Mark H. Beers

A Randomized Trial of a Program to Reduce the Use of Psychoactive Drugs in Nursing Homes

BACKGROUNDnAlthough psychoactive medications have substantial side effects in the elderly, these drugs are used frequently in nursing homes. Few interventions have succeeded in changing this situation, and little is known about the clinical effects of such interventions.nnnMETHODSnWe studied six matched pairs of nursing homes; at one randomly selected nursing home in each pair, physicians, nurses, and aides participated in an educational program in geriatric psychopharmacology. At base line we determined the type and quantity of drugs received by all residents (n = 823), and a blinded observer performed standardized clinical assessments of the residents who were taking psychoactive medications. After the five-month program, drug use and patient status were reassessed.nnnRESULTSnScores on an index of psychoactive-drug use, measuring both the magnitude and the probable inappropriateness of medication use, declined significantly more in the nursing homes in which the program was carried out (experimental nursing homes) than in the control nursing homes (decrease, 27 percent vs. 8 percent; P = 0.02). The use of antipsychotic drugs was discontinued in more residents in the experimental nursing homes than in the control nursing homes (32 percent vs. 14 percent); the comparable figures for the discontinuation of long-acting benzodiazepines were 20 percent vs. 9 percent, and for antihistamine hypnotics, 45 percent vs. 21 percent. In the experimental nursing homes residents who were initially taking antipsychotic drugs showed less deterioration on several measures of cognitive function than similar residents in the control facilities, but they were more likely to report depression. Those who were initially taking benzodiazepines or antihistamine hypnotic agents reported less anxiety than controls but had more loss of memory. Most other measures of clinical status remained unchanged in both groups.nnnCONCLUSIONSnAn educational program targeted to physicians, nurses, and aides can reduce the use of psychoactive drugs in nursing homes without adversely affecting the overall behavior and level of functioning of the residents.

Health outcomes associated with potentially inappropriate medication use in older adults.

The purpose of this study was to examine the prevalence of potentially inappropriate medication use (PIMs) among community-dwelling older adults and the association between PIMs and health care outcomes. Participants were 17,971 individuals age 65 years and older. PIM use was defined by the Beers criteria. Drug-related problems (DRPs) were defined using ICD-9 codes. Forty percent of the 17,971 individuals filled at least 1 PIM prescription, and 13% filled 2 or more PIM prescriptions. Overall DRP prevalence among those with at least 1 PIM prescription was 14.3% compared to 4.7% in the non-PIM group (p < .001). In conclusion, preventing PIM use may be important for decreasing medication-related problems, which are increasingly being recognized as requiring an integrated interdisciplinary approach.

Discontinuing medications: a novel approach for revising the prescribing stage of the medication-use process.

Thousands of Americans are injured or die each year from adverse drug reactions, many of which are preventable. The burden of harm conveyed by the use of medications is a significant public health problem, and therefore, improving the medication‐use process is a priority. Recent and ongoing efforts to improve the medication‐use process have focused primarily on improving medication prescribing, and not much emphasis has been put on improving medication discontinuation. A formalized approach for rationally discontinuing medications is a necessary antecedent to improving medication safety and improving the nations quality of care. This article proposes a conceptual framework for revising the prescribing stage of the medication‐use process to include discontinuing medications. This framework has substantial practice and research implications, especially for the clinical care of older persons, who are particularly susceptible to the adverse effects of medications.

Trends in the prescription of inappropriate drugs for the elderly between 1995 and 1999

BACKGROUNDnUsing criteria developed by Beers et al between 1991 and 1997, previous studies have reported high levels of inappropriate drug prescribing for community-dwelling elderly patients (age>or=65 years). However, it is not known whether the Beers criteria have had a beneficial effect on prescribing practices.nnnOBJECTIVESnThe aims of this study were to compare the prevalence of potentially inappropriate drug use (based on the Beers list) among older Americans between 1995 and 1999; to determine whether any decreases in such use were more likely to be the result of improved adherence to guidelines or of replacement of older medications by newer drugs; and to examine individual characteristics that place elderly patients at increased risk for inappropriate drug use.nnnMETHODSnThis was a panel study involving nationally representative samples of community-dwelling elderly persons from the 1995 and 1999 Medicare Current Beneficiary Surveys (MCBS). For comparison, data were analyzed from samples of disabled Medicare beneficiaries aged <65 years for the same periods. The samples were assessed for the use of 36 individual drugs, drug classes, and combinations carrying a risk for adverse out comes in the elderly based on the 1997 Beers criteria for drugs to be avoided in this population.nnnRESULTSnThe study samples contained 7628 community-dwelling elderly persons from the 1995 MCBS and 8902 from the 1999 MCBS, and 1863 and 1851 disabled Medicare beneficiaries aged <65 years for the respective survey years. The proportion of elderly patients taking >or=1 drug on the Beers list declined from 24.8% in 1995 to 21.3% in 1999 (P<0.05). There was a nonsignificant increase in the proportion of disabled Medicare beneficiaries taking >or=1 drug on the Beers list from 31.1% in 1995 to 31.5% in 1999.nnnCONCLUSIONSnThere was a significant decline in the use of potentially inappropriate drugs by elderly patients between 1995 and 1999, particularly in the use of those drugs linked to the most severe outcomes. However, approximately 7 million elderly patients still received potentially inappropriate drugs in 1999, underscoring the continued need for effective interventions to improve prescribing for this vulnerable population.

Surrogate Decision-Makers' Satisfaction with the Placement of Feeding Tubes in Elderly Patients

Objective: To assess the satisfaction of surrogate decisionmakers with the decision to place feeding tubes in elderly patients with impaired decision‐making capacity.

A Model for Improving Medication Use in Home Health Care Patients

OBJECTIVESn(1) To develop a model for the identification and resolution of problems associated with suboptimal medication use in elderly patients receiving home health care; (2) To select the most important identifiable problems and develop structured procedures for their resolution.nnnDESIGNnExpert panel review, problem selection, and development of a problem resolution model and guidelines.nnnSETTINGnHome health care.nnnPARTICIPANTSnA panel with expertise in home health nursing, pharmacy, clinical pharmacology, gerontology, pharmacoepidemiology, and health services research.nnnINTERVENTIONSnA list of potential problems associated with the most frequently used classes of drugs was compiled for review by the panel. Problems that were controversial or that could not be identified in the home care setting were excluded. Panel members individually ranked the remainder. Detailed procedures for identification and resolution of the 15 top-ranking problems were developed.nnnMAIN OUTCOME MEASURESnNot applicable.nnnRESULTSnPotential medication problems were defined by both drug use and symptoms or clinical signs associated with specific adverse effects, to ensure that clinically relevant problems would be identified. The model developed for problem assessment and resolution was centered on the drug utilization review (DUR) coordinator and the attending home health nurse. Following guidelines developed by the panel, the DUR coordinator advises the home health nurse about identified problems and how to resolve them. One of these practitioners, usually the nurse, then contacts the attending physician to explain their concerns, offer potential solutions, and request instructions.nnnCONCLUSIONnA potentially useful model for the identification and resolution of medication problems in the home health care setting was developed. This model is currently being evaluated in a randomized controlled trial.

A computerized system for identifying and informing physicians about problematic drug use in nursing homes

With growing concern over the quality of medication use in nursing homes, physicians, administrators, pharmacists, and regulators are looking for effective and efficient methods to improve it. Pharmacy consultation alone appears to be ineffective in controlling the use of inappropriate drugs. We describe here a computerized drug utilization review system designed for use in nursing homes. The system evaluates the appropriateness of medication use by criteria developed through the consensus of experts in geriatrics and specifically designed to address the pharmacological needs of elderly, nursing home residents. The program not only determines the frequency of inappropriate prescriptions, but produces written, educational statements to be given to prescribing physicians. These statements can also be given to nurses to educate them about issues in geriatrics pharmacology. Additionally, the system produces medication order forms that may help focus physicians attention on the need to evaluate drugs individually.

National trends in and predictors of propoxyphene use in community-dwelling older adults.

BACKGROUNDnSeveral pain management guidelines and explicit medication-use criteria identify propoxyphene as an inappropriate medication for use in older adults.nnnOBJECTIVEnThis study was conducted to estimate trends in propoxyphene use among community-dwelling elderly (age > or = 65 years) Medicare beneficiaries from 1993 through 1999 and to determine whether beneficiaries drug coverage and specific characteristics of their physicians were associated with receipt of propoxyphene in 1999.nnnMETHODSnData from the Medicare Current Beneficiary Survey (MCBS) were used to examine the prevalence of propoxyphene use in cross-sections of nationally representative samples of community-dwelling elderly Medicare beneficiaries from 1993 through 1999. The 1999 MCBS was linked with the 1999 Area Resource File to examine patient and physician factors associated with propoxyphene use in the community-dwelling elderly at the county level.nnnRESULTSnRates of propoxyphene use were generally stable over the 7-year period, from an annual prevalence of 6.8% in 1993 to the slightly decreased prevalence of 6.6% in 1999. No protective effects against propoxyphene use were observed based on beneficiaries drug coverage or type of drug coverage. Rather, Medicaid beneficiaries were more likely to receive propoxyphene than those without drug coverage (odds ratio [OR] = 1.40; 95% CI, 1.02-1.92). Among physician characteristics, male sex (OR = 1.34; 95% CI, 1.02-1.75) and medical specialty (OR = 0.81; 95% CI, 0.65-1.00) were strongly correlated with prescribing of propoxyphene.nnnCONCLUSIONnThis study found a continuing high prevalence of propoxyphene use in the community-dwelling elderly Medicare population from 1993 through 1999, with > 2 million beneficiaries receiving the drug in 1999.

Computer-assisted drug data collection

Computerized systems for recording information about medication prescribing and use are important for studies in health services and pharmacoepidemiology. Such systems, if properly designed, can facilitate analysis as well as data collection. Although drug information systems exist for pharmacy service delivery applications, there are currently no descriptions of systems developed primarily for research applications in this area. This paper describes a computerized data collection system, developed for researchers, usable on portable equipment, and containing error checking features; the system has been extensively tested in over 850 study subjects taking part in a study of medication use in nursing homes that examines the impact of educational interventions for doctors and nurses on prescribing practices.

THE UNINTENDED OUTCOME OF A SUPPLEMENTAL FORMULARY IN HOMEBOUND SENIORS

fractures, type 2 diabetes mellitus, ischemic heart disease, hypertension, stroke, and other endocrine, gastrointestinal, and renal disorders are observed in patients with TS, who have a mortality rate three times as great and a shorter life expectancy by up to 13 years than people without TS. Even after deaths from heart disease, their most common cause of death, are excluded, mortality rates remain high. Although this patient demonstrated many of the classic physical and endocrine features of TS, this diagnosis was not suspected until late in life, when there is not much information regarding health care for women with TS. If TS had been diagnosed earlier in this patient, hormonal therapy and calcium supplementation could have been started during a physiologically more efficacious period so as to decrease the rate of osteoporosis. Cardiovascular risk control would have helped prevent ischemic heart disease. Estrogen replacement therapy would have enabled the functions of the vaginal mucosa to be maintained (endometrial adenocarcinoma is the most frequent gynecological malignant neoplasm in these patients). Consistent with this patient’s nulliparity, her risk of developing breast cancer would also be somewhat elevated. This stresses the importance of regular breast examinations and mammography. This case illustrates the importance of including a genetic syndrome in the differential diagnosis in adult patients, especially given that this is one of the most common chromosomal abnormalities encountered. The prevalence of TS in elderly patients remains unclear, but a standard of care (e.g., mammography, echocardiography, and optimal hormone and calcium replacement therapy) must be defined, because early medical intervention can reduce morbidity and improve life expectancy.