Explicit versus implicit evaluation to detect inappropriate medication use in geriatric outpatients

Figures & data

Table 1. Characteristics of the study population.

Characteristics	Mean ± SD or proportion (n)
Age (n = 206) (years)	77.5 ± 6.6
Sex (n = 206)
Female	63.6% (n = 131)
Male	36.4% (n = 75)
Functionality (n = 203)
ADL
Independent	86.2%
Partially dependent	11.8%
Dependent	2%
IADL
Independent	53.7%
Partially dependent	35%
Dependent	11.3%
Nutritional assessment (n = 190)
Malnutrition	26.3% (n = 50)
Malnutrition risk	32.6% (n = 62)
Dementia (n = 206)	31.6% (n = 65)
Depression (n = 181)	36.5% (n = 66)
Falls (n = 206)	38.8% (n = 80)

ADL: activities of daily living; IADL: instrumental activities of daily living; Falls: one or more falls in previous year.

Table 2. The data on inappropriate precriptions by explicit evaluation^a versus implicit evaluation^b.

Explicit evaluation^a^,c
Patients with PIP (n, %)	83 (40.3%)
PIP number (n, %)	129 (62.6%)
PIP per patient	0.6
Implicit evaluation^b
(i) Clinician’s implicit evaluation identified by the explicit criteria set
Patients with PIP (n, %)	74 (35.9%)
PIP number (n, %)	110 (53.4%)
PIP per patient	0.5
(ii) Clinician’s implicit evaluation not identified by the explicit criteria set (additional PIPs)
Patients with PIP (n, %)	80 (38.8%)
PIP number (n, %)	122 (59.2%)
PIP per patient	0.6
(iii) Clinician’s total implicit evaluation
Patients with PIP (n, %)	117 (56.8%)^c
PIP number (n, %)	232 (112.6%)
PIP per patient	1.1
Non-compliance to explicit evaluation^d
Patients with non-compliance (n, %)	18 (21.7%)
PIPs with non-compliance (n, %)	19 (14.7%)

PIP: potentially inappropriate prescription.

^a Explicit evaluation by STOPP version 2 criteria among total study patients.

^b Implicit evaluation mediated by comprehensive geriatric assessment among total study patients.

^c n = 37 patients were common in two groups of implicit evaluation.

^d Non-compliance to explicit evaluation was evaluated among patients identified having PIP by systematic application of STOPP criteria (n = 83 patients, total PIP number= 129).

Table 3. The criteria and reasons related to non-compliance to systematic application of STOPP version 2 criteria (n = 19).

I. Need of treatment despite the likelihood of anticipated side effects, n = 13

Criterion

B9. Loop diuretic for treatment of hypertension with concurrent urinary incontinence (may exacerbate incontinence), n = 6

Reason of non-compliance

Presence of congestive heart failure and/or renal failure necessitating use of loop diuretics to control hypertension

Criterion

K2. Drugs that predictably increase the risk of falls in older people: Neuroleptic drugs (may cause gait dyspraxia, Parkinsonism), n = 4

Reason of non-compliance

Presence of severe behavioural symptoms necessitating use of neuroleptics in dementia patients prone to falls

Criterion

D8. Anticholinergics/anti-muscarinics in patients with delirium or dementia (risk of exacerbation of cognitive impairment), n = 3

Reason of non-compliance

Presence of problematic urinary incontinence necessitating use of bladder anti-muscarinics in demented patients

II. Need of treatment in the absence of anticipated side effects, n = 6

Criterion

D11. Acetylcholinesterase inhibitors with a known history of persistent bradycardia (<60 beats/min), heart block or recurrent unexplained syncope or concurrent treatment with drugs that reduce heart rate such as beta-blockers, digoxin, diltiazem, verapamil (risk of cardiac conduction failure, syncope and injury), n = 2

Reason of non-compliance

Presence of congestive heart failure or atrial fibrillation necessitating use of beta-blockers (no bradycardia or heart block)

Criterion

G3. Anti-muscarinic bronchodilators (e.g. ipratropium, tiotropium) with a history of narrow angle glaucoma (may exacerbate glaucoma) or bladder outflow obstruction (may cause urinary retention), n = 2

Reason of non-compliance

Presence of chronic obstructive pulmonary disease in patients with benign prostate hyperplasia (no urinary retention)

Criterion

B3. Combined use of beta blockers with verapamil or diltiazem (risk of heart block risk), n = 1

Reason of non-compliance

Presence of atrial fibrillation necessitating use of combined beta-blocker and diltiazem for rate control (no heart block)

Criterion

G4. Non-selective beta blocker (whether oral or topical for glaucoma) with a history of asthma requiring treatment (risk of increased bronchospasm), n = 1

Reason of non-compliance

Presence of oesophageal varices necessitating use of non-selective beta blocker (no bronchospasm)

Table 4. The details and reasons of inappropriate prescriptions that were not identified by STOPP version 2^a (additional PIPs).

Vitamin–mineral–dietary supplements, n = 27 (22.1%)

Use without indication, n = 23

Potential drug interaction, n = 4

Anti-hypertensives, n = 21 (17.2%)

Presence of hypotension or orthostatic hypotension, n = 19

Diuretic (thiazide) as first line treatment in patients with incontinence or falls, n = 2

Proton pump inhibitors, n = 13 (10.7%)

Use without indication (for polypharmacy, n = 8 or low dose aspirin, n = 5)

Piracetam, n = 10 (8.2%)

Use without indication (for cognitive impairment)

Antidiabetics, n = 9 (7.4%)

Use despite presence of low blood glucose/HbA1c and/or malnutrition

PIP: potentially inappropriate prescription.

^a n = 80 patients, additional PIP number= 122.