Elsevier

The Lancet

Volume 370, Issue 9582, 14–20 July 2007, Pages 173-184
The Lancet

Series
Appropriate prescribing in elderly people: how well can it be measured and optimised?

https://doi.org/10.1016/S0140-6736(07)61091-5Get rights and content

Summary

Prescription of medicines is a fundamental component of the care of elderly people, and optimisation of drug prescribing for this group of patients has become an important public-health issue worldwide. Several characteristics of ageing and geriatric medicine affect medication prescribing for elderly people and render the selection of appropriate pharmacotherapy a challenging and complex process. In the first paper in this series we aim to define and categorise appropriate prescribing in elderly people, critically review the instruments that are available to measure it and discuss their predictive validity, critically review recent randomised controlled intervention studies that assessed the effect of optimisation strategies on the appropriateness of prescribing in elderly people, and suggest directions for future research and practice.

Introduction

Prescription of medicines is a fundamental component of the care of elderly people. Several characteristics of ageing and geriatric medicine affect medication prescribing for these people and render the selection of appropriate pharmacotherapy a challenging and complex process. Interindividual variability in health, disease, and disability increases substantially with ageing, which is a gerontological principle known as aged heterogeneity.2 This heterogeneity means that the health status of elderly people ranges widely from those who are fit to those who are frail, which makes generalisation of prescribing decisions difficult for clinicians.

Although there are increasing numbers of fit, healthy elderly people, there are also increasing numbers of those who are vulnerable and frail and have limited physiological reserve, reduced homoeostasis, dysregulations in immune and inflammation mechanisms, several comorbidities, and take many drugs.3, 4 These individuals claim a disproportionate share of medical care and medication use and make prescribing decisions complex. Some syndromes related to age, especially cognitive impairment, affect the ability of elderly people to engage with health services. For example, elderly people with dementia have increased difficulty with taking drugs, and dementia impedes their ability to make autonomous decisions about their medicines. Finally, frail elderly people have age-related impairments in the hepatic metabolism and renal clearance of medications, and enhanced pharmacodynamic sensitivity to specific drugs.5

Evidence suggests that the use of drugs in elderly people is often inappropriate partly because of the complexities of prescribing as well as other patient, provider, and health-system factors. Inappropriate prescribing can cause substantial morbidity, and represents a clinical and economic burden to patients and society.6, 7, 8 Inappropriate prescribing in elderly people has therefore become an important public-health issue worldwide.

In this review we aim to define and categorise appropriate prescribing in elderly people, critically review the instruments that are available to measure it and discuss their predictive validity, critically review recent randomised controlled intervention studies that assessed the effect of optimisation strategies on the appropriateness of prescribing in elderly patients, and suggest directions for future research and practice.

Section snippets

Definition and categories of appropriate prescribing

What is appropriate prescribing and how is it different for elderly people? Appropriate prescribing is a general phrase encompassing and compressing a range of values and behaviours to express in a simple term the quality of prescribing. Many other words are used to describe prescribing quality, such as good, poor, appropriate or inappropriate, optimal or suboptimal, and error. Additionally, some terms are specific to some types of inappropriateness—eg, underprescribing refers to failure to

Measures of appropriateness of prescribing

Appropriateness of prescribing can be assessed by process or outcome measures that are explicit (criterion-based) or implicit (judgment-based).12 Process measures assess whether the prescription accords with accepted standards—they are direct measures of performance.13, 14 However, they might be costly to apply, and might not have face validity for patients.14 Also, to be valid, process measures should have causal links to important outcomes.15 Outcome measures are indicators of adverse

Approaches for optimisation of prescribing

Approaches for optimisation of prescribing in younger patients might not be applicable to frail, elderly patients. Older patients usually have several comorbidities, associated polymedication, and objectives of treatment that may differ from that of younger adults. The application of guidelines for specific chronic disorders is not always suited to this older population,95, 96 and enrolment in several separate programmes for the management of multiple disease (eg, diabetes, heart failure) might

References (154)

  • RR Aparasu et al.

    Prevalence, correlates, and associated outcomes of potentially inappropriate psychotropic use in the community-dwelling elderly

    Am J Geriatr Pharmacother

    (2004)
  • GG Fillenbaum et al.

    Impact of inappropriate drug use on health services utilization among representative older community-dwelling residents

    Am J Geriatr Pharmacother

    (2004)
  • E Rahme et al.

    Impact of a general practitioner educational intervention on osteoarthritis treatment in an elderly population

    Am J Med

    (2005)
  • A Donabedian

    The quality of care. How can it be assessed?

    JAMA

    (1988)
  • EA Nelson et al.

    Aged heterogeneity: fact or fiction? The fate of diversity in gerontological research

    Gerontologist

    (1992)
  • L Fried et al.

    Frailty and failure to thrive

  • KW Woodhouse et al.

    Frailty and ageing

    Age Ageing

    (1997)
  • AA Mangoni et al.

    Age-related changes in pharmacokinetics and pharmacodynamics: basic principles and practical applications

    Br J Clin Pharmacol

    (2004)
  • JH Gurwitz et al.

    Improving medication prescribing and utilization in the nursing home

    J Am Geriatr Soc

    (1990)
  • JT Hanlon et al.

    Suboptimal prescribing in older inpatients and outpatients

    J Am Geriatr Soc

    (2001)
  • W Simonson et al.

    Medication-related problems in the elderly: defining the issues and identifying solutions

    Drugs Aging

    (2005)
  • A Cribb et al.

    Prescribers, patients and policy: the limits of technique

    Health Care Anal

    (1997)
  • N Barber et al.

    Measuring the appropriateness of prescribing in primary care: are current measures complete?

    J Clin Pharm Ther

    (2005)
  • RH Brook

    Quality-can we measure it

    N Engl J Med

    (1977)
  • T Higashi et al.

    Quality of care is associated with survival in vulnerable older patients

    Ann Intern Med

    (2005)
  • SM Campbell et al.

    Consensus methods in prescribing research

    J Clin Pharm Ther

    (2001)
  • GM Anderson et al.

    Auditing prescription practice using explicit criteria and computerized drug benefit claims data

    J Eval Clin Pract

    (1997)
  • CM Boyd et al.

    Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance

    JAMA

    (2005)
  • ME Tinetti et al.

    Potential pitfalls of disease-specific guidelines for patients with multiple conditions

    N Engl J Med

    (2004)
  • MH Beers et al.

    Explicit criteria for determining inappropriate medication use in nursing home residents. UCLA Division of Geriatric Medicine

    Arch Intern Med

    (1991)
  • MH Beers

    Explicit criteria for determining potentially inappropriate medication use by the elderly. An update

    Arch Intern Med

    (1997)
  • DM Fick et al.

    Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts

    Arch Intern Med

    (2003)
  • PJ McLeod et al.

    Defining inappropriate practices in prescribing for elderly people: a national consensus panel

    CMAJ

    (1997)
  • CT Naugler et al.

    Development and validation of an improved prescribing in the elderly tool

    Can J Clin Pharmacol

    (2000)
  • CA Oborne et al.

    Development of prescribing indicators for elderly medical inpatients

    Br J Clin Pharmacol

    (1997)
  • NJ MacKinnon et al.

    Preventable drug-related morbidity in older adults. 1. Indicator development

    J Managed Care Pharm

    (2002)
  • CJ Morris et al.

    Preventing drug-related morbidity—determining valid indicators

    Int J Qual Health Care

    (2002)
  • D Fialova et al.

    Potentially inappropriate medication use among elderly home care patients in Europe

    JAMA

    (2005)
  • G Onder et al.

    Inappropriate medication use among hospitalized older adults in Italy: results from the Italian Group of Pharmacoepidemiology in the Elderly

    Eur J Clin Pharmacol

    (2003)
  • N Steel et al.

    Developing quality indicators for older adults: transfer from the USA to the UK is feasible

    Qual Saf Health Care

    (2004)
  • MN Marshall et al.

    Can health care quality indicators be transferred between countries?

    Qual Saf Health Care

    (2003)
  • A Elliott et al.

    Indicators of prescribing quality for elderly hospital inpatients

    Aust J Hosp Pharm

    (2001)
  • BA Briesacher et al.

    The quality of antipsychotic drug prescribing in nursing homes

    Arch Intern Med

    (2005)
  • CA Oborne et al.

    An indicator of appropriate neuroleptic prescribing in nursing homes

    Age Ageing

    (2002)
  • TJ Bungard et al.

    Underutilisation of ACE inhibitors in patients with congestive heart failure

    Drugs

    (2001)
  • DT Ko et al.

    Quality of care and outcomes of older patients with heart failure hospitalized in the United States and Canada

    Arch Intern Med

    (2005)
  • SB Soumerai et al.

    Adverse outcomes of underuse of beta-blockers in elderly survivors of acute myocardial infarction

    JAMA

    (1997)
  • SE Andrade et al.

    Low frequency of treatment of osteoporosis among postmenopausal women following a fracture

    Arch Intern Med

    (2003)
  • G Mendelson et al.

    Underutilization of warfarin in older persons with chronic nonvalvular atrial fibrillation at high risk for developing stroke

    J Am Geriatr Soc

    (1998)
  • J Unutzer et al.

    Pharmacotherapy of pain in depressed older adults

    J Am Geriatr Soc

    (2004)
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