Summary Top of page Summary Introduction Challenges in prescribing for older people Polypharmacy Adverse drug reactions Drug utilization review tools Beers’ criteria Improved prescribing in the elderly tool Potentially inappropriate prescribing in europe Outcome studies of drug utilization review tools Conclusion References Background and objective:68 Drug therapy is necessary to treat acute illness, maintain current health and prevent further decline. However, optimizing drug therapy for older patients is challenging and sometimes, drug therapy can do more harm than good. Drug utilization review tools can highlight instances of potentially inappropriate prescribing to those involved in elderly pharmacotherapy, i.e. doctors, nurses and pharmacists. We aim to provide a review of the literature on potentially inappropriate prescribing in the elderly and also to review the explicit criteria that have been designed to detect potentially inappropriate prescribing in the elderly. Methods:68 We performed an electronic search of the PUBMED database for articles published between 1991 and 2006 and a manual search through major journals for articles referenced in those located through PUBMED. Search terms were elderly , inappropriate prescribing , prescriptions , prevalence , Beers criteria , health outcomes and Europe . Results and discussion:68 Prescription of potentially inappropriate medications to older people is highly prevalent in the United States and Europe, ranging from 12% in community-dwelling elderly to 40% in nursing home residents. Inappropriate prescribing is associated with adverse drug events. Limited data exists on health outcomes from use of inappropriate medications. There are no prospective randomized controlled studies that test the tangible clinical benefit to patients of using drug utilization review tools. Existing drug utilization review tools have been designed on the basis of North American and Canadian drug formularies and may not be appropriate for use in European countries because of the differences in national drug formularies and prescribing attitudes. Conclusion:68 Given the high prevalence of inappropriate prescribing despite the widespread use of drug-utilization review tools, prospective randomized controlled trials are necessary to identify useful interventions. Drug utilization review tools should be designed on the basis of a country's national drug formulary and should be evidence based.

Abstract Medication toxic effects and drug-related problems can have profound medical and safety consequences for older adults and economically affect the health care system. The purpose of this initiative was to revise and update the Beers criteria for potentially inappropriate medication use in adults 65 years and older in the United States. This study used a modified Delphi method, a set of procedures and methods for formulating a group judgment for a subject matter in which precise information is lacking. The criteria reviewed covered 2 types of statements: (1) medications or medication classes that should generally be avoided in persons 65 years or older because they are either ineffective or they pose unnecessarily high risk for older persons and a safer alternative is available and (2) medications that should not be used in older persons known to have specific medical conditions. This study identified 48 individual medications or classes of medications to avoid in older adults and their potential concerns and 20 diseases/conditions and medications to be avoided in older adults with these conditions. Of these potentially inappropriate drugs, 66 were considered by the panel to have adverse outcomes of high severity. This study is an important update of previously established criteria that have been widely used and cited. The application of the Beers criteria and other tools for identifying potentially inappropriate medication use will continue to enable providers to plan interventions for decreasing both drug-related costs and overall costs and thus minimize drug-related problems.

Background Inappropriate medication use is a major healthcare issue for the elderly population. This study explored the prevalence of potentially inappropriate prescriptions (PIPs) in long-term care in metropolitan Quebec. Methods A cross sectional chart review of 2,633 long-term care older patients of the Quebec City area was performed. An explicit criteria list for PIPs was developed based on the literature and validated by a modified Delphi method. Medication orders were reviewed to describe prescribing patterns and to determine the prevalence of PIPs. A multivariate analysis was performed to identify predictors of PIPs. Results Almost all residents (94.0%) were receiving one or more prescribed medication; on average patients had 4.8 prescribed medications. A majority (54.7%) of treated patients had a potentially inappropriate prescription (PIP). Most common PIPs were drug interactions (33.9% of treated patients), followed by potentially inappropriate duration (23.6%), potentially inappropriate medication (14.7%) and potentially inappropriate dosage (9.6%). PIPs were most frequent for medications of the central nervous system (10.8% of prescribed medication). The likelihood of PIP increased significantly as the number of drugs prescribed increased (odds ratio [OR]: 1.38, 95% confidence interval [CI]: 1.33 1.43) and with the length of stay (OR: 1.78, CI: 1.43 2.20). On the other hand, the risk of receiving a PIP decreased with age. Conclusion Potentially inappropriate prescribing is a serious problem in the highly medicated long-term care population in metropolitan Quebec. Use of explicit criteria lists may help identify the most critical issues and prioritize interventions to improve quality of care and patient safety.

Study Objective. To determine the prevalence and risk factors of potentially inappropriate drug prescribing among first-visit elderly outpatients.Design. Cross-sectional survey.Setting. An urban tertiary care and academic medical center in southern Taiwan.Patients. Eight hundred eighty-two patients aged 65 years or older who were prescribed drugs at their first visit to either the medical center's outpatient internal medicine clinic or family medicine clinic between March 1, 2001, and July 31, 2001.Measurements and Main Results. Potentially inappropriate drug prescribing was assessed according to updated Beers criteria. Ninety-seven potentially inappropriate drugs were identified in 93 (10.5%) patients. The most common classes were sedative-hypnotics (18.6%) and muscle relaxants (17.5%). Twenty (20.6%) of these inappropriate drugs had a high severity potential according to the Beers criteria. Patients prescribed potentially inappropriate drugs were more likely to be prescribed several drugs versus those who were not prescribed potentially inappropriate drugs (4.0 卤 1.9 vs 2.8 卤 1.4, p<0.001). Multiple logistic regression analysis revealed an interaction between age and the number of prescribed drugs on the risk of having potentially inappropriate drugs prescribed. In patients who were prescribed four agents or less, the risk was not associated with increasing age; in those who were prescribed five drugs or more, the risk was positively associated with increasing age.Conclusion. Potentially inappropriate drug prescribing among first-visit elderly outpatients was relatively low. Increasing patient age combined with increased number of drugs prescribed was associated with increased risk of having potentially inappropriate drugs prescribed.

Objective To determine the prevalence of inappropriate medication use among hospitalized older adults and to identify predictors of this use. Methods A total of 5734 patients (mean age 7902years) admitted to geriatric and internal medicine wards participating in the study in 1995 and 1997 were included in this analysis. Inappropriate medication use was defined on the basis of the criteria published by Beers in 1997. Only medications used during hospital stay were considered for the present study. Results During hospital stay, 837 (14.6%) patients received one or more medications classified as inappropriate based on Beers criteria. Ticlopidine ( n =346; 6.0% of the study sample) was the most frequently used medication among those in Beers' list, followed by digoxin ( n =174; 3.0%) and amytriptyline ( n =113; 2.0%). The multivariate analysis showed that age [75–8402years vs 65–7402years, odds ratio (OR) 0.85, 95% confidence interval (CI) 0.71–1.00; ≥8502years vs 65–7402years, OR 0.58, 95% CI 0.46–0.73], cognitive impairment (OR 0.77, 95% CI 0.64–0.94), Charlson co-morbidity index (≥2 vs 0–1, OR 1.20, 95% CI 1.02–1.40) and overall number of medications used during hospital stay (5–8 medications vs <5 medications, OR 2.20, 95% CI 1.72–2.82; ≥9 medications vs <5 medications, OR 3.68, 95% CI 2.86–4.73) were significantly associated with use of inappropriate medications. Conclusions Inappropriate medication use was common among hospitalized older adults. The most important determinant of risk of receiving an inappropriate medication was the number of drugs being taken. Older age and cognitive impairment were associated with a reduced likelihood of using an inappropriate medication.

OBJECTIVE: To examine healthcare outcomes associated with Beers' criteria of inappropriate medication use based on a literature review. DATA SOURCES: A search of MEDLINE, International Pharmaceutical Abstracts, and Cumulative Index to Nursing and Allied Health Literature was conducted to identify articles published from October 1991 to October 2006. The following key words were used: Beers, inappropriate, medication, drug, use, prescribing, and elderly. A manual search was also conducted using the references listed in the articles identified through the database search. STUDY SELECTION AND DATA EXTRACTION: Studies that examined the impact or outcomes of Beers' criteria of inappropriate medication use (1991, 1997, and 2003 critera) were selected. Each article was examined for study setting, data source, study sample, study design, criteria, analysis and covariates, type of healthcare outcome, and study findings. Of 235 articles retrieved, 18 presented studies that examined healthcare outcomes associatedwith inappropriate medication use based on Beers' criteria. Specifically, setting-specific evidence as well as overall evidence was examined from the selected studies. The review considered evidence of association if more than 50% of the findings were statistically significant. DATA SYNTHESIS: Most of the 18 studies evaluated were retrospective cohort studies involving patients 65 years of age or older from diverse healthcare settings. In community settings, there was no evidence of association with respect to mortality and other healthcare use, and evidence regarding quality of life and costs was inconclusive. However, inappropriate medication use was associated with hospitalization measures in community elderly. In nursing homes, there was no evidence of association with mortality and the association with hospitalization measures was inconclusive. In hospitals, there was inconclusive evidence to make any generalizations. Across healthcare settings, inappropriate medi

What is known and Objective Potentially inappropriate prescribing (PIP) has significant clinical, humanistic and economic impacts. Identifying PIP in older adults may reduce their burden of adverse drug events. Tools with explicit criteria are being developed to screen for PIP in this population. These tools vary in their ability to identify PIP in specific care settings and jurisdictions due to such factors as local prescribing practices and formularies. One promising set of screening tools are the STOPP (Screening Tool of Older Person's potentially inappropriate Prescriptions) and START (Screening Tool of Alert doctors to the Right Treatment) criteria. We conducted a systematic review of research studies that describe the application of the STOPP/START criteria and examined the evidence of the impact of STOPP/START on clinical, humanistic and economic outcomes in older adults.<br/>Methods We performed a systematic review of studies from relevant biomedical databases and grey literature sources published from January 2007 to January 2012. We searched citation and reference lists and contacted content experts to identify additional studies. Two authors independently selected studies using a predefined protocol. We did not restrict selection to particular study designs; however, non-English studies were excluded during the selection process. Independent extraction of articles by two authors used predefined data fields. For randomized controlled trials and observational studies comparing STOPP/START to other explicit criteria, we assessed risk of bias using an adapted tool.<br/>Results and Discussion We included 13 studies: a single randomized controlled trial and 12 observational studies. We performed a descriptive analysis as heterogeneity of study populations, interventions and study design precluded meta-analysis. All observational studies reported the prevalence of PIP; however, the application of the criteria was not consistent across all studies. Seven of the observational studies compared STOPP/START with other explicit criteria. The STOPP/START criteria were reported to be more sensitive than the more-frequently-cited Beers criteria in six studies, but less sensitive than a set of criteria developed in Australia. The STOPP criteria identified more medications associated with adverse drug events than the 2002 version of the Beers criteria. Patients with PIP, as identified by STOPP, had an 85% increased risk of adverse drug events in one study (OR=1<bold>85</bold>, 95% CI: 1<bold>51</bold>-2<bold>26</bold>; P<0<bold>001</bold>). There was limited evidence that the application of STOPP/START criteria optimized prescribing. Research involving the application of STOPP/START on the impact on the quality of life was not found. The direct costs of PIP were documented in three studies from Ireland, but more extensive analyses on the economic impact or studies from other jurisdictions were not found.<br/>What is new and Conclusion The STOPP/START criteria have been used to review the medication profiles of community-dwelling, acute care and long-term care older patients in Europe, Asia and North America. Observational studies have reported the prevalence and predictors of PIP. The STOPP/START criteria appear to be more sensitive than the 2002 version of the Beers criteria. Limited evidence was found related to the clinical and economic impact of the STOPP/START criteria.

目的 了解中枢神经系统药物对老年患者发生跌倒的影响,并提出针对性的护理措施.方法 2007年3月-2009年3月在我科入住的老年患者中,因服用中枢神经系统药物后发生跌倒的患者38例,分析患者服用中枢神经系统药物后跌倒的发生率与 性别、教育程度、健康状况、泌尿问题、视力问题及认知功能障碍的关系,以及服药时间与药物剂量与跌倒之间关系.结果 男性跌倒发生率达78.95%,明显高于女性(21.05%);年龄在76~85岁之间跌倒发生率最高,达52.63%;伴发心血管疾病和代谢疾病发生跌 倒率明显高于其他类疾病;有基础性疾病者跌倒率明显增高.高剂量组和服药后0.5~1 h跌倒发生率明显增高,与低剂量和其他时间段比较差异有统计学意义,P<0.05.结论 服用中枢神经系统药物对老年人跌倒的发生有严重影响;护理人员应特别重视老年患者中使用高剂量药物以及服药后1 h内的观察,日常应加强用药宣教和陪护者跌倒防范意识的指导,减少老年患者跌倒事件的发生,有助于患者的康复.

目的：评价胺碘酮对我院房颤患者Q Tc间期的影响及其药品不良反应。方法：研究纳入2013年1月-2014年5月间上海交通大学医学院附属仁济医院房颤住院患者共l56例，记录患者一般 资料及合用药物等信息，观察应用胺碘酮注射液或胺碘酮片剂后心率、Q T间期、Q Tc间期的变化，以及在胺碘酮用药期间是否发生与用药相关的不良反应。结果：用药后房颤患者的平均心率显著减慢(79.2±21.6)bpm比 （72.9±13.1）bpm (P500ms，17例患者用药后QTc50ms。共有22例患者合并使用一种或多种可延长QT间期的 药物，包括氟哌噻吨美利曲辛片（10例），多塞平（7例），左氧氟沙星（6例）等。心动过缓、2型糖尿病、合用其他影响QT间期药物为延长QTc间期的因 素(P500ms、△QTc>50ms或合并使用其他可延长QT间期药物的患者，需调 整胺碘酮剂量并严密监测心电图，警惕恶性心律失常的发生。

Background: The high prevalence of drug-related problems (DRPs) in the elderly, occurring as a result of multiple drug use combined with age-related changes in pharmacokinetics and pharmacodynamics, is a well known phenomenon. However, effective intervention strategies are uncommon. Objective : A pharmacy-based controlled trial (SMOG [Screening Medicatie Oudere Geneesmiddelgebruiker; Screening Medications in the Older Drug User]) was performed to investigate whether a community pharmacist-led intervention reduces the number of potential DRPs in patients aged ≥65 years using six or more drugs concomitantly. Methods: This intervention study was conducted from June 2002 until June 2003 in 16 community pharmacies in the Netherlands. Medication assessment was undertaken in elderly patients aged ≥65 years using six or more drugs concomitantly on the date of inclusion. Ten types of potential DRPs were determined and grouped into the following three categories: (i) patient-related potential DRPs: non-compliance; (ii) prescriber-related potential DRPs: expired indication, therapeutic duplication, inappropriate dosage (over- and under-dosage), off-label use, undertreatment, inconvenience of use; and (iii) drug-related potential DRPs: contraindications, drug-drug interactions, drug treatment of adverse drug reactions. A list of recommended changes in medication was compiled by the pharmacist for the patients in the intervention group. Recommendations for medication change were discussed with the general practitioner (GP). Four months after the date of inclusion, the medications of each patient were again reviewed and screened for potential DRPs. The primary outcome corresponded to the change in the number of potential DRPs; the secondary outcome was related to the change in number of used medications between the intervention group and the control group at baseline and 4 months later. Results: A total of 174 patients were analysed: 87 patients in the intervention arm and 87 patients in the usual care arm. After a 4-month period, we observed a significant reduction in the mean number of DRPs per patient (mean difference 6116.3%; 95% CI 6124.3, 618.3). The mean number of drugs per patient was not significantly reduced (mean difference 614.7%; 95% CI 619.6, 0.2). Conclusion: This study showed a positive influence of the community pharmacist in reducing potential DRPs in the elderly. Future interventions should also focus on actual outcomes, including quality of life, morbidity and mortality.