Geriatrics and gerontology special section
Review
Minimizing Inappropriate Medications in Older Populations: A 10-step Conceptual Framework

https://doi.org/10.1016/j.amjmed.2011.09.021Get rights and content

Abstract

The increasing burden of harm resulting from the use of multiple drugs in older patient populations represents a major health problem in developed countries. Approximately 1 in 4 older patients admitted to hospitals are prescribed at least 1 inappropriate medication, and up to 20% of all inpatient deaths are attributable to potentially preventable adverse drug reactions. To minimize this drug-related iatrogenesis, we propose a quality use of medicine framework that comprises 10 sequential steps: 1) ascertain all current medications; 2) identify patients at high risk of or experiencing adverse drug reactions; 3) estimate life expectancy in high-risk patients; 4) define overall care goals in the context of life expectancy; 5) define and confirm current indications for ongoing treatment; 6) determine the time until benefit for disease-modifying medications; 7) estimate the magnitude of benefit versus harm in relation to each medication; 8) review the relative utility of different drugs; 9) identify drugs that may be discontinued; and 10) implement and monitor a drug minimization plan with ongoing reappraisal of drug utility and patient adherence by a single nominated clinician. The framework aims to reduce drug use in older patients to the minimum number of essential drugs, and its utility is demonstrated in reference to a hypothetic case study. Further studies are warranted in validating this framework as a means for assisting clinicians to make more appropriate prescribing decisions in at-risk older patients.

Section snippets

Proposed Multi-Step Framework for Optimizing Prescribing Quality

We propose a 10-step framework for optimizing medication prescribing in individual older patients that addresses the decision-making needs of clinicians identified in other studies (Table 1).22, 23 Each step in the framework is based on a search of relevant literature and captures, in a logical sequence, issues that have been raised in other frameworks24, 25 but that, to date, have not been synthesized into one integrated schema. The aim of the framework is to rationalize drug use and reduce

Conclusions

Our framework encourages a systematic approach to medication use aimed at selecting the right drug at the right dose for clear-cut clinical indications determined on a case-by-case basis. This framework draws attention to the dangers of therapeutic inertia, whereby drugs continue to be prescribed in the absence of any periodic review of continuing indication or net benefit, and therapeutic momentum, where more drugs are added in response to new but questionable indications, including treatment

References (79)

  • J.T. Hanlon et al.

    Adverse drug events in high risk older outpatients

    J Am Geriatr Soc

    (1997)
  • H.J.M. Beijer et al.

    Hospitalisations caused by adverse drug reactions (ADRs): a meta-analysis of observational studies

    Pharm World Sci

    (2002)
  • J. Doucet et al.

    Preventable and non-preventable risk factors for adverse drug events related to hospital admissions in the elderlyA prospective study

    Clin Drug Invest

    (2002)
  • A.J. Leendertse et al.

    Frequency of and risk factors for preventable medication-related hospital admission in the Netherlands

    Arch Intern Med

    (2008)
  • D.M. Fick et al.

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

    Arch Intern Med

    (2003)
  • S.M. Willcox et al.

    Inappropriate drug prescribing for the community-dwelling elderly

    JAMA

    (1994)
  • P.F. Gallagher et al.

    Inappropriate prescribing in an acutely ill population of elderly patients as determined by Beers' Criteria

    Age Ageing

    (2008)
  • E. Somers et al.

    Quality use of medicines in residential aged care

    Aust Fam Phys

    (2010)
  • G. Onder et al.

    Development and validation of a score to assess risk of adverse drug reactions among in-hospital patients 65 years or olderThe gerontoNet adverse drug reactions risk score

    Arch Intern Med

    (2010)
  • S.N. Hilmer et al.

    The effects of polypharmacy in older adults

    Clin Pharmacol Ther

    (2009)
  • C.M. Boyd et al.

    Clinical practice guidelines and quality of care for older patients with multiple comorbid diseasesImplications for pay for performance

    JAMA

    (2005)
  • I.A. Scott et al.

    Cautionary tales in the interpretation of clinical studies involving older persons

    Arch Intern Med

    (2010)
  • N.S. Beckett et al.

    Treatment of hypertension in patients 80 years of age and older

    N Engl J Med

    (2008)
  • V.M. Musini et al.

    Pharmacotherapy for hypertension in the elderly

    Cochrane Database Syst Rev

    (2009)
  • S.P. Fitzgerald et al.

    Patient attitudes to commonly promoted medical interventions

    Med J Aust

    (2000)
  • B.G. Fincke et al.

    The interaction of patient perception of overmedication with drug compliance and side effects

    J Gen Intern Med

    (1998)
  • T.R. Fried et al.

    Effects of benefits and harms on older persons' willingness to take medication for primary cardiovascular prevention

    Arch Intern Med

    (2011)
  • T.R. Fried et al.

    Primary care clinicians' experiences with treatment decision making for older persons with multiple conditions

    Arch Intern Med

    (2011)
  • L. Fraenkel et al.

    Individualised medical decision making: necessary, achievable, but not yet attainable

    Arch Intern Med

    (2010)
  • M. Pollock et al.

    Appropriate prescribing of medications: an eight-step approach

    Am Fam Physician

    (2007)
  • M.A. Steinman et al.

    Managing medications in clinically complex elders“There's got to be a happy medium”

    JAMA

    (2010)
  • I. Bayoumi et al.

    Interventions to improve medication reconciliation in primary care

    Ann Pharmacother

    (2009)
  • I. Klarin et al.

    The association of inappropriate drug use with hospitalisation and mortality: a population-based study of the very old

    JAMA

    (2005)
  • T.S. Field et al.

    Risk factors for adverse drug events among nursing home residents

    Arch Intern Med

    (2001)
  • R.S. Evans et al.

    Risk factors for adverse drug events: a 10 years analysis

    Ann Pharmacother

    (2005)
  • H.G. Welch et al.

    Estimating treatment benefits for the elderly: the effect of competing risks

    Ann Intern Med

    (1996)
  • S.J. Lee et al.

    Development and validation of a prognostic index for 4-year mortality in older adults

    JAMA

    (2006)
  • E.C. Carey et al.

    Prediction of mortality in community-living frail elderly people with long term care needs

    J Am Geriatr Soc

    (2008)
  • B.C. Huyhn et al.

    Identification of older patients with heart failure who may be candidates for hospice care: development of a simple four-item risk score

    J Am Geriatr Soc

    (2008)

    • Cited by (91)

    • Pharmacist-led home medication review for older adults: A stepwise process and an algorithm for face-to-face or online approach

      2023, Research in Social and Administrative Pharmacy

    • Polypharmacy, inappropriate prescribing, and deprescribing in older people: through a sex and gender lens

      2021, The Lancet Healthy Longevity
      Citation Excerpt :

      Discontinuing or reducing the dose of the initial drug therapy could avoid or reverse these cascades. The prescribing cascade has been incorporated into many deprescribing protocols,65,78,79 and process mapping can be used by clinicians to identify prescribing cascades in their patients.80 Further, researchers have reported that there are five key factors for physicians to consider with regard to prescribing cascades.81

    • Polypharmacy in Older Adults: Practical Applications Alongside a Patient Case

      2020, Journal for Nurse Practitioners
      Citation Excerpt :

      Many of these algorithms or questionnaires require more judgment because they do not provide any drug-specific information. Some examples of these include The Good Palliative-Geriatric Practice Algorithm,30 Medication Appropriateness Index,31 and the 10-step drug minimization guide.32 Based on the medication profile, the patient has several comorbidities for which she is taking a total of 11 different medications, 7 routine medications for the management of chronic health conditions, and 4 medications as needed for other ailments.

    • Consolidated Medication Review Algorithm to Improve Medications Use in Older Adults: Components, Scoring Scheme, and Implementation

      2018, Journal of the American Medical Directors Association

    • CONSIGNELA: A multidisciplinary patient-centered project to improve drug prescription comprehension and execution in elderly people and parkinsonian patients

      2018, Telematics and Informatics
      Citation Excerpt :

      Moreover, as they tend to suffer from several chronic diseases, they are faced with more complex medication regimens than younger patients. Medication regimen complexity increases the risk of non-adherence (Scott et al., 2012). Non-adherence averages 50% in older patients and can go up to 60% (Hawkins et al., 2013).

    • Polypharmacy and Deprescribing in Older Adults

      2024, Annual Review of Medicine
    View all citing articles on Scopus

    Michael W. Rich, MD, Section Editor

    Funding: None.

    Conflict of Interest: None.

    Authorship: All authors had access to the data and played a role in writing this manuscript.

    View full text
    Copyright © 2012 Elsevier Inc. All rights reserved.