Five ways you can reduce inappropriate prescribing in the elderly: A systematic review
Though research has shown that physicians welcome pharmacists’ recommendations, further study is needed to look at ways in which physicians and pharmacists may work together effectively to decrease inappropriate prescribing in the elderly. In addition, since the studies reviewed were conducted before the implementation of Medicare Part D and its change in pharmacy scope of practice, further study is needed to help define this new role of the pharmacist.
The studies reviewed also show that serious medication errors can be decreased by 55% and adverse drug events by 84% when physicians use computerized alerts in the inpatient setting. Considering the significance of hospital safety and quality care issues, this method provides an avenue for hospitals to decrease inappropriate prescribing in elderly hospitalized patients. However, for computerized alerts to work in the inpatient setting, the physician should have access to all pertinent patient information to make an adequate decision. Further study is also needed to determine why physicians routinely bypass or override computerized alerts.
In addition, inappropriate prescribing and polypharmacy can be reduced when a multidisciplinary team consisting of a consulting pharmacist, physician, and nurse reviews a patient’s medications through a “brown bag” review including nonprescription substances such as vitamins and herbal products. This method of intervention will not only decrease the number of medications used by older patients but also medication costs. Further study is needed to see if similar results are achieved in Geriatric Assessment Clinics and also by using the patient’s primary care physician versus a comprehensive team approach for medication review.
Reducing inappropriate prescribing in the elderly can also be achieved through a simple patient educational intervention such as a single letter recommending medications be reduced. Patient education through an outpatient evaluation and management program consisting of regular assessments and medication review protocols can reduce serious adverse drug events by 35%.
The Beers Criteria have been widely used for well over 10 years and have been adopted by the Centers for Medicare and Medicaid Services for nursing home regulation. They are, however, based on a US Consensus Panel of experts using a modified Delphi Method rather than on any research evidence. The Beers Criteria may be helpful solely as a guide in assisting the practitioner to determine whether or not a certain medication may be considered inappropriate for use in the older patient. However, further evidence-based research is needed to determine which medications are considered inappropriate for use in the older adult.
Limitations
This systematic review has several limitations. First, there are few randomized controlled trials that address inappropriate prescribing in patients 65 years of age and older, thus, limiting the strength of evidence. Secondly, the majority of studies reviewed involved healthy elderly and not ill elderly; thus, recommendations for reducing inappropriate prescribing in the elderly may not apply to ill elderly. Finally, the systematic review involved studies prior to Medicare Part D and thus do not take into account the provision of management programs under Medicare Part D. With the changing scope of pharmacy practice that Medicare Part D brings, further study will be needed to define the role of the pharmacist in prevention of medication errors.
CORRESPONDENCE
Robert M. Garcia, MD, St. Joseph’s Hospital and Medical Center, Family Medicine Residency Program, 2927 N. 7th Ave, Phoenix, AZ 85013. E-mail: Bob.Garcia@chw.edu
