Drugs & Aging

, Volume 22, Issue 1, pp 69–82 | Cite as

The Association of Inappropriate Drug Use with Hospitalisation and Mortality

A Population-Based Study of the Very Old
  • Inga KlarinEmail author
  • Anders Wimo
  • Johan Fastbom
Original Research Article


Background and objective

Inappropriate prescribing is an important and possibly preventable risk factor for adverse drug reactions (ADRs) in the elderly, and hospital-based studies have shown that a large proportion of admissions is a result of ADRs. However, little is known about how inappropriate drug use (IDU) affects the elderly at the population level. The aim of this study was to explore possible associations of IDU with acute hospitalisation and mortality in an elderly population during 3 years of follow-up.

Patients and methods

Data from a rural, population-based, longitudinal cohort study within the Kungsholmen Project, Sweden, were used. 785 participants, ≥75 years of age, had complete data on drug use and selected covariates collected during baseline investigation from 1995 to 1998, and were included in the study. Hospitalisation and mortality data during 3 years after inclusion were collected. IDU was assessed at baseline using consensus-based criteria applicable to available data (derived from Beers’ criteria, Canadian criteria and clinical indicators of drug-related morbidity in older adults) with the addition of potentially dangerous drug duplication and additional potentially hazardous drug-drug interactions. IDU was defined as presence of at least one inappropriate drug regimen according to the study criteria. Logistic regression and proportional hazard models were used, respectively, to study the association of IDU with hospitalisation and mortality.


Drugs were used on a regular or ‘as needed’ basis by 91.6% of the study population, with a mean of 4.4 drugs per person. IDU was common, with a prevalence of 18.6% and was associated with increased risk of at least one acute hospitalisation in community-living elderly, after adjustment for age, sex, education, comorbidity, dependency in activities of daily living (ADL) and smoking. The odds ratio was 2.72 (95% CI 1.64, 4.51). No association with mortality was found, after adjustment for age, sex, housing, education, comorbidity, ADL-dependency, smoking and body mass index.


Polypharmacy and IDU are common among the elderly and IDU is associated with acute hospitalisation in community-living elderly. Although causality cannot be established with this study design, the results are consistent with the high prevalence of drug-related hospital admissions found in hospital-based studies. Our results indicate that it is desirable with current knowledge, to reduce IDU through information to physicians and careful prescribing.


Nursing Home Disopyramide Inappropriate Drug Sheltered Housing Drug Utilisation Review 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



This study was supported by The National Board of Health and Welfare, Sweden; Forum for Research and Development (FOU-forum), The County Council of Gävleborg, Sweden; The Federation of Swedish County Councils (Landstingsförbundet), Sweden, Dnr 1297/00; The National Corporation of Swedish Pharmacies’ Fund for Research and Studies in Health Economics and Social Pharmaceutics (Stiftelsen Apoteksbolagets fond för forskning och studier i hälsoekonomi och socialfarmaci), Sweden.

The authors have no conflicts of interest directly relevant to this review.


  1. 1.
    Lindley CM, Tully MP, Paramsothy V, et al. Inappropriate medication is a major cause of adverse drug reactions in elderly patients. Age Ageing 1992; 2: 294–300CrossRefGoogle Scholar
  2. 2.
    Aparasu RR, Mort JR. Inappropriate prescribing for the elderly: Beers criteria-based review. Ann Pharmacother 2000 Mar; 34: 338–46PubMedCrossRefGoogle Scholar
  3. 3.
    Giron MST, Wang HX, Bernsten C, et al. The appropriateness of drug use in an older nondemented and demented population. J Am Geriate Soc 2001; 49(3): 277–83CrossRefGoogle Scholar
  4. 4.
    Hanlon JT, Schmader KE, Boult C, et al. Use of inappropriate prescription drugs by older people. J Am Geriate Soc 2002; 50(1): 26–34CrossRefGoogle Scholar
  5. 5.
    Liu GG, Christensen DB. The continuing challenge of inappropriate prescribing in the elderly: an update of the evidence. J Am Pharm Assoc (Wash) 2002; 42(6): 847–57Google Scholar
  6. 6.
    Beijer HJM, de Blaey CJ. Hospitalisations caused by adverse drug reactions (ADR): a meta-analysis of observational studies. Pharm World Sci 2002; 24(2): 46–54PubMedCrossRefGoogle Scholar
  7. 7.
    Atkin PA, Veitch PC, Veitch EM, et al. The epidemiology of serious adverse drug reactions among the elderly. Drugs Aging 1999; 14(2): 141–52PubMedCrossRefGoogle Scholar
  8. 8.
    Stewart RB, Cooper JW. Polypharmacy in the aged: practical solutions. Drugs Aging 1994; 4(6): 449–61PubMedCrossRefGoogle Scholar
  9. 9.
    Stuck AE, Beers MH, Steiner A, et al. Inappropriate medication use in community-residing older persons. Arch Intern Med 1994; 154: 2195–200PubMedCrossRefGoogle Scholar
  10. 10.
    Spore DL, Mor V, Larrat P, et al. Inappropriate drug prescriptions for elderly residents of board and care facilities. Am J Public Health 1997; 87(3): 404–9PubMedCrossRefGoogle Scholar
  11. 11.
    Rochon PA, Gurwitz JH. Optimising drug treatment for elderly people: the prescribing cascade. BMJ 1997; 315(7115): 1096–9PubMedCrossRefGoogle Scholar
  12. 12.
    Buajordet I, Ebbesen J, Erikssen J, et al. Fatal adverse drug events: the paradox of drug treatment. J Intern Med 2001; 250: 327–41PubMedCrossRefGoogle Scholar
  13. 13.
    Shelton PS, Fritsch MA, Scott MA. Assessing medication appropriateness in the elderly: a review of available measures. Drugs Aging 2000; 16(6): 437–50PubMedCrossRefGoogle Scholar
  14. 14.
    Hanlon JT, Fillenbaum GG, Kuchibhatla M, et al. Impact of inappropriate drug use on mortality and functional status in representative community dwelling elders. Med Care 2002; 40(2): 166–76PubMedCrossRefGoogle Scholar
  15. 15.
    Fillenbaum GG, Hanlon JT, Landerman LR, et al. Impact of inappropriate drug use on health services utilization among representative older community-dwelling residents. Am J Geriate Pharmacother 2004; 2(2): 92–101CrossRefGoogle Scholar
  16. 16.
    Gupta S, Rappaport HM, Bennett LT. Inappropriate drug prescribing and related outcomes for elderly Medicaid beneficiaries residing in nursing homes. Clin Ther 1996; 18(1): 183–96PubMedCrossRefGoogle Scholar
  17. 17.
    Chin MH, Wang LC, Jin L, et al. Appropriateness of medication selection for older persons in an urban academic emergency department. Acad Emerg Med 1999; 6(12): 1232–42PubMedCrossRefGoogle Scholar
  18. 18.
    Aparasu RR, Mort JR. Prevalence, correlates and associated outcomes of potentially inappropriate psychotropic use in the community-dwelling elderly. Am J Geriate Pharmacother 2004; 2(2): 102–11CrossRefGoogle Scholar
  19. 19.
    Fu AZ, Liu GG, Christensen DB. Inappropriate medication use and health outcomes in the elderly. J Am Geriate Soc 2004; 52(11) 1934–9CrossRefGoogle Scholar
  20. 20.
    Fratiglioni L, Viitanen M, Backman L, et al. Occurrence of dementia in advanced age: the study design of the Kung-sholmen Project. Neuroepidemiology 1992; 11Suppl. 1: 29–36PubMedCrossRefGoogle Scholar
  21. 21.
    Klarin I, Fastbom J, Wimo A. A population-based study of drug use in the very old living in a rural district of Sweden, with focus on cardiovascular drug consumption: comparison with an urban cohort. Pharmacoepidemiol Drug Saf 2003; 12: 669–78PubMedCrossRefGoogle Scholar
  22. 22.
    WHO Collaborating Centre for Drug Statistics and Methodology. Guidelines for ATC classification and DDD assignment. Oslo, Norway: World Health Organization, 1995Google Scholar
  23. 23.
    Beers MH. Explicit criteria for determining potentially inappropriate medication use by the elderly: an update. Arch Intern Med 1997 Jul 28; 157: 1531–6PubMedCrossRefGoogle Scholar
  24. 24.
    McLeod PJ, Huang AR, Tamblyn RM, et al. Defining inappropriate practices in prescribing for elderly people: a national consensus panel. CMAJ 1997; 156(3): 385–91PubMedGoogle Scholar
  25. 25.
    Robertson HA, MacKinnon NJ. Development of a list of consensus-approved clinical indicators of preventable drug-related morbidity in older adults. Clin Ther 2002; 24(10): 1595–613PubMedCrossRefGoogle Scholar
  26. 26.
    Sjöqvist F. Drug interactions [in Swedish]. In: FASS. Läkemedel i Sverige. Forteckning over humanläkemedel. Stockholm, Sweden: LINFO Läkemedelsinformation AB, 1997: 1220–73Google Scholar
  27. 27.
    Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls in older people: a systematic meta-analysis. I: psychotropic drugs. J Am Geriate Soc 1999; 47(1): 30–9Google Scholar
  28. 28.
    Moore AR, O’Keeffe ST. Drug-induced cognitive impairment in the elderly. Drugs Aging 1999; 15(1): 15–28PubMedCrossRefGoogle Scholar
  29. 29.
    Miller EA, Weissert WG. Predicting elderly people’s risk for nursing home placement, hospitalization, functional impairment, and mortality: a synthesis. Med Care Res Rev 2000, 97Google Scholar
  30. 30.
    Charlson ME, Pompei P, Ales KL, et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987; 40(5): 373–83PubMedCrossRefGoogle Scholar
  31. 31.
    Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol 1992; 45(6): 613–9PubMedCrossRefGoogle Scholar
  32. 32.
    Buntinx F, Niclaes L, Suetens C, et al. Evaluation of Charlson’s comorbidity index in elderly living in nursing homes. J Clin Epidemiol 2002; 55: 1144–7PubMedCrossRefGoogle Scholar
  33. 33.
    Bravo G, Dubois MF, Réjean H, et al. A prospective evaluation of the Charlson comorbidity index for use in long-term care patients. J Am Geriate Soc 2002; 50(4): 740–5CrossRefGoogle Scholar
  34. 34.
    Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron 1976; 16: 31–41PubMedCrossRefGoogle Scholar
  35. 35.
    Jassal V, Fillit H, Oreopoulos DG. Diseases of the aging kidney. In: Tallis R, Fillit H, Brocklehurst JC, editors. Brocklehurst’s textbook of geriatric medicine and gerontology. 5th ed. London: Churchill Livingstone, 1998: 949–71Google Scholar
  36. 36.
    Flodin L, Svensson S, Cederholm T. Body mass index as a predictor of 1 year mortality in geriatric patients. Clin Nutr 2000; 19(2): 121–5PubMedCrossRefGoogle Scholar
  37. 37.
    Grabowski DC, Ellis JE. High body mass index does not predict mortality in older people: analysis of the longitudinal study of aging. J Am Geriate Soc 2001; 49(7): 968–79CrossRefGoogle Scholar
  38. 38.
    Katz S, Ford AB, Moskowitz RW, et al. Studies of illness in the aged. The index of ADL: a standardized measure of biological and psychosocial function. JAMA 1963; 185(12): 914–9PubMedCrossRefGoogle Scholar
  39. 39.
    Jörgensen TM, Isacsson DGL, Thorslund M. Prescription drug use among ambulantory eldery in a Swedish municipality. Ann Pharmacother 1993 Sep; 27: 1120–5PubMedGoogle Scholar
  40. 40.
    Chen Y-F, Dewey ME, Avery AJ, et al. Self-reported medication use for older people in England and Wales. J Clin Pharm Ther 2001; 26: 129–40PubMedCrossRefGoogle Scholar
  41. 41.
    Lassila HC, Stoehr GP, Ganguli M, et al. Use of prescription medications in an elderly rural population: the MoVIES project. Ann Pharmacother 1996 Jun; 30: 589–95PubMedGoogle Scholar
  42. 42.
    Biverkningsrapportering i Sverige 1998 [in Swedish]. Information från Läkemedelsverket (Information from the Medical Product Agency, Sweden) 1999; 10(4): 23 [online]. Available from URL: [Accessed 2004 Nov 21]
  43. 43.
    Table 60: population by sex, marital status and age by single years. In: Statistical yearbook of Sweden. Örebro, Sweden: Statistics Sweden, 2000: 57–8Google Scholar
  44. 44.
    Freeman G, Hjortdahl P. What future for continuity of care in general practice? BMJ 1997; 314(7098): 1870–3PubMedCrossRefGoogle Scholar
  45. 45.
    Piecoro LT, Browning SR, Prince TS, et al. A database analysis of potentially inappropriate drug use in an elderly Medicaid population. Pharmacotherapy 2000; 20(2): 221–8PubMedCrossRefGoogle Scholar
  46. 46.
    Dhalla IA, Anderson GM, Mamdani MM, et al. Inappropriate prescribing before and after nursing home admission. J Am Geriate Soc 2002; 50(6): 995–1000CrossRefGoogle Scholar
  47. 47.
    Hanlon JT, Fillenbaum GG, Schmader KE, et al. Inappropriate drug use among community-dwelling elderly. Pharmacotherapy 2000; 20(5): 575–82PubMedCrossRefGoogle Scholar
  48. 48.
    Stuart B, Coulson NE. Dynamic aspects of prescription drug use in an elderly population. Health Serv Res 1993; 28: 237–64PubMedGoogle Scholar
  49. 49.
    Garrard J, Dunham T, Makris L, et al. Longitudinal study of psychotropic drug use by elderly nursing home residents. J Gerontol 1992; 47(6): M183–8PubMedCrossRefGoogle Scholar
  50. 50.
    Hanlon JT, Schmader KE, Ruby CM, et al. Suboptimal prescribing in older inpatients and outpatients. J Am Geriate Soc 2001; 49(2): 200–9CrossRefGoogle Scholar

Copyright information

© Adis Data Information BV 2005

Authors and Affiliations

  1. 1.Division of Geriatric Epidemiology, NeurotecKarolinska InstitutetStockholmSweden
  2. 2.Stockholm Gerontology Research CenterStockholmSweden
  3. 3.Clinic of Geriatric MedicineKarolinska University Hospital HuddingeStockholmSweden

Personalised recommendations