Int J Clin Pharm DOI 10.1007/s11096-015-0125-0
RESEARCH ARTICLE
Prevalence and predictors of potentially inappropriate medications among home care elderly patients in Qatar Eman Alhmoud1 • Sabah Khalifa1 • Asma Abdulaziz Bahi2
Received: 30 October 2014 / Accepted: 15 April 2015 Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie 2015
Abstract Background Older patients receiving home health care are particularly at risk of receiving potentially inappropriate medications compared to community-dwelling population. Data on appropriateness of prescribing in these patients is limited. Objective To investigate the prevalence, patterns and determinants of potentially inappropriate medications among elderly patients receiving Home Health Care Services in Qatar. Setting Home Health Care Services department in Hamad Medical Corporation-Qatar. Methods A cross-sectional study, conducted over a 3 months period. Patients 65 years and older, taking at least one medication and receiving home care services were included. Potentially inappropriate medications were identified and classified in accordance with the American Geriatrics Society 2012 Beers Criteria. Main outcome measure Prevalence of potentially inappropriate medications using updated Beers criteria. Results A total of 191 patients (38.2 %) had at least one potentially inappropriate medication. As per Beers criteria, 35 % of medications were classified as medications to be avoided in older adults regardless of conditions and 9 % as potentially inappropriate medications when used with certain diseases or syndromes. The majority of potentially inappropriate medications (56 %) were classified as medications to be used with caution. The two leading classes of potentially inappropriate medications were antipsychotics (27.4 %) and selective serotonin reuptake inhibitors (16 %). Significant predictors of inappropriate prescribing were hypertension [adjusted OR
1.7; 95 % CI (1.0, 2.8)], dementia [adjusted OR 2.0; 95 % CI (1.2, 3.1)], depression [adjusted OR 21.6; 95 % CI (2.8, 168.4)], and taking more than ten prescribed medications [adjusted OR 1.9; 95 % CI (1.3, 2.8)]. Conclusion Prescribing potentially inappropriate medications is common among older adults receiving home health care services in Qatar, a finding that warrants further attention. Polypharmacy, hypertension, depression and dementia were significantly associated with potentially inappropriate prescribing.
& Eman Alhmoud [email protected]
Introduction
1
Clinical Pharmacy Services-Pharmacy Department, Hamad General Hospital-Hamad Medical Corporation, Doha, Qatar
2
Home Healthcare Services Department, Hamad Medical Corporation, Doha, Qatar
Keywords Beers criteria Home care patients Potentially inappropriate medications (PIM) Qatar
Impact on Practice •
•
•
Inappropriate prescribing among elderly home care patients is a significant problem in Qatar that warrants attention and further evaluation. As an effective part of multidisciplinary teams caring for home care patients, the role of clinical pharmacists in optimizing drug therapy, monitoring and limiting inappropriate prescribing should be further defined and supported. Explicit criteria for prescribing in elderly, such as Beers criteria, can be used as valuable tools to guide clinicians about safe medications use without surpassing clinical judgment or patients’ values and preferences.
Evidence suggests that the use of drugs in geriatrics is frequently inappropriate, which is believed to be due to the complexities of prescribing as well as other patient; provider; and health-system factors [1, 2].
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Inappropriate prescribing can cause substantial morbidity, and represents a clinical and economic burden to patients and society [3–5]. It has therefore become an important public-health issue worldwide. Compared to the general ambulatory elderly patients, those receiving home-based healthcare are at increased risk of potentially inappropriate medications (PIMs) use [6–9]. Data on appropriateness of prescribing among these patients however is limited. Previous studies have demonstrated that 20–40 % of home care patients were exposed to at least one potentially inappropriate medication [6, 10, 11]. In general, these studies utilized explicit criteria (criterion based) for detecting medications that are deemed inappropriate. The Beers criteria [12] and the screening tool of older people’s prescriptions–screening tool to alert to right treatment (STOPP–START) criteria [13] are among the most commonly used methods for the identification of PIMs. Beers list [12] was first released in 1991 and its last updated edition, issued in 2012, was supported by a new partnership with the American Geriatrics Society (AGS) and an evidence based approach to improve its quality and relevance to practice. It encompasses a list of 53 potentially inappropriate medications/medication classes that are considered potentially inappropriate for use in elderly and divided into three categories: (1) Medications to avoid in older adults regardless of medical conditions; (2) medications considered potentially inappropriate when used in older adults with certain diseases or syndromes that the drugs listed can exacerbate; and (3) medications that should be used with caution. On the other hand, STOPP–START tool was initially published in 2008 [13]. It was updated later in 2014 [14] to reflect Europe-wide prescribing practice by consulting a wider range of experts from across Europe than the panel of Irish and UK experts involved in the validation of the first version. Compared to Beers criteria, STOPP–START tool recognizes the dual nature of inappropriate prescribing by including a list of 80 potentially inappropriate medications (STOPP criteria) and 34 potential prescribing omissions (START criteria). Previous studies suggested that STOPP–START criteria identified more inappropriate medications than Beers criteria across different healthcare settings [15–19]. An Irish study that investigated inappropriate prescribing among residents of long term care facilities found that the 2008 STOPP criteria identified a higher percentage of PIMs than the 2012 updated Beers criteria. It’s is unknown, though, if this was due to the design and validation of STOPP in an Irish setting [20]. However, the application of STOPP–START criteria is limited by the reliance on healthcare professionals’ skills in reviewing patients’ medications based on medical history, duration of drug use, drug–drug and drug–disease
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interaction [15] and by the availability of such data in patients’ records. Emerging data suggests that the updated version of Beers criteria could detect more PIMs than the older versions of both Beers and STOPP–START criteria. This is supported by results of the Italian REPOSI trial which demonstrated that the 2012 Beers criteria identified more PIMs (23.5 %) than the 2003 version (20.1 %). The difference between the two versions was mainly attributed to prescriptions of benzodiazepines for insomnia or agitation; chronic use of non-benzodiazepine hypnotics; prescription of antipsychotics in people with dementia and oral iron at dosage higher than 325 mg/day [21]. A more recent study conducted in Spain revealed that the 2012 Beers criteria detected the highest number of PIMs (44 %) when compared to the 2003 Beers and the 2008 STOPP–START criteria (24.3 and 35.4 %, respectively) [22]. To date, comparisons between the updated versions of both criteria in the identification of PIMs are lacking.
Aim of the study To investigate the prevalence of potentially inappropriate medications use among elderly patients receiving Home Health Care Services (HHCS) in Qatar by applying the 2012 Beers criteria and to identify possible predictors of inappropriate prescribing. Ethical approval The study protocol was approved by the medical research centre (MRC) of Hamad Medical Corporation (HMC).
Method This was a cross-sectional study, conducted over a 3 months period, between January and April 2013 in Home Health Care Services in Qatar (HHCS). Qatar is one of the six Gulf Cooperation Council (GCC) countries in Middle East. It has the world’s second smallest proportion of people aged over 65, estimated as 1 % of the total population. [23]. The country’s health system is regulated by the Supreme council of health, which funds and supervises Qatar’s two largest public health provider networks: the Primary Health Care Corporation (PHCC) and the Hamad Medical Corporation (HMC). Home Health Care Services (HHCS) is a department that runs under HMC, the nation’s premier non-profit public healthcare providing facility. It serves more than 800 patients, with geriatrics being a majority.
Int J Clin Pharm
The organization consists of multidisciplinary healthcare providers who work in collaboration to support the patients and make them more independent at homes and community through the provision of several services that include health education, consumables supply and medication administration. Each patient followed by HHCS has a medical chart kept centrally within the department, where medical notes and an updated list of active medications can be found. Clinical pharmacy service in HHCS was launched in 2005. The three participating pharmacists conduct charts review and home visits on regular basis. They evaluate and optimize drug therapy through effective communication with care providers and document their recommendations in patients’ medical charts to ensure safe and effective drug use. The study included all patients 65 years and older, taking at least one medication and receiving HHCS. Two pharmacists conducted a comprehensive review of patients’ medical notes and updated medications lists. Collected data include patients’ demographics, co-morbidities, number of prescribed medications, duration under the care of HHCS, and any reported recent hospital admissions, falls or adverse drug events. PIMs were identified and classified on the basis of the updated AGS Beers Criteria (2012). Subsequently, data were reviewed by a third pharmacist to ensure appropriate identification and classification of PIMs and perform computer entry. All statistical analyses were done by Statistical Package for the Social Sciences (SPSS) 19.0. Categorical and continuous values were expressed as frequency (percentage) and mean ± SD, respectively. Descriptive statistics were used to summarize all demographic and other characteristics of the participants. The primary outcome variable, the prevalence of PIMs among elderly, was estimated and tested using appropriate Z test with the corresponding 95 % confidence interval computed to measure the precision of the estimate. Quantitative variables means between the patients prescribed PIMs and their counterparts were analyzed using unpaired ‘t’ test. Association between two or more categorical variables was assessed using Chi square test. For small cell frequencies, Chi square test with continuity correction factor was used. The strength and direction of the association between PIMs and the possible predictors was determined by logistic regression analysis. For non-normal (skewed) data an appropriate data transformation or corresponding non-parametric test was applied. A two-sided P value \0.05 was considered to be statistically significant.
Results Five hundred and one patients were included, of whom the majority were females (n = 336, 67.1 %). Patients had a mean age (±SD) of 79 (±8) years, a mean length of stay under the care of HHCS of 3 years (±2.6) and received a mean number of ten prescribed medications (±5). The most common co-morbidities in the studied patients were hypertension (79.2 %); diabetes mellitus (66.1 %) and cerebro-vascular disease (40.7 %). Table 1 describes the demographic and clinical characteristics of the study population. A total of 191 patients (38.2 %) received at least one potentially inappropriate medication (Figure 1). Based on Beers criteria, 35 % of medications were classified as medications to be avoided in older adults regardless of conditions and 9 % as PIMs when used in patients with certain underlying diseases or syndromes that can be exacerbated by the listed drugs. The majority of PIMs (56 %) were classified as medications to be used with caution. The leading therapeutic classes of PIMs were antipsychotic medications (27.4 %); selective serotonin reuptake inhibitors (SSRIs) (16 %); skeletal muscle relaxants (9.3 %) and non-cox 2 selective non-steroidal anti-inflammatory drugs (NSAIDs) (6.4 %). Mirtazapine was prescribed in (9.3 %) of patients (Table 2). History of fall was documented in six patients only, of whom two were prescribed SSRIs antidepressants.
Table 1 Demographic and clinical characteristics of the study sample N (%)
Mean (SD)
Demographics Female
336 (67.1)
–
Age (years)
–
79 (7.8)
Number of prescribed drugs
5286
10 (7.5)
–
2.9 (2.5)
HHCS stay (years) Comorbidities Hypertension
397 (79.2)
–
Diabetes mellitus
331 (66.1)
–
Cerebrovascular disease
204 (40.7)
–
Dementia
122 (24.4)
–
Ischemic heart disease
111 (22.2)
–
Osteoarthritis
75 (15.0)
–
Chronic kidney disease
44 (8.8)
–
Heart failure
27 (5.4)
–
Depression
16 (3.2)
–
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Fig. 1 Distribution of patients according to the number of prescribed PIMs
Table 2 Top ten potentially inappropriate drugs/drug classes Potentially inappropriate drugs/drug classes
Number (%)
Antipsychotic medications
85 (27.4)
Selective serotonin reuptake inhibitors (SSRI)
45 (16)
Mirtazapine
26 (9.3)
Skeletal muscle relaxants
26 (9.3)
Non-cox 2 selective non-steroidal anti-inflammatory
18 (6.4)
Benzodiazepines (long acting and short acting)
12 (4.3)
Aspirin for primary prevention
11 (3.9)
Long acting sulphonylureas
11 (3.9)
Serotonin norepinephrine reuptake inhibitots
9 (3.2)
Anti-infective (nitrofurantoin)
6 (2.1)
Tertiary tricyclic antidepressants
6 (2.1)
Eighteen patients (6.4 %) with a documented diagnosis of dementia received an antipsychotic drug. Adjusted for potential confounders like age; gender and co-morbidities, multiple logistic regression analysis revealed that hypertension [adjusted OR 1.7; 95 % CI (1.0, 2.8)], dementia [adjusted OR 2.0; 95 % CI (1.2, 3.1)], depression [adjusted OR 21.6; 95 % CI (2.8, 168.4)], and taking more than ten prescribed medications [adjusted OR 1.9; 95 % CI (1.3, 2.8)] were the only significant predictors of PIMs use.
Discussion The study revealed a relatively high prevalence of PIMs prescribing among elderly patients receiving HHCS in Qatar (38.2 %). Significant predictors of PIMs use were hypertension, dementia, depression and polypharmacy. These findings are comparable to the results of previous studies where the prevalence of PIMs in similar settings ranged between 20 and 40 % [6, 10, 11].
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Bao et al. [6] found that 38 % of the United States home health patients were prescribed at least one PIM according to the 2003 Beers list. The study identified poly-pharmacy as the main predictor of PIMs use. Interestingly, this prevalence was three times higher than that found in ambulatory visits [6, 7] and about double that identified in two large elderly outpatient centres [6, 8, 9]. Estimates appear to be lower in Europe. A cross-sectional study [10] that utilized all available explicit criteria of inappropriate prescribing at that time revealed a 20 % prevalence of PIMs among elderly receiving home care in eight European countries. Of note, significant predictors of inappropriate prescribing were poly-pharmacy, poor economic status and the use of anxiolytic drugs. Recently, a Japanese study [11] that adopted version 1 of STOPP–START criteria [14] to assess prescribing among elderly home care patients found that 40.4 % had at least one PIM and 60.7 % had at least one incidence of under-prescribing. The study demonstrated that hypertension and constipation were risk factors for inappropriate prescribing, whereas osteoporosis increased risk of underprescribing. Interestingly, poly-pharmacy was found to increase both inappropriate and under-prescribing. The high prevalence of PIMs in homecare patients is partly explained by the coexistence of multiple medical conditions, polypharmacy and variable prescribers [6, 24]. Polypharmacy, for instance, has been identified as an independent predictor of inappropriate prescribing in older adults by several studies [6, 10, 11, 25, 26]. An interesting finding in our study is the high percentage of PIMs classified as medications to be used with caution (65 %), which was a new addition to the updated version of Beers criteria. A finding that obliges prescribers’ attention and warrants frequent assessment of risk against anticipated benefit associated with the use of these PIMs. Noteworthy, this class consists of fourteen medications that can be potentially misused or harmful, yet the consensus view of the panel sought that their use can be adequately justified in some individuals [12]. Our study revealed a high rate of prescribing CNS active drugs including antipsychotics and SSRIs antidepressants. These drugs have been shown to be associated with a substantial risk of falls and fractures in this fragile patient population [27–30]. Worth mentioning, risk of fracture appears to be comparable between first generation antipsychotics and the newer second-generation agents [29], as well as the risk among tri-cyclic and SSRIs antidepressant drugs [30]. Therefore, the Beers criteria recommend against using these medications in elderly with history of falls or fractures due to their ‘‘Ability to produce ataxia, impaired psychomotor function, syncope, and additional falls, unless safer alternatives are not available’’ [12].
Int J Clin Pharm
In our study, a correlation between the use of psychotropic drugs and risk of falls or fractures could not be established as only six patients were documented to have a history of fall, of which two received SSRIs antidepressants. In addition, the expert panel of Beers criteria advises for prescribing antipsychotics, SSRIs, serotonin–norepinephrine reuptake inhibitors, tri-cyclic antidepressants and mirtazapine with caution and recommends close monitoring of serum sodium upon initiation and dose up-titration due to their potential of causing or exacerbating syndrome of inappropriate antidiuretic hormone secretion and hyponatremia. Noteworthy, the use of antipsychotics in controlling neuropsychiatric symptoms of dementia had been strongly discouraged by the Beers criteria due to increased risk of cardiovascular complications and mortality [31–38], ‘‘unless non-pharmacological options have failed and patient is threat to self or others’’. Fortunately, our study revealed a relatively low rate (6.4 %) of prescribing antipsychotic drugs in demented patients. Findings of our study emphasize the importance of promoting and strengthening the role of pharmacists participating in home care services. Literature supports improved pharmacotherapy for older patients with proactive participation of pharmacists in performing medication reviews and in the active education of other healthcare professionals [39]. In a retrospective evaluation of medication appropriateness among home-based primary care veterans, pharmacist contribution significantly improved the appropriateness of medication use evaluated by Medication Appropriateness Index (MAI). Pharmacist’s recommendations to primary care providers and nurses involved drug initiation/discontinuation; laboratory monitoring; dosage adjustment; as well as monitoring for medication adherence; efficacy and adverse events [40]. Our study has certain strengths. First, it utilized Beers criteria, the most updated prescribing tool for elderly at the time of study conduction. The criteria was supported by the evidence based standards of the Institute of Medicine and the development of a partnership with the AGS to regularly update it, which potentially solved the past criticisms of being less relevant to clinicians and health outcomes [41]. Second, the study was the first to evaluate the pattern of prescribing in elderly patients receiving HHCS in the region and the overall elderly patients in Qatar, a population that is highly fragile and clinically complex yet understudied. Third, the review process to identify and classify PIMs was carried out by two pharmacists, independently, which was intended to avoid information bias. The study, however, has limitations. First, an association between inappropriate prescribing and clinical effects, such as adverse events or risk of fall,
could not be established. This is partly due to incomplete documentation in patients’ medical records. For example, we could not find any recorded drug-related adverse reaction and only six patients (1.2 %) were reported to have a history of fall. Second, identification and classification of PIMs was based solely on one tool, Beers list, which was criticized to have several limitations. Those include overlooking important causes of potential inappropriate prescribing like drug–drug interactions, drug class prescription duplication, and prescribing omission errors compared to other criteria like the STOPP–START developed in United Kingdom and Ireland [13]. However, studies mentioned earlier proved that updated Beers list could detect more PIMs than older versions of Beers [20, 21] and STOPP–START [21] tools, as most of the available comparisons were based on older criteria. The main reason why STOPP–START criteria was not utilized in our study is the concern related to potential deficiencies in patients records due to incomplete documentation and the difficulty of gathering information about medical history. This was expected to limit the applicability of the criteria in evaluating PIMs use in the light of medical history, duration of drug use, drug–drug and drug–disease interactions. Another limitation of Beers criteria is the inclusion of drugs that are not considered contraindicated in geriatrics by updated evidence-based drug formularies like the British National Formulary; e.g., amitriptyline, nitrofurantoin and amiodarone [14]. The criteria, along with other available explicit criteria, is also criticized by the conflicting evidence of whether their application can achieve objective and measurable improvements in clinical outcomes and prevent possible drug-related adverse events [20, 22, 42–46]. In the Italian REPOSI trial, PIMs prescribing was not associated with a higher risk of adverse clinical events, re-hospitalization and all-cause mortality at 3-months follow-up [20]. Nevertheless, Beers criteria remain a valuable tool to guide clinicians about safe medications use in older adults and alert them to monitor their patients and possibly reduce the risk of preventable drug-related adverse events. They are not intended, however, to surpass clinical judgment or patients’ values and preferences.
Conclusion Prescribing potentially inappropriate medications is common among older adults receiving home health care services in Qatar, a finding that warrants further attention. Significant predictors of PIMs prescribing in this study were hypertension, dementia, depression and polypharmacy.
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As an effective part of multidisciplinary teams caring for HHCS patients, the role of clinical pharmacists in optimizing drug therapy, monitoring and limiting inappropriate prescribing should be further defined and supported. Future studies are warranted to evaluate prescribing across different healthcare facilities caring for older adults in Qatar, and preferably investigate the value of applying medication review tools like Beers and others in reducing drug-related adverse events, hospitalization and mortality.
Funding This study received funding from the medical research centre in Hamad Medical Corporation, Doha-Qatar. Conflicts of interest interest to declare.
The authors have no (potential) conflict of
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RESEARCH ARTICLE
Prevalence and predictors of potentially inappropriate medications among home care elderly patients in Qatar Eman Alhmoud1 • Sabah Khalifa1 • Asma Abdulaziz Bahi2
Received: 30 October 2014 / Accepted: 15 April 2015 Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie 2015
Abstract Background Older patients receiving home health care are particularly at risk of receiving potentially inappropriate medications compared to community-dwelling population. Data on appropriateness of prescribing in these patients is limited. Objective To investigate the prevalence, patterns and determinants of potentially inappropriate medications among elderly patients receiving Home Health Care Services in Qatar. Setting Home Health Care Services department in Hamad Medical Corporation-Qatar. Methods A cross-sectional study, conducted over a 3 months period. Patients 65 years and older, taking at least one medication and receiving home care services were included. Potentially inappropriate medications were identified and classified in accordance with the American Geriatrics Society 2012 Beers Criteria. Main outcome measure Prevalence of potentially inappropriate medications using updated Beers criteria. Results A total of 191 patients (38.2 %) had at least one potentially inappropriate medication. As per Beers criteria, 35 % of medications were classified as medications to be avoided in older adults regardless of conditions and 9 % as potentially inappropriate medications when used with certain diseases or syndromes. The majority of potentially inappropriate medications (56 %) were classified as medications to be used with caution. The two leading classes of potentially inappropriate medications were antipsychotics (27.4 %) and selective serotonin reuptake inhibitors (16 %). Significant predictors of inappropriate prescribing were hypertension [adjusted OR
1.7; 95 % CI (1.0, 2.8)], dementia [adjusted OR 2.0; 95 % CI (1.2, 3.1)], depression [adjusted OR 21.6; 95 % CI (2.8, 168.4)], and taking more than ten prescribed medications [adjusted OR 1.9; 95 % CI (1.3, 2.8)]. Conclusion Prescribing potentially inappropriate medications is common among older adults receiving home health care services in Qatar, a finding that warrants further attention. Polypharmacy, hypertension, depression and dementia were significantly associated with potentially inappropriate prescribing.
& Eman Alhmoud [email protected]
Introduction
1
Clinical Pharmacy Services-Pharmacy Department, Hamad General Hospital-Hamad Medical Corporation, Doha, Qatar
2
Home Healthcare Services Department, Hamad Medical Corporation, Doha, Qatar
Keywords Beers criteria Home care patients Potentially inappropriate medications (PIM) Qatar
Impact on Practice •
•
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Inappropriate prescribing among elderly home care patients is a significant problem in Qatar that warrants attention and further evaluation. As an effective part of multidisciplinary teams caring for home care patients, the role of clinical pharmacists in optimizing drug therapy, monitoring and limiting inappropriate prescribing should be further defined and supported. Explicit criteria for prescribing in elderly, such as Beers criteria, can be used as valuable tools to guide clinicians about safe medications use without surpassing clinical judgment or patients’ values and preferences.
Evidence suggests that the use of drugs in geriatrics is frequently inappropriate, which is believed to be due to the complexities of prescribing as well as other patient; provider; and health-system factors [1, 2].
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Inappropriate prescribing can cause substantial morbidity, and represents a clinical and economic burden to patients and society [3–5]. It has therefore become an important public-health issue worldwide. Compared to the general ambulatory elderly patients, those receiving home-based healthcare are at increased risk of potentially inappropriate medications (PIMs) use [6–9]. Data on appropriateness of prescribing among these patients however is limited. Previous studies have demonstrated that 20–40 % of home care patients were exposed to at least one potentially inappropriate medication [6, 10, 11]. In general, these studies utilized explicit criteria (criterion based) for detecting medications that are deemed inappropriate. The Beers criteria [12] and the screening tool of older people’s prescriptions–screening tool to alert to right treatment (STOPP–START) criteria [13] are among the most commonly used methods for the identification of PIMs. Beers list [12] was first released in 1991 and its last updated edition, issued in 2012, was supported by a new partnership with the American Geriatrics Society (AGS) and an evidence based approach to improve its quality and relevance to practice. It encompasses a list of 53 potentially inappropriate medications/medication classes that are considered potentially inappropriate for use in elderly and divided into three categories: (1) Medications to avoid in older adults regardless of medical conditions; (2) medications considered potentially inappropriate when used in older adults with certain diseases or syndromes that the drugs listed can exacerbate; and (3) medications that should be used with caution. On the other hand, STOPP–START tool was initially published in 2008 [13]. It was updated later in 2014 [14] to reflect Europe-wide prescribing practice by consulting a wider range of experts from across Europe than the panel of Irish and UK experts involved in the validation of the first version. Compared to Beers criteria, STOPP–START tool recognizes the dual nature of inappropriate prescribing by including a list of 80 potentially inappropriate medications (STOPP criteria) and 34 potential prescribing omissions (START criteria). Previous studies suggested that STOPP–START criteria identified more inappropriate medications than Beers criteria across different healthcare settings [15–19]. An Irish study that investigated inappropriate prescribing among residents of long term care facilities found that the 2008 STOPP criteria identified a higher percentage of PIMs than the 2012 updated Beers criteria. It’s is unknown, though, if this was due to the design and validation of STOPP in an Irish setting [20]. However, the application of STOPP–START criteria is limited by the reliance on healthcare professionals’ skills in reviewing patients’ medications based on medical history, duration of drug use, drug–drug and drug–disease
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interaction [15] and by the availability of such data in patients’ records. Emerging data suggests that the updated version of Beers criteria could detect more PIMs than the older versions of both Beers and STOPP–START criteria. This is supported by results of the Italian REPOSI trial which demonstrated that the 2012 Beers criteria identified more PIMs (23.5 %) than the 2003 version (20.1 %). The difference between the two versions was mainly attributed to prescriptions of benzodiazepines for insomnia or agitation; chronic use of non-benzodiazepine hypnotics; prescription of antipsychotics in people with dementia and oral iron at dosage higher than 325 mg/day [21]. A more recent study conducted in Spain revealed that the 2012 Beers criteria detected the highest number of PIMs (44 %) when compared to the 2003 Beers and the 2008 STOPP–START criteria (24.3 and 35.4 %, respectively) [22]. To date, comparisons between the updated versions of both criteria in the identification of PIMs are lacking.
Aim of the study To investigate the prevalence of potentially inappropriate medications use among elderly patients receiving Home Health Care Services (HHCS) in Qatar by applying the 2012 Beers criteria and to identify possible predictors of inappropriate prescribing. Ethical approval The study protocol was approved by the medical research centre (MRC) of Hamad Medical Corporation (HMC).
Method This was a cross-sectional study, conducted over a 3 months period, between January and April 2013 in Home Health Care Services in Qatar (HHCS). Qatar is one of the six Gulf Cooperation Council (GCC) countries in Middle East. It has the world’s second smallest proportion of people aged over 65, estimated as 1 % of the total population. [23]. The country’s health system is regulated by the Supreme council of health, which funds and supervises Qatar’s two largest public health provider networks: the Primary Health Care Corporation (PHCC) and the Hamad Medical Corporation (HMC). Home Health Care Services (HHCS) is a department that runs under HMC, the nation’s premier non-profit public healthcare providing facility. It serves more than 800 patients, with geriatrics being a majority.
Int J Clin Pharm
The organization consists of multidisciplinary healthcare providers who work in collaboration to support the patients and make them more independent at homes and community through the provision of several services that include health education, consumables supply and medication administration. Each patient followed by HHCS has a medical chart kept centrally within the department, where medical notes and an updated list of active medications can be found. Clinical pharmacy service in HHCS was launched in 2005. The three participating pharmacists conduct charts review and home visits on regular basis. They evaluate and optimize drug therapy through effective communication with care providers and document their recommendations in patients’ medical charts to ensure safe and effective drug use. The study included all patients 65 years and older, taking at least one medication and receiving HHCS. Two pharmacists conducted a comprehensive review of patients’ medical notes and updated medications lists. Collected data include patients’ demographics, co-morbidities, number of prescribed medications, duration under the care of HHCS, and any reported recent hospital admissions, falls or adverse drug events. PIMs were identified and classified on the basis of the updated AGS Beers Criteria (2012). Subsequently, data were reviewed by a third pharmacist to ensure appropriate identification and classification of PIMs and perform computer entry. All statistical analyses were done by Statistical Package for the Social Sciences (SPSS) 19.0. Categorical and continuous values were expressed as frequency (percentage) and mean ± SD, respectively. Descriptive statistics were used to summarize all demographic and other characteristics of the participants. The primary outcome variable, the prevalence of PIMs among elderly, was estimated and tested using appropriate Z test with the corresponding 95 % confidence interval computed to measure the precision of the estimate. Quantitative variables means between the patients prescribed PIMs and their counterparts were analyzed using unpaired ‘t’ test. Association between two or more categorical variables was assessed using Chi square test. For small cell frequencies, Chi square test with continuity correction factor was used. The strength and direction of the association between PIMs and the possible predictors was determined by logistic regression analysis. For non-normal (skewed) data an appropriate data transformation or corresponding non-parametric test was applied. A two-sided P value \0.05 was considered to be statistically significant.
Results Five hundred and one patients were included, of whom the majority were females (n = 336, 67.1 %). Patients had a mean age (±SD) of 79 (±8) years, a mean length of stay under the care of HHCS of 3 years (±2.6) and received a mean number of ten prescribed medications (±5). The most common co-morbidities in the studied patients were hypertension (79.2 %); diabetes mellitus (66.1 %) and cerebro-vascular disease (40.7 %). Table 1 describes the demographic and clinical characteristics of the study population. A total of 191 patients (38.2 %) received at least one potentially inappropriate medication (Figure 1). Based on Beers criteria, 35 % of medications were classified as medications to be avoided in older adults regardless of conditions and 9 % as PIMs when used in patients with certain underlying diseases or syndromes that can be exacerbated by the listed drugs. The majority of PIMs (56 %) were classified as medications to be used with caution. The leading therapeutic classes of PIMs were antipsychotic medications (27.4 %); selective serotonin reuptake inhibitors (SSRIs) (16 %); skeletal muscle relaxants (9.3 %) and non-cox 2 selective non-steroidal anti-inflammatory drugs (NSAIDs) (6.4 %). Mirtazapine was prescribed in (9.3 %) of patients (Table 2). History of fall was documented in six patients only, of whom two were prescribed SSRIs antidepressants.
Table 1 Demographic and clinical characteristics of the study sample N (%)
Mean (SD)
Demographics Female
336 (67.1)
–
Age (years)
–
79 (7.8)
Number of prescribed drugs
5286
10 (7.5)
–
2.9 (2.5)
HHCS stay (years) Comorbidities Hypertension
397 (79.2)
–
Diabetes mellitus
331 (66.1)
–
Cerebrovascular disease
204 (40.7)
–
Dementia
122 (24.4)
–
Ischemic heart disease
111 (22.2)
–
Osteoarthritis
75 (15.0)
–
Chronic kidney disease
44 (8.8)
–
Heart failure
27 (5.4)
–
Depression
16 (3.2)
–
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Fig. 1 Distribution of patients according to the number of prescribed PIMs
Table 2 Top ten potentially inappropriate drugs/drug classes Potentially inappropriate drugs/drug classes
Number (%)
Antipsychotic medications
85 (27.4)
Selective serotonin reuptake inhibitors (SSRI)
45 (16)
Mirtazapine
26 (9.3)
Skeletal muscle relaxants
26 (9.3)
Non-cox 2 selective non-steroidal anti-inflammatory
18 (6.4)
Benzodiazepines (long acting and short acting)
12 (4.3)
Aspirin for primary prevention
11 (3.9)
Long acting sulphonylureas
11 (3.9)
Serotonin norepinephrine reuptake inhibitots
9 (3.2)
Anti-infective (nitrofurantoin)
6 (2.1)
Tertiary tricyclic antidepressants
6 (2.1)
Eighteen patients (6.4 %) with a documented diagnosis of dementia received an antipsychotic drug. Adjusted for potential confounders like age; gender and co-morbidities, multiple logistic regression analysis revealed that hypertension [adjusted OR 1.7; 95 % CI (1.0, 2.8)], dementia [adjusted OR 2.0; 95 % CI (1.2, 3.1)], depression [adjusted OR 21.6; 95 % CI (2.8, 168.4)], and taking more than ten prescribed medications [adjusted OR 1.9; 95 % CI (1.3, 2.8)] were the only significant predictors of PIMs use.
Discussion The study revealed a relatively high prevalence of PIMs prescribing among elderly patients receiving HHCS in Qatar (38.2 %). Significant predictors of PIMs use were hypertension, dementia, depression and polypharmacy. These findings are comparable to the results of previous studies where the prevalence of PIMs in similar settings ranged between 20 and 40 % [6, 10, 11].
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Bao et al. [6] found that 38 % of the United States home health patients were prescribed at least one PIM according to the 2003 Beers list. The study identified poly-pharmacy as the main predictor of PIMs use. Interestingly, this prevalence was three times higher than that found in ambulatory visits [6, 7] and about double that identified in two large elderly outpatient centres [6, 8, 9]. Estimates appear to be lower in Europe. A cross-sectional study [10] that utilized all available explicit criteria of inappropriate prescribing at that time revealed a 20 % prevalence of PIMs among elderly receiving home care in eight European countries. Of note, significant predictors of inappropriate prescribing were poly-pharmacy, poor economic status and the use of anxiolytic drugs. Recently, a Japanese study [11] that adopted version 1 of STOPP–START criteria [14] to assess prescribing among elderly home care patients found that 40.4 % had at least one PIM and 60.7 % had at least one incidence of under-prescribing. The study demonstrated that hypertension and constipation were risk factors for inappropriate prescribing, whereas osteoporosis increased risk of underprescribing. Interestingly, poly-pharmacy was found to increase both inappropriate and under-prescribing. The high prevalence of PIMs in homecare patients is partly explained by the coexistence of multiple medical conditions, polypharmacy and variable prescribers [6, 24]. Polypharmacy, for instance, has been identified as an independent predictor of inappropriate prescribing in older adults by several studies [6, 10, 11, 25, 26]. An interesting finding in our study is the high percentage of PIMs classified as medications to be used with caution (65 %), which was a new addition to the updated version of Beers criteria. A finding that obliges prescribers’ attention and warrants frequent assessment of risk against anticipated benefit associated with the use of these PIMs. Noteworthy, this class consists of fourteen medications that can be potentially misused or harmful, yet the consensus view of the panel sought that their use can be adequately justified in some individuals [12]. Our study revealed a high rate of prescribing CNS active drugs including antipsychotics and SSRIs antidepressants. These drugs have been shown to be associated with a substantial risk of falls and fractures in this fragile patient population [27–30]. Worth mentioning, risk of fracture appears to be comparable between first generation antipsychotics and the newer second-generation agents [29], as well as the risk among tri-cyclic and SSRIs antidepressant drugs [30]. Therefore, the Beers criteria recommend against using these medications in elderly with history of falls or fractures due to their ‘‘Ability to produce ataxia, impaired psychomotor function, syncope, and additional falls, unless safer alternatives are not available’’ [12].
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In our study, a correlation between the use of psychotropic drugs and risk of falls or fractures could not be established as only six patients were documented to have a history of fall, of which two received SSRIs antidepressants. In addition, the expert panel of Beers criteria advises for prescribing antipsychotics, SSRIs, serotonin–norepinephrine reuptake inhibitors, tri-cyclic antidepressants and mirtazapine with caution and recommends close monitoring of serum sodium upon initiation and dose up-titration due to their potential of causing or exacerbating syndrome of inappropriate antidiuretic hormone secretion and hyponatremia. Noteworthy, the use of antipsychotics in controlling neuropsychiatric symptoms of dementia had been strongly discouraged by the Beers criteria due to increased risk of cardiovascular complications and mortality [31–38], ‘‘unless non-pharmacological options have failed and patient is threat to self or others’’. Fortunately, our study revealed a relatively low rate (6.4 %) of prescribing antipsychotic drugs in demented patients. Findings of our study emphasize the importance of promoting and strengthening the role of pharmacists participating in home care services. Literature supports improved pharmacotherapy for older patients with proactive participation of pharmacists in performing medication reviews and in the active education of other healthcare professionals [39]. In a retrospective evaluation of medication appropriateness among home-based primary care veterans, pharmacist contribution significantly improved the appropriateness of medication use evaluated by Medication Appropriateness Index (MAI). Pharmacist’s recommendations to primary care providers and nurses involved drug initiation/discontinuation; laboratory monitoring; dosage adjustment; as well as monitoring for medication adherence; efficacy and adverse events [40]. Our study has certain strengths. First, it utilized Beers criteria, the most updated prescribing tool for elderly at the time of study conduction. The criteria was supported by the evidence based standards of the Institute of Medicine and the development of a partnership with the AGS to regularly update it, which potentially solved the past criticisms of being less relevant to clinicians and health outcomes [41]. Second, the study was the first to evaluate the pattern of prescribing in elderly patients receiving HHCS in the region and the overall elderly patients in Qatar, a population that is highly fragile and clinically complex yet understudied. Third, the review process to identify and classify PIMs was carried out by two pharmacists, independently, which was intended to avoid information bias. The study, however, has limitations. First, an association between inappropriate prescribing and clinical effects, such as adverse events or risk of fall,
could not be established. This is partly due to incomplete documentation in patients’ medical records. For example, we could not find any recorded drug-related adverse reaction and only six patients (1.2 %) were reported to have a history of fall. Second, identification and classification of PIMs was based solely on one tool, Beers list, which was criticized to have several limitations. Those include overlooking important causes of potential inappropriate prescribing like drug–drug interactions, drug class prescription duplication, and prescribing omission errors compared to other criteria like the STOPP–START developed in United Kingdom and Ireland [13]. However, studies mentioned earlier proved that updated Beers list could detect more PIMs than older versions of Beers [20, 21] and STOPP–START [21] tools, as most of the available comparisons were based on older criteria. The main reason why STOPP–START criteria was not utilized in our study is the concern related to potential deficiencies in patients records due to incomplete documentation and the difficulty of gathering information about medical history. This was expected to limit the applicability of the criteria in evaluating PIMs use in the light of medical history, duration of drug use, drug–drug and drug–disease interactions. Another limitation of Beers criteria is the inclusion of drugs that are not considered contraindicated in geriatrics by updated evidence-based drug formularies like the British National Formulary; e.g., amitriptyline, nitrofurantoin and amiodarone [14]. The criteria, along with other available explicit criteria, is also criticized by the conflicting evidence of whether their application can achieve objective and measurable improvements in clinical outcomes and prevent possible drug-related adverse events [20, 22, 42–46]. In the Italian REPOSI trial, PIMs prescribing was not associated with a higher risk of adverse clinical events, re-hospitalization and all-cause mortality at 3-months follow-up [20]. Nevertheless, Beers criteria remain a valuable tool to guide clinicians about safe medications use in older adults and alert them to monitor their patients and possibly reduce the risk of preventable drug-related adverse events. They are not intended, however, to surpass clinical judgment or patients’ values and preferences.
Conclusion Prescribing potentially inappropriate medications is common among older adults receiving home health care services in Qatar, a finding that warrants further attention. Significant predictors of PIMs prescribing in this study were hypertension, dementia, depression and polypharmacy.
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As an effective part of multidisciplinary teams caring for HHCS patients, the role of clinical pharmacists in optimizing drug therapy, monitoring and limiting inappropriate prescribing should be further defined and supported. Future studies are warranted to evaluate prescribing across different healthcare facilities caring for older adults in Qatar, and preferably investigate the value of applying medication review tools like Beers and others in reducing drug-related adverse events, hospitalization and mortality.
Funding This study received funding from the medical research centre in Hamad Medical Corporation, Doha-Qatar. Conflicts of interest interest to declare.
The authors have no (potential) conflict of
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