Inappropriate Medication in the Geriatric Population

Function

Rationale: Potentially Inappropriate Medication

Polypharmacy is associated with an increased incidence of adverse drug events, decreased functional status, and increased healthcare costs. A relationship between PIM and multiple geriatric syndromes (eg, falls, cognitive decline, urinary retention) has been established. Adverse effects are 1 of the leading causes of hospitalization in geriatric patients in the United States and Canada.[6] Explicit tools such as the AGS Beers Criteria® and STOPP/START criteria are designed to reduce complications caused by PIM. Nonetheless, inappropriate prescriptions are still common, with several studies demonstrating that around half of the geriatric population takes at least 1 medication included in these lists.[7][8] The use of multiple medications, long durations of treatment, and shared mechanisms of action are associated with higher morbidity, particularly regarding falls and functional capacity. Drugs such as diuretics and other antihypertensives, sedatives, and antipsychotics contribute to the high incidence of adverse effects. Moreover, there is an important correlation between polypharmacy and frailty.[9][10][11] Although an objective reduction in mortality or improvement in quality of life is yet to be proven, it is understood that addressing polypharmacy and optimizing pharmacological treatment contribute to better patient outcomes. The ongoing POLITE-RCT trial attempts to prove this relationship directly via critical primary and secondary interprofessional interventions.[6][12]

Issues of Concern

Epidemiology

The prevalence of potentially inappropriate medication use in the geriatric population varies widely depending on geographical, institutional, cultural, and idiosyncratic factors.[13] Studies report that around 40% of adults older than 65 are prescribed at least 1 medication included in the AGS Beers Criteria®.[4] Antianxiety (benzodiazepines) and antidepressant (selective serotonin reuptake inhibitors and tricyclic antidepressants) drugs are the most commonly included, particularly in nursing homes and long-term care facilities.[13][14] The most important predictor for PIM use is polypharmacy, which is present in up to 91% of long-term care facility patients. Other factors, such as female sex and comorbidity, are associated with PIM risks.[1][15][14] Dementia is associated with an 11% increase in PIM use.[3]

Aging, Pharmacokinetics, and Pharmacodynamics

The epidemiological transition has led to an aging population, with a significant increase in chronic conditions and a need for geriatric care. Older adults are at increased risk for adverse drug effects due to comorbidities and changes in the pharmacokinetics and pharmacodynamics associated with aging.[6] Until recent years, clinical trials failed to include significant numbers of geriatric patients, and results were not validated for all populations.[16] The main age-related changes in pharmacokinetics are a decrease in first-pass metabolism, variations in the volume of distribution due to sarcopenia, and progressive renal function decline. These and other disease-related changes make drug responses challenging to predict. These factors vary from patient to patient and are not linearly related to age or disease progression. Therefore, drug administration should be individualized, considering goals, indications, and expectations.[16]

Polypharmacy

Polypharmacy is classically defined as the use of 5 or more medications by a single patient in a chronic manner. However, utilizing a numerical cutoff does not account for many factors involving this concept, and thus, qualitative definitions should be considered. Polypharmacy includes using multiple inappropriate, unwarranted, and harmful medications.[16][17] Medication appropriateness encompasses adequacy, cost-effectiveness, the patient's preferences, comorbidities, cognitive states, and treatment goals. Patients with multiple comorbidities, attending physicians, and residing in assisted-living facilities are at a higher risk of suffering from polypharmacy.[15] 

The Prescribing Cascade

The prescribing cascade is a term coined in the late 20th Century by Rochon and Gurwitz; it entails the utilization of 1 or more drugs to prevent or treat the side effects caused by another medication. For instance, when prescribing a non-steroidal anti-inflammatory drug, physicians often add a proton pump inhibitor to prevent gastrointestinal bleeding, or when using opioids to treat pain, a laxative is given to treat opioid-induced constipation. The prescribing cascade should be avoided when possible, considering the risks and benefits of adding multiple medications to a patient's pill burden.[15][16] Some consequences of polypharmacy and the prescribing cascade are provoking drug-drug interactions, potentiation of adverse effects, frailty, geriatric syndromes, cost burden, and negative outcomes.[16]

Inappropriate Prescriptions

The spectrum of inadequate drug prescriptions ranges from misprescribing to underprescribing and overprescribing. Misprescription occurs when the risk of adverse effects of medication significantly outweighs its clinical benefits, including incorrect dosing or drug combinations. Underprescription is the omission of an indicated drug. Overprescription is the introduction of a drug not indicated for treating a condition.[1][5]

Awareness and Prevention

The relevance of the AGS Beers Criteria® relies on professional awareness. Many approaches have been described to reduce the use of PIM and reach the goal of informed, safer prescribing practices. Explicit and implicit criteria should be utilized to assess patients holistically.[5] The AGS Beers Criteria® names potentially, not definitively, inappropriate medications and should be applied with a comprehensive understanding of each patient's clinical scenario and the medication in question.[4][3] A comprehensive geriatric assessment should be performed when possible, evaluating the individual's functional, cognitive, social, and health status. In addition, automatized warnings and reviews could be implemented in digital health records to address potential mistakes.[5][18] Comprehensive medication monitoring and pharmacovigilance are innovative strategies that prevent adverse drug effects. Implementing these systems, which physician assistants, students, and other healthcare professionals can track at discharge and in the ambulatory setting, leads to further awareness among attending physicians.[16]

Clinical Significance

How to Apply the AGS Beers Criteria®?

The AGS Beers Criteria® evaluates 5 aspects of PIM: drugs to avoid, drugs to use with caution, drug interactions, medications to avoid in particular situations, and dosage according to kidney function. These aspects should be considered when prescribing single or multiple drug regimens in older adults.[3] There are 7 key points to apply the AGS Beers Criteria® with real-world judgment, entitled "Using Wisely," which include utilizing the criteria as guidelines for a patient-centered approach.[19][20] These include:

Aspects to Evaluate in a Medical Visit

The assessment and evaluation of patients in an integral, multi-dimensional fashion is necessary to avoid adverse drug events. Optimal medication prescription is paramount when treating older adults. Many protocols, such as the Assess, Review, Minimize, Optimize, Reassess (ARMOR) and the Prescribing Optimization Method (POM), attempt to standardize and guide these processes. However, these have not been validated.[17] A stepwise approach to treatment implementation is recommended. There are several key points to evaluate when encountering these situations to avoid inappropriate prescriptions.[17][16] These include:

• First, is there a clear indication for administering the medication?
• Do the benefits of the drug outweigh the potential harms?
• Do any of the medicines present significant interactions?
• Is the indicated duration of treatment appropriate?
• Are there any duplicated drugs?
• Is there a need for renal-adjusted dosage?
• Is there a non-pharmacological alternative to avoid PIM?
• What is the patient's functional status?
• What are the patient's preferences?
• Is the patient adherent to their treatment?

These questions are helpful when assessing PIM and implementing prescription management programs. The patient must be involved in decision-making.[16] Some helpful strategies to prevent adverse events include monitoring drug efficacy, assessing drug-drug interactions, avoiding overprescription, and periodically monitoring a patient's pharmacological treatment. Other essential aspects of assessing are reviewing adherence and dosage formulations. For example, certain patients might chew, spit, or combine their medication with food, affecting effectiveness. Moreover, patients with swallowing difficulties might find it challenging to take their medications, and alternatives should be offered. Often, herbal treatments and over-the-counter medications are forgotten and might contribute to unexpected events.[16]

Medication Reconciliation

Medication reconciliation is another technique for evaluating polypharmacy and appropriate prescriptions without sacrificing time. It entails asking the patients to bring a list of all their medications or the actual bottles (also known as the brown bag assessment) to a consultation. This practice is often very revealing and results in discovering potential risks for medication errors, including duplicate bottles of the same medication at different dosages, discovering medications prescribed by other providers, and medications the patient forgot to mention as they may use them intermittently. The American Geriatrics Society recommends only prescribing new drugs after reviewing all of a patient's medications.[15]

Deprescribing

Deprescribing is a necessary intervention that reduces harm and prevents adverse drug events; it is defined as reducing or discontinuing a medication. Treatment efficiency and minimal effective dosage are the goals of deprescribing.[21][15] This process should be implemented whenever necessary, considering the evidence, patient preferences, and potential risks and benefits. Deprescribing should be seen as therapeutic, not as a harmful intervention. Interprofessional communication is essential to promote patient and provider confidence and achieve treatment goals.[21][22] The Choosing Wisely Initiative and the Canadian Deprescribing Network are useful tools for safely deprescribing. Both aim to optimize treatments and reduce PIM use.[22] Another useful tool is the ACB Calculator, an online calculator that can quantify the anticholinergic burden of multiple medications, individually and in combination, and suggest safer alternatives.[23] Deprescribing should be systematically implemented, reducing patient hesitancy and improving acceptance.[15]

Other Issues

Limitations to the AGS Beers Criteria®

The AGS Beers Criteria® complements clinical judgment and decision-making and should not be used independently to add or remove medications for patients. Treatment should be individualized, understanding that patients are complex and conditions differ between individuals.[3] The AGS Beers Criteria® does not always apply to hospitalized and palliative care patients. Risk-benefit ratios vary in these settings, and there are innumerable scenarios to consider.[3][4] Finally, the AGS Beers Criteria® was validated using evidence from the United States and is not necessarily applicable in all countries.[3]

Enhancing Healthcare Team Outcomes

The AGS Beers Criteria® was developed to be utilized in an interprofessional, patient-centered approach to avoid adverse drug events and assess the prescription of PIM. Clinicians, pharmacists, nurses, and other professionals should be involved in the integral care of geriatric patients.[3] Several studies have shown that using real-world data based on direct measurements improves patient outcomes and reduces adverse drug events. Databases such as FAERS, WHO VigiBase, and the SYMPATHY Project provide useful information for implementing safe prescribing strategies.[9][6][10] Physicians play an essential role in prescriptions. Nonetheless, it is often challenging for medical professionals to monitor patients' behaviors and global health. Nurses are better positioned to follow patients and understand changes in health status closely. Pharmacists have a deep understanding of medications.[24] In a study conducted in Malaysia, awareness of the AGS Beers Criteria® was less than 40% among pharmacists, meaning that prescriptions were filled without further assessment. Interdisciplinary education and familiarity with the AGS Beers Criteria® are crucial to utilizing system-based review and reducing PIM prescriptions. Promoting pharmacist review of medications, assuming their familiarity with the AGS Beers Criteria®, is a simple intervention that could reduce mistakes.[25]

The Finnish Interprofessional Medication Assessment was a randomized controlled trial that compared adverse drug events when assessing medications with an interprofessional team versus a conventional approach. The intervention resulted in a statistically significant decrease in adverse events.[26] Another study showed that when utilizing multiple tools to assess medications and a pharmacist-led deprescribing approach, the identification of PIM increased considerably.[22] When collaboration is encouraged, medication management is simplified, and risks are minimized.[24] Physicians should be in constant, reciprocal communication with patients and other professionals. Adequate care transfer helps address barriers and limitations that could harm patients.[6] Appropriately prescribing medications is a key intervention to improve patient outcomes. Medical knowledge is not sufficient to guarantee the elimination of harmful medications. Interprofessional collaboration is essential to achieve the goals of care. Prescriber education, feedback and auditing, and clinical decision support tools should be systematically implemented to improve healthcare practices.[24][21][20]