Potentially inappropriate medication in geriatric patients: the Austrian consensus panel list

Potentiell inadäquate Medikation bei geriatrischen Patienten: Die Österreichische PIM-Liste

Zusammenfassung

HINTERGRUND: Bei geriatrischen Patienten stellen inadäquate Medikamentenverordnungen einen wichtigen Risikofaktor für unerwünschte Arzneimittelereignisse dar. Sie führen in diesem Zusammenhang zu einer Zunahme von Spitalszuweisungen, welche die Gesundheitskosten belasten. Die Entwicklung Konsensus-basierter Listen von Medikamenten, die bei geriatrischen Patienten im Allgemeinen vermieden werden sollten, wird als eine mögliche Strategie angesehen, um die Qualität der medikamentösen Behandlung zu steigern. ZIEL: Erstellung einer, den österreichischen Verschreibungsgewohnheiten und der Marktsituation angepassten, Konsensus-basierten Liste von Arzneimitteln, deren Verordnung potentiell inadäquat für geriatrische Patienten ist, und die deshalb vermieden werden sollten. METHODE: Als Evaluierungsmethode wurde ein zwei-stufiger Delphi Prozess gewählt, an dem acht Experten mit Erfahrung in der medikamentösen Therapie geriatrischer Patienten teilnahmen. In der ersten Runde bewerteten die Experten Medikamente einer vorgegebenen Liste anhand einer 5-stufigen Likert Skala von sicher potentiell unangemessen bis sicher nicht potentiell unangemessen. Alle Medikamente, für deren Bewertung die obere Grenze des 95 % Konfidenzintervalls unter 3,0 lag, wurden als potentiell unangemessen klassifiziert. Medikamente, deren 95 % KI den Wert 3,0 umschloss, wurden in der zweiten Runde wieder anhand einer 5-stufigen Likert Skala bewertet, ebenso wie die in der ersten Runde neu vorgeschlagenen Medikamente. Nach Analyse der Ergebnisse der zweiten Runde wurde die finale Liste erstellt. RESULTATE: Von den vorgegebenen 102 Medikamenten wurden 61 Medikamente (59,2 %) bereits in der ersten Runde als potentiell unangemessen für ältere Menschen eingestuft. Sechs Medikamente, die in der zweiten Runde erneut evaluiert wurden, und sechs in der ersten Runde neu vorgeschlagene Medikamente wurden in der zweiten Runde als potentiell inadäquat klassifiziert. Die finale Liste enthält 73 Arzneimittel, die aufgrund eines ungünstigen Nutzen/Risiko Profils oder aufgrund fraglicher Wirksamkeit bei geriatrischen Patienten nicht verordnet werden sollten. SCHLUSSFOLGERUNG: Die Österreichische PIM Liste kann für klinisch tätige Ärzte ein in der Praxis anwendbares Instrument darstellen, das zu einer Verbesserung der Qualität von Medikamentenverordnungen bei älteren Patienten beiträgt. Studien zur Validierung der PIM-Liste stehen in Österreich ebenso wie in anderen Ländern mit bereits veröffentlichten PIM-Listen noch aus.

Summary

BACKGROUND: The practice of inappropriate medication and drug prescription is a major risk factor for adverse drug reactions in geriatric patients and increases the individual, as well as overall, rates of hospital admissions, resulting in increased health care expenditures. A consensus-based list of drugs, generally to be avoided in geriatric patients, is a practical tool to possibly improve the quality of prescribing. OBJECTIVE: The aim was to develop a consensus-based list of potentially inappropriate medications (PIM) for geriatric patients in Austria. Local market characteristics and documented prescribing regimens were considered in detail. METHODS: A two-round Delphi process involving eight experts in the field of geriatric medicine was undertaken to create a list of potentially inappropriate medications. Using a 5-point Likert scale (from strong agreement to strong disagreement), mean ratings from the experts were evaluated for each drug selected in the first round. The participants were first asked to comment on the potential inappropriateness of a preliminary list of drugs, and to propose alternate substances missing in the previous questionnaire for a second rating process. All drugs whose upper limit of the 95% CI was less than 3.0 were classified as potentially inappropriate. Drugs with a 95% CI enclosing 3.0 entered a second rating by the experts, in addition to other substances suggested during the first questionnaire. Drugs in the second rating were evaluated in comparable fashion to the first one. The final list was synthesized from the results in both rounds. RESULTS: Out of a preliminary list of 102 drugs, 61 drugs (59.2%) were classified as potentially inappropriate for geriatric persons in the first Delphi- round. In the second rating, six drugs that were reevaluated, and six drugs proposed additionally, were rated as potentially inappropriate. The final list contains 73 drugs to be avoided in older patients because of an unfavorable benefit/risk profile and/or unproven effectiveness. The list also contains suggestions for therapeutic alternatives and information about pharmacological and pharmacokinetic characteristics of all drugs judged as potentially inappropriate. CONCLUSION: The current Austrian list of potentially inappropriate medications may be a helpful tool for clinicians to increase the quality of prescribing in older patients. Like all explicit lists previously published, its validity needs to be proven in validation studies.

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References

  1. Beers MH, Ouslander JG, Rollingher J, Reuben DB, Beck JC. Explicit criteria for determining inappropriate medication use in nursing home residents. Arch Intern Med 1991;151:1825–32

    PubMed  Article  CAS  Google Scholar 

  2. Gurwitz JH, Rochon P, and the Food and Drug Administration. Improving the Quality of Medication Use in Elderly Patients: A Not-So-Simple Prescription. Arch Intern Med 2002;162:1707–12

    Article  Google Scholar 

  3. Onder G, Landi F, Cesari M, Gambassi G, Carbonin P, Bernabei R. Inappropriate medication use among hospitalized older adults in Italy: results from the Italian Group of Pharmacoepidemiology in the Elderly. Eur J Clin Pharmacol 2003;59:157–62

    PubMed  Google Scholar 

  4. Lang PO, Hasso Y, Drame M, Vogt-Ferrier N, Prudent M, Gold G, Michel JP. Potentially inappropriate prescribing including under-use amongst older patients with cognitive or psychiatric co-morbidties. Age Ageing 2010;39(3):373–81

    PubMed  Article  Google Scholar 

  5. Nygaard HA, Naik M, Ruths S, Straand J. Nursing-home residents and their drug use: a comparison between mentally intact and mentally impaired residents. The Bergen district nursing home (BEDNURSE) study. Eur J Clin Pharmacol 2003;59:463–9

    PubMed  Article  Google Scholar 

  6. Ruggiero C, Lattanzio F, Dell'Aquila G, Gasperini B, Cherubini A. Inappropriate drug prescriptions among older nursing home residents. Drugs Aging 2009;26(suppl.):15–30

    PubMed  Article  Google Scholar 

  7. Landi F, Russo A, Liperoti R, Barillaro C, Danese P, Pahor M, et al. Impact of inappropriate drug use on physical performance among a frail elderly population living in the community. Eur J Clin Pharmacol 2007;63:791–9

    PubMed  Article  CAS  Google Scholar 

  8. Ryan C, O'Mahony D, Kennedy J, Weedle P. Byrne S. Potentially inappropriate prescribing in an Irish elderly population in primary care. Br J Clin Pharmacol 2009;68:936–47

    PubMed  Article  Google Scholar 

  9. Laroche ML, Charmes JP, Nouaille, Y, Picard N, Merle L. Is inappropriate medication use a major cause of adverse drug reactions in the elderly? Br J Clin Pharmacol 2007;63:177–86

    PubMed  Article  Google Scholar 

  10. Passarelli, MC, Jacob-Filho V, Figueras A. Adverse drug reactions in an elderly hospitalised population: inappropriate prescription is a leading cause. Drugs Aging 2005;22:767–77

    PubMed  Article  Google Scholar 

  11. Lindley CM, Tully MP, Paramsothy V, Tallis RC. Inappropriate medication is a major cause of adverse drug reactions in elderly patients. Age Ageing 2009;21:294–300

    Article  Google Scholar 

  12. Albert SM, Alberto C, Hanlon J. Potentially inappropriate medications and risk of hospitalization in retirees: analysis of a US Retiree Health Claims Database. Drugs Aging 2010;27(5):407–15

    PubMed  Article  Google Scholar 

  13. Schneeweiss S, Hasford J, Göttler M, Hoffmann A, Riethling A-K, Avorn J. Admissions caused by adverse drug events to internal medicine and emergency departments in hospitals: a longitudinal population-based study. Eur J Clin Pharmacol 2002;58:285–91

    PubMed  Article  Google Scholar 

  14. Budnitz DS, Shebab N, Kegler SR, Richards CL. Medication use leading to emergency department visits for adverse drug events in older adults. Ann Intern Med 2007;147:755–65

    PubMed  Google Scholar 

  15. Fu AZ, Jiang JZ, Reeves JH, Fincham JE, Liu GG, Perri M 3rd. Potentially inappropriate medication use and healthcare expenditures in the US community-dwelling elderly. Med Care 2007;45:472–6

    PubMed  Article  Google Scholar 

  16. Kölzsch M, Kopke K, Fischer T, Hofmann W, Kuhnert R, Bolbrinker J, et al. Prescribing of inappropriate medication in nursing home residents in Germany according to a French consensus list: a cross-sectional cohort study. Pharmacoepidemiol Drug Saf 2010 Sept 16 [Epub ahead of print]

  17. Hanlon JT, Schmader KE, Koronkowski MJ, Weinberger M, Landsman PB, Samsa GP, et al. Adverse drug events in high risk older outpatients. J Am Geriatr Soc 1997;45:945–8

    PubMed  CAS  Google Scholar 

  18. Beers MH. Explicit criteria for determining potentially inappropriate medication use by the elderly. Arch Intern Med 1997;157:1531–6

    PubMed  Article  CAS  Google Scholar 

  19. Fick DM, Cooper JW, Wade WE, Waller JL, Maclean R, Beers MH. Updating the Beers Criteria for potentially inappropriate medication use in older adults. Arch Intern Med 2003;163:2716–24

    PubMed  Article  Google Scholar 

  20. McLeod PJ, Huang A, Tamblyn RM, Gayton DC. Defining inappropriate practices in prescribing for elderly people: a national consensus panel. Can Med Assoc J 1997;156:385–91

    CAS  Google Scholar 

  21. Laroche ML, Charmes JP, Merle L. Potentially inappropriate medications in the elderly: a French consensus panel list. Eur J Clin Pharmacol 2007;63:725–31

    PubMed  Article  Google Scholar 

  22. Holt S, Schmiedl S, Thürmann PA. Potentiell inadäquate Medikation für ältere Menschen: Die PRISCUS Liste. Deutsches Ärzteblatt 2010;107:543–51

    Google Scholar 

  23. Gallagher P, Ryan C, Byrne S, Kennedy J, O'Mahony D. Screening tool of older person's prescriptions (STOPP) and screening tool to alert doctors to right treatment (START). Consensus validation. Int J Clin Pharmacol Ther 2008;46:72–83

    PubMed  CAS  Google Scholar 

  24. Dalkey NC. The Delphi method: an experimental study of a group opinion. Rand Corporation, Santa Monica, RM–5888-PR; 1969

  25. Matell MS, Jacoby J. Is there an optimal number of alternatives for Likert scale items? Reliability and validity. Educ Psychol Measure 1971;31:657–74

    Article  Google Scholar 

  26. Leendertse AJ, Egberts AC, Stoker LJ, van den Bemt P, for the HARM Study Group. Frequency of and risk factors for preventable medication-related hospital admissions in the Netherlands Arch Intern Med 2008;168(17):1890–6

    PubMed  Article  Google Scholar 

  27. Fialova D, Topinkova E, Gambassi G, Finne-Soveri H, Jonsson PV, Carpenter I, et al. AdHOC Project Research Group. Potentially inappropriate medication use among elderly home care patients in Europe. JAMA 2005;293:1348–58

    PubMed  Article  CAS  Google Scholar 

  28. Schuler J, Dückelmann C, Beindl W, Prinz E, Michalski T, Pichler M. Polypharmacy and inappropriate prescribing in elderly internal-medicine patients in Austria. Wien Klin Wochenschr 2008;120:733–41

    PubMed  Article  Google Scholar 

  29. Trelle S, Reichenbach S, Wandel S, Hildebrand P, Tschannen B, Villiger PM, Egger M, Jüni P. Cardiovascular safety of non-steroidal ant-inflammatory drugs: network meta-analysis. BMJ 2011;342:c7086

    PubMed  Article  Google Scholar 

  30. Masso Gonzalez EL, Patrignani P, Tacconelli S, Garcia Rodriguez LA. Variability among nonsteroidal anti-inflammatory drugs in risk of upper gastrointestinal bleeding. Arthritis Rheum 2010;62(6):1592–601

    PubMed  Article  Google Scholar 

  31. Stirnimann G, Kessebohm K, Lauterburg B. Liver injury caused by drugs: an update. Swiss Med Wkly 2010;140:w13080

    PubMed  Google Scholar 

  32. Sudano I, Flammer AJ, Periat D, Enseleit F, Hermann M, Wolfrum M et al. Acetaminophen increases blood pressure in patients with coronary artery disease. Circulation 2010;122(18):1789–96

    PubMed  Article  CAS  Google Scholar 

  33. Salomon DH, Rassen JA, Glynn RJ, Garneau K, Levin R, Lee J, Schneeweiss S. The comparative safety of opioids for non-malignant pain in older adults. Arch Intern Med 2010;170(22):1979–86

    Article  Google Scholar 

  34. Mann E, Köpke S, Haastart B, Pitkälä K, Meyer G. Psychotropic medication use among nursing home residents in Austria: a cross-sectional study. BMC Geriatrics 2009;21(9):18

    Article  Google Scholar 

  35. Lonergan E, Britton AM, Luxenberg J. Antipsychotics for delirium. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD005594. DOI: 10.1002/14651858.CD005594.pub2

  36. Alexopoulos GS, Streim J, Carpenter D, Docherty JP. Expert Consensus Panel for Using antipsychotic agents in older patients. J Clin Psychiatry 2004;65 (Suppl. 2):5–99

    PubMed  Google Scholar 

  37. Bloom HG, Ahmned J, Alessi CA, Ancoli-Israel S, Buysse DJ, Kryger MH, et al. Evidence-based recommendations for the assessment and management of sleep disorders in older persons. JAGS 2009;57:671–789

    Article  Google Scholar 

  38. Glass J, Lanctot KL, Herrmann N, Sproule BA, Busto UE. Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits. BMJ 2005;331:1169–76

    PubMed  Article  Google Scholar 

  39. Diener HC, Putzki N. Leitlinien für die Diagnostik und Therapie in der Neurologie, Georg Thieme Verlag, 4th revised edition 2008, available from http://www.dgn.org/neurologische-leitlinien-online.html, accessed December 16, 2010

  40. Stahlmann R, Lide H. Safety considerations of fluorquinolones in the elderly: an update. Drugs Aging 2010;27(3):193–209

    PubMed  Article  Google Scholar 

  41. Gallagher P, O'Mahony D. STOPP Screening tool of older persons' potentially inappropriate prescriptions: application to acutely ill elderly patients and comparison with Beers' criteria. Age Ageing 2008;37:673–9

    PubMed  Article  Google Scholar 

  42. Hamilton H, Gallagher P, Ryan C, Byrne S, O'Mahony D. Potentially Inappropriate medications defined by STOPP Criteria and the risk of adverse drug events in older hospitalized patients. Arch Intern Med 2011;171(11):1013–9

    PubMed  Article  Google Scholar 

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Mann, E., Böhmdorfer, B., Frühwald, T. et al. Potentially inappropriate medication in geriatric patients: the Austrian consensus panel list. Wien Klin Wochenschr 124, 160–169 (2012). https://doi.org/10.1007/s00508-011-0061-5

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Keywords

  • Pharmacotherapy
  • Inappropriate prescribing
  • Older patients
  • Aged
  • Delphi method
  • Austria