Potentially Inappropriate Medication Use in Community Residential ...

Pharmacoepidemiology

Potentially Inappropriate Medication Use in Community Residential Care Facilities Shelly L Gray, Susan C Hedrick, Ellen E Rhinard, Anne E Sales, Jean H Sullivan, Jane B Tornatore, and Michael P Curtis

OBJECTIVE: To describe the prevalence of potentially inappropriate medication use in community residential care (CRC) facilities at baseline, describe exposure to potentially inappropriate drugs during the 1-year follow-up, and examine characteristics associated with potentially inappropriate use. DESIGN: A cohort study was conducted using 282 individuals aged ≥65 years entering a CRC facility in a 3-county area in the Puget Sound region of Washington State between April 1998 and December 1998 on Medicaid funding. MAIN OUTCOME MEASURE:

Use of potentially inappropriate medications as defined by explicit criteria (e.g., drugs that should generally be avoided in the elderly because potential risks outweigh any potential benefits).

RESULTS: Sixty-two (22%) residents took a total of 75 potentially inappropriate medications at baseline. The most common agents used at baseline were oxybutynin (3.5%) and amitriptyline (3.5%). The incidence of new use of potentially inappropriate medications was 0.1/100 person-days during the follow-up period. Potentially inappropriate use was related to self-reported fair or poor health (adjusted OR 1.42; 95% CI 1.05 to 1.92) and number of prescription drugs (adjusted OR 1.12; 95% CI 1.05 to 1.19). In the Cox proportional hazard model, no characteristics predicted new potentially inappropriate medication use during the follow-up. CONCLUSIONS: Potentially inappropriate medication use is common among residents in CRC facilities. A comprehensive periodic review may be beneficial for reducing potentially inappropriate use, especially for patients taking multiple drugs. KEY WORDS: community residential care, drug utilization, elderly.

Ann Pharmacother 2003;37:988-93. Published Online, 16 Jun 2003, www.theannals.com, DOI 10.1345/aph.1C365

ommunity residential care (CRC) facilities are becomC ing a popular housing option for older adults with physical and/or mental disabilities who are unable to live independently. Clients living in CRC facilities often meet Author information provided at the end of the text. This research was supported by The John A Hartford Foundation, Inc., New York City, and the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service. Gray was supported by Grant K08AG0080801 from the National Institute on Aging. Earlier versions of this article were presented at the Annual Meetings of the Gerontological Society of America (2001) and American Society on Aging (2002). This report presents the findings and conclusions of the authors. It does not necessarily represent those of The John A Hartford Foundation or VA Health Services Research and Development Service.

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the criteria for nursing home placement and, therefore, their associated medical problems and drug regimens are often complex. On average, residents of CRC facilities take between 3.8 to 6.2 regularly scheduled medications,1-4 which falls midway between the extent of drug use of older adults residing independently in the community (average 2.7–3.9) and those in long-term care (average 8.9).5 High medication use carries many risks including use of unnecessary agents, drug– drug interactions, and excess morbidity and mortality due to adverse events.5 The prescribing of potentially inappropriate medications in older adults is a major public health issue that has received unprecedented attention over the past decade. As-

2003 July/August, Volume 37

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sessing the quality, or appropriateness, of prescribing in older adults is an inherently complex task. A commonly employed approach has been the application of explicit criteria developed in 1991 by Beers et al. for nursing home residents6 and later updated and expanded to be applied to all care settings.7 The criteria include medications that should generally be avoided in the elderly because the potential risks outweigh any potential benefits. Researchers have assessed the prevalence of potentially inappropriate drug use in many care settings8-13; however, only a few studies have examined use in CRC. The prevalence of potentially inappropriate medication use was 25% in a 10-state survey of board and care facilities3 and, more recently, 16% in a 4state sample of residential care and assisted-living facilities.4 Several concerns surround medication use in CRC, which lacks the safety nets found in skilled nursing facilities. Unlicensed staff typically provide assistance with drug administration. Lack of training in medication use and effects may hinder the ability to monitor and promptly detect drug-induced problems. Given that CRC is growing in importance as a housing choice for the elderly, more information is needed regarding the quality of drug prescribing in these settings. Little is known about the extent of use over time, such as: Is use of potentially inappropriate medication intermittent or more chronic in nature? The objectives of this study were to describe the prevalence of potentially inappropriate medication use in CRC at baseline, describe exposure to potentially inappropriate drugs during the 1-year follow-up, and examine characteristics associated with potentially inappropriate use. Methods SAMPLE

A prospective cohort study was conducted using residents in CRC in a 3-county area in the Puget Sound region of Washington State.14 Eligible individuals were those entering a CRC (adult family home, adult residential care, or assisted living) between April and December 1998 on Medicaid funding who agreed to participate in the study. Residents could either be newly admitted to the setting or already residing in the setting but newly converted to Medicaid funding. This study was approved by the University of Washington and State of Washington human subjects review committees. Of the 583 potentially eligible residents, 132 (23%) residents refused, 102 (17%) were ineligible (died or no longer in CRC by baseline interview), and 349 (60%) were enrolled. The sample for this analysis consisted of 282 residents; 17 were excluded because baseline medication information was not available and 50 were excluded because they were 1 claim for each target agent. The second approach is more conservative with the goal of eliminating individuals who may have had a single claim for a medication that they did not actually consume. STATISTICAL ANALYSES

Missing Data

DATA COLLECTION AND MEASURES

Information was obtained from 2 sources: in-person interviews by trained personnel with the resident or proxy and state databases. Demographic information, such as date of birth, gender, and race, was collected from the state database. Information collected through resident interviews included education, activities of daily living (ADLs), global health status, and cognitive status. When the resident was unable to complete an interview (46.1%), this information was provided by a proxy, usually the family caregiver. Residents or proxies were asked about the performance of 6 ADLs (bathing, dressing, locomotion, transfer, toileting, eating) over the past 7 days.15 Residents were categorized as requiring supervision or more help

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Multiple imputation was performed to accommodate missing values for 4 of the covariates using Statistical Solutions software.18,19 Table 2 identifies the variables that were imputed and the sample size for each variable. The problems with only including individuals with complete data (complete case analysis) in the analyses are that the remaining sample may not be representative of the target population and the estimates may be biased.

Analysis Descriptive statistics were performed using STATA (version 6.0) and SAS was used for performing multivariable models. Logistic regression


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was used to examine the characteristics associated with potentially inappropriate use at baseline (n = 282). A Cox proportional hazard regression model was used to examine factors associated with new use of a potentially inappropriate medication during the 1-year follow-up (n = 217).

USE OF POTENTIALLY INAPPROPRIATE MEDICATIONS

Baseline

Sixty-two (22%) residents took a total of 75 potentially inappropriate medications. Most (80.6%) residents used only 1 potentially inappropriate agent and 54.8% used a potentially inappropriate medication classified as severe (e.g., long-acting benzodiazepine, doxepin, amitriptyline). The most common potentially inappropriate medications used at baseline were tricyclic antidepressants (6.0%), antihistamines (5.3%), urinary antispasmodics (3.5%), and long-acting benzodiazepines (3.5%) (Table 1). In a multi-

Results A description of the sample characteristics is given in Table 2. The average age of the residents was 83 years (range 65–102). Most residents were taking at least 1 prescription medication (94.2%), with 26% using 10 or more drugs. Over two-thirds of the participants had functional and/or cognitive impairments.

Table 1. Summary of Potentially Inappropriate Medication Use at Baseline and During 1-Year Follow-Upa During 1-y Follow-Up (n = 277)b,c,d

Baseline (n = 282) Any Use Drug Tricyclic antidepressants amitriptyline doxepin Long-acting BZDse clonazepam clorazepate diazepam flurazepam Short- or intermediate-acting BZDs alprazolam >2 mg lorazepam >3 mg temazepam >15 mg triazolam 0.25 mg Non-BZD hypnotic zolpidem >5 mg Analgesics meperidine propoxyphene Antihistamines chlorpheniramine diphenhydramine hydroxyzine promethazine Skeletal muscle relaxants carisoprodol cyclobenzaprine metaxalone methocarbamol Urinary antispasmodics oxybutynin Cardiovascular dipyridamole methyldopa reserpine ticlopidine GI antispasmodics dicyclomine diphenoxylate propantheline

Severity high

high

low

low

high low low

low

low

low high low high high

Any Use

n

%

n

%

17 10 7 10 5 1 3 1 2 1 0 1 0 2 2 4 2 2 15 0 8 6 1 5 1 1 1 2 10 10 7 2 1 1 3 3 0 2 1

6.0 3.5 2.5 3.5 1.8 0.4 1.1 0.4 0.7 0.4 0 0.4 0 0.7 0.7 1.4 0.7 0.7 5.3 0.0 2.9 2.1 0.4 1.8 0.4 0.4 0.4 0.7 3.5 3.5 2.5 0.7 0.4 0.4 1.1 1.1 0.0 0.7 0.4

25 14 11 14 6 1 5 2 14 2 9 2 1 8 8 25 1 24 44 1 19 15 9 11 1 3 2 5 19 19 5 2 1 1 1 11 2 9 0

9.0 5.1 4.0 5.1 2.2 0.4 1.8 0.7 5.1 0.7 3.2 0.7 0.4 2.9 2.9 9.0 0.4 8.7 15.9 0.4 6.9 5.4 3.2 4.0 0.4 1.1 0.7 1.8 6.9 6.9 1.8 0.7 0.4 0.4 0.4 4.0 0.7 3.2 0.0

Days of Exposure (of users) Median (range)

Days of Exposure (entire sample) per 100 Person-Days

121 (10–349)

4.26

121 (1–347)

2.14

13.5 (4–140)

0.46

26 (3–233)

1.49

24 (1–337)

3.58

36 (6–316)

1.44

203 (18–362)

3.80

253 (64–319)

1.11

20 (2–52)

0.26

BZD = benzodiazepine; GI = gastrointestinal. a Other medication included in the criteria but not used (low severity if not specified): chlordiazepoxide, mebropamate (high severity if recently started), indomethacin, phenylbutazone, pentazocine (high severity), cyproheptadine, tripelennamine, dexchlorpheniramine, chlorzoxazone, disopyramide (high severity), chlorpropamide (high severity), trimethobenzamide, hydergine, barbiturates except phenobarbital (high severity if started recently). b Five people had missing medication information for follow-up. c Total days of follow-up were 90 510 person-days; 58 subjects who died after baseline had an average of 176 days of follow-up (range 5–356). d Calculation based on any fill for a target medication; results were similar when restricting to those who had >1 fill. e Clonazepam, clorazepate added by authors.

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variable model adjusting for characteristics listed in Table 2, fair or poor self-rated health (adjusted OR 1.42; 95% CI 1.05 to 1.92) and number of prescription medications (adjusted OR 1.12; 95% CI 1.05 to 1.19) were found to be associated with use of potentially inappropriate medications. One-Year Follow-Up

Overall, 121 (43.7%) residents had a claim for at least 1 potentially inappropriate medication during the 1-year follow-up, which included 66 new users and 55 past users. Most drugs used at baseline were refilled during the follow-up. The incidence of new potentially inappropriate use was 0.1/100 person-days. The most common potentially inappropriate agents during the follow-up were antihistamines, tricyclic antidepressants, narcotic analgesics, and urinary antispasmodics (Table 1). In order to examine the regularity of use, medication use was summarized according to the number of days of exposure during the follow-up among participants and for the entire sample (Table 1). Days of exposure to a therapeutic class exceeded 100 days of the follow-up year for tricyclic antidepressants, long-acting benzodiazepines, cardiovascular agents, and urinary antispasmodics. A similar pattern was noted for exposure among the entire sample, with tricyclic antidepressants (4.26/100 person-days) and urinary antispasmodics (3.80/100 person-days) having the highest days of exposure. Among subjects taking antihistamines, the median days of exposure was low (n = 24); however, in the entire sample, antihistamines had one of the highest days of exposure (3.58/100 person-days). This result is explained by the fact that antihistamines were used by many residents (n = 44) for a limited period. The results were similar when restricted to residents who had >1 claim for a target medication, indicating most participants had multiple claims for a specific potentially inappropriate medication (data not shown). In the Cox proportional hazard model, no characteristics predicted new use of a potentially inappropriate medication during the follow-up.

Table 2. Description of Sample at Baseline (n = 282) Parameter Demographic characteristics age gender (female) race (white) high school education Health-related variables fair/poor health needs assistance with ≥1 ADLs has cognitive impairment prescription medications Type of facility adult family home assisted living adult residential care ADLs = activities of daily living. a Mean ± SD.

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Sample Size (n)

n (%)

282 282 282 243

82.9 ± 7.9a 207 (73.4) 263 (93.3) 150 (61.7)

264 235 211 282 282

128 (48.5) 163 (69.4) 146 (69.2) 6.8 ± 4.8a 163 (57.8) 90 (31.9) 29 (10.3)

Discussion In this study of individuals residing in CRC facilities, 1 in 5 were using a potentially inappropriate medication at baseline. The incidence of new use over the 1-year followup was 0.1/100 person-days. The comparison of our results with the prevalence reported by other investigators should be made cautiously. With this caveat in mind, the results of this study are promising in that use of potentially inappropriate medications in CRC was similar to the prevalence reported for older adults living independently in the community (18–24%).11-13 It might be expected that prevalence would be higher in these settings because of the strong link with high medication use.3,4,11,13 To our knowledge, this is the first study to examine the days of exposure to potentially inappropriate medications over time. Tricyclic antidepressants were used for 4.26 days per 100 person-days, which translates into roughly 4 days if the medication patterns of 1 person were examined for 100 days or 20 people for 5 days. Expressing potentially inappropriate drug use as days of exposure is important for several reasons. First, although it could be argued that any use of these agents should be avoided, long-term use is probably more problematic than short-term use. Second, the proportion of residents using 2 drugs may be similar, but regularity of use may differ considerably. For example, tricyclic antidepressants and analgesics were both taken by 9% of the sample during follow-up; however, the days of exposure was roughly threefold higher with the tricyclic antidepressants (4.26/100 person-days vs. 1.49/100 person-days). We found that potentially inappropriate medication use was associated with the number of prescription drugs3,4,11,13 and self-reported health.11 We did not find that cognitive impairment was associated with lower use of a potentially inappropriate medication as has been reported by 2 studies conducted in CRC facilities.3,4 Sloane et al.4 reported that facility level factors were associated with potentially inappropriate medication use. Many of these agents can be used to manage incontinence, insomnia, or behavioral problems associated with dementia; these conditions may place extra burden and require more staff time if not well controlled. The small sample of our study hindered our ability to examine the association of facility level factors and potentially inappropriate medication use. The most common potentially inappropriate medications were amitriptyline, doxepin, diphenhydramine, and oxybutynin. Tricyclic antidepressants are often used for the management of neuropathic pain, insomnia, or urinary incontinence. For most of these indications, safer alternatives are available; however, use in low doses may be well tolerated.20,21 Oxybutynin has been effective and well tolerated for some women with urge incontinence and has the advantage of being less expensive compared with alternative therapeutic options. Consistently, other investigators have found propoxyphene to be one of the most prevalent potentially inappropriate medications (2.8–6.3%).3,4,11,13 The low prevalence found in our study at baseline (0.7%) may be


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because propoxyphene is often taken as needed, and we may have missed intermittent users by our definition of use. The development of explicit criteria, as used in this study, was an important step to increase awareness among clinicians of the special issues of prescribing medications for older adults who may have altered drug response because of disease- and/or age-related physiologic changes. Nonetheless, defining prescribing as potentially inappropriate based solely on explicit criteria without taking into consideration patient level information has generated considerable controversy. For a given individual, the benefit of using a potentially inappropriate medication may outweigh the risk and may have been initiated after an unsuccessful trial of a more preferred agent. Clinical evaluation is necessary to determine whether a medication is truly inappropriate for a given individual. The adverse event profile for many of these agents has been clearly documented; however, this does not preclude safe use in particular individuals given careful oversight. Nevertheless, these criteria have influenced public policy and are indicators for quality of drug use for residents of long-term care facilities.22 A few limitations should be noted. First, these results may not be generalizable beyond the sample of state-funded recipients from a 3-county area of Washington State. It is unlikely that the prevalence of potentially inappropriate medication use is influenced by state funding of drugs given that, at the time of the study, Washington State did not have a drug formulary. Furthermore, a representative study of residential care facilities in 4 states found that receipt of state assistance was not related to prevalence of potentially inappropriate use.4 Second, the small sample size may explain our inability to find factors associated with new potentially inappropriate medication use during the follow-up. Third, we did not assess negative health outcomes associated with potentially inappropriate medication use. Fourth, we were unable to determine whether the potentially inappropriate drugs were truly inappropriate given the individual’s medical status and history, since these environments lack detailed medical charts. Summary We conclude that potentially inappropriate medication use is common among residents of CRC facilities. These results should serve as a reminder that a comprehensive periodic review of drugs may be beneficial for older adults taking multiple agents in these settings. If use of a potentially inappropriate medication is deemed clinically warranted, the resident should be carefully evaluated to determine whether the drug is effective and not causing adverse effects. Consultant pharmacists may be successful in reducing potentially inappropriate medication use in these settings.23 Many have urged a shift in thinking regarding how we measure optimal drug use in older adults.24,25 Although explicit criteria are helpful for identifying potential problem areas in drug prescribing, this is only the tip of the iceberg in the arena of suboptimal prescribing. Future research should focus on a more comprehensive view of suboptimal 992

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prescribing in older adults residing in CRC facilities and take into consideration patient level information. Shelly L Gray PharmD MS, Associate Professor, School of Pharmacy, University of Washington, Seattle, WA

Susan C Hedrick PhD, Research Career Scientist, Health Services Research and Development Center of Excellence, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA; Professor, Department of Health Services, University of Washington Ellen E Rhinard PharmD, at time of writing, PharmD Student, School of Pharmacy, University of Washington; now, Specialty Pharmacy Resident in Family Practice, University of Washington Medical Center–Roosevelt, Seattle Anne E Sales MSN PhD, Research Scientist, Health Services Research and Development Center of Excellence, VA Puget Sound Health Care System; Assistant Professor, Department of Health Services, University of Washington Jean H Sullivan BA, Program Director, Health Services Research and Development Center of Excellence, VA Puget Sound Health Care System Jane B Tornatore PhD, at time of writing, Post-doctoral Fellow, Health Services Research and Development Center of Excellence, VA Puget Sound Health Care System; Research Associate, Department of Health Services, University of Washington; now, Research Director, Screen Inc., Seattle Michael P Curtis PhD, at time of writing, Post-doctoral Fellow, Health Services Research and Development Center of Excellence, VA Puget Sound Health Care System; now, Research Scientist II, Epidemiology and Evaluation Section, Maternal and Child Health Branch, California Department of Health Services, Sacramento, CA Reprints: Shelly L Gray PharmD MS, School of Pharmacy, Box 357630, University of Washington, Seattle, WA 98195-7360, FAX 206/543-3835, E-mail [email protected]

References 1. Armstrong EP, Rhoads M, Meiling F. Medication usage patterns in assisted living facilities. Consult Pharm 2001;16:65-9. 2. Garrard J, Cooper SL, Goertz C. Drug use management in board and care facilities. Gerontologist 1997;37:748-56. 3. Spore DL, Mor V, Larrat P, Hawes C, Hiris J. Inappropriate drug prescriptions for elderly residents of board and care facilities. Am J Public Health 1997;87:404-9. 4. Sloane PD, Zimmerman S, Brown LC, Ives TJ, Walsh JF. Inappropriate medication prescribing in residential care/assisted living facilities. J Am Geriatr Soc 2002;50:1001-11. 5. Hanlon JT, Ruby CM, Shelton PS, Pulliam CC. Geriatrics. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: a pathophysiological approach. Stamford, CT: Appleton & Lange, 1999. 6. Beers MH, Ouslander JG, Rollingher I, Reuben DB, Brooks J, Beck JC. Explicit criteria for determining inappropriate medication use in nursing home residents. Arch Intern Med 1991;151:1825-32. 7. Beers MH. Explicit criteria for determining potentially inappropriate medication use by the elderly. An update. Arch Intern Med 1997;157: 1531-6. 8. Beers MH, Ouslander JG, Fingold SF, Morgenstern H, Reuben DB, Rogers W, et al. Inappropriate medication prescribing in skilled-nursing facilities. Ann Intern Med 1992;117:684-9. 9. Dhalla IA, Anderson GM, Mamdani MM, Bronskill SE, Sykora K, Rochon PA. Inappropriate prescribing before and after nursing home admission. J Am Geriatr Soc 2002;50:995-1000. 10. Golden AG, Preston RA, Barnett SD, Llorente M, Hamdan K, Silverman MA. Inappropriate medication prescribing in homebound older adults. J Am Geriatr Soc 1999;47:948-53. 11. Zhan C, Sangl J, Bierman AS, Miller MR, Friedman B, Wickizer SW, et al. Potentially inappropriate medication use in the community-dwelling elderly: findings from the 1996 Medical Expenditure Panel Survey. JAMA 2001;286:2823-9. 12. Willcox SM, Himmelstein DU, Woolhandler S. Inappropriate drug prescribing for the community-dwelling elderly. JAMA 1994;272:292-6.


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Research Reports 13. Hanlon JT, Fillenbaum GG, Schmader KE, Kuchibhatla M, Horner RD. Inappropriate drug use among community-dwelling elderly. Pharmacotherapy 2000;20:575-82. 14. Hedrick SC, Sales AEB, Sullivan J, Gray SL, Tornatore J, Curtis M. Resident outcomes of Medicaid funded community residential care. Gerontologist, In press. 15. Morris JN, Hawes C, Fries BE, Phillips CD, Mor V, Katz S, et al. Designing the national resident assessment instrument for nursing homes. Gerontologist 1990;30:293-307. 16. Ware J Jr, Kosinski M, Keller SD. A 12-item short-form health survey: construction of scales and preliminary tests of reliability and validity. Med Care 1996;34:220-33. 17. Katzman R, Brown T, Fuld P, Peck A, Schechter R, Schimmel H. Validation of a short orientation–memory–concentration test of cognitive impairment. Am J Psychiatry 1983;140:734-9. 18. Little RJA, Rubin DB. Statistical analysis with missing data. New York: John Wiley and Sons, 1987. 19. Statistical Solutions. Statistical solutions for data analysis. 2nd ed. Saugus, MA: Statistical Solutions, 1999. 20. Gnann JW Jr, Whitley RJ. Clinical practice. Herpes zoster. N Engl J Med 2002;347:340-6. 21. Max MB, Lynch SA, Muir J, Shoaf SE, Smoller B, Dubner R. Effects of desipramine, amitriptyline, and fluoxetine on pain in diabetic neuropathy. N Engl J Med 1992;326:1250-6. 22. Summary of HCFA changes to nursing facility survey procedures and interpretive guidelines. Alexandria, VA: American Society of Consultant Pharmacists, July 1999. 23. Monane M, Matthias DM, Nagle BA, Kelly MA. Improving prescribing patterns for the elderly through an online drug utilization review intervention: a system linking the physician, pharmacist, and computer. JAMA 1998;280:1249-52. 24. Avorn J. Improving drug use in elderly patients: getting to the next level. JAMA 2001;286:2866-8. 25. Hanlon JT, Schmader KE, Ruby CM, Weinberger M. Suboptimal prescribing in older inpatients and outpatients. J Am Geriatr Soc 2001; 49:200-9.

EXTRACTO OBJETIVO: Describir la prevalencia del uso de medicamentos de manera potencialmente inapropiado en facilidades de cuidado comunitario (FCC) al inicio de la investigación y describir la exposición a estos medicamentos al cabo de 1 año de seguimiento. Además, analizar las características asociadas al uso inapropiado de medicinas. DISEÑO DEL ESTUDIO: Este estudio de cohorte contó con la participación de 282 personas de 65 años de edad o más entrando a una FCC en la región de Puget Sound del estado de Washington entre abril de 1998 a diciembre de 1998 bajo el programa federal de Medicaid. PRINCIPAL OBSERVACIÓN A MEDIR: El uso potencialmente inapropiado de medicamentos según definido. Ejemplo: medicamentos que deben evitarse en los viejos porque los posibles riesgos sobrepasan los beneficios potenciales. RESULTADOS: El análisis inicial demostró que 62 (22%) residentes tomaron un total de 75 medicamentos potencialmente inapropiados. Los

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agentes mas comúnmente utilizados fueron el oxybutinin (3.5%) y la amitriptilina (3.5%). La incidencia de nuevos fármacos de uso potencialmente inapropiado fue de 0.1/100 días-persona durante el período de seguimiento. Hubo relación entre el uso inapropiado de medicamentos y auto informes de salud satisfactorios o pobres (RO ajustada 1.42; 95% IC 1.05 a 1.92) y el número de medicamentos recetados (RO ajustada de 1.12; 95% IC 1.05 a 1.19). En el modelo de riesgo proporcional Cox, no hubo características que predijeran el uso de medicamentos potencialmente inapropiados durante el período de seguimiento. CONCLUSIONES: El uso de medicamentos de manera potencialmente inapropiado es común entre residentes de FCC. Una revisión periódica del perfil de medicamentos puede ser beneficiosa para reducir este riesgo, particularmente entre personas tomando múltiples medicamentos. Mitchell Nazario RÉSUMÉ

Décrire la prévalence de base de l’utilisation de médicaments potentiellement inappropriés en maison de retraite, décrire l’exposition à des médicaments potentiellement inappropriés sur 1 année de suivi, et examiner les caractéristiques associées à l’utilisation de médicaments potentiellement inappropriés. METHODES: Etude d’une cohorte de 282 personnes âgées de 65 ans et plus entrant dans une maison de retraite conventionnée d’une zone de 3 départements de la région de Puget Sound dans l’état de Washington, entre avril 1998 et décembre 1998. INDICATEUR PRINCIPAL: Utilisation de médicaments potentiellement inappropriés selon une définition de critères explicites (ex: médicaments qui devraient en général être évités chez les personnes âgées en raison d’un rapport bénéfice/risques défavorable). RESULTATS: Soixante-deux (22%) des résidents prenaient au total 75 médicaments potentiellement inappropriés au départ. Les produits les plus couramment utilisés au départ étaient l’oxybutynine (3.5%) et l’amitriptyline (3.5%). L’incidence de l’utilisation nouvelle de médicaments potentiellement inappropriés était de 0.1/100 personnesjours durant la période de suivi. L’utilisation potentiellement inappropriée était corrélée à un état de santé autoestimé correct ou médiocre (OR 1.42; 95% CI 1.05 á 1.92) et au nombre de médicaments prescrits (OR 1.12; 95% CI 1.05 á 1.19). Selon le modèle de probabilité Cox-proportionnel, aucune caractéristique n’était prédictive d’utilisation nouvelle de médicaments potentiellement inappropriés au cours du suivi. CONCLUSIONS: L’utilisation de médicaments potentiellement inappropriés est courante parmi les résidents de maison de retraite. Une revue d’utilisation de médicaments complète et périodique peut être propice à la réduction de l’utilisation de médicaments potentiellement inappropriés, particulièrement pour ceux prenant de nombreux médicaments. OBJECTIF:


Michel Le Duff

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