Inappropriate Medications Commonly Prescribed to the Elderly in the ICU

Fran Lowry

January 18, 2011

January 18, 2011 (San Diego, California) — More than half of elderly people admitted to the intensive care unit (ICU) receive prescriptions for drugs they do not need when it's time to go home, according to a study presented here at the Society of Critical Care Medicine 40th Critical Care Congress.

"We already know from the literature that potentially inappropriate medications are quite prevalent among the elderly living in the community — somewhere around 60%," Alessandro Morandi, MD, from Vanderbilt University School of Medicine, Nashville, Tennessee, told Medscape Medical News. "What we found in the present study was that after a critical illness, the proportion of patients with both potentially and actually inappropriate medications increased by about 20%, and that half of these were initiated in the intensive care unit."

Elderly patients are often prescribed medications in the hospital that are considered potentially inappropriate in general, but turn out to be appropriate for them in a clinical context. The classic example is the use of an antipsychotic drug to combat the delirium that is common in the ICU. Such a drug should be stopped at discharge because there is no longer a need for it, Dr. Morandi explained.

"Having a lot of drugs in the elderly is associated with worse cognitive function, increases the risk of falls, and also increases healthcare costs. We wanted to look specifically at this population because we suspected that they might have a higher risk of being discharged with inappropriate medications, especially because of their many transitions within the hospital," he said.

Dr. Morandi and his team collected information on home medications, actual medications administered while in the ICU and on the ward, and medications prescribed at ICU and hospital discharge from 120 patients who were consecutively admitted to their medical and surgical ICU at Vanderbilt University Medical Center.

All patients in this prospective cohort study were 60 years or older (median age, 68 years) with a median Acute Physiology and Chronic Health Evaluation (APACHE) II score of 27 (range, 20 to 32) who survived to discharge after septic or cardiogenic shock or respiratory failure.

The investigators used 2003 Beers criteria and recent medication safety literature to identify potentially inappropriate medications (PIMs). In addition, a hospitalist, geriatrician, and clinical pharmacist evaluated whether potentially inappropriate medications at discharge were also overtly inappropriate medications (AIMs) on the basis of their indication, efficacy, dosages, and drug interactions.

They found that the proportion of patients receiving 3 or more PIMs increased from 16% before they were admitted to 38% at hospital discharge.

Of the 104 patients who had at least 1 PIM at discharge, 59% were also considered to have at least 1 AIM.

Further analysis showed that the total number of PIMs increased from 159 at preadmission to 253 at discharge. The median preadmission PIM was 1 (range, 0 to 2); at hospital discharge, the median PIM was 2 (range, 1 to 3; P < .001).

The researchers also found that 49% of the discharge PIMs and 58% of the discharge AIMs were initiated in the ICU.

The most commonly prescribed drugs were anticholinergics, Dr. Morandi noted.

"These data suggest that physicians should be careful at the transition of care to conduct an appropriate medication reconciliation at each time point during the patient's hospitalization so that we can avoid the prescribing of inappropriate medications," he said.

Finding a solution to this problem is especially important because of the graying of the population, he added. "We know that by 2030, 70 million people in the United States will be over the age of 65 and will account for 20% of the population; older patients currently account for about half of all ICU admissions."

Providing independent commentary on this study for Medscape Medical News, Jason M. Kane, MD, from Rush University Medical Center in Chicago, Illinois, noted that the findings might be due to a reluctance on the part of the discharging physician to interfere with the original doctor–patient relationship that exists outside of the hospital.

"Patients coming into the hospital on what are being deemed inappropriate meds prescribed by their primary care physician may be put back on those medications at discharge potentially because the ICU team or the hospital team does not provide continuity of care and does not want to disrupt a pharmaceutical relationship between the patient and his or her primary care giver.

"I think the thought is to put them back on their home medications and let the primary care physician deal with it, which may or may not be an appropriate strategy. I don't know what the answer is."

Tina L. Palmieri, MD, from the Shriners Hospital for Children Northern California in Sacramento, added that worry about the long-term impact of the drugs that are started in the ICU is universal.

"It's very valuable to look and see what happens with the drugs that we start in an ICU. Do they get changed? Do they get discontinued?," wondered Dr. Palmieri, who was not part of the study. "A very important aspect of our care is to take a look and see what the long lasting impact of ICU care is. Drugs are just one aspect of that."

Dr. Morandi, Dr. Kane, and Dr. Palmieri have disclosed no relevant financial relationships.

Society of Critical Care Medicine (SCCM) 40th Critical Care Congress: Abstract 569. Presented January 17, 2011.