Springer Nature is making SARS-CoV-2 and COVID-19 research free. View research | View latest news | Sign up for updates

Criteria for Drug Selection in Frail Elderly Persons

  • 392 Accesses

  • 15 Citations

Abstract

Background: Elderly patients with multiple morbidities and polypharmacy are at an increased risk of adverse drug events (ADEs). Appropriate prescribing, preserving the balance between drug effectiveness and safety, and treatment adherence may prevent these ADEs. In this study, we investigated which drug properties, such as effectiveness, safety, clinical experience and convenience, are relevant to the choice of medicine most appropriate for frail elderly patients.

Objectives: The primary aim of this study was to develop a set of criteria to assist in the selection of the most appropriate drug within a drug class for the treatment of frail elderly patients. A secondary goal was to test the usefulness of the set of criteria in the prescription of antipsychotics for delirium and behavioural and psychological symptoms of dementia (BPSD).

Methods: Thirty-one criteria potentially relevant to the choice of appropriate drugs for frail elderly patients were selected on the basis of a literature search in MEDLINE (1966–2008), EMBASE (1947–2008) and the Cochrane Library (1993–2008). This list was reviewed by 46 experts (24 physicians, 22 pharmacists), who scored each item for relevance in clinical practice on a scale from 1 to 10 (where 1 is not important and 10 is very important). By consensus, the authors selected the most relevant criteria for the final set of criteria. The usefulness of the final set of criteria was assessed with regard to the prescription of antipsychotics for delirium and BPSD.

Results: The final set of 23 items consisted of 3 items on effectiveness, 14 on safety, including pharmacokinetic and pharmacodynamic criteria, 3 on clinical experience and 3 on convenience. Assessment using these criteria of the appropriateness of antipsychotics prescribed for delirium and BPSD revealed that certain drugs should be prescribed with caution to patients with Parkinson’s disease and Lewy body dementia.

Conclusions: The criteria identified in this study, selected on the basis of a literature review and clinical expert opinion, represent a promising approach for determining the appropriateness of a drug for use in frail elderly individuals relative to alternative drugs for the same indication or from the same class.

This is a preview of subscription content, log in to check access.

Table I
Table II
Table III
Table IV

References

  1. 1.

    Rockwood K, Hogan DB, MacKnight C. Conceptualisation and measurement of frailty in elderly people. Drugs Aging 2000 Oct; 17(4): 295–302

  2. 2.

    Gobbens RJ, Luijkx KG, Wijnen-Sponselee MT, et al. Towards an integral conceptual model of frailty. J Nutr Health Aging 2010 Mar; 14(3): 175–81

  3. 3.

    Fried LP, Ferrucci L, Darer J, et al. Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care. J Gerontol A Biol Sci Med Sci 2004 Mar; 59(3): 255–63

  4. 4.

    Cusack BJ. Pharmacokinetics in older persons. Am J Geriatr Pharmacother 2004 Dec; 2(4): 274–302

  5. 5.

    Mangoni AA, Jackson SH. Age-related changes in pharmacokinetics and pharmacodynamics: basic principles and practical applications. Br J Clin Pharmacol 2004 Jan; 57(1): 6–14

  6. 6.

    Hajjar ER, Cafiero AC, Hanlon JT. Polypharmacy in elderly patients. Am J Geriatr Pharmacother 2007 Dec; 5(4): 345–51

  7. 7.

    Beijer HJ, de Blaey CJ. Hospitalisations caused by adverse drug reactions (ADR): a meta-analysis of observational studies. Pharm World Sci 2002 Apr; 24(2): 46–54

  8. 8.

    De Groot M, Van Grootheest K. Be careful with painkillers for the elderly: high use, high risk. Pharm Weekbl 2007; 142(44): 31–2

  9. 9.

    Leendertse AJ, Egberts AC, Stoker LJ, et al. Frequency of and risk factors for preventable medication-related hospital admissions in the Netherlands. Arch Intern Med 2008 Sep 22; 168(17): 1890–6

  10. 10.

    van der Hooft CS, Sturkenboom MC, van GK, et al. Adverse drug reaction-related hospitalisations: a nationwide study in The Netherlands. Drug Saf 2006; 29(2): 161–8

  11. 11.

    Leendertse AJ, Visser D, Egberts AC, et al. The relationship between study characteristics and the prevalence of medication-related hospitalizations: a literature review and novel analysis. Drug Saf 2010 Mar 1; 33(3): 233–44

  12. 12.

    Trinh-Duc A, Doucet J, Bannwarth B, et al. Admissions of elderly to French emergency departments related to adverse drug events [in French]. Therapie 2007 Sep; 62(5): 437–41

  13. 13.

    GIP: the drug information system of the Dutch Health Care Insurance Board [in Dutch]. Amsterdam: College voor zorgverzekeringen (CVZ), 2008 Apr

  14. 14.

    Dutch College of General Practitioners (NHG). NHG — dementia standard [in Dutch]. Utrecht: NHG, 2003 [online]. Available from URL: http://nhg.artsennet.nl/kenniscentrum/k_richtlijnen/k_nhgstandaarden/NHGStandaard/M21_std.htm [Accessed 2011 Feb 21]

  15. 15.

    Dutch College of General Practitioners (NHG). NHG — delirium in the elderly standard [in Dutch]. Utrecht: NHG, 2003 [online]. Available from URL: http://nhg.artsennet.nl/kenniscentrum/k_richtlijnen/k_nhgstandaarden/Samenvattingskaartje-NHGStandaard/M77_svk.htm [Accessed 2011 Feb 21]

  16. 16.

    Dutch Institute for Healthcare Improvement CBO guideline: delirium [in Dutch]. Utrecht: Bestuur Nederlandse Vereniging voor Psychiatrie (NVVP), 2004 [online]. Available from URL: http://www.cbo.nl/Downloads/208/delirium_rl_2005.pdf [Accessed 2011 Feb 21]

  17. 17.

    American Psychiatric Association (APA). Practice guideline for the treatment of patients with delirium. Arlington (VA): APA, 2004 [online]. Available from URL: http://www.psychiatryonline.com/content.aspx?aID=147863 [Accessed 2011 Feb 21]

  18. 18.

    Dutch Institute for Healthcare Improvement CBO guideline: dementia [in Dutch]. Utrecht: Nederlandse Vereniging voor Klinische Geriatrie (NVKG), 2005 [online]. Available from URL: http://www.cbo.nl/Downloads/387/rl_dement_2005.pdf [Accessed 2011 Feb 21]

  19. 19.

    Shelton PS, Fritsch MA, Scott MA. Assessing medication appropriateness in the elderly: a review of available measures. Drugs Aging 2000 Jun; 16(6): 437–50

  20. 20.

    Spinewine A, Schmader KE, Barber N, et al. Appropriate prescribing in elderly people: how well can it be measured and optimised? Lancet 2007 Jul 14; 370(9582): 173–84

  21. 21.

    Drenth-van Maanen AC, van Marum RJ, Knol W, et al. Prescribing optimization method for improving prescribing in elderly patients receiving polypharmacy: results of application to case histories by general practitioners. Drugs Aging 2009; 26(8): 687–701

  22. 22.

    Hanlon JT, Schmader KE, Samsa GP, et al. A method for assessing drug therapy appropriateness. J Clin Epidemiol 1992 Oct; 45(10): 1045–51

  23. 23.

    Beers MH, Ouslander JG, Rollingher I, et al. Explicit criteria for determining inappropriate medication use in nursing home residents. UCLA Division of Geriatric Medicine. Arch Intern Med 1991 Sep; 151(9): 1825–32

  24. 24.

    Beers MH. Explicit criteria for determining potentially inappropriate medication use by the elderly: an update. Arch Intern Med 1997 Jul 28; 157(14): 1531–6

  25. 25.

    Fick DM, Cooper JW, Wade WE, et al. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med 2003 Dec 8; 163(22): 2716–24

  26. 26.

    Laroche ML, Charmes JP, Merle L. Potentially inappropriate medications in the elderly: a French consensus panel list. Eur J Clin Pharmacol 2007 Aug; 63(8): 725–31

  27. 27.

    McLeod PJ, Huang AR, Tamblyn RM, et al. Defining inappropriate practices in prescribing for elderly people: a national consensus panel. CMAJ 1997 Feb 1; 156(3): 385–91

  28. 28.

    Rognstad S, Brekke M, Fetveit A, et al. The Norwegian General Practice (NORGEP) criteria for assessing potentially inappropriate prescriptions to elderly patients: a modified Delphi study. Scand J Prim Health Care 2009; 27(3): 153–9

  29. 29.

    Barry PJ, Gallagher P, Ryan C, et al. START (screening tool to alert doctors to the right treatment): an evidence-based screening tool to detect prescribing omissions in elderly patients. Age Ageing 2007 Nov; 36(6): 632–8

  30. 30.

    Gallagher P, Ryan C, Byrne S, et al. STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment): consensus validation. Int J Clin Pharmacol Ther 2008 Feb; 46(2): 72–83

  31. 31.

    van Roon EN, van den Bemt PM, Jansen TL, et al. An evidence-based assessment of the clinical significance of drug-drug interactions between disease-modifying antirheumatic drugs and non-antirheumatic drugs according to rheumatologists and pharmacists. Clin Ther 2009 Aug; 31(8): 1737–46

Download references

Acknowledgements

The project was supported by the Dutch College of Health Insurance (CVZ), and this article was written with their consent. The CVZ did not participate in the writing process. The authors have no conflicts of interest that are directly relevant to the content of this study.

We would like to thank the experts who answered the questionnaire, and especially the experts who participated on the expert panel and discussed the results of the literature study concerning efficacy, safety, experience and convenience of antipsychotics in the frail elderly. The experts who answered the questionnaire were W. Achterberg, A.J. Arends, F. Boersma, M.L. Bouvy, H. Buurma, C.M. Dantuma-Wering, C. de Groot, S. de Rooy, W. Denneboom, T. Dhondt, A.C.G. Egberts, S. Flikweert, H. Folmer, J.C. Heijboer-Vinks, J. Hugtenburg, R. Janknegt, P. Jue, B. Kleijer, C.A.J. Knibbe, W. Knol, R. Kok, A.W. Lenderink, J. Lüers, C.K. Manesse, J.G. Maring, K.L.L. Movig, F. Oostervink, T. Schalekamp, A.F.A.M. Schobben, M. Smalbrugge, M.J. Swart-Zuijderduijn, D.J. Touw, Th.F.J. Tromp, C. van ‘t Hooft, D.Z.B. van Asselt, P.M.L.A. van de Bemt, B.J.F. van den Bemt, C.J. van der Graaf, J.R. van der Laan, C.M.J. van der Linden, K. van Dijk, T. van Gelder, N.A.E.M. van Lent-Evers, E.J.M. van Melick, L. Veehof, R.W. Vingerhoets, E.P. Walma and S. Zuidema. The experts who participated on the expert panel and discussed the literature results were A. Arends, F. Boersma, W. Knol, F. Moolenaar, F. Oostervink, T. Schalekamp, K. Taxis and J. van der Laan.

Author information

Correspondence to Dr Rob J. van Marum.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Huisman-Baron, M., van der Veen, L., Jansen, P.A.F. et al. Criteria for Drug Selection in Frail Elderly Persons. Drugs Aging 28, 391–402 (2011). https://doi.org/10.2165/11587200-000000000-00000

Download citation

Keywords

  • Clozapine
  • Olanzapine
  • Aripiprazole
  • Community Pharmacist
  • Paliperidone