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Assessment of drug therapy in geriatric patients using Beer's criteria

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 Original Article

Assessment of Drug Therapy in Geriatric Patients Using Beer’s

Criteria

RJ Lihite *, M Lahkar **, S Roy *

Abstract

Aim: Inappropriate medication use (IMU) in the elderly population has long been an issue of health-
care quality along with over and under-use of medications. Therefore, this study aimed to determine
the prevalence and also the predictors of inappropriate prescribing (IP) for elderly inpatients.
Method: The prospective interventional study was conducted to evaluate the quality of geriatric
pharmacotherapy in a tertiary care centre of a government hospital. Data of 502 patients were used
to carry out the analysis by using modified Beer’s Criteria (2003).
Results: The analysis of data for appropriateness of drug therapy showed that 6.9% of the 502
patients received at least 1 inappropriate medication. Out of 35 inappropriate prescriptions, the most
frequent was digoxin (48.6%) followed by nifedipine (11.4%), bisacodyl (5.7%). Drug identified
according to the second list of inappropriate medications was NSAIDs.
Conclusion: Inappropriateness of medication use in elderly inpatients increased with advanced age,
increase in number of medications, number of diagnoses and length of hospitalization. In more than
half of the cases, clinician agreed that the provided information about inappropriate medication was
clinically significant and the given suggestions were accepted.
(Journal of The Indian Academy of Geriatrics, 2010; 6: 155-159)

Introduction further decline. However, optimizing drug therapy

Sickness is as natural as the process of ageing.
Since time unknown diseases have been associated
with old age. Thus have begun man’s pursuit of
healing and health. Today, when science has
conquered the unimaginable, disease free world still
remains elusive. Advancement in medical science
marked by the wonder drugs, new state-of-art
medical techniques and equipments has improved
the quality of life of elderly and increased the life
expectancy. However, like two sides of a same coin,
these medical facilities also have few shortcomings.
For example, a drug given to elicit therapeutic
effect may cause side effects.
Drug therapy is necessary to treat acute
illness, maintain current health and prevent
*NIPER, Guwahati, **Chief Academic Coordinator,
NIPER Guwahati & Head, Department of Pharm-
acology, Gauhati Medical College, Guwahati-781032.
Address for correspondence: Dr (Mrs) M Lahkar,
Head, Department of Pharmacology, Gauhati Medical
College,Guwahati-781032. E-mail: r.lihite@yahoo.com
for older patients is challenging and sometimes it
can do more harm than good. This is because people
over the age of 65 years have a higher prevalence of
chronic illnesses, disabilities and dependency than
those <65 years. They are more likely to be on
medications than younger people. They are often
taking several drugs to treat concomitant disease
processes. Hence elderly patient constitute a special
group requiring special concern.
India comprises approximately 16% of the
world population and it is reasonable to believe that
we will have a large number of elderly patients.1 A
World Health Organization (WHO) report has
projected that the elderly population of the world
will cross the one billion mark by the year 2020 and
by that time, over 700 million elderly people will be
living in developing countries.2
Appropriateness in healthcare has been
defined as “the outcomes of process of decision
making that maximizes net health gains within
society’s available resources”.3 Inappropriate
medication use (IMU) in the elderly population has
156 Journal of The Indian Academy of Geriatrics, Vol. 6, No. 4, December, 2010
long been an issue of healthcare quality along with
over and under-use of medications.4 Such IMU can
be expected to affect both well being and use of
health-care service. This subject has gained
attention among health care researchers, providers
and policy makers. The effort to reduce IMU in
elderly patients is likely to have a substantial
impact upon reducing drug-related morbidity. It is
important that elderly people should not be taken
as a burden on society but rather as an asset.5 The
assessment of suitability of pharmacotherapy aims
to modify the existing geriatric care practice(s).
This is possible only when age-related problems are
studied well and problems related to pharmacothe-
rapy are identified. This will lead to improvement
in the existing geriatric pharmacotherapy practice.
The results of the earlier studies done in the same
setting had shown that the prevalence rate of IMU
in elderly patients was 17.51% according to updated
Beers Criteria.6-8 Therefore, this study aimed to
determine the prevalence and also the predictors of
inappropriate prescribing (IP) for elderly
inpatients.
Methodology
Study design and setting: To achieve the
objectives, a prospective interventional study was
carried out in an inpatient setting of the Gauhati
Medical College and Hospital, Guwahati after the
approval of the Institutional Human Ethics
Committee. The patients were recruited from 14
wards. Out of these 6 were male medicine units, 6
female medicine units and 2 cardiology male &
female units.
Patients: Patients were recruited in the
study as per the criteria given below.
 Inclusion criteria
a. 60 years or above, patients of either gender.
b. Number of drugs prescribed more than one.
c. One or more concurrent diseases.
 Exclusion criteria
Incomplete information regarding patient
Data collection: The prescriptions were
studied using chart review method. The data was
collected from prescriptions and medicine charts of
the patients. For each patient, a study form was
completed at the time of admission and updated
daily until the patient was discharged.
Assessment using Beer’s criteria: Each
prescription was checked individually for
inappropriate drug prescribing by using Modified
Updated Beers Criteria 2003. In 2002, US expert
panel updated the previously established Beers
criteria and included newer drugs and incorporated
new knowledge of drug product and clinical
evidence. According to the updated Beers criteria
2003, 48 medications or classes of medications
should be avoided regardless of condition or disease
in elderly and it also lists 20 diseases and the
medications to be avoided in elderly. This has led to
two lists of inappropriate medications: one of
medications deemed to be inappropriate regardless
of the disease condition being treated and the other
of medications whose use would be inappropriate in
patients with certain diseases. The criterion used in
this study is known as modified updated Beers
Criteria 2003 because of the modifications done for
the Indian setting. These modifications are:
1. The cut off age considered in this study was
60 years instead of age 65 years or more.
2. Some medications which were banned after
2002 by the Drug Controller General India
(DCGI) were removed from the list for eg.
reserpine, propoxyphene and cimetidine etc.
A prescription is known to be inappropriate if
it contains one or more drugs included in Beers list
of inappropriateness.
Feedback: Suggestions were given to the
clinical pharmacologist and consultants for
inappropriate medications.
Statistical analysis: All the data was
presented as average ± SEM and percentages.
Relative risk (RR) was used to assess IMU by
comparing inappropriate with AMU. The confidence
interval (CI) and RR was calculated for determining
the predictors of IMU.
Results
Analysis of IMU using modified Beer’s criteria
The analysis of data for appropriateness of
drug therapy showed that 6.9% (n=35) of the 502
patients received at least 1 inappropriate medic-
ation. Out of 35 inappropriate prescriptions, the
most frequently used inappropriate medications
identified were digoxin (48.6%) followed by nifedi-
pine (11.4%), bisacodyl (5.7%) etc. A drug identified
according to the second list of inappropriate
medications was NSAIDs (Table 1).
Assessment of Drug Therapy in Geriatric Patients Using Beer’s Criteria 157

Table 1. Prevalence of inappropriate medicine use There were several inappropriate medications
by Beer’s Criteria 2003 (n =35). which were repeatedly noted in different patients
during the period of study. The prevalence of inapp-
Independent of diagnosis(1 st LIST) ropriate medications were reported and feedback
Name of Drugs Severity No. of patients obtained from 51 clinicians and clinical pharmaco-
Digoxin low 17 (48.6%) logists practicing in the medicine and cardiology
Nifedipine high 4 (11.4%) ward of the hospital (Table 3). Out of 51, 62.74%
Bisacodyl high 2 (5.7%) clinicians agreed that therapeutic drug monitoring
Indomethacin high 2 (5.7%) (TDM) should be done. 56.86% clinicians found
Dicyclomine high 2 (5.7%) monitoring of adverse drug reaction (ADR) would be
Ketorolac high 2 (5.7%) helpful and 54.90% clinicians accepted that specific
laboratory test should be indicated (Fig 1).
Nitrofurantoin high 2 (5.7%)
Promethazine high 1 (2.8%) Table 3. Clinician’s (n=51) response for various
Amiodarone high 1 (2.8%) types of suggestions.
Chlorpheniramine high 1 (2.8%)
ND Suggestions Accepted Not accepted
Dependent on Diagnosis (2 LIST)
Name of Drugs Severity No. of patients TDM should be done 32 19

NSAIDs high 1 (2.8%) Monitoring for ADR should be done 29 22

Specific laboratory test should be 28 23
indicated
Predictors of IMU: The presence of certain Monitor for efficacy of drug should be 21 30
factors increased the likelihood of IMU. These risk involved
factors associated with inappropriate medications Further information required for 17 34
were divided into two groups of variables. Socio- taking decision about clinical
demographic characteristics consisting of age, implication of provided information.
gender and clinical variables comprising of number Rescheduling of drug administration 12 39
of medications prescribed number of diagnoses and should be done
length of hospitalization. The RR was calculated for Avoid concurrent use of drugs 9 42
determining the predictors of IMU (Table 2). Use drugs with caution 6 45
Others 4 47
Table 2. Predictors of IMU using modified updated
Beer’s Criteria 2003. TDM = Therapeutic drug monitoring
ADR = Adverse drug reaction
Variable Total Patie- Patie- Preva- OR (95% CI*)
(n) nts nts with lence of
with AMU IMU
IMU
All 502 35 467 6.97%
Age 60-69 386 25 358 6.47% 1 (reference)
70-79 105 9 99 8.57% 0.75(0.71-0.78)
≥ 80 11 1 10 9.09% 0.71(0.67-0.74)
Sex Female 194 11 183 5.56% 1 (reference)
Male 308 24 284 7.79% 1.40(1.33-1.46)
No. of ≤5 137 8 129 5.83% 1 (reference)
medic- 6-10 192 13 179 6.77% 1.17(1.13-1.20)
ation ≥11 173 14 159 8.09% 1.32(1.26-1.37)
Length ≤5 209 12 197 5.74% 1 (reference)
of stay 6-10 219 17 202 7.76% 1.38(1.31-1.44)
≥11 74 6 68 8.1% 1.44(1.37-1.50) Fig. 1. Clinician’s (n=51) response for various types of
No. of 1 74 2 72 2.70% 1 (reference) suggestions.
diag- 2 153 11 142 7.18% 0.37(0.33-0.41)
nosis ≥3 275 22 253 8.00% 0.33(0.29-0.37) Discussion

Inappropriate medication use: IMU is a

Feedback from clinicians: A total of 35 major, common health problem in older people.
inappropriate medications were noted in this study. IMU among the elderly in other countries has been
158 Journal of The Indian Academy of Geriatrics, Vol. 6, No. 4, December, 2010
well-documented with the estimated prevalence
ranging from 11% to 43%. The finding of this study
also confirmed the prevalence of IMU in elderly
inpatients in a tertiary care centre.
The inappropriateness was found to be 6.97%
by using Modified Updated Beer’s Criteria 2003.
The prevalence of IP as shown in this study was
lower than the rates reported in different countries.
Varying prevalence of IP is reflected from the
studies conducted around the world; 32% (n=191) in
Ireland in 2007, 23.7% (n=5741) in Taiwan in 2008,
43.5% (n=212) in Israel in 2009, 33% (n=965756) in
Canada in 2007 and 21% (n=1669) in Japan in
2005.9-13 The difference in the prevalence of IMU in
different countries can be attributed to diverse
demographic characteristics of patients, varying
disease characteristics, difference in prescribing
patterns, physician specialties, sample size and
pharmaceutical market of the various countries.
In this study the most commonly prescribed
inappropriate drugs were digoxin (48.6%) followed
by nifedipine (11.4%) and bisacodyl (5.7%). Similar
pattern of inappropriateness was observed in the
Taiwanese medical setting where amiodarone,
bisacodyl and nifedipine were the most frequently
prescribed potentially inappropriate medications of
high severity. A study conducted to assess the risk
of digoxin toxicity in elderly patient reported that
out of 2030 patients on digoxin, total of 34
hospitalizations occurred due to toxicity.14
The second list of IP according to the Beers
was drugs, whose dose should not be exceed
maximum dose and drugs which are to be avoided
in specific disease condition. NSAIDs should be
avoided as they may exacerbate existing ulcer
disease or create new ulcer. One study has found
that important risk factors for the development of
gastrointestinal complications in patients taking
NSAIDs include: increasing age, concomitant use of
anticoagulation therapy, previous gastrointestinal
events and concomitant use of corticosteroids. The
risk of gastrointestinal complications in NSAID
users over the age of 65 years is increased approxi-
mately 2-3.5 fold when compared with younger
patients.15
Predictors of inappropriate medication
use: Two categories of predictors were determined,
i.e. socio-demographic variables consisting of age
and gender and continuous clinical variables like
number of medications, number of diagnoses and
length of hospitalization.16,17 According to the
findings of this study, older men were more likely
than older women to receive inappropriate
medications. It was found that patients prescribed
with larger number of medications were more likely
to receive inappropriate medications.18 Patients
prescribed with more than 10 medications were
found to have more prevalence of inappropriate
medication than those who were prescribed less
than 10 medications. Number of diagnoses also had
significant impact on the IP. This may be explained
by a simple example that as the number of
diagnosis increases, number of medications to treat
each particular disease condition also increases
which ultimately leads to polypharmacy and IMU.19
Hence this study suggests that polypharmacy is
common and is significantly associated with IP.
Similarly, length of hospitalization also contributed
to IMU. The patients staying for more than ten
days were twice more likely to receive inappropriate
medication than patients staying for less than ten
days.
Feedback
Feedback was recorded from 51 clinicians and
clinical pharmacologists about their opinion
regarding inappropriate medication from the
medicine and cardiology wards. In more than half of
the cases clinicians agreed that the provided
information about inappropriate medication was
clinically significant and the given suggestions were
accepted.
The results of this study reflect the need to
update the clinicians on the pharmacotherapy of
the elderly patients. This could be done by provid-
ing continuous feedback to them on the pharma-
cotherapy of elderly patients.
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