CC BY
8
ISSN 2304-3415, Russian Open Medical Journal
2021. Volume 10. Issue 2 (June). Article CID e0211 DOI: 10.15275/rusomj.2021.0211_
Original article
Inappropriate medication use in older adults according to Beers Criteria in a Tertiary Referral Hospital,
in Bolu, Turkey
Burcin M. Atak, Gulali Aktas, Tuba T. Duman, Ozge Kurtkulagi, Satilmis Bilgin, Gizem Kahveci,
Muhammed E. Demirkol
Abant Izzet Baysal University Hospital, Department of Internal Medicine, Bolu, Turkey
Received 5 October 2020, Revised 2 February 2021, Accepted 20 April 2021
© 2020, Atak B.M., Aktas G., Duman T.T., Kurtkulagi O., Bilgin S., Kahveci G., Demirkol M.E. © 2020, Russian Open Medical Journal
Abstract: Aims — We aimed to study the medications used by older adults for any potentially inappropriate medications.
Material and Methods — A hundred and four consecutive subjects over 65 years of age who visited our clinic were enrolled in the study.
Possible inappropriate medications were defined according to Beers Criteria.
Results — A total of 57 women and 49 men were enrolled in the study. Mean ages of the women and men were 78.6±6.1 years and 77.4±5.4 years, respectively (p=0.30). While 18 subjects (17%) had no increased risk due to inappropriate use of medications, 30 were on inappropriate medications that increased renal failure risk, 5 were on inappropriate medication that amplified neurological side effects, 12 were on inappropriate medications that augmented bleeding risk, 20 were on inappropriate medication that lack safety and efficacy data, and 30 were on inappropriate medication that amplified the risk of falls. The number of increased risks according to Beers Criteria was significantly and positively correlated with number of medications used (r=0.366, p<0.001) and the number of comorbidities (r=0.312, p=0.001).
Conclusion — The number of increased risks due to inappropriate use of medicines in older adults is positively correlated with the number of medicines used and the number of accompanied diseases. Therefore we suggest that the medicines used by older people should be reviewed in all settings, and unnecessary drugs should be avoided to be prescribed.
Keywords: inappropriate medicine, older adults, comorbidity, Beers criteria.
Cite as Atak BM, Aktas G, Duman TT, Kurtkulagi O, Bilgin S, Kahveci G, Demirkol ME. Inappropriate medication use in older adults according to Beers Criteria in a Tertiary Referral Hospital, in Bolu, Turkey. Russian Open Medical Journal 2021; 10: e0211.
Correspondence to Gulali Aktas. Phone: +903742534656. Fax: +903742534615. E mail: draliaktas@yahoo.com.
Introduction
Human population of the world is increasing day by day due to several factors including prolonged life expectancy. In Europe, mean age at death is increased from 50 years in 1900s to over 80 years in 2000s. In United States, life is increased from 47 years in 1900s to 73 years in 1980s [1] The ratio of population over 65 years of age to general population was 4.1% in 1900s in United States and increased to 12.4% by 2000s [2]. Chronic diseases are increased by the aging in most individuals. Coronary heart disease, hypertension, type 2 diabetes mellitus are some of the chronic conditions that are more frequent in older adults. Significant proportion of the older population has one or more of these chronic conditions [3]. An older patient uses over 5 drugs every day for accompanying diseases, but it has been reported to be as high as 11 per day [4]. The risk of inappropriate drug combinations and their hazard increase due to polypharmacy.
Inappropriate medication use in older adults is a common issue worldwide [5]. Studies in literature showed that older subjects who visit emergency rooms of the institutions have greater number of possible inappropriate medication use [6]. Therefore, it is important to develop methods for detecting
inappropriate medication use by older population. For this purpose, Beers Criteria list was developed and updated in 2019 by American Geriatrics Society to detect potentially inappropriate medications in older adults [7]. More than 90% of the older adults experience one or more unwanted events related to medicines used daily [8], therefore, medications used by individual older adults should be reviewed for possible drug interactions and possible harm sensu these criteria.
In present study, we aimed to observe inappropriate medication use in older adults who visited outpatient internal medicine clinics of our institution, according to Beers Criteria. We also aimed to compare increased risks due to inappropriate medication use in older women and men.
Material and Methods
Study design
After obtaining approval from local ethics committee (approval number: 2019/160) and informed consent from the participants, patients over 65 years of age were enrolled in the observational study. The study has been approved by the appropriate institutional and/or national research ethics committee and have
ISSN 2304-3415, Russian Open Medical Journal
2021. Volume 10. Issue 2 (June). Article CID e0211 DOI: 10.15275/rusomj.2021.0211_
been performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. A hundred and six consecutive subjects that given consent and visited our clinic were included.
Age, gender, medications used daily, accompanying diseases (such as; type 2 diabetes mellitus, hypertension, heart failure, chronic obstructive pulmonary disease, osteoporosis, chronic kidney disease, neurological disorders, etc.), and number of medications used daily were noted. Combined drugs were accounted for as separate entities. All medications used by the participants for over two weeks were taken into account. Recently used and cessated drugs such as antibiotics and pain killers were not considered. Any potentially inappropriate medication use was defined according to the Beers Criteria. A total of 106 older adult subjects (57 women and 49 men) were enrolled in the study.
Laboratory parameters, such as blood urea, creatinine, fasting glucose, serum electrolytes (sodium (Na), potassium (K)), alanine and aspartate transaminases (ALT, AST), albumin, leukocyte count (WBC), blood hemoglobin level (Hb) and platelet count (Plt) were recorded. Possible inappropriate medications and interactions were defined sensu Beers Criteria [7]. Possible inappropriate medications were defined as either those with a lack of data on safety and efficacy, or those with increased risk of hypoglycemia, fall, renal failure, gastrointestinal side effects (e.g., gastroduodenal ulcer), bleeding, hyperkalemia, and neurological side effects.
Statistical analysis
Statistical analyses were conducted with SPSS software (SPSS 15.0 for Windows, IBM Co, Chicago, IL, USA). Kolmogorov Smirnov test was used to determine distribution of the variables in study groups. Comparison of the variables with or without normal distribution were conducted by independent samples Student's t-test and Mann Whitney U test, respectively. Variables with or without normal distribution were expressed, correspondingly, as either mean±standard deviation, or median (min-max) with interquartile range (IQR). Comparison of categorical variables was carried out via chi-square test and expressed as percentages. A p value lower than 0.05 was considered as statistically significant.
Results
Mean ages of women and men were 78.6±6.1 years and 77.4±5.4 years, respectively (p=0.296).
There were no significant differences between women and men according to WBC (p=0.163), AST (p=0.334), ALT (p=0.073), blood urea (p=0.193), creatinine (p=0.171), GFR (p=0.099), albumin (p=0.291), Na (p=0.317) and K (p=0.707) levels. On the other hand, blood Hb of women (11.8±1.6 g/dL) was significantly lower than the Hb level (13.5±2.2 g/dL) of men (p<0.001), and blood Plt level of women (286±87 k/mm3) was significantly higher than Plt value (247±79 k/mm3) in men (p=0.017).
Number of medications used by women and men were 7 (213) (IQR: 3.5) and 7 (1-11) (IQR: 2.5), respectively. There was no significant difference between older women and men according to number of medications used daily (p=0.613). Number of comorbidities in women and men were 3 (1-7) (IQR: 3) and 3 (1-8) (IQR: 2), correspondingly. There was no significant difference between older women and men according to the number of comorbidities (p=0.252). Number of increased risks due to inappropriate medications in women and men were 1 (0-3) (IQR:
1) and 1 (0-2) (IQR: 0.5), respectively. There was no significant difference between older women and men in terms of the number of increased risks due to inappropriate medications (p=0.193).
A total of 18 subjects (17%) - 8 women and 10 men - had no increased risk due to inappropriate use of medications in the study population. Increased risks in women and men are summarized in able 1. Thirty subjects: 15 (26%) of women and 15 (31%) of men were on inappropriate medications that increase renal failure risk (p=0.624). Five subjects: 5 (9%) of women and 0 (0%) of men were on inappropriate medication that increase neurological side effects (p=0.034). Twelve subjects: 8 (14%) of women and 4 (11%) of men were on inappropriate medications that increase bleeding risk (p=0.341). One subject: 1 (2%) of women and 0 (0%) of men were on inappropriate medication that increase the risk of hyperkalemia (p=0.352). Twelve subjects: 10 (17.5%) of women and 10 (19%) of men were on inappropriate medication that lack safety and efficacy data (p=0.707). Thirty subjects: 19 (33%) of women and 11 (28%) of men were on inappropriate medication that increase the risk of fall (p=0.215). Twelve subjects: 8 (14%) of women and 4 (11%) of men were on inappropriate medication that increase gastrointestinal side effects (p=0.341). Thirteen subjects: 6 (10.5%) of women and 7 (12%) of men were on inappropriate medication that increase hypoglycemia risk (p=0.556) (Table 1).
In correlation analysis, number of increased risks according to Beers Criteria significantly and positively correlated with number of used medications (r=0.366, p<0.001) and the number of comorbidities (r=0.312, p=0.001). The number of used medications also correlated with the number of comorbid situations (r=0.530, p<0.001). Neither number of used medications (r=0.068, p=0.487) nor number of increased risks (r=0.017, p=0.865) correlated with age. Table 2 summarizes the correlation between study parameters.
Discussion
Present study showed that only 17% of the older adult population was not subjected to increased risk due to used medicines according to the Beers Criteria, which means remaining 83% of the older adults were at increased risk due to medications they were taking. Second important result of the study is that the number of increased risks due to inappropriate use of medicines in older adults positively correlated with the number of used medicines and the number of accompanying diseases. The third outcome of our project is that increased risks due to inappropriate use of medicines were similar both in men and women, except increased neurological side effect risk, which was more common in women.
Table 1. Increased risks due to inappropriate medication use in study population
Women (n) Men (n) P
Increased renal failure risk 15 15 0.624
Increased neurological side effects 5 0 0.034
Increased bleeding risk 8 4 0.341
Increased risk of hyperkalemia 1 0 0.352
Medication without safety and efficacy data 10 10 0.707
Increased risk of fall 19 11 0.215
Increased gastrointestinal side effects 8 4 0.341
Increased hypoglycemia risk 6 7 0.556
ISSN 2304-3415, Russian Open Medical Journal
2021. Volume 10. Issue 2 (June). Article CID e0211 DOI: 10.15275/rusomj.2021.0211_
Table 2. Correlation between study parameters
Age
Number of medicines used
Number of Number of increased risks due comorbidities to inappropriate medicines
Age - r=0.068 p=0.487 r=0.157 p=0.109 r=0.017 p=0.865
Number of medicines used r=0.068 p=0.487 - r=0.531 p<0.001 r=0.366 p<0.001
Number of comorbidities r=0.157 p=0.109 r=0.531 p<0.001 - r=0.312 p=0.001
Number of increased risks due to inappropriate medicines r=0.017 p=0.865 r=0.366 p<0.001 r=0.312 p=0.001 -
Comorbidities among older adult population increased since the ratio of older people over 60 years of age to general population increased dramatically [9]. The number of diseases also increases with age [10]. About 80% of older adults had one comorbidity, while the proportion of older patients with two or more comorbidities was 50% [11]. The median number of accompanying diseases in present study was 3 in both women and men.
Using more medications is common among older population [10]. About 30% of prescription drugs were prescribed to older adults, although they constitute only 12% of the general population [12]. The median number of medicines used in present study was 7 in both women and men.
Polypharmacy in older adults is very important because an association between potentially harmful drugs and increased number of continuously used drugs [13-16]. Exponential [17] and linear [15, 16] associations between number of used drugs and increased drug-related harm have been reported. Significant positive correlation between number of used drugs and number of increased risks caused by inappropriate medicines has been shown in the present study.
Published sources reported no differences between men and women in terms of the number of risks caused by inappropriate medications [14]. However, some studies reported fewer risks in women compared with men [18]. Similarly, except increased risk of neurological side effects, which were more common in women, there was no significant difference between men and women in terms of increased risks caused by inappropriate medicines in our study.
Older subjects with inappropriate medication use are more likely to develop unwanted diseases. In a study by Wong et al., the authors reported that older patients with inappropriate medication use visit emergency departments of health institutions more often than the older patients without inappropriate medication use [6].
A study from Sweden reported that review of the medications taken by older adults in primary care setting reduced the use of inappropriate medications [4]. That study has also showed that the most common problem of the older adults with multiple comorbidities was unnecessary medication use [4]. In our study, we also reported that number of risks, caused by inappropriate medications in older adults, correlated with comorbidities and the number of used medications. We think that these risks could be deterred by careful review and withdrawal of unnecessary drugs.
Two important limitations of our study are relatively small sample size and lack of data on drug interactions after review of the drugs at our clinic. However, the results of our study that showed significant correlation between the number of daily used medicines and the number of increased risks caused by these medications are very important for consideration in various healthcare settings.
Conclusion
The number of increased risks due to inappropriate use of medicines in older adults positively correlates with the number of used medicines and the number of accompanying diseases. Therefore, we propose that the medicines used by older people should be reviewed in all settings, and unnecessary drug taking should be stopped for the sake of decreasing the risks, associated with inappropriate medicines in older adult population.
Conflict of Interest
None to declare
Ethical approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.
References
1. Fries JF. Aging, natural death, and the compression of morbidity. Bulletin of the World Health Organization: the International Journal of Public Health 2002; 80(3): 245-250. https://apps.who.int/iris/handle/10665/71278.
2. Cox HG. Later Life. The Realities of Aging. New York: Taylor And Francis Group. 2015: 432 p. https://doi.org/10.4324/9781315663715.
3. Zhao C, Wong L, Zhu Q, Yang H. Prevalence and correlates of chronic diseases in an elderly population: A community-based survey in Haikou. PloS One 2018; 13(6): e0199006. https://doi.org/10.1371/journal.pone.0199006.
4. Lenander C, Bondesson A, Viberg N, Beckman A, Midlov P. Effects of medication reviews on use of potentially inappropriate medications in elderly patients; a cross-sectional study in Swedish primary care. BMC Health Serv Res 2018; 18(1): 616. https://doi.org/10.1186/s12913-018-3425-y.
5. Guaraldo L, Cano FG, Damasceno GS, Rozenfeld S. Inappropriate medication use among the elderly: a systematic review of administrative databases. BMC Geriatr 2011; 11: 79. https://doi.org/10.1186/1471-2318-11-79.
6. Wong J, Marr P, Kwan D, Meiyappan S, Adcock L. Identification of inappropriate medication use in elderly patients with frequent emergency department visits. Can Pharm J (Ott) 2014; 147(4): 248256. https://doi.org/10.1177/1715163514536522.
7. By the 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Am GeriatrSoc 2019; 67(4): 674-694. https://doi.org/10.1111/jgs.15767.
8. Milos V, Rekman E, Bondesson A, Eriksson T, Jakobsson U, Westerlund T, et al. Improving the quality of pharmacotherapy in elderly primary care patients through medication reviews: a randomised controlled study. Drugs Aging 2013; 30(4): 235-246. https://doi.org/10.1007/s40266-013-0057-0.
9. Cully JA, Gfeller JD, Heise RA, Ross MJ, Teal CR, Kunik ME. Geriatric depression, medical diagnosis, and functional recovery during acute
ISSN 2304-3415, Russian Open Medical Journal
2021. Volume 10. Issue 2 (June). Article CID e0211 DOI: 10.15275/rusomj.2021.0211_
rehabilitation. Arch Phys Med Rehabil 2005; 86(12): 2256-2260. https://doi.org/10.1016/j.apmr.2005.07.292.
10. Salazar JA, Poon I, Nair M. Clinical consequences of polypharmacy in elderly: expect the unexpected, think the unthinkable. ExPert OPin Drug Saf 2007; 6(6): 695-704. https://doi.org/10.1517/14740338.6.6.695.
11. He W, Sengupta M, Velkoff V, DeBarros K. 65+ in the United States: 2005. In: Current Population Reports U.S. Census Bureau. Washington DC: U.S. Government Printing Office. 2005: 23-209. https://www.census.gov/prod/2006pubs/p23-209.pdf.
12. Hanlon JT, Fillenbaum GG, Burchett B, Wall WE Jr, Service C, Blazer DG, et al. Drug-use patterns among black and nonblack community-dwelling elderly. Ann Pharmacother 1992; 26(5): 679-685. https://doi.org/10.1177/106002809202600514.
13. Cannon KT, Choi MM, Zuniga MA. Potentially inappropriate medication use in elderly patients receiving home health care: a retrospective data analysis. Am J Geriatr Pharmacother 2006; 4(2): 134-143. https://doi.org/10.1016/j.amjopharm.2006.06.010.
14. Janchawee B, Wongpoowarak W, Owatranporn T, Chongsuvivatwong V. Pharmacoepidemiologic study of potential drug interactions in outpatients of a university hospital in Thailand. J Clin Pharm Ther 2005; 30(1): 13-20. https://doi.org/10.1111/j.1365-2710.2004.00598.x.
15. Astrand B, Astrand E, Antonov K, Petersson G. Detection of potential drug interactions - a model for a national pharmacy register. Eur J Clin Pharmacol 2006; 62(9): 749-756. https://doi.org/10.1007/s00228-006-0143-x.
16. Cruciol-Souza JM, Thomson JC. Prevalence of potential drug-drug interactions and its associated factors in a Brazilian teaching hospital. J Pharm Pharm Sci 2006; 9(3): 427-433. https://pubmed.ncbi.nlm.nih.gov/17207423.
17. Cadieux RJ. Drug interactions in the elderly. How multiple drug use increases risk exponentially. Postgrad Med 1989; 86(8): 179-186. https://doi.org/10.1080/00325481.1989.11704506.
18. Merlo J, Liedholm H, Lindblad U, Bjorck-Linne A, Falt J, Lindberg G, et al. Prescriptions with potential drug interactions dispensed at Swedish pharmacies in January 1999: cross sectional study. BMJ 2001; 323(7310): 427-428. https://doi.org/10.1136/bmj.323.7310.427.
Authors:
Burcin M. Atak - MD, Assistant Professor, Department of Internal Medicine, Abant Izzet Baysal University Hospital, Bolu, Turkey. https://orcid.org/0000-0003-4201-9757.
Gulali Aktas - MD, Professor, Department of Internal Medicine, Abant Izzet Baysal University Hospital, Bolu, Turkey. https://orcid.org/0000-0001-7306-5233.
Tuba T. Duman - MD, Associate Professor, Department of Internal Medicine, Abant Izzet Baysal University Hospital, Bolu, Turkey. https://orcid.org/0000-0002-3836-2125.
Ozge Kurtkulagi - MD, Assistant Professor, Department of Internal Medicine, Abant Izzet Baysal University Hospital, Bolu, Turkey. https://orcid.org/0000-0002-4162-5563.
Satilmis Bilgin - MD, Assistant Professor, Department of Internal Medicine, Abant Izzet Baysal University Hospital, Bolu, Turkey. https://orcid.org/0000-0003-2811-0052.
Gizem Kahveci - MD, Assistant Professor, Department of Internal Medicine, Abant Izzet Baysal University Hospital, Bolu, Turkey. https://orcid.org/0000-0003-4520-4085.
Muhammed E. Demirkol - MD, Assistant Professor, Department of Internal Medicine, Abant Izzet Baysal University Hospital, Bolu, Turkey. https://orcid.org/0000-0001-6262-6103.
