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

Abstract and Introduction

Abstract

Objectives To determine types of potentially (PIMs) and actually inappropriate medications (AIMs), which PIMs are most likely to be considered AIMs, and risk factors for PIMs and AIMs at hospital discharge in elderly intensive care unit (ICU) survivors.

Design Prospective cohort study.

Setting Tertiary care, academic medical center.

Participants One hundred twenty individuals aged 60 and older who survived an ICU hospitalization.

Measurements Potentially inappropriate medications were defined according to published criteria; a multidisciplinary panel adjudicated AIMs. Medications from before admission, ward admission, ICU admission, ICU discharge, and hospital discharge were abstracted. Poisson regression was used to examine independent risk factors for hospital discharge PIMs and AIMs.

ResultsOf 250 PIMs prescribed at discharge, the most common were opioids (28%), anticholinergics (24%), antidepressants (12%), and drugs causing orthostasis (8%). The three most common AIMs were anticholinergics (37%), nonbenzodiazepine hypnotics (14%), and opioids (12%). Overall, 36% of discharge PIMs were classified as AIMs, but the percentage varied according to drug type. Whereas only 16% of opioids, 23% of antidepressants, and 10% of drugs causing orthostasis were classified as AIMs, 55% of anticholinergics, 71% of atypical antipyschotics, 67% of nonbenzodiazepine hypnotics and benzodiazepines, and 100% of muscle relaxants were deemed AIMs.

Abstract and Introduction
Methods
Results
Discussion
References

Table 1. Demographic and Clinical Characteristics of Critically Ill Elderly Survivors (N = 120)
Characteristic	Value
Age, median (IQR)	68 (64–74)
Male, n (%)	64 (53)
Race, n (%)
Caucasian	115 (96)
African American	5 (4)
Charlson Index at enrollment, median (IQR)	2 (1.0–4.0)
Intensive care unit type at admission, n (%)
Medical	57 (48)
Surgical	63 (52)
Acute Physiology and Chronic Health Evaluation II score, median (IQR)	27 (20–32)
Admission diagnosis, n (%)
Surgery	39 (32)
Sepsis or acute respiratory distress syndrome	23 (19)
Cardiogenic shock, myocardial infarction, congestive heart failure	22 (18)
Airway protection	17 (14)
Acute respiratory distress syndrome without infection	9 (7)
Other^[a]	10 (9)
Hospital length of stay, days, median (IQR)	10 (6–16)
Delirium duration, days, median (IQR)	3 (1–6)
Discharging service, n (%)
Surgical	64 (53)
Medical	56 (47)
Discharge disposition, n (%)
Home	56 (47)
Rehabilitation	36 (30)
Long-term acute care	17 (14)
Nursing home	11 (9)

IQR = interquartile range.
a Abdominal; urological; cardiovascular; transplant; orthopedic; ear, nose, throat.
Cirrhosis, hepatic failure, hemorrhagic shock, arrhythmia, gastrointestinal bleeding.

Table 2. Categories of Potentially Inappropriate Medications (PIMs) Before Admission and Categories of PIMs and Actually Inappropriate Medications (AIMs) at Discharge
PIM Categories^a	N (%)			Positive Predictive Value^f
PIM Categories^a	Preadmission PIMs,^b,c	Discharge PIMs,b^,d	Discharge AIMs,^b,e	%
Opioids	21 (13)	69 (28)	11 (12)	16
Anticholinergics	39 (25)	60 (24)	33 (37)	55
Antidepressants	32 (20)	30 (12)	7 (8)	23
Drugs causing orthostasis	14 (9)	20 (8)	2 (2)	10
Nonbenzodiazepine hypnotics	14 (9)	18 (7)	13 (14)	67
Benzodiazepines	8 (5)	12 (5)	8 (9)	67
Atypical antipsychotics	1 (1)	14 (6)	10 (11)	71
Antiarrhythmics	8 (5)	13 (5)	1 (1)	8
Typical antipsychotics	0 (0)	2 (1)	0 (0)	0
Muscle relaxants	4 (3)	3 (1)	3 (3)	100
Nonsteroidal anti-inflammatory drugs	6 (4)	0 (0)	0 (0)	Not applicable
Other^g	10 (6)	9 (4)	2 (2)	22

^a Although some medications may exhibit multiple properties, the medications have been classified to be mutually exclusive as described in the methods. The specific medicationns evaluated, according to their category, are listed in Appendix S1.
^b Percentages in these columns show the proportion of total PIMs or AIMs that were accounted for by individual PIMs categories.
^c A total of 157 PIMs were prescribed to 79 participants before admission.
^d A total of 250 PIMs were prescribed to 103 participants at hospital discharge.
^e A total of 90 AIMs were prescribed to 61 participants at hospital discharge.
^f Proportion of PIMs in each PIM category considered to be AIMs at hospital discharge .
^g Digoxin, ferrous sulfate, furosemide, nitrofurantoin, and torsemide.

Table 3. Risk Factors for Potentially Inappropriate Medications (PIMs) at Hospital Discharge
Risk Factor	Rate Ratio (95% Confidence Interval) P-Value
Age	1.00 (0.99–1.02) .72
Number of preadmission PIMs	1.16 (1.08–1.25) <.001
Charlson comorbidity score	1.03 (0.97–1.08) .37
Days of delirium	1.00 (0.97–1.03) .93
Hospital length of stay	1.02 (1.00–1.04) .08
Discharge service (surgical vs medical)	1.45 (1.20–1.69) <.01
Discharge disposition (not home vs home)	1.38 (1.10–1.66) .03

Authors and Disclosures

Alessandro Morandi, MD, MPH,^abc Eduard Vasilevskis, MD,^decf Pratik P. Pandharipande, MD, MSCI,^gh Timothy D. Girard, MD, MSCI,^dicf Laurence M. Solberg, MD,^ecf Erin B. Neal, PharmD,^j Tyler Koestner, MS,^k Renee E. Torres, MS,^l Jennifer L. Thompson, MPH,^l Ayumi K. Shintani, PhD, MPH,^l Jin H. Han, MD, MSc,^m John F. Schnelle, PhD,^dc Donna M. Fick, PhD,ⁿ E. Wesley Ely, MD, MPH,^dicf and Sunil Kripalani, MD, MSc^de

^aRehabilitation and Aged Care Unit Hospital Ancelle, Cremona, ^bGeriatric Research Group, Brescia, Italy; ^cCenter for Quality Aging, ^dCenter for Health Services Research, ^eDivision of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University, ^fDepartment of Veterans Affairs Medical Center, Geriatric Research, Education and Clinical Center, Tennessee Valley Healthcare System, ^gDivision of Critical Care, Department of Anesthesiology, Vanderbilt University, ^hAnesthesia Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, ⁱDivision of Allergy, Pulmonary and Critical Care Medicine, ^jDepartment of Pharmaceutical Services, Vanderbilt University, Nashville, Tennessee; ^kCollege of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee; ^lDepartment of Biostatistics, School of Medicine, ^mDepartment of Emergency Medicine, School of Medicine, Vanderbilt niversity, Nashville, Tennessee; and ⁿSchool of Nursing, Pennsylvania State University, University Park, Pennsylvania.

Conflict of Interest
Dr. Pandharipande has received honoraria from Hospira, Inc. and Orion Pharma. Dr. Girard has received honoraria from Hospira, Inc. Dr. Ely has received honoraria from GSK, Pfizer, Lilly, Hospira, and Aspect. Dr. Kripalani is a consultant to and holds equity in PictureRx, LLC, and has received honoraria from Pfizer. All other authors report no financial conflict of interest.

Dr. Pandharipande is supported by the Veterans Affairs (VA) Clinical Science Research and Development Service (VA Career Development Award). Dr. Ely is supported by the VA Clinical Science Research and Development Service (VA Merit Review Award) and the National Institutes of Health (AG027472). Dr. Girard is supported by the National Institutes of Health (NIH; AG034257). Dr Han is supported by the National Institute on Aging K23AG032355. Drs. Vasilevskis, Ely, and Girard are supported by the VA Tennessee Valley Geriatric Research, Education and Clinical Center. Dr. Vasilevskis is also supported by the VA Clinical Research Training Center of Excellence. Dr. Fick acknowledges partial support for this work from Award R01 NR011042 from the National Institute of Nursing Research (NINR). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NINR or NIH.

Address correspondence to
Alessandro Morandi, Rehabilitation and Aged Care Unit Hospital Ancelle, Via Aselli, 14, 26100 Cremona, Italy. E-mail: morandi.alessandro@gmail.com