Practice recommendations
- Obtain pharmacist recommendations to reduce inappropriate prescribing and adverse drug events (B).
- In the inpatient setting, use computerized alerts to reduce serious medication errors and help prevent adverse drug events (B).
- Review a patient’s medications to reduce polypharmacy and inappropriate prescribing (A).
- Educate patients to improve compliance with medications, reduce polypharmacy, reduce inappropriate prescribing, and decrease adverse events (A).
- Consider using the Beers criteria for avoiding inappropriate drugs in the elderly.
A round one third of elderly persons hospitalized end up there because of adverse drug events. Among the ambulatory elderly, 35% experience such events in a single year. The hopeful outlook is that, depending on the setting, between 25% and 95% of these events can be prevented by reducing inappropriate prescribing.
In this article we discuss 5 recommendations for reducing inappropriate medications, and offer steps to implement these recommendations.
Factors that lead to inappropriate prescribing
Inappropriate prescribing to elderly patients is increasing. It is not uncommon for older patients to receive 1 or more medications from their primary care physician and additional medications from specialty physicians, with each physician unaware of medications prescribed by the others.1 As the number of providers following the patient increases, so does the number of medications.2
One result is that the elderly use a disproportionate number of medications. They make up 13% of the US population but receive 34% of all prescriptions and consume 40% of all nonprescription medications.3,4 A recent national study of non-institutionalized US adults revealed that 90% of persons 65 years or older used at least 1 medication per week. More than 40% used 5 or more medications per week, and 12% used 10 or more per week.5 This situation may become more complicated as by the year 2030, the elderly are expected to make up 20% of the US population.6
Inappropriate prescribing, including polypharmacy, is a major contributing factor to adverse drug events in older patients (see Scope of the problem). A recent nested case-controlled study in a large multi-specialty group revealed an association between number of medications, doses of medications, and adverse drug events.13 The problem of polypharmacy as it relates to adverse drug events is so extensive that it was designated as the principal medication safety issue in the Healthy People 2000 report.14
Scope of the problem
In the year 2000, medication-related problems were responsible for 106,000 deaths at a cost of $85 billion to our healthcare system.7,8
It has been estimated that 30% of hospital admissions in elderly patients are due to drug-related problems.9 In addition, approximately two thirds of nursing facility residents will experience an adverse drug event over a 4-year period of time, with 1 in 7 of these residents requiring hospitalization.10,11
Ambulatory patients are also affected. A cohort study revealed that approximately 35% of ambulatory elderly experienced an adverse drug event over a 1-year period, 63% of whom required the attention of a physician.9 Another large cohort study, involving 30,347 Medicare enrollees cared for by a multispecialty group practice, demonstrated that adverse drug events are not only common among the elderly, but over 25% of the adverse events during a 12-month period were preventable.12 Other studies have estimated that up to 95% of adverse drug events are preventable.3 These figures are particularly troubling when considering our older patient population because 51% of all deaths caused by adverse reactions to medications occur in patients over 60 years of age.4
Adverse drug events may occur for several reasons including noncompliance, drug-drug interactions, and physician error.
Methods
In this systematic review, English language studies from January 1990 to January 2006 were searched on Medline and the Cochrane Database of Systematic Reviews. Among the specific keywords and phrases we used: adverse drug events in the elderly; inappropriate medications in the elderly; polypharmacy in the elderly; reduction of polypharmacy in the elderly; drug-drug interactions in the elderly; prevention of adverse drug events; and reduction of inappropriate prescribing in the elderly. The search was limited to studies of patients over 65 years of age.
Fifty-nine articles were identified using the above search strategy. In selecting articles on which to base the recommendations in this paper, we gave first priority to randomized controlled trials. When randomized controlled trials did not exist, we used cohort studies or meta-analyses. We excluded review articles and articles that did not specifically address the issue of reducing inappropriate prescribing for elderly patients.
Results
TABLE W1 describes the results of the systematic review. Of the initial 59 articles, we excluded 26 review articles and 13 that did not address inappropriate prescribing. The remaining 19 articles were classified into 5 categories based on the methods studied for reducing inappropriate prescribing. The methods recommended in each of the 5 categories were supported by varying levels of evidence.