Skip to main content

Some NLM-NCBI services and products are experiencing heavy traffic, which may affect performance and availability. We apologize for the inconvenience and appreciate your patience. For assistance, please contact our Help Desk at info@ncbi.nlm.nih.gov.

British Journal of Clinical Pharmacology logoLink to British Journal of Clinical Pharmacology
. 2015 May 26;80(2):315–324. doi: 10.1111/bcp.12615

Potentially inappropriate drug use in older people: a nationwide comparison of different explicit criteria for population-based estimates

Lucas Morin 1,, Johan Fastbom 1, Marie-Laure Laroche 2,3, Kristina Johnell 1
PMCID: PMC4541979  PMID: 25702921

Abstract

Aims

The aim was to investigate the prevalence of potentially inappropriate medication use among older people in Sweden according to five different published sets of explicit criteria from Europe and the US.

Methods

This was a nationwide cross-sectional, register-based study across the whole of Sweden in 2008. All individuals aged 65 years and older were included (n = 1 346 709, both community-dwelling and institutionalized persons). We applied all drug-specific criteria included in the 2012 Beers Criteria, the Laroche’s list, the PRISCUS list, the NORGEP criteria and the Swedish National Board of Health and Welfare criteria. The main outcome was the potentially inappropriate drug use according to each set of criteria, separately and combined. Multivariate logistic regression models were used to identify individual factors associated with the use of potentially inappropriate drugs.

Results

The prevalence of potentially inappropriate medication use varied between the explicit criteria from 16% (NORGEP criteria) to 24% (2012 Beers criteria). Overall, 38% of the older people were exposed to potentially inappropriate drug use by at least one of the five sets of criteria. While controlling for other possible covariates, female gender, institutionalization and polypharmacy were systematically associated with inappropriate drug use, regardless of the set of explicit criteria we considered.

Conclusion

Although explicit criteria for inappropriate drug use among older people have been reported to be quite different in their content, they provide similar measures of the prevalence of potentially inappropriate drug use at the population level.

Keywords: inappropriate drug use, medications, older adults, pharmacoepidemiology

What is Already Known about this Subject

  • Identifying potentially inappropriate medications is of central importance in order to reduce the occurrence of drug-related problems and adverse drug events in older patients.

  • Several assessment tools for inappropriate drug use have been developed over the past two decades, both in the US and in Europe.

  • Recent reviews have emphasized major differences in the development, structure and content of these tools. However, only a handful of original studies have compared the actual prevalence of potentially inappropriate drug use according to the different existing criteria.

What this Study Adds

  • For the first time, a nationwide, population-based study used five different sets of criteria developed in five different countries to measure the prevalence of potentially inappropriate drug use among older people.

  • Overall, 16% to 24% of all older adults (≥65 years) in Sweden are exposed to medications whose expected benefits are deemed lower than the risks they present.

  • The different sets of criteria we compared measure the overall exposure to potentially inappropriate drug use to a very similar extent (in particular the criteria developed in Europe), even though these sets of criteria overlap very little both in content and in the population they cover.

  • This study supports the use of these criteria by public health policy makers, stakeholders and researchers to evaluate the quality of drug use at the population level, especially in a cross-national perspective. However, at the clinical level, our results raise important questions regarding the comprehensiveness of each of these tools, and therefore their applicability in daily practice.

Introduction

Background

Ageing is often associated with chronic conditions and multiple morbidities, leading to an increased use of medications. At the same time, age-related pharmacokinetic and pharmacodynamic changes (e.g. denutrition, increase of the ratio body fat: body water and decline of liver and renal function) affect the distribution, metabolism and excretion of drugs 13. As a consequence of this combination, older people are at high risk of drug–drug interactions and adverse drugs reactions 4,5 that may, in turn, cause adverse health outcomes, including emergency department visits, hospitalizations, functional decline and mortality 610. Drugs are considered to be potentially inappropriate for older people when the risk of harmful effects exceeds their expected benefit for the patient and when a safer, better tolerated or more effective alternative drug is available 5. Identifying these ’potentially inappropriate medications’ is therefore of central importance in order to reduce the occurrence of drug-related problems and adverse drug events in older patients.

Several assessment tools for inappropriate drug use have been developed over the past two decades, based on implicit or explicit approaches 11. The latter usually consist of a list of medications that have been considered inappropriate for older people through a literature review and expert consensus methods. These lists include either single drug, drug combination or drug–disease criteria. In contrast to implicit tools (i.e. clinician’s assessment), explicit criteria are highly reproducible and can easily be applied to large scale studies of patients with a limited cost 5,12.

Such explicit criteria have been developed in the US 1317, Canada 18,19, Australia 20, Ireland 21, France 22, Germany 23, Sweden 24,25, Norway 26, Italy 27, Austria 28, Thailand 29 and Taiwan 30. However, recent reviews have outlined major differences in the development, structure and content of the published criteria 11,3134. These discrepancies raise important concerns about their respective ability to detect potentially inappropriate drug use in older people in different care settings 35. Only a few original studies have compared the prevalence of potentially inappropriate drug use in a single large cohort according to different sets of explicit criteria 3538. These studies have also often been restricted in their generalizability, either by their small sample size or by their selective study setting. Yet, as these criteria have become an important tool in geriatric care, comparisons in large, population-based studies are needed to ascertain the performance of the individual criteria in detecting potentially inappropriate drug use and to determine if the prevalence estimates are consistent across criteria.

Therefore, the aim of the present study was to investigate the prevalence of potentially inappropriate medication use among older people in Sweden according to five different published sets of explicit criteria, in order to compare the estimates provided by these criteria. We also examined individual factors associated with use of potentially inappropriate medications based on each of the five sets of criteria, in order to determine if some of these tools were more sensitive to older people’s characteristics (i.e. age, gender, living situation, number of drugs) than others.

Methods

Study population

We used the Swedish Prescribed Drugs Register (SPDR) to analyze the prevalence of prescribed and dispensed drugs to older people aged 65 years and over. This individual-based register was implemented in 2005 and covers all prescribed drugs delivered from pharmacies to the whole Swedish population (9.7 million inhabitants in 2014) 39. The SPDR includes, among others, the patients’ age, gender and place of residence, and detailed information about the drug and dosage.

In Sweden, drugs are prescribed for a maximum duration of 3 months 40. For this study, we analyzed information related to people aged 65 years and older who were included in the register between 1 July and 30 September 2008. Based on data about the date of prescription, amount of delivered drug and dosage of each medication, a list of current medications for each individual was computed at the arbitrarily chosen date of 30 September 2008. If the same drug was dispensed more than once during the study period, it was counted as one drug 4143.

In addition, we obtained data on the living arrangements of each individual by linking the SPDR to the Swedish Social Services Register, which contains information about institutional care provided by municipalities to older people at the national level (in Sweden, the municipality system includes almost all elderly care) 44. The living situation was categorized into ’community-dwelling’ and ’institutionalized’, according to a procedure described elsewhere 43. After exclusion of records with missing values on the living situation (n = 855), the study population consisted of 1 346 709 people, accounting for 81.2% of the entire Swedish population aged ≥ 65 years in September 2008 45.

Measurements

We included sets of explicit criteria that were developed in Europe or in Northern America, published in 2005 or later, and containing a major proportion of drug-specific criteria, as the Swedish Prescribed Drugs Register does not include information about the underlying clinical indications and diagnoses. The STOPP-START criteria, which contain a majority of drug–disease items could, for instance, not be computed based on the available data. Therefore, five different sets of explicit criteria were included in the comparison:

  • The 2012 update of the Beers criteria, released by the American Geriatrics Society 17. The first version of the Beers criteria was issued in 1991 to identify potentially inappropriate medication use among nursing home residents 13 and was revised in 1997 and 2003 in order to be applicable also for community-dwelling older people 14,16. The fourth revised edition contains 53 individual medications or medication classes (of which 34 are single drug and drug specific criteria) that are considered as inappropriate for people aged 65 years and older in ambulatory and institutional settings.

  • The Laroche list was published in 2007 and was designed to detect potentially inappropriate drug use for people aged 75 years and over both in the community and in nursing home facilities in France 22. Among the 34 statements included in this list, 29 are drug-specific criteria (including 27 single drugs and two drug combinations).

  • The Norwegian General Practice (NORGEP) criteria were published in 2009, with a focus on older adults aged ≥70 years 26. This set contains 36 drug-specific criteria (21 single drugs and 15 drug combinations) deemed to be potentially inappropriate in general practice.

  • The PRISCUS list was established in Germany in 2010 23. In this set, 83 drugs or drug classes are considered potentially inappropriate for all older people aged ≥65 years, regardless of their disease or the clinical condition, both in the community and in the institutional setting.

  • The updated version of the criteria issued by the Swedish National Board of Health and Welfare (’Socialstyrelsen’) in 2010 25. Eight of these 34 criteria are drug-specific, including six single drug criteria and two drug combination criteria 24. These criteria are applicable for the entire population aged 65 years and older, in the community and in nursing home facilities.

All the drug-specific criteria were extracted from each of these five sets. Corresponding Anatomical Therapeutic Chemical (ATC) codes and dosages were applied to measure the prevalence of potentially inappropriate medication use in our study population. Criteria involving the disease or the clinical conditions of the individuals were not considered. For each set of criteria, the overall prevalence of potentially inappropriate drug use was defined as the proportion of individuals exposed to at least one criterion within the study population.

Statistical analysis

We computed descriptive statistics to measure the overall prevalence of potentially inappropriate drug use according to each set of criteria, separately and combined. When applicable, crude proportions were also used to compare the exposure to single drug and drug combinations criteria. In addition, we carried out a series of multivariate logistic regression models to investigate the associations between the characteristics of the individuals (i.e. gender, age, living situation and number of prescribed medications) and the use of at least one potentially inappropriate drug according to each set of criteria separately. We also examined if these associations remained stable after combining the sets of criteria either into an ’alternative’ model (i.e. detection by at least one of the five sets of criteria) or into a ’cumulative’ model (i.e. detection by each of the five sets of criteria). Adjusted odd ratios (ORs) and 95% confidence intervals (CIs) were estimated. We used the area under the ROC curve (AUC) as a proxy to assess the goodness-of-fit of each model. Finally, we measured the level of agreement between the different sets of criteria by using both the sensitivity/specificity and the kappa coefficient. All statistical analyses were performed using SAS JMP v.11.0 (SAS Institute, Inc., USA).

The study was approved by the ethics review board in Stockholm (Dnr 2009/477-31/3).

Results

Characteristics of the study population

Table1 presents the main characteristics of the study population. The mean (± SD) age was 76.2 (7.2) years and about 6.4% of the study population lived in nursing homes. Overall, they received an average (± SD) of 4.6 (3.4) drugs; 42% received five drugs or more and 9.1% received 10 different drugs or more. The mean (± SD) number of prescribed drugs was higher among institutionalized than among community-dwelling elderly (7.3 ± 3.7 vs. 4.4 ± 3.3, respectively, P < 0.001).

Table 1.

Characteristics of the study population (n = 1 346 709), Sweden 2008

Male (n = 572 150) Female(n = 774 559)
n % n %
Age (years)
 Mean (SD) 75.3 (7.5) - 77.0 (8.1) -
 Median (IQR) 74 (12) - 76 (13) -
 65 to 74 291 783 51.0% 334 118 43.1%
 75 to 84 202 774 35.4% 281 581 36.4%
 85 to 94 74 036 12.9% 145 843 18.8%
 95 and over 3557 0.6% 13 017 1.7%
Living situation
 Home 546 467 95.5% 713 930 92.2%
 Nursing home 25 683 4.5% 60 629 7.8%
Number of drugs
 Mean (SD) 4.4 (3.3) - 4.7 (3.5) -
 Median (IQR) 4 (4) - 4 (5) -
 0 23 737 4.1% 24 441 3.2%
 1 89 294 15.6% 109 834 14.2%
 2 83 619 14.6% 107 868 13.9%
 3 77 006 13.5% 99 901 12.9%
 4 69 085 12.1% 90 007 11.6%
 5 and more 229 409 40.1% 342 508 44.2%

Overall prevalence of potentially inappropriate drug use

The prevalence of potentially inappropriate medication use varied from 16% (NORGEP criteria) to 24% (2012 Beers criteria) of the study population (Table2). The application of the criteria from the Swedish National Board of Health and Welfare provided a prevalence of 19%, very similar to the prevalence measured by PRISCUS and Laroche’s criteria (18% and 19%, respectively). For single drug criteria, the prevalence ranged from 9.4% (NORGEP) to 24% (2012 Beers), and for drug combination criteria from 4.6% to 11% (Laroche’s and Swedish National Board of Health and Welfare criteria, respectively).

Proportion of older people exposed to potentially inappropriate medications in Sweden, 2008 (n = 1 346 709)

Single drug criteria Drug combinations criteria* Overall exposure
n % n % n %
NORGEP 126 094 9.4% 120 143 8.9% 215 088 16.0%
PRISCUS 238 387 17.7% - - 238 387 17.7%
Laroche 240 573 17.9% 62 162 4.6% 256 167 19.0%
Swedish National Board of Health and Welfare 161 240 12.0% 152 240 11.3% 257 079 19.1%
Beers (2012) 325 256 24.1% - - 325 256 24.1%
At least one of the five sets of criteria 447 111 33.2% 232 754 17.3% 506 607 37.6%
All the sets of criteria 50 753 3.8% 26 953 2.0% 70 209 5.2%
*

The PRISCUS list and the Beers criteria contain no criteria based on drug combinations

Overall, 38% of the older people were exposed to potentially inappropriate drug use according to at least one of these five sets of criteria. 25% were detected by at least two sets of criteria and 18% by three sets of criteria or more. Exposure to potentially inappropriate medications according to all five criteria was prevalent in 5.2% of the study population (Table2 and Supplementary material, Appendix 2). Among the individuals exposed to potentially inappropriate drugs according to any of the five sets of criteria, 14% were detected simultaneously by all five sets of criteria, 27% were detected by at least four sets of criteria and 34% were detected by only one of the sets of criteria (Supplementary material, Appendix 3).

The most common potentially inappropriate medications

The most common potentially inappropriate medications detected by at least one of the five sets of criteria were benzodiazepines or benzodiazepine-like drugs with hypnotic or sedative proprieties (zolpidem: 5.4% of all individuals in total, 2.0% receiving >5mg day–1, oxazepam: 4.6%, 0.01% receiving >60mg day–1, zopiclone: 7.3%, 3.9% receiving >3.75mg day–1). Diazepam was the most commonly used drug among those deemed inappropriate by all sets of criteria (1.3%) (Supplementary material, Appendix 1). Overall, drugs with anticholinergic properties were used by 5.5 % (n = 73,917) of the older people.

Factors associated with potentially inappropriate medications

Overall, whatever the set of criteria, women were more often exposed to potentially inappropriate drugs than men (range 18%–27% vs. 13%–21%, respectively). Older people living in institutions also more often received these medications than community-dwelling individuals (range 36–51% vs. 15%–22%) (Table3). In adjusted multivariate logistic regression analysis (Table3), older age and higher number of prescribed medications were independently correlated with an increased likelihood of being exposed to potentially inappropriate drug use, regardless of the set of criteria we used to detect this exposure (OR ranges 1.01–1.02 and 1.27–1.67, respectively). Institutionalization was also significantly associated with greater odds of being prescribed potentially inappropriate medications (OR range 1.44–2.29).

Factors associated with the exposure to potentially inappropriate medications in Sweden, 2008

NORGEP PRISCUS Laroche Swedish National Board of Health and Welfare Beers 2012
n (%) Adjusted OR (95% CI)* n (%) Adjusted OR (95% CI)* n (%) Adjusted OR (95% CI)* n (%) Adjusted OR (95%CI)* n (%) Adjusted OR (95%CI)*
Gender
Male 75 010 (13.1%) 1 89 685 (15.7%) 1 94 075 (16.4%) 1 90 752 (15.9%) 1 117 616 (20.6%) 1
Female 140 078 (18.1%) 1.36 (1.35, 1.37) 148 702 (19.2%) 1.15 (1.14, 1.16) 162 092 (20.9%) 1.21 (1.20, 1.22) 166 327 (21.5%) 1.35 (1.34, 1.36) 207,640 (26.8%) 1.31 (1.30, 1.33)
Age group
65–74 years 79 507 (12.7%) 1 82 896 (13.2%) 1 86 294 (13.8%) 1 92 044 (14.7%) 1 120 998 (19.3%) 1
75–84 years 82 320 (17%) 1.03 (1.02, 1.04) 91 439 (18.9%) 1.20 (1.18, 1.21) 99 496 (20.5%) 1.25 (1.23, 1.26) 100 742 (20.8%) 1.09 (1.08, 1.1) 124 482 (25.7%) 1.12 (1.11, 1.13)
85–94 years 48 753 (22.2%) 1.08 (1.06, 1.09) 58 540 (26.6%) 1.49 (1.47, 1.51) 64 385 (29.3%) 1.56 (1.54, 1.58) 59 473 (27.1%) 1.11 (1.09, 1.12) 73 314 (33.3%) 1.24 (1.23, 1.26)
95 years and over 4508 (27.2%) 1.13 (1.08, 1.17) 5512 (33.3%) 1.72 (1.65, 1.78) 5992 (36.2%) 1.73 (1.67, 1.79) 4820 (29.1%) 0.91 (0.87, 0.94) 6462 (39%) 1.23 (1.19, 1.28)
Living situation
Home 183 700 (14.6%) 1 204 852 (16.3%) 1 218 091 (17.3%) 1 217 785 (17.3%) 1 281 146 (22.3%) 1
Nursing home 31 388 (36.4%) 1.93 (1.90, 1.96) 33 535 (38.9%) 1.79 (1.77, 1.82) 38 076 (44.1%) 2.01 (1.97, 2.04) 39 294 (45.5%) 2.29 (2.25, 2.33) 44 110 (51.1%) 2.16 (2.12, 2.19)
Number of drugs
Less than 5 44 319 (5.7%) 1 63 404 (8.2%) 1 63 148 (8.2%) 1 46 185 (6%) 1 94 510 (12.2%) 1
Five or more 170 769 (29.9%) 6.5 (6.42, 6.57) 174 983 (30.6%) 4.42 (4.38, 4.47) 193 019 (33.8%) 5.07 (5.02, 5.12) 210 894 (36.9%) 8.44 (8.34, 8.53) 230 746 (40.4%) 4.41 (4.37, 4.45)

OR odds ratio; CI confidence interval; All outcomes were significant at the 0.001 level.

*

Multivariate logistic regression models performed separately, with the use of potentially inappropriate drugs (yes vs. no) as categorical dependent variable. Independent variables included gender, age group, living situation and number of delivered drugs. 1 indicates the reference category.

We also found that most of these associations remained of similar magnitude when we combined the criteria in either an ’alternative’ model (i.e. detection as user of potentially inappropriate drugs by at least one of the six sets of criteria) or a ’cumulative’ model (i.e. detection by each of the six sets of criteria). However, in this second model, higher age was associated with slightly decreased odds (OR 0.99, 95% CI 0.98, 0.99) of being detected as a potential user of inappropriate medications (Supplementary material, Appendix 2).

Level of agreement between the different sets of criteria

The overall average sensitivity of the sets of criteria towards each other varied from 48% (NORGEP criteria) to 69% (2012 Beers criteria). The average level of specificity ranged from 85% (2012 Beers criteria) to 92% (PRISCUS criteria). The kappa coefficient varied from 0.37 (Swedish Indicators and 2012 Beers criteria) to 0.75 (Laroche and PRISCUS lists) (Supplementary material, Appendix 4 and 5).

Discussion

In this nationwide study of 1.3 million individuals aged 65 years and older in Sweden, comparing the analyses by five different sets of criteria developed in five different countries, we found that 16% to 24% of all older people were exposed to potentially inappropriate drug use.

In the community setting, potentially inappropriate drugs were used by 15% to 22% of the population. This prevalence is very consistent with the results of a recent systematic review, which reported a median rate of inappropriate medication prescriptions of 20% (IQR 18.1–25.6%) 46. In contrast, between 36% and 51% of the individuals living in institutions received potentially inappropriate medications, in line with prior studies conducted in Europe 10,43,4750 and in North America 19,51. As expected, the number of prescribed drugs was positively associated with an increased likelihood of being exposed to potentially inappropriate medications 40,47,52,53. Also, similar to most studies investigating gender differences 27,47,53,54, women were at greater risk of being exposed to potentially inappropriate drugs, even after adjusting for the number of medications used.

However, we found a surprisingly small overlap between the populations covered by each of the five sets of explicit criteria we applied in this study. Among people exposed to potentially inappropriate drugs according to any of the five sets of criteria, only 14% were captured simultaneously by all sets of criteria (while for 34% of them we found no overlap at all between the different criteria). In our opinion, this raises important questions about the comprehensiveness of each of these tools. The heterogeneity in the lists of medications included in each of these sets of criteria probably explains most of these discrepancies. As reported in prior original studies 35,36 and systematic reviews 11,32,33, only a few drugs are common to all the lists of potentially inappropriate drugs published over the last decade (e.g. diazepam, clomipramine and amitriptyline). Moreover, the dosage criteria may vary from one list to the other. Hence, although haloperidol is considered as inappropriate at a dosage >2mg day–1 in the PRISCUS list, there is no dosage restriction in the Beers criteria. Likewise, although both Laroche’s and the PRISCUS lists have deemed zopiclone to be inappropriate in doses >3.75mg day–1, the NORGEP criteria have established the threshold at 7.5mg day–1, while neither the Swedish nor the Beers criteria mention this medication as being potentially inappropriate. These differences can lead to considerable variations, especially in the case of zolpidem (ranging from 5.4% to 1.9%) and oxazepam (ranging from 4.6% to 0.01%). Moreover, several of the commonly prescribed drugs are included in only one of the five sets of criteria we compared, leading to even more variations, e.g. tramadol, propiomazine (Swedish criteria), dextropropoxyphene (NORGEP criteria), spironolactone or risperidone (Beers criteria).

In fact, the most striking finding lies in this apparent paradox. The different sets of criteria we compared measure the overall exposure to potentially inappropriate drug use to a very similar extent (in particular criteria developed in Europe), even though these sets of criteria overlap very little both in content and in the population they cover. In addition, no matter which set of criteria we applied, we found similar associations between older people’s socio-demographic characteristics and their use of potentially inappropriate drugs, suggesting that these tools are consistent in capturing not only the overall prevalence of potentially inappropriate drug use but also the differences across subgroups of the population. These findings strongly support the idea that besides their role at the clinical level in identifying inappropriate use of specific drugs among older people, at a population level these five sets of criteria have the ability to provide robust prevalence measures within a narrow range (stretching from a ’minimal estimate’ [NORGEP] to a ’maximal estimate’ [Beers]). In addition, our results suggest that the PRISCUS list, the Laroche list and the Swedish criteria provide very consistent ’intermediate’ estimates that may prove useful in cross-national comparisons at the European level.

Several limitations should be noticed and should call for caution in the interpretation of our results. First, we used data from 2008 (last available data at the time this study was conducted) and the patterns of drug use in Sweden might have slightly changed since that year, although the overall trend seems to have been relatively stable between 2008 and 2013 24.

Second, our findings rely on the exposure to potentially inappropriate drugs for a given period of 90 days, based on the assumption that the drugs prescribed and dispensed during that period reflect with accuracy the actual drug consumption. This means that neither the drugs prescribed before that 3 month period and consumed at a slower rate than intended, nor the drugs that were prematurely discontinued during that period would have been taken into account in our analyses. In addition, due to the nature of the Swedish Prescribed Drugs Register, over-the-counter drugs were not included in the prevalence measures. However, in Sweden almost all drugs are available only on prescriptions. It should also be noted that drugs administered during a hospitalization and from drug store rooms in long term care facilities are not included in the register, which might have induced a small underestimation of the use of drugs among institutionalized people 55.

Third, among the drugs detected by applying the different sets of criteria, several were specific to the Swedish market (e.g. propiomazine) or to the Swedish national guidelines (e.g. tramadol). On the other hand, many of the drugs listed in the different sets of criteria were not available in Sweden in 2008 (including temazepam, reserpine, loprazolam, bromazepam and pentobarbital). The difficulty of applying criteria or quality indicators developed in other national settings has been reported in previous studies 35,5658 and has led to the development of country-specific assessment tools. Differences in availability of drugs across countries also restrict the generalizability of our results beyond Sweden, especially to non-European countries. However, again, our findings show a very similar overall prevalence of potentially inappropriate drugs use, although the US criteria capture a slightly broader population compared with the four European lists.

Fourth, the lack of information about the clinical conditions associated with the use of potentially inappropriate drugs is another limitation. In fact, this absence of information about the chronic illnesses and co-morbidities of the individuals justifies our choice not to include the STOPP-START criteria 21,59, which contain many drug–disease criteria that make them very valuable and accurate as a screening tool in the clinical setting 37,6062 but more difficult to use in nationwide register-based studies. We strongly believe that future register studies should consider record-linkage methods to match pharmacy claims data with clinically relevant information from inpatient and primary care databases, in order to gain more insight on the disease-specific inappropriate medications 63. Finally, a more general limitation lies in the fact that register-based studies can only report drug prescription and delivery patterns, and merely assume that these reflect adequately the actual use of drugs by the patients (given that adherence to treatments may vary) 64.

In conclusion, for the first time, a nationwide, population-based study used five different sets of criteria developed in five different countries to examine the prevalence of potentially inappropriate drug use among older people. Overall, 16% to 24% of the elderly population in Sweden is exposed to medications whose expected benefits are deemed lower than the risks they present. Although explicit criteria for inappropriate drug use have been reported to be quite different in their content and outcomes, they give strikingly similar measures of the prevalence of potentially inappropriate drug use.

In our opinion, this study supports the use of these criteria by public health policy makers, stakeholders and researchers to evaluate the quality of drug use at the population level, especially in a cross-national perspective. However, at the clinical level, our results raise important questions regarding the comprehensiveness of each of these tools, and therefore their applicability in the daily practice.

This research was supported financially by a grant from the Swedish Research Council.

Competing Interests

All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare Kristina Johnell had support from the Swedish Research Council for the submitted work. There are no financial relationships with any organizations that might have an interest in the submitted work in the previous 3 years and no other relationships or activities that could appear to have influenced the submitted work.

Supporting Information

Additional Supporting Information may be found in the online version of this article at the publisher's web-site:

Supporting info item

bcp0080-0315-sd1.doc (167.5KB, doc)

References

  1. Shi S, Klotz U. Age-related changes in pharmacokinetics. Curr Drug Metab. 2011;12:601–10. doi: 10.2174/138920011796504527. [DOI] [PubMed] [Google Scholar]
  2. Mangoni AA, Jackson SHD. Age-related changes in pharmacokinetics and pharmacodynamics: basic principles and practical applications. Br J Clin Pharmacol. 2003;57:6–14. doi: 10.1046/j.1365-2125.2003.02007.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Merle L, Laroche ML, Dantoine T, Charmes JP. Predicting and preventing adverse drug reactions in the very old. Drugs and Aging. 2005;22:375–92. doi: 10.2165/00002512-200522050-00003. [DOI] [PubMed] [Google Scholar]
  4. Mallet L, Spinewine A, Huang A. The challenge of managing drug interactions in elderly people. Lancet. 2007;370:185–91. doi: 10.1016/S0140-6736(07)61092-7. [DOI] [PubMed] [Google Scholar]
  5. Spinewine A, Schmader KE, Barber N, Hughes C, Lapane KL, Swine C, Hanlon JT. Appropriate prescribing in elderly people: how well can it be measured and optimised? Lancet. 2007;370:173–84. doi: 10.1016/S0140-6736(07)61091-5. [DOI] [PubMed] [Google Scholar]
  6. Gurwitz JH, Field TS, Harrold LR, Rothschild J, Debellis K, Seger AC, Cadoret C, Fish LS, Garber L, Kelleher M, Bates DW. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA. 2003;289:1107–16. doi: 10.1001/jama.289.9.1107. [DOI] [PubMed] [Google Scholar]
  7. Budnitz DS, Pollock DA, Weidenbach KN, Mendelsohn AB, Schroeder TJ, Annest JL. National surveillance of emergency department visits for outpatient adverse drug events. JAMA. 2006;296:1858–66. doi: 10.1001/jama.296.15.1858. [DOI] [PubMed] [Google Scholar]
  8. Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med. 2011;365:2002–12. doi: 10.1056/NEJMsa1103053. [DOI] [PubMed] [Google Scholar]
  9. Corsonello A, Pedone C, Lattanzio F, Lucchetti M, Garasto S, Di Muzio M, Giunta S, Onder G, Di Iorio A, Volpato S, Corica F, Mussi C, Antonelli IncalziR. Potentially inappropriate medications and functional decline in elderly hospitalized patients. J Am Geriatr Soc. 2009;57:1007–14. doi: 10.1111/j.1532-5415.2009.02266.x. [DOI] [PubMed] [Google Scholar]
  10. Ruggiero C, Dell’Aquila G, Gasperini B, Onder G, Lattanzio F, Volpato S, Corsonello A, Maraldi C, Bernabei R, Cherubini A. Potentially inappropriate drug prescriptions and risk of hospitalization among older, Italian, nursing home residents: the ULISSE project. Drugs Aging. 2010;27:747–58. doi: 10.2165/11538240-000000000-00000. [DOI] [PubMed] [Google Scholar]
  11. Kaufmann CP, Tremp R, Hersberger KE, Lampert ML. Inappropriate prescribing: a systematic overview of published assessment tools. Eur J Clin Pharmacol. 2013;70:1–11. doi: 10.1007/s00228-013-1575-8. [DOI] [PubMed] [Google Scholar]
  12. Laroche ML, Charmes JP, Bouthier F, Merle L. Inappropriate medications in the elderly. Clin Pharmacol Ther. 2009;85:94–7. doi: 10.1038/clpt.2008.214. [DOI] [PubMed] [Google Scholar]
  13. Beers MH, Ouslander JG, Rollingher I, Reuben DB, Brooks J, Beck JC. Explicit criteria for determining inappropriate medication use in nursing home residents. Arch Intern Med. 1991;151:1825–32. [PubMed] [Google Scholar]
  14. Beers MH. Explicit criteria for determining potentially inappropriate medication use by the elderly. An update Arch Intern Med. 1997;157:1531–6. [PubMed] [Google Scholar]
  15. Zhan C, Sangl J, Bierman A. Potentially inappropriate medication use in the community-dwelling elderly. Findings from the 1996 Medical Expenditure Panel Survey. JAMA. 2001;286:2823–9. doi: 10.1001/jama.286.22.2823. [DOI] [PubMed] [Google Scholar]
  16. Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med. 2003;163:2716–24. doi: 10.1001/archinte.163.22.2716. [DOI] [PubMed] [Google Scholar]
  17. Campanelli CM. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60:616–31. doi: 10.1111/j.1532-5415.2012.03923.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. McLeod PJ, Huang AR, Tamblyn RM, Gayton DC. Defining inappropriate practices in prescribing for elderly people: a national consensus panel. CMAJ. 1997;156:385–91. [PMC free article] [PubMed] [Google Scholar]
  19. Rancourt C, Moisan J, Baillargeon L, Verreault R, Laurin D, Grégoire J-P. Potentially inappropriate prescriptions for older patients in long-term care. BMC Geriatr. 2004;4:9. doi: 10.1186/1471-2318-4-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Basger BJ, Chen TF, Moles RJ. Inappropriate medication use and prescribing indicators in elderly Australians: development of a prescribing indicators tool. Drugs Aging. 2008;25:777–93. doi: 10.2165/00002512-200825090-00004. [DOI] [PubMed] [Google Scholar]
  21. Gallagher P, O’Mahony D. STOPP (Screening Tool of Older Persons’ potentially inappropriate Prescriptions): application to acutely ill elderly patients and comparison with Beers’ criteria. Age Ageing. 2008;37:673–9. doi: 10.1093/ageing/afn197. [DOI] [PubMed] [Google Scholar]
  22. Laroche M-L, Charmes J-P, Merle L. Potentially inappropriate medications in the elderly: a French consensus panel list. Eur J Clin Pharmacol. 2007;63:725–31. doi: 10.1007/s00228-007-0324-2. [DOI] [PubMed] [Google Scholar]
  23. Holt S, Schmiedl S, Thürmann PA. Potentially inappropriate medications in the elderly: the PRISCUS list. Dtsch Arztebl Int. 2010;107:543–51. doi: 10.3238/arztebl.2010.0543. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Hovstadius B, Petersson G, Hellström L, Ericson L. Trends in inappropriate drug therapy prescription in the elderly in sweden from 2006 to 2013: assessment using national indicators. Drugs Aging. 2014;31:379–86. doi: 10.1007/s40266-014-0165-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Indicators of good drug therapy in the elderly. Stockholm: Swedish National Board of Health and Welfare; 2010. p. 96. [Google Scholar]
  26. Rognstad S, Brekke M, Fetveit A, Spigset O, Wyller TB, Straand J. The Norwegian General Practice (NORGEP) criteria for assessing potentially inappropriate prescriptions to elderly patients. A modified Delphi study. Scand J Prim Health Care. 2009;27:153–9. doi: 10.1080/02813430902992215. [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Maio V, Del Canale S, Abouzaid S. Using explicit criteria to evaluate the quality of prescribing in elderly Italian outpatients: a cohort study. J Clin Pharm Ther. 2010;35:219–29. doi: 10.1111/j.1365-2710.2009.01094.x. [DOI] [PubMed] [Google Scholar]
  28. Mann E, Böhmdorfer B, Frühwald T, Roller-Wirnsberger RE, Dovjak P, Dückelmann-Hofer C, Fischer P, Rabady S, Iglseder B. Potentially inappropriate medication in geriatric patients: the Austrian consensus panel list. Wien Klin Wochenschr. 2012;124:160–9. doi: 10.1007/s00508-011-0061-5. [DOI] [PubMed] [Google Scholar]
  29. Winit-Watjana W, Sakulrat P, Kespichayawattana J. Criteria for high-risk medication use in Thai older patients. Arch Gerontol Geriatr. 2008;47:35–51. doi: 10.1016/j.archger.2007.06.006. [DOI] [PubMed] [Google Scholar]
  30. Chang C-B, Yang S-Y, Lai H-Y, Wu R-S, Liu H-C, Hsu H-Y, Hwang S-J, Chan D-C. Using published criteria to develop a list of potentially inappropriate medications for elderly patients in Taiwan. Pharmacoepidemiol Drug Saf. 2012;21:1269–79. doi: 10.1002/pds.3274. [DOI] [PubMed] [Google Scholar]
  31. Levy HB, Marcus E-L, Christen C. Beyond the Beers criteria: A comparative overview of explicit criteria. Ann Pharmacother. 2010;44:1968–75. doi: 10.1345/aph.1P426. [DOI] [PubMed] [Google Scholar]
  32. Dimitrow MS, Airaksinen MSA, Kivelä S-L, Lyles A, Leikola SNS. Comparison of prescribing criteria to evaluate the appropriateness of drug treatment in individuals aged 65 and older: a systematic review. J Am Geriatr Soc. 2011;59:1521–30. doi: 10.1111/j.1532-5415.2011.03497.x. [DOI] [PubMed] [Google Scholar]
  33. Chang C-B, Chan D-C. Comparison of published explicit criteria for potentially inappropriate medications in older adults. Drugs Aging. 2010;27:947–57. doi: 10.2165/11584850-000000000-00000. [DOI] [PubMed] [Google Scholar]
  34. Marriott J, Stehlik P. A critical analysis of the methods used to develop explicit clinical criteria for use in older people. Age Ageing. 2012;41:441–50. doi: 10.1093/ageing/afs064. [DOI] [PubMed] [Google Scholar]
  35. Chang C-B, Chen J-H, Wen C-J, Kuo H-K, Lu I-S, Chiu L-S, Wu S-C, Chan D-CD. Potentially inappropriate medications in geriatric outpatients with polypharmacy: application of six sets of published explicit criteria. Br J Clin Pharmacol. 2011;72:482–9. doi: 10.1111/j.1365-2125.2011.04010.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Vishwas HN, Harugeri A, Parthasarathi G, Ramesh M. Potentially inappropriate medication use in Indian elderly: comparison of Beers’ criteria and Screening Tool of Older Persons’ potentially inappropriate Prescriptions. Geriatr Gerontol Int. 2012;12:506–14. doi: 10.1111/j.1447-0594.2011.00806.x. [DOI] [PubMed] [Google Scholar]
  37. Hudhra K, García-Caballos M, Jucja B, Casado-Fernández E, Espigares-Rodriguez E, Bueno-Cavanillas A. Frequency of potentially inappropriate prescriptions in older people at discharge according to Beers and STOPP criteria. Int J Clin Pharm. 2014;36:596–603. doi: 10.1007/s11096-014-9943-8. [DOI] [PubMed] [Google Scholar]
  38. San-José A, Agustí A, Vidal X, Formiga F, López-Soto A, Fernández-Moyano A, García J, Ramírez-Duque N, Torres OH, Barbé J. Inappropriate prescribing to older patients admitted to hospital: A comparison of different tools of misprescribing and underprescribing. Eur J Intern Med. 2014;25:6–8. doi: 10.1016/j.ejim.2014.07.011. [DOI] [PubMed] [Google Scholar]
  39. Statistics Sweden. Population statistics, January-June 2014. Stockholm: Statistiska Centralbyråns (SCB); 2014. [Google Scholar]
  40. Johnell K, Fastbom J, Rosén M, Leimanis A. Inappropriate drug use in the elderly: a nationwide register-based study. Ann Pharmacother. 2007;41:1243–8. doi: 10.1345/aph.1K154. [DOI] [PubMed] [Google Scholar]
  41. Wettermark B, Hammar N, Fored CM, MichaelFored C, Leimanis A, Otterblad Olausson P, Bergman U, Persson I, Sundström A, Westerholm B, Rosén M. The new Swedish Prescribed Drug Register--opportunities for pharmacoepidemiological research and experience from the first six months. Pharmacoepidemiol Drug Saf. 2007;16:726–35. doi: 10.1002/pds.1294. [DOI] [PubMed] [Google Scholar]
  42. Johnell K, Fastbom J. Antiepileptic drug use in community-dwelling and institutionalized elderly: a nationwide study of over 1,300,000 older people. Eur J Clin Pharmacol. 2011;67:1069–75. doi: 10.1007/s00228-011-1051-2. [DOI] [PubMed] [Google Scholar]
  43. Haasum Y, Fastbom J, Johnell K. Institutionalization as a risk factor for inappropriate drug use in the elderly: a Swedish nationwide register-based study. Ann Pharmacother. 2012;46:339–46. doi: 10.1345/aph.1Q597. [DOI] [PubMed] [Google Scholar]
  44. Care of older people in Sweden. Stockholm: Swedish National Board of Health and Welfare; 2008. p. 2009. [Google Scholar]
  45. Statistics Sweden. Beskrivning av Sveriges befolkning 2008 [Description of the population in Sweden 2008] Stockholm: Statistiska Centralbyråns (SCB); 2010. [Google Scholar]
  46. Opondo D, Eslami S, Visscher S, de Rooij SE, Verheij R, Korevaar JC, Abu-Hanna A. Inappropriateness of medication prescriptions to elderly patients in the primary care setting: a systematic review. PLoS One. 2012;7:e43617. doi: 10.1371/journal.pone.0043617. [DOI] [PMC free article] [PubMed] [Google Scholar]
  47. Barnett K, McCowan C, Evans JMM, Gillespie ND, Davey PG, Fahey T. Prevalence and outcomes of use of potentially inappropriate medicines in older people: cohort study stratified by residence in nursing home or in the community. BMJ Qual Saf. 2011;20:275–81. doi: 10.1136/bmjqs.2009.039818. [DOI] [PubMed] [Google Scholar]
  48. Shah SM, Carey IM, Harris T, DeWilde S, Cook DG. Quality of prescribing in care homes and the community in England and Wales. Br J Gen Pract. 2012;62:e329–36. doi: 10.3399/bjgp12X641447. [DOI] [PMC free article] [PubMed] [Google Scholar]
  49. Ruggiero C, Lattanzio F, Dell’Aquila G, Gasperini B, Cherubini A. Inappropriate drug prescriptions among older nursing home residents: the Italian perspective. Drugs Aging. 2009;15–30 doi: 10.2165/11534630-000000000-00000. [DOI] [PubMed] [Google Scholar]
  50. Hosia-Randell HMV, Muurinen SM, Pitkälä KH. Exposure to potentially inappropriate drugs and drug-drug interactions in elderly nursing home residents in Helsinki, Finland: a cross-sectional study. Drugs Aging. 2008;25:683–92. doi: 10.2165/00002512-200825080-00005. [DOI] [PubMed] [Google Scholar]
  51. Lau DT, Kasper JD, Potter DEB, Lyles A, Bennett RG. Hospitalization and death associated with potentially inappropriate medication prescriptions among elderly nursing home residents. Arch Intern Med. 2005;165:68–74. doi: 10.1001/archinte.165.1.68. [DOI] [PubMed] [Google Scholar]
  52. Bongue B, Laroche ML, Gutton S, Colvez A, Guéguen R, Moulin JJ, Merle L. Potentially inappropriate drug prescription in the elderly in France: a population-based study from the French National Insurance Healthcare system. Eur J Clin Pharmacol. 2011;67:1291–9. doi: 10.1007/s00228-011-1077-5. [DOI] [PubMed] [Google Scholar]
  53. Schubert I, Küpper-Nybelen J, Ihle P, Thürmann P. Prescribing potentially inappropriate medication (PIM) in Germany ’ s elderly as indicated by the PRISCUS list. An analysis based on regional claims data. Pharmacoepidemiol Drug Saf. 2013;22:719–27. doi: 10.1002/pds.3429. [DOI] [PubMed] [Google Scholar]
  54. Johnell K, Weitoft GR, Fastbom J. Sex differences in inappropriate drug use: a register-based study of over 600,000 older people. Ann Pharmacother. 2009;43:1233–8. doi: 10.1345/aph.1M147. [DOI] [PubMed] [Google Scholar]
  55. Läkemedel 2007. 2008. p. 144. En jämförelse baserad på Socialstyrelsens läkemedelsregister.
  56. Leikola S, Dimitrow M, Lyles A, Pitkälä K, Airaksinen M. Potentially inappropriate medication use among Finnish non-institutionalized people aged ≥65 years: a register-based, cross-sectional, national study. Drugs Aging. 2011;28:227–36. doi: 10.2165/11586890-000000000-00000. [DOI] [PubMed] [Google Scholar]
  57. Fialová D, Topinková E, Gambassi G, Finne-Soveri H, Jónsson PV, Carpenter I, Schroll M, Onder G, Sørbye LW, Wagner C, Reissigová J, Bernabei R. Potentially InappropriateMedication Use Among Elderly Home Care Patients in Europe. JAMA. 2005;293:1348–58. doi: 10.1001/jama.293.11.1348. [DOI] [PubMed] [Google Scholar]
  58. Kölzsch M, Kopke K, Fischer T, Hofmann W, Kuhnert R, Bolbrinker J, Kuhlmey A, Dräger D, Kreutz R. Prescribing of inappropriate medication in nursing home residents in Germany according to a French consensus list: a cross-sectional cohort study. Pharmacoepidemiol Drug Saf. 2011;20:12–9. doi: 10.1002/pds.2005. [DOI] [PubMed] [Google Scholar]
  59. 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. 2015;44:213–8. doi: 10.1093/ageing/afu145. [DOI] [PMC free article] [PubMed] [Google Scholar]
  60. O’Sullivan DP, O’Mahony D, Parsons C, Hughes C, Murphy K, Patterson S, Byrne S. A prevalence study of potentially inappropriate prescribing in Irish long-term care residents. Drugs Aging. 2013;30:39–49. doi: 10.1007/s40266-012-0039-7. [DOI] [PubMed] [Google Scholar]
  61. Hill-Taylor B, Sketris I, Hayden J, Byrne S, O’Sullivan D, Christie R. Application of the STOPP/START criteria: a systematic review of the prevalence of potentially inappropriate prescribing in older adults, and evidence of clinical, humanistic and economic impact. J Clin Pharm Ther. 2013;38:360–72. doi: 10.1111/jcpt.12059. [DOI] [PubMed] [Google Scholar]
  62. Grace AR, Briggs R, Kieran RE, Corcoran RM, Romero-Ortuno R, Coughlan TL, O’Neill D, Collins R, Kennelly SP. A Comparison of Beers and STOPP Criteria in Assessing Potentially Inappropriate Medications in Nursing Home Residents Attending the Emergency Department. J Am Med Dir Assoc. 2014;15:830–4. doi: 10.1016/j.jamda.2014.08.008. [DOI] [PubMed] [Google Scholar]
  63. Cahir C, Fahey T, Teeling M, Teljeur C, Feely J, Bennett K. Potentially inappropriate prescribing and cost outcomes for older people: a national population study. Br J Clin Pharmacol. 2010;69:543–52. doi: 10.1111/j.1365-2125.2010.03628.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  64. Johnell K, Råstam L, Lithman T, Sundquist J, Merlo J. Low adherence with antihypertensives in actual practice: the association with social participation--a multilevel analysis. BMC Public Health. 2005;5:17. doi: 10.1186/1471-2458-5-17. [DOI] [PMC free article] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supporting info item

bcp0080-0315-sd1.doc (167.5KB, doc)

Articles from British Journal of Clinical Pharmacology are provided here courtesy of British Pharmacological Society

RESOURCES