Journal of Gerontology & Geriatric Medicine Category: Medical Type: Research Article

Potentially Inappropriate Medication-Related Adverse Drug Reaction among Hospitalized Geriatric Patients: A Combined Interventional Study

Muath Fahmi Najjar1*, Syed Azhar Syed Sulaiman2, Hashim Balubaid3, Mohamed Sallout3, Mohammed Alessa3, Numan Alabdan3 and Majed Al Jeraisy3
1 King Abdullah International Medical Research Centre, Ministry Of National Guard-Health Affairs, King Saud Bin Abdulaziz University For Health Science, King Abdulaziz Medical City,Riyadh 11426, Riyadh, Saudi Arabia
2 Pharmaceutical Sciences School, Universiti Sains Malaysia (USM), Penang, Malaysia
3 King Abdullah International Medical Research Centre, College Of Pharmacy, King Saud Bin Abdulaziz University For Health Science, Riyadh, Saudi Arabia

*Corresponding Author(s):
Muath Fahmi Najjar
King Abdullah International Medical Research Centre, Ministry Of National Guard-Health Affairs, King Saud Bin Abdulaziz University For Health Science, King Abdulaziz Medical City,Riyadh 11426, Riyadh, Saudi Arabia
Tel:+966 4294432,
Email:moad1970@gmail.com

Received Date: Nov 04, 2019
Accepted Date: Nov 11, 2019
Published Date: Nov 19, 2019

Abstract

Purpose: Prescribing appropriate medications for geriatric patients is still a challenge for health care professionals. Potentially Inappropriate Medications (PIMs) should be discontinued because of the high risk of Drug-Drug Interactions (DDIs), drug-disease interaction and Adverse Drug Reactions (ADRs). The aim of this study was to assess the effectiveness of a combined intervention program: educational and clinical pharmacist interventions on the incidence of ADRs among hospitalized geriatric patients who received PIMs as defined by Screening Tool of Older Persons’ Prescriptions (STOPP) and American Geriatric Society Beers criteria.

Methods: The study was a prospective before-and-after interventional design. A combined intervention program involving educational and clinical pharmacist-initiated intervention was conducted in the medical wards at King Abdulaziz Medical City in Riyadh, Saudi Arabia.

Results: Among 400 geriatric patients enrolled in the study, 200 in a pre-intervention group (control) and 200 in the intervention group. The incidence rate of PIMs was 61% in the pre-intervention phase which decreased to 29.5% in the intervention phase with a statistically significant difference between the two groups. After the combined intervention, the incidence rate of ADRs decreased significantly from 90 (45 %) to 56 (28%). Using multivariate analysis, Activities of Daily Living (ADL), haemodialysis, hospital readmission, polypharmacy, DDIs and PIMs were the potential predictors which predispose the geriatric patients to ADRs.

Conclusion: Using a combined educational and clinical pharmacist intervention program would add a significant value to improve prescribing patterns in hospitalized geriatric patients. PIMs should be discontinued because of the high risk of ADRs.

Keywords

Clinical pharmacist; Education; Inappropriate; Intervention; Knowledge; Prescribing

INTRODUCTION

With advancing age, medical diseases become more common and tend to occur concurrently [1]. Accordingly, multiple medications are a logical result of the concurrent occurrence of multiple diseases among geriatric patients [2]. However, concurrent administration of several medications is problematic, because of their possible Drug-Drug Interactions (DDIs), polypharmacy, Potentially Inappropriate Medications (PIMs) and Adverse Drug Reactions (ADRs) [3]. PIMs usage poses a significant dilemma among geriatric patients, which may contribute to increased morbidity and mortality [4]. Therefore, multiple lists were designed to identify drugs inappropriate for use by geriatric populations [5]. The best-known explicit screening tool is the Beers criteria, but there are several medications have a high risk of ADRs in geriatric patients and not included in the Beers criteria. Therefore, Screening Tool of Older Persons’ Prescriptions (STOPP) criteria were developed to address some of the limitations of Beers criteria. Many previous studies recommended STOPP and Beers criteria, in order to optimize prescribing for geriatric population with multiple diseases [6]. Beers and STOPP criteria are valid and reliable which is useful in geriatric patients as an important intervention method to assess and assist in minimizing the incidence of polypharmacy, DDIs and ADRs [7]. Prescribing PIMs can be attributed to the fact that many physicians are unaware of PIMs usage. The awareness of PIMs by physicians and clinical pharmacists is important, especially for patients with a high number of medications [8]. Educational intervention has been recommended to improve prescribing pattern in the geriatric population. Educational interventions targeting physicians can be passively by printing material alone, or by interactive educational outreach (e.g., Academic detailing). Previous studies found that educational interventions designed to improve appropriate prescribing knowledge of physicians had a significant effect in reducing PIMs [8,9]. In a recent study conducted in Germany, the physician-related reasons of PIMs prescribing were; lack of knowledge, lack of applicability of PIMs criteria in practice, lack of time and lack of alternatives in medication for specific diagnoses [10].

Clinician geriatricians play leading roles in educating healthcare professionals, training non-geriatrician physicians, research and development applied to clinical quality and safety improvement. Potentially inappropriate medications among geriatric inpatients are often related to the lack of knowledge and training in geriatric medicine and geriatric pharmacotherapy education. Educational sessions, seminars and workshops are the effective way to improve the awareness of physicians and pharmacists towards using PIMs among geriatric patients [9,10].

Clinical pharmacist responsible for medication reviews of patients’ prescriptions to optimize medication treatment and outcomes through the improvement of prescribing patterns of physicians. Clinical pharmacists can play an important role to create changes in prescribing practices in accordance with guidelines from the literature and utilize the effective tools and interventions in prescribing practice [9]. Clinical pharmacist is responsible for detecting PIMs and recommending appropriate use of alternative medications among geriatric patients. This task is the core of the clinical pharmacist’s role in which remarkable knowledge exists regarding the efficacy and safety of drug therapies [11]. The persistent lack of geriatric physicians and geriatric pharmacists is the most concern not only in Saudi Arabia, but also in the most of developing and developed countries [12]. Hence, the current study conducted to determine the impact of combined intervention program: an educational and clinical pharmacist's interventions to reduce the incidence of PIMs-related ADRs among hospitalized geriatric patients.

METHODOLOGY

The study was a prospective before-and-after interventional design, investigating the impact of combined intervention program; an educational and a clinical pharmacist intervention to minimize PIMs and ADR among hospitalized geriatric patients. The pre-intervention (Phase I) and the intervention (phase II) were conducted by three clinical pharmacists in the Department of Medicine from March 2015 to July 2016. The study population consisted of all geriatric patients (≥65 years old) admitted to one ward of the Department of Medicine at King Abdulaziz Medical City (KAMC) for at least three days were enrolled in the study. The primary outcome of this study was the incidence rate of PIMs, as measured in the pre-intervention and the intervention group. Based on the literature, the reduction in the incidence rate of PIMs from 50% to 25%, using an alpha of 0.05, the power of 80% and a two-sided McNemar’s test for paired proportions, the estimated number of geriatric inpatients to be included is 384 patients [13]. A random sample of 400 hospitalized geriatric patients who met the inclusion criteria was enrolled using the BEST Care® which is the Computerized Physician Order Entry (CPOE) and Hospital Information System (HIS). The educational program was consisting of one-hour of weekly educational lectures for one month in the Department of Medicine. In addition, collaboration between the clinical pharmacists and the prescribers who aimed to utilize the STOPP and Beers criteria to optimize prescribing among hospitalized geriatric patients. The clinical pharmacists offered all possible interventions that might prevent PIM prescribing; the interventions included audit of the physicians’ orders and providing feedback and recommendations during medical rounds, reminders, and discussions with physicians. The interventions and recommendations were carried-out by three clinical pharmacists working in the medical wards in KAMC Hospital. The clinical pharmacists were trained before starting the current phase using 2015 AGS Beers and 2014 STOPP criteria [6,14]. To facilitate the clinical pharmacists’ interventions, the authors of the study developed the pocket-sized “Handbook of PIMs Use Among Geriatric Patients®” as an interventional tool based on the guidelines on prescribing appropriate medications in hospitalized geriatric patients. This tool was tailored to the drugs available in the formulary of KAMC Hospital. The purpose of the Handbook was to save physicians’ time during clinical ward rounds and to improve their prescribing decisions. The study’s investigator compiled the data of PIMs based on STOPP and Beers criteria only. Statistical Package for Social Sciences (SPSS) software program version 22 for Windows was applied in this study. The difference in the incidence rate of PIMs between the two phases was detected by two-sided McNemar’s test for paired proportions. In addition, several predictors of ADRs were identified using multivariate regression analysis.

RESULTS

The sample of geriatric patients which screened from the Computerized Physician Order Entry (CPOE) and Hospital Information System (HIS) was 400 geriatric patients who were admitted to the Department of Medicine wards of King Abdulaziz Medical City (KAMC) in pre-interventions and intervention phase. The data of the final sample enrolled in the study were collected from the time of patients’ admission till they discharged, transferred to other than Department of Medicine wards or died. There was no significant difference between pre-intervention and intervention groups in all socio-demographic characteristics of the study geriatric patients admitted to KAMC Hospital (Table 1). The incidence rate of PIMs was 61% in the pre-intervention phase and decreased to 29.5% in the intervention phase with a statistically significant difference between the two groups (p-value ?0.001). About half of geriatric patients (54%) were on ≥2 Beers criteria drugs during hospitalization in the pre-intervention phase, which decreased significantly to 10.5% in the intervention phase (p-value <0.05). Several medications which were considered potentially inappropriate by STOPP and Beers criteria were found to be prescribed in high rate among hospitalized geriatric patients (Tables 2 and 3). The intervention phase was conducted by three clinical pharmacists in the Department of Medicine. Out of 317 recommendations given by the clinical pharmacist, the prescribers accepted a total of 196 (61.83%) recommendations. The most commonly accepted interventions were 96 (48.9%) to change PIMs among geriatric inpatients to safe alternatives. The other accepted recommendations were to stop PIMs as listed in Beers criteria (31; 15.8%), followed by to decrease dose (25; 12.7%), to stop STOPP criteria (21; 10.7%), to stop drug duplications (14; 7.1%) and stop DDIs9 (4.6%). As the incidence of ADRs is the outcome of this study, of the 200 geriatric patients in the pre-intervention group, 90 (45 %) patients had suspected ADRs. The incidence rate significantly decreased in the intervention group to 56 (28%), (OR: 0.475, 95% CI, 0.314-0.720); (p-value ?0.001). Moreover, the incidence rate of PIMs-related ADRs was 82 (20.5%) and the non-PIMs-related ADRs were 67 (16.8%). The difference was significance (p-value <0.001). Diuretics, anticoagulants, insulin sliding scale, beta-blocker, benzodiazepines, glyburide, antidepressants, antihistamines, NSAIDs, digoxin and metformin were the most common medications or medication classes related to ADRs (Table 4). Both lists of PIMs were associated with ADRs in geriatric patients who were received Tricyclic Antidepressants (TCA), anticholinergic drugs, and non Cyclooxygenase 2-selective (COX-2) Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) and long-acting benzodiazepines (Table 4). In our findings, there was no significant difference in the incidence rate of mortality between the pre-intervention and interventional group of the hospitalized geriatric patients (p=0.338). A total of 44 deaths (11%) were found among hospitalized geriatric patients in the present study. Only 14 (3.5%) associated with ADRs. Backward stepwise logistic regression test was carried out for each independent variable with PIMs as the dependent variable to determine predictors of ADRs among hospitalized geriatric patients. The main predictors were Activities of Daily Living (ADL), Charlson-Age Comorbidity Index (CACI), Length of Hospital Stay (LOHS), haemodialysis, readmission, polypharmacy at admission and PIMs. The odds of ADRs were doubled by PIMs use (OR: 1.98, 95% CI, 1.16-14.31) (Table 5). 

Characteristics

Group

Pre-intervention

N=200

n.(%)

Intervention

N=200

n.(%)

P-value*

Age (years) (mean± SD)

 

76.47 ± 9.43

77.10 ± 10.20

0.524

BMI (kg/m2) (mean± SD)

 

27.81 ± 6.41

27.48 ± 6.32

0.612

Gender

Male

88 (44.0)

95 (47.5)

0.482

Ethnicity

 

Arab

187 (93.5)

175 (87.5)

0.122

Others

13 (06.50)

25 (12.50)

Smoking status

Smoker

53 (26.5)

46 (23.0)

0.417

Alcohol consumption

Drinker

04 (2.0)

07 (3.5)

0.359

Family care Giver

Spouse

124 (62.0)

126 (63.0)

0.631

Children

65 (32.5)

59 (29.5)

Others

11 (5.5)

15 (7.5)

Functional level

Dependent

41 (20.5)

36 (18.0)

0.060

ADL

 

Partially dependent

26 (13.0)

44 (22.0)

Independent

133 (66.5)

120 (60.0)

 

CACI

 

≤5

41 (20.5)

54 (27.0)

0.127

?5

159 (79.5)

146 (73.0)

Frailty

 

Yes

61 (30.5)

67 (33.5)

0.52

No

139 (69.5)

133 (66.5)

 

Malnutrition

 

Yes

54 (27.0)

74 (37.0)

0.032

No

146 (73.0)

126 (63.0)

History of falls

 

Yes

05 (2.5)

02 (1.0)

0.253¥

No

195 (97.5)

198 (99.0)

 

Polymorbidity

 

≥4 diseases

109 (54.5)

95 (47.5)

0.161

?4 diseases

91 (45.5)

105 (52.5)

Polypharmacy

≥5 drugs

77 (85.6)

48 (85.7)

0.979

LOHS (days)(mean± SD)

 

12.88 ± 10.87

10.64 ± 6.80

0.014

Table 1: Clinical characteristics of the geriatric patients (n=400) admitted to KAMC at pre-intervention and intervention group.

*Chi square test, ¥Fischer’s Exact test, KAMC: King Abdulaziz Medical City; BMI: Body Mass Index; ADL: Activities of Daily Living; CACI: Charlson-Age Comorbidity Index; BMI: Body Mass Index; LOHS: Length of Hospital Stay 

PIMs categories

Beers criteria

 

Pre-intervention

N=200

n.(%)

Intervention

N=200

n.(%)

P-value*

Drugs to be avoided

Antihistamines

Chlorpheniramine, Hydroxyzine

32 (16.0)

9 (4.5)

< 0.001

Antispasmodics

Atropine, Scopolamine

18 (9.0)

7 (3.5)

0.023

Antipsychotics

Conventional, Atypical

13 (6.5)

7 (3.5)

0.169

Antiparkinson agents

Benztropine, Trihexyphenidyl

7 (3.5)

3 (1.5)

0.338

Antiarrhythmic drugs

Amiodarone, Procainamide

30 (15.0)

12 (6.0)

0.003

Alpha1 blockers

Prazosin,  Terazosin

14 (7.0)

4 (2.0)

0.016

Alpha agonists

Clonidine, Methyldopa

11 (5.5)

5 (205)

0.201

Benzodiazepines

Lorazepam, Diazepam

19 (9.5)

6 (3.0)

0.007

Tertiary TCAs

Amitriptyline, Clomipramine

13 (6.5)

4 (2.0)

0.026

Gastrointestinal medications

Metoclopramide

29 (14.5)

11 (5.5)

0.003

Endocrine medications

Androgens, Estrogens, Insulin

37 (18.5)

13 (6.5)

? 0.001

Sulfonylureas, long-duration

Glyburide

31 (15.5)

14 (7.0)

0.007

Pain Medications

Meperidine, NSAIDs

18 (9.0)

7 (3.5)

0.023

Drug-Disease interaction

Heart failure

NSAIDs, COX-2 inhibitors, CCBs

13 (6.5)

3 (1.5)

0.011

Chronic seizures

Olanzapine, Chlorpromazine

7 (3.5)

1 (0.5)

0.006

Delirium

Benzodiazepines, Corticosteroids

9 (4.5)

0 (0.0)

0.004

Dementia

 

Anticholinergics, Benzodiazepines

9 (4.5)

2 (1.0)

0.031

Antipsychotics

     

History of falls or fractures

Antipsychotics, Benzodiazepines, Antidepressants, Opioids

5 (2.5)

2 (1.0)

0.449

Insomnia

Pseudoephedrine, Phenylephrine

7 (3.5)

1 (0.5)

0.068

Parkinson’s disease

Anticholinergics (antispasmodics)

6 (3.0)

4 (2.0)

0.751

Chronic constipation

CCB, Antipsychotics

13 (6.5)

5 (2.5)

0.044

History of GIT ulcer

 

Aspirin (>325 mg/day)

11 (5.5)

3 (1.5)

0.053

Non–COX-2 selective NSAIDs

     

Chronic kidney disease

NSAIDs

9 (4.5)

3 (1.5)

0.140

Benign Prostatic Hyperplasia

Strongly anticholinergic drugs

8 (4.0)

1 (0.5)

0.037

Lower urinary tract symptoms

Alpha-blockers

6 (3.0)

3 (1.5)

0.503

Drugs to be used with caution

 

 

 

 

Aspirin

35 (17.5)

18 (9.0)

0.012

Antipsychotics

13 (6.5)

7 (3.5)

0.169

TCAs

13 (6.5)

4 (2.0)

0.026

Vasodilators

25 (12.5)

9 (4.5)

0.004

Mirtazapine

5 (2.5)

3 (1.5)

0.724

Drugs to be avoided or reduced with Kidney disease

 

 

 

 

 

Spironolactone

8 (4.0)

2 (1.0)

0.105

Amiloride

4 (2.0)

2 (1.0)

0.685

Dabigatran

5 (2.5)

2 (1.0)

0.449

Triamterene

3 (1.5)

1 (0.5)

0.623

Pregabalin

2 (1.0)

2 (1.0)

1.000

Levetiracetam

3 (1.5)

2 (1.0)

1.000

Table 2: Potentially Inappropriate Medication (PIMs) categories among geriatric patients (n=400) at pre-intervention and intervention group based on Beers Criteria. 

Fischer’s Exact test; TCAs: Tricyclic Antidepressant; NSAIDs: Non-Steroidal Anti-Inflammatory Drugs; COX-2: Cyclooxygenase-2; GIT: Gastrointestinal Tract 

Drug or Drug Class STOPP criteria

 

Pre-intervention

N=200

n.(%)

Intervention

N=200

n.(%)

P-value*

 

ACE inhibitors or ARB

With hyperkalemia

25 (12.5)

9 (4.5)

0.004

 

Amiodarone

First-line antiarrhythmic therapy

17 (8.5)

9 (4.5)

0.105

 

Beta-blocker

Bradycardia, or with verapamil, in DM or Asthma patients

27 (13.5)

10 (5.0)

0.003

 

Calcium channel blockers

Heart failure or with beta-blocker

18 (9.0)

7 (3.5)

0.023

 

Digoxin

Long-term dose greater than 125µg/day

11 (5.5)

9 (4.5)

0.646

 

Loop diuretic

Initial monotherapy for hypertension

36 (18.0)

18 (9.0)

0.008

 

Spironolactone

With concurrent potassium-conserving drugs

15 (7.5)

6 (3.0)

0.044

 

Thiazide

Hypokalaemia, Hyponatraemia

7 (3.5)

3 (1.5)

0.338¥

 

Vasodilators

With orthostatic hypotension

25 (12.5)

9 (4.5)

0.004

 

Anticoagulants

Clopidogrel, Enoxaparin, Heparin Na, Warfarin

 

With bleeding risk, with aspirin, For first deep venous, thrombosis, For first pulmonary embolus, with NSAID

24 (12.0)

13 (6.5)

0.083

 

If eGFR < 15 ml/min/1.73m2

       

Aspirin

Dose over 160 mg, History of peptic ulcer disease, with clopidogrel, warfarin, NSAID

19 (9.5)

7 (3.5)

0.026

 

Acetylcholinesterase inhibitors

History of persistent bradycardia, heart block, syncope or with beta-blockers, digoxin, diltiazem, verapamil

4 (2.0)

1 (0.5)

0.372¥

 

Anticholinergics

 

To treat neuroleptic extrapyramidal side effects, or with dementia, chronic constipation, BPH, or with glaucoma

82 (41.0)

50 (25.0)

0.001

 

Concomitant use of two or more drugs

       

Antihistamines

Use for more than one week

32 (16.0)

9 (4.5)

? 0.001

 

Benzodiazepines

Use of long-acting agent, with one or more falls in past three months

19 (9.5)

6 (3.0)

0.007

 

Neuroleptics (Antipsychotics)

As a hypnotic, with parkinsonism over one month, with fall in past three months

13 (6.5)

7 (3.5)

0.169¥

 

Tricyclic Antidepressants

As first-line antidepressant treatment

13 (6.5)

4 (2.0)

0.026¥

 

With dementia, glaucoma, arrhythmias, constipation, opioids, CCB, BH or with urinary retention

       

Iron (oral)

Use in patients with chronic constipation, or >200 mg daily

21 (10.5)

6 (3.0)

0.003¥

 

Corticosteroids, systemic

COPD maintenance

20 (10.0)

13 (6.5)

0.203

 

NSAIDs

With history of ulcer or GI bleed, unless with concurrent PPI or H2 antagonist, with blood pressure 160/100 mmHg or higher, with heart failure, Long-term use of NSAID, with GFR<50 mL/min/1.73m2, with warfarin, or with corticosteroids without PPI prophylaxis

18 (9.0)

7 (3.5)

0.023¥

 

Opioids

Long-term use of strong opioids (e.g., morphine), or as 1st line for mild to moderate pain, use in patients with chronic constipation, or using of regular opioids without concomitant laxative

11 (5.5)

8 (4.0)

0.638

 

Alpha-blockers

With urinary catheter for over two months

14 (7.0)

4 (2.0)

0.016

 

Sulphonylureas
(Glyburide)

With symptomatic orthostatic hypotension with a long duration of action with type 2 diabetes mellitus

31 (15.5)

14 (7.0)

0.007

 
 

Table 3: Potentially Inappropriate Medication (PIMs) categories among geriatric patients (n=400) at pre-intervention and intervention group based on STOPP Criteria.

Chi square test, ¥Fischer’s Exact test; NSAID: Non-Steroidal Anti-Inflammatory Drugs; ACEI: Angiotensin-Converting-Enzyme Inhibitor; ARB: Angiotensin II Receptor Blockers; PPI: Proton-Pump Inhibitors; COPD: Chronic Obstructive Pulmonary Disease; DM: Diabetes Mellitus; CCB: Calcium Channel Blockers; BPH: Benign Prostatic Hyperplasia

Medication class

ADR

Pre-intervention

N=90

n. (%)

Intervention group

N=56

n. (%)

Diuretics

Electrolyte disturbance, dehydration

12 (6.0)

7 (3.5)

Anticoagulants

Haemorrhage

11 (5.5)

4 (2.0)

Insulin SS

Hypoglycemia

8 (4.0)

3 (2.0)

Beta-blocker

Hypotension, bradycardia

8 (4.0)

8 (4.0)

Benzodiazepines

Fall, drowsiness, dizziness

7 (4.5)

2 (2.0)

Glyburide

Hypoglycemic

5 (2.5)

3 (1.5)

Antidepressants

Insomnia, confusion, anxiety

5 (2.5)

3 (1.5)

Antihistamines

Fall, Dizziness

4 (2.0)

5 (2.5)

NSAIDs

Nephropathy, Haemorrhage

3 (1.5)

3 (1.5)

Digoxin

AV-block, Bradycardia,

3 (1.5)

2 (1.0)

Metformin

Gastric disturbances, Metabolic acidosis, Hypoglycemia

3 (1.5)

2 (1.0)

Opioids

Drowsiness, Constipation

3 (1.5)

2 (1.0)

Vasodilators

Fluid retention, Nausea or vomiting, Dizziness.

3 (1.5)

0 (0.0)

Amlodipine

Urinary incontinence, Water retention

2 (1.0)

1 (0.5)

Antibiotics

Allergy, Anaphylactic reactions

2 (1.0)

2(1.0)

Amiodarone

QT interval prolongation

2 (1.0)

3 (1.5)

ACEIs

Renal impairment, Electrolyte disturbance

2 (1.0)

2 (1.0)

Allopurinol

Stevens-Johnson syndrome

1 (0.5)

0 (0.0)

Quetiapine

Hepatotoxicity (hepatitis)

1 (0.5)

1 (0.5)

Candesartan

ARF with electrolyte imbalance

1 (0.5)

1 (0.5)

Colchicine

Electrolyte disturbance, Diarrhoea

1 (0.5)

0 (0.0)

 Losartan

Hyperkalemia

1 (0.5)

1 (0.5)

Phenytoin

Hepatotoxicity

1 (0.5)

0 (0.0)

Risperidone

Dysphagia

1 (0.5)

1 (0.5)

Table 4: Medication or medication classes related to Adverse Drug Reactions (ADRs) among geriatric inpatients (n=400) in the pre-intervention and intervention group.

ADR: Adverse Drug Reaction; Insulin SS: Insulin Sliding Scale; NSAID: Non-Steroidal Anti-Inflammatory Drugs; ACEI: Angiotensin-Converting-Enzyme Inhibitor; ARF: Acute Renal Failure 

Predictors

B

SE

OR

95% CI

P-value

Age (Years)

-0.12

0.04

0.88

0.82-0.95

0.001

ADL

-3.3

0.85

0.04

0.01-0.19

0.001

CACI

1.75

0.82

5.73

1.16-28.43

0.033

Malnutrition

1.26

0.63

3.53

1.03-12.08

0.044

Haemodialysis

-2.75

1.02

0.06

0.01-0.48

0.007

LOHS (days)

-0.04

0.04

0.96

0.88-1.05

0.401

Outpt visit

1.76

0.67

5.83

1.56-21.80

0.009

Polypharmacy

-0.26

0.13

0.77

0.59-0.98

0.036

DDIs

-0.51

0.85

0.6

0.11-1.04

0.270

PIMs

1.93

0.91

6.88

1.16 -14.31

0.005

Table 5: Predictors of ADRs use among geriatric patients (n=400) on PIMs in the pre-intervention and intervention groups during hospitalization at KAMC.

*Backward stepwise logistic regression test, ªOR: Odds Ratio, CI: Confident Interval, B: regression coefficient value, ADL: Activities Of Daily Living; CACI: Charlson-Age Comorbidity Index; LOHS: Length Of Hospital Stay; DDIs: Drug-Drug Interactions, ADRs: Adverse Drug Reactions; DDI: Drug-Drug Interaction; PIM: Potentially Inappropriate Medication

DISCUSSION

Geriatric patients at excessive danger of receiving high-risk medications. There is a lack of published interventional studies among geriatric population in Saudi Arabia; therefore, an educational and clinical pharmacists interventions were conducted for hospital physicians to reduce PIMs prescribing among hospitalized geriatric patients. The findings from the current study demonstrate that the combined intervention program reduced the incidence of ADRs among hospitalized geriatric patients who were exposed to PIMs. STOPP and Beers criteria have been used as two of the main interventional tools in the literature to assess and assist in minimizing the incidence of PIMs among geriatric patients [15]. There are several interventional tools were developed in every region in the world, but the most valid and reliable explicit criteria were the Screening Tool of Older Persons’ Prescriptions (STOPP) and Beers criteria [16].

In the pre-intervention phase, we found a deviation between the evidence-based guidelines for geriatric patients as stated in STOPP and Beers criteria and the clinical practice of the study’s physicians. The incidence rate of PIMs was 61% in the pre-intervention phase and decreased to 29.5% in the intervention phase with a statistically significant difference between the two groups (p-value <0.001). In many previous studies, the incidence rates of PIMs prescribing among hospitalized geriatric patients ranged from 12% to 40% [17,18]. In agreement with our analysis, a combined intervention involving educational and clinical pharmacists’ interventions was significantly effective in reducing the incidence of PIMs [17]. This result was also reported in previous studies [19,20]. Therefore, an educational intervention program was needed to improve the knowledge of hospital physicians. In an extensive systematic review, the effectiveness of educational interventional for physicians and other healthcare professionals had little or no effect on clinical practice [21]. Hence, it is recommended in the literature to use a combined intervention instruments to reduce the PIMs incidence rate among geriatric inpatients instead of using single intervention [18]. In the present study, the combined intervention was consisted of the delivery of educational sessions on inappropriate prescribing of PIMs. Consistent with previous studies, we found a significant correlation between the educational program among our physicians and the knowledge level of the STOPP and Beers criteria [22]. As reported by Ramaswamy et al., we found the positive impact of educational intervention and the physicians’ knowledge score of PIMs among geriatric patients [23]. Also, there was a significant difference in the median total score of knowledge of PIMs concept according to the qualification of the physicians of Medicine Department (p-value <0.001) [23]. An exception is a study conducted by Allard et al., who failed to demonstrate a significant association between the educational intervention and reducing the rate of PIMs [24].

In tandem with the educational sessions, the clinical pharmacists screened the hospitalized geriatric patients who were admitted to the Medicine Department wards in the KAMC hospital. The physicians in the interventional group received the recommendations for geriatric patients at the ordering time during multidisciplinary round in the Department of Medicine. Similar to the literature findings, we found that the clinical pharmacist’s audit and recommendations were effective in improving professional medical practice by reducing the incidence of PIMs prescribing among hospitalized geriatric patients [23]. We hypnotized that the clinical pharmacists' interventions will improve clinical outcomes of geriatric inpatients in term of decreasing the incidence rate of ADRs, DDIs and drug-disease interactions as listed in STOPP and Beers criteria. In agreement with previous studies, we found that the geriatric patients who received PIMs had a significantly higher risk of DDIs and ADRs [16]. Hence, the STOPP and Beers criteria are useful in geriatric patients to decrease DDIs and ADRs [7]. The combined interventions of educational and clinical pharmacist intervention of the current study led to a statistically and clinically significant decrease in the incidence rate of ADRs as STOPP and Beers criteria are stress more on the potentially inappropriate ADRs. In our geriatric sample, DDIs were widespread, especially in those receiving PIMs and 60% of the DDIs lead to ADRs. We found that the combined interventions targeted the prescribers was effective in reducing the incidence of ADRs among hospitalized geriatric patients. The findings from the current study demonstrate that the geriatric patients on PIMs experienced more ADRs than those without PIMs (p-value ?0.001). Most of ADRs were non-serious and recovered during hospitalization (64%). Several previous studies reported that geriatric patients who received PIMs had a significantly higher risk of ADRs and DDIs [25]. The occurrence of ADRs during hospitalization of geriatric patients in this study increased with polypharmacy and PIMs. Similar to our findings, the comorbidity in the geriatric population is correlated to PIMs [26]. About 114 (57.0%) of geriatric patients with high comorbidity index were received PIMs as described by STOPP and/or Beers criteria. In the present study, it was found that there was no significant association between PIMs and mortality. In contrast to our result, the appropriate prescribing of medications among geriatric patients has reduced the rate of mortality [25]. Recent findings in Saudi Arabia found that PIMs prescribing is possibly related to mortality [27]. Although no significant relationship is proved, PIMs prescribing is an important preventable error of mortality in the geriatric patients, but there was no apparent association with mortality of geriatric patients and PIMs [26]. PIMs may increase the risk of ADR, which may lead to morbidity or mortality [28].

CONCLUSION

This study demonstrates that the combined intervention program which targeted the physicians at medical wards was effective in reducing the incidence of PIMs prescribing among hospitalized geriatric patients. Geriatric patients who received PIMs had a significantly higher risk of ADRs. Moreover, reducing the incidence rate of PIMs by medical physicians after the educational and clinical pharmacist intervention program resulted in a significant decrease in the incidence of ADR.

ACKNOWLEDGEMENT

This research was funded by the King Abdullah International Medical Research Center (KAIMRC). We would like to thank the School of Pharmaceutical Sciences at Universiti Sains Malaysia (USM), King Saud bin Abdulaziz University for Health Sciences (KSAU-HS) and King Abdullah International Medical Research Center (KAIMRC) for providing with facility to conduct this study.

DISCLOSURE

The authors report no conflicts of interest in this work.

ETHICS APPROVAL

This study was approved by the Institutional Review Board of the KAMC. Waiver of Informed Consent Form (ICF) did not adversely affect the rights of the patients. Data collected from the patients were fully anonymized and only used for the study purposes and future treatment planning of prescribing among geriatric patients. Hence, the investigators request the Institutional Review Board to approve an exemption from administering informed consent from the patients.

AUTHOR CONTRIBUTIONS

Dr. Muath Najjar and Dr. Syed Azhar contributed to the design and concept of the manuscript and wrote the draft. Dr. Hashim and Dr. Majed review the data collection and results analysis. Mohamed Sallout, Mohammed Alessa and Numan Alabdan were the clinical pharmacists who perform the pharmaceutical care interventions. All authors contributed and commented to the manuscript and approved the final version.

REFERENCES

  1. Stegemann S, Ecker F, Maio M, Kraahs P, Wohlfart R, et al. (2010) Geriatric drug therapy: Neglecting the inevitable majority. Ageing Res Rev 9: 384-398.
  2. Winit-Watjana W, Sakulrat P, Kespichayawattana J (2008) Criteria for high-risk medication use in Thai older patients. Arch Gerontol Geriatr 47: 35-51.
  3. Galvin R, Moriarty F, Cousins G, Cahir C, Motterlini N, et al. (2014) Prevalence of potentially inappropriate prescribing and prescribing omissions in older Irish adults: Findings from The Irish LongituDinal Study on Ageing study (TILDA). Eur J Clin Pharmacol 70: 599-606.
  4. Berryman SN, Jennings J, Ragsdale S, Lofton T, Huff DC, et al. (2012) Beers criteria for potentially inappropriate medication use in older adults. Medsurg nurs 21: 129-132.
  5. Beers MH, Ouslander JG, Rollingher I, Reuben DB, Brooks J, et al. (1991) Explicit criteria for determining inappropriate medication use in nursing home residents. Arch Intern Med 151: 1825-1832.
  6. O’Mahony D, Gallagher P, Ryan C, Byrne S, Hamilton H, et al. (2010) STOPP and START criteria: A new approach to detecting potentially inappropriate prescribing in old age. European Geriatric Medicine 1: 45-51.
  7. Brown JD, Hutchison LC, Li C, Painter JT, Martin BC (2016) Predictive Validity of the Beers and Screening Tool of Older Persons' Potentially Inappropriate Prescriptions (STOPP) Criteria to Detect Adverse Drug Events, Hospitalizations, and Emergency Department Visits in the United States. J Am Geriatr Soc 64: 22-30.
  8. Al-Aama T (2016) Basic Geriatrics Knowledge Among Internal Medicine Trainees in a Teaching Hospital in Saudi Arabia. J Cross Cult Gerontol 31: 213-220.
  9. Martin P, Tamblyn R, Ahmed S, Benedetti A, Tannenbaum C (2015) A consumer-targeted, pharmacist-led, educational intervention to reduce inappropriate medication use in community older adults (D-PRESCRIBE trial): Study protocol for a cluster randomized controlled trial. Trials 16: 266.
  10. Voigt K, Gottschall M, Köberlein-Neu J, Schübel J, Quint N, et al. (2016) Why do family doctors prescribe potentially inappropriate medication to elderly patients? BMC Fam Pract 17: 93.
  11. Carson GL, Crosby K, Huxall GR, Brahm NC (2013) Acceptance Rates for Pharmacist-Initiated Interventions in Long-Term Care Facilities. Pharmacy Practice 4: 135.
  12. Fisher JM, Hunt K, Garside MJ (2014) Geriatrics for juniors: Tomorrow's geriatricians or another lost tribe? J R Coll Physicians Edinb 44: 106-110.
  13. Slaney H, MacAulay S, Irvine-Meek J, Murray J (2015) Application of the beers criteria to alternate level of care patients in hospital inpatient units. Can J Hosp Pharm 68: 218-225.
  14. By the American Geriatrics Society 2015 Beers Criteria Update Expert Panel (2015) American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc 63: 2227-2246.
  15. Vogt-Ferrier N (2010) Reviewing a complicated geriatric drug regimen. European Geriatric Medicine 1: 198-202.
  16. Hill-Taylor B, Walsh KA, Stewart S, Hayden J, Byrne S, et al. (2016) Effectiveness of the STOPP/START (Screening Tool of Older Persons' potentially inappropriate Prescriptions/Screening Tool to Alert doctors to the Right Treatment) criteria: systematic review and meta-analysis of randomized controlled studies. J Clin Pharm Ther 41: 158-169.
  17. Petrovic M, Somers A, Onder G (2016) Optimization of Geriatric Pharmacotherapy: Role of Multifaceted Cooperation in the Hospital Setting. Drugs Aging 33: 179-188.
  18. Galván-Banqueri M, González-Méndez AI, Alfaro-Lara ER, Nieto-Martín MD, Pérez-Guerrero C, et al. (2013) Evaluation of the appropriateness of pharmacotherapy in patients with high comorbidity. Aten Primaria 45: 235-243.
  19. Clyne B, Fitzgerald C, Quinlan A, Hardy C, Galvin R, et al. (2016). Interventions to Address Potentially Inappropriate Prescribing in Community-Dwelling Older Adults: A Systematic Review of Randomized Controlled Trials. J Am Geriatr Soc 64: 1210-1222.
  20. Keijsers CJ, van Hensbergen L, Jacobs L, Brouwers JR, de Wildt DJ, et al. (2012) Geriatric pharmacology and pharmacotherapy education for health professionals and students: A systematic review. Br J Clin Pharmacol 74: 762-773.
  21. Bloom BS (2005) Effects of continuing medical education on improving physician clinical care and patient health: a review of systematic reviews. Int J Technol Assess Health Care 21: 380-385.
  22. Cojutti P, Arnoldo L, Cattani G, Brusaferro S, Pea F (2016) Polytherapy and the risk of potentially inappropriate prescriptions (PIPs) among elderly and very elderly patients in three different settings (hospital, community, long-term care facilities) of the Friuli Venezia Giulia region, Italy: Are the very elderly at higher risk of PIPs? Pharmacoepidemiol Drug Saf 25: 1070-1078.
  23. Ramaswamy R, Maio V, Diamond JJ, Talati AR, Hartmann CW, et al. (2011) Potentially inappropriate prescribing in elderly: assessing doctor knowledge, confidence and barriers. J Eval Clin Pract 17: 1153-1159.
  24. Allard J, Hébert R, Rioux M, Asselin J, Voyer L (2001) Efficacy of a clinical medication review on the number of potentially inappropriate prescriptions prescribed for community-dwelling elderly people. CMAJ 164: 1291-1296.
  25. Fu AZ, Liu GG, Christensen DB (2004) Inappropriate medication use and health outcomes in the elderly. J Am Geriatr Soc 52: 1934-1939.
  26. Samuelsson KS, Egenvall M, Klarin I, Lökk J, Gunnarsson U (2016) Inappropriate drug use in elderly patients is associated with prolonged hospital stay and increased postoperative mortality after colorectal cancer surgery: A population-based study. Colorectal Dis 18: 155-162.
  27. Al-Omar HA, Al-Sultan MS, Abu-Auda HS (2013) Prescribing of potentially inappropriate medications among the elderly population in an ambulatory care setting in a Saudi military hospital: trend and cost. Geriatr Gerontol Int 13: 616-621.
  28. Lavan AH, Gallagher PF, O’Mahony D (2016) Methods to reduce prescribing errors in elderly patients with multimorbidity. Clin Interv Aging 11: 857-866.

Citation: Najjar MF, Sulaiman SAS, Balubaid H, Sallout M, Alessa M, et al. (2019) Potentially Inappropriate Medication-Related Adverse Drug Reaction among Hospitalized Geriatric Patients: A Combined Interventional Study. J Gerontol Geriatr Med 5: 039.

Copyright: © 2019  Muath Fahmi Najjar, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

© 2022, Copyrights Herald Scholarly Open Access. All Rights Reserved!