The elderly experiences more chronic medical conditions than younger people, takes more medications, and is more likely to suffer from the adverse effects of multiple medications. Potentially inappropriate medications (PIMs), defined as those adverse risks exceeding their health benefits when compared with alternative therapies, are a preventable cause of negative clinical and economic consequences in older people.
With aging, geriatric patients, especially in very old age, are more vulnerable to drug-related problems, including PIM and potential adverse drug reactions. The Beers criteria are one of the most popular guidelines for PIM use in elderly, which was initially released in 1991 and updated in 1997, 2003, and 2012. Research has documented widespread PIM prevalence in elderly persons, which ranged from 9.8% to 46.5%. However, to our knowledge, there are not any kind of data to show the comparison of PIM prevalence between the elderly aged 65–79 years and those aged 80 years or older.
In this study, we investigated the different prevalence of PIM use in elderly inpatients between aged 65–79 years and aged 80 years or older, who were discharged from the Geriatric Department of West China Hospital using the 2012 Beers criteria. We found inpatients aged 80 years or older have more PIM use and encounter more potential inappropriate prescription of benzodiazepines, drugs with strong anticholinergic properties, megestrol, antipsychotics, theophylline, and aspirin than patients aged 65–79 years.
Study design and ethical considerations
This was a retrospective cross-sectional study conducted in Geriatric Department of West China Hospital, a nonprofit tertiary care academic hospital. The study protocol was approved by the Research Ethics Committee of Sichuan University before the commencement of the study (ChiCTR-ECS-14004441).
Setting and participants
From October 2012 to April 2013, all patients aged 65 years or older who were discharged from the geriatric wards in West China Hospital were sampled for the study. Then, the subjects were divided into two groups as patients aged 65–79 years, and patients aged 80 years or older. All medications consumed on an as-needed basis; vitamin or mineral supplement, drug for topical use, and herbal medicines were not included in this study. The patients were excluded if no medication was used or the medication administration records were unavailable or incomplete.
The electronic medical records (EMRs) of the patients were retrieved from the Information Center of West China Hospital, and the information obtained was transferred into a prepared spreadsheet. Retrieved information included age, gender, length of stay, prognosis (discharge or death), the total hospital charges, expenses for medicine, the primary medical conditions (diagnosis), and the prescribed drugs and dosages.
The PIM analysis included all subjects who were eligible for this study. To investigate the difference of PIM use occurrence between patients aged 65–79 years and those aged 80 years or older, a full-length updated American Geriatric Society version (2012) of the Beers criteria was downloaded and printed out. All of the drugs included in the Beers criteria were assessed according to their availability in China. The prescribed medications were then assessed using these criteria to determine their appropriateness. To minimize interpretation bias, two raters were trained to use Beers criteria. Each rater evaluated the data set independently, and all disagreements were resolved through discussion.
Data generated from the EMRs were recorded on a spreadsheet and analyzed using SPSS version 16.0 (SPSS Inc., USA). Descriptive statistics was expressed as mean or median, frequencies or percentages. The list of PIMs found among patients was compiled and calculated as percentages. Chi-square test was used to compare categorical data, and the Student's t-test or nonparametric test was applied to compare continuous variables for mean or median, respectively. Logistic regression analysis was carried out to identify the independent factors associated with PIM use–univariate analysis was carried out, and the variables which were statistically significant at α level of 0.1 were included in multivariate stepwise regression. P value of <0.05 was considered statistically significant.
Demographics of participant patients
This study included a total of 1796 participants aged 65 years or older. Ten patients were excluded from the analysis because they were not prescribed any medication at the time of hospitalization. Among 1786 patients, 618 (34.4%) patients aged 65–79 years (74 ± 4 years) and 1178 (65.6%) patients were 80-year-old and above (85 ± 4 years) [Table 1].
Co-morbidity and outcome of death
Patients aged 80 years or older had more co-morbidities than those aged 65–79 years (6.5 ± 1.9 vs. 5.5 ± 2.1, P < 0.001) [Table 1]. Patients aged 80 years or older were greater vulnerability to hypertension, infectious disease, lower urinary tract symptoms (LUTS)/benign prostatic hyperplasia (BPH), chronic obstructive pulmonary disease (COPD), insomnia, coronary heart disease, chronic constipation, cerebrovascular disease, osteoporosis, dementia, chronic kidney disease (CKD), history of fractures, Parkinson's disease, and chronic seizures (all with P < 0.05) [Table 2]. In all of participants, 104 patients died finally. Seventy-eight (6.6%) of them aged 80 years or older, but 26 (4.2%) of them aged 65–79 years (P < 0.001) [Table 1].
Potentially inappropriate medication use
Compared with patients aged 65–79 years, patients aged 80 years or older were prescribed more medications (17.6 ± 10.4 vs. 14.2 ± 9.9). About 58.2% (686) of the patients aged 80 years or older consumed at least one PIM. However, only 43.4% (268) of the patients aged 65–79 years consumed at least one PIM (χ;2 = 40.18, P < 0.001) [Table 1]. Table 3 lists top 10 of PIM categories using the 2012 Beers criteria prescribed in each group respectively. Notably, more patients aged 80 years or older were prescribed with benzodiazepines, drugs with strong anticholinergic properties, megestrol, antipsychotics, theophylline, and aspirin. When categorized by gender, female patients encountered more PIMs than male (54.5% vs. 52.6%, P < 0.05). However, except drugs with strong anticholinergic properties and non-COX-selective nonsteroidal anti-inflammatory drugs (NSAIDs), other prescriptions in top 10 PIMs were not different between female and male patients [Table 4].
Health economics outcomes
Patients aged 80 years or older had longer hospital stays (23 [14–34] vs. 16 [11–28] days, P < 0.001). In all the participants, median hospitalization cost was $3244.9 ($1886.3–$6174.7). Patients aged 80 years or older showed higher hospitalization cost ($3558.4 [$2057.8–$6818.8] vs. $2699.8 [$1583.1–$5323.7], P < 0.001), compared with patients aged 65–79 years [Table 1].
Factors associated with potentially inappropriate medication use
In univariate analysis, we included the variables such as age, gender, number of prescribed medication, length of hospital stay, hospitalization cost, and number of diagnostic diseases. Among variables, the multivariate Logistic regression detected that the characteristics such as female gender (odds ratio [OR] = 1.411, 95% confidence interval [CI] = 1.106–1.799), age (OR = 1.017, 95% CI = 1.001–1.033), number of diagnostic disease (OR = 1.291, 95% CI = 1.215–1.370), and number of prescribed medication (OR = 1.082, 95% CI = 1.064–1.100) were significantly associated with PIM exposure [Table 5].
Inappropriate use of medications in elderly patients has not caught attention widely in China until recently. Our data showed that patients aged 80 years or older encountered more PIM use (58.2%) than patients aged 65–79 years (43.4%) identified by 2012 Beers criteria. In the most commonly taken PIMs, patients aged 80 years or older have been uncovered to encounter more prescription of benzodiazepines, drugs with strong anticholinergic properties, megestrol, antipsychotics, theophylline, and aspirin than patients aged 65–79 years.
Comorbidity and potentially inappropriate medication
Several data from our study could explain the phenomena. First of all, patients aged 80 years or older had more co-morbidities (6.5 ± 1.9) than younger (5.5 ± 2.1). Patients aged 80 years or older suffered more from COPD, LUTS/BPH, insomnia, chronic constipation, osteoporosis, dementia, CKD, history of fractures, Parkinson's disease, and chronic seizures [Table 2]. As the result, increasing number of multimorbidity with age often makes it necessary to prescribe several drugs for one patient at a time. Gallagher et al. found that the average number of drugs prescribed to 65-year-old patients is five simultaneously and prescription peaks in the 75–84 years old group. Hence, these frailty senile patients were more vulnerable to damage with PIMs. Similarly, patients aged 80 years or older in our study were more often prescribed with inhaled anticholinergic agents and theophylline to treat COPD, benzodiazepines to improve insomnia, and antipsychotics to control behavioral problems of dementia and so on. It has been shown that anticholinergic drugs could increase the risk for dementia and mortality. Benzodiazepines and antipsychotics can significantly increase the risk of fall, fracture, and mortality in the elderly. Unfortunately, these medications are often prescribed by physicians in China due to the lack of necessary vigilance of PIMs in elderly.
Polypharmacy and potentially inappropriate medication
Second, as the result of co-morbidities, patients aged 80 years or older were prescribed with more medications (17.6 ± 10.4) than younger (14.2 ± 9.9). Polypharmacy is particularly common among the elderly, making them especially susceptible to drug-drug interactions (DDIs). Polypharmacy has been shown to significantly associate with PIM and DDIs. According to a study in 2007, DDIs caused 4.8% of hospital admissions among the elderly, increasing their risk nearly 8.5-fold relative to the general population. DDIs also contribute to higher cost and prolonged duration of hospital stays.
Benzodiazepines were the most common potentially inappropriate medication
Finally with aging, more elderly were troubled with insomnia and depression. To solve this problem, benzodiazepines were commonly used in hospitalized elderly by physicians. Our data suggested that the most commonly encountered PIM in this study was benzodiazepine. Older patients (age ≥80 years) were prescribed with more benzodiazepine than younger (65 years ≤ age < 80 years), which makes our result different from other studies. Keith et al. and Fadare et al. discovered that NSAIDs were the most common PIM use in the elderly patients in Italy and Nigeria, respectively. However, Oliveira et al. showed that short-acting nifedipine was the most one in Brazilian. It might due to the difference of doctor's prescription behaviors among these countries. Other potential factors of high prevalence of benzodiazepines use in hospitalized elderly in China are often solely for the convenience for the staff, which were also found in nursing home in the USA before. Few of doctors are willing to try nondrug therapy to help elderly patients solve problems such as insomnia or delirium before prescribing medication. On the other hand, many of the elderly with co-morbidities are unwilling to try nondrug method and are convinced that it is the best choice to take medicine.
Several limitations should be noted in this study. First, updated 2012 Beers criteria are utilized to screen PIM in this study due to the lack of national criteria. Some authors have formulated new explicit and implicit criteria that have been adapted for a specific country. Beers criteria allow for a relative assessment of drug use risk in the elderly but do not address other type of potential PIMs that are not unique to aging, including dosing of primarily renal cleared medications, DDIs, therapeutic duplication, and traditional Chinese medicine. Second, this is a retrospective cross-sectional study. All of the data were gathered from EMR, and we could not rule out several interference factors such as accuracy and integrity of diagnosis. Third, its single-center nature seems to influence adversely the generalizability of the results in the mainland of China. However, the study uncovered the prevalence of PIM use in different age China elderly. The EMR of the inpatients in West China Hospital are complete and detailed. Finally, this study does not describe the adverse drug interaction caused by PIM use because it is a retrospective cross-sectional study and analysis was based on EMR-reported data. It is difficult to review and predicate the relationship between adverse outcome and PIM use exactly.
In conclusion, the finding from this study revealed that inpatients aged 80 years or older encountered more PIM use than those aged 65–79 years. PIMs defined by the 2012 Beers criteria have been shown to be associated with female gender, age, polypharmacy, and co-morbidities. Taking into account the increasing elderly population and the importance of the health program for the care of this population, all of the physicians in China must pay more attention to the information about PIM and carefully choose drugs that are safer for the elderly, especially the elderly aged 80 years or older.
Financial support and sponsorship
This work was supported in part by grants from the National Natural Science Foundation of China (Nos. 81270926 and 81471068), Outstanding Scholar Foundation of Sichuan University (No. 2013SCU04A17), Program of Health and Family Planning Commission of Sichuan Province (No. YN20140026), and Program of Science and Technology Department of Sichuan Province (No. 2014SZ0153).
Conflicts of interest
There are no conflicts of interest.
1. Stuck AE, Beers MH, Steiner A, Aronow HU, Rubenstein LZ, Beck JC. Inappropriate medication use in community-residing older persons Arch Intern Med. 1994;154:2195–200 doi: 10.1001/archinte.1994.00420190095011
2. Keith SW, Maio V, Dudash K, Templin M, Del Canale S. A physician-focused intervention to reduce potentially inappropriate medication
prescribing in older people: A 3-year, Italian, prospective, proof-of-concept study Drugs Aging. 2013;30:119–27 doi: 10.1007/s40266-012-0043-y
3. Fu AZ, Liu GG, Christensen DB. Inappropriate medication use and health outcomes in the elderly J Am Geriatr Soc. 2004;52:1934–9 doi: 10.1111/j.1532-5415.2004.52522.x
4. Gupta S, Rappaport HM, Bennett LT. Inappropriate drug prescribing and related outcomes for elderly medicaid beneficiaries residing in nursing homes Clin Ther. 1996;18:183–96 doi: 10.1016/S0149-2918(96)80189-5
5. Kaur S, Mitchell G, Vitetta L, Roberts MS. Interventions that can reduce inappropriate prescribing in the elderly: A systematic review Drugs Aging. 2009;26:1013–28 doi: 10.2165/11318890-000000000-00000
6. Corona-Rojo JA, Altagracia-Martínez M, Kravzov-Jinich J, Vázquez-Cervantes L, Pérez-Montoya E, Rubio-Poo C. Potential prescription patterns and errors in elderly adult patients attending public primary health care centers in Mexico City Clin Interv Aging. 2009;4:343–50 doi: 10.2147/CIA.S5198
7. Chan DC, Hao YT, Wu SC. Polypharmacy among disabled Taiwanese elderly: A longitudinal observational study Drugs Aging. 2009;26:345–54 doi: 10.2165/00002512-200926040-00005
8. Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergency hospitalizations for adverse drug events in older Americans N Engl J Med. 2011;365:2002–12 doi: 10.1056/NEJMsa1103053
9. Beers MH. Explicit criteria for determining potentially inappropriate medication
use by the elderly. An update Arch Intern Med. 1997;157:1531–6 doi: 10.1001/archinte.157.14.1531
10. Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating the Beers criteria for potentially inappropriate medication
use in older adults: Results of a US consensus panel of experts Arch Intern Med. 2003;163:2716–24 doi: 10.1001/archinte.163.22.2716
11. . American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication
use in older adults J Am Geriatr Soc. 2012;60:616–31 doi: 10.1111/j.1532-5415.2012.03923.x
12. Golden AG, Preston RA, Barnett SD, Llorente M, Hamdan K, Silverman MA. Inappropriate medication prescribing in homebound older adults J Am Geriatr Soc. 1999;47:948–53 doi: 10.1111/j.1532-5415.1999.tb01289.x
13. Ryan C, O’Mahony D, Kennedy J, Weedle P, Cottrell E, Heffernan M, et al Potentially inappropriate prescribing in older residents in Irish nursing homes Age Ageing. 2013;42:116–20 doi: 10.1093/ageing/afs068
14. Zhan C, Sangl J, Bierman AS, Miller MR, Friedman B, Wickizer SW, et al Potentially inappropriate medication
use in the community-dwelling elderly: Findings from the 1996 Medical Expenditure Panel Survey JAMA. 2001;286:2823–9 doi: 10.1001/jama.286.22.2823
15. Liu CL, Peng LN, Chen YT, Lin MH, Liu LK, Chen LK. Potentially inappropriate prescribing (IP) for elderly medical inpatients in Taiwan: A hospital-based study Arch Gerontol Geriatr. 2012;55:148–51 doi: 10.1016/j.archger.2011.07.001
16. Gallagher PF, Barry PJ, Ryan C, Hartigan I, O’Mahony D. Inappropriate prescribing in an acutely ill population of elderly patients as determined by Beers’ Criteria Age Ageing. 2008;37:96–101 doi: 10.1093/ageing/afm116
17. Fox C, Richardson K, Maidment ID, Savva GM, Matthews FE, Smithard D, et al Anticholinergic medication use and cognitive impairment in the older population: The medical research council cognitive function and ageing study J Am Geriatr Soc. 2011;59:1477–83 doi: 10.1111/j.1532-5415.2011.03491.x
18. Herings RM, Stricker BH, de Boer A, Bakker A, Sturmans F. Benzodiazepines and the risk of falling leading to femur fractures. Dosage more important than elimination half-life Arch Intern Med. 1995;155:1801–7 doi: 10.1001/archinte.1995.00430160149015
19. Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls in older people: A systematic review and meta-analysis: I. Psychotropic drugs J Am Geriatr Soc. 1999;47:30–9 doi: 10.1111/j.1532-5415.1999.tb01898.x
20. Lenzer J. FDA warns about using antipsychotic drugs for dementia BMJ. 2005;330:922 doi: 10.1136/bmj3307497922-c
21. Wang PS, Schneeweiss S, Avorn J, Fischer MA, Mogun H, Solomon DH, et al Risk of death in elderly users of conventional vs. atypical antipsychotic medications N Engl J Med. 2005;353:2335–41 doi: 10.1056/NEJMoa052827
22. Gill SS, Bronskill SE, Normand SL, Anderson GM, Sykora K, Lam K, et al Antipsychotic drug use and mortality in older adults with dementia Ann Intern Med. 2007;146:775–86 doi: 10.7326/0003-4819-146-11-200706050-00006
23. Turner JP, Shakib S, Singhal N, Hogan-Doran J, Prowse R, Johns S, et al Prevalence and factors associated with polypharmacy in older people with cancer Support Care Cancer. 2014;22:1727–34 doi: 10.1007/s00520-014-2171-x1
24. Beloosesky Y, Nenaydenko O, Gross Nevo RF, Adunsky A, Weiss A. Rates, variability, and associated factors of polypharmacy in nursing home patients Clin Interv Aging. 2013;8:1585–90 doi: 10.2147/CIA.S52698
25. Oliveira MG, Amorim WW, de Jesus SR, Rodrigues VA, Passos LC. Factors associated with potentially inappropriate medication
use by the elderly in the Brazilian primary care setting Int J Clin Pharm. 2012;34:626–32 doi: 10.1007/s11096-012-9656-9
26. Lao CK, Ho SC, Chan KK, Tou CF, Tong HH, Chan A. Potentially inappropriate prescribing and drug-drug interactions among elderly Chinese nursing home residents in Macao Int J Clin Pharm. 2013;35:805–12 doi: 10.1007/s11096-013-9811-y
27. Nishtala PS, Bagge ML, Campbell AJ, Tordoff JM. Potentially inappropriate medicines in a cohort of community-dwelling older people in New Zealand Geriatr Gerontol Int. 2014;14:89–93 doi: 10.1111/ggi.12059
28. Becker ML, Kallewaard M, Caspers PW, Visser LE, Leufkens HG, Stricker BH. Hospitalisations and emergency department visits due to drug-drug interactions: A literature review Pharmacoepidemiol Drug Saf. 2007;16:641–51 doi: 10.1002/pds.1351
29. Moura CS, Acurcio FA, Belo NO. Drug-drug interactions associated with length of stay and cost of hospitalization J Pharm Pharm Sci. 2009;12:266–72
30. Fadare JO, Agboola SM, Opeke OA, Alabi RA. Prescription pattern and prevalence of potentially inappropriate medications among elderly patients in a Nigerian rural tertiary hospital Ther Clin Risk Manag. 2013;6:115–20 doi: 10.2147/TCRM.S40120
31. Christensen DB, Benfield WR. Alprazolam as an alternative to low-dose haloperidol in older, cognitively impaired nursing facility patients J Am Geriatr Soc. 1998;46:620–5 doi: 10.1111/j1532-5415.1998.tb01081.x
32. Siegler EL, Capezuti E, Maislin G, Baumgarten M, Evans L, Strumpf N. Effects of a restraint reduction intervention and OBRA ‘87 regulations on psychoactive drug use in nursing homes J Am Geriatr Soc. 1997;45:791–6 doi: 10.1111/j.1532-5415.1997.tb01503.x
33. Barry PJ, O’Keefe N, O’Connor KA, O’Mahony D. Inappropriate prescribing in the elderly: A comparison of the Beers criteria and the improved prescribing in the elderly tool (IPET) in acutely ill elderly hospitalized patients J Clin Pharm Ther. 2006;31:617–26 doi: 10.1111/j.1365-2710.2006.00783.x
34. Hanlon JT, Schmader KE, Samsa GP, Weinberger M, Uttech KM, Lewis IK, et al A method for assessing drug therapy appropriateness J Clin Epidemiol. 1992;45:1045–51 doi: 10.1016/0895-4356(92)90144-C
35. Lam MP, Cheung BM. The use of STOPP/START criteria as a screening tool for assessing the appropriateness of medications in the elderly population Expert Rev Clin Pharmacol. 2012;5:187–97 doi: 10.1586/ecp.12.6
36. Schubert I, Küpper-Nybelen J, Ihle P, Thürmann P. Prescribing potentially inappropriate medication
(PIM) in Germany's elderly as indicated by the PRISCUS list. An analysis based on regional claims data Pharmacoepidemiol Drug Saf. 2013;22:719–27 doi: 10.1002/pds.3429
Edited by: Li-Shao Guo