A Study on Use of Potentially Inappropriate Medication Among Geriatrics According to Beer’s Criteria at A Teritiary Care Hospital

INTRODUCTION

Geriatrics represents the most vulnerable section of our society and tends to be the largest consumers of prescribed drugs. It is commonly observed that geriatrics suffer from multiple comorbid conditions and is also hospitalized several times, so there is an increased occur-rence of polypharmacy and drug related issues which need to be addressed.¹ The inappro-priate prescribing (IP) is a major, public health problem in older people most often resulting from defective choice of medication by the prescriber.²

Potentially inappropriate medication (PIM) is defined as “a drug in which the risk of an ad-verse event outweighs its clinical benefit, particularly when there is a safer or more effective alternate therapy for the same condition”. Many studies have shown the occurrence of ad-verse drug reactions due to potentially inappropriate medications. It is important to identify the potentially inappropriate medication use in this vulnerable group in order to minimize pharmacotherapy related hazards.³ Mark Beers emphasized the importance of prevention of adverse drug events in older adults approximately two decades ago. One of the most widely used medication criteria in the world is the BEERS CRITERIA. The Beers Criteria for the Potentially Inappropriate Medication use in older adults commonly called as Beers list is a guideline for health care professionals to help improvise on the safety of prescribing medica-tions for the older adults.⁴

There are lot of factors that affects the choice of medicines in elderly. Mainly the aging, The aging process is characterized by physiological changes, which can increase the response to both therapeutic and adverse effects of drugs. The main alterations are: reduction of hepatic clearance, glomerular filtration capacity, muscular mass, and homeostatic mechanisms. These changes can affect the pharmacokinetics and pharmacodynamics. Thus, the selection and pre-scription of drugs for this population must be done with particular care. because They are more sensitive to the effects of drugs and are at increased risk of drug related problems.⁵ Due to age related changes in the physiology of elderly, these people also experience altered pharmacokinetics and dynamics of drugs. They have multiple comorbidities and are hospita-lized more often which increases the chances of polypharmacy and inappropriate prescribing.⁶

The world’s elderly population which was 550 million in 1996 is expected to reach 1.2 billion by the year 2025.As a result of decline in birth rate and increased life expectancy, the elderly population in most countries is growing faster than the other population as a whole. Under developed nations are aging faster than their developed counterparts. India’s population aged 60 years and above, is projected to increase over the next decade from 8.3 to 10.7% accord-ing to the United Nations Population Division. This is due to increased life expectancy at birth which is 67.3 years for males and 69.6 years for females. This number may also rise by almost 3 years during the next decade. Geriatrics populations’ projection for 2050 is expected to be 324 million in India, out of 33% world population chronic problems and physiological changes to elderly attributary to various DRP. Hence the study will be carried to know PIM use in geriatrics population. In a study of 2000/2001 Medical Expenditure Panel Survey, the total estimated healthcare expenditures for the use of potentially inappropriate medications (PIMS) was $7.2 billions. Explicit criteria can identify high-risk drugs of PIMS that have been identified through expert panel review as having an unfavourable risks and benefits by themselves and considering alternative treatments available.⁷

THE AIMS OF AGS 2015 CRITERIA

The specific aim for revised version of the beers criteria 2015 was to update the 2012 AGS Beers Criteria using a comprehensive, systematic review and grading of the evidence on drug-related problems and adverse drug events in older adults. The strategies to achieve this aim were to:

• Incorporate new evidence on currently listed PIMs and evidence from new medications or conditions not addressed in the 2012 update.

• Incorporate two new areas of evidence on drug– drug interactions and dose adjustments based on kidney function for select medications.

• Grade the strength and quality of each PIM statement based on the level of evidence and strength of recommendation.

• Convene an interdisciplinary panel of 13 experts in geriatric care and pharmacotherapy who would apply a modified Delphi method to the systematic review and grading to reach consen-sus on the updated 2015 AGS Beers Criteria.

• Incorporate needed exceptions in the criteria as the panel deemed clinically appropriate.

• These exceptions would be designed to make the criteria more individualized to clinical practice and be more relevant across settings of care.8

METHODOLOGY

A prospective observational study was conducted over a period of 6 months in a tertiary care hospital. Patients admitted to the Department of Medicine, Orthopaedic and Surgery were selected randomly and followed from date of admission to date of discharge wee enrolled into the study by considering the study criteria. Patient Informed consent was taken from each patient at the time of enrollment into the study. Details regarding patient demography and medication was collected from the casesheets and noted in a suitably designed patient data collection proforma. Obtained data was analyzed to assessed potentially inappropriate medication use in geriatric population according to Beer’s criteria at the study site. Prior to the study, Institutional Ethical Committee Clearance was taken from the Institutional review Board (IRB).

RESULTS & DISCUSSION

During study period about 345 patients were analysed, among them 207(60%) patients were male and 138(40%) were female as shown in Table-1 which was similar to the study con-ducted by B CHITRA et al.Patients were categorised basedon the age they were 206(59.71%) patients were between 60-69 ,89 (25.79%) patients were between 70-79, 41(11.88%) are between 80-89 and 8(2.31%) patients were in between 90- 99,&100 age were1 (0.28%) as shown in Table-2 which was similar to the study conducted by PRAVEEN KD et al. Patients were also categorised based on length of the stay in hospital among 345prescriptions 107(31.01%) patients stayed for 1-4 days, 153(44.34%) patients were stayed for 5-9 days, 65(18.84%) patients were stayed for 10- 14 days, 16(4.63%) patients were stayed for 15-19 days & 4(1.15%) patients stayed for > 20 days ,as shown in Table-3 which was similar to the study conducted by B CHITRA et al.Out of 345 prescriptions it is found to be 188(54.49%) prescriptions were inappropriate and 157(45.50%) were appropriate prescriptionas shown in Table-5.Among 188 inappropriate prescriptions the categories of drug prescribed were benzodiazipines (12.17%), NSAIDS ( 21.73%),anti infectives (6.95%),central alpha blockers (10.72%),anti cholinergics (1.44%), anti depressants (3.76%), peripheral alpha blockers (0.57%) anti spasmodic (4.05%) anti psychotics (4.05%) anti Parkinson drugs (1.73%) anti muscuranic drugs (0.57%) non benzodiazipines (0.57%) CNS stimulants (0.28%) as shown in Table-6 which were identified as per the AGS GUIDELINES. All the 345 prescriptions were analyzed and major diagnosis were CVA, pneumonia, asthama, fibrosis, BPH, UTI, accelerated HTN, DKA, ortho fractures COPD etcas shown in Table-8 which was compared to the study conducted by B CHITRA et al. In 26 heart failure cases found with no error, among 7 seizures cases, 1 error found that using of clonzpine. where as in 5 case of delirum, 9 errors were found; clonazepam(1), quitiapine (1), lorazepam(2), midazolam(2), clobazam(1), hydrocortisone (1) &mitrazepam(1) Etc. as per the AGS GUIDELINES 2015 Table-3 in 345 prescriptions. As per AGS2015 criteria non anti infective medications that should be avoided or have their dosage reduced with varying levels of kidney function in older adults a study was done among 345 cases out of which 24 spiranolactone (<30ml/min Crcl) cases 2 errors were found. 2 amilloride(<30ml/min Crcl) cases found with no errors etc.

RESULTS

Total No. of prescriptions analysed…….......... 345

Total No. of PIMS prescribed............................. 188

Percentage of encounter................................ 54.49%

CONCLUSION

The study report shows that the prevalence of PIMs are steadily increasing. The use of inap-propriate medications can be avoided using the Beers criteria 2015, which is one of the im-portant clinical tools which can be wisely used by Physicians, Clinical pharmacist and health care providers. Beers criteria can be used as a guideline by the physicians while prescribing the drugs to the geriatric population.Before dispensing a medicine to the geriatric patient, the pharmacist should play an important role in assessing the appropriateness of the prescription so that the quality and efficacy of medical care given to geriatrics can be increased. Clinical Pharmacists can also discuss with the physician about drugs and suggest a better and a safer alternative to the geriatrics so that a proper decision is made regarding the right choice of a drug.Hence this study will help physicians and clinical pharmacists in clinical decision making in geriatrics, where better pharmaceutical care can be provided to the geriatric patients.

SUMMARY

Geriatrics represents the most vulnerable section of our society and tends to be the largest consumers of prescribed drugs.The AGS Beers Criteria are used widely in geriatric clinical care, education, and research and in development of quality indicators.Clinical pharmacist plays an important role in assessing the appropriateness of the prescription so that the quality and efficacy of medical care given to geriatrics can be increased.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

Strength of the study: The present study reviews on use of Potentially Inappropriate Medi-cation among Geriatrics according to Beer’s Criteria at the study site. The study can be uti-lized as a tool by the researchers in order to carry out the same at larger scale.

Limitations of the study: The study was conducted on a small sample size and Patients enrolled randomly therefore larger sample size would give a better outcome.