Abstract
The disproportionate use of medications, combined with age-related pharmacokinetic and pharmacodynamic changes, places older adults at high risk for medication related problems (MRPs). MRPs demonstrate significant morbidity, mortality and economic impact among healthcare systems. The negative outcomes associated with MRPs emphasise the need for more careful and thorough assessments of drug therapy among older adults.
In the 1990s a number of methods and instruments were developed to assist in the assessment of medication appropriateness. These tools may be categorised by criteria as: implicit, explicit or one utilising a combination of implicit and explicit criteria. This article reviews these available tools and outlines the advantages and disadvantages of each. In conclusion, those instruments considered to be comprised of both implicit and explicit criteria offer a more thorough assessment of medication appropriateness.
Similar content being viewed by others
References
Hall WJ. Update in geriatrics. Ann Intern Med 1997; 127(7): 557–64
Stewart RB. Drag use in the elderly. In: Delafuente JC, Stewart RB, editors. Therapeutics in the elderly. 2nd ed. Cincinnati: Harvey Whitney Books, 1995: 174–89
Broderick E. Prescribing patterns for nursing home residents in the US: the reality and the vision. Drags Aging 1997; 11: 255–60
Chrischilles EA, Foley DJ, Wallace RB, et al. Use of medications by persons 65 and over: data from the Established Populations for Epidemiologic Studies of the Elderly. J Gerontol 1992; 47: M137–44
Chrischilles EA, Segar ET, Wallace RB. Self-reported adverse drag reactions and related resource use: a study of community-dwelling persons 65 years of age and older. Ann Intern Med 1992; 117: 634–40
Hanlon JT, Schmader KE, Koronkowski MJ, et al. Adverse drug events in high risk older outpatients. J Am Geriatr Soc 1997; 45: 945–8
May JR. Adverse drug reactions and interactions. In: Dipiro JT, Talbert RL, Yee GC, et al., editors. Pharmacotherapy: apathophysiologic approach. 3rd ed. Stamford: Appleton and Lange, 1997: 101–16
Rochon PA, Gurwitz JH. Optimising drag treatment for elderly people: the prescibing cascade. BMJ 1997; 315: 1096–9
Graves T, Hanlon JT, Schmader KE, et al. Adverse events after discontinuing medications in elderly outpatients. Arch Intern Med 1997; 157: 2205–10
Classen DC, Pestotnik SL, Evans RS, et al. Adverse drug events in hospitalized patients: excess length of stay, extra costs and attributable mortality. JAMA 1997; 277(4): 301–6
Lazarou J, Pomeranz BH, Corey PN. Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. JAMA 1998; 279: 1200–5
Johnson JA, Bootman JL. Drug-related morbidity and mortality: a cost-of-illness model. Arch Intern Med 1995; 155: 1949–56
Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drag events: implications for prevention. JAMA 1995; 274: 29–34
Beers MH, Storrie M, Lee G. Potential adverse drag interactions in the emergency room: an issue in the quality of care. Ann Intern Med 1990; 112: 61–4
Costa AJ. Potential drug interactions in an ambulatory geriatric population. Fam Practice 1991; 8: 234–6
Gosney M, Tallis R. Prescription of contraindicated and interacting drugs in elderly patients admitted to hospital. Lancet 1984; II: 564–7
Jankel CA, McMillan JA, Martin BC. Effect of drag interactions on outcomes of patients receiving warfarin or theophylline. Am J Hosp Pharm 1994; 51: 661–6
Hamilton RA, Gordon T. Incidence and cost of hospital admissions secondary to drug interactions involving theophylline. Ann Pharmacother 1992; 26: 1507–11
Beers MH. Explicit criteria for determining potentially inappropriate medication use by the elderly: an update. Arch Intern Med 1997; 157: 1531–6
Cleeland CS, Gonin R, Hatfield AK, et al. Pain and its treatment in outpatients with metastatic cancer. N Engl J Med 1994; 330: 592–6
Perez-Stable EJ, Miranda J, Munoz RF, et al. Depression in medical outpatients: underrecognition and misdiagnosis. Arch Intern Med 1990; 150: 1083–8
Gurwitz JH, Monette J, Rochon PA, et al. Atrial fibrillation and stroke prevention with warfarin the long-term care setting. Arch Intern Med 1997; 157: 978–84
Stuck AE, Tamai IY. Medication management in the home. Clin Geriatr Med 1991; 7(4): 733–48
Monane M, Monane S, Semla T. Optimal medication use in elders: key to successful aging. West J Med 1997; 167: 233–7
Montamat SC, Cusack BJ, Vestal RE. Management of drag therapy in the elderly. N Engl J Med 1989; 321: 303–9
Beers MH, Ouslander JG, Fingold SF, et al. Inappropriate medication prescribing in skilled-nursing facilities. Ann Intern Med 1992; 117: 684–9
Spore DL, Mor V, Larrat P, et al. Inappropriate drag prescriptions for elderly residents of board and care facilities. Am J Pub Health 1997; 87: 404–9
Aparasu RR, Fliginger SE. Inappropriate medication prescribing for the elderly by office-based physicians. Ann Pharmacother 1997; 31: 823–9
Tamblyn RM, McLeod PJ, Abrahamowicz M, et al. Questionable prescribing for elderly patients in Quebec. Can Med Assoc J 1994; 150(11): 1801–9
Torrible SJ, Hogan DB. Medication use and rural seniors: who really knows what they are taking? Can Fam Physician 1997; 43: 893–989
Der EH, Rubenstein LZ, Choy GS. The benefits of in-home pharmacy evaluation for older persons. J Am Geriatr Soc 1997; 45(2): 211–4
Hunter KA, Florio ER, Langberg RG. Pharmaceutical care for home-dwelling elderly persons: a determination of need and program description. Gerontologist 1996; 36(4): 543–8
Schrader SL, Dressing B, Blue R, et al. The Medication Reduction Project: combatting polypharmacy in South Dakota elders through community-based interventions. S D J Med 1996; 49(12): 441–8
Beers MH, Ouslander JG, Rollingher I, et al. Explicit criteria for determining inappropriate medication use in nursing home residents. Arch Intern Med 1991; 151: 1825–32
Shelton PS, Hanlon JT, Landsman PB, et al. Reliability of drug utilization evaluation as an assessment of medication appropriateness. Ann Pharmacother 1997; 31: 533–42
Morris JN, Hawes C, Murphy K, et al. Resident assessment instrument training manual and resource guide. Natick (MA): Eliot Press, 1991
Hanlon JT, Schmader KE, Samsa GP, et al. A method for assessing drug therapy appropriateness. J Clin Epidemiol 1992; 45: 1045–51
Hamdy RC, Moore SW, Whalen K, et al. Reducing polypharmacy in extended care. South Med J 1995; 88(5): 534–8
Owens NJ, Sherburne NJ, Silliman RA, et al. The Senior Care Study: the optimal use of medications in acutely ill older patients. J Am Geriatr Soc 1990; 38: 1082–7
Johnson RE, Campbell WH, Azevedo DJ, et al. Studying the impact of patient drag profiles in an HMO. Med Care 1976; 14: 799–807
Koepsell TD, Gurtel AL, Diehr PH, et al. The Seattle evaluation of computerized drag profiles: effects on prescribing practice and resource use. Am J Pub Health 1983; 73: 850–5
Tamai IY, Rubenstein LZ, Josephson KR, et al. Impact of computerized drag profiles and a consulting pharmacist on outpatient prescribing patterns: a clinical trial. Drag Intell Clin Pharm 1987; 21: 890–5
Stuck AE, Beers MH, Steiner A, et al. Inappropriate medication use in community-residing older persons. Arch Intern Med 1994; 154: 2195–200
Anderson GM, Beers MH, Kerluke K. Auditing prescription practice using explicit criteria and computerized drug benefit claims data. J Evalu Clin Pract 1997; 3(4): 283–94
Willcox SM, Himmelstein DU, Woolhandler S. Inappropriate drug prescribing for the community-dwelling elderly. JAMA 1994; 272(4): 292–6
McLeod PJ, Huang AR, Tamblyn RM, et al. Defining inappropriate practices in prescribing for elderly people: a national consensus panel. Can Med Assoc J 1997; 156(3): 385–91
Oborne CA, Batty GM, Maskrey V, et al. Development of prescribing indicators for elderly medical inpatients. Br J Clin Pharmacol 1997; 43: 91–7
Knapp DA. Development of criteria for drug utilization review. Clin Pharm Ther 1991; 50(5): 600–5
Davidson HE, Chamberlain TM, Hernandez P, et al. Drug-use evaluation, part II: Drug-use analysis in pharmaceutical care and quality assurance. Consult Pharmacist 1991; 6(10): 836–43
Ben-Joseph R, Segal R, Russell WL, et al. Evaluating the value, accuracy and operational feasibility of DUE criteria. Formulary 1995; 30: 280–3
Winslade NE, Bajcare JM, Bombassaro AM, et al. Pharmacist’s management of drug-related problems: a tool for teaching and providing pharmaceutical care. Pharmacotherapy 1997; 17(4): 801–9
Robertson KE. Process for preventing or identifying and resolving problems in drug therapy. Am J Health Syst Pharm 1996; 53: 639–50
Newton PF, Levinson W, Maslen D. The Geriatric Medication Algorithm: a pilot study. J Gen Intern Med 1994; 9(3): 164–7
Lipton HL, Bird JA, Bero LA, et al. Assessing the appropriateness of physician prescribing for geriatric outpatients: development and testing of an instrument. J Pharm Technol 1993; 9: 107–13
Owens NJ, Fretwell MD, Willey C, et al. Distinquishing between the fit and frail elderly, and optimising pharmacotherapy. Drugs Aging 1994; 4(1): 47–55
Morris JN, Hawes C, Fries BE, et al. Designing the national resident assessment instrument for nursing homes. Gerontologist 1990; 30: 293–307
Riley K. Putting the MDS 2.0 to work in long-term care. Consult Pharmacist 1996; 11(7): 669–75
Riley K. RAPs and the consultant pharmacist. Consult Pharmacist 1997; 12(1): 32–4
Morris JN, Fries BE, Knight S, et al. Comprehensive clinical assessment in community setting: applicability of the MDSHC. J Am Geriatr Soc 1997; 45: 1017–24
Morris JN, Nonemaker S, Murphy K, et al. A commitment to change: revision of HCFA’s RAI. J Am Geriatr Soc 1997; 45: 1011–16
Ouslander JG. The resident assessment instrument (RAI): promises and pitfalls. J Am Geriatr Soc 1997; 45: 975–6
Losben NL. Putting the MDS 2.0 to work to identify and monitor at-risk elderly. Consult Pharmacist 1997; 12(5): 520–34
Tobias DE, Feinberg JL, Troutman WG. The MDS-Med Guide: a tool for the new millenium. Consult Pharmacist 1999; 14(8): 831–60
Samsa GP, Hanlon JT, Schmader KE, et al. A summated score for the medication appropriateness index: development and assessment of clinimetric properties including content validity. J Clin Epidemiol 1994; 47: 891–6
Schmader KE, Hanlon JT, Weinberger M, et al. Appropriateness of medication prescribing in ambulatory elderly patients. J Am Geriatr Soc 1994; 42: 1241–7
Schmader KE, Hanlon JT, Landsman PB, et al. Inappropriate prescribing and health outcomes in elderly veteran outpatients. Ann Pharmacother 1997; 31: 529–33
Fitzgerald LS, Hanlon JT, Shelton PS, et al. Reliability of a modified medication appropriateness index in ambulatory older persons. Ann Pharmacother 1997; 31: 543–8
Naranjo CA, Busto U, Sellers EM. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther 1981; 30: 239–45
Kramer MS, Leventhal JM, Hutchinson TA, et al. An algorithm for the operational assessment of adverse drug reactions. J Am Med Assoc 1979; 242: 623–32
Hepler DC, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm 1990; 47: 533–43
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Shelton, P.S., Fritsch, M.A. & Scott, M.A. Assessing Medication Appropriateness in the Elderly. Drugs & Aging 16, 437–450 (2000). https://doi.org/10.2165/00002512-200016060-00004
Published:
Issue Date:
DOI: https://doi.org/10.2165/00002512-200016060-00004