Hospitals often fail to follow criteria when prescribing for the elderly
Pharmacist leaders should address problem
Hospitalized elderly patients too often have falls, delirium, and other health issues that are caused by medications that should not have been prescribed to them, experts and research suggest.
For nearly 20 years physicians, pharmacists, and hospitals have had access to a well-researched medication list, called the Beers Criteria. The list details which drugs should not be given to elderly patients for safety reasons.
The Centers for Medicare & Medicaid Services (CMS) adopted the Beers Criteria for nursing home regulation more than a decade ago.
Yet many physicians in hospitals continue to make medication decisions that run counter to the Beers Criteria recommendations, experts say.
"This continues to be a sleeper issue," says Jeffrey Delafuente, MS, RPh, FCCP, FASCP, professor and associate dean for professional education at Virginia Commonwealth University School of Pharmacy in Richmond, VA.
"The first Beers list came out in 1991 as part of a research study, and then it evolved into a clinical tool," Delafuente says. "Despite dozens of studies, the prevalence of hospitals using these drugs hasn't changed much."
As the first Baby Boomers turn 65 next year, this likely will become a huge issue unless hospitals start doing a better job of medicating the elderly, he notes.
Also, the new Patient Protection and Affordable Care Act requires prescription drug plans to enhance medication therapy management (MTM) programs, which will shed light on elderly patients' medications and side effects.
Research suggests that it's time for hospitals to change their medication prescription habits when it comes to elderly patients, focusing on the philosophy that less is more in drug therapy. Pharmacists should lead the effort through their pharmacy and therapy (P&T) committees.1,2,3,4
The first step is to take the seven-year-old revised version of the Beers Criteria and turn it into hospital policy because patients' lives, as well as health systems' quality of care and efficiency are at stake.
CMS is pushing for more medication therapy management because MTM is seen as a way to save costs, Delafuente says.
"If you can keep people healthy by using the appropriate drugs, then there are fewer hospital visits, fewer physician visits, and better outcomes," he adds.
Nursing homes no longer prescribe drugs on the list because of CMS' action, but other providers serving the elderly have not followed suit.
"I talk with physicians who say, 'I've been using these drugs for years, but I've never had a problem,'" Delafuente says. "I think they've got a problem, but have not recognized it because the symptoms can be subtle, and doctors will attribute them to old age."
One problem is there are too few good medications for people who are confused or demented, and hospitalization can be very troubling for elderly patients, says Melissa L. P. Mattison, MD, an instructor in medicine at Harvard Medical School and Beth Israel Deaconess Medical Center in Boston, MA.
"Older patients might be barely functioning at home, and then they get sick and end up in the hospital where they stay in bed all day and have further functional decline," Mattison says. "Their muscles get weak and if they're a little demented to begin with and not in a familiar surrounding, then they don't know where they are and which day it is."
These factors make diagnoses and prescribing challenging for physicians.
Beth Israel Deaconess Medical Center is addressing this issue with a new computerized warning system that is programmed to show providers the Beers Criteria whenever they select a medication that is not advisable for elderly patients.
"I worked with a pharmacist and computer programmer, and we went through a list of medications, picking which medications were on our formulary and which were commonly ordered in an inpatient setting," Mattison says.
"Whenever a provider picks one of these selected medications, the warning system displays the Beers article and advises caution," she adds.
Physicians can override the electronic warning, but many won't, Mattison says.
Beth Israel Deaconess Medical Center has started a new initiative that will address the needs of older hospital patients, Mattison says.
"We have the support of the hospital leadership," she adds. "What I'd like to see happen is for us to be a testing ground for things that work."
The medication warning system is one example, but clinicians have some other ideas, as well. One other program involved modifying antipsychotic medications in older patients, she says.
Pharmacy leaders should start any project to change medication prescribing among the elderly by reading the Beers Criteria, he notes.
The actual list can be found very easily with an online search, and it's also listed in Wikipedia under "Beers Criteria." When printed out, it takes just one-and-one-half pages. The online versions often have links to additional information about the drugs on the list.
The 2003 revised Beers Criteria should be required reading for any health care professional involved in treating elderly patients with medications, Delafuente says.
Pharmacy leaders should compare the Beers list against prescribing habits in their hospitals and with the P&T committee's formulary, he suggests.
"A lot of older drugs are the cheaper drugs that tend to make it to the formulary because they're cheap, and those are the same drugs that can cause a lot of problems for older people," Delafuente says. "So I think the P&T committee needs to look carefully at whether they have good alternatives drugs in their formulary for the geriatric patient."
The next step is to read the literature and identify newer drugs that also cause problems for elderly patients, and then add these to the list of medications to avoid.
"The revised Beers Criteria was from work done in 2002, and we've had a lot of drugs come out since then," Delafuente says. "So I teach pharmacy and medical students that you could follow the principles that go into the Beers list and apply these to any drug on the market."
References
- Barnett SR. Polypharmacy and perioperative medications in the elderly. Anesthesiol Clin. 2009;27(3):377-389.
- Delafuente JC. Pharmacokinetic and pharmacodynamic alterations in the geriatric patient. Consult Pharm. 2008;23(4):324-334.
- Boockvar KS, Liu S, Goldstein N, et al. Prescribing discrepancies likely to cause adverse drug events after patient transfer. Qual Saf Health Care. 2009;18(1):32-36.
- Mattison MLP, Afonso KA, Ngo LH, et al. Preventing potentially inappropriate medication use in hospitalized older patients with a computerized provider order entry warning system. Arch Intern Med. 2010;170(15):1331-1336.
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