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Age and Ageing Advance Access originally published online on October 11, 2007
Age and Ageing 2008 37(1):96-101; doi:10.1093/ageing/afm116
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Copyright © The Author 2007. Published by Oxford University Press on behalf of the British Geriatrics Society.

Inappropriate prescribing in an acutely ill population of elderly patients as determined by Beers' Criteria

Paul F. Gallagher1,, Pat J. Barry1, Cristin Ryan2, Irene Hartigan3 and Denis O'Mahony4

1 Specialist Registrar, Geriatric Medicine, Cork University Hospital, Wilton, Cork, Ireland
2 School of Pharmacy, University College, Cork, Ireland
3 School of Nursing, Brookfield Health Sciences Complex, University College, Cork, Ireland
4 Consultant Physician in Geriatric Medicine, Cork University Hospital, Wilton, Cork, Ireland

Address correspondence to: Paul F. Gallagher. Tel: 00353 21 4922396; Fax: 00353 21 4922829. Email: pfgallagher77{at}eircom.net


   Abstract
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 Abstract
Introduction
 Methods
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Introduction: Adverse drug events (ADEs) are associated with inappropriate prescribing (IP) and result in increased morbidity, mortality and resource utilisation. We used Beers' Criteria to determine the three-month prevalence of IP in a non-selected community-dwelling population of acutely ill older people requiring hospitalisation.

Methods: A prospective, observational study of 597 consecutive acute admissions was performed. Diagnoses and concurrent medications were recorded before hospital physician intervention, and Beers' Criteria applied.

Results: Mean patient age (SD) was 77 (7) years. Median number of medications was 5, range 0–13. IP occurred in 32% of patients (n = 191), with 24%, 6% and 2% taking 1, 2 and 3 inappropriate medications respectively. Patients taking >5 medications were 3.3 times more likely to receive an inappropriate medication than those taking ≤5 medications (OR 3.34: 95%, CI 2.37–4.79; P<0.001). Forty-nine per cent of patients with inappropriate prescriptions were admitted with adverse effects of the inappropriate medications. Sixteen per cent of all admissions were associated with such adverse effects.

Conclusion: IP is highly prevalent in acutely ill older patients and is associated with polypharmacy and hospitalisation. However, Beers' Criteria cannot be used as a gold standard as they do not comprehensively address all aspects of IP in older people.

Keywords: Beers Criteria, inappropriate prescribing, elderly


   Introduction
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Methods
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Inappropriate prescribing (IP) of medicines for older people is a major cause of adverse drug events (ADEs) [1, 2]. Such adverse events lead to increased morbidity, mortality and health resource utilisation [1–6]. The age-associated increased incidence of ADEs has been particularly well described for certain drug classes, e.g. benzodiazepines, tricyclic antidepressants, non-steroidal anti-inflammatory drugs (NSAIDs) and opiate analgesics [7–11]. Explicit criteria detailing potentially IP practices in the elderly have been developed, the most frequently cited being Beers' Criteria [12–14]. Beers' Criteria were originally developed for use in the elderly nursing home population and were based on the consensus opinion of a group of experts in geriatric pharmacotherapy in the USA [12]. The criteria were subsequently expanded in 1997 so as to be generalisable to all persons over the age of 65 years, regardless of level of frailty or place of residence [13]. Beers' Criteria were again revised in 2002 to incorporate new prescribing indicators [14].

Beers' Criteria [14] currently consist of two lists of medications that should be avoided in older people (i) independent of diagnosis and (ii) considering diagnosis (see Appendix 1 in the supplementary data on the journal website http://www.ageing.oxfordjournals.org/). The criteria have been used in epidemiological studies both in Europe and the United States to determine the prevalence of, and risk factors for, IP in older people [15–22]. Such prevalence rates range from 12 to 40% depending on the population being evaluated [15–22]. There are limited data from the Republic of Ireland on the prevalence of potentially IP in older people. Barry et al. (using Beers' Criteria) recently reported a 34% rate of IP in a cohort of 350 frail, elderly patients that were selectively admitted to an acute geriatric assessment unit [23]. However, the results from that group are unlikely to reflect the prevalence of IP in elderly patients in Ireland as a whole, as patients presenting to an acute geriatric assessment unit generally represent the frailest and sickest of older people. Ryan et al. again using Beers' Criteria, recently identified a 13% prevalence rate of IP in a medically stable, independently dwelling cohort from the same catchment area as this present study [24]. That cohort had a mean age (SD) of 75(6) years, 58% were female and the median number of medications was five. The prevalence rate of 13% in the medically stable cohort is comparable to recently published European data [16], but is significantly lower than the 34% prevalence in medically unwell elderly patients identified by Barry et al. [23].

The principal aim of the present study was to prospectively determine the prevalence of potentially inappropriate prescriptions (using Beers' Criteria) in an unselected community-dwelling population aged 65 years and over, requiring admission to an acute general hospital, and not specifically to a needs- or age-related geriatric medicine service. We aimed to determine whether polypharmacy, age and gender are independent risk factors for receiving an inappropriate medication, and whether there was a link between IP and reason for admission.


   Methods
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 Methods
Results
 Discussion
 Key points
 Funding
 Supplementary data
 References
 
Study population
We prospectively studied a population of consecutive acutely ill elderly patients who were admitted to a university teaching hospital over a recent 3-month period. All patients were aged 65 years and over, and all were admitted via the Accident and Emergency Department following referral by their General Practitioner (GP) or by self-referral. All patients were admitted under the care of the general medical or surgical services, similar to the admission policies of the National Health Service in the United Kingdom. Concurrent admissions to the acute geriatric medicine assessment unit were specifically excluded from the study, as that cohort generally represents an older frailer group than the general older population attending hospital. Community hospital residents were also excluded because consultant geriatricians in this teaching hospital regularly review these residents and thus may have influenced their prescriptions. The Clinical Research Ethics Committee approved the study protocol.

Data collection
Data collection occurred once for each patient. Baseline demographic details, including gender, age and address, were recorded. Medical co-morbidities, including reason for admission, concurrent medication list and serum biochemistry were abstracted from each patient's admission document and cross referenced with the GP referral letter, except in those patients who self-referred to hospital. Supplementary information was sought from the patient's GP and/or pharmacy when clarification was required. Recorded medications were those that were prescribed prior to hospital physician intervention. Beers' Criteria [14] were applied to the abstracted data by two investigators. The number of potentially inappropriate medications was calculated. The chi-squared test for categorical variables was used to compare the characteristics of participants receiving and not receiving inappropriate medications. A probability value of less than 0.05 was considered statistically significant.


   Results
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Patient characteristics
Data were prospectively collected from 597 consecutive cases, of which 337 (56%) were female. The principal characteristics of the population are illustrated in Table 1. Mean patient age (SD) was 77 (7) years. Most patients presented with an acute medical problem on a background of chronic illness. The majority of diagnoses pertained to diseases of the cardiovascular system. Eighty-two patients (14%) had chronic cognitive impairment, 77 patients (13%) had a history of depression and 111 patients (19%) suffered recurrent falls, i.e. >1 fall in the three months prior to admission.


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  		Table 1. Demographic profile, co-morbidities and medication use (n = 597)

 
General prescribing patterns
A total of 3,197 medications were prescribed to this cohort of 597 patients up to the point of acute admission to hospital (Table 1). Over 95% of patients were taking at least one prescription medication, with a median of 5 and a range of 0–13 medications. High-level polypharmacy, i.e. 10 or more regular prescription drugs, was identified in 9% of patients. Cardiovascular drugs were the most commonly prescribed, with 64% of patients receiving at least one cardiovascular medication. The range of cardiovascular medication was broad and included antihypertensive agents, antiplatelet agents, anticoagulants, angiotensin converting enzyme inhibitors and lipid-lowering drugs. The second most commonly prescribed medication group were those acting on the central nervous system (CNS). Thirty-four per cent of men and 39% of women were prescribed at least one CNS medication with approximately 50% of these patients being prescribed two or more CNS medications concurrently. Regular long-term prescriptions (longer than two months) for CNS drugs in this population were as follows (i) benzodiazepines 19% (n = 115); (ii) antidepressants 17% (n = 99); (iii) neuroleptics 5% (n = 28); (iv) cholinesterase inhibitors 3% (n = 18); (v) anticonvulsants 2% (n = 13). Sedating antihistamines, anticholinergics and drugs for neuropathic pain were prescribed to 4% of patients.

Inappropriate prescriptions as determined by Beers' Criteria
One hundred and ninety-one patients (32%) were prescribed at least one potentially inappropriate medication prior to admission to hospital, as determined by Beers' Criteria. More specifically, 143 patients (24%) were prescribed one potentially inappropriate medication, 38 patients (6%) were prescribed two potentially inappropriate medications concurrently and 10 patients (2%) were prescribed three potentially inappropriate medications concurrently. Of the 3,197 medicines prescribed in this population, 243 (8%) were potentially inappropriate (Table 2). However, these prescriptions affected almost one-third (32%) of all patients.


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  		Table 2. Inappropriate prescriptions as determined by Beers' Criteria

 
Inappropriate prescriptions, adverse drug events and reasons for admission
Forty nine per cent (n = 93) of the 191 patients receiving an inappropriate medicine were admitted to hospital with conditions that were highly likely to be adverse effects of the IP (Table 2). This equates to 16% of the total number of admissions (n = 597) being linked to an IP.

Of the 51 patients inappropriately receiving long-acting benzodiazepines, 16 presented with recurrent falls of which 7 required surgery for long-bone fractures, 4 had severe exacerbations of chronic obstructive pulmonary disease (COPD) and 7 presented with drowsiness or cognitive deterioration. Of the 50 patients inappropriately receiving short-intermediate acting benzodiazepines, 22 had recurrent falls, 14 were admitted with long-bone fractures, and 10 had impaired psychomotor function. Twelve patients were inappropriately prescribed tricyclic antidepressants (principally lofepramine and imipramine) of which 10 were admitted with conditions that could be attributable to the drugs including cognitive deterioration, recurrent falls and urinary retention. Nine patients were inappropriately receiving selective serotonin reuptake inhibitors (SSRIs), of which three were admitted for treatment of significant symptomatic hyponatraemia. Two of 24 patients receiving doxazosin presented with symptomatic postural hypotension. One of 11 patients receiving an inappropriately high dose of digoxin was admitted with digoxin toxicity. Twenty-four patients were inappropriately prescribed NSAIDs, of which four presented with upper gastrointestinal (GI) bleeding and two with acute renal failure. Of the 38 patients receiving propoxyphene inappropriately, 9 had symptoms that were attributable to opiate side effects including acute confusion, severe constipation and drowsiness.

Patients who were prescribed more than five medications were 3.3 times more likely to receive a potentially inappropriate medication than those who were prescribed five or fewer medications (Odds Ratio 3.34: 95% CI 2.37–4.79; P < 0.001). There was no association between gender and age in receiving a potentially inappropriate medication (Table 3). Of the 49 criteria detailed on Beers' ‘Independent of Diagnosis’ list, only 18 IP indicators were encountered. Of the 19 criteria detailed on Beers’ ‘Considering Diagnosis’ list, 5 were identified in this population.


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  		Table 3. Principal characteristics of populations taking inappropriate medications versus those not taking inappropriate medications

 

   Discussion
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 Abstract
 Introduction
 Methods
 Results
 Discussion
Key points
 Funding
 Supplementary data
 References
 
This study demonstrates that 32% of acutely ill elderly patients, who required admission to hospital from the community, were regularly receiving at least one potentially inappropriate medication prior to admission, as determined by Beers’ Criteria [14]. Forty-nine per cent of patients with inappropriate prescriptions presented with well-recognised adverse effects of the inappropriately prescribed medicines. These included falls with resultant fractures in the case of inappropriate psychotropic drug use, and upper GI bleeding with inappropriate NSAID use. In total, 16% of the 597 hospital admissions in this study could be linked to adverse effects of inappropriate prescriptions. This is consistent with international data [2, 5, 6, 25–27] and supports the association between inappropriate drug use, increased morbidity and health resource utilisation.

The IP prevalence rate of 32% in this cohort is similar to the 34% prevalence rate reported by Barry et al. again in an Irish population requiring admission to hospital, albeit an older, frailer, and smaller cohort [23]. Together, these two independent studies indicate a relatively high rate of IP in acutely ill older patients requiring admission to hospital in Ireland, particularly when interpreted in the context of international studies of similar hospital populations [17, 28]. Egger et al. applying the 2002 Beers’ Criteria to acutely ill older people in Switzerland, reported the prevalence rate of IP in patients selectively admitted under General Internal Medicine and Geriatric Medicine to be 16 and 20.8% respectively [28]. Furthermore, the 32% prevalence rate of IP in the present cohort of medically unwell patients is considerably higher than the 13% prevalence rate identified by Ryan et al. in a demographically similar cohort of 500 medically well, community dwelling patients from the same catchment area [24]. This raises the possibility of causative linkage between being sick, receiving an inappropriate medication and being admitted to hospital.

A relatively small range of medications accounted for a high prevalence of IP in this study with only one-third of the proscribed medications in Beers’ Criteria being encountered in this population. This may be explained by the fact that many of the medications listed in Beers’ Criteria are not available in Ireland or the United Kingdom e.g. guanadrel, trimethobenzamide and ethacrynic acid. In fact, up to 50% of the drugs listed in Beers’ Criteria are absent from several European formularies [16–18, 22]. In addition, some of Beers’ Criteria may have value in older people, e.g. amitriptyline at low dose in a broad range of pain syndromes, doxazosin in resistant hypertension, and amiodarone in recurrent ventricular tachycardia or paroxysmal atrial fibrillation. Amiodarone or verapamil might be the only agents to have controlled a clinically significant dysrhythmia, and having tried other drugs may be very appropriate to prescribe. Beers’ Criteria needs updating, in particular, with respect to non-selective NSAIDs versus COX-selective NSAIDs. In light of the safety concerns about increased cardiovascular morbidity, there has been a recent trend towards avoidance of COX-2 selective NSAIDs and a return to the prescription of non-selective NSAIDs with concomitant gastric protection by proton pump inihibitor, histamine H2-receptor antagonist or misoprostol.

Beers’ Criteria do not address several other important aspects of IP in older people, e.g. duplicate drug class prescriptions, harmful drug-drug interactions, inappropriate duration and frequency of therapy, and perhaps most importantly, drugs that are often omitted from older people's prescriptions, e.g. warfarin to prevent cardioembolic events in patients with atrial fibrillation, or beta-blockers in patients with angina. Beers’ Criteria are not organised in such a way as to make them quick and easy for the busy prescribing physician or dispensing pharmacist to use. For these reasons, Beers’ Criteria have not made their way into mainstream geriatric clinical practice.

Because of the limitations associated with Beers’ Criteria, we expect that the actual rate of IP is higher than the 32% identified in this study, particularly when taking into account inappropriate dosing, frequency and duration of medications, drug-drug interactions and the critical omission of clinically indicated medicines. Nonetheless, this study highlights a number of important points in relation to IP in acutely ill older patients in Ireland. Psychotropic drug use is highly prevalent and continues to be problematic, despite explicit evidence of the potential harms associated with such drugs in older people [7–10]. Over 50% of all inappropriate prescriptions in this study were for psychotropic medications, with over 80% of this sub-group being for benzodiazepines. Many long-acting benzodiazepines, some of which have half-lives of several days, e.g. flurazepam, diazepam and clorazepate, continue to be prescribed for older people in Ireland. One-third of older patients who were inappropriately prescribed a psychotropic medication suffered from recurrent falls, and one-quarter had a history of chronic cognitive impairment.

Polypharmacy is common and is significantly associated with IP. Patients who were prescribed more than five medications were over three times more likely to receive an inappropriate prescription than those who received five or fewer medications. Though multiple medications are often necessary to treat multiple concomitant disease processes in older people, unnecessary drugs add to the number, complexity and cost of an older person's drug regimen, reduce compliance and are more likely to be harmful. The reasons why doctors prescribe inappropriate drugs are several and complex [29]. Improved pharmacological education of practitioners, especially with regard to drug adverse effects, is desirable to improve management of elderly patients, reduce unnecessary morbidity and health resource utilisation. Because of the deficiencies of Beers’ Criteria, and the ongoing problem of IP in our ageing population, we contend that a new, comprehensive, easily applicable drug utilisation review tool that incorporates all aspects of IP in the elderly is now warranted.


   Conflicts of interest
 
The authors have no conflicts of interest to declare.


   Key points
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Key points
Funding
 Supplementary data
 References
 

  • Using Beers’ Criteria, IP was detectable in approximately one-third of acutely ill elderly patients presenting to hospital.
  • Sixteen per cent of all admissions could be linked to serious adverse effects of inappropriately prescribed medicines.
  • Inappropriate use of psychotropic medications, principally long- and short-acting benzodiazepines accounted for over 50% of all inappropriate prescriptions. One-third of patients receiving inappropriate psychotropic medications suffered from recurrent falls.
  • IP occurs as a function of polypharmacy. The prescription of more than five medications concurrently is associated with a 3-fold increase in the likelihood of receiving a potentially inappropriate medication in Ireland.
  • Beers’ Criteria are not comprehensive enough to detect all aspects of IP in older people.


   Funding
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Key points
 Funding
Supplementary data
 References
 
Health Research Board of Ireland (Clinical Research Training Fellowship CRT/2006/029).


   Supplementary data
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 Abstract
 Introduction
 Methods
 Results
 Discussion
 Key points
 Funding
 Supplementary data
References
 
Supplementary data for this article are available online at http://ageing.oxfordjournals.org.


   References
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 Introduction
 Methods
 Results
 Discussion
 Key points
 Funding
 Supplementary data
 References
 

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Received 1 May 2007; accepted in revised form 8 August 2007.


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