1. 95Indian J Pharmacol | April 2010 | Vol 42 | Issue 2 | 95-98
Use of potentially inappropriate medicines in elderly: A
prospective study in medicine out-patient department of a
tertiary care teaching hospital
H.G. Zaveri, S.M. Mansuri1
, V.J. Patel
Research Article
Department of Pharmacology,
NHL Municipal Medical College,
Ahmedabad,
1
Department of Pharmacology,
Kesar Sal Medical College,
Ahmedabad, India
Received: 30-11-2008
Revised: 12-10-2009
Accepted: 30-04-2010
DOI: 10.4103/0253-7613.64499
Correspondence to:
Dr. Varsha J. Patel.
E-mail: drvarsha4@rediffmail.com
Introduction
The elderly population is increasing rapidly world wide.[1]
About 55% of community prescriptions dispensed in 2001 in
UK were meant for elderly people. However, safe and effective
prescribing of medicines in elderly continues to present a major
challenge.[2]
In spite of the fact that elderly people are reported
to be responsible for half the total drug usage, less than 5% of
randomized controlled trials have been designed for people over
65 years! With limited evidence available to guide prescribing
for elderly, the prescribers tend to depend on data available
for younger subjects. Moreover, elderly form a heterogeneous
group due to various factors like co-morbidities, interindividual
variability in the aging process and interindividual differences
in age-related pharmacokinetic and pharmacodynamic
changes.[3]
Obviously inappropriate use of drugs is expected to
be high in this population.
Multiple drug use and polypharmacy is highly prevalent
in elderly, exposing them not only to adverse drug reactions
but also to drug interactions, increased cost of therapy, and
compliance errors.[4,5]
The prevalence of adverse reactions
increased in the older people and reactions are reported to be
ABSTRACT
Objective: The present study was undertaken with the aim to detect extent of drug use
in elderly at medicine outpatient department at tertiary care hospital and to evaluate
inappropriate prescribing with the help of Beers’ criteria 2002.
Materials and Methods: The study was carried out at medicine out patient department of
our hospital. 407 geriatric patients were included during the study period of three and
half months. The data was collected in a proforma which included the patients' details
and the prescriptions.
Results: The results reveal that 7.42% of total drugs were prescribed in an inappropriate
manner and 23.59% of total patients received at least one inappropriate drug prescription.
Administration of a drug which is avoided in elderly forms a common category of
inappropriate drug use. Antihistamines, anticholinergic, sedatives and hypnotics and
cardiac glycosides are the most common drug groups prescribed in inappropriate manner.
Conclusion: To conclude, this study shows high prevalence of inappropriate use of drugs
in geriatric practice suggesting urgent need for sincere efforts to improve the situation.
KEY WORDS: Beers criteria, drug use study, elderly, potentially inappropriate medicines
more severe.[6]
Studies on hospitalization due to adverse drug
reactions reveal that elderly are several times more likely to
be admitted due to adverse drug reactions and about half of
these reactions are preventable.[6,7]
In order to prevent adverse reactions in the elderly it
is important to identify the pattern of inappropriate use of
medicines in this population. To evaluate the appropriateness of
drugs prescribed for elderly, Beers defined criteria for potentially
inappropriate medicines in 1997[8]
which were updated in
2003.[9]
Several studies have reported use of potentially
inappropriate medicines (PIMs) in elderly people based on
Beers criteria.[10-14]
The literature related to the use of potentially inappropriate
medications (PIMs) from India is scarce. Hence, this study
was undertaken at a tertiary care teaching hospital with the
objectives of evaluating the prevalence and pattern of PIMs
using Beers criteria 2003.
Materials and Methods
This study was carried out in medicine out-patient
department (OPD) of a tertiary care teaching hospital. The
hospital caters to the health care needs of millions of patients
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2. 96 Indian J Pharmacol | April 2010 | Vol 42 | Issue 2 | 95-98
from Ahmedabad city, many villages and towns around the
city and also to the patients from other neighboring states like
Rajasthan, Madhya Pradesh, and Maharashtra.
The data were collected prospectively. Patients reporting
to medicine OPD for treatment who were aged 65 years and
above and consented for study were included. Only new cases
were included in the study during the period November 2005
to February 2006. Data were collected in a proforma, which
included patient’s demographic details, OPD registration
number, diagnosis/provisional diagnosis, and complete
prescription.
Data Analysis
About 62% drugs were prescribed by their brand names.
After identification of the drugs by their generic name, they
were evaluated for potentially inappropriate use with the help
of Beers criteria 2003. Beers criteria are comprehensive set
of explicit criteria for potentially inappropriate drug use in
ambulatory elderly aged 65 years and above.[8,9]
According to these criteria, drugs which are prescribed
inappropriately are classified into one of the following
categories:
Category A: Drugs that generally should be avoided in older
adults.
Category B: Drugs that exceed maximum recommended daily
dose.
Category C: Drugs to be avoided in combination with specific
co-morbidity.
Statistical Analysis
Data obtained were analyzed with the help of SPSS software
version 13. The chi-square test was used and values with
P<0.05 were considered statistically significant.
Results
A total 407 patients were included during the study period.
Of these, 216 (53.07%) were males and 191 (46.93%) were
females. The age of patients ranged from 65 years to 85 years.
Morbidity Pattern
The morbidity pattern based on ICD-10[15]
during the study
period is shown in Figure 1. Cardiovascular disorders (59.95%)
formed the most common cause for attending the OPD followed
by respiratory disorders (22.85%). Hypertension (40.29%) was
the most common condition affecting the geriatric patients
visiting Medicine OPD, followed by diabetes mellitus (12.28%),
ischemic heart disease (11.30%), upper respiratory infection
(10.31%), and chronic obstructive pulmonary disease (10.31%).
Drug Use Pattern
All 407 patients received a total 1738 drugs. The average
number of drugs per patient was 4.27 (range 1 to 25). Atenolol
was the most frequently used drug, being prescribed to 26.53%
of patients. Other commonly prescribed drugs were paracetamol
(21.86%), aspirin (19.41%), and Vitamin B complex (12.53%).
Use of Potentially Inappropriate Medicines (Beers criteria)
Out of 407 patients, 96 patients (23.58%) received at least
one drug which was potentially inappropriate and 129 out of
total 1738 drugs were prescribed inappropriately; drugs to
be avoided in geriatric patients (Category A) being the most
common category of inappropriate use [Table 1]. According to
Beers criteria 2003, out of 14 drugs prescribed inappropriately
in this study, 10 carried a high degree of risk to the elderly
patients. There was highly significant association between the
number of drugs prescribed and frequency of use of PIMs (P<
0. 0002).
Common Conditions for PIMs
Inappropriate drug use was most frequent in upper
Figure 1: Morbidity pattern in elderly attending medicine OPD (ICD-
10), n= 407
Table 1:
Frequency of use of potentially inappropriate medicines in elderly*
Category Name of drugs (Severity rating) Total=129
A Generally should be avoided in older adults 71
Pheniramine (high) 25
Chlorpheniramine maleate (high) 19
Dicyclomine (high) 13
Dextropropoxyphene (low) 10
Amiodarone (high) 1
Amitriptyline (high) 1
Diazepam (high) 1
Clonidine (high) 1
B Drugs that exceed maximum recommended daily
dose
35
Digoxin >0.125 mg/day (low) 20
Alprazolam >2 mg/day(high) 10
Ferrous sulfate >325 mg/day (low) 3
Lorazepam >3 mg/day (high) 2
C To be avoided in combination with specific
co-morbidity
23
Phenylpropanolamine with hypertension (high) 18
Nifedipine with constipation (low) 5
*According to Beers criteria
Table 2:
Common conditions for use of PIM in elderly
Condition Frequency (%) n=129
Upper respiratory tract infection 51 (39.53)
Abdominal pain 23 (17.82)
Congestive heart failure 18 (13.95)
Hypertension 6 (4.65)
Insomnia 6 (4.65)
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3. 97Indian J Pharmacol | April 2010 | Vol 42 | Issue 2 | 95-98
respiratory tract infection (URTI) followed by abdominal pain
and congestive cardiac failure [Table 2].
Antihitamines pheniramine and chlorpheniramine were
prescribed to 6.1% and 4.6% of patients with URTI, respectively.
Dicyclomine, an antimuscarinic drug, with anticholinergic
properties, was used in 3.1% of elderly patients. There was
no significant association between any disease condition and
use of PIMs.
Discussion
The study reveals typical morbidity pattern observed in
India.[16]
Cardio-vascular system (CVS) was the most common
(45%) system affected. Most common indication in CVS
was hypertension followed by coronary artery disease and
congestive heart failure. The second most common system
affected was the respiratory system, i.e. 17% of total patients.
Upper respiratory tract infection was the most common
respiratory condition followed by COPD.
In this study, 7.42% of total drugs prescribed were
potentially inappropriate, which is higher than that reported
(4.1%) by a study conducted in south India.[16]
Total 96 patients
out of 407, i.e. 23.59%, elderly patients received potentially
inappropriate prescription of at least one drug. These findings
are in agreement with a study from the Netherlands, in which
20% of ambulatory older adults received at least one potentially
inappropriate drug prescription.[10]
In a study carried out in
Japanese long-term facility overall prevalence was 39.1%.[11]
Another study in ambulatory patients reported lower prevalence
at 13.4%.[19]
Several studies carried out in hospitalized patients
show prevalence from 25% to 49%.[12-14,17,18]
Category A which includes drugs which should be avoided
in elderly and should not be prescribed, forms a major category
of inappropriate use of drugs. Beers has enlisted 46 drugs/drug
groups under this category.[9]
Older antihistamines (pheniramine
and chlorpheniramine) prescribed to 10.7%, antispasmodic
drug dicyclomine to 3.1% and dextropropoxyphene to 2.4% of
patients form the majority of PIMs in category A. Other drugs
like amiodarone, a class III antiarrhythmic, amitryptyline,
an antidepressant drug with sedative property, clonidine, a
centrally acting antihypertensive drug and diazepam, a long
acting sedative hypnotic were prescribed to each patient. When
compared to the Netherlands study, our figures are higher for
some drugs such as antihistamines (0.1%), dextropropoxyphene
(0.1%), and clonidine (0.1%), while lower use is evident for
diazepam (2.8%), amitriptyline (2.0%), and amiodarone
(0.7%).[10]
In the Japanese study, the reported prevalence for
different drugs is antihistamines (1.4%), antispasmodic (0.1%),
amitriptyline (0%), and long acting benzodiazepines (0.1%).[11]
Beers criteria define maximum daily dose of certain drugs
for elderly. If dose of any of these drugs exceeds the maximum
dose it is considered as PIM category B, 4 drugs/drug groups
being listed in this category.[9]
Digoxin, a drug with narrow
safety margin, was prescribed to 4.9% patients in a higher
dose (>0.125 mg/day), the prevalence being higher than in
the Netherlands study-0.5%[10]
and 0% in the Japanese study.[11]
Similarly for benzodiazepines, daily doses should not exceed 2
mg for alprazolam, 3 mg for lorazepam, 60 mg for oxazepam,
and 15 mg for temazepam. In our study alprazolam was given
in higher doses to 2.45% of patients and lorazepam to 0.49%
of patients. This is higher compared to the Netherlands study
reporting such use of alprazolam (0%) and lorazepam (0.1%)
and compared to the Japanese study in which none of the
patients were reported with such inappropriate use for these
drugs.[10,11]
According to Beers criteria if dose of ferrous sulfate
exceeds 325 mg daily, then it is inappropriate. In this study 0.7%
of patients received a higher dose (>325 mg/day) compared
to none in the Netherlands study[10]
and 0.2% in the Japanese
study.[11]
Phenylpropanolamine (PPA) is still available as one of
the ingredients of cough and cold preparations in India. It is
inappropriate in a patient of hypertension, as it may produce
elevation of blood pressure secondary to sympathomimetic
activity. Hence, it is a PIM category C which includes drugs
to be avoided in combination with specific co-morbidity.
PPA was prescribed to 4.42% of patients with hypertension.
Similarly,nifedipine, a dihydropyridine calcium channel blocker
and a commonly used antihypertensive was prescribed in
1.22% of patients who had constipation. None of these two
drugs was reported inappropriate by C.S. van der Hooft[10]
However, Niwata et al reported 30.1% prevalence of use of
calcium channel blockers, anticholinergics, and tricyclic
antidepressants in patients with chronic constipation.[11]
The same study has reported inappropriate use of NSAIDs
and anti-platelet drugs in patients with clotting disorder
or on anticoagulant (14.8%), use of metoclopramide and
conventional antipsychotic in patients with Parkinson’s
disease(11.4%) and use of short/intermediate acting
benzodiazepines and tricyclic antidepressants in patients
with history of syncope or falls (22.3%).[11]
In our study none
of these PIMs which carry high risk according to Beers criteria
were observed, which is a positive finding.
Studies to identify the factors for PIM have reported older
patients, polypharmacy, depression immobilization, and
hypertension as some of the factors associated with increased
risk of PIM.[12,19]
In our study polypharmacy is the only factor
associated with use of PIMs, while disease condition and age
did not show significant association.
Some other criteria also exist for evaluating the use of
PIMs in elderly.In a study designed to compare PIM prevalence
rates based on the 1997 Beers criteria and Zhan criteria with
the rate obtained using the 2003 Beers criteria, the prevalence
was estimated at 13.4% based on the 2003 Beers criteria,
compared with 8.8% based on the 1997 Beers criteria and
4.2% based on the Zhan criteria.[20]
STOPP (Screening Tool of
Older Persons' potentially inappropriate Prescriptions) is a new,
systems-defined medicine review tool. In a study comparing the
performance of STOPP to that of established Beers criteria in
detecting potentially inappropriate medicines (PIMs) and related
adverse drug events in older patients presenting for hospital
admission, STOPP criteria identified a significantly higher
proportion of patients requiring hospitalization as a result of
PIM-related adverse events than Beers criteria.[21]
Conclusion
This study suggests that use of PIMs is common in
elderly patients, some of them associated with high degree
of risk in terms of adverse drug reactions or worsening of
the co-morbidity. Evidence indicates that high prevalence of
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4. 98 Indian J Pharmacol | April 2010 | Vol 42 | Issue 2 | 95-98
inappropriate prescribing of medicines in elderly people is
associated with increased morbidity and mortality, increased
cost, and decreased quality of life. Our study has been limited
to only one specialty. More studies in other specialties and
general practice are necessary to sensitize the practitioners
to this important public health issue.
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Source of Support: Nil Conflict of Interest: None declared.
Zaveri, et al.: Use of potentially inappropriate drugs in elderly
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