E-drug: Prescribing in the Elderly (cont)
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There are two very good papers on the general topic of inappropriate
drugs for the elderly.
1. TITLE:
Defining inappropriate practices in prescribing for elderly people: a
national consensus panel [see comments]
AUTHORS:
McLeod PJ; Huang AR; Tamblyn RM; Gayton DC
AUTHOR AFFILIATION:
Department of Medicine, McGill University, Montreal, Que.
SOURCE:
CMAJ 1997 Feb 1;156(3):385-91
CITATION IDS:
PMID: 9033421 UI: 97185740
COMMENT:
Comment in: CMAJ 1997 Jun 15;156(12):1695-6; discussion 1696, 1698
Comment in: CMAJ 1997 Jun 15;156(12):1696; discussion 1696, 1698
ABSTRACT:
OBJECTIVE: To develop a consensus-based list of inappropriate practices in
prescribing for elderly people.
DESIGN: Mail survey of a 32-member national panel.
SETTING: Academic medical centres across Canada.
PARTICIPANTS: Thirty-two specialists selected arbitrarily, including 7
clinical pharmacologists, 9 geriatricians, 8 family practitioners and 8
pharmacists.
OUTCOME MEASURES: Consensus that the practice would introduce a
substantial and significant increase in the risk of serious adverse effect
and is common enough that its curtailment would decrease morbidity among
elderly people, ranking of clinical importance of the risk, and
availability of equally or more effective and less risky alternative
therapy.
RESULTS: The 32-member national panel developed a list of 71 practices in
prescribing for elderly people and rated the clinical significanc of each
on a scale of 1 (not significant) to 4 (highly significant). The practices
in prescribing identified fell into 3 categories: drugs generally
contraindicated for elderly people,
drug- disease interactions and drug-drug interactions. The mean
significance rating was greater than 3 for 39 practices. For each practice,
alternative therapies were recommended. There was surprising congruence
among the specialists on the significance rating and the suggested
alternative therapies.
CONCLUSION: The authors have developed a valid, relevant list of
inappropriate practices in prescribing for elderly people, to be used in a
practice-based intervention study.
2. TITLE:
Inappropriate drug prescribing for thecommunity-dwelling elderly [see comments]
AUTHORS: Willcox SM; Himmelstein DU; Woolhandler S
AUTHOR AFFILIATION:
Victorian Health Department, Melbourne, Australia.
SOURCE:
JAMA 1994 Jul 27;272(4):292-6
CITATION IDS:
PMID: 8028142 UI: 94300757
COMMENT:
Comment in: JAMA 1994 Jul 27;272(4):316-7 Comment in: JAMA 1995 Feb
8;273(6):455; discussion 457-8
Comment in: JAMA 1995 Feb 8;273(6):455-6; discussion 457-8
Comment in: JAMA 1995 Feb 8;273(6):456
Comment in: JAMA 1995 Feb 8;273(6):456-7
Comment in: JAMA 1995 Feb 8;273(6):457
ABSTRACT:
OBJECTIVE--To examine the amount of inappropriate drug prescribing
forAmericans aged 65 years or older living
in the community.
DESIGN--Cross- sectional survey of a national probability sample of older
adults.
SETTING--The 1987 National Medical Expenditure Survey, a national
probability sample of the US civilian noninstitutionalized population, with
oversampling of some population groups, including the elderly.
SUBJECTS--The 6171 people aged 65 years or older in the National
Medical Expenditure Survey sample, using appropriate weighting
procedures to produce national estimates. MAIN OUTCOME MEASURES--
Incidence of prescribing 20 potentially inappropriate drugs, using explicit
criteria previously developed by 13 United States and Canadian geriatrics
experts through a modified Delphi
consensus technique. Three cardiovascular drugs identified as
potentially inappropriate were analyzed separately since they may be
considered appropriate for some noninstitutionalized elderly patients.
RESULTS--A total of 23.5% (95% confidence interval [CI], 22.4% to
24.6%) of people aged 65 years or older living in the community, or 6.64
million Americans (95% CI, 6.28 million to 7.00 million), received at
least one of the 20 contraindicated drugs. While 79.6% (95% CI, 77.2% to
82.0%) of people receiving potentially in appropriate medications received
only one such drug, 20.4% received two or more. The most commonly
prescribed of these drugs were dipyridamole, propoxyphene, amitriptyline,
chlorpropamide, diazepam, indomethacin, and chlordiazepoxide, each used by
at least
half a million people aged 65 years or older. Including the three
controversial cardiovascular agents (propranolol, methyldopa, and
reserpine) in the list of contraindicated drugs increased the incidence of
probably inappropriate medication use to 32% (95% CI, 30.7% to 33.3%), or
9.04 million people (95% CI, 8.64 million to 9.44 million).
CONCLUSION--Physicians prescribe potentially inappropriate medications for
nearly a quarter of all older people living in the community, placing them
at risk of drug adverse effects such as
cognitive impairment and sedation. Although most previous strategies for
improving drug prescribing for the elderly have focused on nursing homes,
broader educational and regulatory initiatives are needed.
Joel Lexchin
Joel Lexchin MD
121 Walmer Rd.
Toronto, Ontario
CANADA M5R 2X8
Phone: +416-964-7186
Fax: +416-923-9515
e mail: joel.lexchin@utoronto.ca
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