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Drug Prescription Appropriateness in the Elderly: an Italian Study

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Drug Prescription Appropriateness in the Elderly: an Italian Study Journal name: Clinical Interventions in Aging Article Designation: Original Research Year: 2017 Volume: 12 Clinical Interventions in Aging Dovepress Running head verso: Allegri et al Running head recto: Drug appropriateness in the elderly open access to scientific and medical research DOI: http://dx.doi.org/10.2147/CIA.S109125 Open Access Full Text Article ORIGINAL RESEARCH Drug prescription appropriateness in the elderly: an Italian study Nicola Allegri1 Purpose: Correct drug prescription in the elderly is a difficult task that requires careful survey Federica Rossi2 of the current pharmacological therapies. In this article, we reviewed the drug prescriptions Federica Del Signore2 provided to 860 persons aged 65 years or over, residing in a small city of Lombardy, Italy. Paolo Bertazzoni3 Methods: Subjects were recruited from a local nursing home, the Pavia and Vigevano Neu- Roberto Bellazzi4 ropsychological Center for Alzheimer’s Disease, general practitioners’ offices, and the local Giorgio Sandrini5 University of the Third Age. For each patient, the amount of potentially inappropriate pre- scriptions (PIPs), sedative and anticholinergic load (SL and AL, respectively), and drug–drug Tomaso Vecchi1 interactions were evaluated. Davide Liccione1 Results: Widespread polypharmacy, giving rise to 10.06% of PIPs in the whole collection of 6 Alessia Pascale prescriptions, was observed. In particular, PIPs mainly concern drugs acting at the central nervous 6 Stefano Govoni system level, mostly benzodiazepines and antipsychotics. Moreover, approximately one-fourth of 1 For personal use only. Department of Brain and Behavioral the subjects had an elevated SL and approximately one-tenth a high AL. Drug–drug interactions 2 Sciences, University of Pavia, Pavia were frequent (266 requiring medical attention), up to five for each single patient. Of concern and Vigevano Neuropsychological Center for Alzheimer’s Disease, was the underuse of antidementia drugs: only 20 patients received a cholinesterase inhibitor or 3”Bertazzoni” Pharmacy General memantine, although 183 patients were potentially suitable for this treatment. 4 Partnership, Vigevano, Nephrology These results demonstrate the need to develop novel strategies aimed at improv- and Dialysis Ward, Civil Hospital Conclusion: of Vigevano, 5C. Mondino National ing the quality of drug prescription. Institute of Neurology Foundation, Keywords: drug prescription, elderly, Beers criteria, drug–drug interactions, sedative load IRCCS, 6Department of Drug Sciences, Section of pharmacology, University of Pavia, Pavia, Italy Introduction Drug prescription inappropriateness represents an issue of major interest in clinical practice, since it increases the prevalence of drug-induced harms, with consequences Clinical Interventions in Aging downloaded from https://www.dovepress.com/ by 54.70.40.11 on 27-Oct-2019 related to patients’ health1 and cost of care.2 This is particularly true for elderly people, whose frailty makes the choice of the correct drug prescription even more difficult.3 Appropriateness can be assessed by measuring explicit (criterion-based) or implicit (judgment-based) outcomes.4,5 In this regard, international explicit criteria have been developed to assess the pertinence of medications in the elderly, such as the Beers cri- teria, which was recently updated by the American Geriatrics Society,6–8 or the STOPP (Screening tool of older person’s prescriptions)/START (Screening tool to alert doctors to right treatment).9 These measures mainly take into account the relationship between a particular drug and the specific medical case. However, it should be stressed that the 10 Correspondence: Nicola Allegri evaluation of prescription appropriateness in the elderly represents a complex issue Pavia and Vigevano Neuropsychological that should also include other clinical dimensions, such as the amount of prescribed Center for Alzheimer’s Disease, drugs,11 drug–drug interactions,12 and the potential sedative and anticholinergic effects Via Sacchetti 1, 27029, Vigevano, Pavia, Italy of the prescribed drugs.13,14 Tel +39 381 23709 473 In this context, the aim of the present work was to evaluate the appropriateness of drug Fax +39 381 82225 Email [email protected] prescription using the Beers criteria and including the assessment of the aforementioned submit your manuscript | www.dovepress.com Clinical Interventions in Aging 2017:12 325–333 325 Dovepress © 2017 Allegri et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you http://dx.doi.org/10.2147/CIA.S109125 hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php). Powered by TCPDF (www.tcpdf.org) 1 / 1 Allegri et al Dovepress aspects in a group of 860 persons, aged 65 years, residing When applying the Beers criteria, specific care was taken in a small city of Lombardy, Italy. regarding the diagnosis of the patient. Methods Sedative load definition As a part of a larger epidemiological study, neuropsycholo- The sedative load (SL) was calculated for each subject gists administered an anonymous questionnaire regarding according to a published model.13 Medications were classified prescribed medicines to 860 subjects. The study participants as follows: Group 1, primary sedatives; Group 2, medications were divided into three groups: 1) belonging to a local nursing with sedation as a prominent side effect or preparations with home (NH patients – n=142); 2) coming to the local memory a sedating component; Group 3, medications with sedation as clinic (MC; Pavia and Vigevano Neuropsychological a potential adverse effect; Group 4, all the other medications Center – Alzheimer Section) for a neurological examination with no known sedative properties. (MC patients – n=572); 3) volunteer subjects (VS patients – n=146), mainly recruited at the local University of the Third Anticholinergic load definition Age, at general practitioners’ offices or in other community The AL was calculated according to the scoring system of the centers. The questionnaire included the age of the patient Anticholinergic Drug Scale.17 On the Anticholinergic Drug (in years), sex, Mini-Mental State Examination (MMSE) Scale, drugs are rated from 0 to 3, with level zero indicating score, current illnesses and treatments. MMSE was assessed no anticholinergic activity, and level 3 indicating an elevated according to the Folstein and McHugh method,15 as adapted anticholinergic activity. The anticholinergic scores relative for the Italian population16 (range 0–30; normal range 24). to each drug taken by the patient were summed up to obtain The results on drug use were correlated with the demographic the total score. and clinical data. The demographic characteristics, which referred to both the whole sample and the subgroups, are Drug interactions reported in Table 1. Figures 1 and 2 give a more detailed Drug interactions were evaluated using the Drug Interac- For personal use only. picture of the heterogeneity, in terms of age and MMSE, tions Checker program available at the website (www. of the participants coming for a neurological examination drugs.com/drug_interactions.html) and further checked by a to the local MC. pharmacologist employing the Stockley’s Drug Interactions18 international source. Appropriateness of the prescription Appropriateness of the prescription was analyzed by the use Statistics of the Beers criteria.8 In case of molecules available on the Drugs were classified according to the Anatomical Thera- Italian market, but not included in the American Geriatrics peutic Chemical (ATC) code, data were collected in an ad Society list of medications, the drug was evaluated (ie, in hoc created database and analyzed using the SPSS software terms of class, pharmacokinetics) and classified by the team version 15.0 (SPSS Inc., Chicago, IL, USA).19 Mean and stan- Clinical Interventions in Aging downloaded from https://www.dovepress.com/ by 54.70.40.11 on 27-Oct-2019 of pharmacologists. dard deviation were calculated for each variable. For some Table 1 Demographic characteristics of the patients Groups Sex Age Education MMSE Number of Number of (years) illnesses (range) prescriptions Whole sample Males: 295 80.36±7.36 4.79±1.4 23.82±5.48 3.91±2.17 5.91±3.46 n=860 Females: 565 NH patients Males: 43 83.5±7.5a 5.01±1.20b 22.31±5.92c 3.65±1.93 7.89±3.92e n=142 Females: 99 MC patients Males: 185 80.65±7.52a 4.94±1.32b 22.91±5.91c 4.16±2.22d 5.81±3.16e n=572 Females: 387 VS Males: 67 76.16±7.19a 4.00±1.59b 28.33±2.31c 3.20±2.03d 4.36±3.24e n=146 Females: 79 Notes: The table reports the main clinical–demographical data of the subjects recruited in this study, including the number of males and females, age, years of education, MMSE score, number of illnesses and prescriptions, all expressed as mean ± SD. aP0.001: among all the three groups, bP0.001: between NH patients and VS subjects and between MC patients and VS subjects, cP0.001: between NH patients and VS subjects and between MC patients and VS subjects, dP0.001: between MC patients and VS subjects, eP0.001:
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