Quality of drug prescribing in older patients: is there a problem and can we improve it?

Abstract

Older patients are at high risk of suboptimal prescribing (overuse, underuse and misuse of drugs), which can lead to serious adverse drug reactions (ADR). About one in four patients admitted to hospital are prescribed at least one inappropriate medication and up to 20% of all inpatient deaths are attributed to potentially preventable ADR. Lists of drugs to avoid (unnecessary or where risks outweigh benefits) and drugs not to be omitted (strong indications if there are no contraindications) can assist in identifying suboptimal prescribing although, to date, no trials have established the ability of such screening, by itself, to improve prescribing quality. Remedial strategies proven to be effective in randomized trials include detailed appraisal of medication lists by multidisciplinary teams, which involve geriatricians and close liaison with specialist clinical pharmacists. A multifaceted quality improvement strategy is proposed that includes an aspirational target of no more than five different drugs be regularly prescribed to vulnerable older patients. Achieving this target involves prioritizing drug selection on the basis of strength of indication which may run counter to current disease-specific clinical guideline recommendations based on trials that have excluded most older patients. Such a strategy is worthy of further evaluation in a multicentre randomized trial.

Applicability of the STOPP/START criteria to older polypathological patients in a long-term care hospital

“…The use of PIM in elderly patients is the cause of 6–30% of hospital admissions 12. Moreover, PIM are also common during the stay in hospital and at discharge,4 13 as was found in this study.…”

Simple prescribing errors and allergy documentation in medical hospital admissions in Australia and New Zealand

“…11,12 Clinical pharmacists are appropriately targeting older patients and those taking larger numbers of medications as a priority for early review. Efficacy of clinical pharmacists' involvement was evident in the higher prevalence of adequate allergy documentation among patients who had been reviewed by a clinical pharmacist in this study.…”

A systematic review of the emerging definition of ‘deprescribing’ with network analysis: implications for future research and clinical practice.

“…11 [1,23,26,28,30,35,38,40,42,44,50] '…supervised by a clinician.' [40] '…planning and communicating a cessation regimen…' [44] Describes deprescribing as involving multiple steps (STEPS) '…with the goal of managing polypharmacy and improving outcomes…' [39] Uses the term 'taper' (TAPER) 4 [39,41,44,55] '…the process of tapering…' [55] The emerging definition of 'deprescribing'…”