TOOLS FOR ADVANCING PHARMACY PRACTICE

Instruments for evaluating medication use and prescribing in older adults Marilyn N. Bulloch and Jacqueline L. Olin

Received December 17, 2013, and in revised form March 13, 2014. Accepted for publication March 14, 2014.

Abstract Objective: To describe primarily implicit instruments for assessing medication use in older adults. Data sources: Literature was identified via PubMed (1966–2014) and Google Scholar using the following search terms: geriatric/medication use, implicit criteria, inappropriate medication use, inappropriate prescribing, older adults/medication use, and polypharmacy. Reference citations from identified publications were also reviewed. Study selection: All articles in English identified from data sources were evaluated. Instruments applicable to pharmacy and multiple medication classes were included. We excluded instruments developed for a single medication or medication class, for a single condition or disease state, as primarily an academic instrument, using primarily explicit criteria, for use primarily by health care practitioners other than pharmacists, or for regulatory purposes. Data synthesis: Seven instruments were reviewed by evaluating characteristics, components of prescribing and medication use addressed, and settings in which they have been evaluated and validated. Screening Medications in the Older Drug User (SMOG) is a six-question instrument developed specifically for community pharmacists. The Medication Appropriateness Index (MAI); Assess, Review, Minimize, Optimize, Reassess (ARMOR) tool; and Tool to Improve Medications in the Elderly via Review (TIMER) are more comprehensive instruments, but they require clinical judgment and are time intensive. Assessing Care of Vulnerable Elders-3 (ACOVE-3) and the Good Palliative–Geriatric Practice Algorithm (GPGPA) are useful in determining need for medication continuation in older adults who are closer to the end of life. The Assessment of Underutilization (AOU) is an implicit tool to guide medication initiation.

Marilyn N. Bulloch, PharmD, BCPS, is Assistant Clinical Professor of Pharmacy Practice, Harrison School of Pharmacy, Auburn University, Auburn, AL, and Adjunct Assistant Professor, College of Community Health Sciences, University of Alabama School of Medicine, Tuscaloosa, AL. Jacqueline L. Olin, MS, PharmD, BCPS, CPP, CDE, is Associate Professor of Pharmacy, Wingate University School of Pharmacy, Wingate, NC. Correspondence: Marilyn N. Bulloch, PharmD, BCPS, University Medical Center, Box 870326, Tuscaloosa, AL 35487. Fax: 205-348-5160. E-mail: [email protected] edu Disclosure: The authors declare no conflicts of interest or financial interest in any product or service mentioned in this article, including grants, employment, gifts, stock holdings, or honoraria.

Conclusion: Each instrument is unique in design, which may be beneficial in some pharmacy practice settings and present barriers in others. The use of multiple instruments may be necessary to optimize therapy in this vulnerable patient population. Keywords: Potentially inappropriate prescribing, older adults, medication use. J Am Pharm Assoc. 2014;54:530–537. doi: 10.1331/JAPhA.2014.13244

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rug-related problems (DRPs) have a strong impact on health care and cost. In 2012, approximately $213 billion was spent on DRPs, the majority of which were attributed to adverse drug reactions (ADRs).1 Those over the age of 65 years are at greatest risk for experiencing ADRs, which have been shown to occur in 35%–80% of geriatric patients.2–4 Up to one-third of older adults require hospitalization secondary to DRPs, accounting for $80 billion in annual health care costs.2–5 A cost-of-illness model for the outpatient setting estimates that medication-related morbidity and mortality accounts for another $76 billion.6 On average, older adults take five or more chronic medications per day. This is the same number of daily medications observed in patients who experience an ADR.1 With the expected increase in the aging population and continued influx of available medications, costs and complications from DRPs could grow in the absence of intervention. By optimizing medication therapy, pharmacists can play an essential role in managing health care quality and costs in this patient population. Multiple instruments have been developed to identify, reduce, and prevent or minimize DRPs and subsequent ADRs in older adults. These instruments are simple and low-cost approaches to identifying medicationrelated issues in the aging adult in clinical practice. For simplification purposes, this report will refer to any tool, questionnaire, list, or algorithm that assesses medication use in geriatric patients as an instrument.

At a Glance

Synopsis: This review of tools, questionnaires, lists, and algorithms employed in assessing the medication use of geriatric patients focuses on those instruments that are applicable to pharmacy and multiple medication classes. The seven instruments identified for study inclusion vary in their approach to evaluating prescribing in older adults—from one developed specifically for community pharmacists to others that are more comprehensive yet also require more time and clinical judgment. The authors advise employing a combination of instruments to ensure a thorough medication review. Analysis: Adults over 65 years are at the greatest risk for experiencing adverse drug reactions. Without intervention, these drug-related problems are likely to become even more costly to the economy and human life as the aging population grows and new medications continue to reach the market. Pharmacists can play an essential role in managing health care quality and costs for older patients by using one or a combination of the simple and low-cost instruments evaluated in this review to identify, reduce, and prevent or minimize medication-​related complications and adverse outcomes.

Journal of the American Pharmacists Association

TOOLS

A number of validated instruments have been described in the literature. While these instruments employ a variety of designs, most use either explicit or implicit criteria to guide medication evaluation. Explicit criteria tend to focus on specific medications or disease states and be developed from literature review and consensus; implicit criteria are more patient-focused and require clinical judgment. Although some instruments have been adopted for regulatory or quality assurance programs (e.g., the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults), no single instrument addresses all potential DRPs. Factors to consider in selecting an instrument include ease of use, ability to reduce DRPs, and applicability of the clinical settings in which it has been validated.

Objective This report describes and differentiates between available, primarily implicit instruments used to evaluate prescribing in older adults to guide pharmacists in choosing the best instrument for their practice.

Data sources Studies describing various instruments for evaluating prescribing in older adults were accessed through PubMed (1966–2014) and Google Scholar using the search terms geriatric/medication use, implicit criteria, inappropriate medication use, inappropriate prescribing, older adults/medication use, and polypharmacy. References of key articles identified were also reviewed. The literature search identified a large number of instruments designed to evaluate medication use in older adults. However, our focus was to present a pertinent summary of data for practicing pharmacists in community, ambulatory, or general medical settings. As a result, we used the following criteria to select instruments to meet the needs of pharmacists in these practice settings: English language, applicability to patients aged 65 years or older, generalizability to pharmacy practice, and applicability to multiple medication classes. We excluded instruments developed for a single medication or medication class, for a single condition or disease state, as primarily an academic instrument, using primarily explicit criteria, for use primarily by health care practitioners other than pharmacists, or for regulatory purposes (Figure 1).

Data synthesis Using the above criteria, we identified the following seven instruments: ❚❚ Assessing Care of Vulnerable Elders-3 (ACOVE-3) ❚❚ Medication Appropriateness Index (MAI) ❚❚ Good Palliative–Geriatric Practice Algorithm (GPGPA) j apha.org

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Figure 1: Literature review process ❚❚

Screening Medications in the Older Drug User (SMOG) ❚❚ Assess, Review, Minimize, Optimize, Reassess (ARMOR) ❚❚ Tool to Improve Medications in the Elderly via Review (TIMER) ❚❚ Assessment of Underutilization (AOU) Information about the design and characteristics of each instrument are provided in Table 1, while Table 2 identifies which instruments are most suitable for particular elements of interest. Below is a summary of the positive and negative characteristics of each geriatric prescribing instrument and each instrument’s application to practice.

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ACOVE-3 This instrument contains 392 quality indicators involving 26 conditions and 14 care processes divided into 29 articles. It is designed to help improve care in vulnerable older adults who are considered likely to pass away or become severely disabled in the next 2 years.7–9 Overall, ACOVE-3 includes 24 indicators about medication indication and use, with one section specifically dedicated to addressing appropriate medication use in older adults. The section includes 12 statements written in “if-then-because” format, each with “supporting evidence” that provides rationale relevant to the indicator. The evidence-based indicators were validated by an expert panel.

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Table 1. Design and characteristics of instruments evaluating medication use in older adults7–27 Tool

Design

ACOVE-3

12 “if-then-because” rules involving indication, education, medication lists, response, DRR, monitoring, and avoidance

MAI

GPGPA SMOG

ARMOR

TIMER

AOU

Includes supporting evidence summary 10 questions/criteria for each medication scored as appropriate (0) or not appropriate (1) multiplied by criterion’s weight Score range: 0 (completely appropriate) to 18 (completely inappropriate) Flow algorithm of six “yes” or “no” questions Potential DRPs identified by individual pharmacist and categorized as 1) patientrelated, 2) prescriber-related, or 3) drug-related Five-step mnemonic for structured review of patient’s medications, functional status, subclinical ADRs, monitoring parameters, cognition, clinical status, and adherence Four sections addressing safety, adherence, goals, and cost Sections divided into screening tasks with explicit questions to ask, with recommendations and potential course of actions for DRPs provided Requires medical record, medication list, and use of clinical guidelines and tertiary resources

Clinical judgment requirement No

Validated

Suitability

Potential for medication regimen change Drug discontinuation, dose adjustment

Yes

Inpatient, outpatient, LTC

Yes

Yes

Inpatient, outpatient

Drug discontinuation, dose reduction, or substitution

Yes

Yes

Yes

No

Inpatient, outpatient, LTC Outpatient

Drug discontinuation, dose reduction, or substitution Drug discontinuation, dose reduction, or substitution

Yes

Yes

Outpatient, LTC

Drug discontinuation, dose reduction, or substitution

Yes

Yes

Inpatient, outpatient, academia

Drug discontinuation, dose reduction, or substitution

Yes

Yes

Outpatient clinic, inpatient, LTC

Drug initiation

Worksheet on which patient’s diseases/ conditions are listed and graded as “A” (no omission); “B” (nonpharmacologic therapy used instead of available, safe, and effective medication or medication omission due to patient preferences, care goals, or focus on symptom management/comfort care); or “C” (medication omission when clinical judgment does not prohibit use or no nonpharmacologic therapies used) Abbreviations used: ACOVE-3, Assessing Care of Vulnerable Elders-3; DRR, drug regimen review; LTC, long-term care; MAI, Medication Appropriateness Index; GPGPA, Good Palliative–Geriatric Practice Algorithm; SMOG, Screening Medications in the Older Drug User; DRPs, drug-related problems; ARMOR, Assess, Review, Minimize, Optimize, Reassess; ADRs, adverse drug reactions; TIMER, Tool to Improve Medications in the Elderly via Review; AOU, Assessment of Underutilization.

Unlike the other instruments discussed in this paper, ACOVE-3 is focused primarily on general medication use concepts rather than recommendations for specific medication avoidance or use. Only 16 medications or classes are specifically mentioned in the instrument, 9 of which relate to drug avoidance. ACOVE-3 has been used to evaluate medication use in older adults in nursing home, managed care, primary care, and inpatient settings with high scores in medication management.10 Journal of the American Pharmacists Association

Advantages of ACOVE-3 include applicability across the continuum of care, ease of use, and provision of data to support recommendations. However, the instrument lacks detail for many of the medication use process indicators (e.g., periodic drug reviews and patient education) other than that the processes should be conducted. While ACOVE-3 does have more explicit components compared with the other instruments discussed here, its emphasis on general pharmaceutical j apha.org

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Table 2. General guide to choosing an instrument on medication use in older adults based on element of interest7–27 Element of interest Indication Efficacy/role in therapy Specific disease states Dosage/dosing Drug–drug interactions Drug–disease interactions Contraindications Duplicative therapy Duration of therapy Cost/generic use Allergies ADRs Goals of therapy Underutilization Adherence Functional status Monitoring

Instrument ACOVE-3, SMOG, GPGPA, TIMER GPGPA, ACOVE-3 TIMER (CHD, diabetes) SMOG, GPGPA SMOG, ARMOR, TIMER ACOVE-3, ARMOR SMOG, ARMOR ACOVE-3, SMOG, ARMOR, TIMER ACOVE-3 MAI, TIMER ACOVE-3, TIMER SMOG, ARMOR, GPGPA, TIMER ACOVE-3, GPGPA, ARMOR, TIMER AOU ACOVE-3, SMOG, ARMOR, TIMER GPGPA, ARMOR ACOVE-3, ARMOR, TIMER

Abbreviations used: ACOVE-3, Assessing Care of Vulnerable Elders-3; SMOG, Screening Medications in the Older Drug User; GPGPA, Good Palliative– ​Geriatric Practice Algorithm; TIMER, Tool to Improve Medications in the Elderly via Review; CHD, coronary heart disease; ARMOR, Assess, Review, Minimize, Optimize, Reassess; MAI, Medication Appropriateness Index; AOU, Assessment of Underutilization.

care concepts still allows for clinical judgment and a patient-specific focus. ACOVE-3 is best reserved for use with patients who have decreased functional status or are at the end of life. MAI Hanlon et al. created the MAI as a systematic, implicit way to evaluate prescribing in geriatrics.11 The instrument consists of 10 criteria that evaluate indication, efficacy, dose, directions, interactions, cost, duplication, and duration of therapy. A summated score (0–18) was later added to provide weight to the individual criteria, and 0.5 point marginally appropriate adaptations from other investigators added numerical values corresponding to the appropriateness rating to be multiplied by the individual criteria’s weight.12,13 A higher overall score on the MAI provides rationale for discontinuing or switching medication. Other individual criteria provide insight on DRPs that, if addressed, would lessen the need to eliminate the medication altogether. In one study, the MAI was shown to positively predict the risk of an ADR, with every unit increase in score increasing the risk by 13% (OR 1.13; 95% CI 1.02–1.26.)14 The MAI was initially validated in a geriatric outpatient clinic but has since been validated for use in inpatient settings. It was found to have good interrater reliability by the developers (median kappa (κ) = 0.88 [0.71–0.96] for individual questions and 0.86 for drugs 534 JAPhA | 5 4:5 | S E P /OCT 2 0 1 4

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overall) and intrarater reliability (κ = 0.92 drugs overall.)11 Reliability by other investigators has been varied. Using the traditional scoring system, interrater reliability κ ranges are 0.47–0.83 overall and 0.29–1 for individual questions.11,13,15,16 Interrater reliability with modified versions have κ ranges of 0.5–0.71 overall and 0.41–87 for individual questions.13,15,17,18 Intraclass correlation coefficients ranged between 0.74 and 0.91.11–13,15,17,19 These variations in reliability may be a result of clinical judgment variation, training with the instrument, or clinical setting and availability of medical data. Advantages of the MAI include its utility and applicability for the entire medication regimen, thorough review, and simple scoring system. Though more comprehensive in its evaluation of prescribing than other instruments, the MAI requires clinical judgment for effective use. Disadvantages of the MAI include the time requirement for use, which in studies has been as great as 10 minutes per drug, and the absence of allergies among its criteria. The MAI’s structured outline is a good format for instructing trainees on the basic principles of pharmaceutical care. The instrument may be useful in a clinic setting with dedicated time to review medication lists and prescribing, but it could also be used in hospital or long-term care settings to evaluate medication appropriateness. Additionally, the MAI may be useful in retrospective evaluations of medication-related events to identify the DRP that contributed to the event or error. GPGPA This instrument addresses nonessential medication discontinuation in patients with noncurable conditions.20,21 The GPGPA is a simple flow algorithm consisting of six questions directed by “yes” or “no” responses requiring clinical judgment, which lead a user to continue at the same dose, reduce dose, discontinue a drug, or change to an alternative medication. The algorithm addresses indication, efficacy, dosage, and dosing; ADRs; therapeutic goals; and functional status. A study using the GPGPA in Israeli nursing departments demonstrated significantly lower 1-year mortality in a study group (n = 119) compared with a control group (n = 71) (21% vs 45%, P

Instruments for evaluating medication use and prescribing in older adults.

To describe primarily implicit instruments for assessing medication use in older adults...
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