Discussion
To our interpretation, this is the first analysis to determine the
prevalence of PIP medication in older adults attending the outpatient
psychiatry department using Beers criteria 2019 and STOPP criteria 2015.
According to Beers criteria 2019, 91.2% (416 out of 456) of older
adults have prescribed at least one PIP medication. Whereas STOPP
criteria 2015 identifies 73.3% (336 out of 456) older adults prescribed
with at least one PIP medication. Results show that recommendations of
Beers criteria have relatively more trespassed for PIMs than STOPP
criteria. In other words, Beer criteria seem to have more comprehensive
and sturdy recommendations for use of psychotropic drugs as compared to
STOPP criteria.
The prevalence of PIP medication reported in our study by using both
sets of criteria is significantly higher than the findings of another
research conducted based on older Beer and STOPP
guidelines.24,25 The difference might be due to
differences in data collection of sample population or difference in
criteria used as this study uses the updated and latest version of both
the criteria.
Out of a total of 456 patients, the Antianxiety agents were prescribed
in nearly 82% (n=378) of the older adults. Out of 378 patients,
potentially inappropriate antianxiety agents were prescribed in 97.3%
(n=362) and 74.6% (n= 282) older adults as per Beers criteria and STOPP
criteria. Beers criteria include a higher proportion of potentially
inappropriate antianxiety agents as compared to STOPP criteria. Beers
criteria 2019 mention to avoid short/intermediate/long-acting
benzodiazepines in all older adults, whereas the STOPP criteria mention
only LABZD, but the literature shows that all the benzodiazepines
including short/intermediate/Long-acting can cause harmful adverse
events (e.g. falls, fractures, cognitive impairment) if use in older
adults.26,27 Beers criteria and STOPP criteria
identify clonazepam as the most common PIP medication irrespective of
any condition. Whereas LABZDs are used in older adults with dementia,
cognitive impairment, history of fall, and delirium are considered
potentially inappropriate.12 The potential risks of
using long-acting agents must be considered while choosing
pharmacotherapy for anxiety in older people.
The present study also examined the predictors of PIP medication
prescribing with bivariate analysis. The most important predictors of
PIP medication prescribing were the rural background of living, ≥4
psychotropic medication prescribed, TCA use, SNRI use, LABZD use,
short-acting benzodiazepine use, atypical antipsychotic use according to
Beers criteria 2019. On the other hand, alcohol addiction, rural region
of living, TCA use, SSRI use, long-acting benzodiazepine, and atypical
antipsychotic use came out to be the predictor for PIP medication use
according to STOPP criteria 2015.
Our study found that antidepressants were the second most frequently
prescribed psychotropic drug as almost 68.8% of the older adults were
prescribed with at least one antidepressant either TCA, SSRI, SNRI.
Previous studies have reported the same findings on community-dwelling
older adults.25 Although SSRIs are preferred agents to
treat depression in older adults, TCA is still prescribed in older
adults and is considered potentially inappropriate psychotropic
medication according to STOPP criteria.28 The use of
TCA and SNRI has been associated with substantial anticholinergic
effects, sedation effects. Moreover, SNRI users are more prone to
cerebrovascular events as compared to SSRI users.4Beers criteria recommend all TCA, SSRI, and SNRI in older adults with
syncope, and only TCA should be avoided in older adults with a history
of falls or fractures due to its associated strong anticholinergic
adverse effects such as confusion, dry mouth, sedation, and orthostatic
hypotension. However, STOPP criteria only mention TCA that it should not
be used as a first-line treatment in older adults with depression.
Atypical Antipsychotics were the third most prescribed psychotropic drug
in older adults. Beers criteria have given the list of conventional and
atypical antipsychotic list, irrespective of diagnosis/conditions that
should be avoided in older adults. Among Atypical antipsychotics
medication class quetiapine, olanzapine, risperidone is the most common
PIP medication prescribed in older adults. Beers criteria recommend
avoiding antipsychotics in older adults with dementia, cognitive
impairment, history of falls or fractures, delirium due to its strong
anticholinergic effects, and extrapyramidal side effects. Whereas STOPP
criteria only recommend avoiding antipsychotics in older adults with
dementia, delirium. In our study, 132 older adults out of 456 patients
were prescribed with at least three or more CNS active drug combinations
that are considered potentially clinically important drug-drug
interactions as mentions in Beers criteria 2019. Thirty-four clinically
important drug-drug interactions were identified in older adults by
using Beers criteria. In contrast, STOPP criteria don’t recommend any
guidelines on clinically important drug-drug interaction.
It was observed that most of the countries have developed their own
criteria or guidelines to identify PIM in the geriatric population.
However, there is a major number of developed as well as developing
countries where no guideline/criteria have been chalked out. Healthcare
professionals from all over the world use Beers criteria or STOPP
criteria to identify PIM in older adults, but there has always been a
state of confusion in most countries for uniform use of these
guidelines. Hence there is a need that all geriatric societies of the
world should come together to make a unified guideline for identifying
PIM in the geriatric population.
The present study highlight that the prevalence of PIP medication as
determined by the use of Beers criteria and STOPP criteria in older
adults is very high that demands immediate attention. The study also
reflects a more comprehensive and sturdy nature of AGS Beer criteria as
the Beers criteria detect significantly more PIMs than STOPP criteria
due to the inclusion of clinically important drug-drug interaction and
more conditions in drug-disease interaction. TCA, long-acting
benzodiazepine, and atypical antipsychotic use were some of the risk
factors for potentially inappropriate psychotropic medication use in
older adults. Although this study gives a greater understanding of PIP
medication prescribing in older adults attending the psychiatry
outpatient department, there are some drawbacks in the present study
that need to be recognized. The study’s findings are focused on older
adults attending the outpatient psychiatry department, so extrapolation
of results to inpatients older adults will not be feasible. Finally, the
study did not evaluate the Adverse drug reactions/outcomes resulting
from the use of PIP medication detected by Beers criteria and STOPP
criteria.