Potentially inappropriate medications in elderly

Abstracts

OBJETIVO: Comparar PRISCUS com Beers-Fick na detecção de medicamentos potencialmente inapropriados (MPI) para idosos à primeira consulta ambulatorial geriátrica. MÉTODOS: Análise retrospectiva de prontuários por PRISCUS e Beers-Fick adaptados à farmacopeia brasileira, comparando-se o encontro de MPI à primeira consulta ambulatorial geriátrica pelos dois critérios. RESULTADOS: Idade média de 77,4 ± 7,7 anos, 64 mulheres e 36 homens, consumo médio de 3,9 ± 2,5 fármacos. Este estudo encontrou significância estatística no número de mulheres em uso de benzodiazepínicos e de homens quanto a salicilatos. Média de 0,5 ± 0,7 MPI/paciente por Beers-Fick e 0,7 ± 0,8 MPI/paciente pela PRISCUS. Medicamentos de Beers-Fick mais referidos: benzodiazepínicos, metildopa e derivados do ergot. Medicamentos de PRISCUS mais referidos: benzodiazepínicos, anti-hipertensivos e antidepressivos tricíclicos. Não houve significância estatística comparando-se o número de idosos com MPI pelos dois critérios. Constatou-se significância estatística (PRISCUS versus Beers-Fick) no consumo de benzodiazepínicos de longa ação e laxantes. Ambos não incluem fármacos como vitaminas, fitoterápicos e colírios, relatados por percentual da casuística. CONCLUSÃO: Os dois critérios são úteis para a prevenção de MPI em idosos, sendo PRISCUS mais atualizada e abrangente, mas não são completos para a realidade ambulatorial brasileira.

Doença iatrogênica; medicamentos sob prescrição; assistência a idosos; reconciliação de medicamentos


OBJECTIVE: To compare PRISCUS with Beers-Fick in detecting potentially inappropriate medication (PIMs) in elderly at their first outpatient geriatric visit. METHODS: Retrospective medical record analysis by PRISCUS and Beers-Fick adapted to Brazilian pharmacopoeia, comparing the finding of PIMs at the first outpatient geriatric visit by both criteria. RESULTS: Cases had mean age of 77.4 ± 7.7 years (64 females and 36 males), and mean consumption of 3.9 ± 2.5 drugs. This study found statistical significance for the numbers of women using benzodiazepines and men using salicylates. The mean was 0.5 ± 0.7 PIMs/patient by Beers-Fick criteria and 0.7 ± 0.8 PIMs/patient by PRISCUS. Medications most often reported by Beers-Fick criteria were: benzodiazepines, methyldopa and ergot-derived drugs. Medications most often reported by PRISCUS criteria were: benzodiazepines, antihypertensive drugs, and tricyclic antidepressants. No statistical significance was found when the number of elderly patients with PIMs was compared between both criteria. Statistical significance was found (PRISCUS versus Beers-Fick) for the consumption of long acting benzodiazepines and laxatives. Both criteria do not include drugs such as vitamins, herbal medications, and eye drops, reported by a percentage of cases. CONCLUSION: Both criteria are useful to prevent PIMs in the elderly, with PRISCUS being more updated and comprehensive, but they are not complete for the Brazilian outpatient reality.

Iatrogenic disease; prescription drugs; elderly care; medication reconciliation


ORIGINAL ARTICLE

IAdjunct Professor, Department of Medical Clinic, Faculdade de Ciências Médicas da Santa Casa de São Paulo (FCMSCSP); Coordinator, Disciplines of Geriatrics and Gerontology Basics, FCMSCSP, São Paulo, SP, Brazil

IIAssistant Professor, FCMSCSP; Area II, Medical Clinic Service, São Paulo, SP, Brazil

IIIInstructor Professor, FCMSCSP; Technical Director, Hospital Geriátrico e de Convalescentes D. Pedro II, São Paulo, SP, Brazil

Correspondence to

SUMMARY

OBJECTIVE: To compare PRISCUS with Beers-Fick in detecting potentially inappropriate medication (PIMs) in elderly at their first outpatient geriatric visit.

METHODS: Retrospective medical record analysis by PRISCUS and Beers-Fick adapted to Brazilian pharmacopoeia, comparing the finding of PIMs at the first outpatient geriatric visit by both criteria.

RESULTS: Cases had mean age of 77.4 ± 7.7 years (64 females and 36 males), and mean consumption of 3.9 ± 2.5 drugs. This study found statistical significance for the numbers of women using benzodiazepines and men using salicylates. The mean was 0.5 ± 0.7 PIMs/patient by Beers-Fick criteria and 0.7 ± 0.8 PIMs/patient by PRISCUS. Medications most often reported by Beers-Fick criteria were: benzodiazepines, methyldopa and ergot-derived drugs. Medications most often reported by PRISCUS criteria were: benzodiazepines, antihypertensive drugs, and tricyclic antidepressants. No statistical significance was found when the number of elderly patients with PIMs was compared between both criteria. Statistical significance was found (PRISCUS versus Beers-Fick) for the consumption of long acting benzodiazepines and laxatives. Both criteria do not include drugs such as vitamins, herbal medications, and eye drops, reported by a percentage of cases.

CONCLUSION: Both criteria are useful to prevent PIMs in the elderly, with PRISCUS being more updated and comprehensive, but they are not complete for the Brazilian outpatient reality.

Keywords: Iatrogenic disease; prescription drugs; elderly care; medication reconciliation.

INTRODUCTION

Significant percentages of elderly have several concomitant diseases, which leads to the concomitant use of three or more medications1-4. In parallel, changes in body composition and kidney and liver functions caused by natural human aging are observed5. Thus, pharmacokinetic and pharmacodynamic interference exists among various drugs, some of them prescribed regularly in clinical practice5-6. This medication consumption pattern, associated with age-linked diseases and changes, constantly triggers side effects and drug interactions with serious outcomes for patients in this age group4-8.

Medication intake involves serial steps - prescription, communication, dispensation, administration, and clinical follow-up -, making it a complex and iatrogenic-prone act, particularly in the elderly. A significant portion of these adverse events can be prevented at the prescription stage9. Lists of potentially inappropriate medications (PIMs) - defined as drugs at risk of causing more side effects than benefits in the elderly - are useful aids in clinical practice regarding the preventive action. Several lists have been published over the last two decades10-15. Versions of Beers criteria10,11 and later, Beers-Fick criteria13 have become the most cited and used worldwide9,16. However, there is criticism of these criteria, particularly regarding their drug scope and adaptability to specific pharmacopoeias in each country9,14-16. In the search for reducing the criticized aspects of Beers-Fick criteria, Holt et al.17 defined a PIM list for the elderly - termed PRISCUS - primarily to be used in Germany. The generated list - a total of 83 drugs in 18 drug classes - includes comments for clinical practice and therapeutic options.

Which list or criteria are used in PIM evaluations in Brazil? A survey performed in PubMed on April 23, 2011 with the following keywords: Beers Fick criteria Brazil OR Beers criteria Brazil OR potentially inappropriate medication elderly Brazil OR inappropriate prescription elderly Brazil retrieved six articles6,18-22, all of them with a methodology based on Beers-Fick criteria13. A survey at SciELO, using the same keywords and on the same date, located seven articles4,5,18-22; five of which had been already retrieved by the former portal18-22 and two more4,5, the first of which4 cites another report by Beers23 and the second5 comments on the first two versions of Beers criteria10,11. Thus, no PIM list or criteria for the elderly have been developed in Brazil. The studies published in Brazil follow a global trend, as they use literature based on articles produced by Beers et al.10,11,13,23.

Considering the above description, the question asked is: would the PRISCUS17 list adapted to Brazilian pharmacopoeia be more adequate than Beers-Fick13 criteria to detect PIMs in elderly Brazilian patients?

OBJECTIVES

To compare the PRISCUS17 list with Beers-Fick13 criteria to detect PIMs in the elderly assessed at the first outpatient geriatric visit.

METHODS

Review of elderly outpatients' medical records through the PRISCUS17 list adapted to Brazilian pharmacopoeia (Box 1). The same number of cases and same methodology as in a study published in 20061 by the authors regarding the applicability of Beers-Fick criteria17 also adapted to Brazilian pharmacopoeia (Box 2) at the first outpatient geriatric visit were used.

The patients were attended to by the authors in an outpatient facility belonging to the Irmandade da Santa Casa de Misericórdia de São Paulo between the years 2000 and 2004. Later on (2005), through analysis of the standard history taking used at the institute, the drugs in continuous use on the days preceding the first geriatric assessment between 2000 and 2004 were reviewed. Both Beers-Fick13 criteria and the PRISCUS list17 were used to define PIM quantitative and qualitative values. PIM standards for the elderly were sequentially compared between the two adapted criteria/lists13,17 (Boxes 1 and 2). The expected result aims to determine the PIM prevalence in elderly at the onset of outpatient geriatric follow-up. The statistical analysis used a chi-squared test (Yates's and/or Fisher's exact test, both with an alpha of 5.0%), dividing the number of cases into females and males and into ages 74 and younger and 75 and older. The cases were further divided according to the main PIM classes used by both criteria13,17 studied.

The present study is a part of Projects # 344/10 and 404/10 approved by the local institutional ethics committee.

RESULTS

The cases consisted of 100 elderly people (64 females and 36 males) with a mean age of 77.4 ± 7.7 years and a mean consumption of 3.9 ± 2.5 drugs in continuous use/patient (Table 1). Statistical significance was reached for the number of women using benzodiazepines and men using salicylates.

By Beers-Fick13 criteria, 0.5 ± 0.7 PIMs/patient and by the PRISCUS17 list 0.7 ± 0.8 PIMs/patient were observed. The drugs in Beers-Fick13 criteria most often reported by the elderly assessed were: benzodiazepines, methyldopa, ergot-derived drugs, amitriptyline, and amiodarone. The drugs in the PRISCUS17 list most often reported by the same patients were: benzodiazepines, antihypertensives, tricyclic antidepressants, ergot-derived drugs, and laxatives. No statistical significance could be found upon comparing the global number of elderly patients using PIMs between both criteria13,17. However, statistical significance was found by the PRISCUS17 list versus the Beers-Fick13 criteria for long acting benzodiazepine and laxative consumption. Both criteria do not include drugs such as vitamins, herbal medicines, and eye drops reported by a percentage of cases (Table 1).

DISCUSSION

Periodical review of drugs used by the elderly must be an intrinsic part of clinical practice. Several concomitant and usually chronic diseases generate a potential for concomitant and significant medication consumption1-4. The association of medication use with pharmacokinetic and pharmacodynamic aging-linked changes creates conditions for a high risk of side effects and drug-drug interactions observed in the elderly4-8.

Usually, there is a higher number of females and patients older than 70 among the elderly in need of a special care in drug prescription4,6,20-22. These data were also observed in the present cases and are warranted by the remarkable female longevity and the progressive multiplicity of chronic diseases in older age groups24-27. The mean medication use among the elderly reviewed in this study was another parallel outcome correlated with that reported in the literature4,6,8,20,22. Thus, lists and/or criteria of inappropriate medications for elderly are effective both in detecting use and in avoiding prescription.

The subsequent issue is: which criteria and/or lists would be more appropriate to the Brazilian reality, since no national tool that meets this clinical practice need could be found in the literature?

Potentially inappropriate medication guidelines for the elderly, such as Beers-Fick13 criteria, are timehonored in the literature and used in several countries. They are practical and easily memorized, although they do not consider local realities as for the standard of medications delivered and prescribed to certain populations9,12,14- 16,18,19. The PRISCUS list17, primarily conceived for German pharmacopoeia, intends to be wider, as it contains drugs not mentioned by the Beers-Fick13 criteria. In the current study, a slight numeric PIM difference favoring the list was observed,17 possibly resulting from its higher discrimination of drug classes and drugs over the Beers-Fick criteria13 (61 versus 52 drugs marketed in Brazil - Boxes 1 and 2).

Both PIM evaluation tools detected approximately 21 drugs in common, notably benzodiazepines, antihypertensive drugs, ergotamine and ergot-derived drugs, laxatives, antiarrhythmic drugs, anti-inflammatory drugs, and antidepressants. However, a number of details differentiate them, such as the larger number of drugs separately cited in the Beers-Fick13 criteria and drug classes with no mention to PIMs linked to them in the PRISCUS list17. Differences are also noted between them, such as in lorazepam contraindicated dosage and no doses for alprazolam, fluoxetine, and digoxin13,17. Phenobarbital is further contraindicated in the PRISCUS17 list, but there is an indication by the Beers-Fick criteria13. Thus, they are two useful tools for clinical practice, but attention to a few details is recommended when they are used.

The presence of significant percentages of vitamin, cinnarizine-flunarizine, and Gingko-biloba users in the present sample is noteworthy, since both evaluation tools13,17 did not analyze the potential inappropriateness of these drugs. This caution is warranted, since chronic use of antivertigo medication, such as cinnarizine and flunarizine, might trigger movement disorders28; the combination of Gingko-biloba and salicylates and/or non-steroidal antiinflammatory drugs enhances the inhibition of platelet aggregation and raises bleeding risk29; and indiscriminate vitamin intake shows no evidence of benefits to users30.

CONCLUSION

Both criteria are useful for detecting PIMs in the elderly, with PRISCUS list being more updated and comprehensive, but care should be taken - they are not complete for the Brazilian outpatient reality.

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  • Potentially inappropriate medications in elderly
    Milton Luiz GorzoniI; Renato Moraes Alves FabbriII; Sueli Luciano PiresIII

Publication Dates

  • Publication in this collection
    24 Aug 2012
  • Date of issue
    Aug 2012

History

  • Received
    31 Oct 2011
  • Accepted
    19 Feb 2012
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