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Inappropriate Drug Prescribing in Home-Dwelling, Elderly Patients
A Population-Based Survey
Kaisu H. Pitkala, MD, PhD;
Timo E. Strandberg, MD, PhD;
Reijo S. Tilvis, MD, PhD
Arch Intern Med. 2002;162:1707-1712.
ABSTRACT
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Background In 1997, a US expert panel developed explicit criteria on potentially
inappropriate drugs for the general elderly population.
Objective To investigate the proportion of inappropriate medications among home-dwelling,
elderly patients in Helsinki, Finland, between November 1, 1998, and March
31, 1999.
Methods A cross-sectional mail survey was sent to a random sample of 3921 elderly
urban residents aged 75, 80, 85, 90, and 95 years. Of these, 3219 were home
dwellers.
Main Outcomes Measures Prevalence of potentially inappropriate drugs and prevalence of drugs
considered inappropriate related to 15 common medical conditions according
to recommendations given by the expert panel in 1997.
Results The response rate was 78%. Of the respondents, 12.5%, 1.3%, and 0.2%
were taking at least 1, 2, or 3 inappropriate drugs, respectively. The most
prevalent inappropriate drugs were dipyridamole (3.6%), long-acting benzodiazepines
(2.6%), amitriptyline hydrochloride (1.6%), ergot mesyloids (1.6%), muscle
relaxants (1.2%), and meprobamate (1.1%). Use of medications considered inappropriate
with certain medical conditions was higher: 27.2% of patients with chronic
obstructive pulmonary disease were taking  -blockers and 19.3% used sedatives.
Of diabetic individuals taking oral hypoglycemics or insulin, 32.5% were taking
a concomitant -blocker. Of those with a peripheral vascular disease,
37.9% were taking -blockers. However, two thirds of all these patient
groups had concomitant coronary heart disease.
Conclusions Compared with previous surveys, the use of inappropriate medications
in our home-dwelling, elderly population is conspicuously low. In contrast,
use of certain drugs considered inappropriate with different medical conditions
was relatively high. However, the inappropriateness of the latter treatments
may be questioned in individual patients.
INTRODUCTION
MULTIPLE DRUG use is common in elderly patients because of an increase
in the number of medical conditions as one ages.1-2
Multiple drug use increases the risk of drug interaction, adverse outcomes,3-5 and noncompliance as
well as increasing the cost of care.6 Polypharmacy
and use of inappropriate drugs are associated with age, multiple diseases,
recent hospitalization, female sex, depression, and the number of physicians
prescribing drugs to elderly patients.1, 3, 7-8
Iatrogenic syndromes associated with inappropriate drug use have accounted
for a large number of hospital admissions in elderly patients.9-13
Since 1991, attention has been focused on the quality of prescribing
drugs for frail, elderly patients after an expert panel using Delphi techniques
gave recommendations on appropriate drug prescribing.14
Investigations of elderly populations according to the 1991 criteria have
suggested that inappropriate drug prescribing is surprisingly common among
elderly patients in the community,15-16
outpatient departments,17 board and care facilities,18 and nursing homes.19-20
Most of these studies did not apply the full set of criteria but modified
them by omitting, for example, antihypertensive drugs or ergot mesyloids and
cerebral vasodilators from the list.21 Furthermore,
application of these criteria to general elderly populations has been criticized.22 Consequently, new criteria were developed by a second
expert panel for general elderly populations and elderly persons with certain
medical conditions.22 The updated criteria
extended the 1991 criteria by adding gastrointestinal antispasmodics, antihistamines
with anticholinergic properties, disopyramide, meperidine hydrochloride, and
ticlopidine hydrochloride to the list of inappropriate medications and by
including 35 criteria that defined potentially inappropriate medication use
in older persons known to have any of 15 common medical conditions. One study
has applied the latest criteria to a selected elderly population (clients
enrolled in a Medicaid-supported managed care plan in the United States) and
found that 39.7% were using at least 1 inappropriate drug from the general
criteria.23 Moreover, 2 studies24-25
have investigated inappropriate medications in general populations in which
22% to 27% of individuals were found to be using contraindicated drugs. However,
these studies did not apply the criteria developed for elderly persons with
certain diseases. In addition, they applied the criteria from 1997 to population
data derived from a time preceding development of these criteria.
Evidence concerning the efficacy and safety of drugs changes rapidly.
Similarly, the prevalence of drug use at the population level evolves with
time. Thus, the use of inappropriate drugs should be evaluated regularly to
give feedback to clinicians. As far as we know, no studies exist that have
applied the criteria of inappropriate drug use to elderly populations outside
the United States and Canada.
The aim of our study was to use the explicit criteria developed by the
expert panel in 1997 to evaluate how the guidelines for inappropriate medications
had been applied to an urban, home-dwelling, elderly population at the end
of the 1990s. We also wanted to investigate whether factors that previously
have been discovered to be associated with the use of inappropriate drugs
determine drug use in an elderly Finnish population.
PATIENTS AND METHODS
In 1999, we obtained a random sample of birth cohorts aged 75, 80, and
85 years (n = 1000 in each) and all 90-year-olds (n = 774) and 95-year-olds
(n = 147) from the Helsinki city area. This area has a population of approximately
500 000 inhabitants, with 13.5% of these 65 years or older. All Finnish
citizens are covered by the public health care system, but a private system
is also available. Thus, hundreds of physicians are involved in prescribing
medication for this population. However, because of the restricted number
of medical schools and comprehensive national guidelines, the practice of
individual physicians is considered uniform. The random sampling was performed
and addresses provided by the Central Population Register of Finland; 82%
of the sample were home dwellers.
Mailed questionnaires were sent between November 1, 1998, and March
31, 1999, and questionnaires were resent once to nonresponders. Those individuals
who provided incomplete answers were contacted by the study nurse via telephone.
Participants were asked to list prescription and nonprescription drugs, vitamins,
and natural products used. The questionnaire also contained questions on symptoms
and diseases as well as demographic characteristics, functioning, quality
of life, and social aspects of the participants. Inappropriate drugs were
coded according to the classes proposed by an expert committee.22
We also coded drugs considered inappropriate with certain diagnoses and symptoms.
The study was approved by the local ethics committee.
Questionnaires were coded using the Microsoft ACCESS software (Microsoft
Inc, Redmond, Wash) and analyzed with the NCSS (Number Cruncher Statistical
System) for Windows statistical program (NCSS, Kaysville, Utah). Drug use
was reported as percentages and the proportions were compared with  2 tests. Confidence intervals (CIs) were calculated as previously described.26 P .05 was considered
statistically significant.
RESULTS
The response rate among home-dwelling, elderly patients was 78%. This
rate was calculated by excluding those who had died before the questionnaire
was mailed (5.1%) and those permanently institutionalized (10.4%).
Although 79.9% of women and 75.7% of men had some regular medication,
12.5% (95% CI, 11.2%-13.8%) used at least 1 inappropriate drug routinely (Table 1 and Table 2). Of these, the most commonly used were dipyridamole (3.6%),
long-acting benzodiazepines (2.6%), amitriptyline hydrochloride (1.6%), ergot
mesyloids (1.6%), muscle relaxants (1.2%), and meprobamate (1.1%). Use of
other inappropriate drugs was uncommon (Table 2). No statistical differences were found between sexes.
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Table 1. Demographic Characteristics of the Study Population
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Table 2. Prevalence of Elderly Patients Using Drugs Considered Potentially
Inappropriate for the General Elderly Population22*
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The use of medications that are considered inappropriate with the 15
common medical conditions was common (Table
3). A -blocker was used by 32.5% of diabetic patients taking
oral hypoglycemics or insulin, 37.9% of patients with peripheral vascular
disease, 21.4% of patients with asthma, and 27.2% of those with chronic obstructive
pulmonary disease (COPD). However, two thirds of these patients had concomitant
coronary artery disease. In addition, 19.3% of patients with COPD were using
a sedative, and 1 in 10 with a history of gastroduodenal ulcer was taking
a nonsteroidal anti-inflammatory drug or high-dose aspirin. However, one third
of the latter individuals had a concomitant gastroprotective drug (histamine2 blocker, proton pump inhibitor, or misoprostol). One in 5 patients
with constipation requiring laxatives was using an anticholinergic or narcotic
drug or a tricyclic antidepressant.
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Table 3. Prevalence of Elderly Patients Using Drugs Considered Inappropriate
in Relation to Common Medical Conditions22*
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The population was divided into groups according to the characteristics
known from previous studies1, 3, 7-8
to be associated with the use of inappropriate drugs, and the subgroups were
compared accordingly (Table 4).
Analyses showed that older age (80 years or older), multiple use of medications,
depressive feelings, and poor subjective health were risk factors for the
use of inappropriate drugs.
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Table 4. Rate of Inappropriate Medication Use in Different Patient
Subgroups*
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In addition, we tested how elderly individuals with certain diagnoses
taking essential drugs for their disease differ from those with same diagnoses
but not taking essential drugs in their concomitant use of inappropriate drugs.
However, those patients with coronary heart disease or previous myocardial
infarction taking both aspirin and a -blocker27
(n = 277) did not differ in their use of inappropriate drugs (14.4%) from
other patients (15.4%) with the same diagnoses (n = 449) but not taking aspirin
or a -blocker. In addition, patients with chronic heart failure using
angiotensin-converting enzyme inhibitors28
(n = 162) did not differ in their use of inappropriate drugs (16.0%) from
other patients (16.3%) with chronic heart failure who were not using angiotensin-converting
enzyme inhibitors (n = 569).
COMMENT
In the Finnish, urban, elderly population, the rate of use of at least
1 inappropriate drug was 12.5%, which is markedly less than the rates previously
reported from the United States.15-16,24-25
To our knowledge, this is the first study to apply the additional criteria,
which define potentially inappropriate medications in association with 15
common medical conditions in elderly patients.22
Our findings show that the use of these contraindicated drugs is common, especially
the use of -blockers in conjunction with diabetes, asthma, COPD, and
peripheral vascular disease.
Findings from many former studies16, 24-25
of community-dwelling, elderly patients have shown that 20% to 27% use inappropriate
drugs. However, the proportion of these patients depends on the criteria used,
and with a more conservative application of criteria, the proportion is reduced
to 14%.15 Among frail, elderly patients and
those in nursing homes, the use may be as high as 40%,19, 23
but again, lower figures have been found when only a portion of the inappropriate
drugs were studied.20
Of the most commonly used inappropriate drugs, dipyridamole, long-acting
benzodiazepines, and amitriptyline have frequently appeared in previous studies,15-20,23-25
but their use was clearly less frequent in our study. However, some of the
most commonly used inappropriate drugs in the United States (eg, chlorpropamide)
are not available in Finland. In fact, the national drug policy may have a
great impact on inappropriate drug use. Drugs such as phenylbutazone, pentazocine,
trimethobenzamide hydrochloride, chlorpropamide, and meperidine hydrochloride
are no longer available in Finland. In addition, ticlopidine hydrochloride
has been replaced by clopidogrel as a substitute for aspirin or after coronary
stenting. Prescribing diphenhydramine hydrochloride is difficult because it
is only available in a combination and a separate prescription is needed for
each package.
On the other hand, because no evidence-based treatments exist for many
common medical conditions, such as leg cramps or vertigo, available symptomatic
drugs are used regardless of their effectiveness. Accordingly, use of meprobamate
derives from only one preparation containing meprobamate and quinine hydrochloride
for leg cramps. The use of long-acting benzodiazepines is increased because
a popular combination preparation for vertigo contains small doses of diazepam
and cyclizine hydrochloride. Moreover, the higher price of some new medications
compared with older ones may have an impact. For example, selective serotonin
reuptake inhibitors or tetracyclic antidepressants are 3 to 10 times more
expensive than tricyclics. If a depressed, elderly person cannot afford a
selective serotonin reuptake inhibitor, the physician may elect to prescribe
the second best choice, even with the risk of adverse effects. In addition,
since tricyclic agents are evidence-based treatment for neuropathic pain,29-30 a significant proportion of their
use may derive from this indication. Thus, inappropriate use is not always
easy to define explicitly, and individual decisions may be justified.
The use of dipyridamole has increased only recently in Finland. At the
beginning of the 1990s, results from a meta-analysis31
indicated that dipyridamole had no benefit over aspirin alone in the prevention
of stroke. However, the European Stroke Prevention Study 2,32
a randomized study with more than 6600 patients and 4 treatment arms (aspirin
alone, dipyridamole alone, aspirin plus dipyridamole, placebo), showed that
aspirin alone and dipyridamole alone were more effective than placebo in reducing
the risk of stroke in secondary prevention. Most effective in this respect
was a combination of aspirin and dipyridamole. In our study, 46 (51%) of 90
dipyridamole users reported having had a previous stroke or transient ischemic
attack, with 38 (83%) of these 46 users taking the most effective regimen
according to the European Stroke Prevention Study 2 (ie, the combination of
dipyridamole and aspirin). Thus, about half of the users may be taking dipyridamole
inappropriately.
A large proportion of inappropriate drug use is derived from patients
with the following medical conditions taking -blockers: diabetes (only
with oral hypoglycemics or with insulin), peripheral vascular disease, asthma,
or COPD. However, comorbidity of coronary heart disease is common in patients
with diabetes and peripheral vascular disease. In our cohort, 68.5% of patients
with type 2 diabetes mellitus and 70.5% of those with peripheral vascular
disease who were taking a -blocker had a concomitant coronary artery
disease. Because -blockers improve prognosis of diabetic patients with
coronary artery disease33 or hypertension,34 physicians may justify their decisions if they follow
up the patients and possible adverse effects properly. The same applies to
patients with asthma and COPD, among whom coronary artery disease was also
found to be very common (58.3% and 68.3%, respectively). Fortunately, most -blockers
were 1-selective agents. Of asthmatic patients using -blockers,
29% were taking superselective agents (bisoprolol fumarate, celiprolol) and
an additional 63% were taking 1-selective agents. For patients
with COPD using -blockers, the respective figures were 30% and 46%.
These findings suggest that physicians generally are aware of the possible
harms of -blockers on respiratory function and make their choices accordingly.
However, a closer look at, for example, patients with peripheral vascular
disease but without coronary artery disease who were taking -blockers
revealed other ambiguities in drug use: 7 of 18 used another inappropriate
drug (tricyclics, sedatives, dipyridamole, indomethacin) and an additional
4 of 18 used weak opioids. This may suggest that the latter medications were
used to counteract the adverse effects of -blockers.
On the other hand, older individuals are at risk of underuse of essential
medications.27, 35 We hypothesized
that there might be an inverse relationship between prescribing evidence-based
drugs for certain diagnoses in a patient and prescribing inappropriate medications
in the same patient. However, this was not the case: the use of evidence-based
drugs did not protect the patient from using inappropriate medications, at
least not among patients with coronary heart disease or heart failure.
Our study contained several possible limitations. First, mailed surveys
may not be a reliable method when questioning elderly people about drug use
and actual daily doses used. Nonetheless, the proportion using, for example,
analgesics was very similar to the figures based on another survey of health
behavior among Finnish, elderly patients in 1997.36
Second, all the Beers criteria could not be used with our participants because
of the cross-sectional nature of the study. Some criteria are based on data
of the length of use of medications (corticosteroids), others on daily doses
(short half-life benzodiazepines, digoxin, iron supplements). The latter data
were not considered sufficiently reliable.
Third, one may also question the reliability of self-report on diagnoses.
However, the prevalences of all major diagnoses corresponded well to the epidemiologic
Helsinki Aging Study, in which a random sample of the same age groups from
the same area was assessed carefully and individually for diseases.37 No other population data are currently available
in Finland for these age groups. We could not apply some of the Beers criteria
since definitions of certain medical conditions could not be formulated reliably
in our survey (benign prostate hyperplasia, arrhythmias, syncope, and falls).
On the other hand, definitions of cardiovascular conditions were adhered to
strictly; for example, peripheral vascular disease was defined as a self-report
of diagnosis plus daily symptoms in peroneal muscles while walking. Applying
the criteria in a conservative manner may underestimate the actual use of
inappropriate medications. However, to the best of our knowledge, we have
included more of the Beers criteria than any previous study.
Weighing the potential benefits and harms against individual patients
may lead to prescribing decisions that are inappropriate if inflexible and
explicit criteria are used. Older people are a heterogeneous group, and choice
of treatment should depend on assessing individual predictors of outcome.
A closer look at the diagnoses and drug indications reveals the difficulty
in applying inflexible criteria. In addition, the evidence for potential benefits
and harms changes rapidly, and thus, the criteria should be reviewed regularly.
However, truly problematic use of inappropriate drugs tends to occur among
individuals who use criteria-based inappropriate drugs. Thus, the criteria
might be used to flag persons at risk rather than to impose explicit and inflexible
standards for appropriate prescribing.
AUTHOR INFORMATION
Accepted for publication December 10, 2001.
We thank the Academy of Finland (Helsinki) (grant No. 48613) and the
Ragnar Ekberg Foundation (Nummela, Finland) for financial support.
Corresponding author and reprints: Kaisu H. Pitkala, MD, PhD, Department
of Medicine, Geriatric Clinic, Helsinki University Hospital, PO Box 340, FIN-00029
HUS, Finland (e-mail: kaisu.pitkala{at}hus.fi).
From the Department of Medicine, Geriatric Clinic, Helsinki University
Hospital, Helsinki, Finland.
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