Study, Sep/19: Potentially inappropriate meds for seniors -- Southern India

The full title of this Indian/Australian study is "Potentially inappropriate medications prescribed for older persons: A study from two teaching hospitals in Southern India".

 

https://www.ncbi.nlm.nih.gov/pubmed/31572049 

Abstract

 

BACKGROUND:

 

Potentially inappropriate medications (PIMs) are a major concern in geriatric care. The primary objective of our study was to assess the prevalence of PIMs prescribed for older persons attending outpatient setting of two teaching hospitals in Kerala state in South India, where the population is aging.

 

MATERIALS AND METHODS:

 

A cross-sectional study was carried out in two teaching hospitals in Kerala. Four hundred consecutive outpatient medical records of patients aged 65 years and above were selected. The current medications of the patients were analyzed to identify PIMs by the Beers criteria 2015. Polypharmacy and hyperpolypharmacy were defined as 5-9 medications and ≥10 medications, respectively. Chi-square test was done to identify demographic variables and the pattern of health-care facility use associated with PIM prescription. Binary logistic regression was performed to adjust for confounding associations.

 

RESULTS:

 

The prevalence of PIMs prescription was 34.0% (95% confidence interval: 29.4%-38.6%) and that of polypharmacy and hyperpolypharmacy was 45.8% and 13.5%, respectively. The common PIMs were proton-pump inhibitors, benzodiazepines, peripheral α-1 blockers, and first-generation antihistamines. Inpatient admission, visits to the emergency department, multiple diagnoses, polypharmacy, and hyperpolypharmacy were associated with PIM prescription (P < 0.05). Age, gender, number of outpatient visits, and specialist consultation were not associated with PIM prescription. Polypharmacy (adjusted odds ratio [aOR] =2.11) and hyperpolypharmacy (aOR = 5.55) had independent association with PIM prescription (P < 0.05).

 

CONCLUSION:

 

PIM prescription appears to be common in teaching hospitals in Kerala. Polypharmacy and hyperpolypharmacy in older people should trigger a review of medication to reduce the use of PIM.

Lapis, 5-9 medications!!! That's terrible. Drugs all have interactions which can be quite difficult to deal with. Over the long haul, this many pills puts a load on the kidneys and liver, too, if the drugs are processed through the liver. The patient might end up on dialysis. They might have a paradoxical effect, too.

 

It's frightening, to say the least, that older patients would take that many drugs. At their age (and mine as well) they can't process drugs as quickly as a younger person, and the drugs stay longer in the body.

 

I remember when I came out of the hospital in 2016 because of having a TIA, the doctor gave me 8 medications! On my next visit to a doctor, it turned out that my platelets were at 1.8 million!! They're supposed to be somewhere between 150,000-450,000. I was scared to death I would suffer a stroke or something else.

 

I had to get off most of the pills I was given. The doctor luckily okayed it. Only then did my platelets go down to 700,000. Since this benzo mess, I've always had high platelets, but that was the worst. It was obviously a paradoxical effect from the pills.

 

So I learned a lesson!

Lapis, 5-9 medications!!! That's terrible. Drugs all have interactions which can be quite difficult to deal with. Over the long haul, this many pills puts a load on the kidneys and liver, too, if the drugs are processed through the liver. The patient might end up on dialysis. They might have a paradoxical effect, too.

 

It's frightening, to say the least, that older patients would take that many drugs. At their age (and mine as well) they can't process drugs as quickly as a younger person, and the drugs stay longer in the body.

 

I remember when I came out of the hospital in 2016 because of having a TIA, the doctor gave me 8 medications! On my next visit to a doctor, it turned out that my platelets were at 1.8 million!! They're supposed to be somewhere between 150,000-450,000. I was scared to death I would suffer a stroke or something else.

 

I had to get off most of the pills I was given. The doctor luckily okayed it. Only then did my platelets go down to 700,000. Since this benzo mess, I've always had high platelets, but that was the worst. It was obviously a paradoxical effect from the pills.

 

So I learned a lesson!

 

When my father was sick before he died of cancer, they had him on 14-16 meds. Seems like his cardiologist and oncologist were competing to see who could get him on the most meds. 

I'm so sorry, thinkstopthink!! That's just awful. My dad had kidney cancer, and it got to the point where he would throw a lot of pills that my mother was giving him over the couch when she wasn't looking. He just couldn't be bothered with them. We never knew he did that until moving the couch after he passed away. Just what will that many pills do to HELP a person???

 

My sister was given Valium, Ativan, and Xanax when she had lung cancer. She was also given 2 opiates...

 

 

I'm so sorry, thinkstopthink!! That's just awful. My dad had kidney cancer, and it got to the point where he would throw a lot of pills that my mother was giving him over the couch when she wasn't looking. He just couldn't be bothered with them. We never knew he did that until moving the couch after he passed away. Just what will that many pills do to HELP a person???

 

My sister was given Valium, Ativan, and Xanax when she had lung cancer. She was also given 2 opiates...

 

How any doctor can claim they understand what is happening with that many meds is beyond me.

I agree wholeheartedly!

One of the things that continues to strike me as I post these abstracts about "potentially inappropriate medications" for seniors is that all doctors should know better. I don't understand why this continues to happen when the research is already there. That's why the list of PIMs was created! If they know they're prescribing a potentially problematic medication, then why.....?? I don't even know how to ask the question anymore! It just doesn't make sense to me.

 

And, if you guys noticed, I posted another abstract on the same topic from Portugal. It's taking place all over the world -- wherever these medications are available. Doctors continue to ignore the warnings, and studies continue to be done that come to the same conclusions.

 

What the hell? Really...what the hell is going on?

 

It boggles my mind.

 

 

I don't know why, Lapis. It seems that's a doctor's MO. Give more pills. My doctor always wants to do that, too, but I refuse. I'm afraid of being a non-compliant patient, but I'm only trying to protect myself!

One of the things that continues to strike me as I post these abstracts about "potentially inappropriate medications" for seniors is that all doctors should know better. I don't understand why this continues to happen when the research is already there. That's why the list of PIMs was created! If they know they're prescribing a potentially problematic medication, then why.....?? I don't even know how to ask the question anymore! It just doesn't make sense to me.

 

And, if you guys noticed, I posted another abstract on the same topic from Portugal. It's taking place all over the world -- wherever these medications are available. Doctors continue to ignore the warnings, and studies continue to be done that come to the same conclusions.

 

What the hell? Really...what the hell is going on?

 

It boggles my mind.

 

What appears to be potentially inappropriate medications to some may be considered completely appropriate to others. That's why I continue to advocate for transparency and the right of individuals to choose what they consider appropriate for themselves.

Buyer always beware! Just like with anything one buys to consume.

 

I should have looked up Lasix when the doctor prescribed it. I'm VERY allergic to sulfa. I told him I was allergic, but he prescribed this pill, which is part of the sulfonamide family. If I had looked up the drug, I would have refused to take it and thus avoided the AWFUL rash/pimples/itching that I've had for the last 3 months, gradually getting worse but now slowly going away.

 

If I told the doctor about the rash, he would have automatically (I'm thinking) prescribed a steroid or an antihistamine, which I cannot take because I'd get terribly high bp and who knows what other benzo symptoms.

 

We have to be smarter consumers of drugs. After all, this is something that's circulating throughout the body every single day.

 

Lesson learned!

Just to clarify:

 

Multiple comorbidities with medication burden are common in the elderly population [1]. In addition, the concurrent use of potentially inappropriate medications (PIMs) has been associated with adverse drug reactions, disability, mortality, hospitalization, institutionalization to aged care facilities, and high health costs [2–4]. PIM use is not uncommon.

 

This excerpt is from this study:

 

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0211947 

 

Aside from the meds that on the list of PIMs, it's important to keep in mind that as we age, our metabolism of medications changes due to liver and kidney changes. Things slow down. We can accumulate medications in our bodies due to slower clearing rates. That's why seniors are especially vulnerable to the effects of various medications.

 

Fi, there should always be informed consent, but as you know, most of us didn't get the opportunity to weigh the risks and benefits of the medications we were prescribed because doctors and pharmacists didn't explain those things to us. That was their responsibility.

 

Benzos are only indicated for two to four weeks of use, but most of us were on them much longer than that. We should all have been warned of the dangers of being on these medications for long periods of time. I, for one, was not. I was also on multiple medications, and the interactions between those medications is likely one of the reasons that I'm dealing with such long-term effects. There were known contraindications for that polypharmacy.

 

 

Just to clarify:

 

Multiple comorbidities with medication burden are common in the elderly population [1]. In addition, the concurrent use of potentially inappropriate medications (PIMs) has been associated with adverse drug reactions, disability, mortality, hospitalization, institutionalization to aged care facilities, and high health costs [2–4]. PIM use is not uncommon.

 

This excerpt is from this study:

 

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0211947 

 

Aside from the meds that on the list of PIMs, it's important to keep in mind that as we age, our metabolism of medications changes due to liver and kidney changes. Things slow down. We can accumulate medications in our bodies due to slower clearing rates. That's why seniors are especially vulnerable to the effects of various medications.

 

Fi, there should always be informed consent, but as you know, most of us didn't get the opportunity to weigh the risks and benefits of the medications we were prescribed because doctors and pharmacists didn't explain those things to us. That was their responsibility.

 

Benzos are only indicated for two to four weeks of use, but most of us were on them much longer than that. We should all have been warned of the dangers of being on these medications for long periods of time. I, for one, was not. I was also on multiple medications, and the interactions between those medications is likely one of the reasons that I'm dealing with such long-term effects. There were known contraindications for that polypharmacy.

 

I'm curious: When was a time frame (be it 2 to 4 weeks, 6 months or whatever), first officially associated with prescribing Valium? I have tried to search out this answer but I have been unsuccessful.

I'm not sure, but I watched the whole four hours of the Benzodiazepine Withdrawal Symposium, and the professors and researchers said there was never any study that followed people for longer than four weeks. As a result, there wasn't any clear information about what happens to people's bodies beyond that time, which is why it's so worrisome that benzodiazepines are prescribed beyond that time frame. Too many unknowns.

 

Here's a link to the Symposium. Start watching just after the 31:00 mark, where Dr. Robert Raffa begins his talk about what we do and do not know about how benzodiazepines work:

 

Another link which may be of interest to people reading this thread:

 

"The 2019 American Geriatrics Society Updated Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults"

 

https://consultgeri.org/try-this/general-assessment/issue-16 

But they said something in the symposium about the Beers list - it seems that I remember someone commenting on the fact that doctors don't read it. This was in connection with benzos.

I'm not sure, but I watched the whole four hours of the Benzodiazepine Withdrawal Symposium, and the professors and researchers said there was never any study that followed people for longer than four weeks. As a result, there wasn't any clear information about what happens to people's bodies beyond that time, which is why it's so worrisome that benzodiazepines are prescribed beyond that time frame. Too many unknowns.

 

Here's a link to the Symposium. Start watching just after the 31:00 mark, where Dr. Robert Raffa begins his talk about what we do and do not know about how benzodiazepines work:

 

 

Thank you for the link, Lapis! I was trying to find it so I could send it to Rep. Ullman in Pennsylvania.

But they said something in the symposium about the Beers list - it seems that I remember someone commenting on the fact that doctors don't read it. This was in connection with benzos.

 

Is it not REQUIRED READING for all prescribers?? 

But they said something in the symposium about the Beers list - it seems that I remember someone commenting on the fact that doctors don't read it. This was in connection with benzos.

 

Is it not REQUIRED READING for all prescribers?? 

 

I'm just sharing information here in response to your question. I'm not trying to be critical:

 

"The Beers Criteria are intended to serve as a guide for clinicians and not as a substitute for professional judgment in prescribing decisions."

 

https://en.wikipedia.org/wiki/Beers_criteria

But they said something in the symposium about the Beers list - it seems that I remember someone commenting on the fact that doctors don't read it. This was in connection with benzos.

 

Is it not REQUIRED READING for all prescribers?? 

 

I'm just sharing information here in response to your question. I'm not trying to be critical:

 

"The Beers Criteria are intended to serve as a guide for clinicians and not as a substitute for professional judgment in prescribing decisions."

 

https://en.wikipedia.org/wiki/Beers_criteria

 

Yes, but they should read it. The idea is to improve outcomes and prevent harm.

 

TARGET POPULATION: The AGS Beers Criteria® are to be used in the care of older adults >65 years of age in all ambulatory, acute, and institutional care settings. The overall intent is to improve outcomes, such as medication selection and education of interprofessionals, older adults, and caregivers, while preventing unintended harms, such as use of potentially inappropriate medications and adverse drug events.

Lapis, where is the actual list that shows all the drugs? Or am I missing something?

 

It has to be up to us to bring in the list to doctors. I guess they're too busy to look it up themselves.

Lapis, I believe this list was updated in 2019 along with some caveats regarding the use of this list among medical professionals and the patients they serve.

Here's the 2012 list:

 

https://www.bcbsm.com/content/dam/public/Providers/Documents/help/ags-beers-criteria-2012.pdf 

 

And some info on updates:

 

https://www.ncbi.nlm.nih.gov/pubmed/30693946

 

https://consultgeri.org/try-this/general-assessment/issue-16

 

 

This "Intended Use" information, which precedes the Beers List, is especially important:

 

INTENDED USE

The goal of this clinical tool is to improve care of older adults by reducing their exposure to Potentially Inappropriate Medications (PIMs). 

-This should be viewed as a guide for identifying medications for which the risks of use in older adults outweigh the benefits.

-These criteria are not meant to be applied in a punitive manner.

-This list is not meant to supersede clinical judgment or an individual patient’s values and needs. Prescribing and managing disease conditions should be individualized and involve shared decision-making.

-These criteria also underscore the importance of using a team approach to prescribing and the use of non-pharmacological approaches and of having economic and organizational incentives for this type of model.

-Implicit criteria such as the STOPP/START criteria and Medication Appropriateness Index should be used in a complementary manner with the 2012 AGS Beers Criteria to guide clinicians in making decisions about safe medication use in older adults.

 

The criteria are not applicable in all circumstances (eg, patient’s receiving palliative and hospice care). If a clinician is not able to find an alternative and chooses to continue to use a drug on this list in an individual patient, designation of the medication as potentially inappropriate can serve as a reminder for close monitoring so that the potential for an adverse drug effect can be incorporated into the medical record and prevented or detected early.