high comorbidity index score or history of falls was associated with having a PPO at discharge. Conclusion : Hospitalization significantly reduces the prevalence of PIMs, but not PPOs or polypharmacy, among elderly patients. The number of discharge medications and the history of falls are predictors of discharge PIM, whilst high comorbidities and the history of falls were the predictors of discharge PPO. Improving the knowledge of hospital practitioners regarding geriatric pharmacotherapy is required to optimize prescribing in elderly patients during hospitalization. Keywords : Hospitalization, STOPP criteria, START criteria, Inappropriate prescribing, Co-morbidity, Polypharmacy, Elderly patients

Improvement on prescribing appropriateness after implementing an interdisciplinary pharmacotherapy quality programme in a long-term care hospital

ObjectivesTo determine the prevalence of inappropriate prescribing in elderly patients with polypharmacy admitted to a long-term care hospital (LTCH) and to evaluate the impact of an interdisciplinary pharmacotherapy quality programme...