Magazine article Drug Topics

Inappropriate Prescribing in Geriatric Patients: Dementia and Falls Prevention

Magazine article Drug Topics

Inappropriate Prescribing in Geriatric Patients: Dementia and Falls Prevention

Article excerpt

Adverse drug events (ADEs) have a profound impact on morbidity, mortality, and the healthcare economy, particularly among the older population. In the general hospitalization population in 2000, an estimated 2,216,000 ADEs resulted in $85 billion in expenses and 106,000 deaths. If ranked as a discrete disease, medication-related problems would rank as the fifth most common cause of death in this country, according to the Institute of Safe Medication Practices.

The United States is concomitantly experiencing a steady rise in its geriatric population (patients > 65 years). In 2000, geriatric patients comprised 12.4% of the population. By 2030, this will increase to 19.6% and will double in the next 75 years. Geriatric patients, with their age-related changes in physiology and increased number of prescribed drugs, are particularly vulnerable to ADEs. Approximately 35% of ambulatory older patients experience an ADE, and 29% of these require intervention by the healthcare system. Two-thirds of nursing home residents experience an ADE over a fouryear period, and one in seven of these results in hospitalization.

In order to prevent an escalation in ADEs, evidence-based guidelines for appropriate medication use in geriatric patients are necessary. Unfortunately, few well-designed studies exist that clearly document ADEs in the elderly. Several groups have devised guidelines based upon review of the current literature and consensus opinion. The bestknown of these are the Beers criteria, which were originally released in 1991 and updated in 1997 and 2003 (Table 1). The purpose of the criteria was to give general guidance and be updated to become more evidence-based as data became available. The lack of evidence to support the guidelines has sparked debate as to how useful the guidelines are. Using delirium and falls as example ADEs, this article will examine the evidence supporting or refuting the guidelines.

Who is at risk?

In one survey of 18 nursing homes, ADEs occurred at a rate of 1.89 per 100 resident-months, and 0.96 of these were preventable. Of the preventable ADEs, 38.1% were deemed significant, 51.3% serious, 10.2% lifethreatening, and one ADE was fatal. Neuropsychiatrie effects occurred in 28.8%, followed by falls in 19.9%, hemorrhages in 14.6%, and gastrointestinal manifestations in 11.1%. Risk factors that independently increase the risk for any ADE among nursing home residents include: recent nursing home admission (less man one to two months), more than five scheduled medications, and current treatment with an antibiotic/anti-infective, antipsychotic, or antidepressant. Additional risk factors in preventable ADEs included higher illness burden, immobility, lack of nutrients or supplements, and active treatment with anticoagulants, antiseizure medications, cardiovascular drugs, hypoglycemics, opioids, and/or sedatives or hypnotics. Men were less likely than women to have a preventable ADE.

Case example ADEs: Delirium and falls

As demonstrated in the above epidemiologic study, neuropsychiatric symptoms and falls were the most common ADEs. The two are also intertwined, because psychomotor function depends in part upon cognitive function. Patients with conditions that affect gait, such as Parkinson's disease, Lewy-body dementia, or cerebrovascular accident are at an increased risk for falling. Patients with Alzheimer's disease have a relative risk of fracturing a hip of 2.7 (CI [confidence interval] 1.8-4.2) within the first year of diagnosis, and it occurs at three times the rate of controls.

Delirium is an acute confusional state. It frequently goes unrecognized in geriatric patients and is often misdiagnosed as dementia, depression, or a part of the aging process. More than two million geriatric patients experience delirium annually, at a cost to Medicare of $4 billion. The mortality from any condition doubles when delirium is present and may be as high as 76% in hospitalized patients. …

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