BEERS CRITERIA-BASED REVIEW OF MEDICATION APPROPRIATENESS IN

109 Pages·2006·1.1 MB·English

BEERS CRITERIA-BASED REVIEW OF MEDICATION
APPROPRIATENESS IN BRITISH COLUMBIA SENIORS
LIVING IN RESIDENTIAL CARE
Rita Cormier
B. Sc. (Pharm), University of British Columbia, 1998
THESIS SUBMITTED IN PARTIAL FULFILLMENT OF
THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF ARTS
In the
Department
of
Gerontology
@ Rita Cormier 2006
SIMON FRASER UNIVERSITY
Spring 2006
All rights reserved. This work may not be
reproduced in whole or in part, by photocopy
or other means, without permission of the author.
APPROVAL
Name: Rita Cormier
Degree: Master of Arts (Gerontology)
Title of Thesis: Be!ers Criteria-Based Review Of Medication
Appropriateness In British Columbia Seniors
Living In Residential Care
Examining Committee:
Chair: Dr. Habib Chaudhury,
Assistant Professor, Gerontology Department, SFlU
Dr. Andrew Wister,
Senior Supervisor
Professor, Gerontology Department, SFU
Dr. Gloria Gutman,
Supervisor
Professor E!meritus, Gerontology Department, SFlU
Dr. Duncan Robertson,
S~~pervisor
Adjunct Professor, Gerontology Department, SFU
Dr. Lynn Beattie,
Professor Emeritus, Geriatric Medicine, UBC
External Examiner
Date Defended: March 9,2006
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STATEMENT OF
ETHICS APPROVAL
The author, whose name appears on the title page of this work, has obtained, for
the research described in this work, either:
(a) Human research ethics approval from the Simon Fraser University Office of
Research Ethics,
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Committee of Simon Fraser University;
or has conducted the research
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research, by the Office of Research Ethics.
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ABSTRACT
A study was conducted to explore the prevalence and predictors of inappropriate
prescribing, as defined by the 2002 Beers criteria, in a sample of nursing home residents
in British Columbia, Canada (n=,449). Medication-related data were extracted from
residents' medication review letters. The overall prevalence of inappropriate prescribing
was 29.4 percent. The prevalence rates for the three sub-types of inappropriate
prescribing, namely unconditionally inappropriate prescribing, inappropriate drug-
disease combinations, and inappropriate doses or durations, were 16.9, 12.4, and 5.1
percent, respectively. The likelihood of inappropriate prescribing was increased with the
total number of prescription medications and the number of prescribing physicians. The
single most commonly prescribed inappropriate medication was anticholinergics,f or
residents with cognitive impairment. Clinicians need to be extra vigilant to distinguish
between the central nervous system effects of anticholinergic medications and the
effects of the underlying disease.
I would like to express my appreciation to my thesis supervisor, Dr. Andrew
Wister, and my thesis committee, Dr. Gloria Gutman and Dr. Duncan Robertson, for their
scholarly advice and guidance. I would also like to thank the Social Sciences and
Humanities Research Councill of Canada for their support. I am also grateful to my
friends and classmates, especially Heather Cooke, Elizabeth Kelson, and Salima
Karmali, for their encouragement and for sharing this journey with me.
TABLE OF CONTENTS
........................................................................................................................
Approval ii
...
....................................................................................................................
Abstract 111
......................................................................................................
Acknowledgements iv
..........................................................................................................
Table of contents v
..
............................................................................................
List of figures and tables VII
....................................................................................................
List of abbreviations ix
.....................................................................................................................
Definitions x
.................................................................................................
Chapter 1: Introduction 1
Medication use amongst older adults ........................................................................... 1
Significance of medication appropriateness in older adults .......................................... 2
Adverse drug reactions ............................................................................................ 2
Factors leading to an increased risk of ADRs in the older adult population .............. 4
Defining medication appropriateness in the elderly ...................................................... 6
Criteria for determining rriedication appropriateness in older adults ......................... 6
Implicit methods ....................................................................................................... 8
Explicit methods ....................................................................................................... 8
Prevalence and patterns of inappropriate prescribing ................................................ 20
Conceptual framework and correlates of inappropriate prescribing ............................ 25
Residentlpatient characteristics. ............................................................................. 26
Physician-related variables .................................................................................... 28
Health care system ................................................................................................ 28
Medication-related variables .................................................................................. 31
Summary ...............................................................................................................3 1
Outcomes associated with iinappropriate prescribing ................................................. 32
Limitations of existing research. ................................................................................. 35
Research objectives .................................................................................................. 36
.............................................................................................
Chapter 2: Methodology 37
Sampling. ................................................................................................................... 37
Data sources ............................................................................................................. 37
Measurement ..........................................................................................................3 9
Dependent variables ............................................................................................4..0
Independent variables ............................................................................................ 40
Data cleaning. ............................................................................................................ 43
Ethics ......................................................................................................................... 44
Analysis ..................................................................................................................... 44
........................................................................................................
Chapter 3: Results 46
Descriptive results ..................................................................................................... 46
Results of bivariate analyses ..................................................................................... 53
Presence of any Beers medication ......................................................................... 53
Presence of any unconditionally inappropriate medication ..................................... 56
Presence of any inappropriate drug-disease combination ...................................... 60
Results of logistic regression analyses ....................................................................... 61
Presence of any Beers medication .......................................................................... 63
Presence of any unconditionally inappropriate medication ..................................... 64
Presence of any inappropriate drug-disease combination ...................................... 67
...............................................................................................
Chapter 4: Discussion 68
Review of results and implications .............................................................................. 68
Prevalence rate and patterns of inappropriate prescribing. ..................................... 68
Predictors of inappropriate prescribing .................................................................... 75
Linkages to Tamblyn's conceptual framework ............................................................ 78
Limitations .................................................................................................................. 82
Future directions ........................................................................................................ 85
Conclusion ................................................................................................................. 88
................................................................................................................
Reference list 90
LIST OF FIGURES AND TABLES
Figure 1 Tamblyn's conceptual framework for factors influencing the risks
versus benefits of prescription medication use .............................................. 26
Table 1: Comparison of explicit criteria ......................................................................... 9
Table 2: Beers 2002 criteria for potentially inappropriate medication use in older
adults independent of dose. duration. frequency. or diagnoses ..................... 12
Table 3: Beers 2002 criteria for potentially inappropriate medication use in older
adults considering diagnoses or conditions ................................................... 16
Table 4: Beers 2002 criteria for doses and durations of medications that should
not be exceeded in the older adult population ............................................... 18
Table 5: Independent and dependent variables for the bivariate analyses .................. 40
Table 6: Age and sex distribution for the study sample compared with
population 65 years and older living in residential care facilities for the
aged in British Columbia. 2001. ..................................................................... 46
Table 7: Prevalence rates of inappropriate prescribing in the study sample ................4 7
Table 8: Unconditionally inapp~ropriatem edication orders ........................................... 48
Table 9: Inappropriate drug-disease combinations. .....................................................5 0
Table 10: Medications with moderate or strong anticholinergic activity ......................... 51
Table 11: Medications with maximum dosage or duration exceeded ............................. 52
Table 12: Crosstabulation of the presence of any Beers medication and the
number of diagnoses ..................................................................................... 54
Table 13: Crosstabulation of the presence of any Beers medication and the
number of prescription (Rx) medications ......................................................5. 4
Table 14: Crosstabulation of the presence of any Beers medication and the
number of prescribers each resident had ...................................................... 55
Table 15: Crosstabulation of the presence of any unconditionally inappropriate
medication and the presence of cognitive impairment or dementia ............... 57
Table 16: Crosstabulation of the presence of any unconditionally inappropriate
medication and the number of prescribers each resident had ....................... 58
Table 17: Crosstabulation of the presence of any unconditionally inappropriate
medication and the number of patients each resident's primary
physician had in the facility ..........................................................................5.9
Table 18: Crosstabulation of the presence of any unconditionally inappropriate
medication and the number of prescription medications of each
resident ........................................................................................................5. 9
Table 19: Crosstabulation of the presence of any inappropriate drug-disease
combination and the number of diagnoses ..................................................... 60
vii
Table 20: Crosstabulation of the presence of any inappropriate drug-disease
combination and the presence of cognitive impairment or dementia ............. 61
Table 21: Hierarchical blocks of independent variables for the logistic regression
analyses.. .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Table 22: Beta coefficients (odds ratios) for the presence of any Beers
medication ......................................................................... ........................... 64
Table 23: Beta coefficients (odds ratio) for the presence of any unconditionally
inappropriate medication ............................................................................... 65
Table 24: Beta coefficients (odds ratio) for the presence of any inappropriate
drug-disease combination ............................................................................. 67
Table 25: Predictors of inappropriate prescribing per the 2002 Beers criteria ............... 75
viii