Potentially Inappropriate Medications

By Richard Baron, MD, and Jonathan Vandergrift

More education is needed about this ongoing quality issue for older adults.

Most geriatricians are probably aware that older patients are often prescribed medications that may be dangerous for them despite the fact that alternative, more age-appropriate medications are typically available. The American Geriatrics Society (AGS) Beers criteria is the most widely known guideline regarding these potentially inappropriate medications (PIMs), though there are other lists, such as the START/STOP criteria.1,2 The medications that comprise these PIM lists are numerous and may be prescribed for multiple ailments in younger patients. Recent estimates suggest at least 20% of community-dwelling adults age 65 or older are prescribed PIMs annually in the United States, the most common PIMs being benzodiazepines, non-benzodiazepine hypnotics, tricyclic antidepressants, and first-generation antihistamines.3

Why Might These Medications Be Inappropriate?
The reason older patients should avoid these medications is basic: The risks exceed the benefits, especially compared with more appropriate alternative therapies.4 Much of this is due to age-related physiological changes concerning drug metabolism and clearance as well as a greater sensitivity to medication side effects. In aggregate, PIMs have been associated with a higher risk of adverse drug events, emergency department visits, and hospitalizations.5,6

Specific serious bad outcomes though can differ depending on the medications prescribed. For example, benzodiazepines cause delirium and mobility issues and are associated with a 15% increased risk of fracture and a 35% increased risk of a hip fracture.7 The latter injury is especially consequential given that one-quarter of older adults with a hip fracture die within one year.8 A similar increased risk of falls is also observed for tricyclic antidepressants. Anticholinergic medications, such as first-generation antihistamines or antidepressants, can have an array of short-term side effects including reduced cognitive and physical functioning.9 Cumulative use of anticholinergic medications can also have serious longer-term risks including a 50% increased risk of dementia and Alzheimer’s disease.10

Why, Then, Are PIMs So Often Prescribed?
Although the reasons for PIM prescribing may be varied, a recent empirical study by researchers from the American Board of Internal Medicine (ABIM) suggests that gaps in knowledge, coupled with a lack of awareness of safer alternative medications, may be important drivers of more PIM prescribing.11 You might think, in a world where knowledge is always accessible, that walking around with knowledge doesn’t mean much, but this study correlating performance on the ABIM knowledge exam and prescribing of PIMS tells a very different story. In particular, if all outpatient general internists prescribed PIMs as did those scoring in the top quartile on their internal medicine Maintenance of Certification assessment, then 40,000 fewer older-age patients with fee-for-service Medicare Part D drug coverage would be prescribed a PIM each year. This is a sizable number despite that this estimate does not include PIMs prescribed by physicians from other specialties or prescribing for patients with Medicare advantage plans.

More evidence regarding the link between knowledge and PIM prescribing comes from the real lived experience of physicians as described in a recent systematic review of qualitative studies.12 This review illustrates the ways in which knowledge gaps, such as not being aware of age-specific risks of individual medications or alternative safer therapeutic options, are important barriers to safer prescribing. For example, a superficial awareness of safe prescribing guidelines might lead one to view them as too general and not applicable to “their” patients, leading one to prescribe potentially inappropriate medications more liberally. With a greater awareness of the evidence and clinical reasoning on which the guidelines are based, this same physician might arrive at a different, safer prescribing recommendation.

Another example illustrating the interplay between guidelines and physician knowledge comes from a recent study of opioid prescribing for older patients with new-onset lower back pain.13 This study compared opioid prescribing before vs after guidelines were changed in 2015 to recommend against prescribing opioids for new back pain. Following these guideline changes, only the most knowledgeable physicians, as measured by performance on the ABIM’s internal medicine Maintenance of Certification assessment, reduced their opioid prescribing for new-onset low back pain. In contrast, less knowledgeable physicians continued to prescribe opioids at an elevated rate.

Knowledge limitations can also exacerbate another important barrier to safer prescribing, namely, a physician’s lack of self-confidence or motivation to change or reduce medications prescribed by another physician.12 Physicians’ self-confidence is partially rooted in their depth of medical knowledge, and it’s understandable how a generalist might be unwilling to alter a prescription written by a specialist because they believe the specialist must know something they do not. A generalist well versed in not only the guideline recommendations but also the evidence and clinical reasoning on which they are based is better equipped to challenge prescribing decisions that might be dangerous for their patients.

Can More Knowledge Help?
Reinforcing the importance of knowledge in addressing PIM prescribing issues is that a number of successful interventions designed to reduce inappropriate prescribing over the last decade have included physician education as a major component. In the primary care setting, the IMPROVE program funded by the VA significantly reduced PIM prescribing from 23% to 17% among rural primary care physicians in Georgia.14 In emergency medicine, the VA’s EQUiPPED program reduced PIM prescribing at four large urban VA emergency departments, including one where PIM prescriptions were cut from 12% to 5% of patients.15 The structure of these educational programs included components such as didactic group lectures and tailored one-on-one medication reviews. Often, interventions take a multipronged approach, combining different educational approaches with other components such as electronic tools to flag prescribed PIMs. Program evaluations have also demonstrated the potential benefits of providing educational material to a physician’s patients along with tailored academic detailing for the physician.16

Another opportunity to reduce PIM prescribing through education is during residency. The Accreditation Council for Graduate Medical Education requires four weeks of internal medicine residency be dedicated to training in geriatric medicine.17 It’s unclear though how much time is focused on addressing safe prescribing for older adult patients. One study aimed at reducing PIM prescribing among internal medicine residents during their emergency medicine rotations found that though 90% were confident in their ability to prescribe safely to older adults, 86% did not routinely consider Beers criteria when prescribing, and 50% said they had never heard of or not used the Beers criteria when making prescribing decisions.18 After attending a didactic seminar on safe prescribing for older adults coupled with periodic feedback and academic detailing regarding their actual prescribing recommendations, the residents reduced their PIM prescribing by 27%. While this only represents the experience of a single large program during the 2013/2014 training year, it suggests that internal medicine residents are not receiving an adequate education about safe prescribing for older adults.

The continued importance of medical knowledge in the treatment of older populations goes beyond prescribing safety. Greater physician knowledge has also been linked to a dramatic reduction in the risk of death and hospitalizations for older patients presenting with condition that were at high risk for diagnostic errors such as stroke after a patient presents with dizziness.19 Here, older patients were 30% less likely to be hospitalized or die if their first contact physician had a high vs low level of diagnostic knowledge.

What About Practice Infrastructure and/or Health IT Solutions?
One of the key motivators for the large expansion of health information technology (IT) and practice infrastructure across the United States over the last decade was to improve quality care by improving access to information at the point of care. One would think that electronic health record alerts that flag potentially inappropriate prescriptions or compile aggregate feedback on PIM prescribing rates would, alone, be an effective means of reducing these prescriptions. As it turns out, these system interventions need to be accompanied by physician education to be effective, such as one-on-one counseling with a clinical pharmacist or geriatrics specialist.20 Individual medication alerts or feedback on prescribing patterns has tremendous utility for a clinician who is knowledgeable of the dangers of a particular medication as well as alternative medication choices that might be safer. For others, these alerts might be swept aside with good intentions, such as physicians trying to do what they think is the best to help their patients who are suffering with a particular ailment. As such, the most effective system interventions have combined elements such as electronic health record alerts with academic detailing by a knowledgeable clinician, such as a geriatric specialist or pharmacist, to discuss medication choice.21

So, What’s the Answer?
Even in an age in which physicians carry a complete medical library in their pockets, their medical knowledge continues to be critically important to providing high-quality care. In the hands of a skilled and knowledgeable physician, these health IT and practice infrastructure tools can be employed to their maximum effectiveness. However, they do not seem to serve the function of closing quality gaps between physicians with differing levels of medical knowledge.22 In the final analysis, geriatrics is a cognitive discipline in which clinical knowledge across a wide variety of subjects continues to be central to geriatricians’ effectiveness as caregivers for older adult patients.

— Richard Baron, MD, board certified in internal medicine and geriatric medicine, is president and CEO of the American Board of Internal Medicine and the ABIM Foundation. He is a former chair of the American Board of Internal Medicine's Board of Directors and served on the ABIM Foundation Board of Trustees.

— Jonathan Vandergrift is health services researcher, Assessment & Research, at the American Board of Internal Medicine in Philadelphia.

References
1. 2019 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2019;67(4):674-694.

2. O'Mahony D, O'Sullivan D, Byrne S, O'Connor MN, Ryan C, Gallagher P. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2014;44(2):213-218.

3. Li G, Andrews HF, Chihuri S, et al. Prevalence of potentially inappropriate medication use in older drivers. BMC Geriatr. 2019;19(1):260.

4. Hanlon JT, Semla TP, Schmader KE. Alternative medications for medications in the use of high-risk medications in the elderly and potentially harmful drug-disease interactions in the elderly quality measures. J Am Geriatr Soc. 2015;63(12):e8-e18.

5. Brown JD, Hutchison LC, Li C, Painter JT, Martin BC. 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. 2016;64(1):22-30.

6. Chen CC, Cheng SH. Potentially inappropriate medication and health care outcomes: an instrumental variable approach. Health Serv Res. 2016;51(4):1670-1691.

7. Xing D, Ma X, Ma J, Wang J, Yang Y, Chen Y. Association between use of benzodiazepines and risk of fractures: a meta-analysis. Osteoporos Int. 2014;25(1):105-120.

8. Panula J, Pihlajamäki H, Mattila VM, et al. Mortality and cause of death in hip fracture patients aged 65 or older-a population-based study. BMC Musculoskelet Disord. 2011;12:150.

9. Fox C, Smith T, Maidment I, et al. Effect of medications with anti-cholinergic properties on cognitive function, delirium, physical function and mortality: a systematic review. Age Ageing. 2014;43(5):604-615.

10. Gray SL, Anderson ML, Dublin S, et al. Cumulative use of strong anticholinergics and incident dementia: a prospective cohort study. JAMA Intern Med. 2015;175(3):401-407.

11. Vandergrift JL, Weng W, Gray BM. The association between physician knowledge and inappropriate medications for older populations. J Am Geriatr Soc. 2021;69(12):3584-3594.

12. Anderson K, Stowasser D, Freeman C, Scott I. Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis. BMJ Open. 2014;4(12):e006544.

13. Gray BM, Vandergrift JL, Weng W, Lipner RS, Barnett ML. Clinical knowledge and trends in physicians' prescribing of opioids for new onset back pain, 2009-2017. JAMA Netw Open. 2021;4(7):e2115328-e2115328.

14. Vandenberg AE, Echt KV, Kemp L, McGwin G, Perkins MM, Mirk AK. Academic detailing with provider audit and feedback improve prescribing quality for older veterans. J Am Geriatr Soc. 2018;66(3):621-627.

15. Stevens M, Hastings SN, Markland AD, et al. Enhancing Quality of Provider Practices for Older Adults in the Emergency Department (EQUiPPED). J Am Geriatr Soc. 2017;65(7):1609-1614.

16. Martin P, Tamblyn R, Benedetti A, Ahmed S, Tannenbaum C. Effect of a pharmacist-led educational intervention on inappropriate medication prescriptions in older adults: the D-PRESCRIBE Randomized Clinical Trial. JAMA. 2018;320(18):1889-1898.

17. Accreditation Council for Graduate Medical Education. ACGME program requirements for graduate medical education in internal medicine. https://www.acgme.org/globalassets/pfassets/program
requirements/140_internalmedicine_2021.pdf. Updated July 1, 2021. Accessed December 1, 2021.

18. Moss JM, Bryan WE 3rd, Wilkerson LM, et al. An interdisciplinary academic detailing approach to decrease inappropriate medication prescribing by physician residents for older veterans treated in the emergency department. J Pharm Pract. 2019;32(2):167-174.

19. Gray BM, Vandergrift JL, McCoy RG, Lipner RS, Landon BE. Association between primary care physician diagnostic knowledge and death, hospitalisation and emergency department visits following an outpatient visit at risk for diagnostic error: a retrospective cohort study using Medicare claims. BMJ Open. 2021;11(4):e041817.

20. O’Mahony D. STOPP/START criteria for potentially inappropriate medications/potential prescribing omissions in older people: origin and progress. Expert Rev Clin Pharmacol. 2020;13(1):15-22.

21. Monteiro L, Maricoto T, Solha I, Ribeiro-Vaz I, Martins C, Monteiro-Soares M. Reducing potentially inappropriate prescriptions for older patients using computerized decision support tools: systematic review. J Med Internet Res. 2019;21(11):e15385.

22. Vandergrift JL, Gray BM. Physician clinical knowledge, practice infrastructure, and quality of care. Am J Manag Care. 2019;25(10):497-503.