Home and Community Care Digest

Home and Community Care Digest December 2005 : 0-0

Unnecessary drug use at hospital discharge among frail elderly patients

Abstract

Inappropriate prescribing and prescription drug use contributes to increased expenditures on prescription drugs in Canada, and may lead to detrimental health effects. This study found that more than four out of ten frail elderly patients were found to have an unnecessary medication upon discharge. Unnecessary medications were identified by chart review and were conducted by a clinical pharmacist and a physician using a standardized tool. Patients with multiple prescribers and multiple medications were more likely to be the recipients of an unnecessary medication. A structured discharge medication review procedure could decrease the frequency of unnecessary medication use among the frail elderly population following hospital discharge.
Background: Unnecessary medications (duplications, lack of indication, or lack of effectiveness) increase the number of drugs used by frail elderly patients and may lead to detrimental health effects. Typically, these patients are already receiving numerous medications for their multiple medical conditions. Unnecessary medications lead to increased costs for the patient and health care system and increased likelihood of patient harm due to adverse drug reactions, drug-drug interactions, and decreased compliance. This study assesses how frequently frail elderly patients are discharged from the hospital with an unnecessary medication, and whether there are any predictors of unnecessary medication use.

Methods: Participants were recruited from 11 Veterans Affairs Medical Centers across the United States. Patients were defined as frail if they were at least 65 years of age and met two of ten frailty criteria (moderate functional disability, recent stroke with neurological deficit, history of falls, walking difficulties, malnutrition, dementia, depression, recent fracture, unplanned hospital admission, and prolonged bed rest). A clinical pharmacist and physician reviewed the hospital admission and discharge records of eligible patients. Unnecessary medication was defined as medication use with no documented indication, medications lacking evidence of effectiveness, or therapeutic duplication of medications. A structured assessment tool was used to determine unnecessary drug usage.

Findings: The 384 eligible patients were predominantly male (97%), Caucasian (71%), married (51%), and aged 65-74 (54%). Most patients had some degree of functional dependence and multiple comorbidities. Approximately 40% of the patients were taking 9 or more medications. Overall, 44% of the patients were found to have at least one unnecessary medication upon discharge. The most common reason was lack of indication (32%), followed by lack of efficacy (18%), and duplication (8%). Several classes of medications were found more commonly among the unnecessary drugs, including, for example, gastrointestinal, central nervous system, and therapeutic nutrients. Specifically, antihistamines, laxatives, antispasmodics, and tricyclic antidepressants were the most common unnecessary drugs. The study also found several predictors of unnecessary drug use. Patients with multiple prescribers were more than 3 times as likely to receive an unnecessary medication upon discharge. Patients with nine or more medications were nearly twice as likely to receive an unnecessary medication. Patients with high blood pressure were almost half as likely to receive an unnecessary medication. Since the study participants were a homogenous group consisting largely of elderly, frail, Caucasian male veterans, the results of this study may not be applicable to other settings. Furthermore, the rate of unnecessary drug use due to lack of indication may have been overestimated if patients had clinical conditions that were not evident due to poor chart documentation.

Conclusions: Nearly half of the frail elderly patients discharged during this study were found to have at least one unnecessary medication. Frail elderly patients are a vulnerable group at increased risk of poor outcomes because of multiple medical conditions and decreased functional ability. Increasing the number of medications also increases the likelihood of adverse drug reactions and harmful drug-drug interactions. The study suggests that improving communication between prescribers, and instituting a systematic medication review during discharge planning, could aid in decreasing the number of unnecessary drugs. The authors note that this intervention could also be utilized in post-discharge settings such as nursing homes and the outpatient clinic

Reference: Emily R, Hajjar ER, Hanlon JT, Sloane RJ, Lindblad CI, Pieper CF, Ruby CM, Branch LC, Schmader KE. "Unnecessary Drug Use in Frail Older People at Hospital Discharge." Journal of the American Geriatric Society, 2005; 53: 1518-1523.

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