The Core Problem of Inappropriate Prescribing
Inappropriate prescribing is a broad term that covers several specific issues that arise in medication management for older adults. It isn't just about receiving the wrong medication, but also includes administering the correct drug in the wrong way or overlooking crucial medications. This complex issue is compounded by the physiological changes that occur with aging, which can alter how a body processes and responds to medication.
Types of Inappropriate Prescribing
Inappropriate prescribing is often broken down into several categories to help healthcare professionals and caregivers understand the full scope of the problem.
- Misprescribing: This occurs when a medication is prescribed despite the risk of side effects or adverse events significantly outweighing its clinical benefit. A classic example is prescribing a medication known to cause confusion to an older patient with cognitive impairment.
- Overprescribing: Often a result of polypharmacy, overprescribing happens when a patient is prescribed too many medications, or a drug is continued for an unnecessary duration. This can also include the "prescribing cascade," where a new drug is prescribed to treat a side effect of a different medication.
- Underprescribing: The flip side of the issue, underprescribing is the omission of a medication that is clinically indicated and would likely benefit the patient. A common example is the failure to prescribe a bone anti-resorptive drug for a patient with documented osteoporosis.
The Impact on Older Adults
Age-related changes in pharmacokinetics (how the body absorbs, distributes, metabolizes, and excretes drugs) and pharmacodynamics (how the body responds to drugs) mean that older adults often require different drug regimens than younger patients. Factors like decreased liver and kidney function, lower muscle mass, and increased body fat can alter a drug's effectiveness and increase the risk of side effects. These issues are further complicated by the presence of multiple comorbidities and often lead to polypharmacy, which in turn dramatically increases the risk of adverse drug events.
Tools for Identifying Inappropriate Prescribing
To combat this pervasive issue, various tools and criteria have been developed to help healthcare providers, and even patients and their families, identify potentially inappropriate prescriptions. These criteria provide a systematic approach to reviewing medication lists.
Explicit vs. Implicit Criteria
Methods for assessing prescribing appropriateness are typically divided into two categories.
- Explicit (Criterion-Based) Tools: These tools, such as the widely used AGS Beers Criteria®, list specific medications or drug classes that should be avoided or used with caution in older adults. They are easy to apply but may lack the nuance required for individual patient situations. The AGS Beers Criteria® provides clear guidelines on medications to avoid, medications to use with caution, and drug-disease interactions.
- Implicit (Judgment-Based) Tools: These require clinical judgment to assess the appropriateness of a prescription in the context of an individual patient's health status, life expectancy, and care goals. While more time-consuming, they allow for a more personalized assessment of the risks and benefits of a particular medication. The Medication Appropriateness Index is an example of an implicit tool.
Comparative Overview of Screening Tools
| Feature | AGS Beers Criteria® | STOPP/START Criteria | Medication Appropriateness Index (MAI) |
|---|---|---|---|
| Type | Explicit (Criterion-based) | Explicit (Physiological systems-based) | Implicit (Judgment-based) |
| Focus | Medications to avoid, use with caution, or with dose adjustments in older adults | Screening Tool of Potentially Inappropriate Prescriptions (STOPP) and Screening Tool to Alert doctors to Right Treatment (START) for prescribing omissions | Assessment of medication appropriateness based on ten criteria, including indication, effectiveness, and drug-drug interactions |
| Ease of Use | Relatively straightforward to apply | Structured by physiological systems, which can be easier to navigate for some clinicians | Requires more time and clinical expertise for comprehensive review |
| Scope | Comprehensive list of potentially inappropriate medications (PIMs) | Includes PIMs (STOPP) and potential prescribing omissions (PPOs) (START) | Allows for a more holistic review of all aspects of a patient's medication regimen |
The Role of Deprescribing
One of the most effective strategies for addressing inappropriate prescribing is "deprescribing," which is the planned and supervised process of reducing or stopping medications. This is done with the goal of managing polypharmacy and improving health outcomes. Deprescribing is a shared decision-making process that involves a conversation between the patient, their caregivers, and their healthcare team.
How to Be Proactive About Medication Safety
For older adults and their caregivers, being proactive is key to preventing inappropriate prescribing. Start by asking questions and advocating for a full medication review. Maintaining an up-to-date and complete list of all medications, including over-the-counter drugs and supplements, is crucial for healthcare providers. Regular communication with the patient’s doctor or pharmacist about any concerns is essential.
For a comprehensive review of medication safety guidelines for older adults, the American Geriatrics Society (AGS) is an excellent resource. Their website offers detailed information about the Beers Criteria and best practices for geriatric care: https://www.americangeriatrics.org/.
Conclusion
Understanding what is inappropriate prescribing in older adults is a vital step toward improving their health and quality of life. It goes beyond simply avoiding certain drugs; it encompasses ensuring that medication regimens are both appropriate and necessary for the individual patient's needs and goals. By utilizing screening tools, promoting deprescribing when safe, and fostering open communication between patients and healthcare providers, the risks associated with inappropriate medication use can be significantly reduced. This collaborative approach empowers patients and their families to take an active role in their healthcare, leading to safer and more effective treatment plans.
