Risk factors for the prescription of potentially inappropriate medication (PIM) in the elderly

Abstract

Elderly people are especially prone to suffer adverse drug reactions (ADR). Main reasons for the higher vulnerability of the elderly to ADR are changes in metabolism as i.e. slower renal clearance and polypharmacie which often results from multimorbidity. To prevent ADR careful prescription with special consideration of these aspects is warranted. To help physicians avoid drugs which are especially likely to cause ADR lists have been developed following the consensus method process. For Germany this list is called the PRISCUS list. It was developed based on a literature review, review of international lists such as the American Beers list, and a consensus process based on a Delphi survey. It contains 83 drugs from 18 classes which are classified as potentially inapropriate medication (PIM). It also lists alternatives for each PIM. If a drug is registered with the PRISCUS list this does not mean automatically that it is contraindicated in the elderly but that special caution should be excercised in prescribing the drug, alternatives should be considered and the patient carefully monitored.Prescription rates for PIMs in Germany in the elderly is pretty much stable at around 23% with only a small decline in the past years. Also, more than 5% of all prescriptions in the elderly are PIM prescriptions. Physicians specially trained in geriatrics tend to prescribe less PIMs compared to other physicians.

General practitioners’ views on (long-term) prescription and use of problematic and potentially inappropriate medication for oldest-old patients—A qualitative interview study with GPs (CIM-TRIAD study)

“…Lists of PIM are not uncontroversial [40, 55] and it still needs to be definitely proven that drugs deemed to be potentially inappropriate for elderly patients, really have worse benefit-risk-ratios and are responsible for more ADRs than other drugs [56]. Many lists of PIMs, interventions aimed at reducing polymedication, drug-drug-interactions, ADRs and tools to support physicians’ (de-)prescription exist, but do not seem to have reached the intended goals yet.…”

Impact of a tailored program on the implementation of evidence-based recommendations for multimorbid patients with polypharmacy in primary care practices—results of a cluster-randomized controlled trial

“…In other German studies, this rate was lower between 25 to 50% [17] indicating that there might have been a selection bias of practices and/or patients, maybe due to the fact that all practices participated in quality circles, where pharmaceutical issues are regularly discussed. The PIM prescription rate of 26–32%, however, was comparable to larger studies [12, 13]. Furthermore, it may be possible that important implementation factors were not successfully addressed by the program, either because they were not identified or because the selected strategies were not effective.…”

“…Medication errors according to implicit criteria appear in 5% of all prescriptions [11]. The PIM prescription rate in the elderly according to the PRISCUS list in Germany is relatively stable around 23% with only a small decrease within the past years [12, 13]. Patients taking PIM are at higher risk for ADR [14] and hospital admission [15].…”

Geriatric patients in the ICU

“…(25) Even very simple systems can be helpful, and it generally holds true that physicians with training in geriatrics are less likely to prescribe potentially inappropriate medications. (26,27) These issues need to be given first line priority by the decision makers to allow adequate development of geriatric medicine at all levels of a health care system. The general scheme of old patient management is shown in the figure (Fig 1).…”