Prescribing in Elderly People 1. Appropriate prescribing in elderly people: how well can it be measured and optimised? Lancet, 370, 173-184

Duke University, Durham, North Carolina, United States
The Lancet (Impact Factor: 45.22). 08/2007; 370(9582):173-84. DOI: 10.1016/S0140-6736(07)61091-5
Source: PubMed


Prescription of medicines is a fundamental component of the care of elderly people, and optimisation of drug prescribing for this group of patients has become an important public-health issue worldwide. Several characteristics of ageing and geriatric medicine affect medication prescribing for elderly people and render the selection of appropriate pharmacotherapy a challenging and complex process. In the first paper in this series we aim to define and categorise appropriate prescribing in elderly people, critically review the instruments that are available to measure it and discuss their predictive validity, critically review recent randomised controlled intervention studies that assessed the effect of optimisation strategies on the appropriateness of prescribing in elderly people, and suggest directions for future research and practice.

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Available from: Anne Spinewine,
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    • "A review of Beer's criteria, IPET and MAI found results ranging from a positive association with a higher risk of death, adverse drug reactions and health service utilisation to no association with mortality and hospital admissions (Spinewine et al. 2007). STOPP indicators have recently been significantly associated with preventable medication-related hospitalizations (Hamilton et al. 2011). "
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    ABSTRACT: Given the growing aged care population, the complexity of their medication-related needs and increased risk of adverse drug events, there is a necessity to systematically monitor and manage medication-related quality of care. The aim of this systematic review was to identify and synthesise medication-related quality of care indicators with respect to application to residential aged care. MEDLINE (Ovid), Psychinfo, CINAHL, Embase and Google® were searched from 2001 to 2013 for studies that were in English, focused on older people aged 65+ years and discussed the development, application or validation of original medication-related quality of care indicators. The quality of selected articles was appraised using the Critical Appraisal Skills Program and psychometric qualities extracted and synthesised using content analysis. Indicators were mapped to six medication-related quality of care attributes and a minimum indicator set derived. Thirty three articles describing 25 indicator sets met the inclusion criteria. Thirteen (52%) contained prescribing quality indicators only. Eight (32%) were developed specifically for aged care. Twenty three (92%) were validated and seven (28%) assessed for reliability. The most common attribute addressed was medication appropriateness (n = 24). There were no indicators for evaluating medication use in those with limited life expectancy, which resulted in only five of the six attributes being addressed. The developed minimum indicator set contains 28 indicators representing 22 of 25 identified indicator sets. Whilst a wide variety of validated indicator sets exist, none addressed all aspects of medication-related quality of care pertinent to residential aged care. The minimum indicator set is intended as a foundation for comprehensively evaluating medication-related quality of care in this setting. Future work should focus on bridging identified gaps.
    SpringerPlus 12/2015; 4(1). DOI:10.1186/s40064-015-0984-9
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    • "For a given patient, a benefit-to-risk ratio for each drug has to be assessed considering clinical conditions, comorbidities, functional status, other drugs taken and prognosis. Further, the issue of prescribing appropriateness, in its broader sense, must encompass steps in favor of non-drug approaches (beneficial drug omission) and include also patients’ preferences to achieve optimal results (Spinewine et al. 2007). "
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    ABSTRACT: In order to improve patient care, OMEDIT (Observatory of drugs, medical devices and therapeutic innovation) Alsace, conducted a study to develop a Preferential list of Drugs adapted to the Elderly (PDE list) in nursing homes. The study conducted from December 2011 to June 2012 was organized in 4 phases: 1) creation of a preliminary list of drugs from those currently used in nursing homes in Alsace, 2) application of a two-round Delphi process to evaluate the preliminary list involving mobilization of experts from different backgrounds (geriatricians, general practitioners, pharmacists …), 3) identification of molecules considered in literature as potentially inappropriate, 4) generation of a final PDE list, including information concerning proper use of drugs for prescription and administration. 53 experts participated in the study. In the first round, 338 drugs were on the preliminary list, 246 were considered as appropriate by experts and 28 as inappropriate. 64 drugs without consensus were submitted to a second round. 32 of them were considered as inappropriate and 32 others remained on the list with no consensus. These last 32 were evaluated by OMEDIT and 3 were considered as appropriate drugs for the elderly. Totally, 252 drugs constitute the final PDE list from our study. The PDE list constitutes a new guide for optimization of both prescription and administration of drugs in nursing homes and could help reduce misuses and poly-medication, which are constant preoccupations to avoid adverse drug reactions in elderly. Key points ● The study was carried out with the aim to create a Preferential list of Drugs adapted to the Elderly (PDE list) in nursing homes using a modified Delphi method. ● The PDE list constitutes a new guideline to harmonize practices in nursing homes and to help physicians and nurses to achieve best possible care management.
    SpringerPlus 08/2014; 3(1):413. DOI:10.1186/2193-1801-3-413
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    • "Explicit process measures are criterion-based and indicate drugs to be avoided in older people, independent of diagnoses or in the presence of certain diagnoses [3-5]. Explicit measures, requiring little clinical detail, can often be applied to large prescribing databases [2]. "
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    ABSTRACT: Background: Potentially inappropriate prescribing (PIP) in older people is associated with increases in morbidity, hospitalisation and mortality. The objective of this study was to estimate the prevalence of and factors associated with PIP, among those aged ≥70 years, in the United Kingdom, using a comprehensive set of prescribing indicators and comparing these to estimates obtained from a truncated set of the same indicators. Methods: A retrospective cross-sectional study was carried out in the UK Clinical Practice Research Datalink (CPRD), in 2007. Participants included those aged ≥ 70 years, in CPRD. Fifty-two PIP indicators from the Screening Tool of Older Persons Potentially Inappropriate Prescriptions (STOPP) criteria were applied to data on prescribed drugs and clinical diagnoses. Overall prevalence of PIP and prevalence according to individual STOPP criteria were estimated. The relationship between PIP and polypharmacy (≥4 medications), comorbidity, age, and gender was examined. A truncated, subset of 28 STOPP criteria that were used in two previous studies, were further applied to the data to facilitate comparison. Results: Using 52 indicators, the overall prevalence of PIP in the study population (n = 1,019,491) was 29%. The most common examples of PIP were therapeutic duplication (11.9%), followed by use of aspirin with no indication (11.3%) and inappropriate use of proton pump inhibitors (PPIs) (3.7%). PIP was strongly associated with polypharmacy (Odds Ratio 18.2, 95% Confidence Intervals, 18.0-18.4, P < 0.05). PIP was more common in those aged 70-74 years vs. 85 years or more and in males. Application of the smaller subset of the STOPP criteria resulted in a lower PIP prevalence at 14.9% (95% CIs 14.8-14.9%) (n = 151,598). The most common PIP issues identified with this subset were use of PPIs at maximum dose for > 8 weeks, NSAIDs for > 3 months, and use of long-term neuroleptics. Conclusions: PIP was prevalent in the UK and increased with polypharmacy. Application of the comprehensive set of STOPP criteria allowed more accurate estimation of PIP compared to the subset of criteria used in previous studies. These findings may provide a focus for targeted interventions to reduce PIP.
    BMC Geriatrics 06/2014; 14(1):72. DOI:10.1186/1471-2318-14-72 · 1.68 Impact Factor
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