Inappropriate Medication Prescriptions in Elderly Adults Surviving an Intensive Care Unit Hospitalization

Alessandro Morandi, MD, MPH; Eduard Vasilevskis, MD; Pratik P. Pandharipande, MD, MSCI; Timothy D. Girard, MD, MSCI; Laurence M. Solberg, MD; Erin B. Neal, PharmD; Tyler Koestner, MS; Renee E. Torres, MS; Jennifer L. Thompson, MPH; Ayumi K. Shintani, PhD, MPH; Jin H. Han, MD, MSc; John F. Schnelle, PhD; Donna M. Fick, PhD; E. Wesley Ely, MD, MPH; Sunil Kripalani, MD, MSc

Disclosures

J Am Geriatr Soc. 2013;61(7):1128–1134 

In This Article

Results

One hundred thirty-five participants enrolled in the parent study between May 2008 and 2010 who were aged 60 and older and were discharged alive from the hospital were identified; 11 of these were discharged to hospice, and four withdrew from the study before discharge. The remaining 120 participants were included in the current study and are described in Table 1. The cohort had a median age of 68 years, and nearly one in four participants was 75 years of age or older. A median APACHE score of 27 indicated a high severity of illness, and comorbid illness was common.

Categories of PIMs and AIMs: Frequency at Discharge and Time of Initiation

A total of 250 PIMs were prescribed at discharge. The four most common types of PIMs at discharge were opioids, anticholinergic medications, antidepressants, and drugs causing orthostasis (Table 2).

Ninety of the 250 discharge PIMs (36%) were classified as AIMs, with the three most common types being anticholinergics, nonbenzodiazepine hypnotics (e.g., zolpidem), and opioids (Table 2). Of the anticholinergic AIMs, the histamine blockers (61%) and promethazine (15%) were the most common. Three of the four most commonly prescribed discharge PIM categories had low PPVs (i.e., these PIMs were infrequently classified as AIMs). Specifically, 16% of opioids, 23% of antidepressants, and 10% of drugs causing orthostasis were found to be actually inappropriate after the individual's circumstances were considered. Discharge PIM categories with the highest PPV for AIMs included the anticholinergics (55%), nonbenzodiazepine hypnotics (67%), benzodiazepines (67%), atypical antipsychotics (71%), and muscle relaxants (100%; Table 2). Appendix S2 shows the distribution of PIM and AIM categories at the participant level.

Of the AIMs most often prescribed at hospital discharge, 67% of anticholinergic AIMs were initiated in the ICU, 21% were started on the wards, and 12% were present before admission. Of the nonbenzodiazepine hypnotic AIMs, 46% were initiated in the ICU, 23% were started on the wards, and 31% were present before admission. Of the opioids determined to be AIMs, 73% were initiated in the ICU, 18% were started on the wards, and 9% were present before admission. Four of every five atypical antipsychotics classified as AIMs were started in the ICU, 20% were initiated on the ward, and none were present before admission. Certain offending medications were initiated almost exclusively in the hospital. For example, only 1% of participants (1/120) were receiving an atypical antipsychotic before admission and 12% (14/120) were discharged from the hospital on an atypical antipsychotic.

PIMs and AIMs: Risk Factors for Number at Discharge

In a multivariable analysis, the number of preadmission PIMs (P < .001), discharge to somewhere other than home (P = .03), and discharge from a surgical service (P < .001) were found to be significant independent predictors of the number of PIMs prescribed to an individual at hospital discharge (Table 3), but none of the factors examined were associated with the number of AIMs at hospital discharge. Neither age (P = .90), number of preadmission PIMs (P = .49), Charlson comorbidity score (P = .96), delirium duration (P = .68), hospital length of stay (P = .15), discharge disposition (P = .72), nor discharge service (P = .08) predicted number of discharge AIMs.

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