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.