Five ways you can reduce inappropriate prescribing in the elderly: A systematic review

Intensive counseling reaps big benefits. In a second study, the South Dakota Medication Reduction Project, educational presentations by pharmacists and one-on-one sessions between pharmacists and patients resulted in patients taking fewer medications and reducing dosages in medical regimens. This longitudinal study involved over 1000 older adults in rural and urban southeastern South Dakota communities over 6 months.

A pharmacist specializing in geriatrics gave a 30-minute presentation at various sites on medication-associated problems and “do’s” and “don’ts” of medication use. This was followed by a 15-minute question-and-answer session.

A one-on-one 20-minute consultation between the pharmacist and patients followed the group presentation. The pharmacist recorded demographic data, medical history, medication names, doses, directions, and intended purposes, and obtained feedback about compliance and side effects. The pharmacist also provided oral counseling and written information about medications.

If a potentially serious drug-related problem was identified, a letter was sent to the patient’s primary care physician, identifying key inappropriate prescribing concerns and offering alternative interventions for the physician’s consideration.

Three months after the educational intervention, a telephone survey was performed. Survey results indicated that older adults participating in the one-on-one reviews were taking fewer medications, were more likely to take their medications, had dosage reductions, and increased their use of nonpharmacologic alternatives.²⁶

But even modest intervention pays off. In another randomized study, a simple education intervention significantly reduced inappropriate prescribing for elderly patients. Participants in the intervention group taking more than 10 medications were sent a single letter recommending that medications be reduced. Similar participants in the control group did not receive letters.

The outcome measured was number of medications. In the notification group, an average reduction of approximately 3 medications occurred over a 4-month period. More complex intervention did not reduce inappropriate prescribing any further.²

Value of visual reminders. Another study showed that a simple visual intervention significantly reduced inappropriate prescribing. In this controlled trial, physicians were shown a medication grid that displayed all of their patient’s medications and times of administration for 1 week. In the intervention group, medications decreased by 2.47 per patient. In the control group, medications increased by 1.65 per patient and doses increased by 3.83 per patient.²⁷

Try a team approach? Yet another randomized study showed that compared with usual care, education through an outpatient geriatric evaluation and management program reduced the number of serious adverse drug events and inappropriate prescribing for frail elderly patients. Patient management guideline interventions consisted of regular assessments and medication recommendations by pharmacists. There was also a core team comprised of a geriatrician, social worker, and a nurse who participated in evaluation and management protocols such as medication reviews. The program reduced the risk of serious adverse drug events by 35%, compared with usual care of the geriatric patient.²⁸

Method 5: Avoid inappropriate medications

The Beers criteria aid in identifying medications to be avoided in older persons. They were developed in 1991, then updated in 1997 and again in 2003. In short, these criteria designate as “inappropriate” any medication that has shown the potential for adverse effects in the elderly.^7,29,30

In the 2003 update, a US consensus panel of experts used a modified Delphi method to review medications potentially ineffective or unsafe in the elderly.^7,29,30 The TABLE shows selected examples of commonly used medications considered inappropriate.^7,29-32

Limited research supports use of the Beers criteria. The 1996 Medical Expenditure Panel Survey controlled for a number of confounding factors and found strong evidence of a sizable and consistent negative effect of using medications identified as inappropriate by the Beers criteria.³²

TABLE
Potentially inappropriate medications in the elderly

Discussion

The key findings of this study are that little evidence-based literature is available to guide recommendations for reducing inappropriate prescribing in elderly patients. Only a handful of randomized controlled trials have been conducted on the topic, and none of those trials involved persons older than age 85.

However, 4 methods for reducing inappropriate prescribing in the elderly are supported by some evidence: 1) incorporating pharmacist recommendations; 2) using computerized alerts in the inpatient setting; 3) reviewing medications; and 4) educating patients. No research evidence supports use of the Beers Criteria, which are based solely on consensus guidelines and expert opinions.

Limited evidence suggests that inappropriate prescribing and polypharmacy can be reduced by up to 24% using pharmacists’ recommendations based on review of patients’ charts and medications lists. This method of intervention may also reduce adverse drug events by 25% without adversely affecting health related quality of life.