Andreas Schoenenberger works with the Division of Geriatrics, Department of General Internal Medicine at Bern University Hospital, and with the University of Bern, Switzerland. Here he describes his recent editorial in Age and Ageing journal, written with Andreas Stuck.
Despite recent efforts to improve drug management for older people, we have not yet arrived at an optimal strategy for reducing inappropriate drug use. Drugs are considered inappropriate, if the risk outweighs the potential benefit of the drug. Along with pathophysiological changes during the ageing process, and the increasing number of co-morbidities/-medications, the potential risks of drugs increase with age and adverse drug reactions (ADRs) are encountered more frequently in older persons.
Inappropriate drug use and ADRs are hot topics in geriatric medicine. ADR is an important outcome the clinician wants to avoid, and inappropriate drug use is one of the potentially modifiable risk factors. Therefore, several tools to detect inappropriate drug use have been developed in recent years (e.g., Beers criteria, STOPP list). These tools were found to identify a high prevalence of potentially inappropriate drug use. An interesting study from Tosato et al., published recently in Age and Ageing, showed that both, the updated Beers criteria and the STOPP list, not only identified a high prevalence of potentially inappropriate drug use, but also that potentially inappropriate drug use was associated with ADR and another important outcome, functional decline.
Currently one important question remains: does the use of tools such as the Beers or STOPP list ultimately improve patient outcomes? Current evidence from intervention trials suggests that the implementation of both these tools reduces inappropriate drug use and the level of polypharmacy, as well as drug-drug and drug-disease interactions, but no study so far showed that this improves important patient outcomes such as mortality and morbidity.
To move the field in the right direction, we offer three suggestions. First, intervention trials should demonstrate if tools, such as the Beers criteria or the STOPP list, ultimately improve important patient outcomes, including mortality. Second, medical education should address the question of drug management in older persons, and issues of inappropriate drug use, beginning in the first year of medical school and continuing throughout later medical education. Third, to improve drug management in older persons, currently available tools for the identification of inappropriate drug use, such as the Beers criteria or the STOPP list, should be systematically implemented and used in the clinical care of older persons. There is potential for optimization, for example, by incorporating these tools into electronic databases which clinicians can automatically check for potential inappropriate drug use and drug-drug interaction, or by building computer-based decision-support and electronic prescribing systems. Concomitantly, additional tools for other aspects of drug management should be implemented, such as the START list to avoid drug underuse or the CRIME recommendations specifically developed for complex patients. It is time for action.
The full editorial can be read in Age and Ageing journal here.
It accompanies a research paper by Onder Graziano et al: Inappropriate Drug Use among Hospitalized Older Adults: Results from the CRIME Study.
In the UK whilst Community Pharmacists are reimbursed through dispensing fees and medicines reimbursement their undoubted capability to contribute to poly-pharmacy management etc is clearly at odds with their present mechanism of reimbursement. For Care Homes we need to consider and explore new models where fees are paid for Pharmacy services not item based dispensing and medicines costs reimbursed with a handling charge. These rather organisational (=difficult) revisions could change the landscape very quickly