Jane R. Mort

Inappropriate Prescribing for the Elderly: Beers Criteria-Based Review

OBJECTIVE: To review currently available literature applying the Beers criteria for inappropriate medication use in the elderly to prescribing practices in various settings. DATA SOURCE: Key words including inappropriate, Beers, medication, prescribing, elderly, geriatric, and criteria were used to search MEDLINE records from January 1992 to June 1999. DATA EXTRACTION: Eight relevant studies were found that applied the Beers criteria in various healthcare settings. DATA SYNTHESIS: Each study was examined for methodologic issues, criteria used, prevalence, nature and extent of inappropriate medication use, and factors associated with their use. Despite the methodologic differences, the review revealed some consistent patterns across healthcare settings. This review has shown that: (1) most of the researchers modified the Beers criteria to examine inappropriate medication use in the elderly; (2) studies using patient-based prevalence showed that between nearly one in four (23.5%) and one in seven (14.0%) elderly patients received an inappropriate medication as defined by either the Beers list of 20 inappropriate medications or the Modified Beers list; (3) the majority of these patients received one inappropriate agent; and (4) long-acting benzodiazepines, dipyridamole, propoxyphene, and amitriptyline were among the most frequently prescribed inappropriate medications. Univariate analyses indicated that women, patients >80 years old, and Medicaid patients appeared to receive more inappropriate medications than others; however, multivariate analyses found that only a higher number of medications was consistently associated with inappropriate medication use. CONCLUSIONS: Inappropriate prescribing or use trends are noteworthy because they were observed despite methodologic differences. The findings can be instrumental in developing targeted interventions to influence future prescribing practices. More research is needed to address the national trends and healthcare impact of inappropriate drug use in the elderly.

Psychotropic Prescription Use by Community-Dwelling Elderly in the United States

OBJECTIVES: To examine psychotropic prescription use in community‐dwelling elderly in the United States and its association with predisposing, enabling, and need factors.

Prevalence, correlates, and associated outcomes of potentially inappropriate psychotropic use in the community-dwelling elderly

BACKGROUND Previous applications of the Beers criteria have shown significant prescribing of potentially inappropriate psychotropic agents for the community-dwelling elderly. However, there is limited information at the national level on potentially inappropriate psychotropic use, the characteristics of elderly persons at risk, and the impact of this inappropriate use on health care outcomes. OBJECTIVE This study addressed the prevalence, correlates, and associated outcomes of potentially inappropriate psychotropic use among community-dwelling elderly persons in the United States who were receiving psychotropic medications. METHODS Data from the 1996 Medical Expenditure Panel Survey (MEPS) were employed to examine the use of psychotropic medications that generally should be avoided in the elderly and those that should be avoided in elderly patients with certain preexisting conditions, as defined by the Beers criteria. The MEPS sampling weights were used to derive national estimates. Cross-sectional data were analyzed by multivariate analyses to examine the correlates and associated health care outcomes (health care utilization, economic, and humanistic) of potentially inappropriate psychotropic use in the elderly. RESULTS An estimated 2.30 million community-dwelling elderly persons received potentially inappropriate psychotropic medications in 1996. This represented 7.14% of all community-dwelling elderly persons and 37.86% of all community-dwelling elderly persons using psychotropic agents; 32.94% of those taking psychotropic drugs received agents that were generally inappropriate, and 10.21% received agents that were inappropriate in the presence of specific conditions. The rates of potentially inappropriate psychotropic use in those receiving antidepressant, antianxiety, and sedative/hypnotic agents were 50.93%, 31.84%, and 23.49%, respectively. Multivariate analyses showed that correlates of potentially inappropriate psychotropic use in the elderly were age <75 years and use of multiple psychotropic agents. After controlling for predisposing, enabling, and need factors, no association was found between the use of potentially inappropriate psychotropic medications and differences in health care utilization, economic, or humanistic outcomes. CONCLUSIONS The study findings suggest that although the use of potentially inappropriate psychotropic medications is common among the community-dwelling elderly who are prescribed psychotropic agents, the unfavorable risk-benefit ratio of these inappropriate medications does not appear to influence broad measures of health care utilization, costs, or quality of life in this population.

Prescribing of psychotropics in the elderly: why is it so often inappropriate?

Psychotropic medications are an important treatment approach to mental health disorders; such disorders are common in the elderly population. Elderly patients are more likely to experience adverse effects from these agents than their younger counterparts due to age-related changes in pharmacodynamic and pharmacokinetic parameters. Because of these factors, inappropriate use of psychotropic medications in elderly patients has become a focus of concern.In general an agent is considered inappropriate if the risk associated with its use exceeds its benefit. Implicit and explicit criteria for inappropriate use of medications in the elderly have been created and include psychotropic agents. These criteria vary in their make-up but the explicit criteria tend to agree that amitriptyline, doxepin, and benzodiazepines that have long half-lives are not appropriate.Although explicit inappropriate medication criteria have been in existence since 1991, elderly patients continue to receive inappropriate psychotropic medications. A wide array of factors may be responsible for this practice. Provider-related causes include deficits in knowledge, confusion due to the lack of a consensus on the inappropriate psychotropic criteria, difficulties in addressing an inappropriate medication started by a previous provider, multiple prescribers and pharmacies involved in the care of a patient, negative perceptions regarding aging, and cost issues. Patients may contribute to the problem by demanding an inappropriate medication. Finally, the healthcare setting may inadvertently contribute to inappropriate prescribing by such policies as restrictive formularies or lack of reimbursement for pharmacists’ clinical services.Successful approaches to optimising prescribing have been either educational or administrative. Educational approaches (e.g. one-on-one sessions, academic detailing) seek to influence decision making, while administrative approaches attempt to enforce policies to curtail the undesired practice. The US Omnibus Budget Reconciliation Act of 1987, which improved psychotropic medication use in long-term care, is an excellent example of administrative intervention.More research specifically focused on the causes of inappropriate psychotropic medication use and methods to avoid this practice is needed before targeted recommendations can be made.

Interaction Between Selective Serotonin Reuptake Inhibitors and Nonsteroidal Antiinflammatory Drugs: Review of the Literature

Objective. To evaluate the evidence of an interaction between selective serotonin reuptake inhibitors (SSRIs) and nonsteroidal antiinflammatory drugs (NSAIDs) producing an increased risk for gastrointestinal adverse outcomes such as bleeding.

Timing of Blood Pressure Measurement Related to Caffeine Consumption

Objective: To determine whether patients should wait 30 minutes after caffeine consumption to have their blood pressure measured. Data Sources: Literature was obtained by searching MEDLINE (1980–September 2007), International Pharmaceutical Abstracts (1980–September 2007), and the Cochrane Database of Systematic Reviews (1994–September 2007). Search terms included caffeine and blood pressure. Literature was also obtained from citations in relevant articles. Study Selection and Data Extraction: Articles that examined caffeines acute effect on blood pressure were reviewed, with additional focus on caffeine tolerance and hypertensive status. Data Synthesis: Caffeine appears to affect blood pressure through adenosine receptor inhibition and an increased release of select neurotransmitters. Caffeine levels peak 30–120 minutes after oral intake and caffeines half-life is 3–6 hours. The effect of caffeine on blood pressure has been examined for decades, with variable results depending on factors such as population examined (eg, hypertensive status, physical stressors, age) and study design (eg, acute effects, chronic ingestion, retrospective epidemiologic review). Caffeine tolerance diminishes the acute effect of caffeine on blood pressure, and hypertensive individuals are more susceptible to blood pressure changes. Reviews of caffeines acute effect on blood pressure indicate changes of 3–15 mm Hg systolic and 4–13 mm Hg diastolic. Typically, blood pressure changes occur within 30 minutes, peak in 1–2 hours, and may persist for more than 4 hours. Conclusions: Having a patient abstain from caffeine for 30 minutes prior to blood pressure monitoring is not adequate to avoid caffeines potential effects. An alternative approach to blood pressure monitoring would be to ask the patient about recent caffeine consumption and interpret the blood pressure reading based on this information. In addition, healthcare practitioners should provide education regarding caffeines effects.

Pschotropic prescribing for the elderly in office-based practice

This study employed data from the National Ambulatory Medical Care Survey (NAMCS) 1995 to (1) determine the prevalence of the prescribing of psychotropic drugs for elderly patients by office-based physicians in the United States; (2) estimate the prevalence of the prescribing of potentially inappropriate psychotropic drugs in this patient population; and (3) identify any factors that predict such prescribing. For the purposes of this study, previously developed consensus criteria were adopted defining inappropriate psychotropic drugs as those that should be avoided in the elderly. According to the NAMCS data, psychotropic medications were prescribed in an estimated 12.02 million visits by elderly patients (95% confidence interval [CI], 11.07-12.97 million). The psychotropic medications most frequently prescribed for elderly patients by office-based physicians were antidepressants and antianxiety agents. The occurrence of visits at which psychotropic medications were prescribed was greater in patients who were over 84 years of age, female, white, or from the western United States. Primary care physicians prescribed the majority of these psychotropic drugs, and most visits to psychiatrists by elderly patients resulted in the prescribing of psychotropic drugs. Office-based physicians prescribed at least one potentially inappropriate psychotropic medication in 2.03 million visits by the elderly (95% CI, 1.70-2.36 million), or 16.87% of visits by the elderly involving prescriptions for psychotropic drugs. The most frequently prescribed potentially inappropriate psychotropic drugs were amitriptyline and long-acting benzodiazepines such as diazepam, chlordiazepoxide, and flurazepam. Logistic regression analyses revealed that inappropriate prescribing of psychotropic drugs for elderly patients was associated with particular patient characteristics (visit due to an injury), drug characteristics (number of medications prescribed and the drug being an antidepressant or antianxiety agent), and physician characteristics (psychiatric specialty and location in the South or Northeast). The patterns of psychotropic prescribing found in the ambulatory setting raise concerns about the quality of care being received by elderly patients with psychiatric illnesses.

Opioid-Paracetamol Prescription Patterns and Liver Dysfunction

AbstractBackground: Paracetamol (acetaminophen) is the most common cause of acute liver failure (ALF). ALF attributed to paracetamol is most often associated with the following features: an unintentional overdose, a single product, an opioid-paracetamol combination, duration of <7 days, and a median dose of 7.5 g/day. Currently, the recommended maximum daily dose of paracetamol is 4 g. Objectives: The aims of the study were to determine opioid-paracetamol prescription patterns, including prescriptions exceeding the recommended dose of paracetamol (4 g/day) [prescriptions and beneficiaries]; examine factors associated with receiving opioid-paracetamol prescriptions in excess of paracetamol 4 g/day; and evaluate opioid-paracetamol prescription patterns for beneficiaries with liver dysfunction. Methods: A retrospective cohort study examining prescription data of 4.8 million beneficiaries from a US health benefits organization from 1 January 2009 through 31 December 2009. The main outcomes examined were daily paracetamol dose and liver dysfunction. Results: A large proportion (8.1%) of the 5.3 million prescriptions for opioid-paracetamol exceeded the recommended maximum daily dose of paracetamol (4 g/day), putting over one-quarter of a million (255 123 [18.9%]) of the 1.35 million beneficiaries receiving an opioid-paracetamol prescription at risk of toxicity. The most frequently prescribed products that exceeded paracetamol dose guidelines contained dextropropoxyphene and hydrocodone. Multiple factors, including type of product (i.e. dextropropoxyphene or oxycodone-containing), geographical location (Midwest), strength of the paracetamol in the opioid-paracetamol product (>325 mg) and prescriber specialty (dentist, physician assistant), were associated with high-dose paracetamol prescriptions. Liver dysfunction was diagnosed in 3818 cases, and 23.4% of these beneficiaries received an opioid-paracetamol prescription in the 90 days prior to the liver dysfunction diagnosis. Conclusions: Although most opioid-paracetamol prescriptions are written and dispensed for <4 g/day of paracetamol, a significant portion of beneficiaries are being prescribed and dispensed excessive doses of paracetamol. Efforts to curtail this practice may involve provision of prescriber and pharmacist education, utilization of benefit manager systems to flag excessive dosing or that require confirmation of dosing, and implementation of US FDA recommendations supported by these data.

Comparison of psychotropic agent use among rural elderly caregivers and noncaregivers

Objective To determine the prescription and over-the-counter (OTC) psychotropic medication and social drug (alcohol and caffeine) use patterns of community-based elderly caregivers of patients with dementia and elderly noncaregivers. Design Cross-sectional study design in which characteristics of psychotropic medication and social drug use were collected including the specific agent, frequency, dose, and reason for use. Setting A rural, sparsely populated agricultural area in the midwest region of the US. Sample Thirty elderly caregivers of patients with dementia were recruited through a public health agency and homemaker health aid service. Thirty elderly noncaregivers were recruited through the senior citizens center in a neighboring rural community. Data were collected by interview. Results A significantly greater number of caregivers used OTC psychotropic agents (43%) than did noncaregivers (3%; p < 0.001). In all cases these agents were used for sleep. The combined number of caregivers using prescription and OTC psychotropic products (63%) also achieved statistical significance compared with the control group (10%; p < 0.001). Caffeine was used by all members of both groups and alcohol was consumed by eight caregivers and seven noncaregivers. Conclusions A greater percentage of rural caregivers of patients with dementia in this study took psychotropic agents compared with the noncaregiver group. OTC products for sleep were the most frequently used agents.

Nightmare Cessation following Alteration of Ophthalmic Administration of a Cholinergic and a Beta-Blocking Agent

OBJECTIVE: To document the termination of nightmares brought about by an alteration in the ophthalmic administration of beta-blocking and cholinergic agents. PATIENT: A 75-year-old man residing in a long-term care facility experienced nightly nightmares of approximately one-year duration. INTERVENTION: Other potential causes for the nightmares were eliminated. The administration of the ophthalmic agents was evaluated and the resident was then instructed to alter administration to include closure of his eyes for one to two minutes after administration. OUTCOME: Following the alteration in administration the nightmares were not present and have not reappeared in the ensuing year. CONCLUSIONS: Ophthalmic application of beta-blocking and cholinergic agents is used for the treatment of glaucoma and has been reported to cause a wide variety of central nervous system effects. Researchers have documented reduced systemic absorption and enhanced ocular retention time with specific modifications in the administration of the ophthalmic products. Based on this research the suggestion has been made that systemic adverse effects may be reduced by altering administration through use of lid closure and lacrimal occlusion. This case validates this hypothesis and provides strong evidence for the need to counsel all patients receiving ophthalmic agents on proper administration, including techniques to reduce absorption in order to avoid undesirable systemic effects.