Our January 15, 2008 Patient Safety Tip of the Week ““ focused on prescribing of medications on Beer’s List that may be potentially inappropriate for elderly patients. That column discussed the origin and updating of Beer’s List and ways to improve medication management in the elderly. Most of the published literature on Beer’s List has focused on outpatient or nursing home settings. Relatively little attention has focused on patterns of prescribing for hospitalized elderly inpatients.
An article by Rothberg et al (2008) recently published in the Journal of Hospital Medicine sheds some light on use of such medications on the inpatient side. They found that almost half of all inpatients over the age of 65 in a widely representative hospital sample received at least one medication meeting criteria as a “potentially inappropriate medication” (PIM) from the Beer’s classification. 49% received at least one PIM, 38% received at least one PIM with a high severity rating, and 6% received 3 or more PIM’s.
Prescribing of high severity PIM’s varied substantially across attending physician specialities, being highest for cardiologists (48%) and lowest for geriatricians (24%). Internists, family practitioners, and hospitalists all had median rates of 33%.
There was also great variation across hospitals in PIM usage, especially by geographic location. PIM usage ranged from 34% in the Northeast to 55% in the South. Teaching status of the hospital had little impact. Smaller hospitals had better rates than larger hospitals. Having geriatricians on staff also improved overall hospital prescribing of PIM’s. Patients older than 85 were much less likely to receive a PIM than those aged 65-84 and there was some variation depending on the specific reason for hospitalization.
Note that the study, which was based on review of administrative data, was not able to determine which PIM’s might have been continuation of medications prescribed prior to admission vs. medications newly started in the hospital. The process of medication reconciliation, which is now done on admission and discharge and should be done at all transfers of care, offers a good opportunity to minimize use of PIM’s. In our previous column, we mentioned that when a system in the outpatient setting notifies physicians that one of their patients is on a drug that is on the Beers List, the physician seldom discontinues the flagged drug in that individual patient. However, the number of new prescriptions for that drug diminishes in the patient population cared for by that physician. Perhaps the event of hospitalization may present the opportunity to reassess the potential benefits and risks of those drugs and might lead to their discontinuation.
As we implement CPOE (computerized physician order entry) with clinical decision support, alerts can be programmed to trigger when a PIM is ordered on a patient over a specified age. To minimize the number of alerts a physician may encounter (to avoid “alert fatigue”), we usually try to use standardized order sets wherever possible. However, the Rothberg article raises the possibility that sometimes the standardized order set, which often fails to take into consideration the age of the patient, might actually promote use of certain PIM’s. Therefore, organizations would be wise to review their standardized order sets to see whether any modification for Beer’s list medications is desirable.
While, to our knowledge, no one has ever “validated” the significance of Beer’s List for inpatients, common sense tells us that many of the medications on the list are potentially dangerous for elderly inpatients. Certainly, the sedating agents and several of the medications that produce orthostatic hypotension will increase the risk of falls. And the sedating agents, analgesics, muscle relaxants and anticholinergic agents all have the potential of precipitating or aggravating delirium. Falls and delirium are of importance not only from a human standpoint, but both are on the list of complications for which CMS will no longer be paying come October 2008 (though see our April 22, 2008 Patient Safety Tip of the Week “CMS Expanding List of No-Pay Hospital-Acquired Conditions” where we speculate that delirium may not make the final cut). And several of the drugs may depress respiration or predispose to aspiration or inspissation of secretions, all potentially complicating several conditions that might have led to hospitalization. So while the “evidence base” for use of Beer’s List in elderly inpatients may be scant, we have no problem recommending its use in inpatients.
So don’t hesitate to use some of our most important patient safety interventions, like medication reconciliation and CPOE, to reduce the risk of adverse events from Beer’s List drugs in the elderly hospitalized patient as well as the elderly outpatient.
Update: See also our Patient Safety Tips of the Week for January 15, 2008 “ and October 19, 2010 “ ” and September 22, 2009 “Psychotropic Drugs and Falls in the SNF” and our What’s New in the Patient Safety World columns for September 2010 “Beers List and CPOE”.
Rothberg MB, Pekow PS, Liu F, Korc-Grodzicki B, Brennan MJ, Bellantonio S, Heelon M, Lindenauer PK. Potentially Inappropriate Medication Use in Hospitalized Elders. Journal of Hospital Medicine 2008; 3: 91-102 http://www3.interscience.wiley.com/journal/118860229/abstract