Inappropriate medication use in hospitalized older adults—Is it time for interventions?

M edications are central to managing the health of older patients. In 2006, more than 93% of adults 65 years or older reported taking at least 1 medication in the last week, 58% reported taking 5 or more medications, and 18% reported taking 10 or more. Medication use by older adults will likely increase further as the U.S. population ages, new drugs are developed, and new therapeutic and preventive uses for medications are discovered. Older patients, especially those who are chronically frail or acutely ill, may require special consideration when making prescribing decisions because of age-related changes in the metabolism and clearance of medications and enhanced pharmacodynamic sensitivities. Thus, panels of experts in pharmacology and geriatrics have compiled lists of medications to avoid prescribing for patients 65 years of age or older. The most commonly used list is the Beers criteria, which were introduced in 1991 to serve researchers evaluating prescribing quality in nursing homes. The Beers criteria were updated in 1997 and again in 2003 to include 48 ‘‘potentially inappropriate medications’’ (PIMs) for which, according to the consensus panel, there are more effective or safer alternatives for older patients. Numerous studies in the last 15 years have found that PIMs continue to be used in 12% to 40% of older patients in community and nursing home settings. To address the continued use of PIMs, the Centers for Medicare and Medicaid Services incorporated the Beers criteria into federal safety regulations for longterm care facilities in 1999. In 2006, the prescription rate of PIMs was introduced as a Health Plan and Employer Data and Information Set (HEDIS) quality measure for managed care plans. Despite adoption of the Beers criteria to monitor prescribing quality and safety in nursing homes and outpatient settings, there has been considerably less study of potentially inappropriate medication use in hospitalized patients. In this issue of the Journal of Hospital Medicine, Rothberg and colleagues analyzed administrative data from nearly 400 hospitals across the United States and found that nearly half of all older patients hospitalized for 7 common conditions were prescribed at least 1 PIM. Thus, the incidence of PIM use in hospitalized older patients far exceeded that reported in most studies of community-dwelling or nursing home patients. Most notable, however, was the variability found in prescribing rates based on a number of physician and hospital characteristics. For example, although hospitalists and geriatricians were found to be less likely to prescribe PIMs than cardiologists and general internists, among high-volume cardiologists and internists, PIM prescribing rates ranged widely, from 0% to more than 90%. The findings and conclusions expressed are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention.