Discussion
To our knowledge, this is the first study to determine the PIMs use in
Indian older adult patients admitted with cardiovascular disease in the
medicine/ cardiology department of a tertiary care teaching hospital.
This study identified a high frequency of PIMs use in older adult
patients according to Beers criteria 2019. It was observed that out of
250 older adult patients, 156 patients had been prescribed with at least
one PIM during their entire hospital stay. Inappropriate use of
medication is more often occur in older adults as they take multiple
drugs simultaneously to treat multiple conditions. A few studies have
been conducted worldwide to find out the prevalence of PIMs in CVD, and
some studies have reported lower prevalence as compared to our study. On
the other hand, few have reported higher prevalence. This difference
could be due to a study participant included in different studies,
variations in prescribing habits in different countries with different
healthcare settings. Another important factor causing variation in the
prevalence of PIMs is different criteria used in a different study. In
concordance with other studies conducted in different countries, this
study’s prevalence was lower than that reported by Aguiar et al
identified 87.4% of the patients were taking ≥1
PIM.[6] On the other hand, a study conducted in
Spain by Garcia- Ramos et al. reported a 27.9% prevalence of PIMs in
cardiovascular care.[14]
The most frequently used PIMs in our study were Proton pump inhibitors
from independent of diagnosis category as identified by Beers criteria.
Proton pump inhibitor (PPI) is the most commonly prescribed drugs and is
chronically consumed without an indicated diagnosis. It is necessary
that all health care providers monitor the use of PPI in older adults if
prescribed for long term as these drugs may increase the risk of
clostridium difficile infection, bone and hip
fracture.[15] The second most prescribed PIMs were
Insulin Sliding Scale (insulin regimens containing only short or
rapid-acting insulin dosed according to current blood glucose levels
without concurrent use of basal or long-acting insulin) is an agent
approved for diabetic patient. However, in the older adult patients, the
older adult patients may have a higher risk of hypoglycaemia without
improving hyperglycaemia management.[16, 17]
According to Beers criteria, Drugs such as diuretics that may cause or
exacerbate Syndrome of Inappropriate Antidiuretic hormone secretion and
hyponatremia should be used with caution in older adults, especially
cardiovascular patients, diuretics are often prescribed to get rid of
fluid retention.[18, 19] Health care providers are
advised to keep a close look at sodium level whenever older adults are
prescribed with these medications. However, Beers criteria suggest that
Aspirin should be used with caution in older adults with age ≥70.
Nitrofurantoin is first-line therapy for Urinary tract infection. Still,
it is considered as potentially inappropriate medication in older adults
as these drugs have the potential to cause pulmonary toxicity,
hepatotoxicity, and peripheral neuropathy with long term
use.[20]
Long-acting Benzodiazepine was amongst the most commonly prescribed
PIMs. As the older adult is mostly suffering from anxiety, depression,
and other psychiatric disorders. So, Benzodiazepines are often
prescribed to treat these complications in older adults. But Beers
criteria recommends that all benzodiazepines should be avoided in older
adults as they increase the risk of cognitive impairment, falls,
fractures. Moreover, it may worsen the
delirium.[21]
However, age-related significant changes were observed in the kidney
function of older adults. Certain medications should be either avoided
or their dosage reduced according to the creatinine clearance of the
patient. Despite a clear-cut indication, in our study, we have
identified 7 PIMs that have been prescribed to 63 older adult patients
with CVD. Among them, especially anti-coagulant, was the most commonly
prescribed PIMs. Their dosage either should be reduced or avoided
according to Creatinine clearance of the patient as they may pose a
threat to older adult patients.[22]
The present study also highlights the predictors of PIMs prescribing in
older adult patients with CVD. It was observed that the most important
predictors of PIMs prescribing were female gender, three or ≥4 number of
diagnosis, 7- 9 days of hospital stay, 5- 8 medications and ≥ 9
medications prescribed during their hospital stay, and CrCl of 31-
60ml/min and 61- 90ml/min. These findings results are consistent with
the results from previous findings that have reported the same
predictors for PIMs prescribing.[11, 23]
Although the female gender is increasingly perceived as a key predictor
of PIMs, systemic gender studies in the older adults patients
hospitalized with CVD are still lacking. Compared to male diabetics, the
probability of lethal Coronary Heart Disease (CHD) has been reported to
be 50% higher in women with diabetes.[24] the
reason for this higher PIMs used in the female older adults with CVD is
multifarious and related to India’s social structure. Major factors
include sluggishness to move to specialists, social
bindings/miserliness, non-adherence to treatment plants due to
commitment toward family, increase self-medication for ailments, and
easy availability of over the counter drugs.[25]
It was observed that the older adults with 3 or ≥4 numbers of
diagnosis/comorbidities are more vulnerable to PIMs use than the
population with fewer diagnosis/comorbidities. Several studies have
reported a decline in quality of care when patients have multiple
morbidities.[26, 27] several factors contribute to
the increased use of PIMs in the older adults with comorbidities.
Multimorbid patients tends to have frequent and intensive contact with
different specialists’ physicians resulting in increased medication
prescribing for various conditions.[28] On the
other hand, there is a high possibility of a lack of coordination
amongst specialists for different disease prescribing under one roof,
leading to the prescription of multiple drugs, which increases the
likelihood of PIMs prescription.
Prolonged hospital stays (7-9 days) are one of the main predictors of
PIMs use as prolonged hospitalization increases the risk of
hospital-acquired infection, increased mortality, economic burden, and
poor outcomes in the older adults.[29] As the
hospital stay of the older adults increases, the consultants intend to
get the patient out of the disease irrespective of the drug’s side
effects and adverse effects. Moreover, there is a complete lack of
awareness among physicians about the PIMs and Beers criteria.
Patients with deterioration in kidney function are more susceptible to
nephrotoxic injury due to the inappropriate dosing of
medication.[30] Moreover, due to the unwanted
effects of drugs mentioned in Beers criteria, there is a strong chance
of prescribing an inappropriate drug dose that may cause nephrotoxicity
in the older adults with altered kidney function.
Nowadays, the older adult is often on polypharmacy/high-level
polypharmacy to treat their condition. Furthermore, increased use of
drugs in older adult further exacerbates the risk of adverse drug
events, drug-drug interactions, and PIMs use. Sometimes, prescribing
cascades occur due to the use of multiple
drugs.[8]
In conclusion, the present study results showed a higher prevalence of
PIMs in the older adult patients with CVD and females with CVD has
emerged as a potential PIM indicator. The study further reflects the
need for physician’s special attention on polypharmacy/high-level
polypharmacy with comorbidities and extended hospital stay due to high
risk for PIM. There is a need for compulsory training of physicians at
all levels for the use of Beer criteria for better geriatric health
care. Regulatory bodies need to set up geriatric health care desks in
tertiary care hospitals to check such PIM incidences to reduce
unnecessary economic burden due to infringement in following beer
criteria. There is also a strong need to find out disease-wise PIM
predictors in a broader range of the populations.